Evidence-based Anesthesia: Difficult Airway … 2 Objectives Review the ASA Difficult Airway Algorithm and Airway Approach Algorithm Describe components of the preoperative airway

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Dennis Spence PhD, CRNA

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1&sk=

Disclaimer The views expressed in this presentation are those of

the author and do not reflect official policy or position of the Department of the Navy, the Department of Defense, the Uniformed Services University of the Health Sciences, or the United States Government.

The author does not endorse, promote or advertise any products presented in this presentation.

Disclosure Nothing to disclose

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Objectives Review the ASA Difficult Airway Algorithm and

Airway Approach Algorithm

Describe components of the preoperative airway assessment

Discuss current evidence as it relates difficult airway management

Describe how to prepare for a difficult intubation

Review the various equipment/alternative airway devices and methods used for management of the DA

Clinical Vignette 67 y/o male presents

with angioedema tongue

PMH- HTN 15 yrs, high cholesterol

Meds- lisinopril, zocor

How would you manage this airway?

Difficult Airway Management Is the approach to the

difficult airway changing?

Is the direct laryngoscope going the way of the rotary telephone?

What about the Awake Fiberoptic Intubation (AFOB)?

Do new graduates know how to do an AFOB?

Spence DL. Anesthesia Abstracts. 2010.4(12): 1-34.

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ASA Difficult Airway Algorithm 2013

Apfelbaum HL et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118.

Updated evidence and findings from surveys

No major changes

Changes some terms used

Expands step 1 assessment of potential difficulties

Addition of video-assisted laryngoscopy to algorithm





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The Airway Approach Algorithm

Rosenblatt W H , Whipple J Anesth Analg 2003;96:1233-

1233

©2003 by Lippincott Williams & Wilkins

ASA Difficult Airway Algorithm Skeleton

WAKE-UP?

HELP!!!

Call for Help

Rosenblatt W H , Whipple J. The Difficult Airway Algorithm of the American Society of Anesthesiologists. Anesth Analg 2003;96:1233-1233.

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Preoperative Airway Exam

http://www.bing.com/images/search?q=images+preoperative+airway+examination&qs=n&form=QBIR&pq=images+preoperative+airway+examination&sc=0-14&sp=-1&sk= Dr Benumof Airway lecture

Airway Exam Airway Exam Component Abnormal Finding

1. Length of upper incisors Relatively long

2. Relation of maxillary and mandibular incisors during normal jaw closure

Prominent “overbite”

3. Relation of maxillary and mandibular incisors during voluntary protrusion of mandible

Cannot bring mandibular incisors anterior to maxillary incisors

4. Interincisor distance < 3 cm

5. Visibility of uvula Not visible when tongue is protruded with patient in sitting position e.g., Mallampati class > II)

6. Shape of palate Highly arched or very narrow

Airway Exam Airway Exam Component Abnormal Finding

7. Compliance of mandibular space

Stiff, indurated, occupied by mass, or nonresilient

8. Thyromental distance <3 ordinary finger breaths

9. Length of neck Short

10. Thickness of neck Thick (>40-42 cm)

11. Range of motion of head and neck Patient cannot touch tip of

chin to chest or cannot extend neck

Other findings/predictors of DA: Obesity, OSA, AHI≥30

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Mallampati Score

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Submandibular & Submental Abscesses


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Severe Retrognathia


Rosenblatt W et al. Anesth Analg 2011;112:602-607

©2011 by Lippincott Williams & Wilkins

What about upper airway pathology?

Preoperative Endoscopic Airway Exam (PEAE)

In patients with upper airway pathology does a performance of a PEAE change the plan?

Asleep Intubations = 83% Majority intubated asleep • asleep asleep = 62% • awake asleep = 20%

• FOB = 43% • DL/VL = 56% • N = 1 retrograde wire

Awake Intubation = 24% • awake awake = 12% • asleep awake = 6% Conclusion: PEAE may ID pts with upper airway pathology who truly need AFOB

Rosenblatt WH et al. Preoperative Endoscopic Airway Examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth Analg 2011;112:602–7 Spence D. Anesthesia Abstracts 2011;(5)3:3-7.

