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First Case of the Day


ASA Definition
The Difficult Airway-
is defined as the clinical situation in which a
conventionally trained Anesthesiologist experiences
difficulty with facemask ventilation of the upper
airway, difficulty with tracheal intubation, or both
Difficult to Ventilate-
is when signs of inadequate ventilation could not be
reversed by mask ventilation or oxygen saturation
could not be maintained above 90%
Difficult to Intubate-
is when a trained Anesthetist using conventional
laryngoscope take’s more than 3 attempts


Degrees of Airway Difficulty 5 .

Overlap Difficult Mask Ventilation 6 .

Overlap Difficult Mask Difficult Ventilation SGA 7 .

Triple Failure Difficult Difficult Mask SGA Ventilation Difficult Intubatio DANGER ZONE n 8 .

An Emergent Surgical Airway is Not Always Assured Difficult Mask Difficult Ventilation surgical airway Difficult Danger Zone Intubation 9 .

900.904 GA’s from 309 hospitals over a 2 week period • 184 serious airway complications. including: -Death (14) -Brain Damage -Emergent Surgical Airway 10 .000 GA performed in the UK • Data collected on 114. 4th National Audit Project • Sept 2008-Sept NAP4 2009 estimated 2.

NAP4 Lessons Learned 11 .

Failure to match strategy to assessment (technique) 2.Failure to have prepared strategy (plan B and C) 12 . NAP4 Lessons Learned Poor Airway Assessment & Poor Planning contributed to Poor Outcomes 1.

NAP4 Lessons Learned Emergency Percutaneous Cricothyrotom y failed 60% of the time 13 .

•The project identified numerous cases where awake fiber-optic intubation was indicated but not used 14 . NAP4 Lessons Learned A common theme was “failure to plan for failure” •In some cases when airway management was unexpectedly difficult the response was unstructured. In these cases outcomes were generally poor.

15 . NAP4 Lessons Learned • Aspiration was the single most common cause of death in anesthesia events • Importantly most aspirations occur due to failure to recognize risk factors and failure to adjust the anesthetic technique accordingly • Aspiration remains the most frequent cause of airway related deaths during anesthesia.

Obstruction was the common cause in these events Recommendations: •Nasal Trumpets •Oral Airway •Airway exchange catheter •SGA prior to removal of ETT (Bailey Maneuver) •Awaken patient with SGA in place 16 . NAP4 Lessons Learned One third of the events occurred during emergence or in recovery.

Predictors of Difficult Mask Ventilation • Beard • OSA • Obesity • Male Gender • Mallampati class III or IV • Neck Circumference 17 .

• History of difficult intubation • Inadequate equipment • Experience not enough. • Increased Age • Mallampati III or IV . • Poor technique. Predictors of Difficult Intubation • Inadequate Preoperative Assessment.

• Increase in either anterior depth or Posterior depth of the mandible decrease in Atlanto Occipital distance • Limited cervical range of motion • Small mouth opening • Temporomandibular joint pathology . Anatomical Factors Affecting Laryngoscopy • Neck Circumference (Single Major Predictor in Obese) • Short Neck. • Protruding incisor teeth. • Long high arched palate.

face. maxilla and mandible • Jaw movements • Head extension and movements • The teeth and oropharynx • The soft tissues of the neck • Recent chest and cervical spine x-rays 20 .Basic Airway Evaluation in All Patients • Previous anesthetic problems • General appearance of the neck.

Obstruction? Neck mobility. Mallampati.Think L-E-M-O-N When Assessing a Difficult Airway Look externally. Evaluate the 3-3-2 rule. .

L: Look Externally • Obesity or very small. • Short Muscular neck • Large breasts • Prominent Upper Incisors (Buck Teeth) • Receding Jaw (Dentures) • Burns • Facial Trauma • Stridor • Macroglossia (Lg Tongue) .

E-Evaluate the 3-3-2 Rule • 3 fingers fit in mouth • 3 fingers fit from mentum to hyoid cartilage • 2 fingers fit from the floor of the mouth to the top of the thyroid cartilage 23 .

