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Emergency Airway Emergency Airway ManagementManagement
Pat Melanson, MDPat Melanson, MD
Safe Safe airway airway managementmanagement
airway evaluationairway evaluation identification of the difficult airwayidentification of the difficult airway assessment of other clinical factorsassessment of other clinical factors selection of the likely most selection of the likely most
successful plan of actionsuccessful plan of action reasonable alternative planreasonable alternative plan
Algorithmic Approach to Airway Algorithmic Approach to Airway ManagementManagement
Have a precompiled plan of airway Have a precompiled plan of airway management ready for implementation management ready for implementation as clinical airway difficulties are as clinical airway difficulties are encounteredencountered
develop a plan and a back-up plandevelop a plan and a back-up plan Practice guidelines for management of Practice guidelines for management of
the difficult airwaythe difficult airway– ASA taskforceASA taskforce– Anesthesiology 78 : 597 - 602, 1993Anesthesiology 78 : 597 - 602, 1993
Emergency AirwayEmergency Airway full stomachfull stomach altered level of consciousnessaltered level of consciousness deteriorating cardiorespiratory deteriorating cardiorespiratory
physiologyphysiology abnormal or distorted upper abnormal or distorted upper
airway anatomyairway anatomy no time for pre-assessment or planno time for pre-assessment or plan
Airway AssessmentAirway Assessment
compromise or threatscompromise or threats potentially difficult airwaypotentially difficult airway
The Three Pillars of Airway The Three Pillars of Airway ManagementManagement
Patency ( airflow integrity )Patency ( airflow integrity )
Protection against aspirationProtection against aspiration
Assurance of oxygenation and Assurance of oxygenation and ventilationventilation
Indications for Active Indications for Active Airway InterventionAirway Intervention
Patency - relief of obstructionPatency - relief of obstruction Protection from aspirationProtection from aspiration Hypoxic/ hypercapnic respiratory Hypoxic/ hypercapnic respiratory
failurefailure Airway access for pulmonary toilet, Airway access for pulmonary toilet,
drug delivery,therapeutic drug delivery,therapeutic hyperventilationhyperventilation
ShockShock
Clinical Signs of Airway Clinical Signs of Airway
CompromiseCompromise : Patency : Patency
Inspiratory stridorInspiratory stridor Snoring ( pharyngeal obstruction )Snoring ( pharyngeal obstruction ) Gurgling ( foreign matter/ secretions )Gurgling ( foreign matter/ secretions ) Drooling ( epiglottitis )Drooling ( epiglottitis ) Hoarseness ( laryngeal edema/ vc Hoarseness ( laryngeal edema/ vc
paralysis)paralysis) Paradoxical chest wall movementParadoxical chest wall movement Tracheal tugTracheal tug
Clinical Signs of Airway Clinical Signs of Airway
Compromise :Compromise : Protection Protection
Blood in upper airwayBlood in upper airway Pus in upper airwayPus in upper airway persistant vomitingpersistant vomiting
Loss of protective airway reflexesLoss of protective airway reflexes
Clinical Signs of Airway Clinical Signs of Airway Compromise:Compromise:
Oxygenation and Oxygenation and VentilationVentilation
Central cyanosisCentral cyanosis Obtundation and diaphoresisObtundation and diaphoresis rapid shallow respirationsrapid shallow respirations Accessory muscle useAccessory muscle use RetractionsRetractions Abdominal paradoxAbdominal paradox
The Difficult AirwayThe Difficult Airway
Difficult laryngoscopyDifficult laryngoscopy
Difficult bag-mask ventilationDifficult bag-mask ventilation
Lower airway difficultyLower airway difficulty
Techniques for the Techniques for the Compromised AirwayCompromised Airway
Bag-Valve-Mask VentilationBag-Valve-Mask Ventilation Endotracheal IntubationEndotracheal Intubation Rapid Sequence IntubationRapid Sequence Intubation Alternate techniques for the Alternate techniques for the
difficult airwaydifficult airway
Golden Rules of BaggingGolden Rules of Bagging
“ “ Anybody (Anybody ( almost almost ) can be ) can be oxygenated and ventilated with a oxygenated and ventilated with a bag and a mask “bag and a mask “
The art of bagging should be The art of bagging should be mastered before the art of intubationmastered before the art of intubation
