Difficult Airway Management

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JOSEPH C. GABEL PROFESSOR & CHAIR ∣ DEPT. OF ANESTHESIOLOGY THE UNIVERSITY OF TEXAS MEDICAL SCHOOL AT HOUSTON

MEDICAL DIRECTOR ∣ PERIOPERATIVE SERVICES MEMORIAL HERMANN HOSPITAL, HOUSTON, TX

CARIN A. HAGBERG, MD

Current Concepts

Sir Robert Reynolds Macintosh

3 ingredients of a good anesthetic...

GOOD AIRWAY

GOOD AIRWAY

GOOD AIRWAY

Perhaps the most

fundamental principle in all

of anesthesiology

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Scope of the Problem

Local: 25k GA’s performed

- 250-75 possible unanticipated DA/DIs per yr

National: 46k ASA members

- 46k DIs per yr

- Doesn’t consider other clinical settings/nonmember care providers

International: HUGE problemIn patients undergoing GA, 1-3% incidence of

unanticipated DA

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Prospective Study All major airway events

over a 1yr period Anesthesia, ICU, ED

Important insights regarding airway management

complications

Elective ASA I-II, <60 Obese ENT Obstructive lesions

Case Types

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Deficiencies in airway assessment Underutilization of awake intubation Inappropriate use of SGA Poor planing

Outcomes

Most frequent cause of anesthesia-related mortality 56% SGA complications

Aspiration

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Extrinsic Factors: Clinician

features commonly included judgement & training

personal + institutional preparedness

Intrinsic Factors: Patient

features contributed to >75% anesthetic events

Increasing use of capnography is

the single change with the greatest

potential to prevent deaths

INTEGRATION

Mallampati score Neck circumference Thyromental distance

Neck ROM

Critical in deciding best approach

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Prediction of Difficult Tracheal Intubation Time for a Paradigm Change

Langeron O, MD, PhD, Cuvillon P, MD, Ibanez-Esteve C, MD, Lenfant F, MD, PhD, Riou B, MD, PhD, LeManach Y, MD, PhD Anesthesiology 2012; 117:1123-33

Gray Zone

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Important to assess risk of DI beyond a dichotomous approach

Patients should be identified as low, intermediate, & high risk

Implement an airway management strategy accordingly

Difficult Airway

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Endoscopy

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Ultrasoundi-CAT™

Award-Winning Cone Beam 3D Imaging System

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Anticipated Difficult Airway

ASA Awake intubation: non-invasive (e.g. fiberoptics) vs. invasive access (e.g. cricothyroidotomy)

Canada No recommendations

France Awake technique (fiberoptic intubation, transtracheal oxygenation, retrograde intubation or tracheostomy)

UK (DAS) No recommendations

Italy (SIAARTI)

Awake intubation in severe cases (expert decision): fiberoptic or retrograde intubation; general anaesthesia in borderline cases

Germany (DGAI)

Maintenance of spontaneous breathing, awake technique: (fiberoptic intubation, LMA, tracheostomy)

Heidegger T, Gerig HJ. Best Pract Res Clin Anaesthesiol 2005; 19:661-741

Indications for Awake Intubation

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‣ Previous DI ‣ Anticipated DA𝘈

- Prominent protruding teeth - Small mouth opening - Narrow mandible - Micrognathia - Macroglossia - Short muscular neck - Very long neck - Limited neck ROM - Congenital airway anomalies - Obesity - Pathology involving airway - Malignancy involving airway - Upper airway obstruction

Benumof JL: Airway Management Principles & Practice. 1996; 9:161

Indications for Awake Intubation

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‣ Trauma: - Face - Upper airway - Cervical spine

‣ Anticipated difficult BMV

‣ Severe risk of aspiration

‣ Respiratory failure

‣ Severe hemodynamic instability

Benumof JL: Airway Management Principles & Practice. 1996; 9:161

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Marco Brunori

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Other options include (not limited to): surgery utilizing face mask or SGA anesthesia (LMA, ILMA, laryngeal tube), local anesthesia infiltration or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore, these options may be of limited value if this step in the algorithm has been reached via the Emergency Pathway.

Invasive airway access includes surgical or percutaneous airway, jet ventilation, & retrograde intubation.

Alternative DI approaches include (not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (LMA, ILMA) as an intubation conduit (w/ or w/out fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation.

Consider re-preparation of the patient for awake intubation or canceling surgery.

Emergency non-invasive airway ventilation consists of a SGA.

Anesthesiology 2013 118:251-70.

