SAFETY FIRST
THE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIST, PLAYS A UNIQUE
ROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAIN
EITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERAL
ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.
AS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLE
RELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUS
PHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, AND
HIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITH
EACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEX
BODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODY
TEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFERED
WITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC AND
METABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATION
SHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCE
OF THE ANESTHETIZED STATE
INTRODUCTION
AIRWAY ANATOMY
THE SUPRAGLOTTIC AIRWAY
SUBGLOTTIC AIRWAY
MANAGEMENT OF PATIENTS WITH NORMAL AIRWAY
ANATOMY
MANAGEMENT OF PATIENT WITH THE DIFFICULT AIRWAY
PREDICTION
PREPARATION
PRACTICE
TOOLS FOR MANAGEMENT OF THE DIFFICULT AIRWAY
INTRODUCTION
VARIOUS STUDIES REPORT THAT BETWEEN 1% AND 18% OF
PATIENTS HAVE DIFFICULT AIRWAY ANATOMY. OF THESE, 0.050.35% ARE NOT INTUBATED SUCCESSFULLY; AND A
SIGNIFICANT PORTION MAY BE DIFFICULT TO VENTILATE BY
MASK. IT IS LIKELY THAT THE PRACTITIONER WILL ENCOUNTER
BETWEEN ONE AND 10 PATIENTS PER YEAR IN WHOM
INTUBATION OF THE TRACHEA WILL BE DIFFICULT OR
IMPOSSIBLE.
WILL BE DISCUSS, THE BASICS OF AIRWAY ANATOMY AND
NORMAL AIRWAY MANAGEMENT, AND TO HIGHLIGHT SOME OF
THE FACTORS THAT CONTRIBUTE TO THE SAFE MANAGEMENT
OF THE PATIENT WITH A DIFFICULT AIRWAY
ANATOMY AIRWAY
AIRWAY ANATOMY
THE SUPRAGLOTTIC AIRWAY
SUBGLOTTIC AIRWAY
MANAGEMENT OF PATIENTS WITH NORMAL AIRWAY ANATOMY
MANAGEMENT OF THE DIFFICULT AIRWAY
PREDICTION
PREPARATION
PRACTICE
TAKEN AS A SYSTEM, THE AIRWAY BEGINS AT THE EXTERNAL OPENINGS OF THE MOUTH
AND NOSE AND ENDS IN THE ALVEOLAR UNITS.
AIRWAY ANATOMY WILL BE DISCUSSED IIN TERMS OF THE SUPRAGLOTTIC AIRWAY, THE
LARYNX AND THE SUBGLOTTIC AIRWAY.
THE SUPRAGLOTTIC AIRWAY
THE NOSE
THE NOSE SERVES TO WARM AND HUMIDITY AIR AS IT ENTERS THE BODY. THE NASAL
PASSAGE MAY BE LIMITED BY THE SIZE OF THE TURBINATES, WHICH ARE HIGHLY
VASCULAR. PASSAGE OF ENDOTRACHEAL TUBES OR BRONCHOSCOPES THROUGH THE
NOSE MAY BE ASSOCIATED WITH PROFUSE BLEEDING. THE NASAL SEPTUM IS OFTEN
DEVIATED, GIVING A SMALLER PASSAGE ON ONE SIDE THAN THE OTHER. THE
NASOPHARYNX OPENS INTO THE OROPHARYNX BRANCHES OF THE FIFTH CRANIAL
NERVE PROVIDE SENSORY INNERVIATION TO THE NOSE
THE PHARYNX
THE SPACE IN THE POSTERIOR PORTION. THE NASOPHARYNX,
AND HYPOPHARYNX. LYMPHOID TISSUE AROUND THE PHARYNX
MAY HINDER PASSAGE OF AN ENDOTRACHEAL TUBE.
THE INTERNAL MUSCLES OF THE PHARYNX SERVE TO ELEVATE
THE PALATE DURING SWALLOWING.
THE EXTERNAL MUSCLES OF THE PHARYNX ARE
CONSTGRICTORS AND SERVE TO PUSH FOOD INTO THE
ESOPHAGUS, BUT MAY IMPAIR PASSAGE OF AN ENDOTRACHEAL
TUBE OR BRONCHOSCOPE IN AWAKE OR LIGHTLY ANESTHETIZED
PATIENTS.
