what equipment should be in your difficult airway cart ? margaret healy cnm 2 anaesthesia university...
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What equipment should What equipment should be in your Difficult be in your Difficult Airway Cart ?Airway Cart ?
Margaret HealyMargaret HealyCNM 2 AnaesthesiaCNM 2 AnaesthesiaUniversity College HospitalUniversity College HospitalGalwayGalway
What is a “Difficult What is a “Difficult Airway”?Airway”?
The difficult airway is defined as The difficult airway is defined as the clinical situation in which a the clinical situation in which a
conventionally trained conventionally trained anaesthetist experiences anaesthetist experiences
difficulty with mask ventilation, difficulty with mask ventilation, difficulty with tracheal intubation, difficulty with tracheal intubation,
or bothor both
Difficult Airway Society Difficult Airway Society recommendations recommendations
Practitioners should be competent in a number of Practitioners should be competent in a number of core airway skills.core airway skills.
Work in an appropriate environment (trained assistance, Work in an appropriate environment (trained assistance, with access to a range of airway devices and techniques, with access to a range of airway devices and techniques, appropriate monitoring during surgery and facilities for appropriate monitoring during surgery and facilities for the appropriate level of post op care) the appropriate level of post op care)
That equipment is stocked in dedicated trolleys. That equipment is stocked in dedicated trolleys. These should be regularly checked and stocked. These should be regularly checked and stocked. The exact number and location of each trolley The exact number and location of each trolley should be determined locallyshould be determined locally
All anaesthetists and anaesthetic assistants should be All anaesthetists and anaesthetic assistants should be familiar with the contents and location of the trolleyfamiliar with the contents and location of the trolley
Training should be provided in the use of equipment Training should be provided in the use of equipment selected by each departmentselected by each department
There should be a Consultant Airway Coordinator in There should be a Consultant Airway Coordinator in each department, a training room and dedicated lists for each department, a training room and dedicated lists for airway trainingairway training
CORE SKILLSCORE SKILLS
LMA for ventilationLMA for ventilation
FOI through LMA, FOI through LMA,
Aintree or other airwayAintree or other airway
ILMAILMA
Indirect laryngoscopes Indirect laryngoscopes
Glidescope, Airtraq etc Glidescope, Airtraq etc
Emergency Emergency
cricothyrotomycricothyrotomy
Difficult Airway TrolleyDifficult Airway Trolley
A A shelfshelf and and 5 Drawers5 Drawers that follow sequence that follow sequence of Difficult Airway of Difficult Airway AlgorithmAlgorithm
MobileMobile RobustRobust Clearly labelledClearly labelled Easily cleanedEasily cleaned Attach DAS algorithmsAttach DAS algorithms Restocking listRestocking list
Recommended equipment for Recommended equipment for management of unanticipated management of unanticipated difficult intubationdifficult intubation
DAS guidelines algorithm flowchartsDAS guidelines algorithm flowcharts Equipment list for restockingEquipment list for restocking At least one alternative blade(e.g. straight, At least one alternative blade(e.g. straight,
McCoy)McCoy) Intubating LMA (Size 3,4,5 with dedicated Intubating LMA (Size 3,4,5 with dedicated
tubes and pushers)tubes and pushers) Flexible fibreoptic laryngoscope (with Flexible fibreoptic laryngoscope (with
portable/battery light source)portable/battery light source) Aintree Intubation CatheterAintree Intubation Catheter Proseal LMA / Supreme LMAProseal LMA / Supreme LMA Cricothyroid cannulae with High pressure jet Cricothyroid cannulae with High pressure jet
ventilation system (Manujet) ventilation system (Manujet) OROR Large bore cricothyroid cannulae (e.g. Cuffed Large bore cricothyroid cannulae (e.g. Cuffed
Melker) Melker) OROR Surgical Cricothyroidotomy kitSurgical Cricothyroidotomy kit
Miller Blades Miller Blades (Straight)(Straight) The Miller blades are commonly used for The Miller blades are commonly used for
infants. It is easier to visualize the glottis infants. It is easier to visualize the glottis using these blades than the Macintosh blade using these blades than the Macintosh blade in infants, due to the larger size of the in infants, due to the larger size of the epiglottis relative to that of the glottis. epiglottis relative to that of the glottis.
