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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. Acquired causes . Congenital causes 2.

Binnion’s LEMON Law BONES The 4 D’s . Basic airway evaluation in all patients Dr.

Dr. . M allampati. Binnions Lemon Law: An easy way to remember multiple tests… L ook externally. E valuate the 3-3-2 rule. 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 .

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

O: Obstruction?  Blood  Vomitus  Teeth  Epiglottis  Dentures Tumors .

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

Mental Distance Measure from upper edge of thyroid cartilage to chin with the head fully extended. • > 7 cm is usually = easy intubation • < 6 cm = difficult airway 18 .Thyro. • A short thyromental distance = an anterior larynx .

MANAGEMENT PLAN OF ANTICIPATED DIFFICULT AIRWAY 02/22/17 19 .

Is mask ventilation going to be difficult? Can’t ventilate e Defined by “BONES” • Beard i l a t • Obesity en t • No teeth ’ t v Ca n • Elderly • Snoring .

Distortion 3.Dysmobility 4.Disproportion 2. Is laryngeal visualization going to be difficult? Can’t intubate Defined by 4 D’s 1.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 .

BEFORE an intervention is undertaken . Is cricothyroidotomy going to be difficult? Can’t Rescue Should assessment reveal a potentially difficult airway the cricothyroid membrane should be identified and marked.

Awake intubation 2. Possible Options! Following airway assessment.Quick look 3.Induction and paralysis . the person performing the intubation should be in a position to decide between three possible options 1.

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.

In this case the patient is assessed as having a low risk of laryngoscopy and/or mask ventilation   . 3. Induction & Paralysis The patient may be induced and paralyzed.

Pre-oxygenation: How Much Is Enough? Two techniques common in use: 1. Deep breaths (DB) 4 times within 0.5 min Both are equally effective in increasing arterial oxygen tension (Pao2). 60: 313–5 . Anesth Analg 1981. Tidal volume breathing (TVB) of oxygen for 3–5 min 2.

95: 754-759 . 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. 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 .

. Know this answer before you tube.What are we going to do if we don’t get the Tube? Plans “A”.“C” and plan “D”. “B” .

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starting the rescue plan too late Not involving. and preparing. surgical colleagues . 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.

Levitan scope Fibreoptic bronchoscope . GALLERY OF TOOLS ILMA Video laryngoscopes Malleable video stillet.

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ELECTIVE EMERGENCY .

ELECTIVE Old case of Hemi-mandibulectomy with forehead flap with trismus for block dissection of neck nodes .

G.Anesthesia of choice . Intubating technique of choice ? .A.

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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 .

cricothyroidotomy……………. ILMA.g. Take home message Be familiar with the alternative methods of intubating technique and use it regularly in your day today practice e. Videolaryngoscopes. So that you won’t fumble at the time of crisis 02/22/17 47 . FOB.

Challenges may be Waiting for you 02/22/17 48 .

Thank .