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Do the same predictors of difficult intubation apply to

indirect video laryngoscopy?

Predictors of Difficult Airway with the GlideScope©

Tremblay et al. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope® videolaryngoscope. Anesth Analg 2008;10(6): 1495–1500.

Time to Intubate

• Poorer glottic view on DL:

• r = .273

• Higher upper lip bit test score:

• r = 250

• Short sternothyriod distance:

• r = - .146

• Most difficulties due to difficulty navigating ETT into glottis

Weak correlations

Predictors of Difficult Airway with the GlideScope©

1st Attempt Success and Mallampati Class

MP class not predictive of DI

Other risk factors not individually predictive

Díaz-Gómez JL, Satyapriya A, Satyapriya SV, et al. Standard clinical risk factors for difficult laryngoscopy are not independent predictors of intubation success with the GlideScope. J Clin Anesth. 2011;23(8):603-610.

1st Attempt Success

MP I or II MP III or IV0

20

40

60

80

10088%

83%

N = 357P = NS

pe

rce

nta

ge

of

pa

tie

nts

(%

)

96% intubated ≤3 attempts

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Important Question: Can I ventilate the patient?

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Can I ventilate the patient?


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•1 in 690 IMV

•25% were DI

•1 in 2800 IMV +DI

Predictors of Impossible Mask Ventilation (n = 77/53,041)

Predictor Odds Ratio

Neck radiation changes 7.1

Male gender 3.3

Sleep apnea 2.4

MP III or IV 2.0

Presence of beard 1.9

Kheterpal S et al. Prediction and outcomes of impossible mask ventilation: review of 50,000 anesthetics. Anesthesiology 2009;110:891-897.

• N = 176,679 DAs = DMV + DL • 2.5% DMV • 4.4% DL • 1 in 250 DMV + DL

• DMV rate lower w/NMB • 2.6% vs. 3.6%, P < 0.01

Predictors of DMV + DL

Kheterpal S et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy. Anesthesiology 2013;119:1360-9

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Airway Exam Summary Consider overall airway exam, risk of difficult

ventilation, and aspiration risk when making plan

Coexisting diseases

Further research needed on predictors of DI with indirect video laryngoscopy

Err on the side of caution and assume DI

Always consider AFOB in DI, especially w/ upper airway pathology

Positioning

What is the optimal position for intubation?


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Rao Sl et al. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial. Anesth Analg 2008;107:1912-1918.

Ramping the Patient

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DMV & Which NMB to Give?

Amathieu R et al. An algorithm for difficult airway management, modified for modern optical devices (airtraq laryngoscope; ctrach™): a 2-year prospective validation in patients for elective abdominal, gynecological, and thyriod surgery. Anesthesiology 2011;114:25-33 Spence DL. Anesthesia Abstracts 2010;(4)12: 8-13.

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Results • 99% <3 RF easy FMV • 93% >3 RF easy FMV • n = 2 IMV • DMV n = 90

• FMV improve w/ sux = 62% • Intubated 1st attempt = 98.05% • Bougie used 1st in DA = 1.7% • AirTrach 2nd = 0.19% • LMA-C use = 0.024%

Conclusion

• New algorithm successful

• More aggressive use of NMBs + backup devices contribute high success rate

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How to Improve Glottic View?

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Indirect Video Laryngoscopy

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Indirect Video Laryngoscopy

Does indirect video laryngoscopy improve success rate in novices?

Does the use of an indirect video laryngoscopy device improve the view in potential difficult airways?

Does the use of an indirect video laryngoscope device speed up the time to intubation? 1st attempt success in experts?

Does video laryngoscopy improve success after failed direct laryngoscopy?

What are the risk factors for failed indirect video laryngoscopy?

What are the potential complications with indirect video laryngoscopy?

