logging in or signing up AIRWAY guptaarun71 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 28 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: January 12, 2012 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript AIRWAY MANAGEMENT : AIRWAY MANAGEMENT When you can’t breath, nothing else matters Dr.Arun Kr Gupta Asst. Professor Dept. of Anesthesiology & Critical Care Airway management is really easy… : Airway management is really easy… …except when it isn’t… Slide 3: Perhaps the most important responsibility of the anesthesiologist is “management of the patient’s airway” Miller RD’s Anesthesia 2000 Barash PG, Cullen BF, Stoelting RK’s Clinical Anesthesia 2001 Goals : Goals Predict a difficult airway based on clinical criteria Plan for appropriate action in the difficult airway Initiate appropriate plans of attack with confidence in the “Can’t Ventilate/Can't Intubate” (CVCI) situation Become informed about some new (and not so new) airway options out there. Slide 5: What should we know about “airway management” ? Airway anatomy and function Evaluation of airway Clinical management of the airway Maintenance and ventilation Intubation and extubation Difficult airway management Airway anatomy : Airway anatomy The term “airway” refers to the upper airway consisting of ● Nasal and oral cavities ● Pharynx ● Larynx ● Trachea ● Principle bronchi Larynx in Laryngoscopic view : Larynx in Laryngoscopic view Slide 8: If only they looked this good… How many of our Pt’s are like That? : How many of our Pt’s are like That? In Reality Our patients are: : In Reality Our patients are: Immobilized Traumatized Compromised Prioritized Beer-n-Pizza-ized They Tend to look like This: : They Tend to look like This: And This: : And This: And This (after failed ETT attempt) : And This (after failed ETT attempt) Most of our Patients are already “difficult airways” by “OR” Standards. Why should EMS personnel try to further identify a difficult airway? : Most of our Patients are already “difficult airways” by “OR” Standards. Why should EMS personnel try to further identify a difficult airway? So what do we do? : So what do we do? A little pre-planning goes a long way… : A little pre-planning goes a long way… Principles of Airway Management : Principles of Airway Management Indications for airway protection : Indications for airway protection Decreased level of consciousness GCS <9 Cerebral injury Surgery Medical problems Potential causes of airway obstruction : Potential causes of airway obstruction Tongue Dentures Food stuffs Vomit Blood Secretions Techniques to clear material from airway : Techniques to clear material from airway Suction Postural airway manoeuvres Basic life support chocking protocol as discussed earlier Opening the Airway : Opening the Airway Check the airway Open the airway, place one hand on the victims forehead and gently tilt head back Remove any visible obstruction from the victims mouth, including dislodged dentures. Leave well fitting dentures in place DO NOT ATTEMPT ANY FINGER SWEEPS Establishing A Patent Airway : Establishing A Patent Airway Chin Lift and Jaw Thrust Maneuver Oropharyngeal Airway Nasopharyngeal Airway Laryngeal Mask Airway - The above do not protect against aspiration and laryngospasm Opening the airway : Opening the airway Jaw thrust technique may be needed if C-spine injury : Jaw thrust technique may be needed if C-spine injury Simple airway adjuncts : Simple airway adjuncts Nasopharyngeal airway insertion : Nasopharyngeal airway insertion Oropharyngeal airway insertion : Oropharyngeal airway insertion Laryngeal Mask Airways : Laryngeal Mask Airways It can be difficult to… : It can be difficult to… …oxygenate …ventilate …intubate …perform cricothyrotomy To Maximize Success… : To Maximize Success… …recognize and predict difficult airway …choose appropriate technique and equipment …possess technical skills, drugs, and devices Predicting the Difficult Airway…if you have time : Predicting the Difficult Airway…if you have time LEMON Law : LEMON Law Look at anatomy Examine the airway Mallampati Obstructions