Airway Management

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A Short Review about features to assess for Advanced Airway Management in Clinical Scenarios.

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Presentation Transcript

Airway Management : 

"...There is nothing living which does not breathe nor anything with breathing which does not live." Lectures on the Whole of Anatomy (1653) William Harvey Airway Management Vancouver, February 19th, 2010 ICU Friday Morning Seminar:

Outline : 

History of Airway Management ‘Very’ Brief Applied Functional Airway Anatomy The Airway Practitioner and the Clinical Setting Global and Airway Assessment Urgency vs. Emergency Difficult Airway [Anticipated vs. Unanticipated] Difficult Bag Mask Ventilation [DBV] Difficult Tracheal Intubation [DTI] Difficult Extraglottic Device Placement Difficult Surgical Airway Airway Adjuncts Direct Laryngoscopy [Macintosh®/Miller®/ McCoy®] Extraglottic Devices [LMA / PLMA® / ILMA®/ Combitube®] Stylets [Bougie / Trachlight® / Bonfils / Shikani] Videolaryngoscopes [GlideScope® / Bullard / McGrath®] Fiberoptic Intubation Surgical Airway Complications of Tracheal Intubation Summary Outline …in only one hour…!

History of Airway Management : 

History of Airway Management Peter Szmuk, Tiberiu Ezri, Shmuel Evron, Yehudah Roth, Jeffrey Katz, A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age, 2008 Intensive Care Med; 34:222–228

History of Airway Management : 

History of Airway Management Peter Szmuk, Tiberiu Ezri, Shmuel Evron, Yehudah Roth, Jeffrey Katz, A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age, 2008 Intensive Care Med; 34:222–228

Slide 6: 

History of Airway Management

Slide 7: 

Rig Vedas History of Airway Management

Slide 8: 

Rig Vedas Hippocrates History of Airway Management

Slide 9: 

Rig Vedas Hippocrates Galen History of Airway Management

Slide 10: 

Avicenna Rig Vedas Hippocrates Galen History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola George Washington History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola Manuel Rodríguez George Washington History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola Manuel Rodríguez George Washington William MacEwen History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola Manuel Rodríguez Joseph O'Dwyer George Washington William MacEwen History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola Manuel Rodríguez Joseph O'Dwyer George Washington William MacEwen Chevalier Jackson History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola Manuel Rodríguez Joseph O'Dwyer George Washington William MacEwen Chevalier Jackson Sir Ivan MaGill History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola Manuel Rodríguez Joseph O'Dwyer George Washington William MacEwen Chevalier Jackson Robert Miller Sir Ivan MaGill History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola Manuel Rodríguez Joseph O'Dwyer George Washington William MacEwen Chevalier Jackson Robert Miller Sir Ivan MaGill Sir Robert MacIntosh History of Airway Management

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Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola Manuel Rodríguez Joseph O'Dwyer George Washington William MacEwen Chevalier Jackson Robert Miller Sir Ivan MaGill Dr. Archie Brain Sir Robert MacIntosh History of Airway Management

Slide 22: 

Avicenna Rig Vedas Hippocrates Galen Andreas Vesalius Antonio Brasavola Manuel Rodríguez Joseph O'Dwyer George Washington William MacEwen Chevalier Jackson Robert Miller Sir Ivan MaGill Dr. Archie Brain Sir Robert MacIntosh History of Airway Management

‘Very’ Brief Applied Functional Airway Anatomy : 

‘Very’ Brief Applied Functional Airway Anatomy

Question #1 : 

Innervations and blocking the Recurrent Laryngeal Nerve involve the following structures: Nasopharynx, oropharynx, and hypopharynx Nasal cavity and posterior pharynx Base of tongue and back of throat Larynx, vocal cords and trachea Question #1

‘Very’ Brief Applied Functional Airway Anatomy : 

‘Very’ Brief Applied Functional Airway Anatomy The bony lateral wall of the nasal cavity is the origin of the three bony turbinates that project into the nasal cavity. Nonencapsulated lymphoid tissue on the posterior surface of the tongue is part of the ring of Waldeyer. The pharynx is a fibromuscular tube that extends from the base of the skull to the lower border of the cricoid cartilage. It joins the nasal and oral cavities above with the larynx and esophagus below. Both the pharynx and esophagus can be perforated by blind attempts at tracheal intubation. In: Miller: Miller's Anesthesia, 7th ed.2009