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Indirect Video Laryngoscopy & Novices

Nouruzi-Sedeh P et al. Laryngoscopy via Macintosh blade versus Glidescope: success and time for endotracheal intubation in untrained medical personnel. Anesthesiology 2009;110:32-7. Spence DL. Anesthesia Abstracts 2010;(4)6: 7-9.

• N = 20 no experience • 5 intubations each device Intubation within 2 minutes Higher w/ Glidescope 93% vs. 51%, P <0.01 Time to intubation Faster w/ Glidescope 63 ± 30 s vs. 89 ± 35 s; P < 0.01

Spence DL.. Anesthesia Abstracts 2010;(4):12.

Spence DL.. Anesthesia Abstracts 2010;(4):12.

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LESS EXPERIENCE

Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology. 2011;114(1):34-41.

Meta-Analysis GlideScope© vs. Direct Laryngoscopy

Glottic view (Gr I vs. ≥ Gr 2)

Anticipated or simulated DA

3.5x more likely GR I view (P < 0.05)

+publication bias

1st Intubation Success

Non-experts 1.8x more likely intubate (P <0.05)

Experts: No improvement vs. DL (P = NS)

Time to intubation

Non experts: 43 sec faster intubation(P < 0.05)

Experts: 8 sec faster intubation (P = NS)

Conclusion: Improves glottic view, especially in simulated or potential DA. May help non experts more than experts

Greisdale DE et al. Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anesth. 2012; 59(1): 41–52


Indirect Video Laryngoscopy Simulated difficult intubations

McGrath, Airtraq, and GlideScope© provide superior intubating conditions compared to Macintosh blade(P < 0.05)

Pentax-AWS: 99.6% of DI (MAC grade view 3-4) were grade 1-2

Pentax-AWS: rescue device success in DI = 99.3%

McGrath® Series 5: 100% success in simulated DI with in-line stabilization

Difficult intubation success rate Pentax-AWS = 100%, Glidescope = 96%, Macintosh blade = 84%

Savoldelli GL et al. Comparison of the Glidescope, the McGrath, the Airtraq, and the Macintosh laryngoscopes in simulated difficult airways. Anaesthesia, 2008, 63, 1358–1364. Taylor et al. The McGrath® Series 5 videolaryngoscope vs the Macintosh laryngoscope: a randomised, controlled trial in patients with a simulated difficult airway. Anaesthesia 2013;68: 142-47 Asai T et al. Use of the Pentax-AWS® in 293 patients with difficult airways. Anesthesiology 2009; 110:898–904. Malik MA et al. Randomized controlled trial of the Pentax AWS, Glidescope, and Macintosh laryngoscopes in predicted difficult intubation. Br J Anaesth 2009;103(5):761-8.

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Complications with GlideScope©

Incidence = 1% (N = 2004 intubations)

Minor

Lip, gum, dental trauma

Serious

Pharyngeal wall trauma, lingual nerve injury, vocal cord trauma, tonsillar perforation

Causes- blindly passing tube with stylet

Implication

Look down at airway and gently place tube until see on monitor

Appropriate size blade

Evaluate postop

Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Can J Anaesth. 2007 ;54(1):54-7. Leong WL, Lim Y, Sia AT. Palatopharyngeal wall perforation during Glidescope intubation. Anaesth Intensive Care. 2008 ;36(6):870-4. Magboul MM, Joel S. The video laryngoscopes blind spots and possible lingual nerve injury by the Gliderite rigid stylet--case presentation and review of literature. Middle East J Anesthesiol. 2010;20(6):857-60.

Conclusion: Indirect Video Laryngoscopy Devices

All have major role in difficult airway management

Improved success in DI vs. direct laryngoscopy

Seeing vocal cords and placing tube 2 different things

Be careful with blindly placing tube

Limitations of devices Blood, vomit may obscure view Limited ROM, small TM distance and neck pathology/scar &

inexperience increase failure rate

Awake Fiberoptic Intubation How do you secure this

airway?

Awake vs. asleep

AFOB vs. Trach?

Could you ventilate this patient?

Do you know how to do an AFOB?

