183 difficult airway management (gabungan)

7/25/2019 183 Difficult Airway Management (Gabungan)

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KPPIAKURSUS PENYEGAR DAN PENAMBAH ILMU ANESTESIA

5-9 AGUSTUS 2009


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QUALITY OF CARE ANDPATIENT SAFETY


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THE AIMS OF ANESTHESIA IS SAFETY

THE SAFETYIS AN ACCIDENT PREVENTIONAN ACCIDENT PREVENTION BEGINS WITH

A GOOD PREOPERATIVE EVALUATION


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GOOD JUDGMENTGOOD JUDGMENTcomescomes

fromfromEXPERIENCE.EXPERIENCE.

EXPERIENCEEXPERIENCEcomes fromcomes from

BAD JUDGMENT.BAD JUDGMENT.


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.AS SUCH, THE.AS SUCH, THE PRIMARY RESPONSIBILITYPRIMARY RESPONSIBILITYOF THEOF THEANESTHESIOLOGIST AS A CLINICAL ISANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THETO SAFEGUARD THEAIRWAYAIRWAY,, I.E. TO PRESERVE AND PROTECT IT DURINGI.E. TO PRESERVE AND PROTECT IT DURING

INDUCTION, MAINTENANCE, AND RECOVERY FROM THE STATEINDUCTION, MAINTENANCE, AND RECOVERY FROM THE STATEOF ANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITOF ANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLESURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLEINJURY FROM INADEQUATE OR COMPROMISEDINJURY FROM INADEQUATE OR COMPROMISEDOYGENATION.OYGENATION.


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SAFETY FIRSTSAFETY FIRST

THE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIST, PLAYS A UNIQUETHE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIST, PLAYS A UNIQUEROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAINROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAINEITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERALEITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERAL

ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.AS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLEAS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLERELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUSRELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUSPHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, ANDPHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, ANDHIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITHHIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITHEACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEXEACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEXBODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODYBODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODYTEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFEREDTEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFEREDWITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC ANDWITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC ANDMETABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATIONMETABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATIONSHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCESHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCEOF THE ANESTHETIZED STATEOF THE ANESTHETIZED STATE


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THESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFERTHESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFERIF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION ORIF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION ORMAINTENANCE OF THE ANESTHETIZED STATE.MAINTENANCE OF THE ANESTHETIZED STATE.

AS SUCH,AS SUCH, THE PRIMARY RESPONSIBILITYTHE PRIMARY RESPONSIBILITYOF THEOF THEANESTHESIOLOGIST AS A CLINICAL ISANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THETO SAFEGUARD THEAIRWAYAIRWAY,, I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,

MAINTENANCE, AND RECOVERY FROM THE STATE OFMAINTENANCE, AND RECOVERY FROM THE STATE OFANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLESURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLEINJURY FROM INADEQUATE OR COMPROMISED OYGENATION.INJURY FROM INADEQUATE OR COMPROMISED OYGENATION.

TECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) ARETECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) ARE

ERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELL-ERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELL-BEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELL-BEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELL-BEING IS UNSOUND OR TREATENED.BEING IS UNSOUND OR TREATENED.

BUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENTBUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENTAND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.AND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.


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CLINICAL ASSESSMENT OF THECLINICAL ASSESSMENT OF THE

AIRWAYAIRWAY


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INTRODUCTIONAIRWAY ANATOMY

THE SUPRAGLOTTIC AIRWAYSUBGLOTTIC AIRWAY

MANAGEMENT OF PATIENTS WITH NORMAL AIRWAYANATOMYMANAGEMENT OF PATIENT WITH THE DIFFICULT AIRWAY

PREDICTION

PREPARATIONPRACTICE

TOOLS FOR MANAGEMENT OF THE DIFFICULT AIRWAY


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INTRODUCTION

VARIOUS STUDIES REPORT THAT BETWEEN 1% AND 18% OFPATIENTS HAVE DIFFICULT AIRWAY ANATOMY. OF THESE, 0.05

0.!5% ARE NOT INTUBATED SUCCESSFULLY; AND ASIGNIFICANT PORTION MAY BE DIFFICULT TO VENTILATE BY

MAS. IT IS LIELY THAT THE PRACTITIONER WILL ENCOUNTERBETWEEN ONE AND !" PATIENTS PER YEAR IN WHOMINTUBATION OF THE TRACHEA WILL BE DIFFICULT ORIMPOSSIBLE.

WILL BE DISCUSS, THE BASICS OF AIRWAY ANATOMY ANDNORMAL AIRWAY MANAGEMENT, AND TO HIGHLIGHT SOME OFTHE FACTORS THAT CONTRIBUTE TO THE SAFE MANAGEMENT

OF THE PATIENT WITH A DIFFICULT AIRWAY


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AIRWAY ANATOMY

THE SUPRAGLOTTIC AIRWAY

SUBGLOTTIC AIRWAYMANAGEMENT OF PATIENTS WITH NORMAL AIRWAY ANATOMY

MANAGEMENT OF THE DIFFICULT AIRWAYPREDICTION

PREPARATION

PRACTICE

TAEN AS A SYSTEM, THE AIRWAY BEGINS AT THE E"TERNAL OPENINGS OF THE MOUTHAND NOSE AND ENDS IN THE ALVEOLAR UNITS.

AIRWAY ANATOMY WILL BE DISCUSSED IIN TERMS OF THE SUPRAGLOTTIC AIRWAY, THELARYN" AND THE SUBGLOTTIC AIRWAY.

THE SUPRAGLOTTIC AIRWAY

THE NOSE

THE NOSE SERVES TO WARM AND HUMIDITY AIR AS IT ENTERS THE BODY. THE NASALPASSAGE MAY BE LIMITED BY THE SIZE OF THE TURBINATES, WHICH ARE HIGHLYVASCULAR. PASSAGE OF ENDOTRACHEAL TUBES OR BRONCHOSCOPES THROUGH THE

NOSE MAY BE ASSOCIATED WITH PROFUSE BLEEDING. THE NASAL SEPTUM IS OFTENDEVIATED, GIVING A SMALLER PASSAGE ON ONE SIDE THAN THE OTHER. THENASOPHARYNX OPENS INTO THE OROPHARYNX BRANCHES OF THE FIFTH CRANIALNERVE PROVIDE SENSORY INNERVIATION TO THE NOSE

ANATOMY AIRWAY


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THE TONGUE MAY MOVE POSTERIORLY IN THE PHARYNX AND OBSTRUCT

THE AIRWAY BY CONTRACTING THE POSTERIOR WALL OF THEOROPHARYNX.

THIS CONDITION OCCURS IN ANESTHETIZED AND SEDATED PATIENTSBUT MAY ALSO OCCUR IN SLEEPING PATIENTS.

THE OBSTRUCTION OCCURS AS MUSCLE TONE DECREASES AND ADECREASE IN THE FUNCTIONAL LUMEN OF THE PHARYNX ENSUES.

WITH SPONTANEOUSLY BREATHING PATIENTS, A DECREASE INFUNCTIONAL AIRWAY LUMEN MAY BE ASSOCIATED WITH AN INCREASEDRESPIRATORY EFFORT AND RESULTANT GREATER NEGATIVE PRESSUREBELOW THE LEVEL OF OBSTRUCTION.

THIS CAN LEAD TO A WORSENING OF THE OBSTRUCTION AS THE

NEGATIVE PRESSURE PULLS MORE SOFT TISSUE INTO THE AREA OFCOLLAPSE.

A SIGNIFICANT FROM OF THIS PROBLEM IS OBSTRUCTIVE SLEEP APNEA

THE PHARYN


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THE LARYN

THE LARYN" IS A COMPLICATED STRUCTURE THAT SERVES TO PROTECT THELOWER AIRWAYS, AS THE ORGAN OF PHONATION AND AS THE CONDUIT FORRESPIRATION.

THESE FUNCTIONS DEPEND ON THE INTERATCTION OF THE CARTILAGINOUS,BONY AND SOFT TISSUE COMPONENTS OF THE LARYNX AND PHARYNX.

THERE ARE # CARTILAGES OF THE LARYNX. THE MUSCLES OF THE LARYNX AREBOTH EXTRINSIC AND EXTRINSIC.

CARTILAGES OF THE LARYN"

THYROID CARTILAGECRICOID CARTILAGEARYTENOID CARTILAGESEPIGLOTTIS

SUBGLOTTIC AIRWAYTRACHEALOBAR BRONCHI


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MANAGEMENT OF PATIENTS WITH NORMAL AIRWAY ANATOMY

MASTERING VENTILATION BY BAG AND MAS# IS CRITICAL FOR SAFE PRACTICE.THE BASIC MANEUVERS USED TO FACILITATE AIR E"CHANGE IN SPONTANEOUSLYBREATHING OR PARALY$ED PATIENTS ARE DIRECTED TO OPENING THE AIRWAY

ABOVE THE GLOTTIS.MOTIONS THAT MOVE THE TONGUE AND OTHER SOFT TISSUES OF THESUPRAGLOTTIC AIRWAY ANTERIORLY WILL GENERALLY IMPROVE AIR EXCHANGE.

THESE MANEUVERS INCLUDE CHIN LIFT, $AW THRUST, HEAD TILT ANDINTRODUCTION OF ORAL OR NASAL AIRWAYS.

DIFFICULT WITH MAS# VENTILATION MAY BE PREDICTED IN SOME PATIENTS.FACTORS REPORTED TO CORRELATE TO DIFFICULT MAS# VENTILATION INCLUDEDPRESENSE OF A BEARDBODY MASS INDEX GREATER THAN %&LAC OF TEETHAGE OVER '' YEARSHISTORY OF SNORING


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MOTIONS REQUIRED FOR INTUBATION IN THE NORMAL PATIENT ARE PERFORMED TOALLOW VISUALIZATION OF THE LARYNX FROM THE OPENING OF THE MOUTH.

IN PATIENTS WITH NORMAL AIRWAY ANATOMY, THE MA$OR COMPONENTS OF THISPOSITIONING ARE FLEXION OF THE NEC, PARTICULARLY IN THE LOWER CERVICAL SPINEAND EXTENSION OF THE AT THE ATLANTOOCCIPITAL $OINT.

THIS POSITION IS REFERRED TO AS THE SNIFFING POSITION


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MANAGEMENT OF THE DIFFICULT AIRWAY

IDEALLY ALL PATIENTS WOULD HAVE NORMAL AIRWAYANATOMY.