‘Very’ Brief Applied Functional Airway Anatomy : 

‘Very’ Brief Applied Functional Airway Anatomy In: Hagberg: Benumof's Airway Management, 2nd ed. 2007 The cricoid cartilage is a complete ring that articulates with the thyroid and arytenoid cartilage. The arytenoid cartilage sits on the posterolateral border of the cricoid, from where it can be dislocated. The valleculae is formed by depressions between the median and lateral glossoepiglottic folds that connect the lateral edges of the epiglottis to the base of the tongue. In approximately 1% of the population, the tip and posterior aspect of the epiglottis are visible during a pharyngoscopic view with the mouth opened and tongue protruded.

‘Very’ Brief Applied Functional Airway Anatomy : 

‘Very’ Brief Applied Functional Airway Anatomy Ron M. Walls, Michael F. Murphy; Manual of Emergency Airway Management, 3rd Ed 2008

‘Very’ Brief Applied Functional Airway Anatomy : 

‘Very’ Brief Applied Functional Airway Anatomy Ron M. Walls, Michael F. Murphy; Manual of Emergency Airway Management, 3rd Ed 2008 Closed Open The glottis: open for inspiration and closed for swallowing

‘Very’ Brief Applied Functional Airway Anatomy : 

‘Very’ Brief Applied Functional Airway Anatomy Airway obstruction associated with general anesthesia is attributed to reduced genioglossus activity and the consequent posterior displacement of the tongue. Mechanisms that lead to airway obstruction in obstructive sleep apnea and during anesthesia demonstrate physiologic similarities, including reduced tonic activity of the upper airway musculature and reduced lung volume. Findings suggest that the tongue is unlikely to be an important cause of airway obstruction in anesthetized patients. In all our volunteers, obstruction or narrowing of the airway occurred at the level of the soft palate, a finding supported by reduction in the minimum AP diameter of the pharynx at the level of the soft palate. Mathru, Mali MD; Esch, Oliver MD; Lang, John MD; Herbert, Michael E. FRCA; Chaljub, Gregory MD; Goodacre, Brian MD; vanSonnenberg, Eric MD, Magnetic Resonance Imaging of the Upper Airway: Effects of Propofol Anesthesia and Nasal Continuous Positive Airway Pressure in Humans; 1996, 84(2):273-279

‘Very’ Brief Applied Functional Airway Anatomy : 

‘Very’ Brief Applied Functional Airway Anatomy For manipulations involving the pharynx and posterior third of the tongue, glossopharyngeal block is required. Structures more distal in the airway to the epiglottis require block of vagal branches. The glossopharyngeal nerve divides into pharyngeal branches innervating the area of the palatine tonsil and the posterior third of the tongue. The vagus nerve supplies innervation to the mucosa of the airway from the level of the epiglottis to the distal airways through both the superior and recurrent laryngeal nerves. The recurrent laryngeal nerve ascends and innervate the larynx and the trachea caudal to the vocal cords. Brown: Atlas of Regional Anesthesia, 3rd ed. 2006

Question #2 : 

Which of the following statements regarding ventilation – perfusion (V/Q) matching are TRUE? West zone 1 can be best characterized as physiologic shunt West zone 1 can be increased by increased pulmonary artery pressure (PPA) West zone 3 occurs above the level of the third rib in the sitting position West zone 3 has PPA > Pulmonary Venous Pressure (PPV) > Alveolar Pressure (PA) and therefore has perfusion in excess of ventilation In West zone 1, pulmonary capillary wedge pressure (PWCP) is transmitted to the alveoli promoting alveolar collapse, resulting in no ventilation of this area Question #2

Question #2 : 

Which of the following statements regarding ventilation – perfusion (V/Q) matching are TRUE? West zone 1 can be best characterized as physiologic shunt West zone 1 can be increased by increased pulmonary artery pressure (PPA) West zone 3 occurs above the level of the third rib in the sitting position West zone 3 has PPA > Pulmonary Venous Pressure (PPV) > Alveolar Pressure (PA) and therefore has perfusion in excess of ventilation In West zone 1, pulmonary capillary wedge pressure (PWCP) is transmitted to the alveoli promoting alveolar collapse, resulting in no ventilation of this area Question #2 [Barash P, Cullen B, Stoelting R; Clinical Anesthesia, 5th Edition. 2006]