Neck mobility LEMON Look at Anatomy : Look at Anatomy Obesity: rapid desaturation, difficult intubation, ventilation Facial hair: hides small chin, can make bagging difficult / impossible Large teeth: hide airway, obscure tube passage Jagged teeth: lacerate balloon LEMON Look at Anatomy : Look at Anatomy LEMON Look at Anatomy : Look at Anatomy Narrow face, high-arched palate: decreased side-to-side diameter Large tongue: hides airway False teeth: help bagging, remove for intubation LEMON Examine Airway : Examine Airway LEMON Examine Airway : Examine Airway The 3 – 3 – 2 rule Mouth open: 3 fingers Mentum to hyoid: 3 fingers Floor of mouth to thyroid cartilage: 2 fingers LEMON Examine Airway : Examine Airway Mouth open: 3 fingers Allows insertion of tube, laryngoscope Mentum to hyoid: 3 fingers Predicts ability to lift tongue into mandible LEMON Examine Airway : Examine Airway Floor of mouth to thyroid cartilage: 2 fingers If high larynx, airway tucked under base of tongue, hard to visualize LEMON Mallampati Score : Mallampati Score With patient seated: extend neck open mouth stick out tongue Visualize base of tongue, faucial pillars, uvula, pharynx LEMON Mallampati Score : Mallampati Score Airway Obstructions : Airway Obstructions LEMON Airway Obstructions : Airway Obstructions Angioedema? Hematoma? Look under shirt collar Dentures? Epiglottis? LEMON Neck Mobility : Neck Mobility Prior condition Surgery Rheumatoid arthritis Osteoarthritis Others LEMON Neck Mobility : Neck Mobility LEMON Neck Mobility : Neck Mobility Cervical spine rigidity: reduces ability to align anatomic axes Inability to mobilize neck can make intubation difficult or impossible LEMON Moving Beyond Laryngoscopy : Moving Beyond Laryngoscopy Some Equipment, Old & New : Some Equipment, Old & New Difficult Airway Cart : Difficult Airway Cart Bag valve mask Combitube™ LMA Intubation LMA Fiberoptic: rigid, flexible Lightwand Bougie Transtracheal jet Retrograde Digital Cricothyrotomy 1. Bag Valve Mask : 1. Bag Valve Mask B V M 1. Bag Valve Mask (BVM) : 1. Bag Valve Mask (BVM) Practice: skills essential Use appropriate size oral airway or nasal trumpet Leave dentures Use water-soluble lubricant to get good seal, especially if lots of facial hair B V M 2. Combitube® : 2. Combitube® Combitube 2. Combitube® : 2. Combitube® Double lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tube Insert blindly 90% esophageal Inflate proximal balloon: 100 mL Inflate distal balloon: 5 –15mL Combitube 2. Combitube® : 2. Combitube® Seals oropharyngeal and nasopharyngeal cavities Ventilate through blue port Good breath sounds and no air in stomach continue ventilating No breath sounds and air in stomach use white tube Combitube 2. Combitube® : 2. Combitube® Combitube 3. Laryngeal Mask Airway : 3. Laryngeal Mask Airway L M A Indications : Indications Routine / emergency procedures Known / unknown difficult airway During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible L M A Contraindications : Contraindications In elective patient who… …has not fasted …may have gastric contents …has fixed lung compliance …is not profoundly unconscious …resists LMA airway insertion L M A Usage : Usage L M A Usage : Usage L M A Usage : Usage L M A Usage : Usage L M A Usage : Usage L M A 4. Intubating LMA : 4. Intubating LMA L M A Slide 72: L M A LMA Take-Home Points : LMA Take-Home Points Test cuff before use Don’t lubricate anterior mask Insert only in comatose patient Keep cuff inflated until patient awake Don’t throw out!! Used 40 – 50 times L M A 5. Flexible Fiberoptic Scope : 5. Flexible Fiberoptic Scope Fiberoptic 5. Flexible Fiberoptic Scope : 5. Flexible Fiberoptic Scope Advantages Allows direct airway visualization Causes little hemodynamic stress Nasotracheal or orotracheal route Can be done in all age groups Requires minimal neck movement Fiberoptic 5. Flexible Fiberoptic Scope : 5. Flexible Fiberoptic Scope Disadvantages Expensive Expertise requires practice Delicate equipment needs careful maintenance Visual field easily impaired by blood and secretions Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Bullard