The Difficult Airway. The Difficult Airway. Difficult Airway Algorithms: ASA. Ectopic Anesthesia. Cancel Case. Awaken. airway. Defining ng the problem

The Difficult Airway

The Difficult Airway

Robert J. Vissers, MD FACEP Department of Emergency Medicine

Legacy, Emanuel Hospital

Robert J. Vissers, MD FACEP

Robert J. Vissers, MD FACEP Department of Emergency Medicine Department of Emergency Medicine

Legacy, Emanuel Hospital Legacy, Emanuel Hospital

The Difficult Airway

The Difficult Airway

ŠDefining the problem

ŠDefining the difficult airway

ŠIdentifying the difficult airway

ŠManaging the difficult airway

Š

ŠDefiDef

i

nin

i

ng the problemng the problem Š

ŠDefiDef

i

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ng the ding the d

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ffiff

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cult aicult a

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rwayrway Š

ŠIdIdentent

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fyfy

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ng the dng the d

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ffff

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cult acult a

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ŠManagiManag

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Difficult Airway Algorithms: ASA

Difficult Airway Algorithms: ASA

Fig 1ASA DIFFICULT AIRWAY ALGORITHM Anesthesiology 1996;84:686

A

Fig 1ASA DIFFICULT AIRWAY ALGORITHM Anesthesiology 1996;84:686 A

Cancel Case

Ectopic Anesthesia

Ectopic Anesthesia

Problem: ŠUrgency ŠCost of failure

ŠFormula for error

Problem: Problem: Š

ŠUrgencyUrgency Š

ŠCost of failure Cost of failure Š

2

Emergency Airway

Management

Emergency Airway

Management

Solution: ŠPreparation ŠAnticipate difficulties

ŠSimple, consistent, reproducible approach Solution: Solution: Š ŠPreparationPreparation Š

ŠAnticipate difficulties Anticipate difficulties Š

ŠSimple, consistent, reproducible Simple, consistent, reproducible approach

approach

Difficult Airway Algorithms

Difficult Airway Algorithms

Common principles

ŠAssessment of ventilation difficulty

ŠAssessment of intubation difficulty

ŠAwake vs. induction and paralysis

ŠCalling for help

ŠSurgical airway is a potential endpoint

Common principles Common principles

Š

ŠAssessment of ventilation difficultyAssessment of ventilation difficulty Š

ŠAssessment of intubation difficultyAssessment of intubation difficulty Š

ŠAwake vs. induction and paralysisAwake vs. induction and paralysis Š

ŠCalling for helpCalling for help Š

ŠSurgical airway is a potential endpointSurgical airway is a potential endpoint

Decision to intubate Near death? Unresponsive? Difficult Airway? Rapid Sequence Intubation Failed Airway Difficult Airway Techniques Crash Airway

Adapted from: Walls RM, Ed. The Manual of Emergency Airway ManagementPhiladelphia, Lippincott, 2000. Approach to the

Emergency Airway

_{Decision to Intubate}

_{Decision to Intubate}

ŠAirway maintenance ŠOxygenation ŠVentilation ŠFacilitate therapy ŠExpected course Š

ŠAirway maintenanceAirway maintenance Š

ŠOxygenationOxygenation Š

ŠVentilationVentilation Š

ŠFacilitate therapyFacilitate therapy Š

ŠExpected courseExpected course

Decision to intubate

Decision to Intubate: Modifiers

Decision to Intubate: Modifiers

ŠOperator experience

ŠSetting

ŠPotential for a difficult airway

Never take away what you cannot replace

Š

ŠOperator experienceOperator experience Š

ŠSetting Setting Š

ŠPotential for a difficult airwayPotential for a difficult airway

Never take away what you cannot replace Never take away what you cannot replace

National Emergency Airway

Registry (NEAR)

National Emergency Airway

Registry (NEAR)