THE INNERVATION OF THE PHARYNX IS FROM THE NINTH
CRANIAL NERVE FOR SOMATIC SENSORY AND MOTOR FUNCTION.
THE LEVATOR VELI PALATINI, WHICH IS INNERVATED BY THE
FIFTH CRANIAL NERVE
THE PHARYNX
THE TONGUE MAY MOVE POSTERIORLY IN THE PHARYNX AND OBSTRUCT
THE AIRWAY BY CONTRACTING THE POSTERIOR WALL OF THE
OROPHARYNX.
THIS CONDITION OCCURS IN ANESTHETIZED AND SEDATED PATIENTS
BUT MAY ALSO OCCUR IN SLEEPING PATIENTS.
THE OBSTRUCTION OCCURS AS MUSCLE TONE DECREASES AND A
DECREASE IN THE FUNCTIONAL LUMEN OF THE PHARYNX ENSUES.
WITH SPONTANEOUSLY BREATHING PATIENTS, A DECREASE IN
FUNCTIONAL AIRWAY LUMEN MAY BE ASSOCIATED WITH AN INCREASED
RESPIRATORY EFFORT AND RESULTANT GREATER NEGATIVE PRESSURE
BELOW THE LEVEL OF OBSTRUCTION.
THIS CAN LEAD TO A WORSENING OF THE OBSTRUCTION AS THE
NEGATIVE PRESSURE PULLS MORE SOFT TISSUE INTO THE AREA OF
COLLAPSE.
A SIGNIFICANT FROM OF THIS PROBLEM IS OBSTRUCTIVE SLEEP APNEA
THE LARYNX
THE LARYNX IS A COMPLICATED STRUCTURE THAT SERVES TO PROTECT THE
LOWER AIRWAYS, AS THE ORGAN OF PHONATION AND AS THE CONDUIT FOR
RESPIRATION.
THESE FUNCTIONS DEPEND ON THE INTERATCTION OF THE CARTILAGINOUS,
BONY AND SOFT TISSUE COMPONENTS OF THE LARYNX AND PHARYNX.
THERE ARE 9 CARTILAGES OF THE LARYNX. THE MUSCLES OF THE LARYNX ARE
BOTH EXTRINSIC AND EXTRINSIC.
CARTILAGES OF THE LARYNX
THYROID CARTILAGE
CRICOID CARTILAGE
ARYTENOID CARTILAGES
EPIGLOTTIS
SUBGLOTTIC AIRWAY
TRACHEA
LOBAR BRONCHI
PREDICTION
THERE ARE SEVERAL POPULAR METHODS OF PREDICTING EASE OR
DIFFICULTY OF INTUBATION USING A PHYSICAL EXAMINATION.
DIFFICULT IN INTUBATING THE TRACHEA CAN BE SAID TO OCCUR
WHEN AN EXPERIENCED PRACTITIONER IS UNABLE TO PASS AN
ENDOTRACHEAL TUBE IN THE NORMAL TIME AND FASHION, IT MAY
BE DEFINED AS AN INTUBATION THAT REQUIRES MORE THAN ONE
ATTEMPT.
HOWEVER, MORE DIFFICULT INTUBATIONS CAN BE RELATED TO THE
GRADE OF LARYNGOSCOPIC.
DIFFICULTY DURING INTUBATION IS LIKELY WITH A GRADE III OR IV
VIEW.
GRADE I
: VOCAL CORDS ARE VISIBLE
GRADE II
: VOCAL CORDS ARE ONLY PARTLY VISIBLE
GRADE III
: ONLY THE EPIGLOTTIS IS SEEN
GRADE IV
: NOT EVEN THE EPIGLOTTIS IS SEEN
ANKYLOSING
SPONDYLLITIS, MANDIBULAR FRACTURE OR FIXATION, ANKYLOSIS
OF
THE TEMPOROMANDIBULAR JOINT.
- SOFT TISSUES ABNORMALITIES, INCLUDING OBESITY, TUMORS,
HEMANGIOMAS, ABSCESSES, AIRWAY INFECTIONS SUCH AS
EPIGLOTTITIS, BLEEDING.