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Langeron O, MD, PhD, Masso E, MD, Huraux C, MD, Guggiari M, Bianchi A, MD, Coriat, MD, Riou B, MD, PhD Anesthesiology 2009; 92:1229-36

Prediction of Difficult Mask Ventilation ‣ Prospective study

- 1,502 pts - French university hospital

‣ DMV: inability to maintain O2 sat >92% or prevent/reverse signs of inadequate ventilation during PPMV under GA

‣ Incidence 5%

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Difficult Mask Ventilation Pre-Operative Risk Factors

M: mask seal

O: BMI >26 kg/m2

A: Age >55 yrs

N: Lack of teeth

S: History of snoring

>2 risk factors markedly increases risk

Langeron O, MD et al. Anesthesiology 2000; 92:1229-36

53,04 BMV attempts (2004-08)

77 Impossible BMV (0.15%) Inability to exchange air during BMV attempts, despite multiple providers, airway adjustments, or NMB

Independent Predictors M: mask seal O: mouth opening (III or IV) A: adult male N: neck radiation S: history of snoring

>3 risk factors markedly increase risk for IMV

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Prediction & Outcomes: Impossible Mask Ventilation Review of 50,000 Anesthetics

Sachin K, MD, MBA et al. Anesthesiology 2009; 110

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Impossible Mask Ventilation

Difficult Intubation

4x

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Simpler method for CPR??

ABC

!

CAB

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Cardiac-only resuscitation & minimizing delays or interruptions in chest compressions increase survival

Exception: infants/children where cardiorespiratory arrest is usually secondary to hypoxia

Endotracheal intubation remains the gold standard for securing the airway

Against the routine use of cricoid pressure as part of airway management

Continous waveform capnography for confirmation of ETT placement

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Recommendations for Continuous Capnography

‣All patients undergoing advanced life support

‣Undergoing or recovering from moderate or deep sedation

‣ In all anesthetized patients, regardless of the airway device used

‣All patients whose trachea is intubated, regardless of patient location

http://www.aagbi.org/sites/default/files May, 2011

Failed laryngoscopy: 0.04-0.07%

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Marco Brunori

Difficult laryngoscopy: 1.5-13%

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Marco Brunori

Predicts easy intubation in 95% of cases

!

!

!

<3% need any intubation adjuncts

Likely to require gum

elastic bougie, but no other

adjuncts

easy

COOK MODIFICATION CORMACK-LEHANE CLASSIFICATION

Cook TM; Anesthesia 2000; 55:274-9

grade 1

grade 2a

Associated w/ difficult intubation in 75% of

cases !

Specialist intubation techniques are likely required

restricted difficult

grade 2b

grade 3a

grade 3b

grade 4

In current anesthetic practice, there are a myriad of devices & techniques to ensure

that the airway is patent.

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1988-1998 Decade of SGA

Anesth Analg 2010;110:Cover

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2001-2011 Decade of Video Laryngoscopy

Anesth Analg 2010;110:Cover

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Original Research Telemedicine & Telepresence for Prehospital & Remote Hospital Tracheal Intubation Using a GlideScope™ Videolaryngoscope: A Model for Tele-Intubation

Sakles JC, MD, FACEP, Mosler J, MD, Hadeed G, MPH, Hudson M, MD, Valenzuela T, MD, Latifi R, MD, FACSTelemedicine & e-Health, April 2011

Intubation bot lets doctors safely shove tubes down unconscious human throats By Michael Gorman, Apr 16th 2011http://www.engadget.com/2011/04/16/intubation-bot-lets-doctors-safely-shove-tubes-down-unconscious/

!!!

Dr. Thomas M. Hemmerling from McGill University

Health Centre has created the world’s first intubation

robot, called the Kepler Intubation System (KIS), a robotic arm with a video

laryngoscope that’s controlled via a joystick.

!!

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Shikani Optical Stylet

Levitan FPS

Scope

Foley Airway Styler

Air-Vu

Pocket Scope

Video Airway System

FIBEROPTIC LIGHTED STYLETS

SHIKANI FAMILY

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Bonfils Intubation Fiberscope™ ‣ Rigid FOB stylet

‣ Fixed shape w/ 400 curve

‣ Movable eye-piece, adapter

‣ Battery or FOB light source

‣ Portable, rugged

‣ Retromolar or transmolar route - w/ and w/out laryngoscopy

‣ Adult & pedi sizes

Sensa Scope®

- Rigid S-shaped endoscope - Stererable tip

- Built-in camera & LED light source - Connects to a video monitor to all full screen image - Miniaturized CMOS chip allows for high image quality

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Hybrid Scopes

Video Rifl Scope™ - Rigid video styler

- Articulating tip 1350 - Powered solely by lithium CR-123 batteries - LCD screen that rotates 1800 - Miniaturized CMOS chip allows for high image quality