ANY PATIENT REQUIRING A CONTROLLED AIRWAY WOULDHAVE NO ADDITIONAL RIS.

THE ANESTHESIOLOGIST MUST HAVE A WAY TO IDENTIFY ANDCARE FOR PATIENTS WITH ABDNORMAL AIRWAY ANATOMY.

SAFE MANAGEMENT OF PATIENTS WITH A DIFFICULT AIRWAY.PREDICTION

PREPARATIONPRACTICE


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PREDICTION

THERE ARE SEVERAL POPULAR METHODS OF PREDICTING EASE ORDIFFICULTY OF INTUBATION USING A PHYSICAL EXAMINATION.

DIFFICULT IN INTUBATING THE TRACHEA CAN BE SAID TO OCCURWHEN AN E"PERIENCED PRACTITIONER IS UNABLE TO PASS ANENDOTRACHEAL TUBE IN THE NORMAL TIME AND FASHION, IT MAYBE DEFINED AS AN INTUBATION THAT REUIRES MORE THAN ONEATTEMPT.

HOWEVER, MORE DIFFICULT INTUBATIONS CAN BE RELATED TO THEGRADE OF LARYNGOSCOPIC.

DIFFICULTY DURING INTUBATION IS LIELY WITH A GRADE III OR IVVIEW.GRADE I * VOCAL CORDS ARE VISIBLE

GRADE II * VOCAL CORDS ARE ONLY PARTLY VISIBLEGRADE III * ONLY THE EPIGLOTTIS IS SEENGRADE IV * NOT EVEN THE EPIGLOTTIS IS SEEN


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A B

DC


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THERE ARE VARIOUS FACTORS TO EVALUATE WHEN ASSESSING A PATIENTS

FOR ENDOTRACHEAL INTUBATION

HISTORY;HOWEVER, PATIENTS WHO GIVE A HISTORY OF PRIORDIFFICULT INTUBATION HAVE A VERY HIGH INCIDENCE OF DIFFICULTINTUBATION. THE PRESENCE OF CONDITIONS ASSOCIATED WITHDIFFICULT INTUBATION SHOULD BE ASCERTAINED

THESE CONDITIONS INCLUDE * CONGENITAL SYNDROMES, INCLUDING DOWN, GOLDNHAR, TREACHER

COLLINS, PIERRE ROBIN AND MUCOPOLYSACCHARIDOSES, AMONG OTHERS

- BONY DISEASES, INCLUDING RHEUMATOID ARTHRITIS,ANYLOSING

SPONDYLLITIS, MANDIBULAR FRACTURE OR FIXATION, ANYLOSISOF

THE TEMPOROMANDIBULAR $OINT.- SOFT TISSUES ABNORMALITIES, INCLUDING OBESITY, TUMORS,

HEMANGIOMAS, ABSCESSES, AIRWAY INFECTIONS SUCH AS

EPIGLOTTITIS, BLEEDING.

- TRAUMA TO FAE OR NEC, BURNS, POSTOPERATIVE CHANGES

INCLUDING SCARRING, RADIATION-INDUCED CHANGES


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DENTITION

TEMPOROMANDIBULAR JOINT MOBILITY

OROPHARYNGEAL CLASS. THIS IS COMMONLY CALLED MALLAMPATICLASS

THE OPENING IN THE PHARYNX IS EVALUATED. SCORES OF + OR ARE

ASSOCIATED WITH A GREATER CHANGE OF DIFFICULT INTUBATION.

WIDTH OF THE PALATE

THE TYROMENTAL DISTANCE

COMPLIANCE OF THE MANDIBULAR SPACE

BODY HABITUS

NEC! MOBILITY


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ONE SET OF MANEUVERS WITH SEEMS TO WOR WELL AND ALLOWS,

EVALUATION OF THE SIGNIFICANT FACTORS IS OUTLINED BELOW.WITH

THE PATIENT IN A SITTING OR SEMISITTING POSITION EVALUATE & BODY HABITUS, ESPECIALLY THE DISTRIBUTION OF BODY FAT

AROUND THE HEAD AND NEC# THYROMENTAL DISTANCE, MANDIBULAR COMPLIANCE; IM GOING

TO PUT MY HAND UNDER YOUR CHIN TEETH, MOUTH OPENING AND ORALPHARYNGEAL SPACE; OPENYOUR MOUTH AS WIDE AS YOU CAN; IF THE MALLAMPATI SCORE ISNOT ! OR % AS, FOR PLHONATION.

TEMPOROMANDIBULAR 'OINT MOBILITY; RELAX. NOW STIC YOURCHIN OUT TO PUT YOUR LOWER TEETH IN FRONT OF YOUR UPPERTEETH.

NEC# FLE"ION;PIC YOUR HEAD UP AND GTRY TO TOUCH YOURCHIN TO YOUR CHEST

HEAD E"TENSION; IM GOING TO HOLD MY HAND BEHIND YOURNEC . TIP YOUR HEAD BAC AS FAR AS YOU CAN, LIE YOU ARETRYING TO LOO AT THE CEILLING.


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PREPARATION

ADEQUATE PREPARATION TO CARE FOR PATIENTS WITH DIFFICULTAIRWAY ANATOMY REQUIRES ASQUISITION OF NOWLEDGE AND

EQUIPMENT.THE NOWLEDGE NECESSARY FOR SAFE MANAGEMENT OF THESEPATIENTS IS AN EXTENSION OF THE NOWLEDGE NEEDED TOPROVIDE CARE FOR ANY PATIENT BUT WITH ADDITIONAL POINTS.

THE ALGORITHM SUGGESTS THE FOLLOWING STEPS *


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A B


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TOOLS FOR MANAGEMENT OF THE DIFFICULT AIRWAY

AIRWAYS

STYLETS, INTUBATION GUIDES AND BOUGIES

AIRWAY EXCHANGE CATHETER

SPECIALIZED FORCEPS

LARYNGOSCOPY

RIGID DIRECTVISION LARYNGOSCOPESARE AVAILABLE IN A WIDE ASSORTMENT OFBLADE SHAPES AND SIZES.

PATIENTS WITH A LONG, FLOPPY EPIGLOTTIS ARE OFTEN EASIER TO INTUBATEUSING A STRAIGHT BLADE THAN A MACHINTOSH BLADE.

RIGID, SEMIDIRECT LARYNGOSCOPESHAVE A PRISM ON THE BALDE TO ALLOW VISIONOF THE LARYNGEAL STRUCTURES WHEN THE PATIENTS ANATOMY DOESNT ALLOWDIRECT VISION.

RIGID FIBEROPTIC LARYNGOSCOPESSUCH AS THE BULLARD AND UPSHER SCOPESALLOW VISUALIZATION OF LARYNGEAL STRUCTURES VIA FIBEROPTICS.


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LARYNGOSCOPY

THESE SCOPES MAY BE VERY USEFUL IN PATIENTS WITH ANANTERIOR

LARYNX.

ADVANTAGESOF THE RIGID FIBEROPTIC INTUBATING SCOPESINCLUDE *

RIGID SCOPE MORE SIMILAR TO USUAL LARYNGOSCOPES POSSIBLY SHORTER LEARNING CURVE

POSSIBLY MORE DURABLE THAN FLEXIBLE FIBEROPTIC SCOPES

DISADVANTAGESOF THE RIGID FIBEROPTIC INTUBATING SCOPESINCLUDE *

THE ENDOTRACHEAL TUBE IS PASSED INTO THE LARYNX WHILEWATCHING THROUGH THE FIBEROPTIC EYEPIECE, NOT DIRECTLY

OVER THE SCOPE. TECHNIQUE MAY BE DIFFICULT OR AWWARD PATIENT SIZE LIMITS RELATED TO THE RELATIVELY LARGE BLADE

SIZE

FIBEROPTIC BRONCHOSCOPIC INTUBATION


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FIBEROPTIC BRONCHOSCOPIC INTUBATION (FBI) USES FLEXIBLE BRONCHOSCOPES TOINTUBATE THE TRACHEA.

MANY MANUFACTURERS HAVE DEVELOPED SCOPES SPECIFICALLY FOR INTUBATION THAT ARETYPICALL LONGER AND OF SMALLER DIAMETER THAN STANDARD DIAGNOSTICBRONCHOSCOPES.

THE ADVANTAGES OF FBI INCLUDE :

THE ENDOTRACHEAL TUBE IS PASSED INTO THE TRACHEA DIRECTLY OVERTHE SCOPE

ACCEPTABLE RANGE OF PATIENT SIZES, SINCE DIFFERENT-SIZED SCOPESARE AVAILABLE.

THERAPEUTIC USES INCLUDE PLACEMENT OF BRONCHIAL BLOCERS ANDDOUBLE-LUMEN ENDOTGRACHEAL TUBES. ADDITIONALLY, THEBRONCHOSCOPE MAY BE USEFUL IN REMOVING SECRETIONS FROM THEBRONCHI.

DISADVANTAGES OF FBI INCLUDETHE TECHNIQUE CAN BE DIFFICULT TO LEARNTHE COST AND FRAGILITY OF THE EQUIPMENT ARE OF CONCERN

PITFALLS OF FBI INCLUDEBLOOD SECRETIONS MAY OBSCURE VIEWDISTORTED ANATOMYSPECIAL PROBLEMS WITH FBI *

ENDOTRACHEAL TUBE MAY HANG UP ON LARYNGEAL STRUCTURES

SCOPE MAY LOOP IN PHARYNX LENS MAY FOG


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ROLE OF THE LARYNGEAL MAS! AIRWAY IN DIFFICULT AIRWAY MANAGEMENT

THE LMA CAN BE USED TO CHANGE A CAN"T VENTILATE TO A CAN VENTILATE SITUATION.

THIS ALLOWS YOU TO CONTINUE THE ANESTHETIC WITH THE LMA AS YOUR AIRWAY DEVICE OR AWAEN THE PATIENT TO ALLOW A SAFE ALTERNATIVEINTUBATION OR TRACHEOSTOMY.

HOWEVER, ONCE VENTILATION IS ASSURED THROUGH THE LMA, OTHER TECHNIQUES MAY BE USED TO SECURE THE AIRWAY.

THE INTUBATING LMA #ILMA$ ADDS ANOTHER TOOL FOR MANAGEMENT OF PATIENTS WITH DIFFICULT AIRWAY ANATOMY.

THE ILMA SHOULD BE CONSIDERED EARLY IN MANAGEMENT OF PATIENTS WITH UNSUSPECTED DIFFICULT AIRWAY ANATOMY AS IT MAY ALLOWRAPID CONVERSION OF A DIFFICULT AIRWAY TO A CONTROLLED AIRWAY.

