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Approach to Difficult Approach to Difficult and Failed Airway and Failed Airway Mohd Zakaria Mohd Zakaria 19th August 2010 19th August 2010

MLM Airway Mx

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Page 1: MLM Airway Mx

Approach to Difficult and Failed Approach to Difficult and Failed AirwayAirway

Mohd ZakariaMohd Zakaria

19th August 201019th August 2010

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OutlineOutline

Definitions.Definitions.

Evaluations of Difficult AirwayEvaluations of Difficult Airway

Equipments:Equipments:

Algorithm:Algorithm:-ACEP-ACEP

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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

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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

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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

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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

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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.

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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.

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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.

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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.

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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.

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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®]

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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®]

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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

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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.

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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

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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®

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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.

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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

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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

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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

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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.

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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®]

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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.

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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.

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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

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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.

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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.

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Infra-Glottic Airway Devices

c)Retrograde Intubation

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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.

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Infra-Glottic Airway Devices

d)Cricothyrotomy Surgical

cricothyrotomy; either open or percutaneous, remain the “last box” on every airway algorithm ever published.

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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

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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

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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.

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Difficult Airway

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Difficult Airway

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Emergency Airway AlgorithmEmergency Airway Algorithm

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Crash airway algorithmCrash airway algorithm

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Difficult airway algorithmDifficult airway algorithm

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Failed airway algorithmFailed airway algorithm

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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.

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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