- TRAUMA TO FAE OR NECK, BURNS, POSTOPERATIVE CHANGES
INCLUDING SCARRING, RADIATION-INDUCED CHANGES
DENTITION
BODY HABITUS
NECK MOBILITY
PREPARATION
ADEQUATE PREPARATION TO CARE FOR PATIENTS WITH DIFFICULT
AIRWAY ANATOMY REQUIRES ASQUISITION OF KNOWLEDGE AND
EQUIPMENT.
THE KNOWLEDGE NECESSARY FOR SAFE MANAGEMENT OF THESE
PATIENTS IS AN EXTENSION OF THE KNOWLEDGE NEEDED TO
PROVIDE CARE FOR ANY PATIENT BUT WITH ADDITIONAL POINTS.
THE ALGORITHM SUGGESTS THE FOLLOWING STEPS :
LARYNGOSCOPY
WEIGHT
MAXIMUM
AIR IN CUFF
<5KG
4 ML
5-10KG
7 ML
10-20KG
10 ML
20-30KG
14 ML
30KG TO SMALL ADULT
20 ML
ADULT
30 ML
LARGE ADULT/POOR SEAL WITH 4 40 ML
RETROGRADE INTUBATION
CRICOTHYROIDOTOMY
TRACHEOSTOMY
SIZE
1
1.5
2
2.5
3
4
5
WEIGHT
MAXIMUM
AIR IN CUFF
<5KG
4 ML
5-10KG
7 ML
10-20KG
10 ML
20-30KG
14 ML
30KG TO SMALL ADULT
20 ML
ADULT
30 ML
LARGE ADULT/POOR SEAL WITH 4 40 ML
INTRODUCTION
BEDSIDE ASSESSMENT
MANDIBLE MEASURE MENTAL-TYROID DISTANCE
O PENING OF THE MOUTHS
U VULA VISIBILITY
TEETH PRESENTATION
H EAD MOVEMENT
S ILLOUETTE THE PROFILE OF THE HEAD, NECK AND CHEST
INTRODUCTION
AN INADEQUATE AIRWAY LEADS RAPIDLY TO HYPOXAEMIA AND
UNCORRECTED HYPOXAEMIA WILL RESULT IN BRAIN DAMAGE AND
ULTIMATELY DEATH.
THE GOLD STANDARD FOR A SECURE AIRWAY IS TRACHEAL
INTUBATION.
EVERY AIRWAY ASSESSMENT SHOULD INCLUDE TESTS THAT AIM TO
PREDICT DIFFICULTY WITH TRACHEAL INTUBATION.
NO SINGLE TEST CAN PREDICT AIRWAY OR INTUBATION DIFFICULTY
RELIABLY.
NO SINGLE TEST, OR A COMBINATION OF TESTS, CAN DETECT
DIFFITULTY WITH AIRWAY MANAGEMENT WITH 100% CERTAINTY.
BEDSIDE ASSESSMENT
MOUTHS
THE LETTERS STAND FOR : MANDIBLE, OPENING, UVULA, TEETH, HEAD AN
NECK, SILHOUETTE
MANDIBLE MEASURE MENTAL-TYROID DISTANCE,
JAW THRUST PROTRUSION
- MENTO-TYROID DISTANCE LESS THAN 6 CM A SMALL RECEDING
MANDIBLE
- JAW THRUST PROTRUSION
FULL PROTRUSION :
LOWER INCISORS, ANTERIOR TO UPPER INCISORS IS
CLASSED AS CLASS A,
PART PROTRUSION
UPPER AND LOWER, INCISORS IN LINE AS CLASS B,
NO PROTRUSION
LOWER INCISORS, BEHIND UPPER AS CLASS C
O PENING BE AT LEAST 3 CM
U VULA (INCLUDING THE PALATE AND THE PHARYNGEAL
STRUCTURES)
MALLAMPATI AND MODIFIED BY SAMSOON AN YOUNG. THE TERM
MALLAMPATI GRADE I TO IV.