IF AN ILMA IS NOT AVAILABLE, THE LMA MAY STILL BE USED AS A CONDUIT TO INTUBATION, AS A BLIND TECHNIQUE OR WITH AIRWAYECHANGE CATHETERS OR FIBEROPTIC BRONCHOSCOPES.


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BLINDENDOTRACHEAL TUBE INTUBATION VIA LARYNGEALMAS!

AIRWAY

PLACE LMA AND VERIFY VENTILATION VIA LMA PASS A WELL-LUBRICATED ENDOTRACHEAL TUBE DOWN THE LMA, ROTATED

#""FROM NORMAL TO EASE PASSAGE THROUGH BARS ON LMA; AT %" CM,ROTATE ENDOTRACHEAL TUBE INTO NORMAL POSITION

PASS THE ENDOTRACHEAL TUBE INTO TRACHEA, INFLATE CUFF, VERIFYVENTILATION

SECURE THE ENDOTRACHEAL TUBE AND LMA IN PLACE OR CUT AND SPLIT

LMA TO ALLOW FOR SECURING OF THE ENDOTRACHEAL TUBE ALONE

SIZE

!!.'%%.'+

'

WEIGHT

/'G'-!"G!"-%"G%"-+"G+"G TO SMALL ADULTADULT

LARGE ADULTPOOR SEAL WITH

MAXIMUMAIR IN CUFF

ML0 ML

!" ML! ML%" ML+" ML

" ML

ETT SIZE THAT WILL PASS

+." UNCUFFED

.' UNCUFFED

&." UNCUFFED&." CUFFED

0.' CUFFED

LARYNGEAL MAS! AIRWAY SI%ES ANDCORRESPONDING ENDOTRACHEAL TUBE #ETT$


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FIBEROPTIC INTUBATION VIA LARYNGEAL MAS! AIRWAY PLACE LMA AND VERIFY VENTILATION VIA LMA LUBRICATE ENDOTRACHEAL TUBE WELL, POSITION ON BRONCHOSCOPE PASS BRONCHOSCOPE DOWN LMA, INTO TRACHEA, ADVANCE ENDOTRACHEAL TUBE ALONG BRONCHOSCOPE. VERIFY POSITION OF ENDOTRACHEAL TUBE VISUALLY, WITHDRAW BRONCHOSCOPE SECURE ENDOTRACHEAL TUBE AND LMA IN PLACE OR CUT AND SPLIT LMA TO ALLOW FOR SECURING OF THE ENDOTRACHEAL TUBE ALONE.

PASSAGE OF INTUBATING GUIDE VIA LARYNGEAL MAS! AIRWAY PLACE LMA AND VERIFY VENTILATION VIA LMA PASS VENTILATING OR NONVENTILATING INTUBATION GUIDE VIA LMA 1 VENTILATING GUIDE ALLOWS VERIFICATION OF POSITION OF GUIDE BY CAPNOMETRY BEFORE ENDOTRACHEAL TUBE

PASSAGE. REMOVE LMA, PASS APPROPRIATE-SIZED ENDOTRACHEAL TUBE OVER GUIDE, REMOVE INTUBATING GUIDE VERIFY POSITION OF ENDOTRACHEAL TUBE IN TRACHEA BY BRONCHOSCOPY, CAPNOMETRY AND VENTIL ATION SECURE ENDOTRACHEAL TUBE


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LARYNGEAL MAS! AIRWAYS ALLOW VENTILATION OF PATIENT DURING

OTHER AIRWAY MANAGEMENT TECHNIQUESTRACHEOSTOMY RETROGRADE WIRE-GUIDED INTUBATION

PITFALLS OF LARYNGEAL MAS! AIRWAY IN DIFFICULT AIRWAY

MANAGEMENT EPIGLOTTIS MAY FOLD DOWN DURING INSERTION OF THE AIRWAY AND LIMIT THE ABILITY TO PASS OTHER DEVICES INTO THE TRACHEA-THIS MAY HAPPEN EVEN THROUH SOME

VENTILATION IS POSSIBLE. BARS ON LMA MAY LIMIT PASSAGE OF OTHER DEVICESTHE ENDOTRACHEAL TUBE MAY BE TOO SHORT TO COMPLETELY ENTER THE TRACHEA VIA LMA.THE LMA ENDOTRACHEAL TUBE COMBINATION MAY BE DIFFICULT TO SECURE AND MAY SLIP OUT OF TRACHEA. RIS OF ASPIRATION OF GASTRIC CONTENTS 1 PROSEAL MAY DECREASE THIS RIS


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ADVANCED AIRWAY TECHNIQUES

RETROGRADE INTUBATION

TRANSTRACHEAL $ET VENTILATION

CRICOTHYROIDOTOMY

TRACHEOSTOMY


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SIZE

!!.'%%.'+

'

WEIGHT

/'G'-!"G!"-%"G%"-+"G+"G TO SMALL ADULTADULT

LARGE ADULTPOOR SEAL WITH

MAXIMUMAIR IN CUFF

ML0 ML

!" ML! ML%" ML+" ML

" ML

ETT SIZE THAT WILL PASS

+." UNCUFFED

.' UNCUFFED

&." UNCUFFED&." CUFFED

0.' CUFFED

LARYNGEAL MAS! AIRWAY SI%ES ANDCORRESPONDING ENDOTRACHEAL TUBE #ETT$


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INTRODUCTION

BEDSIDE ASSESSMENT

MANDIBLE MEASURE MENTAL-TYROID DISTANCE

O PENING OF THE MOUTHSU VULA VISIBILITY

TEETH PRESENTATION

H EAD MOVEMENT

S ILLOUETTE THE PROFILE OF THE HEAD, NEC AND CHEST


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INTRODUCTION

AN INADEQUATE AIRWAY LEADS RAPIDLY TO HYPOXAEMIA ANDUNCORRECTED HYPOXAEMIA WILL RESULT IN BRAIN DAMAGE ANDULTIMATELY DEATH.

THE GOLD STANDARD FOR A SECURE AIRWAY IS TRACHEAL

INTUBATION.

EVERY AIRWAY ASSESSMENT SHOULD INCLUDE TESTS THAT AIM TOPREDICT DIFFICULTY WITH TRACHEAL INTUBATION.

NO SINGLE TEST CAN PREDICT AIRWAY OR INTUBATION DIFFICULTY

RELIABLY.

NO SINGLE TEST, OR A COMBINATION OF TESTS, CAN DETECTDIFFITULTY WITH AIRWAY MANAGEMENT WITH !""2 CERTAINTY.


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BEDSIDE ASSESSMENT

MOUTHS

THE LETTERS STAND FOR * MANDIBLE, OPENING, UVULA, TEETH, HEAD ANNEC, SILHOUETTE

MANDIBLE MEASURE MENTAL-TYROID DISTANCE,

$AW THRUST PROTRUSION

- MENTO-TYROID DISTANCE LESS THAN & CM A SMALL RECEDINGMANDIBLE

- $AW 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


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O PENING BE AT LEAST + CM

U VULA (INCLUDING THE PALATE AND THE PHARYNGEALSTRUCTURES)MALLAMPATI AND MODIFIED BY SAMSOON AN YOUNG. THE TERMMALLAMPATI GRADE I TO IV.EVEN WITH BEST STANDARDISATION (PATIENT SITTING, HEAD IN

NEUTRAL POSITION, MAXIMUM MOUTH OPENING AND TONGUEPROTRUSION THERE IS INTER-OBSERVER VARIABILITY AND ARELATIVELY HIGH INCIDENCE OF FALSE NEGATIVES


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TEETHA COMPLETELY EDENTULOUS PATIENT HAS A WIDER GAPE AND THEREFORE ISRELATIVELY EASY TO INTUBATE

H EAD ALL

ASSESS RANGES OF MOVEMENT OF THE HEAD (ATLANTO-OCCIPITAL $OINT) ANDCERVICAL SPINE. AT LEAST A #""DIFFRENCE BETWEEN FULL FLEXION (CHIN ONCHEST) AND EXTENSION (AS THE PATIENT TO LOO AT THE CEILING WHILESITTING UPRIGHT. THE ABSENCE OF MOVEMENT PARTICULARLY IN THE ATLATO-OCCIPITAL $OINT MAY MAE IT PHYSICALLY IMPOSSIBLE TO OBTAIN A LINE OFVISION AT ATTEMPTED DIRECT LARYNGOSCOPY.

S ILLOUETTE THE PROFILE OF THE HEAD, NEC AND CHEST

THE COMBINATION OF MALLAMPATI, 'AW PROTRUSION AND CRANIOCERVICALE"TENSION HAS A SPECIFICITY OF ((% AND POSITIVE PREDICTIVE VALUE OF (!%.

A THROUGH BEDSIDE ASSESSMENT OF THE AIRWAY WILL ALERT THEANAESTHETIST TO MOST CASES OF DIFFICULTIES WITH LARYNGOSCOPY ANDINTUBATION. HOWEVER, SOME CASES WILL ONLY DISCOVERED AT INTUBATION


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EASY OR HARD?


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CLINICALCLINICAL

ASSESSMENTASSESSMENTOF THE AIRWAYOF THE AIRWAY


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INTRODUCTIONINTRODUCTION

GLOBAL ASSESSMENTGLOBAL ASSESSMENT

AIRWAY-COMPROMISING CONDITIONSAIRWAY-COMPROMISING CONDITIONS

OBJECTIVE ASSESSMENTOBJECTIVE ASSESSMENT


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INTRODUCTIONINTRODUCTION

SAFETY FIRSTSAFETY FIRST

THE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIS, PLAYS A UNIQUETHE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIS, PLAYS A UNIQUEROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAINROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAIN

EITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERALEITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERALANESTHESIA TO FACILITATE SURGICAL OPERATIONS.ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.

AS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLEAS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLERELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUSRELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUSPHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, ANDPHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, ANDHIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITHHIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITH

EACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEXEACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEXBODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODYBODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODYTEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFEREDTEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFEREDWITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC ANDWITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC ANDMETABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATIONMETABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATIONSHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCESHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCEOF THE ANESTHETIZED STATEOF THE ANESTHETIZED STATE


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THESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFERTHESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFERIF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION ORIF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION ORMAINTENANCE OF THE ANESTHETIZED STATE.MAINTENANCE OF THE ANESTHETIZED STATE.

