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Airway Management Airway Management TechniquesTechniques
By Hwan Joo MDBy Hwan Joo MD
Airway PresentationAirway Presentation
Normal Airway ManagementNormal Airway Management Closed ClaimsClosed Claims Difficult Intubation and ToolsDifficult Intubation and Tools Difficult Ventilation and ToolsDifficult Ventilation and Tools Intubation tools for SurgeonsIntubation tools for Surgeons Overall goalsOverall goals
Teach surgeons about airway toolsTeach surgeons about airway tools Not necessarily how to intubateNot necessarily how to intubate
Indication for Tracheal Indication for Tracheal IntubationIntubation
Oxygenation and PeepOxygenation and Peep VentilationVentilation Airway protection from AspirationAirway protection from Aspiration Tracheal toilet and/lung washingsTracheal toilet and/lung washings Route for drug administrationRoute for drug administration
Airway AssessmentAirway Assessment
The Mallampati view The Mallampati view may be indicative of may be indicative of difficult airwaydifficult airway
Negative predictive Negative predictive value >99% for MP 1-2value >99% for MP 1-2
PPV for MP 4 only 40%PPV for MP 4 only 40% MP and laryngeal view MP and laryngeal view
not very correlativenot very correlative
Difficult Airway AssessmentDifficult Airway Assessment
History of difficult IntubationHistory of difficult Intubation Physical examinationPhysical examination TraumaTrauma
C-spine precautionC-spine precaution Blood in airwayBlood in airway Airway traumaAirway trauma
Morbid obesityMorbid obesity RSI makes it worse!RSI makes it worse!
Direct LaryngoscopyDirect Laryngoscopy
3# Mcintosh blade most 3# Mcintosh blade most commonly usedcommonly used
No change in design for No change in design for 60 years60 years
High success rates in High success rates in normal airways (99%)normal airways (99%)
However, difficult to learnHowever, difficult to learn >50 uses to be proficient>50 uses to be proficient Not so good with difficult Not so good with difficult
airwaysairways
Laryngeal Mask AirwayLaryngeal Mask Airway
Comes in sizes 3, 4, 5 Comes in sizes 3, 4, 5 (small, medium large)(small, medium large)
Great for ventilationGreat for ventilation Insertion easier if you have Insertion easier if you have
deep anesthesiadeep anesthesia Does not protect against Does not protect against
aspirationaspiration Not able to deliver high Not able to deliver high
pressure ventilationpressure ventilation Useful for difficult airways Useful for difficult airways
and failed laryngoscopyand failed laryngoscopy
Induction of for IntubationInduction of for Intubation
NothingNothing Patient already non-responsivePatient already non-responsive Medications contraindicatedMedications contraindicated
Topical lidocaineTopical lidocaine Midazolam, fentanylMidazolam, fentanyl EtomidateEtomidate±Sux±Sux KetamineKetamine±Sux±Sux PropofolPropofol±Sux±Sux
Closed Claims -Closed Claims -Caplan, Anesthesiology 1990Caplan, Anesthesiology 1990
Airway -Largest and most costly form of Airway -Largest and most costly form of injury (34% of all claims, $200,000+ US)injury (34% of all claims, $200,000+ US) Inadequate ventilation (34%)Inadequate ventilation (34%) Esophageal intubation (18%)Esophageal intubation (18%) Difficult intubation (17%)Difficult intubation (17%)
36% of claims against difficult intubation 36% of claims against difficult intubation cases considered preventablecases considered preventable
Closed Claims in CanadaClosed Claims in Canada
Between 1993-2003, 50% of all large CMPA Between 1993-2003, 50% of all large CMPA suits in anesthesia were airway relatedsuits in anesthesia were airway related Average settlement was $500,000Average settlement was $500,000 75% of patients suffered brain damage or deaths75% of patients suffered brain damage or deaths 50% were associated with difficult airways50% were associated with difficult airways
In half of these patients, difficult airway adjuncts were not In half of these patients, difficult airway adjuncts were not usedused
Therefore, there is room for improvementTherefore, there is room for improvement
ASA Difficult Airway AlgorithmASA Difficult Airway Algorithm
Recognized difficult airwayRecognized difficult airway intubation vs non-intubationintubation vs non-intubation
facemask, LMAfacemask, LMA regionalregional
Unrecognized difficult airwayUnrecognized difficult airway can ventilatecan ventilate
convert to spontaneous ventilation?convert to spontaneous ventilation? awake vs asleepawake vs asleep
cannot ventilatecannot ventilate emergency measures requiredemergency measures required
Difficult Intubation -Ventilation PossibleDifficult Intubation -Ventilation Possible
Awaken patientAwaken patient Asleep fiberoptic intubationAsleep fiberoptic intubation LMA without intubationLMA without intubation Intubation via LMA or ILMAIntubation via LMA or ILMA Lighted styletteLighted stylette CombitubeCombitubeTMTM
Video laryngoscopeVideo laryngoscope
Flexible Fiberoptic IntubationFlexible Fiberoptic Intubation
Awake fiberoptic intubation Awake fiberoptic intubation is the gold is the gold (Rose CJA 1994)(Rose CJA 1994)
Asleep FOI, successful but,Asleep FOI, successful but, It may be more difficult due It may be more difficult due
toto Airway obstruction or apneaAirway obstruction or apnea Blood in pharynxBlood in pharynx Limited time before oxygen Limited time before oxygen
desaturationdesaturation
Should be done with help!Should be done with help!
