Difficult Airway Management: By: Bereket Habtamu Advisor: Leulayehu Akalu
Difficult Airway Management: By: Bereket Habtamu Advisor: Leulayehu Akalu
Difficult Airway Management: By: Bereket Habtamu Advisor: Leulayehu Akalu
April 24/2014
• Acknowledgement
• Objective
• Introduction
–Airway Anatomy
–Comparative Anatomy of pediatric vs. Adult Airway
• Definition of difficult airway
• Prevalence
• Causes of difficult airway
• Airway Assessment
–History
–Physical examination
• Predictive tests of difficult airway
–Investigation
• Management approach to difficult airway
–Basic preparation for difficult airway management
–Strategies For Intubation of Anticipated difficult airway
–Un anticipated Difficult Airway
–Difficult intubation with difficult mask ventilation
–ASA Algorithm of difficult airway
–Cant intubate…cant ventilate and
• Emergency cricothyrodotomy
»Cannula/needle cricothyrodotomy
»Surgical cricothyroidotomy
–Awake fibroptic intubation technique
–Rapid Sequence Induction
• Extubation after difficult intubation
• Follow up care
• Summery
• References
•
OBJECTIVE
• To inculcate the importance of difficult
airway management and there by to
bring changes in clinical practice and
patient safety
INTRODUCTION
. The primary focus of this paper is the management
of the difficult airway encountered during
administration of anesthesia and tracheal
intubation. It is also used to facilitate the
management of the difficult airway and to reduce
the likelihood of adverse outcomes. The principal
adverse outcomes associated with the difficult
airway include (but are not limited to) death, brain
injury, cardiopulmonary arrest, unnecessary surgical
airway, airway trauma, and damage to the teeth
Cont. ….
• Literature report that greater than 30% of
anesthesia related morbidity and mortality is
due to inadequate airway management.
Generally this paper will help us to``
vigorously evaluate and manage the air way
peri-operatively, so that we can bring changes
in airway management and patient safety.
Anatomy of Airway
Anatomy /cont. …
Comparative Anatomy of Pediatric VS Adult
airway
Knowing the differences between the airway of a
child and that of an adult is essential for
anesthetists in order for them to safely administer
anesthesia.
• A child’s nostrils, oropharynx and trachea are
relatively narrow;
• The trachea is short;-4cm from the larynx to the
carina and has a narrow diameter of 6 mm.
• The tongue is relatively large and tends to fall
backwards under anesthesia.
Cont. …
• The salivary secretions of children are more
pronounced than those of adults.
• The larynx of a child is more ventrally located.
Until the age of 8 to 10 years, the most narrow
point is larynx cartilage and not, as is the case
with adults, with the glottis.
• The epiglottis is relatively large and shaped like
a U.
• The size of the tonsils and the adenoid in
children can complicate the intubation process.
DEFFINITION OF DIFFICULT AIR WAY
5. Difficult Tracheostomy :
PREVALENCE/1-4%/
Fact of the matter is even with proper evaluation only
15 to 50 % were picked up while difficult face mask
ventilation in general is about 1:10,000 out of which
again 15% proved to be the difficult intubation,
while incidence of extreme difficult or abandons
intubation in general surgery patients are 1:2000
but in obstetrics is 1:300 and of course most critical
incidence is Hypoxia
CAUSES OF DIFFICULT AIRWAY CAUSES
OF DIFFICULT INTUBATION
Causes of difficult airway can be seen in three dimensions;
Anesthetist, equipment and patient factors.
1. Anesthetist:
Inadequate preoperative assessment
Inadequate equipment preparation
Inexperienced or poor technique
2. Equipment:
Malfunctions
Unavailability
No trained assistance
CONTINUES…………..
3. Patient:
a. Congenital ; Syndromes /Downs, Pierre Robbins, Martans, Anchondroplegia/
b. Acquired; Reduced Jaw movement Reduced neck movement
Truisms Rheumatoid arthritis
Fibroses Ankylosing spondylitis
Rheumatoid arthritis Cervical fracture
Tumors Compression/goiter, surgical
Ankylosing Spondylitis hemorrhage/ Tumors
Jaw wiring Edema/abscess
Morbid obesity
Pregnancy
Acromegally
Steroid therapy
Diabetes
Pediatrics
Anatomical factors associated with Difficult
Laryngoscopy;
• Short muscular neck
• Protruding incisors
• Long, high arched palate
• Receding lower jaw
• Poor mobility of the jaw
• Increased anterior depth of the mandible/decreased
jaw opening, requires x-ray/
• Decreased atlanto-occipital distance/decreased
neck extension, requires x-ray/
Causes of difficult/failed mask ventilation
Laryngospasm Body Mass Index > 26 Kg/m2
Laryngeal pathology History of snoring
3
alternative 4
Cricothyroidotomy, Tracheostomy
4
alternative
MANAGEMENT OF DIFFICULT INTUBATION
Management of intubation difficulties can be
considered as four step processes:-
A . Primary intubation attempt;-
-optimal anesthesia -optimal position
-optimal blade
-optimal laryngeal manipulation
-bougies or stylet
B. Secondary intubation attempt;-
-intubation with LMA,ILMA
-fiber optic intubation/rigid or flexible/
-light wands or
-retrograde intubation
Cont’d…
C. Oxygenation/ventilation via face mask /but
includes use of supraglotic adjuncts
D. Invasive tracheal techniques;
- needle cricothyroidotomy
- cannula cricothyroidotomy
- surgical airways
In most cases senior help should be called
when plan A fails.
Plan D should be reserved for cannot ventilate
cannot intubate conditions with progressive
desaturation despite adequate oxygenation
attempt.
Difficult intubation with
difficult/impossible mask ventilation
1
-An emergency life threatening if not well managed.
-Insertion of LMA can rescue the airway in greater than
90% of cases.
Where oxygenation is not possible, plan D is life saving
technique and all anesthetists should be equipped and
prepared to perform plan D when ever required.
N.B But in case of Rapid sequence Induction after two
attempts of intubation, proceed directly to plan C/omit
plan B/ and wake the patient up.
ASA DIFFICULT AIRWAY ALGORITHM
Cont’d ...
Cont’d…
Can’t intubate …. Can’t ventilate/CICV
It is always a life-threatening condition.
It occurs in 1:5000 routine anesthetics.
It is more common in;
Emergency anesthesia
Intubation in the emergency department
After multiple attempts at intubation and
Inexperienced anesthetists
Immediate management;
• Call for help
• Attempt oxygenation by airway.
• Emergency oxygen flush
• Two man ventilation…CPAP
Cont’d…
• Rescue air way with insertion of LMA. Effective in
greater than 90% of cases
• If the patient is making spontaneous effort and
respiratory noise, maintain CPAP and 100%
oxygen until they awake.
• But if there is progressive desaturation with
above techniques consider emergency surgical air
way.
.
Cont’d…
Subsequent management
Emergency cricothyroidotomy
Speed is essential to prevent hypoxic cardiac arrest or brain
damage.
Extend the neck and simultaneously apply slight traction
bilaterally to neck tissues.
Find cricothyroid membrane b/n thyroid cartilage and cricoid
cartilage/.
Options are surgical and needle/cannula cricothyroidotomy.
Cannulla of less than 2.0 mm ID require jet ventilation
Catheters of greater than 4.0 mm ID allows conventional
ventilation
Special considerations;