AS SUCH, THE PRIMARY RESPONSIBILITY OF THEAS SUCH, THE PRIMARY RESPONSIBILITY OF THEANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THEANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THEAIRWAYAIRWAY,, I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,

MAINTENANCE, AND RECOVERY FROM THE STATE OFMAINTENANCE, AND RECOVERY FROM THE STATE OFANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLESURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLEINJURY FROM INADEQUATE OR COMPROMISED OYGENATION.INJURY FROM INADEQUATE OR COMPROMISED OYGENATION.

TECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) ARETECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) AREERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELL-ERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELL-

BEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELL-BEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELL-BEING IS UNSOUND OR TREATENED.BEING IS UNSOUND OR TREATENED.

BUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENTBUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENTAND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.AND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.


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GLOBAL ASSESSMENTGLOBAL ASSESSMENT

ALTHOUGH AIRWAY ASSESSMENT IS ESSENTIALLY A REGIONALALTHOUGH AIRWAY ASSESSMENT IS ESSENTIALLY A REGIONALANATOMIC ASSESSMENT A GENERAL ASSESSMENT OF THEANATOMIC ASSESSMENT A GENERAL ASSESSMENT OF THEBODY BUILD AND OF THE HEAD AND NEC.BODY BUILD AND OF THE HEAD AND NEC. TO VIEW THETO VIEW THE

HEAD AND NEC! FRONTALLY AS WELL AS N PROFILE ANDHEAD AND NEC! FRONTALLY AS WELL AS N PROFILE ANDTA!E INTO CONSIDERATION THE BODY BUILD AS WELL.TA!E INTO CONSIDERATION THE BODY BUILD AS WELL.

THE SHORT, THIC NEC THAT IS OFTEN ASSOCIATED WITHTHE SHORT, THIC NEC THAT IS OFTEN ASSOCIATED WITHDIFFICULT INTUBATION IS WELL NOWN AS IS THE CASE WITHDIFFICULT INTUBATION IS WELL NOWN AS IS THE CASE WITHMORBID OBESITY.MORBID OBESITY.

AIRWAYS DIFFICULTIES TEND TO BE ASSOCIATED WITHAIRWAYS DIFFICULTIES TEND TO BE ASSOCIATED WITHSHORT AND STUMPY INDIVIDUALS MORE OFTEN THANSHORT AND STUMPY INDIVIDUALS MORE OFTEN THANTALL AND THIN INDIVIDUALSTALL AND THIN INDIVIDUALS; THIS IS ESPECIALLY TRUE; THIS IS ESPECIALLY TRUEWITH PREGNANT WOMEN, PERHAPS ALSO AS A REFLECTION OFWITH PREGNANT WOMEN, PERHAPS ALSO AS A REFLECTION OFFLUID RETENTION DURING PREGNANCY.FLUID RETENTION DURING PREGNANCY.


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ANATOMICALLY, THE AIRWAY MAY BE COMPROMISED BY AANATOMICALLY, THE AIRWAY MAY BE COMPROMISED BY A

BROADBROAD

ARRAY OF FACTORS THAT MAY BE CLASSIFIED ON THE BASISARRAY OF FACTORS THAT MAY BE CLASSIFIED ON THE BASIS

OFOF

CAUSE.CAUSE.!.!. DISPROPORTION, PARTICULARLY BETWEEN THE BASE OFDISPROPORTION, PARTICULARLY BETWEEN THE BASE OF

TONGUE AND OROPHARYNGEAL SPACE.TONGUE AND OROPHARYNGEAL SPACE.

%.%. DISTORTIONDISTORTION

+.+. DECREASED MOBILITY OF $OINTS (ATLANTO-OCCIPICALDECREASED MOBILITY OF $OINTS (ATLANTO-OCCIPICAL

AND TEMPOROMANDIBULAR $OINTS)AND TEMPOROMANDIBULAR $OINTS).. DENTAL OVERBITEDENTAL OVERBITE


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CONGENITALCONGENITAL PIERRE ROBIN SYNDROMEPIERRE ROBIN SYNDROME

TEACHER COLLINSTEACHER COLLINSSYNDROMESYNDROME

GOLDENHARS SYNDROMEGOLDENHARS SYNDROME

DOWNS SYNDROMEDOWNS SYNDROME

LIPPEL-FEIL SYNDROMELIPPEL-FEIL SYNDROME

GOITERGOITER

MICROGNETHIA, MACROGLOSSIA, CLEFT SOFMICROGNETHIA, MACROGLOSSIA, CLEFT SOFPALATEPALATE

AURICULAR AND OCULAR DEFECTS; MALARAURICULAR AND OCULAR DEFECTS; MALAR

AND MANDIBULAR HYPOPLASIAAND MANDIBULAR HYPOPLASIA

AURICULAR AND OCULAR DEFECTS; MALARAURICULAR AND OCULAR DEFECTS; MALARAND MANDIBULAR HYPOPLASIA;AND MANDIBULAR HYPOPLASIA;

OCCIPITALIZATION OF ATLASOCCIPITALIZATION OF ATLAS

POORLY DEVELOPED OR ABSENT BRIDGE OFPOORLY DEVELOPED OR ABSENT BRIDGE OFTHE NOSE; MACROGLOSSIA.THE NOSE; MACROGLOSSIA.

CONGENITAL FUSION OF A VARIABLECONGENITAL FUSION OF A VARIABLE

NUMBER OF CERVICAL VERTEBRAE;NUMBER OF CERVICAL VERTEBRAE;

RESTRICTION OF NEC MOVEMENTRESTRICTION OF NEC MOVEMENT

COMPRESSION OF TRACHEA, DEVIATION OFCOMPRESSION OF TRACHEA, DEVIATION OF

LARYNXTRACHEALARYNXTRACHEA

AIRWAY-COMPROMISING CONDITIONS

AIRWAY-COMPROMISING CONDITIONS


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ACQUIREDACQUIRED INFECTIONSINFECTIONS

SUPRAGLOTTITISSUPRAGLOTTITIS

CROUPCROUP

ABSCESS (INTRAORAL,ABSCESS (INTRAORAL,RETROPHARNGEAL)RETROPHARNGEAL)

LUDWIGS ANGINALUDWIGS ANGINAARTHRITISARTHRITIS

RHEUMATOID ARTHRITISRHEUMATOID ARTHRITIS

ANYLOSING SPONDYLITISANYLOSING SPONDYLITIS

BENIGN TUMORSBENIGN TUMORS

EXAPLES; CYSTIC HYGROMA,EXAPLES; CYSTIC HYGROMA,LIPOMA, ADENOMA, GOITERLIPOMA, ADENOMA, GOITER

MALIGNANT TUMORSMALIGNANT TUMORS

EXAMPLES; CARCINOMA OFEXAMPLES; CARCINOMA OFTONGUE, CARCIONAMA OFTONGUE, CARCIONAMA OFLARYNX, CARCINOMA OFLARYNX, CARCINOMA OF

THYROID.THYROID.

TRAUMATRAUMA

EXAMLES; FACIAL IN$URY,EXAMLES; FACIAL IN$URY,CERVICAL SPINE IN$URY,CERVICAL SPINE IN$URY,

LARYNGEALTRACHEAL TRAUMALARYNGEALTRACHEAL TRAUMA

OBESITYOBESITY

ACROMEGALYACROMEGALY

ACUTE BURNSACUTE BURNS

LARYNGEAL EDEMALARYNGEAL EDEMA

LARYNGEAL EDEMALARYNGEAL EDEMA

DISTORTION OF THE AIRWAY AND TRISMUSDISTORTION OF THE AIRWAY AND TRISMUS

DISTORTION OF THE AIRWAY AND TRISMUSDISTORTION OF THE AIRWAY AND TRISMUS

TEMPOROMANDIBULAR $OINT ANYLOSIS,TEMPOROMANDIBULAR $OINT ANYLOSIS,CRICOARYTENOID ARTHRITIS, DEVIATION OFCRICOARYTENOID ARTHRITIS, DEVIATION OFLARYNX, RESTRICTED MOBILITY OF CERVICALLARYNX, RESTRICTED MOBILITY OF CERVICALSPINESPINE

ANYLOSIS OF CERVICAL SPINE; LESS COMMONLYANYLOSIS OF CERVICAL SPINE; LESS COMMONLYANYLOSIS OF TEMPOROMANDIBULAR OOINTS;ANYLOSIS OF TEMPOROMANDIBULAR OOINTS;LAC OF MOBILITY OF CERVICAL SPINE.LAC OF MOBILITY OF CERVICAL SPINE.

STENOSIS OR DISTORTION OF THE AIRWAYSTENOSIS OR DISTORTION OF THE AIRWAY

STENOSIS OR DISTORTION OF THE AIRWAY;STENOSIS OR DISTORTION OF THE AIRWAY;

FIXATION OF LARYNX OR AD$ACENT TISSUESFIXATION OF LARYNX OR AD$ACENT TISSUESSECONDARY TO INFILTRATION OR FIBROSIS FROMSECONDARY TO INFILTRATION OR FIBROSIS FROM

IRRADIATION.IRRADIATION.

EDEMA OF THE AIRWAY, HEMATOMA, UNSTABLEEDEMA OF THE AIRWAY, HEMATOMA, UNSTABLEFRACTURES(S) OF THE MAXILLAE, MANDIBLE ANDFRACTURES(S) OF THE MAXILLAE, MANDIBLE ANDCERVICAL VERTEBRAECERVICAL VERTEBRAE

SHORT, THIC NEC; REDUNDANT TISSUE IN THESHORT, THIC NEC; REDUNDANT TISSUE IN THEOROPHARYNX; SLEEP APNEAOROPHARYNX; SLEEP APNEA

MACROGLOSSIA; PROGNATHISMMACROGLOSSIA; PROGNATHISMEDEMA OF AIRWAYEDEMA OF AIRWAY


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OBJECTIVE ASSESSMENTOBJECTIVE ASSESSMENT

DIFFICULT LARYNGOSCOPY CAN STILL BE ENCOUNTEREDDIFFICULT LARYNGOSCOPY CAN STILL BE ENCOUNTERED

DURING INDUCTION IN INDIVIDUALS WITH NO OBVIOUSDURING INDUCTION IN INDIVIDUALS WITH NO OBVIOUS

ANATOMIC VARIATIONS, UNRESTRICTED MOVEMENT OF HEADANATOMIC VARIATIONS, UNRESTRICTED MOVEMENT OF HEAD

AND NEC, ADEQUATE RELAXATION, OPTIMAL POSITIONING,AND NEC, ADEQUATE RELAXATION, OPTIMAL POSITIONING,

AND SOUND TECHNIQUE.AND SOUND TECHNIQUE.