E-Evaluate the 3-3-2 Rule 02/22/17 24 .

and uvula Class-III Class-IV soft palate and base of uvula Only hard palate . fauces Uvula.Mallampati classification Class-I Class-II soft palate. pillars. the soft palate. M. fauces.

Mallampati ? 26 .

Cormack & Lehane Grading 27 .

O-Obstruction Blood Vomit Teeth Dentures Epiglottis Tumors Foreign Body (piercings) 28 .

N-Neck mobility -Measurement of Atlanto-Occipital Angle .

> 35° Grade II –.22-34° Grade III – 12-21° Grade IV -.< 12° 30 . Atlanto-Occipital Angle Estimates the angle traversed by the occluded surface of the upper teeth Grade I --.

• A short thyromental distance equates with an anterior larynx • Greater than 7 cm is usually a sign of an easy intubation • Less than 6 cm is an indicator of a difficult airway • Relatively unreliable test unless combined with other tests 31 . Thyromental Distance • Measure from upper edge of thyroid cartilage to chin with the head fully extended.

Thyromental Distance 32 .

Definite plan (B) than option of awake intubation 6. Definite initial plan (A) for ventilation and intubation 5. MANAGEMENT PLAN OF ANTICEPATED DIFFICULT AIRWAY 1. Discussion with colleagues in advance 2. Ideal situation surgery team standby . Equipment tested before 3. Senior help backup 4.

5 min (Time to desaturation is consistently shorter then preferred method) Why Preoxygenate? • O2 Consumption Vo2=250ml/min and 2500ml O2 in FRC (after preO2) = 10 minutes to use this O2 . Preoxygenation Two Techniques Common in Use: 1. Tidal volume breathing (TVB) of 100% oxygen via a tight-fitting face mask for 5 minutes (Preferred Method) 2. Deep breaths/Vital Capacity 4 times within 0.

Airway Management A-B-C Start with Plan A If plan A fails- Go to plan B If plan B fails- Go to plan C .

Plan “A”: (ALTERNATE) • Different Length of blade • Different Type of Blade • Different Position • Different Equipment .

Plan “B”: (BVM and BLIND INTUBATION Techniques ) • Mask Ventilation • Bougie • Combi-Tube? • LMA an Option? • Fiberoptic? .

. Can’t Ventilate • Needle Cricothyrotomy • Transtracheal Jet Ventilation • Retrograde Wire Intubation . Plan-C Can’t Intubate.

starting the rescue plan too late • Not involving.. and preparing.Failure. surgical colleagues 39 . Why does it happen • 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.


Rigid Laryngoscope Blades Of Alternate Design And Size Mc Coy Macintosh Magill Miller Polio 41 .

Video Laryngoscopy Airtraq McGrath C-Mac 42 .

Video Laryngoscopy • VL Calls on a Alternative Skill Set • In Critical Situations Unpracticed Techniques may not be Helpful 43 .

Video Laryngoscopy • Use a stylet and shape it to match your VL Blade • Watch the patient not the monitor when • inserting the VL Blade • Trouble passing tube -Withdraw 44 .

Video Laryngoscopy Versus Direct Laryngoscopy • Improved Glottic View • Experienced vs Inexperienced • Cost • Standard of the future? • Picture Confirmation? 45 .

Bullard Rigid Fiberoptic Laryngoscope • Time • Experience • Limited Maneuverability 46 .

Stylet Devices Optical Stylet Lighted Stylet • No Nasal Intubation • No Suction • Limited to above Cords 47 .

GUM ELASTIC BOUGIE (GEB) – First used in England – Cheap – Good in patients in whom only epiglottis is visualized 48 .

Supraglottic Airways SGA Combitube LMA 49 .

The Esophageal- Tracheal Combitube •Useful as emergency airway •Two lumens allow function whether place in esophagus or trachea •Esophageal balloon minimizes aspiration 50 .

Laryngeal Mask Airway .

VARIATIONS OF LMA • LMA – Classic (standard) • LMA – Flexible (reinforced) • LMA – Unique (disposable LMA) • LMA – Fastrach (intubating LMA) • LMA – C-Trach (Visualization/Intubation) • LMA – Proseal (gastric LMA) 52 .

