management of difficult airway in emergency

Management of Difficult Airway : 

Management of Difficult Airway When you can’t breathe, nothing else matter Presented By Dr Parmeet Bhatia

Introduction : 

Introduction Airway management is a fundamental aspect of emergency and critical care medicine Expertise in airway management – an important skill “An experienced EMS provider will tell you that, when treating a patient, the three most important considerations are airway, airway, airway."

Importance : 

Importance

What should we know about the “airway management”? : 

What should we know about the “airway management”? Airway anatomy and function Evaluation of airway Clinical management of airway Maintenance and ventilation Intubation Difficult airway management

Airway Anatomy : 

Airway Anatomy

Airway Anatomy : 

Airway Anatomy The term “Airway” refers to the upper airway consisting of: Nasal cavity Oral cavity Pharynx Larynx Trachea Principal bronchi

Anterior view of Larynx : 

Anterior view of Larynx

Laryngoscopic View : 

Laryngoscopic View

Slide 9: 

…except when it isn’t… Airway management is really easy…

Our Options are Different : 

Our Options are Different Anaesthesiology Emergency Plan in advance Can’t get airway …. …. Awake patient …. Regroup …. Go for coffee What will be, will be ……… Can’t get airway …. …. Wipe brow …. Run for help …. Call HOD

Scenario is different : 

Scenario is different Patients Limited physiological reserves Co-morbidities Evaluation Inability or lack of time Conditions Not ideal Instruments Not working properly Insufficient Well wishers around you Not well versed with airway management

Our patients are different : 

Our patients are different

They tend to look like this : 

They tend to look like this

Or even this : 

Or even this

And this – after failed intubation attempt : 

And this – after failed intubation attempt

It can be difficult : 

It can be difficult … oxygenate … ventilate … intubate … perform cricothyrotomy

To maximize success : 

To maximize success Recognize and predict difficult airway Choose appropriate technique and equipment Possess technical skills and devices

Predicting the Difficult Airway…if you have time : 

Predicting the Difficult Airway…if you have time

Airway Evaluation : 

Airway Evaluation History Global Assessment Regional Assessment

History : 

History Previous history of difficult intubation or difficult airway management Airway related symptoms and signs Stridor or hoarseness of voice Snoring or Obstructive sleep apnea syndrome Tracheostomy Limited neck movement Restricted mouth opening Dysphagia

Global Assessment : 

Global Assessment Body stature Head and Neck examination Congenital anomalies Disfigurement of face Injuries around neck Pathological & Physiological conditions

Congenital Problems : 

Congenital Problems Pierre Robin syndrome Treacher Collin syndrome Goldenhar’s syndrome Down’s syndrome Klippel Fiel syndrome

Acquired Problems : 

Acquired Problems Infections – Ludwig’s angina, Retropharyngeal abscess Arthritis – Rheumatoid arthritis, Ankylosing spondylitis Tumors – Goiter, Cystic hygroma, oral carcinoma Trauma – Facio maxillary Miscellaneous – Diabetes, Obesity, Pregnancy & Burns

Difficult Mask Ventilation : 

Difficult Mask Ventilation Presence of Beard Disfiguring malignancy Obesity Lack of teeth Presence of snoring Jewellery

Difficult Mask Ventilation : 

Difficult Mask Ventilation Presence of 2 or more than 2 conditions – Difficult Bag Mask Ventilation M. M. Ali Magboul. Airway Evaluation And Assessment For Anesthesia And Resuscitation . The Internet Journal of Health. 2007 Volume 6 Number 1

Teeth : 

Look for Loose teeth Dentures, missing teeth – document Mal alignment Buck teeth Teeth Dental injury is GRIEVIOUS INJURY Avoid it during laryngoscopy

Specific Indices and Tests : 

Specific Indices and Tests

Inter incisor distance : 

