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DIFFICULT AIRWAY

ASSESSMENT AND
MANAGEMENT
BY
DR AZHAR

DEFFINATION
American society of Anesthesiologist (ASA)
suggested that when sign of inadequate
ventilation could not be reversed by mask
ventilation or oxygen saturation could not be
maintained above 90% or
if a trained Anaesthetist usinig conventional
larangoscope takes more than 3 attempts or
more than 10 minute are required to complete
tracheal intubation

Anatomy of oropharynex and larynx

PREVALENCE
Fact of the matter is even with proper evaluation
only 15 to 50 % were picked up while
difficult face mask ventilation in general is
about 1:10,000 out of which again 15% proved
to be the difficult intubation ,while incidence
of extreme difficult or abandons intubation in
general surgery patients are 1:2000 but in
obstetrics is 1:300 and of course most critical
incidence is Hypoxia

BASIC AIRWAY EVALUATION


1.

2.

3.

Previous anaesthetic problems and general


appearance of the patient.
Neck, face, maxilla and mandible with jaw
movements.
Head extension and movements, teeth,
oropharanx and soft tissue of the neck .

Why does it happens ?


1.
2.
3.

4.

5.

6.

Exaggerated idea of personal ability.


Not requesting for experienced help.
No discussion with colleagues about proposed
management of the case .
Ill conceived plan (A) with no proper back up
plan (B).
Even poorly conducted plan (A) or sticking
extra time to the plan (A) other way delaying
the rescue plan late.
Last not the least not involving surgical friends.

CAUSES OF
DIFFICULT INTUBATION
1.
2.
3.
4.
5.
6.

Anaesthetist
Inadequate preoperative assessment.
Inadequate equipments.
Experience not enough.
Poor technique.
Malfunctioning of equipment.
Inexperience assistanance
Patient

1.
2.

Congenital causes
Acquired causes

Anatomical factors affecting


Larangoscopy
1.
2.
3.
4.
5.

Short Neck.
Protruding incisor teeth.
Long high arched palate.
Poor mobility of neck.
Increase in either anterior depth or Posterior
depth of the mandible decrease in Atlanto
Occipital distance that's why role of
Radiology has increased in our specialty

ASSESSMENT OF AIRWAY
Mallampati classification with
larangoscopic view.

Patils Test

Measurement of
Atlanto-Occepital Angle

MANAGEMENT PLAN OF
ANTICEPATED DIFFICULT
AIRWAY
1.
2.
3.
4.

5.

6.

Discussion with colleagues in advance.


Equipment tested before.
Senior help backup.
Definite initial plan (A) for ventilation and
intubation.
Definite plan (B) than option of awake
intubation.
Ideal situation surgery team standby.

UNEXPECTED DIFFICULT AIRWAY


Problems
1.
2.
3.

Unexpected encounter with difficult airway is mostly gone worse


because mainly GA is already given including (NMB,S).
Equipment may not be in hand.
Senior and back up plan not available so delay occur in active
resuscitation

TECHNIQUE OF MANAGEMENT
1.
2.
3.
4.
5.
6.
7.

Manipulation of the patients airway.


Laryngeal pressure.
Nasal or oral airway.
Different blades of larangoscope like Miller, Magill, Robershaw , Mackintosh and
relatively new laryngoscope McCoy.
Bougies and stylet
LMA.
Combitube.

11

alternative
alternative

22
alternative
alternative

33

1
Manipulation of airway
different blade, bugie

2
LMA, ILMA, Combitube
3
Trantracheal Jet Ventilation

alternative
alternative

44

alternative
alternative

4
Cricothireotomy, Tracheostomy

GALLERY OF TOOLS

GALLERY OF TOOLS
Bullard laryngoscope
optic

Fiber

Mini Tracheostomy

Mini Tracheostomy (Cont.)

BLIND NASAL,
RETROGRADE
AND HIGH FREQUENCY VENTILATION

Awake Intubation

ASA ALLOGORYTHAM

ASA ALLGORYTHAM

C-SPINE OA

THANK YOU
VERY MUCH
FOR YOUR
ATTENTION