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Approach to Difficult and Failed Approach to Difficult and Failed AirwayAirway
Mohd ZakariaMohd Zakaria
19th August 201019th August 2010
OutlineOutline
Definitions.Definitions.
Evaluations of Difficult AirwayEvaluations of Difficult Airway
Equipments:Equipments:
Algorithm:Algorithm:-ACEP-ACEP
DefinitionDefinition
Difficult Airway: Clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both.
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, V 98, No 5, May 2003
DefinitionDefinition
Difficult face mask ventilation: It is not possible for the anesthesiologist to provide adequate face mask ventilation due to one or more of the following problems: inadequate mask seal, excessive gas leak, or excessive resistance to the ingress or egress of gas.
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, V 98, No 5, May 2003
DefinitionDefinition Difficult laryngoscopy: (a) It is not possible to visualize any
portion of the vocal cords after multiple attempts at conventional laryngoscopy
Difficult tracheal intubation: (a) Tracheal intubation requires multiple attempts, in the presence or absence of tracheal pathology.
Failed intubation: (a) Placement of the endotracheal tube fails after multiple intubation attempts.
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, V 98, No 5, May 2003
DefinitionDefinition
A “failed airway” exists when one or both of the following scenarios occur:
1. Inability to ventilate or intubate the patients
2. Three intubation attempts by the same operator, even when O2 saturation able to be maintain
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, V 98, No 5, May 2003
Evaluations for Difficult BVM VentilationEvaluations for Difficult BVM Ventilation
MOANSMOANS: Assesses the Potential for Difficult Bag-Valve-Mask Ventilation
MMask seal -Inadequate mask seal? OObesity/OObstruction ->26 kg/m2 AAge ->55 years NNo teeth -Impair BVM effectiveness SStiff ventilation -Asthma, COPD, ARDS, term
pregnancy
Walls RM and Murphy MF: Manual of Emergency Airway Management, 3rd edition, Philadelphia, Lippincott, Williams, and Wilkins 2008.
Evaluations for Difficult Laryngoscopy
LEMONLEMON: Assesses the Potential for Difficult Laryngoscopy
LLook -Injury, large incisors, large tongue, beard EEvaluate “3-3-2” -finger-breadth measurement* MMallampati Score -≥3 OObstruction -Any condition causing obstruction NNeck -Limited neck mobility
*3= inter-incision; 3=floor of mandible; 2=thyroid to hyoid
Reed MJ. Can an airway assessment score predict difficulty at intubation in the emergency department? Emergency Medicine Journal 2005; 22:99-102.
Evaluations for Difficult Laryngoscopy
This study assessed the ability of the LEMON score to predict difficult airways. 156 ED patients had a LEMON score performed and correlated with the Cormack-Lehane score during laryngoscopy. 73% of patients were classified as “easy intubations,” and 27% were “difficult intubations.” Patients with large incisors [p <0.001], a reduced inter-incisor distance [p <0.05], or a reduced thyroid to mandible distance [p <0.05] were more likely to have a poor laryngoscopic view and a potentially more difficult intubation.
The “Big teeth, small mouth, short neck” all predict a potentially difficult airway. Citing this paper, the LEMON law was recently recommended in the updated 8th edition of the ATLS Guidelines.
Evaluations for Difficult Cricothyrotomy
SHORTSHORT: Assesses the Potential for Difficult Cricothyrotomy
SSurgery -Prior neck surgery HHematoma -Significant midline neck hematoma OObesity ->26 kg/m2 RRadiation -Prior neck radiotherapy TTumor -History of head and neck cancer
Walls RM and Murphy MF: Manual of Emergency Airway Management, 3rd edition, Philadelphia, Lippincott, Williams, and Wilkins 2008.
EpidemiologyEpidemiology
Bair AE. The failed intubation attempt in the emergency department: analysis of prevalence, techniques, and personnel. Journal of Emergency Medicine 2002; 23:131.
Prospective, observational study of ED airway management in 30 hospitals in the U.S., Canada, and Singapore participating in the National Emergency Airway Registry [NEAR].Jan 1998-Feb 2001.
Patients were enrolled if the first technique was unsuccessful and a rescue was required.
7,712 emergency intubation with 207(2.7%) meets inclusion criteria.
Conclusion …Failed airways are rare and therefore, clinician experience with any specific rescue device is typically very limited.