Distance between upper and lower incisors with mouth fully open Commonly known as “Mouth opening” Normal – 3 finger breaths or 4.6 cm < 3 cm - impossible to pass laryngoscope < 1.5 cm – impossible to insert LMA Inter incisor distance

Temporomandibular Joint : 

Temporomandibular Joint TMJ functions are Rotation of the condyle in the synovial cavity Forward displacement of condyle Test Place index finger infront of tragus, thumb in front of lower part of mastoid process behind the ear Ask the patient to wide open the mouth Index finger can be indented in space of condyle (sliding) Thumb can feel sliding movement Lloyd F. Redick. The Temporomandibular Joint and Tracheal Intubation. Anaest Analg: 1987; 66 (7) : 675 – 676.

Mallampati classification : 

Mallampati classification Correlates tongue size to pharyngeal size How test is performed? Patient in sitting position Mouth wide open Tongue protruded to its maximum Should not be actively encouraged to phonate Classification is assigned according to the extent the base of tongue is able to mask the pharyngeal structures Mallampati SR, Gatt SP et al. A clinical sign to predict difficult intubation; A prospective study. Can Anaesth Soc J 1985; 32: 429-434.

Mallampati classification : 

Mallampati classification Samsoon GLT, Young JRB, Difficult tracheal intubation: a retrospective study. Anaesthesia 1987; 42: 487 – 490.

Cormack & Lehane Grading : 

Cormack & Lehane Grading Difficulty in intubation – classified according to the view obtained during direct laryngoscopy Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105 - 1111. Entire laryngeal aperture Only posterior Commisure of laryngeal aperture Only epiglottis Just Soft palate

Cormack & Lehane Grading : 

Cormack & Lehane Grading Modified by Cook in 1999 Grade IIa – visualization of posterior part of vocal cord Grade IIb – arytenoids only seen Grade IIIa – Epiglottis liftable Grade IIIb – Epiglottis adherent Cook TM . A new practical classification of laryngeal view. Anaesthesia 2000;55:274-9 Grade I & IIa - can be intubated directly Grade IIb & IIIa - needs bougie Grade IIIb & IV - requires alternate techniques

Thyromental distance : 

Distance between mentum and thyroid notch, when neck is fully extended Determine to how readily the laryngeal axis falls in line with pharyngeal axis when AO joint is extended Thyromental distance over 6.5 cm is usually associated with easy intubation Thyromental distance less than 6 cm or 3 fingers breath may predict a difficult intubation – more acute angle between laryngeal and pharyngeal axis Thyromental distance Patil UV, Stechling LC, Zauder HL. Predicting the difficulty of intubating utilizing an intubation guide. Anaesthesiology, 1983;10:32.

Hyomental distance : 

Distance between mentum and hyoid bone Grade I : > 6cm Grade II: 4 – 6cm or three fingers breath Grade III : < 4cm – Impossible laryngoscopy & Intubation Hyomental distance Chow HC, Wu TL. Mandibulo Hyoid distance in difficult laryngoscopy. Br J Anaesth 1993; 71: 335 - 339

Sternomental distance : 

Distance between mentum and suprasternal notch, when head is fully extended on neck and mouth is closed Value < 12 cm – predicts difficult intubation Sternomental distance Savva D. Prediction the difficult tracheal intubation. Br J Anaesth. 1994; 73: 149-153.

Atlanto Occipital Joint Extension : 

Atlanto Occipital Joint Extension S Gupta, Rajesh K R Sharma, Dimple Jain. Airway assessment : Predictors of difficult airway. Indian J Anaesth. 2005; 49 (4): 257 - 262 Measurement of neck mobility Assesses feasibility to make sniffing or Magill’s position for intubation How test is performed? Patient is asked to hold the head erect, facing directly to front Extend the head maximally on fixed neck Estimate the angle transversed by occlusal surface of upper teeth More accurately with goniometer

Atlanto Occipital Joint Extension : 