Wu Scope Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Upsher GlideScope Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Levitan Scope Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Advantages Direct airway visualization Minimal neck movement May overcome difficult view Useful in disrupted airway Durable, sturdy instruments Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Disadvantages Expensive Expertise requires practice Visual field easily impaired by blood and secretions Not readily available Fiberoptic 7. Lightwand (Trachlight) : 7. Lightwand (Trachlight) Lightwand 7. Lightwand (Trachlight) : 7. Lightwand (Trachlight) Lightwand 7. Lightwand (Trachlight) : 7. Lightwand (Trachlight) Advantages Minimal neck movement Useful adjunct to laryngoscopy Portable and inexpensive Usable in bloody airway Provides definitive airway Lightwand 7. Lightwand (Trachlight) : 7. Lightwand (Trachlight) Disadvantages Blind technique May damage airway Usually requires darkened room Expertise requires practice Lightwand 8. Intubating Stylet (Bougie) : 8. Intubating Stylet (Bougie) Bougie 8. Intubating Stylet (Bougie) : 8. Intubating Stylet (Bougie) Gum elastic – use as guidewire Advantages Gives definitive airway Easy to learn Inexpensive Can be used blindly Bougie 8. Intubating Stylet (Bougie) : 8. Intubating Stylet (Bougie) Gum elastic – use as guidewire Disadvantages Expertise requires practice Not recommended in “can’t intubate / can’t ventilate” scenario Bougie 9. Transtracheal Jet Ventilation : 9. Transtracheal Jet Ventilation TTJV 9. Transtracheal Jet Ventilation : 9. Transtracheal Jet Ventilation Advantages Surgical airway of choice if 8 years or younger Effective Can serve as temporary airway before permanent airway Relatively simple procedure TTJV 9. Transtracheal Jet Ventilation : 9. Transtracheal Jet Ventilation Disadvantages Significant complications if misplaced Need proper equipment Need high-pressure oxygen Does not protect against aspiration TTJV 10. Retrograde Intubation : 10. Retrograde Intubation Retrograde 10. Retrograde Intubation : 10. Retrograde Intubation Puncture cricothyroid membrane Thread wire through vocal cords Exit nose or mouth Guide endotracheal tube through vocal cords over wire Retrograde 10. Retrograde Intubation : 10. Retrograde Intubation Advantages Definitive airway Minimal neck movement Does not require full mouth open Retrograde 10. Retrograde Intubation : 10. Retrograde Intubation Disadvantages Takes time Requires skill Not recommended in cannot intubate / cannot ventilate Retrograde 11. Cricothyrotomy : 11. Cricothyrotomy Cric 11. Cricothyrotomy : 11. Cricothyrotomy Life-saving technique Surgical vs. needle / Seldinger vs. percutaneous kit You must know this procedure before starting rapid sequence Cric 11. Cricothyrotomy : 11. Cricothyrotomy Final common pathways for all cannot intubate / cannot ventilate scenarios “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen Cric And finally… : And finally… BURP your patient – grab the larynx and give… …Backward …Upward …Rightward …Pressure BURP Conclusions : Conclusions Recognize the difficult airway How much time do you have? Who else is around? What is your backup procedure Know both old and new methods Choose backups based on skills Mask Ventilation : Mask Ventilation Can Deliver A High FIO2 Avoids The Potential Trauma Of Intubation Does Not Protect Against Aspiration May Result In Gastric Distension Laryngospasm Can Occur Requires Use Of Both Hands Oral/Nasal Intubation : Oral/Nasal Intubation Safe and Common Practice in Patients Undergoing General Anesthesia Atraumatic Intubation requires Knowledge of Anatomy, Appropriate use of Equipment, and Drugs (Muscle Relaxants) Preoperative Evaluation : Preoperative Evaluation Patient History - Prior History of Difficult Intubation - Tumor of Head and Neck - Arthritis - Pregnancy - Trauma - C Spine, Full Stomach Preoperative Evaluation : Preoperative Evaluation Physical Examination - Tongue versus Pharyngeal Size - Atlanto - Occipital Joint Extension Cervical Spine