Equipments for Difficult & Failed AirwaysEquipments for Difficult & Failed Airways
1) Blind insertion supra-glottic airway devices
a) Double-lumen laryngeal devices i) Combitube®
b) Laryngeal mask airwaysi) Standard LMA®ii) Intubating LMA [Fastrach®]
c) Intubating styletsi) Gum-elastic bougieii) Lighted stylet [Trachlight®]
Equipments for Difficult & Failed AirwaysEquipments for Difficult & Failed Airways 2) Direct vision supra-glottic airway devices
a) Hand-held fiberoptic intubating styletsi) Levitan Scope®ii) Shikani Optical Stylet®iii) RIFL®
b) Hand-held fiberoptic laryngoscopesi) McGraf Scope®ii) Glidescope®iii) Storz Videolaryngoscope®iv) Pentax Airway Scope®
c) Traditional flexible fiberoscopesd) Prism/mirror assisted scopes [Airtraq®]
Equipments for Difficult & Failed AirwaysEquipments for Difficult & Failed Airways
3) Infra-glottic airway devices
a) Retrograde intubationb) Transtracheal jet ventilationc) Surgical cricothyrotomy
i) Openii) Percutaneous
Equipments for Difficult & Failed AirwaysEquipments for Difficult & Failed Airways
Before we discuss these devices, remember... always consider the “easy stuff first.”
Effective patient positioning, use of the BURP technique and bimanual laryngoscopy may avert the need to reach for a fancy device
Levitan R. Laryngeal view during laryngoscopy: A randomized trial comparing cricoid pressure, backward-upwardsrightwards pressure and bimanual laryngoscopy. Annals of Emergency Medicine 2006; 46:548.
BID:Supra-Glottic Airway Accurate placement without direct vision Recommended for anatomically intact
airways. Avoids potential iatrogenic injury or
misplacement
a)Double Lumen Laryngeal Devices
BID:Supra-Glottic Airway
AdvantagesAdvantages DisadvantagesInexpensiveEasy to teach and learnVentilation superior to a standard BVMCan intubate with the device in place
Blind-insertion approachNot a definitive airwayRare reports of airway injuryMay cause cervical motion in fractureMay be difficult to insert with neck in-line
Combitube®
BID:Supra-Glottic Airway
b)Laryngeal Mask Airways The LMA® and Intubating-LMA [Fastrach®] both
rely on seating of the device in the esophagus. The Fastrach™ allows for intubation of the
trachea with a cuffed tube.
BID:Supra-Glottic Airway
LMA ..con’tSizes: 2: 10-20kg
3: 30-50kg
4: normal adults
50-70kg
5: large adults
70-100kg
6.>100kg
BID:Supra-Glottic Airway
Fastrach™ Single Use, but may be used up to 40 times Ideal for areas of the hospital where use will be
frequent, especially teaching situations Comes with specially-designed ETT which may be
used up to 10 times Blind intubation success rate as high as 96.4% in
difficult to intubate patients after 3 attempts*
Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A: Use of the intubating LMA Fastrach™ in 254 patients with difficult-to-manage airways. Anesthesiology 2001; 95:1175-81
BID:Supra-Glottic AirwayStandard Laryngeal Mask Airway®
AdvantagesAdvantages DisadvantagesRelatively inexpensiveVentilation superior to a standard BVM
Blind-insertion approachNot a definitive airwayRequires careful sizing to fit in the airway
Intubating Laryngeal Mask Airway [Fastrach®]
AdvantagesAdvantages DisadvantagesVentilation superior to a standard BVMProvides a definitive airway
ExpensiveRequires careful sizing to fit in the airway
BID:Supra-Glottic Airway
c)Intubating Stylets There are a number of intubating stylets
on the market. The classic gum-elastic bougie is inserted under direct vision or blindly “by feel” into the airway.
The Trachlight® relies on trans-illumination of the larynx during blind insertion.
BID:Supra-Glottic Airway
AdvantagesAdvantages DisadvantagesInexpensiveProvides a definite airwayCan use as an adjunct to laryngoscopyCan insert visually or blindly
Blind technique difficult
AdvantagesAdvantages DisadvantagesProvides a definitive airwayCan use as an adjunct to laryngoscopyMinimal neck movement
Technique requires expertise
Gum Elastic Bougie
Lighted Stylet [Trachlight®]
DVD:Supra-Glottic Airway The hand-held fiberoptic stylets and laryngoscopes have
revolutionized emergency airway management. These devices offer the advantage of direct visualization of the
airway without the technical complexity and cost of more traditional flexible fiberoptic scopes.
Each of these has a different design and it is difficult to strongly recommend one over the other.
Furthermore, in videolaryngoscopy is an excellent teaching tool that should rapidly become the standard at Emergency Medicine training programs.