Atlanto Occipital Joint Extension S Gupta, Rajesh K R Sharma, Dimple Jain. Airway assessment : Predictors of difficult airway. Indian J Anaesth. 2005; 49 (4): 257 - 262 Norma angle of extension is 35° or more Limited A-O joint – spondylosis & rheumatoid arthritis Any reduction in extension is expressed in grades: Grade I : > 35° Grade II : 22 - 34° Grade III : 12 - 21° Grade IV : < 12°

LEMON Airway Assessment : 

Look Evaluate 3-3-2 rule Mallampati classification Obstruction Neck mobility LEMON Airway Assessment

Look - Externally : 

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 Narrow face, high-arched palate: decreased side-to-side diameter Large tongue: hides airway False teeth: help bagging, remove for intubation Look - Externally L

Evaluate 3-3-2 Rule : 

The 3 – 3 – 2 rule Mouth open: 3 fingers Allows insertion of tube, laryngoscope Mentum to hyoid: 3 fingers Predicts ability to lift tongue into mandible Floor of mouth to thyroid cartilage: 2 fingers If high larynx, airway tucked under base of tongue, hard to visualize Evaluate 3-3-2 Rule E

Mallampati Score : 

Mallampati Score M

Obstruction : 

Blood Vomitus Dentures FBAO Epiglottitis Peritonsillar Abscess Trauma Angioedema Obstruction O

Neck Mobility : 

Previous Surgery Rheumatoid arthritis Osteoarthritis Others Neck Mobility N Cervical spine rigidity - reduces ability to align anatomic axes Inability to mobilize neck - can make intubation difficult or impossible

Wilson’s Score : 

Wilson’s Score Wilson ME, Spiegelhalter D, Robertson JA et al. Predicting difficult intubation. Br J Anaesth 1988; 61: 211 - 216 <5 Easy intubation; 8-10 very difficult intubation

Palm Print : 

Palm Print Predictor of difficult airway in diabetes Grade 0 – all the phalangeal areas are visible Grade I – deficiency in the interphalangeal areas of 4th & 5th digits Grade II – deficiency in the interphalangeal areas from 2nd to 5th digits Grade III – only tips of digits are seen Nadal JLY, Fernandez BA, et al. Palm print as a sensitive predictor of difficult laryngoscopy in diabetes. Acta Anaesthesiol Scand 1998; 42: 199 – 203.

Prayer Sign : 

Namaste Negative – No gap between palms Positive – Gap between palms Prayer Sign Reissell E, Orko R, Maunuksela EL Lindgren L. Predictability of difficult laryngoscopy in patients with long term diabetes mellitus. Anaesthesia 1990; 45: 1024-1027.

Radiological Assessment : 

Radiological Assessment Lateral cervical X – Ray film of the patients with head in neutral position and mouth closed Posterior depth of the mandible – distance between alveolus immediately behind 3rd molar tooth to lower border of mandible. Difficult > 2.5cm Effective length of mandible – distance between tip of lower incisors to TMJ. Difficult < 3.6 Gap between occiput and spine of C1 – Difficult < 5 mm Samra SK, Schork MA, Guinto FC. A study of radiologic imaging techniques and airway grading to predict a difficult endotracheal intubation. J Clin Anesth 1995; 7: 373-379.

What Next : 

What Next

Difficult Airway : 

Difficult Airway “A clinical situation in which conventionally trained anaesthesiologists experiences difficulty with mask ventilation, tracheal intubation or both” Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2003; 98:1269–77 Failed Intubation

Difficult Face Mask Ventilation : 

Difficult Face Mask Ventilation It is not possible for the anesthesiologist to provide adequate face mask ventilation due to one or more of the following problems: inadequate mask seal excessive gas leak excessive resistance to the ingress or egress of gas Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2003; 98:1269–77

Difficult Face Mask Ventilation : 