Mobility (normal 35 degrees) - Anterior Mandibular Space Thyromental distance - normal is 6 cm - Dental Examination (Loose Teeth, Prostheses) Technique For Orotracheal Intubation : Technique For Orotracheal Intubation Preparation And Equipment (Always Have Suction Available) Head Position - Alignment Of Oral, Pharyngeal, and Laryngeal Axes Choice Of Laryngoscope And Endotracheal Tube Possible Need For Awake Tracheal Intubation - Difficult Airway Algorithm Orotracheal Intubation : Orotracheal Intubation Patient’s Head At The Level Of The Xiphoid Sniffing Position Laryngoscope In LEFT Hand Open Mouth Hold Tracheal Tube In Right Hand Like A Pencil Complications Of Orotracheal Intubation (During) : Complications Of Orotracheal Intubation (During) Dental And Oral Soft tissue Trauma Hypertension And Tachycardia Cardiac Dysrhythmias And Myocardial Ischemia Aspiration Corneal Damage Complications Of Orotracheal Intubation (Intubated Patient) : Complications Of Orotracheal Intubation (Intubated Patient) Tracheal Tube Obstruction Endobronchial Intubation Barotrauma Accidental Disconnect Tracheal Mucosa Ischemia Accidental Extubation Immediate And delayed Complications On Extubation : Immediate And delayed Complications On Extubation Laryngospasm Aspiration Pharyngitis Laryngeal Or Subglottic Edema Vocal Cord Paralysis Arytenoid Cartilage Dislocation Alternatives To Orotracheal Intubation Under Anesthesia : Alternatives To Orotracheal Intubation Under Anesthesia Awake Orotracheal Intubation Nasotracheal Intubation - Awake Blind Nasal - Nasotracheal Intubation After Induction Intubation With Fiberoptic Bronchoscope - Awake versus Under Anesthesia - Orotracheal versus Nasotracheal Retrograde Intubation Verification Of Correct Tube Placement : Verification Of Correct Tube Placement Symmetric Chest Movement Symmetric Breath Sounds End tidal Carbon Dioxide - Greater Than 30 For 3-5 Breaths Condensation Of Water In The tube Palpation Of Cuff In Suprasternal Notch Fiberoptic Bronchoscopy You do not have the permission to view this presentation. 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AIRWAY guptaarun71 Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 28 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: January 12, 2012 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript AIRWAY MANAGEMENT : AIRWAY MANAGEMENT When you can’t breath, nothing else matters Dr.Arun Kr Gupta Asst. Professor Dept. of Anesthesiology & Critical Care Airway management is really easy… : Airway management is really easy… …except when it isn’t… Slide 3: Perhaps the most important responsibility of the anesthesiologist is “management of the patient’s airway” Miller RD’s Anesthesia 2000 Barash PG, Cullen BF, Stoelting RK’s Clinical Anesthesia 2001 Goals : Goals Predict a difficult airway based on clinical criteria Plan for appropriate action in the difficult airway Initiate appropriate plans of attack with confidence in the “Can’t Ventilate/Can't Intubate” (CVCI) situation Become informed about some new (and not so new) airway options out there. Slide 5: What should we know about “airway management” ? Airway anatomy and function Evaluation of airway Clinical management of the airway Maintenance and ventilation Intubation and extubation Difficult airway management Airway anatomy : Airway anatomy The term “airway” refers to the upper airway consisting of ● Nasal and oral cavities ● Pharynx ● Larynx ● Trachea ● Principle bronchi Larynx in Laryngoscopic view : Larynx in Laryngoscopic view Slide 8: If only they looked this good… How many of our Pt’s are like That? : How many of our Pt’s are like That? In Reality Our patients are: : In Reality Our patients are: Immobilized Traumatized Compromised Prioritized Beer-n-Pizza-ized They Tend to look like This: : They Tend to look like This: And This: : And This: And This (after failed ETT attempt) : And This (after failed ETT attempt) Most of our Patients are already “difficult airways” by “OR” Standards. Why should EMS personnel try to further identify a difficult airway? : Most of our Patients are already “difficult