Manual ventilation skill with proper Manual ventilation skill with proper equipment is a fundamental premise equipment is a fundamental premise of advanced airway managementof advanced airway management
Frequent Errors with BVMFrequent Errors with BVM
failure to recognize its importancefailure to recognize its importance forget to bag ( focussed on ETT )forget to bag ( focussed on ETT ) give up on bagging too earlygive up on bagging too early bag but don’t assess efficacybag but don’t assess efficacy failure to assign one person to failure to assign one person to
airway management onlyairway management only
Difficult Airway : BVMDifficult Airway : BVM
Upper airway obstructionUpper airway obstruction Lack of denturesLack of dentures BeardBeard Midfacial smashMidfacial smash facial burns, dressings, scarringfacial burns, dressings, scarring poor lung mechanicspoor lung mechanics
Difficult Airway : BVMDifficult Airway : BVM degree of difficulty from zero to infinitedegree of difficulty from zero to infinite zero = no external effort/internal devicezero = no external effort/internal device one person jaw thrust/ face sealone person jaw thrust/ face seal oropharyngeal or nasopharyngeal AWoropharyngeal or nasopharyngeal AW two person jaw thrust / face sealtwo person jaw thrust / face seal
– both internal airway devicesboth internal airway devices infinite -no patency despite maximal infinite -no patency despite maximal
external effort and full use of OP/NPexternal effort and full use of OP/NP
Difficult Airway : BVMDifficult Airway : BVM
Remove FB - Magill forcepsRemove FB - Magill forceps Triple maneuver if c-spine clear Triple maneuver if c-spine clear
– Head tilt, jaw lift, mouth opening Head tilt, jaw lift, mouth opening
Nasopharyngeal or oropharyngeal Nasopharyngeal or oropharyngeal airwayairway
two-person, four-hand techniquetwo-person, four-hand technique
Prediction of the difficult Prediction of the difficult airway (Intubation)airway (Intubation)
1200 prospectively studied patients1200 prospectively studied patients of 84 patients predicted to have of 84 patients predicted to have
problem, only 22 (25%) actually had a problem, only 22 (25%) actually had a problemproblem
of 43 actual difficult intubations of 43 actual difficult intubations incurred, only 22 (51%) were predictedincurred, only 22 (51%) were predicted
– Latto IP. and Rosen MLatto IP. and Rosen M
Prediction of the difficult Prediction of the difficult airwayairway
history of past airway problems history of past airway problems Careful physical assessmentCareful physical assessment knowledge and experience to knowledge and experience to
overcome the "unpredicted difficult overcome the "unpredicted difficult airway". airway".
learning practical airway management learning practical airway management skills in an environment that is not skills in an environment that is not urgent, stressful or life threateningurgent, stressful or life threatening
Difficult Airway : Difficult Airway : LaryngoscopyLaryngoscopy
Short thick neckShort thick neck Receding mandibleReceding mandible Buck teethBuck teeth Poor mandibular mobility/ limited Poor mandibular mobility/ limited
jaw openingjaw opening Limited head and neck movement Limited head and neck movement
– ( including trauma )( including trauma )
Difficult Airway : Difficult Airway : LaryngoscopyLaryngoscopy
Tumor, abscess or hematomaTumor, abscess or hematoma BurnsBurns Angioneurotic edemaAngioneurotic edema Blunt or penetrating traumaBlunt or penetrating trauma Rheumatoid arthritis, ankylosing Rheumatoid arthritis, ankylosing
spondylitisspondylitis Congenital syndromesCongenital syndromes Neck surgery or radiationNeck surgery or radiation
Difficult Airway : Difficult Airway : LaryngoscopyLaryngoscopy
3 fingerbreadths mentum to hyoid3 fingerbreadths mentum to hyoid 3 fb chin to thyroid notch3 fb chin to thyroid notch 3 fb upper to lower incisors3 fb upper to lower incisors Head extension and neck flexionHead extension and neck flexion Mallimpadi classificationMallimpadi classification Previous history of difficult Previous history of difficult
intubationintubation
Mallimpadi Classification Mallimpadi Classification ( Tongue to Pharyngeal ( Tongue to Pharyngeal
Size )Size )
I - soft palate, uvula, tonsillar I - soft palate, uvula, tonsillar pillarspillars– 99 % have grade I laryngoscopic view99 % have grade I laryngoscopic view