Difficult Face Mask Ventilation Signs of inadequate face mask ventilation include absent or inadequate chest movement absent or inadequate breath sounds auscultatory signs of severe obstruction cyanosis gastric air entry or dilatation decreasing or inadequate oxygen saturation (SpO2) absent or inadequate exhaled carbon dioxide absent or inadequate spirometric measures of exhaled gas flow hemodynamic changes associated with hypoxemia or hypercarbia (hypertension, tachycardia and arrythmias) Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2003; 98:1269–77

Difficult Laryngoscopy : 

Difficult Laryngoscopy It is not possible to visualize any portion of the vocal cords after multiple attempts at conventional laryngoscopy Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2003; 98:1269–77

Difficult Tracheal Intubation : 

Difficult Tracheal Intubation Tracheal intubation requires multiple attempts, in the presence or absence of tracheal pathology As per the “Practice Guidelines for Management of the Difficult Airway. Anesthesiology 1993; 78:597-602 Proper insertion of tracheal tube with conventional laryngoscopy requires more than three attempts or more than ten minutes Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2003; 98:1269–77

Failed Intubation : 

Failed Intubation Placement of the endotracheal tube fails after multiple intubation attempts Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2003; 98:1269–77

Slide 56: 

Some Equipment, Old & New

Gallery of Tools : 

Gallery of Tools Rigid laryngoscope blades of alternate design and size Various sizes of masks and Ambu Bags of various sizes Airways – oropharyngeal and nasophyrengeal Various sizes of tracheal tubes Esophageal tracheal Combitube Tracheal tube guides (stylets, ventilating tube changer, light wands & GEB) Laryngeal mask airways Flexible fiberoptic intubation equipment Retrograde intubation equipment Noninvasive airway ventilation (transtracheal jet ventilator) Emergency invasive airways (Needle & surgical cricothyrotomy) An exhaled CO2 detector

Our Aim : 

Our Aim Maintain patent airway Secure airway Prevent aspiration Adequate and effective ventilation Further resuscitation

Steps in Emergency : 

Steps in Emergency

Clear the Airway : 

Clear the Airway Clear the airway – oropharyngeal cavity of: Any secretions Any blood Vomitus Loose dentures Any foreign body obstructing the airway Remember You always require working suction apparatus

Open the Airway : 

Open the Airway Jaw thrust Head tilt–chin lift

Bag Mask Ventilation : 

Bag Mask Ventilation Key—ventilation volume: “enough to produce obvious chest rise” 1-Persondifficult, less effective 2-Personeasier, more effective

Bag Mask Ventilation : 

Bag Mask Ventilation Sellick’s Maneuver Cricoid Pressure – to prevent regurgitation and aspiration

Oropharyngeal Airway : 

Oropharyngeal Airway

Nasopharyngeal Airway : 

Nasopharyngeal Airway

Endotracheal Intubation : 

Endotracheal Intubation

Endotracheal Intubation : 

Endotracheal Intubation Endotracheal tube is passed into trachea of patient through oral or nasal route to ensure the patent airway and adequate ventilation Achieves all the goals of airway management Rapid, Simple, Safe and Non-surgical Maintains patent airway Protect lungs from aspiration Leak free ventilation Remains GOLD STANDARD of airway management

Correct Size : 

Correct Size Adult Male - 8.5 to 9.5 mm Adult Female – 7 to 8.0 Child < 6.5 yrs – (Age/3) + 3.5 Child > 6.5 yrs – (Age/4) + 4.5 External Diameter of ETT = Diameter of little finger

Insertion : 

Insertion

Insertion : 

Insertion

Laryngoscopic View : 

Laryngoscopic View

ETT in Trachea : 

ETT in Trachea

Conformation : 

Conformation Chest lift Movement of moisture column in ETT Auscultation Improvement and maintenance of SpO2 Exhaled carbon dioxide

Other Side of Coin : 

Other Side of Coin Difficult Laryngoscopy Difficult Intubation Failed Intubation Difficult Airway

Now What? : 

Now What? Other options available with us

BURP Maneuver : 