EVEN WITH BEST STANDARDISATION (PATIENT SITTING, HEAD IN
NEUTRAL POSITION, MAXIMUM MOUTH OPENING AND TONGUE
PROTRUSION THERE IS INTER-OBSERVER VARIABILITY AND A
RELATIVELY HIGH INCIDENCE OF FALSE NEGATIVES
TEETH
A COMPLETELY EDENTULOUS PATIENT HAS A WIDER GAPE AND THEREFORE IS
RELATIVELY EASY TO INTUBATE
H EAD ALL
ASSESS RANGES OF MOVEMENT OF THE HEAD (ATLANTO-OCCIPITAL JOINT) AND
CERVICAL SPINE. AT LEAST A 900 DIFFRENCE BETWEEN FULL FLEXION (CHIN ON
CHEST) AND EXTENSION (ASK THE PATIENT TO LOOK AT THE CEILING WHILE
SITTING UPRIGHT. THE ABSENCE OF MOVEMENT PARTICULARLY IN THE ATLATOOCCIPITAL JOINT MAY MAKE IT PHYSICALLY IMPOSSIBLE TO OBTAIN A LINE OF
VISION AT ATTEMPTED DIRECT LARYNGOSCOPY.
S ILLOUETTE THE PROFILE OF THE HEAD, NECK AND CHEST
THE COMBINATION OF MALLAMPATI, JAW PROTRUSION AND CRANIOCERVICAL
EXTENSION HAS A SPECIFICITY OF 99% AND POSITIVE PREDICTIVE VALUE OF 93%.
A THROUGH BEDSIDE ASSESSMENT OF THE AIRWAY WILL ALERT THE
ANAESTHETIST TO MOST CASES OF DIFFICULTIES WITH LARYNGOSCOPY AND
INTUBATION. HOWEVER, SOME CASES WILL ONLY DISCOVERED AT INTUBATION
EASY OR HARD?
CLINICAL
ASSESSMENT
OF THE AIRWAY
INTRODUCTION
GLOBAL ASSESSMENT
AIRWAY-COMPROMISING CONDITIONS
OBJECTIVE ASSESSMENT
INTRODUCTION
SAFETY FIRST
THE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIS, PLAYS A UNIQUE
ROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAIN
EITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERAL
ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.
AS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLE
RELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUS
PHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, AND
HIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITH
EACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEX
BODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODY
TEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFERED
WITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC AND
METABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATION
SHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCE
OF THE ANESTHETIZED STATE
GLOBAL ASSESSMENT
ALTHOUGH AIRWAY ASSESSMENT IS ESSENTIALLY A REGIONAL
ANATOMIC ASSESSMENT A GENERAL ASSESSMENT OF THE
BODY BUILD AND OF THE HEAD AND NECK. TO VIEW THE
HEAD AND NECK FRONTALLY AS WELL AS N PROFILE AND
TAKE INTO CONSIDERATION THE BODY BUILD AS WELL.
THE SHORT, THICK NECK THAT IS OFTEN ASSOCIATED WITH
DIFFICULT INTUBATION IS WELL KNOWN AS IS THE CASE WITH
MORBID OBESITY.
AIRWAYS DIFFICULTIES TEND TO BE ASSOCIATED WITH
SHORT AND STUMPY INDIVIDUALS MORE OFTEN THAN
TALL AND THIN INDIVIDUALS; THIS IS ESPECIALLY TRUE
WITH PREGNANT WOMEN, PERHAPS ALSO AS A REFLECTION OF
FLUID RETENTION DURING PREGNANCY.
AIRWAY-COMPROMISING CONDITIONS
CONGENITAL
GOITER
AIRWAY-COMPROMISING CONDITIONS
ACQUIRED
INFECTIONS
SUPRAGLOTTITIS
CROUP
ABSCESS (INTRAORAL,
RETROPHARNGEAL)
LUDWIGS ANGINA
ARTHRITIS
RHEUMATOID ARTHRITIS
ANKYLOSING SPONDYLITIS
BENIGN TUMORS
EXAPLES; CYSTIC HYGROMA,
LIPOMA, ADENOMA, GOITER
MALIGNANT TUMORS
EXAMPLES; CARCINOMA OF
TONGUE, CARCIONAMA OF
LARYNX, CARCINOMA OF
THYROID.