Olympus MAF™

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Battery-driven fiber videoscope incorporating video camera, light source, & recording unit

Still images & movies can be recorded to a memory chip

Camera body can rotate either side by 900

LCD panel can tilt 0-1200

2.6 mm working chanel

AMBU® aSCOPE™

Sterile & single-use flexible fiberoptic scope

- 5.3 mm (>6.0 ETT) - 63 cm length

New camera technology

Lightweight, ergonomic handle

Reusable screen, Ambu aScope™ monitor

Always available, no cleaning & repairs, no cross contamination

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aSCOPE™

Flex Intubation Video Endoscope

CMOS distal chip

5.5 mm (w) x 65 cm (l) (6.5 mm ETT)

2.3 mm working channel

Deflection 1400 Integrated LED light source

“Satin Sheath” requires no lubrication

Highly portable w/ battery & AC

Video & still images Compatible w/ C-MAC monitor &

C-HUB

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5 Scope Nasal Intubation

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Difficult Mask Ventilation Can’t Intubate, Can’t Ventilate

ASALMA, help, transtracheal catheterization, surgical cricothyroidotomy Anesthesiology

2003; 98:1261-68

Canada1 intubation attempt, LMA, Combitube, awakening, transtracheal airway Can J Anaesth

1998; 45:757-76

FranceLMA, transtracheal catheterization, surgical cricothyroidotomy Ann Fr Réanim

1996; 15:207-14

UK (DAS)Help, LMA, transtracheal catheterization, surgical cricothyroidotomy Anaesthesia

2004; 59:675-94

Italy (SIAARTI)

Oxygenation; LMA or Combitube; transtracheal catheterization or surgical cricothyroidotomy Minerva Anestesiol

1998; 64:361-73

Germany (DGAI)

Oxygenation; LMA or Combitube; transtracheal catheterization or surgical cricothyroidotomy Anaesth Intensiv

2004; 5:302-6

Heidegger T, Switz , Vergleich - unerwartet schwieriger Atemweg

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AHA Guidelines

!

!

ERC/ITLS Guidelines

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EZ Tube

LTS-D

i-Gel

LMA Supreme

Air-Q

Newer Generation SLA’s

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Gastro-LT™

Designed for obtaining & maintaining airway patency during procedures in which gastric access is desired

Deep sedation or general anesthesia

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Baska Mask

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Single-use, silicone cuffless device

Built-in bite block

Anterior strap to aid placement

Two drain tubes (active suction, drainage)

TulipSingle-use, PVC

Similar to COPA

Depth markings for depth insertion

Green (small) Orange (medium) Red (large)

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Considerations Using SGA as Conduit for Intubation

‣ Type of device - Simple SGA vs Intubating SGA

‣ Difficult airway scenario - Predicted vs Unpredicted - Elective vs Emergent

‣ Technique - Awake vs Asleep - Blind +/- Bougie - FOB +/- Aintree exchange catheter

‣ Exchange or leave in place

‣ Equipment cost & availability

‣ Polyethylene, 1cm markings

‣ 19 Fr, 56 cm, straight distal tip

‣ Hollow, allows FOB passage (4mm scope; distal 3mm free)

‣ 3 distal ports & luer-lock connector for jet ventilation

‣ Used for exchange of SGAs

‣ Limitations of LMA - Length, narrowness, aperture bars

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Aintree Airway Exchange Catheter

POCKET Bougie™

‣ 14 Fr (4.7 mm) solid intubation guide

‣ Balanced rigidity, flexibility, & memory w/ no metal core

‣ Double-sided depth markings

‣ Tactiglide technology

‣ Designed to fit into a pocket

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Difficult Airway Society Pediatric Difficult Airway Guidelines

‣ Target audience is non-specialists - Wish to learn or maintain pediatric

airway skills - Rehearse unexpected difficult

airway scenarios - Teach good practice

‣ Developed 3 separate algorithms, 1-8 yo - DMV after routine induction - Unanticipated DTI as above - CICV after paralysis

‣ Grade I evidence minimal

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Failure to manage the airway continues to be among the leading anesthesia-related causes of

adverse outcomes in obstetrics

“Often we speak of the safety of modern anesthesiology; it is safe because of the

committment to learn from previous errors,

to discover new techniques &

equipment, and to perform at the

highest possible level each and every day”

ASA DA 1993

ASA DA

2003

Miller Blade 1941

Macintosh Blade 1943

Gum Elastic Bougie 1949

Lighted Stylet 1958

Retrograde Intubation 1960

First SGA 1981

FOB Intubation 1972

Bullard 1989

TTJV 1971

Cricothyrotomy comeback

1976

Bonfils 1983

UpsherScope 1996

Shikani 1996

Glidescope 2003

McGrath 2005

WuScope 1994

DCI Video 2002

Sensascope 2007

�54History of Airway Techniques

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Retrograde Intubation

‣ Techniques: classic, silk, guide wire, & FOB

‣ Safe, effective, & fast when technique is familiar

‣Useful whenever anatomic limitations obscure glottic opening (pathology, CSI, upper airway trauma)