ŠProspective airway registry n = 12,000

Š<1% fail rate with RSI

ŠCricothyrotomy rate 0.6%

ŠNo cases of “cannot intubate, cannot ventilate”with death

Š

ŠProspective airway registry n = 12,000Prospective airway registry n = 12,000 Š

Š<1% fail rate with RSI<1% fail rate with RSI Š

ŠCricothyrotomy rate 0.6% Cricothyrotomy rate 0.6% Š

ŠNo cases of No cases of ““cannot intubate, cannot cannot intubate, cannot ventilate

ventilate””with deathwith death

The Difficult Airway

The Difficult Airway

DIFFICULT BAG AND MASK VENTILATION

DIFFICULT LARYNGOSCOPY AND INTUBATION DIFFICULT DIFFICULT CRICOTHYROTOMY CRICOTHYROTOMY

4

The Difficult Airway

The Difficult Airway

DIFFICULT BAG

AND MASK VENTILATION

DIFFICULT LARYNGOSCOPY AND INTUBATION DIFFICULT CRICOTHYROTOMY “SAKLES’ TRIANGLE”

Assessment of Difficult BVM

Assessment of Difficult BVM

Assessment of Difficult BVM

Assessment of Difficult BVM

ŠConsider potential difficulty of BVM

ventilation before RSI

ŠBeware the full stomach

ŠEquipment out and ready

ŠFive predictors of difficult BVM: facial hair, obesity, adentulous, elderly, snoring *

Š

ŠConsider potential difficulty of BVM Consider potential difficulty of BVM ventilation

ventilation beforebeforeRSIRSI Š

ŠBeware the full stomachBeware the full stomach Š

ŠEquipment out and readyEquipment out and ready Š

ŠFive predictors of difficult BVM: facial Five predictors of difficult BVM: facial hair, obesity,

hair, obesity, adentulousadentulous, elderly, , elderly, snoring snoring ** *Langeron O, et al. Anesthesiology, 2000.

Assessment of Difficult BVM:

Bones

Assessment of Difficult BVM:

Bones

M

ask seal

O

besity/obstruction

A

ge > 55

N

o teeth

S

tiff lungs

M

M

ask seal

ask seal

O

O

besity

besity

/obstruction

/obstruction

A

A

ge

ge

> 55

> 55

N

N

o teeth

o teeth

S

The Difficult Airway

The Difficult Airway

DIFFICULT BAG AND MASK VENTILATION

DIFFICULT LARYNGOSCOPY AND INTUBATION DIFFICULT CRICOTHYROTOMY “SAKLES’ TRIANGLE”

Assessment of Difficult

Intubation

Assessment of Difficult

Intubation

ŠLaryngoscopic view (Cormack-Lehane) – too late

ŠSystems too complex, impractical

ŠNeed simple, fast approach

Š

ŠLaryngoscopicLaryngoscopicview (Cormackview (Cormack--LehaneLehane) )

–

– too latetoo late Š

ŠSystems too complex, impracticalSystems too complex, impractical Š

6

Difficult Airway…?

“

“LEMON”

LEMON

”

Law

Law

L

ook externally

E

xamine (3-3-2)

M

allampati grade

O

bstruction

N

eck mobility

L

L

ookookexternallyexternally

E

E

xaminexamine(3(3--33--2)2)

M

M

allampatiallampatigradegrade

O

O

bstructionbstruction

N

N

eckeckmobilitymobility

Cognitive forcing strategies in clinical decisionmaking. P Croskerry. Ann Emerg Med Jan, 2003. Adapted from: Walls RM, Ed. The Manual of Emergency Airway Management

Philadelphia, Lippincott, 2000.

LEMON: Look

L

EMON: Look

Simple visual inspection often reveals obvious potential difficulties

Simple visual inspection often reveals Simple visual inspection often reveals

obvious potential difficulties obvious potential difficulties

LEMON: Examine 3-3-2

L

E

MON: Examine 3-3-2

Assess oral opening - 3 fingers Measure the mandible - 3 fingers

Position of larynx - 2 fingers

Assess oral opening

Assess oral opening --3 fingers3 fingers Measure the mandible

Measure the mandible --3 fingers 3 fingers Position of larynx

Position of larynx --2 fingers 2 fingers

LEMON: Examine 3-3-2

L

E

MON: Examine 3-3-2

Assess oral opening – should be able to accommodate 3 fingers Assess oral Assess oral opening opening –– should be able should be able to to accommodate accommodate 3 fingers 3 fingers

LEMON: Examine 3-3-2

L

E

MON: Examine 3-3-2

Measure the mandible - should be able to fit 3 fingers between the mentum and the hyoid bone

Measure the Measure the mandible

mandible --should should be able to fit 3 be able to fit 3 fingers between fingers between the

the mentummentumand and the hyoid bone the hyoid bone

8

LEMON: Examine 3-3-2

L

E

MON: Examine 3-3-2

Assess position of larynx – should get 2 fingers between the thyroid cartilage and the mandible

Assess position of Assess position of larynx

larynx ––should should get 2 fingers get 2 fingers between the between the thyroid cartilage thyroid cartilage and the mandible and the mandible

Class I Class IV Class II Class III

LEMON: Mallampati

LE

M

ON: Mallampati

LEMON: Obstruction?