DVD:Supra-Glottic Airway
a)Hand-Held Fiberoptic Laryngoscopes The Glidescope® employs similar technology but
a different approach, whereby the device is inserted blindly and guided into the airway by watching a monitor.
DVD:Supra-Glottic Airway
AdvantagesAdvantages DisadvantagesLess expensive than traditional fiberscopeEasier to use than a flexible fiberscopeDirect vision of the airwayDefinitive airwayAllows for “supervised” airway visualization
Relatively expensiveDifferent psychomotor skillTip can be obscured by fog, secretions
Hand-Held Fiberoptic Laryngoscopes
Infra-Glottic Airway Devicesb)Transtracheal Jet Ventilation
TTJV relies on placement of a rigid catheter through the cricothyroid membrane into the airway. Ventilation is delivered in intermittent “jets” using a regulator system attached to a standard medical gas oxygen port.
Infra-Glottic Airway Devices
AdvantagesAdvantages DisadvantagesLess invasive than a surgical airwayLess complex than a surgical airwayProvided a “bridge” to other techniques
Not a definite airwayContraindicated in airway obstructionMay cause barotrauma
Transtracheal Jet Ventilation
If I am that far down the algorithm, i.e.: about to move to an infra-glottic technique… I would choose a formal cricothyrotomy over TTJV. The notable exception is in children <8, where open cricothyrotomy is contraindicated.
Infra-Glottic Airway Devices
c)Retrograde Intubation
Infra-Glottic Airway Devices Retrograde intubation employs a Seldinger guide-
wire system advanced through the cricothyroid membrane and then retrograde into the posterior pharynx. The wire is retrieved through the mouth, a rigid introducer is placed over the wire, a standard endotracheal tube is advanced over the introducer and advanced through the glottis, and the wire removed.
Given the number of steps required and the growing number of less complicated alternatives, I would not recommend retrograde intubation for ED airway rescue during which there is always little time, tenuous physiology, and a full stomach.
Infra-Glottic Airway Devices
d)Cricothyrotomy Surgical
cricothyrotomy; either open or percutaneous, remain the “last box” on every airway algorithm ever published.
Infra-Glottic Airway Devices
Cadaver studies by Chan TM, et al [Journal of Emergency Medicine 1999] and Schaumann N, et al [Anesthesiology 2004] have demonstrated that:
The time to completion is similar for both techniques Success rates [85% to 95%] are similar Misplacement is more common with the percutaneous
technique Tissue injury is more common with the open technique
Surgical Cricothyroidotomy
Equipment: Scalpel - short and rounded(no. 20 or Minitrach scalpel).Small (e.g. 6 or 7 mm) cuffed tracheal or tracheostomy tube
4-step Technique:
1. Identify cricothyroid membrane
2. Stab incision through skin and membrane
Enlarge incision with blunt dissection
(e.g. scalpel handle, forceps or dilator)
3. Caudal traction on cricoid cartilage with tracheal hook
4. Insert tube and inflate cuff
Ventilate with low-pressure source
Verify tube position and pulmonary ventilation
Difficult Airway
Normal Anatomy
Adequate Oxygenation
Abnormal Anatomy
Adequate Oxygenation
Normal Anatomy
Inadequate Oxygenation
Abnormal Anatomy
Inadequate Oxygenation
Michael A. Gibbs, What Is Your Rescue Airway Plan: Advanced Airway Techniques. American College of Emergency Physicians Scientific Assembly 2008: Advanced Airway Techniques; October 28, 2008.
Difficult Airway
Difficult Airway
Emergency Airway AlgorithmEmergency Airway Algorithm
Crash airway algorithmCrash airway algorithm
Difficult airway algorithmDifficult airway algorithm
Failed airway algorithmFailed airway algorithm
References:References:
Difficult Airway Course: Emergency™ Walls RM and Murphy MF: Manual of Emergency Airway
Management, 3rd edition, Philadelphia, Lippincott, Williams, and Wilkins 2008.
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, V 98, No 5, May 2003
Michael A. Gibbs, What Is Your Rescue Airway Plan: Advanced Airway Techniques. American College of Emergency Physicians Scientific Assembly 2008: Advanced Airway Techniques; October 28, 2008.
Morbid ObesityMorbid Obesity
““Stacking” Stacking” maneuvermaneuver• Draw a line to join Draw a line to join
external auditory external auditory meatus to meatus to suprasternal notchsuprasternal notch
Place blankets/ Place blankets/ towel rolls beneath towel rolls beneath shoulder and neck shoulder and neck until the line until the line become horizontalbecome horizontal