‣CAN VENTILATE situations

  Techniques include classic, silk, guide wire (≥ 70 cm), and FOB

  Safe, effective and fast when technique is familiar

  Useful whenever anatomic limitations obscure glottic opening (pathology, CSI, upper airway trauma)

  CAN VENTILATE situations

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Transtracheal Jet Ventilation

‣ May be performed via catheter (cric or AEC) or via bronchoscope (rigid or flexible)

‣ Techniques vary with type of procedure

‣ Vigilance is of the essence

‣ OPEN THE AIRWAY!!!

  May be performed via a catheter (cric or AEC) or via a bronchoscope (rigid or flexible)

  Technique varies with type

of procedure   Vigilance is of the essence   Enk oxygen flow modulator

  OPEN THE AIRWAY !!!!

 

May be perform

ed via a catheter (cric or A

EC

) or via a bronchoscope (rigid or flexible)

 

Technique varies with type

of procedure  

Vigilance is of the essence

 

Enk oxygen flow

modulator

 

OPEN

THE AIR

WAY !!!!

  May be performed via a catheter (cric or AEC) or via a bronchoscope (rigid or flexible)

  Technique varies with type

of procedure   Vigilance is of the essence   Enk oxygen flow modulator

  OPEN THE AIRWAY !!!!

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Site Inferior CTM

Methods Needle

Percutaneous Surgical

Equipment Scalpel Tube Finger

curved blunt dilator

tracheal hook

trousseau tracheal dilator

Cricothyrotomy Final CVCI Option

Cricothyrotomy may be necessary to secure

the airway !

<50% of anesthesiologists felt

competent to perform

Difficult Airway Management: Practice Patterns Among Anesthesiologists Practicing in the United States Have We Made Any Progress?

Ezri T, MD, Szmuk P, MD, Warters RD, MD, Katz J, MD, Hagberg C, MD

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‣ Needle cric rescue technique of choice

!‣ Often unsuccessful

- Barotrauma - BD - Death

!‣ Practitioner must be experienced.

Institute early!!

Trauma

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‣ Bag-mask ventilation during RSI

‣ Cricoid pressure

‣Manual in-line immobilization

‣ ASA Difficult Airway Guidelines

‣ Role of anesthesiologist

  Final CVCI option in airway algorithms

  Methods include needle, percutaneous, and surgical

  Perform in inferior portion CTM

  Universal cricothyrotomy catheter set

  Studies are lacking   Movement of the neck during cric

  Ease of cric with MILS

  Neurological deterioration after cric

Curved blunt dilator

Tracheal hook

Trousseau tracheal dilator

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Summary‣ Algorithms only serve as guidelines

‣ Be cognizant of predictors of the DA

‣ Equipment must be available

‣ Acquire & maintain advanced airway management skills

‣ Do what works best for you

‣ You CAN make a difference!!

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Aphorisms

Practice is the best of all instructors.

The better you are, the luckier you become.

We live a life of choice, not chance.

ASA NEWSLETTER Abouleish EI. Moments With The Pen. <www.momentswiththepen.com>

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BVM Ventilation Prior to Intubation

Difficult to achieve adequate preoxygenation

High risk of arterial desaturation

Pre-existing conditions - Obesity - Lung injury - Altered LOC - Combativeness

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Cricoid Pressure

Removed as a Level I recommendation

May worsen laryngoscopic view

Impair bag-valve mask (BVM/ventilation)

Not reduce incidence of aspiration

Recommendation: Apply throughout induction and intubation attempts if

necessary, alter/remove to ease intubation or SGA insertion.

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Cervical Spine Manual In-Line Stabilization (MILS)

Inferior view/longer time or failure to secure airway

Recommended by ATLS guidelines

No outcome data demonstrating inferior

Benefits should be balanced against potential for hypoxic

damage

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Video Laryngoscopy

Does VL reduce cervical motion compared to DL in

patients w/ known or suspected CSI?

!

Is there improved intubation success rate in the trauma

patient?

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!‣ Common problems

- Hemodynamic instability - Time pressure - Lack of patient cooperation - Risk of aspiration - Need for cervical spine protection - Facial injuries - Limited options (can’t wake up/

cancel case) !!

Airway Management Controversies Trauma Care

�69

Good decisions

come from experience

Unfortunatelyexperience often comes

from bad decisions