Levering Laryngoscope Levering Laryngoscope (McCoy)(McCoy)
Hinged tip which facilitates elevation of the epiglottisHinged tip which facilitates elevation of the epiglottis Less force required to intubateLess force required to intubate Improves view at laryngoscopyImproves view at laryngoscopy Useful in patients wearing cervical hard collarsUseful in patients wearing cervical hard collars InexpensiveInexpensive Steep learning curveSteep learning curve
Supraglottic DevicesSupraglottic Devices
Supraglottic devices are the suitable Supraglottic devices are the suitable alternative to endotracheal intubation, alternative to endotracheal intubation, Useful when endotracheal intubation Useful when endotracheal intubation has failedhas failed
Suitable for use by those with limited Suitable for use by those with limited experience with endotracheal experience with endotracheal intubationintubation
Should be immediately available for Should be immediately available for every difficult airway situationevery difficult airway situation
Various types availableVarious types available
Fastrach (Intubating Fastrach (Intubating LMA)LMA)
Advanced version of the Advanced version of the standard LMA, which allows a standard LMA, which allows a specifically designed ETT to be specifically designed ETT to be passed blindly into the tracheapassed blindly into the trachea
Useful in “can’t intubate, can’t Useful in “can’t intubate, can’t ventilate” scenariosventilate” scenarios
Allows fast insertion into Allows fast insertion into correct position without correct position without moving patients head or neckmoving patients head or neck
Can be used alone or as a Can be used alone or as a guide to intubation guide to intubation
Facilitates ventilation between Facilitates ventilation between ILMA insertion and ETT ILMA insertion and ETT insertioninsertion
Available in 3 sizes, 3, 4 & 5 Available in 3 sizes, 3, 4 & 5 with dedicated ETTs available with dedicated ETTs available in 6 / 6.5 / 7 / 7.5 & 8mmin 6 / 6.5 / 7 / 7.5 & 8mm
LMA Pro-SealLMA Pro-Seal
Not necessarily a Difficult Not necessarily a Difficult Airway Device, but is useful Airway Device, but is useful in situation where patient in situation where patient has not been fastinghas not been fasting
May be useful in failed May be useful in failed obstetric intubationobstetric intubation
This has an extra tube This has an extra tube which provides excess which provides excess access to stomach contentsaccess to stomach contents
Protects against aspiration Protects against aspiration by providing an escape for by providing an escape for unexpected regurgitationunexpected regurgitation
Drain tube prevents against Drain tube prevents against gastric insufflationgastric insufflation
LMA Supreme™LMA Supreme™
Quite new to the market, Quite new to the market, combines all the best features of combines all the best features of all previous LMA except you can’t all previous LMA except you can’t intubate through itintubate through it
The SLMA is easily and rapidly The SLMA is easily and rapidly inserted, providing a reliable inserted, providing a reliable airway and a good airway sealairway and a good airway seal
Rates of failure, manipulations Rates of failure, manipulations required and complications are required and complications are very low. very low.
Can be used when tracheal Can be used when tracheal intubation fails in non-fasted intubation fails in non-fasted patients patients
Can be used in CPRCan be used in CPR
Useful in “failed intubation” and Useful in “failed intubation” and the “can’t intubate-can’t the “can’t intubate-can’t ventilate” situationventilate” situation
Fiberoptic Intubation Fiberoptic Intubation (FBI)(FBI) The use of a flexible bronchoscope to intubate The use of a flexible bronchoscope to intubate
The endotracheal tube is passed directly over the bronchoscope into the The endotracheal tube is passed directly over the bronchoscope into the tracheatrachea
Uses: Uses: - Patients with difficult airways - Patients with difficult airways
- Pre-operative assessment- Pre-operative assessment
- Extubation assessment- Extubation assessment
Advantages:Advantages:
– This technique allows direct visualization of the airwayThis technique allows direct visualization of the airway
– Direct confirmation of ETT placementDirect confirmation of ETT placement
– Can be done awake Can be done awake
Disadvantages:Disadvantages:
– Expensive, difficult, requires care and skillExpensive, difficult, requires care and skill
– View may be hampered by blood or secretionsView may be hampered by blood or secretions
– Requires detailed decontamination / traceabilityRequires detailed decontamination / traceability
Berman AirwayBerman Airway
Berman, an American anaesthetist , Berman, an American anaesthetist , designed airways to aid blind intubationdesigned airways to aid blind intubation
Useful to aid oral fibreoptic intubationUseful to aid oral fibreoptic intubation Also useful as a bite blockAlso useful as a bite block
Aintree Intubation Aintree Intubation CatheterCatheter
Hollow bougie which fits over a standard intubating fibrescopeHollow bougie which fits over a standard intubating fibrescope Aids intubation through a dedicated airway such as a Aids intubation through a dedicated airway such as a
