Some Interesting Airway Cases

1. Some Interesting Airway Cases D. John Doyle MD PhD Cleveland Clinic Foundation

2. Case 1

3. Case 1 Trauma Image Bank

5. Endotrol ETT

6. The Glidescope is a video laryngoscope with a TV camera built into the blade. The views obtained can be quite striking, as with the case shown below. Microminiature TV camera and dual LED light source integrated into the laryngoscope blade Case 112

7. ETT Position Confirmation Devices

8. Portable Capnograph

9. Easy Cap Disposable End-tidal CO2 Detector Changes color from purple to yellow with expired CO2

10. Ambu Tubecheck - Bulb Model

11. Case 2

12. Case 2

13. Retrograde Intubation

14. Description: This technique utilizes a wire passed retrograde from a puncture in the cricothyroid membrane to the mouth to allow passage of an endotracheal tube into the trachea. Advantages: Placement of the wire through the cricothyroid membrane should ensure passage of the endotracheal tube into the trachea. Does not require visualization of the larynx. May be performed rapidly by skilled practitioner. Disadvantages: May cause bleeding in the airway. The endotracheal tube may not pass easily into the larynx, even when the wire is correctly passed. This may occur when the endotracheal tube engages the epiglottis or the glottic cartilaginous structures. It may also occur if the wire kinks or bends during attempted passage of the endotracheal tube. http://www.gasnet.org/airway/opt10.htm

16. http://www.anes.med.umich.edu/intubation/images/topical1.jpg

17. http://www.anes.med.umich.edu/intubation/images/tracheal_injection.jpghttp://www.anes.med.umich.edu/intubation/images/tracheal_injection.jpg

18. Waters DJ. Guided blind endotracheal intubation for patients with deformities of the upper airway." Anaesthesia 1963;18:158-62 (Original description from Nigeria). Sanchez, Tony F. Retrograde intubation. Anesthesiology Clinics of North America 1995 Jun; 13(2):439-450.

19. Synopsis of Retrograde Intubation www.biodigital.org/voz2/W3M.htm www.metrohealthanesthesia.com/edu/airway/retrograde.htm

20. Retrograde Nasal Intubation In A Case Of Subdural Hematoma With Mandible Fracture: A Case Report The Internet Journal of Anesthesiology. 2006 Volume 10 Number 2

21. Case 3

22. Case 3a

23. Case 3b

24. Fiberoptic Intubation

25. Ovassapian Airway

26. Patil-Syracuse Face Mask

27. The Parker Flex-TipTM tubes are available in sizes 6.5, 7.0, 7.5, and 8.0mm ID. • The tapered, centered, flexible tip of the Parker Flex-TipTM Endotracheal Tube is designed for: • Better tip visibility • Gentle sliding off of delicate anatomical structures in the airway • Easier insertion through narrow glottic openings • Snag-free "railroading" along fiberoptic scopes • Gentle "skiing" down tracheal walls

28. Case 4

29. Case 4 28 yr old male, motorcycle collision, fall over pieces of wood. The patient was haemodynamically normal, conscious, just demanding the removal of the stick. Nevertheless, he was submitted to an emergent left thoracotomy, and left laparotomy. The piece of wood was just located behind the sternum and in front of the heart with no major vascular or cardiac injury found, only a perforation of the diaphragm. Intraabdominally, the piece passed between the left lobe of the liver and the spleen with no further injury. We found this almost unbelievable! Luis Filipe Pinheiro, Viseu, Portugal Trauma Image Bank

30. Case 5

31. Case 5

32. Case 6

33. Case 6

34. Case 7

35. Case 7

36. Case 8

38. Case 9

39. Case 9 From Trauma Imagebank at www.trauma.org

40. Case 10

41. Refuses Awake Intubation Case 10 A snarly and demanding 80 year old lady issues an endless stream of demands to her care givers. She is accustomed to getting what she wants, coming from a large family which she was the matriarch.

42. Refuses Awake Intubation She presented with recurrent bowel obstructions following a messy appendectomy complicated by peritonitis. On most occasions an N/G tube would do the trick, but twice a laparotomy became necessary.

43. Refuses Awake Intubation The first time in, she was difficult to intubate because her larynx was just too anterior- despite a “BURP” maneuver seemed to push things into position. However, in the end a colleague got the tube in using a Gum Elastic Bougie he kept nearby for just this situation.

44. Refuses Awake Intubation The next time around the anesthesia team decided on awake fiberoptic intubation, but it required quite a bit of coaxing, and the experience was a terrible one for the patient, remembering that awful choking feeling whenever the scope was introduced.

45. Refuses Awake Intubation The old chart put the picture differently: “Awake FOB intubation L nostril with 2% lidocaine gel, midazolam 1 mg IV and glycopyrrolate 0.2 mg IV. Difficult procedure because of excessive secretions with some bleeding, as well as frequent swallowing and gagging”.

46. Refuses Awake Intubation Now it is your turn to give the anesthetic to allow the surgeons to unwrap her bowels once again. You explain about the awake intubation business, but she’s not biting. She views the whole process as barbaric and she simply will not allow herself to be subjected to awake intubation.

47. Refuses Awake Intubation Just as firmly, she refuses to have any kind of needle put into her back! What should you do after you give up trying to coax her?

48. Refuses Awake Intubation Discussion Options to consider include: 1. Stun her with just a little ketamine (or other agent) and get on with the job of an “awake” intubation, holding her down if necessary. 2. Get a psychiatrist to declare her incompetent. If s/he agrees, go to 1. If s/he disagrees, go to 3, 4 or 5.

49. Refuses Awake Intubation Discussion 3. Try your usual rapid sequence induction and if you can’t get the airway, proceed as per the ASA airway management algorithm. 4. Try your usual rapid sequence induction and if you can’t get the airway, insert an LMA, while continuing cricoid pressure throughout the case. 5. Refuse to be her anesthetist.

50. Case 11