LEM

O

N: Obstruction?

1) Location? 2) Fixed or mobile? 3) Speed of progression? 1) Location? 1) Location? 2) Fixed or mobile? 2) Fixed or mobile? 3) Speed of progression? 3) Speed of progression?

10

LEMON: Neck Mobility

LEMO

N

: Neck Mobility

ŠCan the patient flex and extend the neck?

ŠActively assess in the non-trauma obtunded patient.

ŠCervical spine immobilization - remove anterior collar while c-spine is

immobilized.

Š

ŠCan the patient flex and extend the Can the patient flex and extend the neck?

neck? Š

ŠActively assess in the nonActively assess in the non--trauma trauma obtunded patient.

obtunded patient. Š

ŠCervical spine immobilization Cervical spine immobilization --remove remove anterior collar while c

anterior collar while c--spine is spine is immobilized.

“

LEMON

”

Law

“LEMON”

Law

L

ook externally

E

xamine (3-3-2)

M

allampati grade

O

bstruction

N

eck mobility

L

L

ookookexternallyexternally

E

E

xaminexamine(3(3--33--2)2)

M

M

allampatiallampatigradegrade

O

O

bstructionbstruction

N

N

eckeckmobilitymobility

LEMON: Predictive?

LEMON: Predictive?

Š 156 ED patients requiring intubation Š Scored using LEMON

Š Simple point system used (0 to 10)

Š Compared to laryngoscopic view (Cormack –Lehane)

Š Felt to be predictive, P<0.05 Š

Š 156 ED patients requiring intubation156 ED patients requiring intubation

Š

Š Scored using LEMONScored using LEMON

Š

Š Simple point system used (0 to 10)Simple point system used (0 to 10)

Š

Š Compared to Compared to laryngoscopiclaryngoscopicview (Cormack view (Cormack

–

–LehaneLehane))

Š

12

LEMON: Predictive?

LEMON: Predictive?

Š Reed MJ et al. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 2005 Feb; 22:99-102.

Š

Š Reed MJ et al. Can an airway assessment score predict Reed MJ et al. Can an airway assessment score predict difficulty at intubation in the emergency department? difficulty at intubation in the emergency department? EmergEmerg

Med J

Med J2005 Feb; 22:992005 Feb; 22:99--102. 102.

Airway

alternatives

Airway

alternatives

BVM Intubating LMA® Lightwand Glidescope Fiberoptics Bougie Combitube King-LT TTJV Cricothyrotomy Zone of Increasing Sphincter Tone Supraglottic: Infraglottic: ZIST Nasal BNTI Fiberoptics

Rescue Devices

Rescue Devices

ŠMost require oral access

ŠMost are designed to deal with high anterior cords

ŠI-LMA, King-LT, Combitube

ŠIntubating stylet (bougie, frova, etc.)

ŠVideo - glidescope

Š

ŠMost require oral accessMost require oral access

Š

ŠMost are designed to deal with high Most are designed to deal with high anterior cords

anterior cords

Š

ŠII--LMA, KingLMA, King--LT, LT, CombitubeCombitube

Š

ŠIntubatingIntubatingstyletstylet((bougiebougie, , frovafrova, etc.), etc.)

Š

ŠVideo Video --glidescopeglidescope

Combitube

Combitube

King-LT

14

Video Laryngoscopy

Video Laryngoscopy

LMA CTrach

LMA CTrach

Glidescope

Glidescope

Pediatric Asthmatic

Pediatric Asthmatic

ŠBeginning to fatigue ŠSats dropping ŠNeeds to be intubated Š

ŠBeginning to fatigueBeginning to fatigue

Š

ŠSatsSatsdroppingdropping

Š

ŠNeeds to be Needs to be intubatedintubated

Preoxygenation: Desaturation

Preoxygenation: Desaturation

From: Benumof JL: Anesthesiology 87:979-982, 1997.