laryngeal masklaryngeal mask Place LMA, load Aintree onto fibrescope, pass fibrescope to Place LMA, load Aintree onto fibrescope, pass fibrescope to
the carina and slide off the aintree. Remove the fibrescope the carina and slide off the aintree. Remove the fibrescope and LMA and intubate over the Aintreeand LMA and intubate over the Aintree
Possible to ventilate via this catheter if necessary, throughout Possible to ventilate via this catheter if necessary, throughout the intubation procedurethe intubation procedure
Surgical TechniquesSurgical Techniques
A cricothyrotomy is only indicated when A cricothyrotomy is only indicated when all other devices and techniques have all other devices and techniques have failed or are not availablefailed or are not available
Final step for CICV in all airway Final step for CICV in all airway algorithmsalgorithms
Quicker than a tracheotomyQuicker than a tracheotomy Life savingLife saving Convert to definitive airway asapConvert to definitive airway asap MustMust be provided on all carts be provided on all carts
Surgical Airway Surgical Airway TechniqueTechnique
3 different techniques3 different techniques Needle Cricothyrotomy +TTJVNeedle Cricothyrotomy +TTJV
(Manujet)(Manujet) Large Cannulae Cricothyrotomy Large Cannulae Cricothyrotomy
(Melker / Quicktrach)(Melker / Quicktrach) Surgical CricothyrotomySurgical Cricothyrotomy
1.Needle 1.Needle Cricothyrotomy Cricothyrotomy ((Manujet III with Jet Ventilation Manujet III with Jet Ventilation Catheter)Catheter) Useful for elective or emergency TTJVUseful for elective or emergency TTJV Perc puncture of cricothyroid ligament Perc puncture of cricothyroid ligament It consists of an injector with pressure gauge It consists of an injector with pressure gauge
and adjustable driving pressure (0-4 BAR)and adjustable driving pressure (0-4 BAR) Catheters available in 3 sizes Adult 13g, Child Catheters available in 3 sizes Adult 13g, Child
14g and Baby 16g14g and Baby 16g
1.Transtracheal Jet 1.Transtracheal Jet Ventilation (TTJV)Ventilation (TTJV) Jet ventilation using either specialized ventilator or high Jet ventilation using either specialized ventilator or high
pressure driven valve circuit via a catheter passed pressure driven valve circuit via a catheter passed through the cricothyroid membranethrough the cricothyroid membrane
Similar technique to previousSimilar technique to previous
DisadvantagesDisadvantages– Requires high pressure gas sourceRequires high pressure gas source
– May cause subcutaneous emphysema, pneumo-May cause subcutaneous emphysema, pneumo-mediastinum, pneumothorax or other types of mediastinum, pneumothorax or other types of barotraumabarotrauma
Uses:Uses:– Emergency ventilation in the can’t intubate can’t Emergency ventilation in the can’t intubate can’t
ventilate scenarioventilate scenario
2. Cricothyrotomy 2. Cricothyrotomy Catheter Catheter (Melker cuffed/ (Melker cuffed/ Quicktrach)Quicktrach) SyringeSyringe 18g Introducer 18g Introducer
Needles (5cm & Needles (5cm & 7cm)7cm)
GuidewireGuidewire Curved DilatorCurved Dilator Airway CatheterAirway Catheter
2. Large Cannulae 2. Large Cannulae CricothyrotomyCricothyrotomy
Used for emergency airway access when Used for emergency airway access when conventional ETT intubation cannot be conventional ETT intubation cannot be performedperformed
Percutaneous entry ( Seldinger ) technique Percutaneous entry ( Seldinger ) technique via cricothyroid membranevia cricothyroid membrane
Dilate the tract and tracheal entrance site Dilate the tract and tracheal entrance site to permit passage of the emergency to permit passage of the emergency airwayairway
Cuffed catheter to protect and control Cuffed catheter to protect and control airwayairway
3.Surgical 3.Surgical CricothyrotomyCricothyrotomy
RequirementsRequirements:: No 11 blade No 11 blade Size 6 Shiley tracheostomySize 6 Shiley tracheostomy
( OR small ETT size 5.0-6.0)( OR small ETT size 5.0-6.0) Small artery forcepsSmall artery forceps
Technique:Technique:
• Head fully extended • longitudinal incision is made
through the skin and subcutaneous fat over the thyroid and cricoid cartilages
• Tissue bluntly dissected• Cricothyroid ligament is
transversely incised• Tracheal tube inserted
AccessoriesAccessories
Fibreoptic Bronchoscopy accessories – Fibreoptic Bronchoscopy accessories – suction adaptor, irrigation valve, camera suction adaptor, irrigation valve, camera head, light cable, Leak tester,head, light cable, Leak tester,mouth guard,mouth guard,
Berman airwayBerman airway Endoscopy masksEndoscopy masks Airway anaesthesia – nebuliser, atomiser, Airway anaesthesia – nebuliser, atomiser, Xylocaine Spray , Xylocaine 4% topical, Xylocaine Spray , Xylocaine 4% topical,
Co-Phenylcaine Co-Phenylcaine Battery Light SourceBattery Light Source
DocumentationDocumentation
D.A.S. guidelinesD.A.S. guidelines Set up Set up
instructionsinstructions Decontamination Decontamination
InstructionsInstructions Checking / Checking /
Restocking ListRestocking List
ConclusionConclusion
Lack of clear instructions Lack of clear instructions Technology is changing quicklyTechnology is changing quickly Core skills are vitalCore skills are vital Difficult Airway devices should be Difficult Airway devices should be
used in routine cases to ensure used in routine cases to ensure familiarityfamiliarity
?? Standard Difficult Airway Cart ?? Standard Difficult Airway Cart nationally nationally