II - soft palate, uvulaII - soft palate, uvula III - soft palate, base of uvulaIII - soft palate, base of uvula IV - soft palate not visibleIV - soft palate not visible
– 100% grade III or grade IV views100% grade III or grade IV views
Unsuccessful IntubationUnsuccessful Intubation Bag the patientBag the patient Maximize neck flexion/ head extensionMaximize neck flexion/ head extension Move tongue out of line of siteMove tongue out of line of site Maximize mouth openingMaximize mouth opening Look for landmarks and adjust bladeLook for landmarks and adjust blade BURP maneuverBURP maneuver increasing lifting forceincreasing lifting force consider Miller bladeconsider Miller blade Bag the patientBag the patient
Dilemmas:Dilemmas:
Awake or AsleepAwake or Asleep Oral or NasalOral or Nasal Laryngoscopy or Blind IntubationLaryngoscopy or Blind Intubation To Paralyze or NotTo Paralyze or Not
Case #1Case #1
43 year old female, day 12 post SAH43 year old female, day 12 post SAH 5 unclipped cerebral aneurysms5 unclipped cerebral aneurysms vasospasm with left hemiparesisvasospasm with left hemiparesis hydrocephalus with clotted IV drainhydrocephalus with clotted IV drain rising ICP and BPrising ICP and BP decreasing LOCdecreasing LOC ate breakfastate breakfast
TechniquesTechniques
DL without pharmacologic aidsDL without pharmacologic aids Awake Direct LaryngoscopyAwake Direct Laryngoscopy Awake Blind NasalAwake Blind Nasal Rapid Sequence Intubation (RSI)Rapid Sequence Intubation (RSI) Fiberoptic Fiberoptic Surgical CricothyroidotomySurgical Cricothyroidotomy
Anesthesia Airway MaximsAnesthesia Airway Maxims
the awake airway is the safest to the awake airway is the safest to managemanage
spontaneous breathing is generally spontaneous breathing is generally safer than paralysis with PPV by safer than paralysis with PPV by maskmask
have a low threshold to wake the have a low threshold to wake the patient up and cancel the casepatient up and cancel the case
call for help earlycall for help early
The “Intubation Reflex “The “Intubation Reflex “
Catecholamine release in response to Catecholamine release in response to laryngeal manipulationlaryngeal manipulation
Tachycardia, hypertension, raised ICPTachycardia, hypertension, raised ICP Attenuated by beta-blockers, fentanylAttenuated by beta-blockers, fentanyl ICP rise possibly attenuated by lidocaineICP rise possibly attenuated by lidocaine Midazolam and thiopental have no effectMidazolam and thiopental have no effect
Rapid Sequence Intubation Rapid Sequence Intubation ::
DefinitionDefinition
The near simultaneous administration The near simultaneous administration of a sedative-hypnotic agent and a of a sedative-hypnotic agent and a neuromuscular blocker in the neuromuscular blocker in the presence of continuous cricoid presence of continuous cricoid pressure to facilitate endotracheal pressure to facilitate endotracheal intubation and minimize risk of intubation and minimize risk of aspirationaspiration
modifications are made depending modifications are made depending upon the clinical scenarioupon the clinical scenario
Rapid Sequence Intubation Rapid Sequence Intubation ::
AdvantagesAdvantages
Optimizes intubating conditions/ Optimizes intubating conditions/ facilitates visualizationfacilitates visualization
Increased rate of successful Increased rate of successful intubationintubation
Decreased time to intubationDecreased time to intubation Decreased risk of aspirationDecreased risk of aspiration Attenuation of hemodynamic and Attenuation of hemodynamic and
ICP changesICP changes
Rapid Sequence Intubation Rapid Sequence Intubation ::
ContraindicationsContraindications
Anticipated difficulty with Anticipated difficulty with endotracheal intubationendotracheal intubation– anatomic distortionanatomic distortion
Lack of operator skill or familiarityLack of operator skill or familiarity inability to preoxygenateinability to preoxygenate
Rapid Sequence Intubation Rapid Sequence Intubation ::
ProcedureProcedure
Pre-intubation assessmentPre-intubation assessment Pre-oxygenatePre-oxygenate Prepare ( for the worst )Prepare ( for the worst ) PremedicatePremedicate ParalyzeParalyze Pressure on cricoidPressure on cricoid Place the tubePlace the tube Post intubation assessmentPost intubation assessment
Pre-oxygenate Pre-oxygenate ( Time - 5 Minutes) ( Time - 5 Minutes)