BURP Maneuver Osamu Takahata,, Munehiro Kubota, et al.The Efficacy of the “BURP” Maneuver During a Difficult Laryngoscopy. Anaesthesia 1988; 43: 437-8 Described by Knill in 1993

Intubating Stylet (Bougie) : 

Intubating Stylet (Bougie) Gum elastic – an adjunct for difficult intubation For directional control during routine or difficult intubation when the laryngeal inlet cannot be completely seen - Useful in IIa & IIIb laryngoscopic grades Advantages Gives definitive airway Not very expensive Easy to learn Disadvantages Expertise requires practice Not recommended in “can’t intubate / can’t ventilate” scenario Kidd JF, Dyson A, Latto IP. Successful difficult intubation - use of the gum elastic bougie. Anaesthesia 1988; 43: 437-8

Intubating Stylet (Bougie) : 

Intubating Stylet (Bougie) 60cm long introducer, 5mm in diameter, smooth angled tip, bendable Blind entrance into the glottis is possible and confirmation of placement by detection of clicks as it passes down trachea Tracheal tube then passed over bougie into glottis

Blind Nasal Intubation : 

Blind Nasal Intubation Beware Coagulopathy Fracture base of skull Not of much use Time consuming Patient should be breathing

MaCoy Laryngoscope : 

MaCoy Laryngoscope The 'McCoy-style' blade is based on the standard Macintosh blade It has a hinged tip that is operated by a lever mechanism on the back of the handle It allows elevation of the epiglottis while reducing the amount of force required This blade has been shown to improve the view at laryngoscopy in difficult intubations and in patients wearing cervical hard collars Gabbott DA. Laryngoscopy using the McCoy laryngoscope after application of a cervical collar. Anaesthesia. 1996 Sep;51(9):812-4.

Lightwand (Trachlight) : 

Lightwand (Trachlight) Light-guided intubation using the Trachlight is a safe and gentle technique for both oral and nasal ETT placement and positioning A well defined circumscribed glow can readily be seen in the anterior neck when the endotracheal tube and light enter the glottic opening Felice Agrò, Orlando R, et al. Lightwand intubation using the Trachlight™: a brief review of current knowledge. Can J Anaesth. 2001 Jun;48(6):592-9.

Lightwand (Trachlight) : 

Lightwand (Trachlight) Advantages Minimal neck movement Useful adjunct to laryngoscopy Portable and inexpensive Usable in bloody airway Provides definitive airway Disadvantages Blind technique May damage airway Usually requires darkened room Expertise requires practice

Laryngeal Mask Airway(LMA) : 

Laryngeal Mask Airway(LMA)

Introduction : 

Introduction Most popular supraglottic airway in emergency and short procedures Consist of a tube with an inflatable cuff that is inserted into the pharynx Very useful device in “can’t intubate / can’t ventilate” scenario Part of ASA guidelines for difficult intubation

Laryngeal Mask Airway : 

Laryngeal Mask Airway Designed by Dr Archie Brain in UK in 1981 and released in 1988

Insertion : 

Insertion Index Finger Insertion Technique Hold the LMA Classic with the index finger at the cuff/tube junction

Insertion : 

Insertion Press the mask up against the hard palate

Insertion : 

Insertion Slide the mask inward, extending the index finger. Press the finger towards the other hand, which exerts counter-pressure

Insertion : 

Insertion Hold the outer end of the airway tube while removing the index finger

Insertion : 

Insertion Inflate the LMA Classic cuff

Correct Positioning : 

Correct Positioning Inflation of cuff causes Slight upward movement of device Bulging in front of neck Auscultation Improvement and maintenance of SpO2 Exhaled carbon dioxide Absence of stridor, tracheal tug, or out of phase respiratory movement of chest and abdomen

Short Comings : 

Short Comings Cannot be used in patient with Mouth opening less than 1.5 cm Poor lung compliance Airway pressure more than 20 cm of water Full stomach Does not protect airway from aspiration

