Dr.

Gayathri Ramanathan
Associate Professor
SRM MEDICAL COLLEGE HOSPITAL &
RESEARCHCENTRE
02/22/17 1
 OBJECTIVES
Causes of difficult intubation
Basic airway evaluation
Management plan for Anticipated difficult airway Plan A, Plan
B , Plan C & Plan D
Gallery of tools
The Expected & Unexpected Difficult Airway

02/22/17 2
 DEFINITION
American society of Anesthesiologist (ASA)
suggested

(difficult to ventilate)
That when sign of inadequate ventilation
could not be reversed by mask ventilation
or
oxygen saturation could not be maintained
above 90%
 DEFINITION

(difficult to intubate)
If a trained Anaesthetist using conventional
laryngoscope takes more than 3 attempts
or
more than 10 minute to complete tracheal
intubation
 I T H
N W
EVE PER N !
R O T I O
P LUA
E V A
15-
50%
ARE ONLY PICKED UP
 I CU LT
DIFF
M AS K N
L ATI O
N T I
VE

DIFFICULT INTUBATION
EXTREMELY ABANDON
DIFFICULT

GS 1 in 2000
OBG- 1 in 300
 CAUSES OF
Pre-op assessment
Equipments
DIFFICULT INTUBATION
Anesthetist
Experience not
enough
Poor technique

Malfunctionin
g equipment

Inexperienced
assistance
 CAUSES OF
DIFFICULT INTUBATION
Patient

1. Congenital causes
2. Acquired causes
 Basic airway evaluation
in all patients
Dr. Binnions LEMON Law

BONES

The 4 Ds
Dr. Binnions Lemon Law: An
easy way to remember
multiple tests
L ook externally.
E valuate the 3-3-2 rule.
M allampati.
O bstruction?
N eck mobility.
 L: Look Externally

Obesity
Buck
teeth

Short Recedin
muscular g jaw
neck
Denture
s
L: Look Externally

Macroglossia
Stridor

Facial
trauma
 E:Evaluate the 3-3-2
rule
3 fingers fit in mouth- Inter incisor
distance
3 fingers fit from mentum
to hyoid cartilage
2 fingers fit from the floor
of the mouth to the top of
the thyroid cartilage

14
 M: Mallampati classification

soft palate, fauces;

Class-I the soft palate, fauces Class-II
uvula, anterior and
and uvula
the posterior pillars.

Class-III soft palate and base of uvula Only hard palate Class-IV
O:
Obstruction?
Blood
Vomitus
Teeth
Epiglottis
Dentures
Tumors
N:Neck mobility
-Measurement of
Atlanto-Occipital Angle
Thyro- Mental Distance

Measure from upper edge of thyroid cartilage to chin with

the head fully extended.
A short thyromental distance = an anterior
larynx .
> 7 cm is usually = easy intubation
< 6 cm = difficult airway

18
 MANAGEMENT PLAN
OF
ANTICIPATED
DIFFICULT AIRWAY

02/22/17 19
Is mask ventilation going to
be difficult?
Cant ventilate

e
Defined by BONES
Beard
i l a t
Obesity
en t
No teeth
t v
Ca n
Elderly
Snoring
 Is laryngeal visualization
going to be difficult?
Cant intubate
Defined by 4 Ds
1.Disproportion
2.Distortion
3.Dysmobility
4.Dentition
 Disproportion
Achondroplasi

te
a
a

u b
t
Pierre robin
sequence

i n
t
Acromegal

n
y

C a Prognathis
m
 a t
Distortion
u b
t
Burns contracture

n
Neurofibromatosis

i
t
an Cystic hygroma

C
 Dysmobility
TM joint Ankylosis

t t e
an a
C tub
in
Klippel
Fiel
 Dentitio
n
at e
t u b
i n
n t
Edentulous

Ca Buck teeth
 Is cricothyroidotomy going
to be difficult?
Cant Rescue

Should assessment reveal a potentially

difficult airway the cricothyroid membrane
should be identified and marked, BEFORE an
intervention is undertaken
 Possible Options!
Following airway assessment, the person
performing the intubation should be in a
position to decide between three possible
options
1.Awake intubation
2.Quick look
3.Induction and paralysis
 1. Awake Intubation

The patient needs to be intubated awake

There is significant risk of complications if

sedatives and/or muscle relaxants are
administered prior to airway control.
 2. Quick Look
The patient may be sedated for an attempt at
direct laryngoscopy WITHOUT muscle
relaxation
(Quick Look)

There is some risk of failed laryngoscopy

but
There should be a low risk of failed mask
ventilation.
 3. Induction & Paralysis
The patient may be induced and paralyzed,

In this case the patient is assessed as having a

low risk of laryngoscopy and/or mask
ventilation

Pre-oxygenation: How
Much Is Enough?
Two techniques common in use:
1. Tidal volume breathing (TVB) of oxygen
for 35 min
2. Deep breaths (DB) 4 times within 0.5 min

Both are equally effective in increasing

arterial oxygen tension (Pao2).

Anesth Analg 1981; 60: 3135

 Pre-oxygenation o m
y f r a
v e r n e
e c o a p
s r c e d l y
e o u n d u e n t
t a n e - i c i b i n
o n o l i n su ffi g l o
Sp ylch ccur e m o o s e
cc i n t o n t h w h
s u n o v e c t s
y r e j e d .
ma to p n sub ssiste
c k l y n i o t a
q u i a t i o s n
t u r n i
e s a a t i o
d
Each subject
n t
received i
5 lmg/kg thiopental and 1 mg/kg succinylcholine.
e
v Anesthesiology 2001, 95: 754-759
What are we going to do if
we dont get the Tube?

Plans A, B ,C and plan D.

Know this answer before you tube.
 Failure -Why does it
happens?

No critical discussion with colleagues about

proposed management plan
No request for experienced help
Exaggerated idea of personal ability
Ill-conceived plan A and/or plan B
Poorly executed plan A and/or plan B
Persisting with plan A too long, starting the
rescue plan too late
Not involving, and preparing, surgical
colleagues
 GALLERY OF TOOLS

ILMA
Video laryngoscopes
Malleable video stillet- Levitan scope
Fibreoptic bronchoscope
ELECTIVE EMERGENCY
 ELECTIVE

Old case of Hemi-mandibulectomy with

forehead flap with trismus for block
dissection of neck nodes
Anesthesia of choice - G.A.

Intubating technique of
choice

?
 MANAGEMENT PLAN
OF
UNANTICIPATED
DIFFICULT AIRWAY

02/22/17 45
TheUnexpected
DifficultAirway
Experienced help may not be immediately
available
Special equipment may not be immediately
available
A general anaesthetic has usually been
administered
A long acting relaxant may have been given
Backup airway management plans may be
poorly thought out

46
 Take home
message
Be familiar with the alternative methods of
intubating technique and use it regularly in
your day today practice e.g. ILMA, FOB,
Videolaryngoscopes,
cricothyroidotomy.

So that you wont fumble at the time of crisis

02/22/17 47
 Challenges
may be
Waiting for you

02/22/17 48
Thank