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Preparation for AFOB

Tip Concept

Explanation Pt understands reason

Desiccation Dry the airway

Dilation Prepare the nose

Topicalization Obtund reflexes

Sedation Maintain meaningful contact

Procrastination Don’t rush it!

Dr Rosenblatt’s tips

Preparation

Explain the procedure to them and reason why you are doing it

Desiccation Glycopyrolate 0.2-0.4 mg IV or IM if IV difficult Takes up to 15 minutes

Dilation Always prepare nose Afrin

Topicalization Nasal passage/nasopharynx Base of tongue/posterior oropharynx Hypopharynx/larynx-trachea

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Desiccation

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Airway Innervation


Nasal Topicalization

Anterior ethmoid nerve & nasopalantine nerve

Cotton swabs soaking with 4% lidocaine solution or 5% lidocaine ointment

Advance them slowly into the nasal passage

Incrementally advance

Keep in for 5 minutes


Base of Tongue/Post Oropharynx

Glossopharyngeal nerve (IX)

Controls gag reflex

posterior third of the tongue

vallecula

anterior surface of the epiglottis

walls of the pharynx

tonsils


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Base of Tongue/Post Oropharynx

Nebulizer

Good, but careful with lung uptake

Atomizer

Glossopharyngeal nerve

Blocks vs. cotton swabs


Glossopharyngeal Nerve

Use forceps to slowly advance cotton soaked swabs to pillars and leave for 5 minutes each side


SLN & RLN Superior laryngeal nerve

base of tongue posterior surface epiglottis aryepiglottic fold &

arytenoids

Recurrent laryngeal nerve Vocal cords and trachea


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Hypopharynx/Trachea Blockade

Topical vs. blocks

Syringe w/ LA and angiocatheter

Hold tongue with gauze

Drip on base of the tongue

Drip until stop coughing


Topicalization tips Drying agent VIP

Blocks used less and less

Test with tongue depressor or suction catheter

Make sure “numb enough” before going to OR

Sedation

Options Dexmedetomidine

0.5-1 mcg/bolus over 10 minutes

0.2-0.7 mcg/kg/hr

Titrate to effect

Midazolam

Fentanyl

Remifentanil 0.025-0.075 mcg/kg bolus

0.025-0.075 mcg/kg/min

VIP Maintain meaningful contact

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Williams & Ovassapian Airways


FOB Conduits


Tips for AFOB Take your time with topicalization and procedure

Soften tube in warm saline & use 0.5 to 1 size smaller ETT

Position-supine vs. semi-fowlers

Use Williams or Ovassapian airway

Jaw thrust to open airway

Add 10 mL syringe to side-port of FOB to inject LA on VCs

Rotate tube if meet resistance

Practice “asleep” FOB on healthy airways

Do AFOB whenever can to keep up skills

Other devices- some indirect devices can be used for awake intubation

Rosenstock CV et al. Awake fiberoptic or awake laryngoscopic tracheal intubation in patients with anticipated difficult airway management. Anesthesiology 2012; 116:1210–6

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Permission obtained from patient to videotape.

Extubation of Difficult Airway Can patient maintain patent airway after extubation?

Can the patient maintain adequate ventilation?

Is the patient fully reversed? Fully Awake?

Do you have a plan on how to reintubate?

Consider using airway exchange catheter

Airway Exchange Catheter

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Worst Case Scenario: Emergency Invasive Airway Access

http://emedicine.medscape.com/article/80241-overview#a15 http://www.bing.com/images/search?q=images+of+awake+fiberoptic+intubation&qs=n&form=QBIR&pq=images+of+awake+fiberoptic+intubation&sc=0-15&sp=-1&sk=

Difficult Airway Note

Schaeuble J C , Caldwell J E Anesth Analg 2009;109:684-686

Questions?

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References 1. Spence DL. Anesthesia Abstracts. 2010;4(12): 1-34.

2. Apfelbaum HL et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013; 118.

3. Rosenblatt W H , Whipple J. The Difficult Airway Algorithm of the American Society of Anesthesiologists. Anesth Analg 2003;96:1233-1233.