airways” by “OR” Standards. Why should EMS personnel try to further identify a difficult airway? So what do we do? : So what do we do? A little pre-planning goes a long way… : A little pre-planning goes a long way… Principles of Airway Management : Principles of Airway Management Indications for airway protection : Indications for airway protection Decreased level of consciousness GCS <9 Cerebral injury Surgery Medical problems Potential causes of airway obstruction : Potential causes of airway obstruction Tongue Dentures Food stuffs Vomit Blood Secretions Techniques to clear material from airway : Techniques to clear material from airway Suction Postural airway manoeuvres Basic life support chocking protocol as discussed earlier Opening the Airway : Opening the Airway Check the airway Open the airway, place one hand on the victims forehead and gently tilt head back Remove any visible obstruction from the victims mouth, including dislodged dentures. Leave well fitting dentures in place DO NOT ATTEMPT ANY FINGER SWEEPS Establishing A Patent Airway : Establishing A Patent Airway Chin Lift and Jaw Thrust Maneuver Oropharyngeal Airway Nasopharyngeal Airway Laryngeal Mask Airway - The above do not protect against aspiration and laryngospasm Opening the airway : Opening the airway Jaw thrust technique may be needed if C-spine injury : Jaw thrust technique may be needed if C-spine injury Simple airway adjuncts : Simple airway adjuncts Nasopharyngeal airway insertion : Nasopharyngeal airway insertion Oropharyngeal airway insertion : Oropharyngeal airway insertion Laryngeal Mask Airways : Laryngeal Mask Airways It can be difficult to… : It can be difficult to… …oxygenate …ventilate …intubate …perform cricothyrotomy To Maximize Success… : To Maximize Success… …recognize and predict difficult airway …choose appropriate technique and equipment …possess technical skills, drugs, and devices Predicting the Difficult Airway…if you have time : Predicting the Difficult Airway…if you have time LEMON Law : LEMON Law Look at anatomy Examine the airway Mallampati Obstructions Neck mobility LEMON Look at Anatomy : Look at Anatomy Obesity: rapid desaturation, difficult intubation, ventilation Facial hair: hides small chin, can make bagging difficult / impossible Large teeth: hide airway, obscure tube passage Jagged teeth: lacerate balloon LEMON Look at Anatomy : Look at Anatomy LEMON Look at Anatomy : Look at Anatomy Narrow face, high-arched palate: decreased side-to-side diameter Large tongue: hides airway False teeth: help bagging, remove for intubation LEMON Examine Airway : Examine Airway LEMON Examine Airway : Examine Airway The 3 – 3 – 2 rule Mouth open: 3 fingers Mentum to hyoid: 3 fingers Floor of mouth to thyroid cartilage: 2 fingers LEMON Examine Airway : Examine Airway Mouth open: 3 fingers Allows insertion of tube, laryngoscope Mentum to hyoid: 3 fingers Predicts ability to lift tongue into mandible LEMON Examine Airway : Examine Airway Floor of mouth to thyroid cartilage: 2 fingers If high larynx, airway tucked under base of tongue, hard to visualize LEMON Mallampati Score : Mallampati Score With patient seated: extend neck open mouth stick out tongue Visualize base of tongue, faucial pillars, uvula, pharynx LEMON Mallampati Score : Mallampati Score Airway Obstructions : Airway Obstructions LEMON Airway Obstructions : Airway Obstructions Angioedema? Hematoma? Look under shirt collar Dentures? Epiglottis? LEMON Neck Mobility : Neck Mobility Prior condition Surgery Rheumatoid arthritis Osteoarthritis Others LEMON Neck Mobility : Neck Mobility LEMON Neck Mobility : Neck Mobility Cervical spine rigidity: reduces ability to align anatomic axes Inability to mobilize neck can make intubation difficult or impossible LEMON Moving Beyond Laryngoscopy : Moving Beyond Laryngoscopy Some Equipment, Old & New : Some Equipment, Old & New Difficult Airway Cart : Difficult Airway Cart Bag valve mask Combitube™ LMA Intubation LMA Fiberoptic: rigid, flexible Lightwand Bougie Transtracheal jet Retrograde Digital Cricothyrotomy 1. Bag Valve Mask : 1. Bag Valve