3.4 mL/kg/min 6 mL/kg/min

Preoxygenation: Desaturation

Preoxygenation: Desaturation

16

Awake look/scopes

Awake look/scopes

ŠAntisyalogogue – atropine or glycopyrrolate ŠAnesthesia – lidocaine (2-4%), benzocaine

ŠDecongestant – oxymetazoline (afrin)

ŠNebulize, atomize (MADgic®), viscous

ŠSedation – ketamine, versed

Š

ŠAntisyalogogueAntisyalogogue––atropine or atropine or glycopyrrolate

glycopyrrolate

Š

ŠAnesthesia Anesthesia –– lidocainelidocaine(2(2--4%), 4%), benzocaine

benzocaine

Š

ŠDecongestant Decongestant ––oxymetazolineoxymetazoline((afrinafrin))

Š

ŠNebulizeNebulize, atomize (, atomize (MADgicMADgic®®), viscous), viscous

Š

ŠSedation Sedation –– ketamineketamine, versed, versed

Agitated Burn Case

Agitated Burn Case

42-year-old woman set herself on fire in her car.

Uncooperative, yelling “let me die”. 70-80% burns, mostly 3°, to face, trunk,

anterior arms and thighs. Unable to get a BP or O2 sat.

42

42--yearyear--old woman set herself on fire in old woman set herself on fire in her car.

her car. Uncooperative, yelling

Uncooperative, yelling ““let me dielet me die””. . 70

70--80% burns, mostly 380% burns, mostly 3°°, to face, trunk, , to face, trunk, anterior arms and thighs.

anterior arms and thighs. Unable to get a BP or O2 sat. Unable to get a BP or O2 sat.

Intubating Stylet/Bougie

Intubating Stylet/Bougie

Clinical Issues: Agitated Patient

Clinical Issues: Agitated Patient

ŠAssessment of the difficult airway – beware ego, fear, urgency

ŠThe agitated or violent trauma patient

ŠHaldol, Droperidol, Midazolam, Ketamine

Š

ŠAssessment of the difficult airway Assessment of the difficult airway –– beware ego, fear, urgency

beware ego, fear, urgency Š

ŠThe agitated or violent trauma patientThe agitated or violent trauma patient Š

ŠHaldolHaldol, , DroperidolDroperidol, , MidazolamMidazolam, , Ketamine

Ketamine

Oh, nuts…

Oh, nuts…

Š 5 yo girl, choked on peanuts last night Š Unable to sleep,

trouble breathing Š Looks tired, resp

distress, tripod Š

Š 5 5 yoyogirl, choked on girl, choked on peanuts last night

peanuts last night

Š

Š Unable to sleep, Unable to sleep, trouble breathing

trouble breathing

Š

Š Looks tired, Looks tired, respresp

distress, tripod

18

Airway

alternatives

Airway

alternatives

BVM Intubating LMA® Lightwand Glidescope Fiberoptics Bougie Combitube King-LT TTJV Cricothyrotomy Zone of Increasing Sphincter Tone Supraglottic: Infraglottic: ZIST Nasal BNTI Fiberoptics

No landmarks?

No landmarks?

ŠThe tongue is your friend – find it and follow it to the glottis

ŠSuction, suction, suction…

Š4-finger rule for the cricothyroid membrane

Š

ŠThe The tonguetongueis your friend is your friend ––find it and find it and follow it to the glottis

follow it to the glottis Š

ŠSuctionSuction, suction, suction, suction, suction…… Š

Š44--finger rulefinger rulefor the cricothyroid for the cricothyroid membrane

membrane

Cricothyroid membrane

under the 4

th

_finger

Cricothyroid membrane

20

Consider surgical airway early

Consider surgical airway early

Summary

Summary

ŠOrganized, rapid, simple approach

ŠAssess for difficult ventilation BONES

ŠAssess for difficult intubation LEMON

Š

ŠOrganized, rapid, simple approachOrganized, rapid, simple approach Š

ŠAssess for difficult ventilationAssess for difficult ventilation BONES

BONES Š

ŠAssess for difficult intubationAssess for difficult intubation LEMON

Obese asthmatic

Obese asthmatic