Laryngeal MaskLaryngeal Mask
Airway for intubationAirway for intubation Success for intubation with conventional Success for intubation with conventional
LMA is variable (19-93%)LMA is variable (19-93%) Success may be improved by the use of a Success may be improved by the use of a
pediatric bronchoscope via the ETT in pediatric bronchoscope via the ETT in LMALMA
LMA removal may be difficult after LMA removal may be difficult after intubationintubation
Consider LMA without intubationConsider LMA without intubation
Lighted Stylette (TrachliteLighted Stylette (TrachliteTMTM))
With experienceWith experience Success rates reported to Success rates reported to
be up to 99% in patients be up to 99% in patients with difficult airway with difficult airway (Hung, (Hung, CJA 1995)CJA 1995)
Success rates for novices Success rates for novices 50% 50% (Wilk, Resuc 1997)(Wilk, Resuc 1997)
Success rates decreased Success rates decreased in patient with bull necks in patient with bull necks and obese patientsand obese patients
CombitubeCombitubeTMTM
Success rates by non-Success rates by non-anesthesiologist with combitube anesthesiologist with combitube has ranged (33-93%)has ranged (33-93%)
Average beginner success rates Average beginner success rates expected to be in the 80-90% expected to be in the 80-90% range (Anesthesia-trained)range (Anesthesia-trained)
May be associated with May be associated with esophageal injuries and esophageal injuries and mediastinitis mediastinitis (Vezina, CJA 1998)(Vezina, CJA 1998)
Video LaryngoscopesVideo Laryngoscopes Glidescope Glidescope
Rigid laryngoscope with Rigid laryngoscope with CCD CCD
View is very clear with no View is very clear with no foggingfogging
Blade angle 50-60 degBlade angle 50-60 deg Easy to useEasy to use
Very rapid learning curveVery rapid learning curve Can also be learned by ER Can also be learned by ER
physicians, Surgeonsphysicians, Surgeons
Glidescope in UseGlidescope in Use
Glidescope Success Rates with Glidescope Success Rates with Experience Experience Joo et alJoo et al
0102030405060708090
100
0 to 9 10 to 19 20 to 29 30 to 39 > 40
Success Rate
Glidescope with Disposable BladeGlidescope with Disposable Blade
McGrath VideolaryngoscopeMcGrath Videolaryngoscope
Similar to GlidescopeSimilar to Glidescope Disposable blade coverDisposable blade cover Beautiful all in one designBeautiful all in one design Optics not be as goodOptics not be as good
Narrow field of visionNarrow field of vision
More difficult?More difficult? More portableMore portable
More likely to disappearMore likely to disappear
Video LaryngoscopesVideo LaryngoscopesRES-Q-SCOPERES-Q-SCOPE
LCD ScreenLCD Screen Disposable bladeDisposable blade Much cheaper initial costMuch cheaper initial cost However, $50 per useHowever, $50 per use
AirtraqAirtraqWhat is wrong with this picture?What is wrong with this picture?
Ventilation Difficult or ImpossibleVentilation Difficult or Impossible
Failed intubation is disturbing Failed intubation is disturbing but…..but….. Failed ventilation is universally fatal!Failed ventilation is universally fatal! ChoicesChoices
LMA (will discuss ILMA later)LMA (will discuss ILMA later) CombitubeCombitube Transtracheal airwayTranstracheal airway
cricothryotomycricothryotomy transtracheal jet ventilationtranstracheal jet ventilation tracheostomytracheostomy
Laryngeal Mask AirwayLaryngeal Mask Airway
Success rates for ventilation as high asSuccess rates for ventilation as high as 95% after 1 attempt and 98% after 2 attempts95% after 1 attempt and 98% after 2 attempts
No decrease in success rates in patient’s No decrease in success rates in patient’s with difficult airwayswith difficult airways
Overwhelming data of uses in difficult Overwhelming data of uses in difficult airways and in failed ventilationairways and in failed ventilation may have saved 100’s of lives!may have saved 100’s of lives!
