difficult airway managemnt
TRANSCRIPT
Difficult Airway Management
2009
Adrian Sieberhagen
• Clinical situation in which there is difficulty in Face Mask Ventilation and inability to intubate
What makes it difficult in ED’s
• Training/requirements
• Non-controlled setting
• Limited pre-procedural evaluation
• Hypoxia, hypotension, agitation, dynamic medical conditions
• Numerous logistical & implementation issues
Predicting the Difficult Airway
• History
• Physical Examination
History
Cormack and Lehane
• Class I: the vocal cords are visible
• Class II the vocals cords are only partly visible
• Class III only the epiglottis is seen
• Class IV the epiglottis cannot be seen.
• Pregnancy• Inflammatory Disease• Small mouths• Infections• Endocrine• Congenital• Trauma• Foreign Body• Tumours
Examination
LEMON
• Look for external deformities
• Evaluate 3-3-2 rule
• Mallampati
• Obstruction
• Neck Mobility
Mallampati Score
• Class I– visualization of the soft palate,
fauces, uvula, and both anterior and posterior pillars
• Class II– visualization of the soft palate,
fauces, and uvula
• Class III– visualization of the soft palate
and the base of the uvula
• Class IV– soft palate is not visible at all
• Thyromental Distance• 6.5cm normal
• Sternomental Distance• >12.5cm normal
• Protrusion of Mandible
Management
• Prearranged Emergency airway trolley available
• Most senior staff
Emergency Airway Trolley
• Rigid laryngoscope blades• Tracheal tubes• Tracheal tube guides• Laryngeal Mask Airways• Fibreoptic intubation equipment• Non-invasive/minimally invasive airways• Surgical Airway• CO2 detectors
Management
• Prearranged Emergency airway trolley available
• Most senior staff
• Emergency airway algorithm
• Deliver supplemental O2
Alternative Airway Techniques
• LMA/Laryngeal Tube
• Transtracheal Jet Ventilation
• Fibreoptic Intubation
• Retrograde Intubation
• Lightwand
• Combitube
• Surgical Airway
Laryngeal Mask
• Lubricated LMA inserted into hypopharynx• Tip in upper oesophogeal sphincter• Inflate Cuff• Muscle relaxants not necessary• C/I:
– Need for high Peak Pressures– Risk of Aspiration– Pts with low lung compliance
Laryngeal Tube
Transtracheal Jet Insuflation
Fibreoptic Intubation
Retrograde Intubation
• Place guidewire through cricothyroid membrane
• Guidewire passes cephalad through pharynx and out mouth/nose
• Railroad ET tube
Lightwand
• Flexible
• Inserted through ET tube
• Insert into larynx
• Light dims if entering oesophagus
• Limitations: Dark room
Combitube
• Double lumen tube• Placed into hypopharynx blindly• C/I
– Oesophageal pathology
Surgical Airway
• Cricothyroidotomy– Complications:
• Bleeding• Infection• Vocal cord damage• Tracheal stenosis
– C/I• <12yrs• Laryngotracheal Disruption• Coagulopathy
The End