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Difficult Airway Management. Airway management is really easy…. Except when it isn’t. DEFFINATION. Difficult Intubation is: Failure to intubate with conventional laryngoscopy after an optimal/best attempt with: Reasonable experienced laryngoscopist No significant resistive muscle tone
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Airway management is really easy…. Except when it isn’t
DEFFINATION Difficult Intubation is: Failure to intubate with conventional laryngoscopy after an optimal/best attempt with: • Reasonable experienced laryngoscopist • No significant resistive muscle tone • Use of optimal sniffing position • Use of external laryngeal manipulation • Change of laryngoscope balde type a single time, and • Change of laryngoscope balde length a single time
prevalence Failed tracheal intubation 0.05 – 0.35 % Failed tracheal intubation with inadequate mask ventilation 0.01 – 0.03 % This is in OR when: • Plan in advance • Can’t get airway .. awaken patient .. Regroup • go for coffee
What makes it difficult in emergency situation • Training/requirements • Non-controlled settings • Limited pre-procedural evaluation • Hypoxia, hypotension, agitation, dynamic medical conditions • Numerous logistical & implementation issues
Most of ourpatients are already “difficult airways” by “OR” Standards.
The American Society of Anesthesiology (ASA) has noted: • “there is strong agreement among consultants that preparatory efforts enhance success and minimize risk” • And“The literature provides strong evidence that specific strategies facilitate the management of the difficult airway” • Thusidentifying a potentially difficult airway is essential to preparation and developing a strategy.
We will not talk about • The basic anatomy of the Airway • BLS airway maneuvers and Endotracheal Intubation by Oral and Nasal means • The concept and procedure of RSI
Airway Evaluation Past Medical History • Decreased cervical mobility • Anatomic upper airway abnormalities • History of Previous Problems in surgery
Airway Evaluation • Predictors of difficult mask ventilation “BONES”: • (two or more) • Beard • Obesity with BMI > 26 • No teeth • Elderly > 55 • Snorers
Airway Evaluation • Dr.Binnions LEMON Law: An easy way to remember multiple tests • Look externally • Evaluate 3-3-2 rule • Mallampati • Obstructions • Neck mobility
Airway Evaluation • LEMON Law -Look externally • Obesity or very small. • Short Muscular neck • Large breasts • Prominent Upper Incisors (Buck Teeth) • Receding Jaw (Dentures) • Burns • Facial Trauma • S/S of Anaphylaxis • Stridor
Airway Evaluation • LEMON Law - Evaluate 3-3-2 rule • Mouth opening ≥ 3 fingers • Tip of the chin to the hyoid bone ≥ 3 fingers • Hyoid bone to the top of the thyroid cartilage ≥ 2 fingers
Airway Evaluation LEMON Law –Mallampati (difficult directlaryngoscopyCormack & Lehane grading)
Airway Evaluation • LEMON Law -Obstructions • Blood • Vomitus • Teeth • Tumers • Epiglotitis
Airway Evaluation • LEMON Law -Neck mobility • Prior condition • Surgery • Rheumatoid arthritis • Osteoarthritis • Others
Airway Rescue Tools • Bag valve mask • Combitube • LMA • Intubation LMA • Fiberoptic: rigid, flexible • Lightwand • Bougie • Transtracheal jet • Retrograde • Cricothyrotomy • Tracheostomy
Nasopharyngeal&OropharyngealAirways COPA – Cuffed Oral-pharynageal Airway
CL (Corazelli-London) Flexible Tip Laryngoscope Flexible Tip Laryngoscope Flexiblade
Cricoid pressure vs External Laryngeal Manipulation BURPbackwardsupwardsright pressure