100 % oxygen for 5 minutes100 % oxygen for 5 minutes 4 conscious deep breaths of 100 % O24 conscious deep breaths of 100 % O2 Fill FRC with reservoir of 100 % O2Fill FRC with reservoir of 100 % O2 Allows 3 to 5 minutes of apneaAllows 3 to 5 minutes of apnea Essential to allow avoidance of Essential to allow avoidance of
baggingbagging If necessary bag with cricoid pressureIf necessary bag with cricoid pressure
Preparation Preparation ( Time - 5 Minutes ) ( Time - 5 Minutes )
ETT, stylet, blades, suction, BVMETT, stylet, blades, suction, BVM Cardiac monitor, pulse oximeter, Cardiac monitor, pulse oximeter,
ETCO2ETCO2 One ( preferably two ) iv linesOne ( preferably two ) iv lines DrugsDrugs Difficult airway kit including cric kitDifficult airway kit including cric kit Patient positioningPatient positioning
Pre-treatment/ Prime Pre-treatment/ Prime ( Time - 2 ( Time - 2
Minutes )Minutes )
Lidocaine 1.5 mg/kg ivLidocaine 1.5 mg/kg iv Defasciculating dose of non-depolarizing Defasciculating dose of non-depolarizing
NMBNMB Beta-blocker or fentanylBeta-blocker or fentanyl Induction agentInduction agent
– Thiopental 3 - 5 mg/kgThiopental 3 - 5 mg/kg– Midazolam 0.1 - 0.4mg/kgMidazolam 0.1 - 0.4mg/kg– Ketamine 1.5 - 2.0 mg/kgKetamine 1.5 - 2.0 mg/kg– Fentanyl 2 - 30 mcg/kgFentanyl 2 - 30 mcg/kg
Paralyze ( Time Zero )Paralyze ( Time Zero )
Succinylcholine 1.5 mg/kg ivSuccinylcholine 1.5 mg/kg iv Allow 45 - 60 seconds for complete Allow 45 - 60 seconds for complete
muscle relaxationmuscle relaxation AlternativesAlternatives
– Vecuromium 0.1 - 0.2 mg/kgVecuromium 0.1 - 0.2 mg/kg– Rocuronium o.6 - 1.2 mg/kgRocuronium o.6 - 1.2 mg/kg
PressurePressure
Sellick maneuverSellick maneuver initiate upon loss of consciousnessinitiate upon loss of consciousness continue until ETT balloon inflationcontinue until ETT balloon inflation release if active vomitingrelease if active vomiting
Place the Tube Place the Tube ( Time Zero + 45 Secs ) ( Time Zero + 45 Secs )
Wait for optimal paralysisWait for optimal paralysis Confirm tube placement with Confirm tube placement with
ETCO2ETCO2
Post-intubation Post-intubation HypotensionHypotension
Loss of sympathetic driveLoss of sympathetic drive Myocardial infarctionMyocardial infarction Tension pneumothoraxTension pneumothorax Auto-peepAuto-peep
Succinylcholine Succinylcholine : : ContraindicationsContraindications
Hyperkalemia - renal failureHyperkalemia - renal failure Active neuromuscular disease with Active neuromuscular disease with
functional denervation ( 6 days to 6 functional denervation ( 6 days to 6 months)months)
Extensive burns or crush injuriesExtensive burns or crush injuries Malignant hyperthermiaMalignant hyperthermia Pseudocholinesterase deficiencyPseudocholinesterase deficiency Organophosphate poisoningOrganophosphate poisoning
Succinylcholine : Succinylcholine : ComplicationsComplications
Inability to secure airwayInability to secure airway Increased vagal tone ( second dose )Increased vagal tone ( second dose ) Histamine release ( rare )Histamine release ( rare ) Increased ICP/ IOP/ intragastric Increased ICP/ IOP/ intragastric
pressurepressure MyalgiasMyalgias Hyperkalemia with burns, NM diseaseHyperkalemia with burns, NM disease malignant hyperthermiamalignant hyperthermia
Difficult Airway KitDifficult Airway Kit
Multiple blades and ETTsMultiple blades and ETTs ETT guides ( stylets, bougé, light wand)ETT guides ( stylets, bougé, light wand) Emergency nonsurgical ventilation Emergency nonsurgical ventilation
( LMA, combitube, TTJV ) ( LMA, combitube, TTJV ) Emergency surgical airway access Emergency surgical airway access
( cricothyroidotomy kit, cricotomes ) ( cricothyroidotomy kit, cricotomes ) ETT placement verificationETT placement verification Fiberoptic and retrograde intubation Fiberoptic and retrograde intubation
Emergency Surgical Emergency Surgical Airway MaximsAirway Maxims
they are usually a bloody mess, they are usually a bloody mess, but ...but ...
a bloody surgical airway is better a bloody surgical airway is better than an arrested patient with a than an arrested patient with a nice looking necknice looking neck
Case # 2Case # 2
42 year old female42 year old female right Pancoast tumorright Pancoast tumor RUL, RML, RLL collapseRUL, RML, RLL collapse ARDS on leftARDS on left hypoxemic respiratory failurehypoxemic respiratory failure cord compression C7 - T4cord compression C7 - T4
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