‘Very’ Brief Applied Functional Airway Anatomy : 

‘Very’ Brief Applied Functional Airway Anatomy West zone 1: PA>Ppa>Ppv No Blood Flow West zone 2: Ppa>PA>Ppv Blood Flow determined by (Ppa-PA): ‘upstream river waterfall’ West zone 3: Ppa>Ppv>PA Blood Flow determined by (Ppa-Ppv) West zone 4: Ppa>PISF>Ppv>PA Barash P, Cullen B, Stoelting R; Clinical Anesthesia, 5th Edition. 2006

Question #3 : 

Which of the following situations would be expected to lead to an increase in the amount of the lung under zone 1 conditions? Ascent to 15,000 ft above sea level Blood loss secondary to trauma Moderate exercise Positive-pressure ventilation with positive end-expiratory pressure (PEEP) Changing from the standing to the supine position Question #3

Question #3 : 

Which of the following situations would be expected to lead to an increase in the amount of the lung under zone 1 conditions? Ascent to 15,000 ft above sea level Blood loss secondary to trauma Moderate exercise Positive-pressure ventilation with positive end-expiratory pressure (PEEP) Changing from the standing to the supine position Question #3 [Levitzky MG, Chapter 4, In: Pulmonary Physiology, 7th Edition, 2007]

Slide 36: 

Positioning and FRC In changing from the upright to the supine position, FRC decreases by 0.5 to 1.0 L because of a 4-cm cephalad displacement of the diaphragm by the abdominal viscera . Pulmonary vascular congestion may also contribute to the decrease in FRC in the supine position, particularly in patients who experienced orthopnea preoperatively. These FRC changes are magnified in obese patients, with the decrement directly related to BMI. ‘Very’ Brief Applied Functional Airway Anatomy

The Airway Practitioner and the Clinical Setting : 

The Airway Practitioner and the Clinical Setting Lavery GG, McCloskey BV, The difficult airway in adult critical care; Crit Care Med 2008; 36(7): 2163-73

The Airway Practitioner and the Clinical Setting : 

The Airway Practitioner and the Clinical Setting Lavery GG, McCloskey BV, The difficult airway in adult critical care; Crit Care Med 2008; 36(7): 2163-73 “...Airway management comprises more than a collection of sophisticated devices or techniques...should be a hollistic approach implementing elements of crisis resourse management”. In the critical care unit, all invasive airway maneuvers are potentially difficult. Common errors include: Poor patient positioning Failure to ensure appropriate assistance Faulty light source in laryngoscope Failure to use a longer blade Lack of immediate availability of airway adjuncts. Poor gas exchange in intensive care unit patients may reduce the effectiveness of preoxygenation thus increasing the risk of significant hypoxia if there is delay in securing the airway. Cardiovascular instability may produce hypotension, hypoperfusion, and misleading (or absent) oximetry readings.

Global and Airway Assessment : 

Global and Airway Assessment Lavery GG, McCloskey BV, The difficult airway in adult critical care; Crit Care Med 2008; 36(7): 2163-73

Global and Airway Assessment : 

Assess underlying need for airway control Duration of intubation Nasal intubation less advantageous for potentially prolonged ventilator requirements Permanent support Underlying advanced intrinsic lung or neuromuscular disease Temporary support Anesthesia Presence of reversible intrinsic lung or neuromuscular disease Protection of the airway due to depressed mental status Presence of reversible upper airway pathology Patient care needs (e.g., transport, CT scan, etc.) Significant comorbidities Aspiration potential or increased respiratory secretions Hemodynamic issues such as cardiac disease or sepsis Renal or liver failure Global and Airway Assessment

Global and Airway Assessment : 

Pathophysiology of the respiratory failure Hypoxic respiratory failure In case of hypoxic respiratory failure, different noninvasive oxygen delivery devices can be used. The severity of hypoxia and presence or absence of underlying disease (such as COPD) will dictate the device of choice. Hypercapnic respiratory failure The noninvasive device of choice for hypercapnic respiratory failure is BIPAP. Code status should be clarified prior to proceeding. Global and Airway Assessment

Global and Airway Assessment : 