TRAUMA
EXAMLES; FACIAL INJURY,
CERVICAL SPINE INJURY,
LARYNGEAL/TRACHEAL TRAUMA
OBESITY
ACROMEGALY
ACUTE BURNS
LARYNGEAL EDEMA
LARYNGEAL EDEMA
DISTORTION OF THE AIRWAY AND TRISMUS
DISTORTION OF THE AIRWAY AND TRISMUS
OBJECTIVE ASSESSMENT
DIFFICULT LARYNGOSCOPY CAN STILL BE ENCOUNTERED
DURING INDUCTION IN INDIVIDUALS WITH NO OBVIOUS
ANATOMIC VARIATIONS, UNRESTRICTED MOVEMENT OF HEAD
AND NECK, ADEQUATE RELAXATION, OPTIMAL POSITIONING,
AND SOUND TECHNIQUE.
A TOTALLY UNEXPECTED DIFFICULT LARYNGOSCOPY
MIGHT CONTRIBUTE TO SIGNIFICANT MORBIDITY AND
MORTALITY.
THE BASIS OF AIRWAY CLASSIFICATION :
CLASS 1 : UVULA, FAUCIAL PILLARS, SOFT PALATE VISIBEL
CLASS 2 : FAUCIAL PILLARS, SOFT PALATE VISIBLE
CLASS 3 : SOFT PALATE VISIBLE
GRADE 1
NO.OF PTS
(%)
GRADE 2
NO OF PTS
(%)
GRADE 3
NO.OF PTS
(%)
GRADE 4
NO. OF PTS
(%)
125 (59.5%)
30 (14.3%)
12 (5.7%)
14 (6.7%)
10 (4.7%)
4 (1.9%)
1 (0.5%)
9 (4.3%)
5 (2.4%)
LARYNGOSCOPE
CLINICAL PROBLEM-BASED ASSESSMENT OF
TRADITIONAL LARYNGOSCOPE DESIGN
ANTESTERNAL SPACE RESTRICTION
LIMITED MOUTH OPENING
REDUCED INTRAORAL CAVITY
THE ANTERIOR LARYNX
MANDIBULAR SPACE
UNUSUALLY WIDE, SUCH AS THE
BIZARRI-GUFFRID
NOVEL LARYNGOSCOPE TECHNIQUES
INDIRECT VISUALIZATION OF THE VOCAL CORDS
DIRECT VISUALIZATION OF THE VOCAL CORDS
EPIGLOTTIS POSITIONING
INFANT AND PEDIATRIC REQUIREMENTS
BEAK TIP
WILL THIS ATRAUMATICALLY AND SECURELY TILT OR
LIFT
THE EPIGLOTTIS EFFECTIVELY?
BEAK
WILL A TILT FROM AXIS OF THE SPATULA AID
VISUALIZATION/ACCESS FOR VOCAL CORD
APERTURE?
WILL AN EXPOSED CROSS-SECTIONAL AREA BE
PROTECTED FROM PATHOLOGIC OR
ANATOMICALLY ABNORMAL
TISSUES?
WILL THE SIZE OCCUPY SPACE NEEDED TO
MANIPULATE TIP OF ETT?
SPATULA WITH REFERENCE TO THE LENGTH THAT WILL
BE IN THE ORAL CAVITY
APPROACHING BETWEEN THE INCISOR, TEETH WILL ITS
CURVATURE / STRAIGHTNESS AID VISUALIZATION AID
ACCESS TO THE VOCAL
CORDS?
USING A MOLAR OR RETROMOLAR APPROACH, WILL ITS
CURVATURE / STRAIGHTNESS AID VISUALIZATION AID
ACCESS TO THE VOCAL
CORDS?
WILL ITS WIDTH COMPRESS TH E TONGUE
ADWQUATELY?
WILL ITS SIZE HINDER ETT MANIPULATION?
MOUTH
RESTRICTED OPENING
DENTAL MISALIGNMENT
TONGUE LARGE
INTRAORAL VOLUME SMALL
PHARYNGEAL SPACE-OCCUPYING PATHOLOGY
MALLAMPATI SIGN II-IV
MOLAR TEETH PRESENT
STEP
WILL THE HEIGHT PREVENT ENTRY TO THE PATIENTS
MOUTH ?