LMA ProSeal : 

LMA ProSeal

LMA ProSeal : 

LMA ProSeal Advantages A softer silicone cuff reducing the likelihood of throat irritation and stimulation High seal pressure - up to 30 cm Provides more airway security Enables use of PPV A built-in drain tube designed to channel fluid away and permit gastric access Optional Insertion tool

LMA Fastrach : 

LMA Fastrach Intubating LMA

LMA Fastrach : 

LMA Fastrach

LMA CTrach : 

LMA CTrach

Esophageal Tracheal Combitube : 

Esophageal Tracheal Combitube

Introduction : 

Introduction Combitube is a device designed to facilitate the blind intubation It consists of a cuffed double-lumen tube with one blind end Inflation of the cuff allows the device to function as an endotracheal tube and closes off the esophagus, allowing ventilation and preventing reflux of gastric contents Two sizes 37 F (Small Adult Size) - 4 to 6 feet individuals 41 F (Standard Size) - Above 6 feet individuals

Combitube : 

Combitube

Combitube Placement : 

Combitube Placement

Laryngeal Tube : 

Laryngeal Tube

Laryngeal Tube : 

Laryngeal Tube

Laryngeal Tube : 

Laryngeal Tube Sizes – available in different sizes 0 - new born < 5 Kg 10ml 1 - 5 kg to 12 kg 20 ml 2 - 13 to 35 kg 35 ml 3 - < 155 cm height 60 ml 4 - 156 to 180 cm height 80 ml 5 - > 180 cm height 90 ml

Laryngeal Tube : 

Laryngeal Tube

Retrograde Intubation : 

Retrograde Intubation

Introduction : 

Introduction Direct laryngoscopy and tracheal intubation remains the technique of choice to achieve control of the airway Retrograde intubation is an alternative or additional techniques of airway control used in difficult airway due to anatomical and/or technical reasons

Steps : 

Steps Under aseptic precautions, puncture the cricothyroid membrane with needle Pass guide wire through cricothyroid needle aimed superiorly so that distal end of wire may be retrieved from mouth of patient Withdraw needle off wire Load ETT over oral end of wire, passing wire into tube through Murphy's eye

Steps : 

Steps Pull wire relatively taught and straight Advance ETT over wire into trachea to cricoid area, then, gradually relaxing cricothyroid end of wire, advance ETT to appropriate intratracheal location Release cricothyroid end of wire and withdraw wire out of ETT Inflate cuff and secure ETT and ventilate patient

Steps : 

Steps

Cricothyroidotomy : 

Cricothyroidotomy

Introduction : 

Introduction Final common pathways for all cannot intubate / cannot ventilate scenarios An emergency incision through the skin and cricothyroid membrane to secure a patient's airway during certain emergency situations Performed only when a secure airway need to be maintained and attempts at orotracheal and nasotracheal intubation have failed “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen

Steps : 

Steps Position - supine, with a rolled bath towel under the shoulders, and with the neck in hyperextension Sterilize the field and drape the patient Identify the cricothyroid membrane

Steps : 

Steps Anesthetize the skin over the membrane Make a transverse incision of the skin over the cricothyroid membrane Identify the membrane and then continue the incision through it With the mosquito clamp spread the incision, sufficient to provide an airway for a patient with supraglotic airway obstruction

Steps : 

Steps Insert the tracheostomy tube or the endotracheal tube through the incision into the trachea, directing it caudally Inflate the tube balloon Connect the bag-valve unit to the tube and ventilate the patient with 100% oxygen Observe respiratory movements of the chest and breath sounds

PercutaneousTranstracheal Jet Ventilation : 

PercutaneousTranstracheal Jet Ventilation

Introduction : 

It is a potentially life-saving procedure in “can’t intubate / can’t ventilate” scenario Basically to buy time Simple to perform Can maintain oxygenation of patient for 40 to 45 minutes Removal of carbon dioxide is problem Introduction Patel RG. Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful. Chest. 1999 Dec;116(6):1689-94