For IPPV use large LMA’sFor IPPV use large LMA’s
What is the Best Device for Failed What is the Best Device for Failed Ventilation? LMA vs. CombitubeVentilation? LMA vs. CombitubeTMTM
Success is dependent on more on the Success is dependent on more on the operator’s experience than to tooloperator’s experience than to tool
Majority of anesthesiologist have little or Majority of anesthesiologist have little or no experience with the Combitubeno experience with the Combitube
LMA should be the first choice for difficult LMA should be the first choice for difficult ventilation scenariosventilation scenarios
However, Combitube theoretically However, Combitube theoretically prevents aspirationprevents aspiration
Trans Trachea Airway Trans Trachea Airway FOR UPPER AIRWAY OBSTRUCTIONFOR UPPER AIRWAY OBSTRUCTION
TTJV (jet ventilation)TTJV (jet ventilation) difficult with multiple difficult with multiple
complicationscomplications
Needle cricothryotomyNeedle cricothryotomy High success rates using High success rates using
Seldinger techniqueSeldinger technique No need for jetNo need for jet
Slash or surgical Slash or surgical tracheotomytracheotomy Messy but may do the jobMessy but may do the job
Intubating Laryngeal Mask Intubating Laryngeal Mask Airway (ILMA)Airway (ILMA)
ILMA with FOBILMA with FOB
Things of interestThings of interest Elbow connectorElbow connector
Continuous ventilationContinuous ventilation
PVC TubePVC Tube Metal rings in silicone tube Metal rings in silicone tube
not compatible with FOBnot compatible with FOB
Better than C-Trach?Better than C-Trach? Better manipulationBetter manipulation Higher Success ratesHigher Success rates
What is this?What is this?
The view via ILMA is The view via ILMA is different from regular different from regular FOBFOB
The epiglottis is often The epiglottis is often distorteddistorted
Obviously blind Obviously blind intubation failedintubation failed
Larger ILMA requiredLarger ILMA required
LMA C TrachLMA C Trach
ILMA with LCD screenILMA with LCD screen Improved success rates for intubation over ILMA Improved success rates for intubation over ILMA Success on Success on normal airwaysnormal airways about 90-95% about 90-95%
based on limited studiesbased on limited studies However, need greater mouth opening compared to However, need greater mouth opening compared to
ILMA, 2.5cm versus 2.0 cmILMA, 2.5cm versus 2.0 cm
Same success rate for ventilationSame success rate for ventilation Less traumaLess trauma
Failed IntubationFailed IntubationWhat to do as a SurgeonWhat to do as a Surgeon
Awaken patient if possible/feasibleAwaken patient if possible/feasible Maintain ventilation and oxygenationMaintain ventilation and oxygenation
FacemaskFacemask LMALMA CombitubeCombitube
Call AnesthesiaCall Anesthesia Surgical AirwaySurgical Airway
Attempt ventilation throughoutAttempt ventilation throughout
Airway Tools Airway Tools notnot for Surgeons for Surgeons
FOBFOB Too much effort required to learnToo much effort required to learn Not good with secretions or bloodNot good with secretions or blood Not as useful in unplanned cases (ER)Not as useful in unplanned cases (ER)
Lighted StylettesLighted Stylettes Again, high learning curveAgain, high learning curve Not as useful in patients who are not paralyzedNot as useful in patients who are not paralyzed High incidence of esophageal intubationsHigh incidence of esophageal intubations
What is the Best Tool for What is the Best Tool for Surgeons?Surgeons?
LCD Laryngoscopes are the way of the LCD Laryngoscopes are the way of the futurefuture
Currently, Glidescope is the easiest to use Currently, Glidescope is the easiest to use with the most literature supporting itwith the most literature supporting it Must Practice on routine patientsMust Practice on routine patients
Use it get familiarityUse it get familiarity Bug the anesthesiologists to use it in the ORBug the anesthesiologists to use it in the OR
Gold standard, Glidescope + FOBGold standard, Glidescope + FOB
Glidescope FOB InsertionGlidescope FOB Insertion
Glidescope FOB IntubationGlidescope FOB Intubation
The FutureThe Future The future of intubation will be video assistedThe future of intubation will be video assisted
In the past, intubators In the past, intubators intubated in the dark intubated in the dark by themselvesby themselves
PRIVATE PRIVATE (Like masturbation!)(Like masturbation!)
The future will have The future will have everybody involved in everybody involved in the process of the process of intubation intubation
(ER Doc, Nurses, RT)(ER Doc, Nurses, RT)
PARTY!PARTY! Everyone is involvedEveryone is involved
Final RecommendationFinal Recommendation
When faced with a When faced with a difficult airway, stay difficult airway, stay on the beaten path ofon the beaten path of Practice, Practice…Practice, Practice… Use familiar but Use familiar but
advanced devices advanced devices Do not persist with Do not persist with
techniques that have techniques that have failedfailed Secure ventilationSecure ventilation
Practice in SimulationPractice in Simulation