WILL ANGULATION OF SPATULA TO THE AXIS OF THE
TRACHEA BE HINDERED?
WILL SHALLOWNESS OR ABSENCE ABOLISH ITS PROP
CAPABILITY IN THAT PATIENT?
FITTING
WILL THE ANGLE BETWEEN HANDLE AND BLADE
PREVENT THE BLADE ENTERING THE MOUTH AND ITS
MANIPULOATION?
WILL VISUALIZATION AND MANIPULATION BE
COMPROMISED UNLESS BLADE IS OFFSET?
HANDLE
IS THE HANDLE TOO LONG TO PERMIT BLADE ENTRY
INTO
THE MOUTH?
DO THE PROBLEMS PRESENTED DEMAND VISUAL AND ACCESS AIDS SUCH AS PRISMS OR VISUAL
IMAGE TRANSMISSION VIA RIGID OR FLEXIBLE ROUTE?
THE USER WHO DETERMINES THE USEFULNESS OF AN INSTRUMENT. EXAMINE YOUR PATIENT, UNDERSTAND
LARYNGOSCOPES, LEARN HOW TO USE THEM
(III)
(I)
(II)
METHOD OF INSERTION
THERE ARE SEVERAL TECHNIQUES THAT HAVE BEEN DESCRIBED FOR
INSERTION OF THE LMA. THE STANDARD TECHNIQUE ID DESCRIBED
BELOW:
1. INFLATE THE CUFF UP TO 50% OF ITS MAXIMUM VOLUME AND CHECK
FOR CUFF LEAKS
2. DEFLATE THE CUFF FULLY OR PARTLY AND APPLY A LUBRICANT JELLY
TO LUBRICATE THE BACK OF THE CUFF (I.E. THE PHARYNGEAL SIDE)
3. ENSURE THAT THE PATIENT IS ADEQUATELY ANAESTHETISED
4. EXTENT THE PATIENTS NECK AND STABILISE THE OCCIPUT SO THAT
THE JAW FALLS OPEN. THE ASSISTANT MAY HELP BY HOLDING THE
PATIENTS MOUTH OPEN.
5. GRASP THE LMA LIKE A PEN IN THE DOMINANT HAND AND PRESS THE
DISTALTIP OF THE DFLATED LMA CUFF AGAINST HE HARD PALATE
USING THE INDEX FINGER OF THE NON-DOMINANT HAND TO GUIDE
THE TUBE OVER THE BACK OF THE TONGUE AND INTO THE
OROPHARYNX
METHOD OF INSERTION
combitube
LARYNGEAL TUBE
PAXPRESS
OXYGEN SUPPLEMENTATION
INTRODUCTION
INDICATIONS FOR TRACHEAL INTUBATION
PREPARATION
ASSESSMENT OF THE AIRWAY
EQUIPMENT FOR AIWAY MANAGEMENT
CONDUCT OF ROUTINE INTUBATION
PREPARATION
INDUCTION OF ANESTHESIA
LARYNGOSCOPY
INTUBATION
WARNING
INTRODUCTION
PASSING A CUFFED TRACHEAL TUBE CORRECTLY
SECURES THE AIRWAY, PROVIDED NO OBSTRUCTION IS
BELOW THE TIP OF THE TUBE, AND PROTECTS THE
LUNGS AGAINST ASPIRATION OF STOMACH CONTENTS
PREPARATION
ASSESSMENT : AIRWAY ASSESSMENT
EQUIPMENT LARYNGOSCOPES, BOUGIES MAGILLS FORCEPS,
PLUS A SELECTION OF FACEMASKS, AIRWAY AND TRACHEAL TUBE
OF VARIOUS SIZES
INDUCTION OF ANAESTHESIA
LARYNGOSCOPY
CORMACK AND LEHANE HAVE CLASSIFIED THE LARYNGOSCOPIC VIEW
INTO FOUR GRADES.