Oxygenation and Ventilation Respiratory rate and use of accessory muscles Is the patient in respiratory distress? Amount of supplemental oxygen What is the patient’s oxygen demand? Pulse oximeter or arterial blood gas Patient physiologically capable of providing appropriate supply? Airway Anatomy Will this patient be difficult to intubate? Patency Is there a reversible anatomical cause of respiratory failure as opposed to intrinsic lung dysfunction? Airway device in place Is there a nasopharyngeal airway or combitube in place? Global and Airway Assessment Lavery GG, McCloskey BV, The difficult airway in adult critical care; Crit Care Med 2008; 36(7): 2163-73

Difficult Airway Assessment : 

Difficult Airway Assessment Sharon Elizabeth Mace; Challenges and Advances in Intubation: Airway Evaluation and Controversies with Intubation; Emerg Med Clin N Am 26 (2008) 977–1000

So, what is a difficult airway? : 

So, what is a difficult airway? Orlando Hung, Michael Murphy; Management of the Difficult and Failed Airway. 1st Edition, 2007 “The Difficult Airway is something you anticipate; the Failed Airway is something you experience.” The “Difficult Airway” has five dimensions: 1. Difficult BMV 2. Difficult Laryngoscopy and intubation 3. Difficult EGD 4. Difficult Cricothyrotomy The “Failed Airway” is easily defined as: 1. Three failed attempts at orotracheal intubation by a skilled practitioner and/or 2. Failure to maintain acceptable oxygen saturations, typically 90% or above in otherwise normal individuals. Clinically, the failed airway presents itself in two ways: 1. You have time: “Can’t intubate/can ventilate and oxygenate.” 2. You have no time: “Can’t intubate/can’t ventilate or oxygenate”(CICV or CICO).

Anticipated Difficult Bag-mask Ventilation : 

Anticipated Difficult Bag-mask Ventilation Orlando Hung, Michael Murphy; Management of the Difficult and Failed Airway. 1st Edition, 2007 “Airway management” may be defined as the application of therapeutic interventions that are intended to effect gas exchange in patients. “Gas exchange” is the fundamental feature of this definition. Research has validated many anatomical features that over the years have been implicated in heralding difficult BMV and recalled by MOANS: Mask seal: Bushy beards, crusted blood on the face, or a disruption of lower facial continuity Obese/Obstruction: Patients who are obese (BMI 26 kg·m2) are often difficult to ventilate adequately. Upper-airway obstruction, angioedema, Ludwig’s angina, upper-airway abscesses (e.g., peritonsillar), and epiglottitis. Aged: Age more than 55 is associated with a higher risk of difficult BMV, perhaps because of a loss of muscle and tissue tone in the upper airway. No teeth: An adequate mask seal may be difficult in the edentulous patient as the face tends to cave in. Snores or Stiff: For the former, this mnemonic affords one a reminder to check for sleep apnea, an increasingly important consideration in anesthetic practice today. BMV may be difficult or impossible in the face of substantial increases in airways resistance (e.g., asthma) or decreases in pulmonar compliance (e.g., pulmonary edema).

Anticipated Difficult Laryngoscopy(I) : 

Anticipated Difficult Laryngoscopy(I) Orlando Hung, Michael Murphy; Management of the Difficult and Failed Airway. 1st Edition, 2007 Difficult Laryngoscopy and intubation ordinarily implies that the operator had a poor view of the glottis. Benumof defines the “Best Laryngoscopy Attempt” as being composed of six elements: (1) performance by a reasonably experienced practitioner; (2) no significant muscle tone; (3) the use of the optimal “sniffing” position; (4) the use of external laryngeal manipulation (backward upward rightward pressure [BURP] or optimum external laryngeal manipulation; (5) length of the blade; (6) type of blade. If it is possible to consistently and precisely predict intubation failure, the initial selection of laryngoscopic oral intubation could be eliminated as a strategy and alternative techniques employed. So, how do we quickly identify as many of the risks as possible? The mnemonic LEMON is a useful guide to anticipate Difficult Laryngoscopy and Orotracheal Intubation: Look, Evaluate (3-3-2), Mallampati, Obstruction, Neck Mobility

Anticipated Difficult Laryngoscopy(II) : 

