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AIRWAY MANAGEMENT

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by

Christelle Botha

on 24 March 2014

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Transcript of AIRWAY MANAGEMENT

The Anticipated Difficult Airway
OXYGENATION
LMA

ETT
Endotracheal tube
Laryngeal mask airway
BMV
Bag Mask ventilation
Surgical airway
Asking 5 questions:

1. Does the airway need to be secured?
2. Is there a potential for difficult laryngoscopy?
3. Can supra-laryngeal ventilation be used?
4. Is the stomach empty?
5. Will the patient tolerate an apnaeic period?
1. Does the airway need to be secured?
Is the surgery essential?
Can it be done under regional?
What if the block fails?
What if the airway becomes compromised?

Can the case be done later?
Fasted
Assistance
2. Is there potential for difficult laryngoscopy?




23 y female. Elective LUSCS for twins.
Anaesthetic alert!
Previous Grade 3 with cholecystectomy
CMAC used with bougie
BMV easy with Guedel
Airway looks difficult

How would you proceed?
Predicting difficult AIRWAY

Why airway assessments?

"Failure to evaluate the airway and predict difficulty is the single most important factor leading to a failed airway" ASA closed claim database

Spontaneous ventilation
Regional
Airway assessment

ETT/LMA/BMV/Surgical airway

History
Notes
Careful questioning
Examination
Investigations
Nase-endoscopy
CT/MRI
Predictors difficult LARYNGOSCOPY

TM <6cm (PPV 40)
LMT neck extension <20 deg (PPV 30)
MO <3cm (PPV 25)
MP 3/4 (PPV 21)
Neck circ >44cm
Teeth (partial dentures, long upper incisors)
Pathological

(masses, congenital)
Predictors difficult BMV
Seal
Beard
Edentulous
BMI >26
Age >55
Airway obstruction
Snorer/OSA
Neck radiation
Facial abnormalities
Predictors difficult surgical airway

Neck
Flexed
FAT
Pathology
Tumor
Infection
Radiotherapy
Bleeding
Surgery
3. Can a supra-laryngeal technique be used?

Will I be able to ventilate the pt?

2. Is there potential for a difficult DL?
4. Is the stomach empty?
Awake technique
Surgical
Gas induction
2. Potential difficult ETT
3. LMA ventilation OK?

Awake technique
Surgical
Gas induction
5.Will the patient tolerate an apneic period?
2. Potential difficult DL?
3. LMA ventilation OK?
4. Empty stomach?
Awake technique
Surgical airway
Gas induction
1. ETT needed?
2. Potential difficult DL?
3. LMA ventilation OK?
4. Empty stomach?
5. Tolerate apneic period?
Proceed with routine induction of anaesthesia with LMA available
38 y female.
Admitted for MVR next day.
(Fasted)
MET call on ward for hypoxia, DIB
You are called to intubate for CTPA.
Vitals stable, Sats 92% HMO2.

How do you
proceed?
Options for expected difficult airway
Awake technique
AFOI
Awake laryngoscopy
Video LS
Blind nasal intubation
Awake tracheostomy
Gas induction
Double set up
Practice guidelines for management of the difficult airway: an updated report by the ASA task force on management of the difficult airway
Anesthesiology 2003
What if these bedside test are positive?
PPV increased in high risk group for difficult intubation
PPV increase if 2/> are positive
Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance.
Anesthesiology 2005
Careful!!

Degree of difficulty can change!
Pathology
Pregnancy
Labour
Time
Obesity/OSA
Predictors of difficult LMA
LMT MO <2cm
Abnormal anatomy
Laryngeal obstruction
Decreased chest compliance
Christelle Botha
Important!
PreO2 3min!
Have several back-up plans
If all else fails, remember
BMV
LMA
ETT
then
Surgical airway

Difficult airway
Conventionally trained anaesthetist experience difficulty with ventilation with BMV +/- difficult intubation

Impossible BMV 1/700
1/4 difficult intubation 1/2500

Unanticipated difficult airway
=
Difficult airway algorithms
DAS
Vortex
ASA
DAS
and

ASA
Starting point at intubation
What if SVGA and LMA fails?
Failed intubation
Placement of the ETT fails after:
>3 intubation attempts
> 2 experienced practitioners
>2 different blades
Optimum position
Optimum BURP
1/2500

CICO
Failed intubation
Difficult/impossible BMV
Increasing hypoxaemia
1-2/10 000
Difficult laryngoscopy
Inability to visualize any part of the vocal cords after multiple attempts at conventional laryngoscopy
Definitions...
Difficult intubation
Tracheal intubation requiring multiple attempts in the presence or absence of tracheal pathology
1-3/100
Vortex
Pros:
Simple
Applied to various clinical situations

Cons:
Clarify direction before starting
QUESTIONS?
SUMMARY

Use 5 questions as a cognitive tool:
Clinical context
Airway assessment

ANTICIPATED DIFFICULT AIRWAY


THANK YOU!
Full transcript