Requirement : 

Equipment for needle cricothyrotomy and percutaneous transtracheal jet ventilation (PTJV) consists of the following: High-pressure noncollapsible oxygen tubing Needle catheter 14 gauge Oxygen source with a flow at 10-15 L/min Manual jet ventilator/insufflator device Requirement

Requirement : 

If a manual jet ventilator/insufflator device is not available Equipment required are: Oxygen source with a flow at 10-15 L/min Ambu bag that includes noncollapsible oxygen tubing and a reservoir bag Large-bore, over-the-needle intravenous catheter – 14 G Plastic syringe - 3 mL, with Luer lock tip Inner adapter of 7.5 mm endotracheal tube Requirement

Procedure : 

Procedure

Procedure : 

Procedure

Flexible Fiberoptic Scope : 

Flexible Fiberoptic Scope

Introduction : 

Introduction It remains the gold standard in Operation Theatre for difficult airway or restricted mouth opening cases Both nasal and oral intubation is possible Awake intubation or intubation under anesthesia both possible Limited role in emergency situations

Being Done : 

Being Done

Advantages : 

Advantages Allows direct airway visualization Causes little hemodynamic stress Nasotracheal or orotracheal route Can be done in all age groups Requires minimal neck movement

Disadvantages : 

Disadvantages Expensive Expertise requires practice Delicate equipment needs careful maintenance Visual field easily impaired by blood and secretions

Rigid Fiberoptic Scopes : 

Rigid Fiberoptic Scopes

Introduction : 

Introduction These devices generally consist of an anatomically shaped blade, fiberoptic bundles and light source They allow for visualization of the airway without manipulation of the head and neck Useful in patients with limited mouth opening & reduced neck movement and difficult airways

Types : 

Types Bullard Wu Scope Upsher Glide Scope Levitan Scope

Advantages : 

Advantages Direct airway visualization Minimal neck movement May overcome difficult view Useful in disrupted airway Durable, sturdy instruments

Disadvantages : 

Disadvantages Expensive Expertise requires practice Visual field easily impaired by blood and secretions Not readily available

iGEL : 

iGEL

Introduction : 

Introduction I - gel is new supraglottic airway management device, made of a medical grade thermoplastic elastomer, which is soft, gel-like and transparent The i-gel is designed to create a non-inflatable anatomical seal of the pharyngeal, laryngeal and perilaryngeal structures whilst avoiding the compression trauma that can occur with inflatable supraglottic airway devices Evolved as a device that accurately positions itself over the laryngeal framework providing a reliable perilaryngeal seal and therefore no cuff inflation is necessary

Advantages : 

Advantages Latex free, sterile and single patient use device Potential advantages: Easier insertion Minimal risk of tissue compression Stability after insertion (i.e. no position change with cuff inflation) Has gastric channel Available in all sizes from neonatal to adult Can be used in difficult airway condition Gabbott DA, Beringer R. The iGEL supraglottic airway: a potential role for resuscitation? Resuscitation. 2007 Apr;73(1):161-2.

TruView EVO2Laryngoscope : 

TruView EVO2Laryngoscope

Introduction : 

Applicable to any intubation from laryngoscopic view grade 1 to 4 Reduces difficult by atleast one grade, making difficult cases easier to intubate Continuous oxygen flow at 10 litre per minute extends the window of intubation - cleans away secretions & prevents fogging 46 degree refraction angle enlarges view field and is especially indicated in cervical spine trauma & limited neck extensions Allows easy connection to all hospital operating room endoscopic monitors Introduction

Advantages : 

Advantages

ASA Guidelines : 

ASA Guidelines

Take Home Massage : 

Maintaining and securing a patent airway is primary goal in any emergency and difficult airway situation It’s a challenge But not impossible if we know correct techniques 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 Take Home Massage

Slide 140: 

Thank You