A TOTALLY UNEPECTED DIFFICULT LARYNGOSCOPYA TOTALLY UNEPECTED DIFFICULT LARYNGOSCOPY

MIGHT CONTRIBUTE TO SIGNIFICANT MORBIDITY ANDMIGHT CONTRIBUTE TO SIGNIFICANT MORBIDITY AND

MORTALITY.MORTALITY.

THE BASIS OF AIRWAY CLASSIFICATION *THE BASIS OF AIRWAY CLASSIFICATION *

CLASS ! * UVULA, FAUCIAL PILLARS, SOFT PALATE VISIBELCLASS ! * UVULA, FAUCIAL PILLARS, SOFT PALATE VISIBEL

CLASS % * FAUCIAL PILLARS, SOFT PALATE VISIBLECLASS % * FAUCIAL PILLARS, SOFT PALATE VISIBLE

CLASS + * SOFT PALATE VISIBLECLASS + * SOFT PALATE VISIBLE


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A B C


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CORRELATION BETWEEN VISIBILITY OF FAUCIAL PILLARS,CORRELATION BETWEEN VISIBILITY OF FAUCIAL PILLARS,

SOFT PALATE AND UVULA AND EPOSURE OF GLOTTIS BYSOFT PALATE AND UVULA AND EPOSURE OF GLOTTIS BY

DIRECT LARYNGOSCOPYDIRECT LARYNGOSCOPY

LARYNGOSCOPY GRADELARYNGOSCOPY GRADE

VISIBILITY OFVISIBILITY OF

STRUCTURESSTRUCTURES

NO.OF PTS.NO.OF PTS.

(2)(2)

GRADE !GRADE !

NO.OF PTSNO.OF PTS

(2)(2)

GRADE %GRADE %

NO OF PTSNO OF PTS

(2)(2)

GRADE +GRADE +

NO.OF PTSNO.OF PTS

(2)(2)

GRADE GRADE

NO. OF PTSNO. OF PTS

(2)(2)

CLSS !CLSS !

!'' (0+.32)!'' (0+.32) !%' ('#.'2)!%' ('#.'2) +" (!.+2)+" (!.+2) -- --

CLASS %CLASS %

" (!#2)" (!#2) !% ('.02)!% ('.02) ! (&.02)! (&.02) !" (.02)!" (.02) (!.#2) (!.#2)

CLASS +CLASS +

!' (0.!2)!' (0.!2) -- ! (".'2)! (".'2) # (.+2)# (.+2) ' (%.2)' (%.2)


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LARYNGOSCOPELARYNGOSCOPE

CLINICAL PROBLEM-BASED ASSESSMENT OFCLINICAL PROBLEM-BASED ASSESSMENT OFTRADITIONAL LARYNGOSCOPE DESIGNTRADITIONAL LARYNGOSCOPE DESIGN

ANTESTERNAL SPACE RESTRICTIONANTESTERNAL SPACE RESTRICTION

LIMITED MOUTH OPENINGLIMITED MOUTH OPENING

REDUCED INTRAORAL CAVITYREDUCED INTRAORAL CAVITY

THE ANTERIOR LARYNTHE ANTERIOR LARYN

MANDIBULAR SPACEMANDIBULAR SPACEUNUSUALLY WIDE, SUCH AS THEUNUSUALLY WIDE, SUCH AS THE

BI%ARRI-GUFFRIDBI%ARRI-GUFFRID

NOVEL LARYNGOSCOPE TECHNIQUESNOVEL LARYNGOSCOPE TECHNIQUES

INDIRECT VISUALI$ATION OF THE VOCAL CORDSINDIRECT VISUALI$ATION OF THE VOCAL CORDS

DIRECT VISUALI$ATION OF THE VOCAL CORDSDIRECT VISUALI$ATION OF THE VOCAL CORDS

EPIGLOTTIS POSITIONINGEPIGLOTTIS POSITIONING

INFANT AND PEDIATRIC REQUIREMENTSINFANT AND PEDIATRIC REQUIREMENTS


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VARIOUS LARYNGOSCOPES HAVE BEEN DESIGNED SINCE WILLIAM MACEWAN

USED HIS FINGERS TO GUIDE TUBE FROM THE MOUTH INTO THE TRACHEA.

A LARYNGOSCOPE CONSISTS OF A HANDLE JOINED TO A BLADE.

THIS $UNCTION USUALLY IS REFERRED TO AS THE FITTING.

THE BLADE CONSISTS OF FIVE PARTS.

!. THE SPATULA IS THE MAIN SHAFT OF THE BLADE. THE BOTTOM CONTACTSTHE TONGUE AND THE TOP FACES THE ROOF OF THE MOUTH.

%. THE WEB OR STEP PRO$ECT UPWARD FROM THE BLADE TOWARD THE

ROFF OF THE MOUTH.+. THE FLANGE PRO$ECTS LATERALLY FROM THE WEB. THE DIRECTION MAY

BE OVER THE BLADE SO THAT A CROSS SECTIONAL AREA IS OPENPARTIALLY, OR COMPLETELY ENCLOSED TO FORM A TUBE. ALTERNATIVELY

THE FLANGE BENDS AWAY FROM THE BLADE AND IS REFERRED TO AS AREVERSED FLANGE.

. THE BEA IS THE TIP OF THE BLADE, PLACED IN THE VALLECULA OR

BEYOND THE EPIGLOTTIS TO ELEVATE IT DIRECTLY.'. APPROXIMATING THE BEA IS A LIGHT SOURCE. THERE MAY BE

ADDITIONAL FEATURES, SUCH AS OXYGEN DELIVERY AND SUCTION


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CLINICAL PROBLEM-BASED ASSESSMENT OFCLINICAL PROBLEM-BASED ASSESSMENT OF

TRADITIONAL LARYNGOSCOPE DESIGNTRADITIONAL LARYNGOSCOPE DESIGN

ANTESTERNAL SPACE RESTRICTIONANTESTERNAL SPACE RESTRICTION

LIMITED MOUTH OPENINGLIMITED MOUTH OPENING

REDUCED INTRAORAL CAVITYREDUCED INTRAORAL CAVITY

THE ANTERIOR LARYNXTHE ANTERIOR LARYNX

MANDIBULAR SPACE * TONGUE SIZE DISPROPORTIONMANDIBULAR SPACE * TONGUE SIZE DISPROPORTION

ANY BLADE WITH A REVERSED FLANGE, PARTICULARLY IFANY BLADE WITH A REVERSED FLANGE, PARTICULARLY IF

UNUSUALLY WIDE, SUCH AS THE BIZARRI-GUFFRIDA.UNUSUALLY WIDE, SUCH AS THE BIZARRI-GUFFRIDA.

EPIGLOTTIS POSITIONINGEPIGLOTTIS POSITIONING


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INDIRECT VISUALIZATION OF THE VOCAL CORDSINDIRECT VISUALIZATION OF THE VOCAL CORDS

THE BELLHOUSE BLADE INCORPORATES A PRISM WHENTHE BELLHOUSE BLADE INCORPORATES A PRISM WHEN

NECESSARYNECESSARY



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DIRECT VISUALIZATION OF THE VOCAL CORDSDIRECT VISUALIZATION OF THE VOCAL CORDS

THE BILLARD LARYNGOSCOPE HAS A BROAD BLADETHE BILLARD LARYNGOSCOPE HAS A BROAD BLADE

TERMINATING INTUBATION BROAD CURVE. IT IS THIN ANDTERMINATING INTUBATION BROAD CURVE. IT IS THIN AND

LACS A STEPLACS A STEP


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INFANT AND PEDIATRIC REQUIREMENTSINFANT AND PEDIATRIC REQUIREMENTS

PREANAESTHESIA ASSESSMENT OF INFANT ANDPREANAESTHESIA ASSESSMENT OF INFANT ANDPEDIATRIC PATIENTS IS SIMILAR TO THAT FOR ADULT.PEDIATRIC PATIENTS IS SIMILAR TO THAT FOR ADULT.

THE NORMAL ANATOMY DIFFERS FROM THE ADULT IN THETHE NORMAL ANATOMY DIFFERS FROM THE ADULT IN THEFOLLOWING DETAILS *FOLLOWING DETAILS *THE TONGUE IS LONGERTHE TONGUE IS LONGER

THE EPIGLOTTIS IS MORE CEPHALAD AND MORETHE EPIGLOTTIS IS MORE CEPHALAD AND MOREANTERIORANTERIOR

THE EPIGLOTTIS IS V SHAPED AND NARROWERTHE EPIGLOTTIS IS V SHAPED AND NARROWER

THE HYOID CARTILAGE IS MORE RESISTANT TO PRESSURETHE HYOID CARTILAGE IS MORE RESISTANT TO PRESSURETHE LARYNX IS AT A HIGHER VERVICAL LEVEL (C+-)THE LARYNX IS AT A HIGHER VERVICAL LEVEL (C+-)

THE VOCAL CORDS SLOPE UPWARD AND BACWARDSTHE VOCAL CORDS SLOPE UPWARD AND BACWARDS


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SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND UESTIONS TO GUIDE


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PROBLEMS PRESENTED BY PATIENT

UPPER CHEST WALL

ANTESTERNAL SPACE RESTRICTION

NEC

CHIN-TYROID NOTCH DISTANCE REDUCED

SCARRING, OTHER SPACE-OCCUPYINGPATHOLOGY

TYROID CARTILAGE IMMOBILITY

SUBMENTAL MASS OR SCARRING

ATLANTO-OCCIPITAL $OINT MOBILITYREDUCED

CERVICAL SPINE TRAUMATIZED OR REDUCEDMOBILITY

FACE

MICROGNATHIA

MACROGNATHIA

SPLIT LIP

MANDIBULAR MAXILLARY FRACTURENASAL PATHOLOGY OR TRAUMA

ORAL ORIFICE NARROW

LARYNGOSCOPE DESIGN CHARACTERISTICS

BEA TIPWILL THIS ATRAUMATICALLY AND SECURELY TILT ORLIFT THE EPIGLOTTIS EFFECTIVELY4

BEA

WILL A TILT FROM AXIS OF THE SPATULA AIDVISUALIZATIONACCESS FOR VOCAL CORDAPERTURE4

WILL AN EXPOSED CROSS-SECTIONAL AREA BEPROTECTED FROM PATHOLOGIC ORANATOMICALLY ABNORMAL TISSUES4

WILL THE SIZE OCCUPY SPACE NEEDED TOMANIPULATE TIP OF ETT4

SPATULA WITH REFERENCE TO THE LENGTH THAT WILLBE IN THE ORAL CAVITY

APPROACHING BETWEEN THE INCISOR, TEETH WILL ITSCURVATURE STRAIGHTNESS AID VISUALIZATION AIDACCESS TO THE VOCAL CORDS4

USING A MOLAR OR RETROMOLAR APPROACH, WILL ITSCURVATURE STRAIGHTNESS AID VISUALIZATION AIDACCESS TO THE VOCAL CORDS4

WILL ITS WIDTH COMPRESS TH E TONGUEADWQUATELY4

WILL ITS SIZE HINDER ETT MANIPULATION4

SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND UESTIONS TO GUIDESELCTION OF THE MOST SUITABLE LARYNGOSCOPE BLADE

SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND UESTIONS TO GUIDESELCTION OF THE MOST SUITABLE LARYNGOSCOPE BLADE


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MOUTH

RESTRICTED OPENING

DENTAL MISALIGNMENT

TONGUE LARGE

INTRAORAL VOLUME SMALL

PHARYNGEAL SPACE-OCCUPYING PATHOLOGY

MALLAMPATI SIGN II-IVMOLAR TEETH PRESENT


WITH REFERENCE TO THE LENGTH THAT WILL BEOUTSIDE THE ORAL CAVITY

WILL ITS SHAPE PROVIDE THE WIDEST FIELD OFVIEW NECESSARY

WILL ITS SHAPE HINDER MANIPULATION OF THEETT AND USE OF OTHER AIDS

FLANGE !MODIFIED " REVERSED#

WILL IT AID TONGUE COMPRESSIONWILL IT CROSS-SECTIONAL AREA$ RELATIVE TOTHAT OF ENTRY TO MOUTH$ HINDERMANIPULATION OF THE ETT OUTSIDE THE

LUMEN OF SPATULA AND FLANGE

SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND UESTIONS TO GUIDESELCTION OF THE MOST SUITABLE LARYNGOSCOPE BLADE )CONTINUED*


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UPPER CHEST WALL

ANTESTERNAL SPACE RESTRICTION

NEC

CHIN-THYROID NOTCH DISTANCE REDUCED

SCARRING, OTHER SPACE-OCCUPYING PATHOLOGYTYROID CARTILAGE IMMOBILITY

SUBMENTAL MASS OR SCARRING

ATLANTO-OCCIPITAL $OINT MOBILITY REDUCED

CERVICAL SPINE TRAUMATIZED OR REDUCED MOBILITY

FACE

MICROGNATHIA

MACROGNATHIA

SPLIT LIP

MANDIBULAR MAXILLARY FRACTURE

NASAL PATHOLOGY OR TRAUMA

ORAL ORIFICE NARROW

MOUTH

RESTRICTED OPENING

DENTAL MISALIGNMENT

TONGUE LARGE

INTRAORAL VOLUME SMALL

PHARYNGEAL SPACE-OCCUPYING PATHOLOGY

MALLAMPATI SIGN II-IV

MOLAR TEETH PRESENT


STEPWILL THE HEIGHT PREVENT ENTRY TO THE PATIENTS

MOUTH 4WILL ANGULATION OF SPATULA TO THE AXIS OF THE

TRACHEA BE HINDERED4WILL SHALLOWNESS OR ABSENCE ABOLISH ITS PROP

CAPABILITY IN THAT PATIENT4

FITTINGWILL THE ANGLE BETWEEN HANDLE AND BLADEPREVENT THE BLADE ENTERING THE MOUTH AND ITS

MANIPULOATION4

WILL VISUALIZATION AND MANIPULATION BE

COMPROMISED UNLESS BLADE IS OFFSET4

HANDLE

IS THE HANDLE TOO LONG TO PERMIT BLADE ENTRYINTO THE MOUTH4

DO THE PROBLEMS PRESENTED DEMAND VISUAL AND ACCESS AIDS SUCH AS PRISMS OR VISUALIMAGE TRANSMISSION VIA RIGID OR FLEXIBLE ROUTE4

THE USER WHO DETERMINES THE USEFULNESS OF AN INSTRUMENT. EXAMINE YOUR PATIENT, UNDERSTANDLARYNGOSCOPES, LEARN HOW TO USE THEM


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THE TRIPLE MANOEUVREHEAD TILT

CHIN LIFT'AW THRUST

FACEMAS#SONE HAND TECHNIUE

TWO HAND METHOD

THE OROPHARYNGEAL AIRWAYNASOPHARYNGEAL AIRWAYTHE LARYNGEAL MAS# AIRWAY )LMA*OTHER SUPRAGLOTTIC DEVICES

AIRWAY MANAGEMENT DEVICE, AMD TM.COMBITUBETM,CUFFED OROPHARYNGEAL AIRWAY, COPATM,LARYNGEAL TUBE,LT,PAX

TMOROPHARYNGEAL AIRWAY. PAXPREESSTM


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THE FIRST PART OF FOLLOW, DESCRIBES HOW THE AIRWAY ISMAINTAINED WITHOUT AIRWAY AD'UNCTSAND WITH THE AID OFSUPRAGLOTTIC DEVICES.

AIRWAY MANAGEMENT WITHOUT INTUBATION )AMWI* IS ANIMPORTANT S#ILL THAT MUST BE MASTERED BY THE MEDICAL

STAFF.

IT MAY BE CARRIED OUT & AS A PART OF PRIMARY AIRWAY MANAGEMENT PRIOR TO

EMERGENCY OR ELECTIVE INTUBATION. WHEN INTUBATION EEQUIPMENT OR INTUBATION SILLS ARE

UNAVAILABLE, E.G. ON THE WARDS OR OUT OF HOSPITALSCENARIOS. WHEN INTUBATION IS DIFFICULT WHEN THE PATIENT HAS A PARTIALLY OBSTRUCTED AIRWAY AS A PART OF A GENERAL ANAESTHETIC


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THE UPPER AIRWAY HAS

A RIGID WALL SUPPORTED BY THE VERTEBRA POSTERIORLY

COLLAPSIBLE ANTERIOR WALL FORMED BY THE TONGUE AND THEEPIGLOTTIS ANTERIORLY.

THE ANTERIOR WALL OBSTRUCTS THE AIRWAY IFTHERE IS A LOSS OF MUSCLE TONE (UNCONSCIOUSNESS, PARALYSIS)

THE BUL OF THE SOFT TISSUE IS INCREASED (OEDEMA, ABSCESS, TUMOUR)

AMWI MAY CONSIST OF THE USE OF ONE OR MORE OF THE FOLLOWING &TRIPLE MANOEUVREFACEMASSOROPHARYNGEAL AIRWAY

NASOPHARYNGEAL AIRWAYLARYNGEAL MAS OESOPHAGOTGRACEHAL COMBITUBE AIRWAYMANAGEMENT DEVICES


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!I#!II#

!III#


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THE TRIPLE MANOEUVRE,CLASSICALLY CONSISTS OF *HEAD TILTCHIN LIFT$AW THRUST

THE HEAD TILT AND CHIN LIFT IS AVOIDED IN PATIENTS WITHSUSPECTED HEAD OR CERVICAL SPINE IN'URY

FACEMAS#S

FACEMASS ARE DESIGNED SO AS TO FIT SNUGLY OVER THE PATIENTSMOUTH AND NOSE.

THE PURPOSE OF THE FACEMAS IS TO DELIVER OXYGEN, PLUS MINUSANAESTHETIC GASES FROM THE BREATHING SYSTEMS TO THE PATIENT.

THE OROPHARYNGEAL AIRWAY

NASOPHARYNGEAL AIRWAY

THE LARYNGEAL MAS# AIRWAY )LMA*


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LARYNGEAL MAS# AIRWAY )LMA*

INDICATIONS

THESE CAN BE CLASSIFIED AS EMERGENCY OR ELECTIVE

CONTRAINDICATIONS

WHERE THERE IS A RIS# OF ASPIRATION, SUCH AS PATIENTS WITH FULL STOMACH HISTORY OF ACTIVE REFLUX OR A HIATUS HERNIA MA$OR SURGERY MORBIDLY OBESE PATIENTS PREGNANCY (ELECTIVE SURGERY FROM !& WEES UP TO 3 H

POSTDELIVERY)


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METHOD OF INSERTION

THERE ARE SEVERAL TECHNIQUES THAT HAVE BEEN DESCRIBED FORINSERTION OF THE LMA. THE STANDARD TECHNIQUE ID DESCRIBEDBELOW*

!. INFLATE THE CUFF UP TO '"2 OF ITS MAXIMUM VOLUME AND CHECFOR CUFF LEAS

%. DEFLATE THE CUFF FULLY OR PARTLY AND APPLY A LUBRICANT $ELLY

TO LUBRICATE THE BAC OF THE CUFF (I.E. THE PHARYNGEAL SIDE)+. ENSURE THAT THE PATIENT IS ADEQUATELY ANAESTHETISED. EXTENT THE PATIENTS NEC AND STABILISE THE OCCIPUT SO THAT

THE $AW FALLS OPEN. THE ASSISTANT MAY HELP BY HOLDING THEPATIENTS MOUTH OPEN.

'. GRASP THE LMA LIE A PEN IN THE DOMINANT HAND AND PRESS THEDISTALTIP OF THE DFLATED LMA CUFF AGAINST HE HARD PALATE

USING THE INDEX FINGER OF THE NON-DOMINANT HAND TO GUIDETHE TUBE OVER THE BAC OF THE TONGUE AND INTO THEOROPHARYNX

METHOD OF INSERTION


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&. ADVANCE THE LMA GENTLY UNTIL CHARACTERISTIC RESISTANCE ISFELT AS IT ENGAGES THE UPPER OESOPHAGEAL SPHINCTER

0. THE CUFF IS THEN GENTLY INFLATED WITH AIR NOT EXCEEDINGTHE MAXIMUM RECOMMENDED VOLUME

3. THE LMA MAY FLOAT OUT SLIGHTLY THIS MANOEUVRE AS ITTRIES TO FIT ITSELF IN THE CORRECT POSITION.

#. THE LMA IS THEN CONNECTED TO THE BREATHING SYSTEM

!". CORRECT POSITION IS CHECED WITH GANTLE POSITIVEPRESSURE BREATHS SHOWING CHEST EXPANSION, NOTICING THEMOVEMENTS OF THE RESERVOIR BAG IN A SPONTANEOUSLYBREATHING PATIENT, AUSCULTATION AND WATCHING THE END-TIDAL CARBON DIOXIDE TRACE. THE BLAC LINE ON THE TUBE OFTHE LMA LIES DORSALLY IN THE MIDLINE.