GRADES I AN DII PROVIDE A FULL OR PARTIAL VIEW OF THE GLOTTIS,
WHILE IN GRADES III AND IV THE EPIGLOTTIS COVERS THE GLOTTIS AND
THEREFORE THESE ARE CONSIDERED DIFFICULT.
A FUTHER FACTOR IS A STRAIGHT LINE OF VISION I.E. ALIGNMENT OF THE
ANTERIOR EDGE OF THE INCISORS, THE BASE OF THE TONGUE AND THE
GLOTTIS, TO DISPLACE THE TONGUE LEFT AND LIFT THE LOWER JAW WITH
TRACTION.
INTUBATION
TO DEPTH SUFFICIENT TO PREVENT ACCIDENTAL EXTUBATION BUT NOT TOO FAR TO
PREVENT ENDOBRONCHIAL INTUBATION.
WHEN THE TUBE IS PASSED,
THE ASSISTANT INFLATES THE CUFF
THE ANAESTHETIST SUPPORTS THE TUBE UNTIL SECURED WITH A TIE OR A TAPE.
SEEING THE TUBE PASS BETWEEN THE VOCAL CORDS IS A GOOD CONFIRMTION OF ITS
PLACEMENT.
IN ALL CASES, CONFIRM THE POSITION OF THE TUBE;
LISTEN OVER BOTH LUNG FIELDS IN THE AXILLAE (BREATH SOUNDS SHOULD BE PRESENT
ON BOTH SIDES EQUALLY) AND OVER THE STOMACH (AIR ENTRY SHOULD BE ABSENT)
WATCH THE CHEST RISE AND FALL
OBSERVE A TYPICAL CAPNOGRAPHIC TRACE-EXPIRATORY WAVES OF EQUAL HEIGHT AND
WITH A PLATEAU, REACHING THE SAME HEIGHT > 3KPA OF END-TIDAL CO2 ON REPEATED
BREATHS
REMEMBER
PATIENTS DO NOT DIE OF DIFFICULT LARYNGOSCOPY BUT THEY DO DIE
OR
GET BRAIN DAMAGED FROM HYPOXIA. SATURATIONS LESS THAN 6070%
LASTING LONGER THAN 3 MIN WOULD BE EXPECTED TI PRODUCE SOME
DETRIMENTAL EFFECTS. TAKE ACTION TO IMPROVE SATURATION
BEFORE THEN
SUMMARY
2.
3.
1.
INTRODUCTION
DIFFICULTY WITH MASK VENTILATION
DIFFICULTY WITH INTUBATION
DIFFICULTY WITH INTUBATION AND VENTILATION
INTRODUCTION
WE WILL FIRST CONSIDER WHAT CONSTITUTES AIRWAY, DESCRIBE
AN ALOGORITHM AND METHODS FOR DEALING WITH SPECIFIC
DIFFICULTIES, INCLUDING THE SURGICAL AIRWAY AND FINALLY WITH
STRIDOR.
THE JUNIOR TRAINER IS DISCOURAGED FROM ATTEMPTING TO
ANAESTHETISE PATIENTS WHERE A PROBLEM IS IDENTIFIED AT
ASSESSMENT.
THERE IS NO STANDARD DEFINITION OF THE DIFFICULT
AIRWAY.
THE DIFFICULT AIRWAY DEVINES AS THE CLINICAL SITUATION
IN WHICH A CONVENTIONALLY TRAINED ANETHESIOLOGIST
EXPERIENCES DIFFICULTY WITH MASK VENTILATION,
DIFFICULTY WITH TRACHEAL INTUBATION, OR BOTH.
THE REPORTED INCIDENCE OF DIFFICULT LARYNGOSCOPY IS 313% A DIFFICULT LARYNGOSCOPY DOES NOT ALWAYS EQUATE
WITH DIFFICULT INTUBATION.
A GRADE III LARYNGOSCOPIC VIEW MAY ENABLE RELATIVELY
EASY INTUBATION WITH A BOUGIE, WHILE A GRADE II WITH AN
ANTERIOR AND DEEP LYING LARYNX MAY BE DIFFICULT TO
INTUBATE
5.
PROBLEM
ACTION
SMALL BLADE
SHORT-HANDLE OR POLIO
BLADE
USE A BOUGIE/LARGE BLADE,
LARYNGEAL PRESSURE,
ALTERNATIVE BLADE
3.