0 mm cuffed ETT and is short enough to ensure passage of the ETT cuff beyond the vocal cords • Rigid handle to facilitate one- handed insertion. airway tube that is wide enough to accept an 8. two sizes for adults 53 . anatomically curved. removal • Epiglottic elevating bar in the mask aperture which elevates the epiglottis as the ETT is passed through • Available in three sizes. one size for children.LMA – Fastrach (Intubating LMA) • Rigid.

LMA C-Trach • Ventilation • Visualization • Intubation 54 .

Providing a tighter seal against the glottic opening with no increase in mucosal pressure • Provides more airway security • Enables use of PPV in those cases where it may be required • A built-in drain tube designed to channel fluid away and permit gastric access for patients with GERD 55 . LMA-Proseal • High seal pressure .up to 30 cm H20 .

LMA-Proseal 56 .

Fiberoptic Aided Intubation • Most Versatile Tool Available for Difficult Intubation • Optical Elements are Small • Visualization Below the Cords • Awake Intubation • Unique Skillset • Lens Contamination • Cost 57 .

Can’t Ventilate/Cant Intubate 58 .

Cricothyrotomy • Airway established through the Cricothyroid Membrane • Not a Tracheostomy • Large Bore Catheter • Expected skill of the Anesthetist • Contraindicated in Neonates and Children under age 6 59 .

Pathology or Deformity • 16-Gauge or Larger (16g. • Specialized systems capable of using Low- pressure O2 60 .tidal volume 400- 700) • 15-30 psi with Insufflation 1-1. Transtracheal Jet Ventilation • Maxillofacial. Pharyngeal. or Laryngeal Trauma.5 sec.

(Magill Forceps) • Wire is Clamped/Secured at the entry site • ETT advanced over the wire (Many Techniques) • Wire removed leaving ETT in place 61 . Retrograde Intubation • Local Anesthesia of the airway. • Cricothyrotomy performed with air aspiration • Retrograde wire is advanced until it emerges from the mouth. skin wheel at puncture site.

Retrograde Intubation 62 .

Extubation of the Difficult Airway 63 .

Airway Exchange Catheter Extubation in a controlled manner with a AEC •Well tolerated •Airway can be reintubated •Can deliver Oxygen •Provides an avenue for suction 64 .

Airway Exchange Catheter • Localize the airway through existing ETT • Mark AEC at required depth (tube depth +3 CM) • Insert AEC and remove ETT • Tape AEC in place • Assess for removal of AEC 65 .

Bailey Maneuver Exchange of ETT for a LMA Decreased Severity of • Cough • Maximum change SBP • Maximum change HR • Sore throat 66 .

Bailey Maneuver • Patient is Deep • Oral-pharyngeal suction • Deflated LMA placed behind ETT • LMA cuff inflated • ETT cuff deflated and removed • LMA used for ventilation 67 .

What's New in the ASA Difficult Airway Algorithm 2003 2013 68 .

Added: Difficult Supraglottic airway placement Separated: Intubation and Laryngoscopy 69 .What's New in the ASA Difficult Airway Algorithm Assess Likelihood and Impact section.

What's New in the ASA Difficult Airway Algorithm 2003 2013 Basic Management Choices: Video-assisted Laryngoscopy as initial approach to Intubation 70 .

What's New in the ASA Difficult Airway Algorithm 2003 2013 “LMA” changed to “SGA” 71 .

What's New in the ASA Difficult Airway Algorithm 2003 2013 Video-Assisted Laryngoscopy: Listed first under Alternative Difficult Intubation Approach 72 .

What's New in the ASA Difficult Airway Algorithm

2003 2013

Under Invasive Airway
Access: Percutaneous airway
techniques and jet ventilation
remain but are


Two For The Road


Two For The Road
• Be familiar with alternative
intubating techniques and use
them on a regular basis in your
day to day practice.


Two For The Road 76 .

Questions? 77 .

Questions? 78 .