WHEN THE LMA IS USED FOR CONTROLLED VENTILATION, IT IS IMPORTANT#EEP INFLATION PRESSURES NOT GREATHER THAN +0CM OF WATER,OTHERWISE IT MAY RESULT IN GASTRIC INSUFFLATION


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OTHER SUPRATLOTTIS DEVICES

AIRWAY MANAGEMENT DEVICE, AMD TM. NAGOR LTD, DOUGLAS,ISLE OF MAN.

COMBITUBETM, TYCO HEALTCARE LTD, GOSPORT, U CUFFED OROPHARYNGEAL AIRWAY, COPATM, TYCO HEALTCARE LTD,

GOSPORT, U LARYNGEAL TUBE,LT, VBM GMBH, SULZ GERMANY PAXTMOROPHARYNGEAL AIRWAY. PAXPREESSTMVITAL SIGNS LTD,

BARNHAM U


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56789:8O% WAS =#"2 BEFORE ANAESTHETIC INTERVENTION

IT IS NOT POSSIBLE FOR THE UNASSISTED ANAESTHESIOLOGIST TOPREVENT OR REVERSE SIGNS OF INADEQUATE VENTILATIONDURING POSITIVE PRESSURE MAS VENTILATION

DIFFICULT TRACHEAL INTUBATION IS SAID TO OCCUR IF

PROPER PLACEMENT OF THE TRACHEAL TUBE WITH CONVENTIONAL

LARYNGOSCOPY REQUIRES MORE THAN THERE ATTEMPTS

PROPER INSERTION OF THE TRACHEAL TUBE WITH CONVENTIONALLARYNGOSCOPY REQUIRES MORE THAN (MIN


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THIS WOULD BE MOSTLY IN CASES OF DIFFICULT LARYNGOSCOPY, WHENIT IS NOT POSSIBLE TO VISUALISE ANY PORTION OF THE VOCAL CORDSWITH CONVENTIONAL LARYNGOSCOPY.

THIS CORRESPONDS TO GRADES III AND IV OF THE CORMAC ANDLEHANE CLASISIFICATION.

THE TRAINEE MUST BE BEAR IN MIND THAT THE TIME SPENT DURINGINTUBATION ALSO INCLUDES PERIODS OF OXYGENATION BY ALTERNATIVEMEANS I.E. HAND VENTILATION WITH BAG, MAS AND AIRWAY.

THE INCIDENCE OF FAILED TRACHEAL INTUBATION IS "."'-".++2(DEPENDING ON PATIENT POPULATION, ANAESTHETIC SILL ANDEQUIPMENT.

THE HIGHER FIGURE REFERS TO DATA FROM OBSTETRIC PATIENTS. THE

INCIDENCE OF FAILED MAS VENTILATION AND TRACHEAL INTUBATION IS"."! 1 %."2.


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THE REPORTED INCIDENCE OF DIFFICULT LARYNGOSCOPY IS +-

!+2 A DIFFICULT LARYNGOSCOPY DOES NOT ALWAYS EQUATEWITH DIFFICULT INTUBATION.

A GRADE III LARYNGOSCOPIC VIEW MAY ENABLE RELATIVELYEASY INTUBATION WITH A BOUGIE, WHILE A GRADE II WITH ANANTERIOR AND DEEP LYING LARYNX MAY BE DIFFICULT TO

INTUBATE


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PREVENTION AND PORPER PREPARATION ENABLES THEANAESTHETIST TO DEAL WITH THESE SITUATIONS.

ADEQUATE AIRWAY ASSESSMENT IS IMPORTANT BUT BY NOMEANS GUARANTES AN EASY TIME.

ALWAYS HAVE A PRIMARY AND A SECONDARY PLAN FOR AIRWAYMANAGEMENT.

THE FIRST PLAN MUST INCLUDE PLANNING FOR THE ALTERNATIVE.

ADMINISTER A H% BLOCER TO PATIENTS AT RIS ASPIRATION,SUCH AS THE MORBIDLY OBESE (BMI=+'GM%) OR THOSE WITHHERNIA.

REMEMBER NOT TO DO ANYTHING BEYOND YOUR COMPETENCE,HENCE CALL FOR HELP SOONER RATHER THAN LATER.

INITIAL ATTEMPS AT INTUBATION SHOULD BE INTERPRETED BYTHE $UNIOR TRAINEE AS CALL FOR HELP.


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ASA TAS FORCEDIFFICULT AIRWAY ALGORITHM

DIFFICULTY WITH MAS# VENTILATION

A $UNIOR TRAINEE SHOULD NOT ADMINISTER A LONG ACTING


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MUSCLE RELAXANT TO A PATIENT BAFORE ACHIEVING SEVERAL

SATISFACTORY TEST INFLATIONS VIA THE MAS AND AIRWAY.

IF VENTILATION IS POSSIBLE WITHOUT MUSCLE PARALYSIS, IT WILL

BE EASIER AFTER THE ADMINISTRATION OF THE MUSCLE RELAXANT.

TRY THE FOLLOWING IF THERE IS A PROBLEM WITH MAS#

VENTILATION AT THIS STAGE.!. USE THE CORRECT MAS FIT. TRY A DIFFERENT SIZE MAS

%. TRY AD$USTING THE TRIPLE MANOEUVER; HEAD TILT, CHIN LIFT AND $AWTHRUST.

+. INSERT THE CORRECT SIZE OROPHARYNGEAL OR A NASOPHARYNGEAL AIRWAY.

. TRY TWO-HAND TECHNIQUE, I.E. THE ASSISTANT SQUEENZES THE BAG WHILETHE PRACTITIONER HOLDS THE MAS WITH BOTH HANDS (OFTEN NEEDED INEDENTULOUS PATIENTS OR PATIENTS OF A LARGE BODY MASS INDEX)

'. USE SOME FORM OF SUPRAGLOTTIS DEVICE SUCH AS THE LARYNGEAL MASAIRWAY (LMA)


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DIFFICULTY WITH INTUBATION

VARIOUS ANAESTHETIC ORGANISATIONS HAVE DEVISED THEIROWN

ALGORITHMS FOR THE MANAGEMENT OF THE DIFFICULT AIRWAY.ONE SUCH IS THE ASA ALGORITHM AS DESCRIBED ABOVE.PREVENTION OF DIFFICULT IS PREFERABLE

ANTICIPATE BEFORE THE PROCEDURE 1 MAE AN ASSESSMENT BE PREPARED 1 MAE SURE YOU HAVE GOT ALL THE EQUIPMENT SPOT THE PROBLEM EARLY CALL FOR HELP EARLY DO NOT PANIC 1 MAINTAIN OXYGENATION WITH !""2 OXYGEN HAVE A BAC-UP PLAN

MA#E SURE THE SURGEON IS AWARE OF THE PROBLEM


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IF THE PATIENT IS ANAESTHETISED AND PARALYSED AND THE

INTUBATION IS DIFFICULT (UNABLE TO INTUBATE WITH ACONVENTIONAL LARYNGOSCOPE IN THE FIRST INSTANCE )

THEN *

!. CONTINUE WITH EFFECTIVE MAS VENTILATION ASDECRIBED ABOVE

%. IDENTIFY THE PROBLEM, E.G. BUCED TEETH, SMALLMOUTH, POSITION OF NEC, LARGE BREASTS

+. TAE THE NECESSARY ACTION

. CALL FOR HELP IF MORE THAN TWO ATTEMPTS ATINTUBATION ARE REQUIRED.

REMEMBER, THE PATIENT IS SAFE AS LONG AS EFFECTIVE

VENTILATION CAN BE CONTINUED WITH 100% O"YGEN

PROBLEM ACTION


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POOR VIEW (GRADE III-IV)

SMALL MOUTH, BUCEDETEETH

LARGE OBESE PATIENT, BIGBREASTS

ANTERIOR LARYNX, POOR

VIES

ACTION

APPLY OR RELAX PRESSURE

ON THE LARYNX, ALTERNATIVEBLADE (CURVEDSTRAIGHT)

SMALL BLADE

SHORT-HANDLE OR POLIOBLADE

USE A BOUGIELARGE BLADE,LARYNGEAL PRESSURE,ALTERNATIVE BLADE

VARIOUS LARYNGOSCOPIC BLADES ARE AVAILABLE FOR USE IN DIFFESITUATIONS. FOR A DEEP LYING ANTERIOR LARYN" SELECT A LONG AOR STRAIGHT BLADE& FOR A LARGE FLOPPY EPIGLOTTIS TRY THEM-COY LARYNGOSCOPE WITH A TILTING TIP.


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IS IN AN EMERGENCY OR LIFE-SAQVING SURGERY/

IN AN EMERGENCY OR LIFE-SAVING SURGERY, ONE HAS NOOPTION

OTHER THEN EEPING THE PATIENT ANAESTHETISED, WHILE

MAINTAINING SPONTANEOUS BREATHING OR CONTINUINGEFFECTIVE MAS# VENTILATION UNTIL HELP ARRIVES.

IF IT IS A NONEMERGENCY SURGERY, THE SAFEST OPTION ISTO

WA#E THE PATIENTS UP AND TA#E STOC#.


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TECHNIQUES FOR DIFFICULT INTUBATION

ALTERNATIVE LARYNGOSCOPE 1 LARGE, M5COY OR POLIOBLADE, SHORT HANDLE

INTUBATING STLET GUM ELASTIC BOUGIE BLIND NASAL INTUBATING THROUGH A LMA FIBEROPTIC INTUBATION (AWAE OR UNDER GENERAL

ANAESTHESIA) RETROGRADE INBTUBATION SURGICAL AIRWAY 1 CRICOTHROIDOTOMY, TRACHEOSTOMY


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DIFFICULTY WITH INTUBATION AND VENTILATION

THIS SITUATION MAY ARISE DURING RAPID SEQUENCEINDUCTION WITH CRICOID PRESSURE, FOLLOWING FAILURE TOINTUBATE.

OFTEN THE CRICOID PRESSURE APPLIED BY ANINEXPERIENCED ASSISTANT CONTRIBUTES TO THE DIFFICULTY.

IF LARYNGOSCOPY AND INTUBATION HAVE FAILED USING

STRATEGIES AVAILABLE, MAS VENTILATION OR LMAVENTILATION IS THE NEXT STEP.