Mask B V M 1. Bag Valve Mask (BVM) : 1. Bag Valve Mask (BVM) Practice: skills essential Use appropriate size oral airway or nasal trumpet Leave dentures Use water-soluble lubricant to get good seal, especially if lots of facial hair B V M 2. Combitube® : 2. Combitube® Combitube 2. Combitube® : 2. Combitube® Double lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tube Insert blindly 90% esophageal Inflate proximal balloon: 100 mL Inflate distal balloon: 5 –15mL Combitube 2. Combitube® : 2. Combitube® Seals oropharyngeal and nasopharyngeal cavities Ventilate through blue port Good breath sounds and no air in stomach continue ventilating No breath sounds and air in stomach use white tube Combitube 2. Combitube® : 2. Combitube® Combitube 3. Laryngeal Mask Airway : 3. Laryngeal Mask Airway L M A Indications : Indications Routine / emergency procedures Known / unknown difficult airway During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible L M A Contraindications : Contraindications In elective patient who… …has not fasted …may have gastric contents …has fixed lung compliance …is not profoundly unconscious …resists LMA airway insertion L M A Usage : Usage L M A Usage : Usage L M A Usage : Usage L M A Usage : Usage L M A Usage : Usage L M A 4. Intubating LMA : 4. Intubating LMA L M A Slide 72: L M A LMA Take-Home Points : LMA Take-Home Points Test cuff before use Don’t lubricate anterior mask Insert only in comatose patient Keep cuff inflated until patient awake Don’t throw out!! Used 40 – 50 times L M A 5. Flexible Fiberoptic Scope : 5. Flexible Fiberoptic Scope Fiberoptic 5. Flexible Fiberoptic Scope : 5. Flexible Fiberoptic Scope Advantages Allows direct airway visualization Causes little hemodynamic stress Nasotracheal or orotracheal route Can be done in all age groups Requires minimal neck movement Fiberoptic 5. Flexible Fiberoptic Scope : 5. Flexible Fiberoptic Scope Disadvantages Expensive Expertise requires practice Delicate equipment needs careful maintenance Visual field easily impaired by blood and secretions Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Bullard Wu Scope Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Upsher GlideScope Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Levitan Scope Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Advantages Direct airway visualization Minimal neck movement May overcome difficult view Useful in disrupted airway Durable, sturdy instruments Fiberoptic 6. Rigid Fiberoptic Scope : 6. Rigid Fiberoptic Scope Disadvantages Expensive Expertise requires practice Visual field easily impaired by blood and secretions Not readily available Fiberoptic 7. Lightwand (Trachlight) : 7. Lightwand (Trachlight) Lightwand 7. Lightwand (Trachlight) : 7. Lightwand (Trachlight) Lightwand 7. Lightwand (Trachlight) : 7. Lightwand (Trachlight) Advantages Minimal neck movement Useful adjunct to laryngoscopy Portable and inexpensive Usable in bloody airway Provides definitive airway Lightwand 7. Lightwand (Trachlight) : 7. Lightwand (Trachlight) Disadvantages Blind technique May damage airway Usually requires darkened room Expertise requires practice Lightwand 8. Intubating Stylet (Bougie) : 8. Intubating Stylet (Bougie) Bougie 8. Intubating Stylet (Bougie) : 8. Intubating Stylet (Bougie) Gum elastic – use as guidewire Advantages Gives definitive airway Easy to learn Inexpensive Can be used blindly Bougie 8. Intubating Stylet (Bougie) : 8. Intubating Stylet (Bougie) Gum elastic – use as guidewire Disadvantages Expertise requires practice Not recommended in “can’t intubate / can’t ventilate” scenario Bougie 9. Transtracheal Jet Ventilation : 9. Transtracheal Jet Ventilation TTJV 9. Transtracheal Jet Ventilation : 9. Transtracheal Jet Ventilation Advantages Surgical airway of choice if 8 years or younger Effective Can serve as temporary airway before permanent airway Relatively simple procedure TTJV 9. Transtracheal Jet Ventilation : 9. Transtracheal Jet Ventilation Disadvantages Significant complications if misplaced Need proper equipment Need high-pressure oxygen Does not protect