Difficult Airway Management

Dr. Adel Hammodi ,MRCP (UK)

M.Sc. Anesthesia (Alex. EGY)

Assistant Consultant A-ICU

Flexible endoscopic intubation

Video laryngoscopy

Cricothyrotomy

Introduction

30% percent were rated as easy, 47% as moderately difficult and 23% as difficult. • Every intubation in the ICU setting should be considered

potentially difficult. • A training program for alternative methods of airway

management for difficult intubations should be established.

• Incidence of difficult intubation in intensive care patients: analysis of contributing factors. Anaesth. Intensive Care. 2012 Mar;40(2):351

Flexible endoscopic intubation

• Design / parts

Flexible fibreoptic parts.

A. Insertion tube – Flexible part extending from control section to distal

tip of scope.

B .Control section – Contain the tip control knob which

controls movement of insertion tube.

C. Eye piece section.

D. Light transmission cord – from external light source to hand of fiberscope.

E. Light source

Flexible endoscopic intubation

• Indications Anticipated difficult intubation (upper airway abnormality).

Endotracheal intubation when neck extension is not desirable (cervical spine injury, rheumatoid arthritis.

• Advantages Excellent airway visualization.

Minimal hemodynamic stress.

Gold standard for anticipated difficult intubation any age, any position.

Requires good experience.

Technique

Oral route preferable

Topical anesthesia with 2% lidocaine on a base of the tongue, hypopharynx and vocal cords (aerosolized 10% lidocaine may also be used)

Sedation with midazolam (adult dose 1 to 2.5 mg IV) and fentanyl (adult dose 25-100 mcg IV)

"Jaw thrust" maneuver improve visualization

Technique

Apply oral airway or "bite block" to protect the equipment. Apply 100% oxygen via face mask (oxygen may also be delivered via bronchoscope channel)

After the bronchoscope is lubricated and loaded with an endotracheal tube it is introduced strictly in the midline following the base of the tongue, pass the uvula, behind the epiglottis and between the vocal cords. (see video on the left below).

Once the main carina is visualized endotracheal tube is introduced by rotating movement over the bronchoscope. Proper position (3-5 cm above the carina) is evaluated and the tube secured.

Technique

Most anesthesiologists prefer to stand at the head of the patient, as they do for direct laryngoscopy.

The advantage of this position is that anatomical structures are visualized as accustomed

Technique Fiberoptic bronchoscopy requires a clear visual

pathway. Blood and secretions prevent visualization of the laryngeal structures.

Administration of an antisialogogue prior to the start of the procedure is therefore essential (0.2 mg of glycopyrrolate).

Repeated airway manipulation causes edema and bleeding, both of which impair visualization through the bronchoscope.

The possibility of a fiberoptic technique should therefore be kept in mind, and employed before blood and secretions have rendered this technique unusable.

• Contraindications

Inability to oxygenate

Major bleeding.

• Disadvantages

Costs associated with the need for special equipment and skill.

• Complications

Oxygen desaturation.

Bronchospasm (inadequate local anesthesia).

Trauma (especially lower airway).

Video laryngoscopy

• Advantages • Improved laryngeal Less force used than during direct laryngoscopy

• Less cervical spine movement

• Short learning curve

• Improved portability and cost compared to flexible fiber optic laryngoscopes

• Useful teaching tools

• Generally higher success rate, especially in difficult situations.

• Disadvantages • Passage of the ETT may be difficult despite good view or higher POGO score;

often stylet is needed

• Fogging and secretion may obscure the view.

• Loss of depth perception.

• No single videoscope is ideal.

Video laryngoscopy

Video Laryngoscopes Glidescope

• Rigid laryngoscope with CCD

• View is very clear with no fogging

• Blade angle 50-60 deg

1.The operator should always begin in the midline of the mouth,

• following the uvula as the GlideScope enters.

• If the blade is turned sideways for a small mouth opening or large chest, re-orient to the midline.

2.Obtain the “best view” possible by withdrawing the blade in the vallecula to reveal the epiglottis, vocal cords and arytenoid cartilages.

Glidescope in Use

• technique

Glidescope with Disposable Blade

McGrath Videolaryngoscope

Similar to Glidescope

Disposable blade cover

Optics not be as good

Narrow field of vision

More portable

More likely to disappear

Video Laryngoscopes RES-Q-SCOPE

• LCD Screen

• Disposable blade

• Much cheaper

Airtraq

The Future The future of intubation will be video assisted

• In the past, intubators intubated in the dark by themselves

• PRIVATE

• The future will have everybody involved in the process of intubation

• (ER Doc, Nurses, RT)

• PARTY!

Video Laryngoscope Uses:

• First intubation attempt (Oral or Nasal)

• Known difficult DL (Awake or RSI)

• Unanticipated unsuccessful DL

• Confirmation of function of recurrent laryngeal nerve

• Placement of NGT, ETT, or ECHO probe

• Ancillary Departments: ER, ICU, Pediatrics, NICU, Telemedicine, Air Medical, and Academics

• Adjunct with tracheotomy

Miscellaneous Applications of Video Laryngoscopy

• Passage of nasogastric, orogastric, or enteral feeding tubes • Advancement of dilating bougie for esophageal procedures • Passage of a transesophageal echocardiography probe • Placement of upper gastrointestinal endoscopy equipment • Foreign body extraction (eg bridgework, tooth, crown, filling) • Evaluation of the oral cavity, oro- and hypopharyngeal

structures for trauma, • infections, healing • Visualize laryngeal function Hirabayashi Y. GlideScope-assisted insertion of a transesophageal echocardiography probe. J Cardiothorac Vasc Anesth. 2007;21(4):628. Lai HY, Wang PK, Yang YL, Lai J, Chen TY. Facilitated insertion of a nasogastric tube in trachel intubated patients using the GlideScope.Br J Anaesth. 2006;97(5):749-750.

Cricothyrotomy Quicktrach I

- Available for adults (I.D. 4mm

Quicktrach II with cuff - Set with cuff

Thin cuff seals trachea and

allows efficient ventilation with

aspiration protection.

Stopper and safety clip reduce

the risk of posterior tracheal wall

injury.

Anatomically shaped cannula

adjusts to the trachea due to

“memory effect”. Available for

adults (I.D. 4mm)

minitrach A single vertical incision 3-5 mm in length over cricothyroid

membrane is made and then through obturator the 4 mm

uncuffed tracheal tube is guided.

Compared with I.V. cannula the minitrach has larger diameter

and is better for jet ventilation and even for assisted

spontaneous respiration for a short period.

CRICOTHYROTOMY

• Complications

1. Barotrauma.

2. Trauma.

3. Subcutaneous / mediastinal emphysema.

4. Tracheal stoma granulation.

5. Persistent stoma.

6. Tracheal stenosis.

7. Dysphonia.

8. Vocal cord paresis.

9. Wound infection.

Glidescope Success Rates with Experience Joo et al

0

10

20

30

40

50

60

70

80

90

100

0 to 9 10 to 19 20 to 29 30 to 39 > 40

Success Rate