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IF ALL POSSIBLE MANEUVRES TO ACHIEVE EFFECTIVEVENTILATION HAVE FAILED INTUBATION IS UNSUCCESSFULAND THE PATIENT IS DESATURATING, THEN IMMEDIATEOXYGEN DELIVERY TO THE PATIENT IS ABSOLUTELYNECESSARY. THIS IS A CANNOT INTUBATE, CANNOTVENTILATE.

IN THIS SITUATION THE ONLY WAY TO ACHIEVE OXYGENATIONQUICLY IS EITHER A TRANS-TRACHEAL VENTILATION USING

A TRANS-TRACHEAL CANNULA,

NEEDLE CRICOTHYROIDOTOMY.

SURGICAL CRICOTHYROIDOTOMY.

PRECUTANEOUS NEEDLE CRICOTHYROIDOTOMY


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PRECUTANEOUS NEEDLE CRICOTHYROIDOTOMY

THE CRICOTHYROID MEMBRANE IS PUNCTURED VERTICALLY IN THE

MIDLINE USING A LARGE-BORE INTRAVENOUS CANNULA ATTACHED

TO A SYRINGE

!. THE PATIENTS HEAD IS EXTENDED

%. THE CANNULA IS ADVANCED IN THE MIDLINE VERTICALLYDOWN UNTIL AIR IS ASPIRATED AND IT IS THEN DIRECTED

CAUDALLY SO THAT THE CANNULA SLIDES INTO THE TRACHEAAND THE NEEDLE IS REMOVED.

+. ASPIRATION OF AIR CONFIRMS CORRECT PLACEMENT

. THE CANNULA IS THEN CONNECTED TO A HIGH PRESSUREOXYGEN SOURCE ( BAR) DELIVERING OXYGEN AT !%-!'LMINVIA A SANDARS $ET IN$ECTOR (NEWER DEVICES ALLOW

PRESURE REGULATION), OR USING SOME OTHER DEVICE.


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ADVANTAGES

!. RAPID ACCESS TO THE AIRWAY IN ACUTE UPPER AIRWAYOBSTRUCTION OR THE CANNOT INTUBATE, CANNOTVENTILATE SITUATION.

%. BUYS TIME TO PREPARE FOR A MORE DEFINITIVE FORM OFAIRWAY USING ADVANCED TECHNIQUES.

DISADVANTAGES

!. TRAUMA TO SURROUNDING STRUCTURES, ESPECIALLY THEOESOPHAGUS

%. HAEMORRHAGE

+. SURGICAL EMPHYSEMA

. PULMONARY BAROTRAUMA

SURGICAL CRICOTHYROIDOTOMY #LARYNGOTOMY$


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SURGICAL CRICOTHYROIDOTOMY #LARYNGOTOMY$

A SCALPEL US USED TO PIERCE THE CRICOTHYROIDMEMBRANE. IT IS POSSIBLE TO INSERT A SMALL-CUFFED

TRACHEAL TUBE OR A SPECIFICALLY DESIGNED MMCANNULA.

TRANS-TRACHEAL JET VENTILATION

IT USES THE VENTURI PRINCIPLE WHEREBY A $ET OF OXYGEN

UNDER HIGH PRESSURE (BAR) ENTRAINS A LARGER VOLUMEOF AIR, RESULTING IN CHEST INFLATION.

IT IS A POTENTIALLY DANGEROUS TECHNIQUES THAT CANEASILY RESULT IN BAROTRAUMA.

OTHERWISE USE A SURGICAL CRICOTHYRODOTOMY AND AMINIMUM MM INTERNAL DIAMETER EMERGENCY AIRWAY.

STRIDOR


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IF STRIDOR IS PRESENT, IT MEANS A MA'OR UPPER AIRWAYOBSTRUCTION COMPRESSION.

STRIDOR IS A CLEAR WARNING OF EXPECTED DIFFICULTY WITHMAS VENTILATION AND QUITE LIELY DIFFICULTY WITHLARYNGOSCOPY AND INTUBATION.

PARTIAL AIRWAY OBSTRUCTION WHEN THE PATIENT IS CONSCIOUSMAY RAPIDLY PROGRESS TO COMPLETE AIRWAY OBSTRUCTION

WHEN CONSCIOUSNESS IS LOSTTHE FAILED MAS VENTILATION AND FAILED INTUBATIONALGORITHM IS OF LITTLE USE IN THIS SITUATION.

DO PRE-OPERATIVE ASSESSMENT

OPTIMISING BREATHING


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STRATEGIES FOR INTUBATION

THIS CAN BE ACHIEVED IN EXPERT HANDS WITH AWAE FIBEROPTICINTUBATION.

MANY THEREFORE PREFER INHALATIONAL INDUCTION OF ANAESTHESIAWITH OXYGEN AND A VOLATILE AGENT, MAINTAINING SPONTANEOUSRESPIRATION UNTIL A SUFFICIENTLY DEEP LEVEL OF ANAESTHESIA IS

ACHIEVED TO ALLOW LARYNGOSCOPY

THE TRAINEE ANAESTHETIST SHOULD AVOIDE ANAESTHETISING PATIENTSWITH STIDOR


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SUMMARY

AVOID DIFFICULTY 1 BE PREPAREDOPTIMISE YOUR CONDITIONS (STAFF, EQUIPMENT, PATIENT

PREPARATION)USE ALTERNATIVE MEANS IF PRIMARY STRATEGY FAILSOXYGENATE


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THE DIFFICULT AIRWAYDIFFICULT BMV MOANS DIFFICULT LARYNGOSCOPY AND INTUBATION LEMONS DIFFICULT EGD RODS DIFFICULT CRICOTHYROTOMY SHORT

AIRWAY ALGORITHMTHE UNIVERSAL EMERGENCY AIRWAY ALGORITHMMAIN EMERGENCY AIRWAY MANAGEMENT ALRORITHMTHE CRASH AIRWAY ALGORITHMTHE DIFFICULT AIRWAY ALGORITHM

THE FAILED AIRWAY ALGORITHM


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THE DIFFICULT AIRWAY

IN CLINICAL PACTICE, THE DIFFICULT AIRWAY HAS FIVE DIMENSIONS&

!.DIFFICULT BMV%.DIFFICULT LARYNGOSCOPY

+.DIFFICULT INTUBATION.DIFFICULT EGD

'.DIFFICULT CRICOTHYROTOMY

THESE FIVE DIMENSIONS CAN BE REDUCED TO FOUR TECHNICALOPEATIONS &

!.DIFFICULT BMV%.DIFFICULT LARYNGOSCOPY AND INTUBATION

+.DIFFICULT EGD.DIFFICULT CRICOTHYROTOMY


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DIFFICULT BAG 0 MAS! VENTILATION & MOANS

MAS SEAL

OBESITY OBSTRUCTIONAGENO TEETH

STIFF

DIFFICULT LARYNGOSCOPY AND INTUBATION & LEMON

LOO EXTERNALLYEVALUATE THE +-+-% RULE

MALLAMPATI SCORE

OBSTRUCTION OBESITYNEC MOBILITY


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DIFFICULT ETRAGLOTTIC DEVICES & RODS

RESTRICTED MOUTH OPENING

OBSTRUCTIONDISRUPTED OR DISTORTED AIRWAYSTIFF LUNGS OR CERVICAL SPINE

DIFFICULT CRICOTHYROTOMNY & SHORT

SURGERY (OR OTHER AIRWAY DISRUPTION)HERMATOMA (INCLUDES INFECTION ABSCESS)OBESITY (INCLUDES ANY ACCESS PROBLEM)RADIATION DISTORTION (AND OTHER DEFORMITY)

TUMOR

THE UNIVERSAL EMERGENCY AIRWAY ALGORITHM


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UNCONSCIOUSUNREACTIVENEAR DEATH

DIFFICUTAIRWAY 4

RSI

CRASHAIRWAY

ALGORITHM

DIFFICUT

AIRWAY 4ALGORITHM

FAILED

AIRWAYALGORITHM

YES

YES

NO

NO

FAILS

FAILS

FAILS

NEEDSINTUBATION

CRASHYES

MAIN EMERGENCY AIRWAYMANAGEMENT ALRORITHM


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UNRESPONSIVENEAR DEATH

PREDICT DIFFICULTAIRWAY

RSI

ATTEMPTINTUBATION

SUCCESSFUL

FAILURE TO MAINTAINO%YGENATION

2-' ATTEMPTS AT OTI BYE%PERIENCED OPERATOR

FROM DIFFICULTAIRWAY

CRASHAIRWAY

DIFFICULTAIRWAY

POST INTUBATIONMANAGEMENT

FAILEDAIRWAY

NO

NO

NO

NO

NO

YES

YES

YES

YES

YES

CRASHAIRWAY

MAINTAIN O%YGENATION

THE CRASH AIRWAYALGORITHM


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MAINTAIN O%YGENATION

INTUBATION ATTEMPT

SUCCESSFUL

UNABLE TO BAG VENTILATE

SUCCINYCHOLINE 2 MG"KG IVP

ATTEMPT INTUBATION

SUCCESSFUL


POST INTUBATION

MANAGEMENT

FAILEDAIRWAY


FAILEDAIRWAY

NO

NO

NO

NO

NO

YES

YES

YES

YES

YES( ' ATTEPTS BYE%PERIENCED OPERATOR

DIFFICULT AIRWAYPREDICTED

CALL FOR ASSISTANCE

THE DIFFICULT AIRWAYALGORITHM


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PREDICTED


BMV OR EGDPREDICTED TO BE

SUCCESSFUL

AWAKE DL$ FO$ ORVL SUCCESSFUL

ILMAFO OR VL)

CRICOTHYROTOMYBNTI LIGHTED STYLET

INTUBATION PREDICTEDTO BE SUCCESSCUL

RSI

FAILEDAIRWAY

FAILEDAIRWAY

FAILEDAIRWAY

YES

YES

YES

NO

YES

NO

NO

NO

CALL FOR ASSISTANCEFAILEDAIRWAY CRITERI

A

THE FAILED AIRWAYALGORITHM


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CHOOSE ONE AT

-FIBEROPTIC METHOD-VIDEO LARYNGOSCOPY-E%TRA GLOTTIC DEVICE-LIGHTED STYLET-CRICOTYROTOMY

CUFFED ETT PLACED

CRITOTHYROTOMYYES

NO

NO


YES

E%TRA-GLOTTIC DEVICE

MAY BE ATTEMPTED

183 difficult airway management (gabungan)

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