against aspiration TTJV 10. Retrograde Intubation : 10. Retrograde Intubation Retrograde 10. Retrograde Intubation : 10. Retrograde Intubation Puncture cricothyroid membrane Thread wire through vocal cords Exit nose or mouth Guide endotracheal tube through vocal cords over wire Retrograde 10. Retrograde Intubation : 10. Retrograde Intubation Advantages Definitive airway Minimal neck movement Does not require full mouth open Retrograde 10. Retrograde Intubation : 10. Retrograde Intubation Disadvantages Takes time Requires skill Not recommended in cannot intubate / cannot ventilate Retrograde 11. Cricothyrotomy : 11. Cricothyrotomy Cric 11. Cricothyrotomy : 11. Cricothyrotomy Life-saving technique Surgical vs. needle / Seldinger vs. percutaneous kit You must know this procedure before starting rapid sequence Cric 11. Cricothyrotomy : 11. Cricothyrotomy Final common pathways for all cannot intubate / cannot ventilate scenarios “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen Cric And finally… : And finally… BURP your patient – grab the larynx and give… …Backward …Upward …Rightward …Pressure BURP Conclusions : Conclusions Recognize the difficult airway How much time do you have? Who else is around? What is your backup procedure Know both old and new methods Choose backups based on skills Mask Ventilation : Mask Ventilation Can Deliver A High FIO2 Avoids The Potential Trauma Of Intubation Does Not Protect Against Aspiration May Result In Gastric Distension Laryngospasm Can Occur Requires Use Of Both Hands Oral/Nasal Intubation : Oral/Nasal Intubation Safe and Common Practice in Patients Undergoing General Anesthesia Atraumatic Intubation requires Knowledge of Anatomy, Appropriate use of Equipment, and Drugs (Muscle Relaxants) Preoperative Evaluation : Preoperative Evaluation Patient History - Prior History of Difficult Intubation - Tumor of Head and Neck - Arthritis - Pregnancy - Trauma - C Spine, Full Stomach Preoperative Evaluation : Preoperative Evaluation Physical Examination - Tongue versus Pharyngeal Size - Atlanto - Occipital Joint Extension Cervical Spine Mobility (normal 35 degrees) - Anterior Mandibular Space Thyromental distance - normal is 6 cm - Dental Examination (Loose Teeth, Prostheses) Technique For Orotracheal Intubation : Technique For Orotracheal Intubation Preparation And Equipment (Always Have Suction Available) Head Position - Alignment Of Oral, Pharyngeal, and Laryngeal Axes Choice Of Laryngoscope And Endotracheal Tube Possible Need For Awake Tracheal Intubation - Difficult Airway Algorithm Orotracheal Intubation : Orotracheal Intubation Patient’s Head At The Level Of The Xiphoid Sniffing Position Laryngoscope In LEFT Hand Open Mouth Hold Tracheal Tube In Right Hand Like A Pencil Complications Of Orotracheal Intubation (During) : Complications Of Orotracheal Intubation (During) Dental And Oral Soft tissue Trauma Hypertension And Tachycardia Cardiac Dysrhythmias And Myocardial Ischemia Aspiration Corneal Damage Complications Of Orotracheal Intubation (Intubated Patient) : Complications Of Orotracheal Intubation (Intubated Patient) Tracheal Tube Obstruction Endobronchial Intubation Barotrauma Accidental Disconnect Tracheal Mucosa Ischemia Accidental Extubation Immediate And delayed Complications On Extubation : Immediate And delayed Complications On Extubation Laryngospasm Aspiration Pharyngitis Laryngeal Or Subglottic Edema Vocal Cord Paralysis Arytenoid Cartilage Dislocation Alternatives To Orotracheal Intubation Under Anesthesia : Alternatives To Orotracheal Intubation Under Anesthesia Awake Orotracheal Intubation Nasotracheal Intubation - Awake Blind Nasal - Nasotracheal Intubation After Induction Intubation With Fiberoptic Bronchoscope - Awake versus Under Anesthesia - Orotracheal versus Nasotracheal Retrograde Intubation Verification Of Correct Tube Placement : Verification Of Correct Tube Placement Symmetric Chest Movement Symmetric Breath Sounds End tidal Carbon Dioxide - Greater Than 30 For 3-5 Breaths Condensation Of Water In The tube Palpation Of Cuff In Suprasternal Notch Fiberoptic Bronchoscopy