Anticipated Difficult Laryngoscopy(II) Orlando Hung, Michael Murphy; Management of the Difficult and Failed Airway. 1st Edition, 2007 Look externally: If the airway looks difficult, it probably is. A litany of physical features has been associated with difficult laryngoscopy and intubation (e.g.,small Mandible, Buck teeth, short neck) or where is my LEMON….? Evaluate 3-3-2: Although there is no scientific basis to support the 3-3-2 rule, it serves to ensure that the relevant geometry of the upper airway is assessed adequately. Mallampati Class: Mallampati studied the relationship between the visibility of the posterior oropharyngeal structures and success rate of intubation. Obstruction: There are 3 cardinal signs of upper airway obstruction: muffled voice (“hot potato voice”); difficulty swallowing secretions; and stridor. Neck mobility: The ability to position the head and neck is one of the six components of achieving an optimal view of the larynx on oral laryngoscopy.

Anticipated Difficult Extraglottic Device : 

Anticipated Difficult Extraglottic Device Orlando Hung, Michael Murphy; Management of the Difficult and Failed Airway. 1st Edition, 2007 In an emergency, a laryngeal mask airway (LMA) can serve as the primary rescue airway in a CI/CV scenario or can be used as a bridge or temporary airway while completing a cricothyrotomy. The LMA and Combitube are mentioned in the 2003 ASA difficult airway algorithm. The LMA and Combitube are considered intermediate Airways since they allow ventilation across the larynx but do not provide complete airway control. An anticipated difficult EGD placement can be assessed by RODS: Restricted mouth opening: Depending on the EGD to be employed, more or less oral access may be needed. Obstruction: Upper-airway obstruction at the level of the larynx or below. An EGD will not bypass this obstruction. Disrupted or distorted airway: At least in as much as the “seat and seal” of the EGD may be compromised. Stiff lungs or cervical spine: Ventilation with an EGD may be difficult or impossible in the face of substantial increases in airways resistance (e.g., deadly asthma) or decreases in pulmonary compliance (e.g., pulmonary edema). Seal may be exceedingly difficult or impossible to achieve in the face of a fixed flexion deformity of the neck.

Anticipated Difficult Cricothyrotomy : 

Anticipated Difficult Cricothyrotomy Orlando Hung, Michael Murphy; Management of the Difficult and Failed Airway. 1st Edition, 2007 There are no absolute contraindications to performing an emergency cricothyrotomy. However, some conditions may make it difficult or impossible to perform the procedure, making it imperative to identify those conditions up front, particularly if one is relying on a rapidly performed cricothyrotomy as a rescue technique. The mnemonic SHORT is used to quickly identify features that may indicate a difficult cricothyrotomy: Surgery/disrupted airway: The anatomy of the neck may be furtively or obviously distorted due to previous surgery, making the airway difficult to access. Hematoma or infection: An infective process or hematoma in the pathway of the cricothyrotomy incision may make the procedure technically difficult but should never be considered a contraindication in a life-threatening situation. Obese/access problem: Obesity should be considered a surrogate for any problem that makes percutaneous access to the anterior neck problematic. A fixed flexion deformity of the cervical spine, halo traction, and other situations may also make access to the neck difficult. Radiation: The tissue changes associated with past radiation therapy may distort tissues, making the procedure difficult. Tumor: Tumor either in or around the airway may present difficulty, both from an access perspective as well as bleeding.

Airway Adjuncts : 

Airway Adjuncts

Direct Laryngoscopy and Blades : 

Direct Laryngoscopy and Blades Catherine Marco, Alan P. Marco; Airway Adjuncts; Emerg Med Clin N Am 26 (2008) 1015–1027

Supraglottic Devices : 

Supraglottic Devices Catherine Marco, Alan P. Marco; Airway Adjuncts; Emerg Med Clin N Am 26 (2008) 1015–1027

Stylets : 

Stylets Catherine Marco, Alan P. Marco; Airway Adjuncts; Emerg Med Clin N Am 26 (2008) 1015–1027

Video Laryngoscopes : 

Video Laryngoscopes Catherine Marco, Alan P. Marco; Airway Adjuncts; Emerg Med Clin N Am 26 (2008) 1015–1027

Glidescope : 

Glidescope Rigid laryngoscope with CCD View is very clear with no fogging Blade angle 50-60 deg Easy to use Very rapid learning curve

Thanks…! : 

“The great tragedy of science – the slaying of a beautiful hypothesis by an ugly fact..” Thomas Huxley Thanks…!

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