4. Rosenblatt WH et al. Preoperative Endoscopic Airway Examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth Analg 2011;112:602–7

5. Tremblay et al. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope® videolaryngoscope. Anesth Analg 2008;10(6): 1495–1500.

6. Díaz-Gómez JL, Satyapriya A, Satyapriya SV, et al. Standard clinical risk factors for difficult laryngoscopy are not independent predictors of intubation success with the GlideScope. J Clin Anesth. 2011;23(8):603-610.

References 7. Kheterpal S et al. Prediction and outcomes of impossible mask ventilation:

review of 50,000 anesthetics. Anesthesiology 2009;110:891-897. 8. Rao Sl et al. Laryngoscopy and tracheal intubation in the head-elevated

position in obese patients: a randomized, controlled, equivalence trial. Anesth Analg 2008;107:1912-1918.

9. Ikeda A et al. Effects of muscle relaxants on mask ventilation in anesthetized persons with normal upper airway anatomy. Anesthesiology 2012;117:487-93.

10. Amathieu R et al. An algorithm for difficult airway management, modified for modern optical devices (airtraq laryngoscope; ctrach™): a 2-year prospective validation in patients for elective abdominal, gynecological, and thyriod surgery. Anesthesiology 2011;114:25-33.

11. Nouruzi-Sedeh P et al. Laryngoscopy via Macintosh blade versus Glidescope: success and time for endotracheal intubation in untrained medical personnel. Anesthesiology 2009;110:32-7.

12. Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology. 2011;114(1):34-41.

References 13. Greisdale DE et al. Glidescope® video-laryngoscopy versus direct

laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anesth. 2012; 59(1): 41–52.

14. Savoldelli GL et al. Comparison of the Glidescope, the McGrath, the Airtraq,and the Macintosh laryngoscopes in simulated difficult airways. Anaesthesia, 2008, 63, 1358–1364.

15. Asai T et al. Use of the Pentax-AWS® in 293 Patients with difficult airways. Anesthesiology 2009; 110:898–904.

16. Malik MA et al. Randomized controlled trial of the Pentax AWS, Glidescope, and Macintosh laryngoscopes in predicted difficult intubation. Br J Anaesth 2009 ;103(5):761-8.

17. Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Can J Anaesth. 2007 Jan;54(1):54-7.

18. Leong WL, Lim Y, Sia AT. Palatopharyngeal wall perforation during Glidescope intubation. Anaesth Intensive Care. 2008 Nov;36(6):870-4.

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References 19. Magboul MM, Joel S. The video laryngoscopes blind spots and possible lingual nerve

injury by the Gliderite rigid stylet--case presentation and review of literature. Middle East J Anesthesiol. 2010;20(6):857-60.

20. Rosenstock CV et al. Awake fiberoptic or awake laryngoscopic tracheal intubation in patients with anticipated difficult airway management. Anesthesiology 2012; 116:1210–6

21. Moyers G, McDougle L. Use of the Cook airway exchange catheter in "bridging" the potentially difficult extubation: a case report. AANA J. 2002;70(4):275-278.

22. Schaeuble JC, Caldwell JE. Effective communication of difficult airway management to subsequent anesthesia providers. Anesth Analg. 2009;109(2):684-686.

23. Markowitz JE. Surgical airway access. Medscape. Retrieved from http://emedicine.medscape.com/article/80241-overview#a15 on Jan 21, 2013.

24. Taylor et al. The McGrath® Series 5 videolaryngoscope vs the Macintosh laryngoscope: a randomised, controlled trial in patients with a simulated difficult airway. Anaesthesia 2013;68: 142-47

25. Kheterpal S et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy. Anesthesiology 2013;119:1360-9

http://emedicine.medscape.com/article/80241-overview




Documents

Evidence-based Anesthesia: Difficult Airway … 2 Objectives Review the ASA Difficult Airway Algorithm and Airway Approach Algorithm Describe components of the preoperative airway