4.
ADVANTAGES
1.
RAPID ACCESS TO THE AIRWAY IN ACUTE UPPER AIRWAY
OBSTRUCTION OR THE CANNOT INTUBATE, CANNOT
VENTILATE SITUATION.
2.
BUYS TIME TO PREPARE FOR A MORE DEFINITIVE FORM OF
AIRWAY USING ADVANCED TECHNIQUES.
DISADVANTAGES
1.
TRAUMA TO SURROUNDING STRUCTURES, ESPECIALLY THE
OESOPHAGUS
2.
HAEMORRHAGE
3.
SURGICAL EMPHYSEMA
4.
PULMONARY BAROTRAUMA
STRIDOR
IF STRIDOR IS PRESENT, IT MEANS A MAJOR UPPER AIRWAY
OBSTRUCTION / COMPRESSION.
STRIDOR IS A CLEAR WARNING OF EXPECTED DIFFICULTY WITH
MASK VENTILATION AND QUITE LIKELY DIFFICULTY WITH
LARYNGOSCOPY AND INTUBATION.
PARTIAL AIRWAY OBSTRUCTION WHEN THE PATIENT IS CONSCIOUS
MAY RAPIDLY PROGRESS TO COMPLETE AIRWAY OBSTRUCTION
WHEN CONSCIOUSNESS IS LOST
THE FAILED MASK VENTILATION AND FAILED INTUBATION
ALGORITHM IS OF LITTLE USE IN THIS SITUATION.
DO !
PRE-OPERATIVE ASSESSMENT
OPTIMISING BREATHING
SUMMARY
YES
CRASH
AIRWAY
ALGORITHM
YES
DIFFICUT
AIRWAY ?
ALGORITHM
FAILS
NO
DIFFICUT
AIRWAY ?
NO
RSI
FAILS
FAILS
FAILED
AIRWAY
ALGORITHM
NEEDS
INTUBATION
UNRESPONSIVE
NEAR DEATH
YES
CRASH
AIRWAY
YES
DIFFICULT
AIRWAY
NO
PREDICT DIFFICULT
AIRWAY
FROM DIFFICULT
AIRWAY
NO
RSI
ATTEMPT
INTUBATION
SUCCESSFUL ?
NO
FAILURE TO MAINTAIN
OXYGENATION ?
NO
2-3 ATTEMPTS AT OTI BY
EXPERIENCED OPERATOR ?
NO
YES
FAILED
AIRWAY
CRASH
AIRWAY
MAINTAIN OXYGENATION
INTUBATION ATTEMPT
SUCCESSFUL ?
NO
UNABLE TO BAG VENTILATE ?
YES
FAILED
AIRWAY
NO
SUCCINYCHOLINE 2 MG/KG IVP
ATTEMPT INTUBATION
NO
SUCCESSFUL ?
NO
FAILURE TO MAINTAIN
OXYGENATION ?
NO
> 3 ATTEPTS BY
EXPERIENCED OPERATOR ?
YES
FAILED
AIRWAY
FAILURE TO MAINTAIN
OXYGENATION ?
YES
FAILED
AIRWAY
NO
BMV OR EGD
PREDICTED TO BE
SUCCESSFUL ?
YES
NO
INTUBATION PREDICTED
TO BE SUCCESSCUL ?
YES
RSI
NO
NO
ILMA
FO OR VL+
CRICOTHYROTOMY
BNTI LIGHTED STYLET
YES
FAILED
AIRWAY
FAILED
AIRWAY
FAILED
AIRWAY CRITERIA
EXTRA-GLOTTIC DEVICE
MAY BE ATTEMPTED
FAILURE TO MAINTAIN
OXYGENATION ?
YES
CRITOTHYROTOMY
NO
CHOOSE ONE AT
-FIBEROPTIC METHOD
-VIDEO LARYNGOSCOPY
-EXTRA GLOTTIC DEVICE
-LIGHTED STYLET
-CRICOTYROTOMY
NO
ARRAGE FOR
DEFINITIVE AIRWAY
MANAGEMENT
YES
POST INTUBATION
MANAGEMENT