difficult airway pap pas 20061017

8/2/2019 Difficult Airway Pap Pas 20061017

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The Difficult AirwayThe Difficult Airway

EleniEleni E. Pappas, DDSE. Pappas, DDS

1010--1717--0606


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Questions to AnswerQuestions to Answer

1.1. Must the airway be controlled?Must the airway be controlled?

2.2. Must I stop the patient's reliance on his/her ownMust I stop the patient's reliance on his/her ownphysiologicphysiologic ventilatoryventilatory control and forcecontrol and forcedependence on the success of my owndependence on the success of my own

airway/breathing techniques?airway/breathing techniques?3.3. How dangerous might it be to attempt to takeHow dangerous might it be to attempt to take

control of your patients airway/breathing?control of your patients airway/breathing?

4.4. WillWill laryngoscopylaryngoscopy be difficult? Can we visualizebe difficult? Can we visualizeanything with endoscope?anything with endoscope?

5.5. Is there an aspiration risk?Is there an aspiration risk?


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Physical ExamPhysical Exam single most reliable method of detecting andsingle most reliable method of detecting and

anticipating difficulties in airway managementanticipating difficulties in airway management Is the patient able to sit and talk without becomingIs the patient able to sit and talk without becoming

breathless?breathless?

Is the patient able to swallow their own secretions?Is the patient able to swallow their own secretions?

Is the patient pale or cyanotic,Is the patient pale or cyanotic, cachecticcachectic or acutely ill?or acutely ill?

Is the patient receiving chronic O2 therapy?Is the patient receiving chronic O2 therapy?

Is the patient markedly obese?Is the patient markedly obese? Review vital signs, particularly pulseReview vital signs, particularly pulse oximetryoximetry..

Will chest xWill chest x--ray orray or spirometryspirometry be helpful?be helpful?


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Focused exam of the AirwayFocused exam of the Airway Examine mouth and oral cavity noting the extent andExamine mouth and oral cavity noting the extent and

symmetry of opening (3 fingerbreadths is optimal)symmetry of opening (3 fingerbreadths is optimal)

Health/Position of the teethHealth/Position of the teeth loose, missing, cracked,loose, missing, cracked,protrudingprotruding

Presence of facial hairPresence of facial hair

Presence of dental appliancesPresence of dental appliances

Relative size of the tongueRelative size of the tongue large tongue = more difficultylarge tongue = more difficultyArch of the palateArch of the palate high arch sometimes associated withhigh arch sometimes associated with

difficulty in visualizing the larynxdifficulty in visualizing the larynx

MallampatiMallampati ExamExam I = Pharyngeal pillars, entire palate, uvulaI = Pharyngeal pillars, entire palate, uvula

II = Pharyngeal pillars, soft palate, uvula obstructed by tongueII = Pharyngeal pillars, soft palate, uvula obstructed by tongue

III = Soft palate but pharyngeal pillars and uvula obstructedIII = Soft palate but pharyngeal pillars and uvula obstructed

IV = only hard palate with soft palate, pillars, and uvula obstrIV = only hard palate with soft palate, pillars, and uvula obstructeducted


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MallampatiMallampati ClassificationClassification


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Size of Mandible and TMJSize of Mandible and TMJ FxnFxn ThryomentalThryomental distance avg. = three fingerbreadthsdistance avg. = three fingerbreadths

ShortShort mdmd body may suggest difficulty in visualizingbody may suggest difficulty in visualizingthe larynxthe larynx

TMJTMJ DysfxnDysfxn ==

may have asymmetry or limitations in opening inmay have asymmetry or limitations in opening in

openingopening

Popping clickingPopping clicking

Manipulation duringManipulation during laryngoscopylaryngoscopy may worsenmay worsensymptoms postsymptoms post--opop


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Exam of NeckExam of NeckEvidence of prior surgeries (especiallyEvidence of prior surgeries (especially

tracheostomytracheostomy))Abnormal masses present or trachealAbnormal masses present or tracheal

deviationdeviation

Short or thick neck may prove problematicShort or thick neck may prove problematic

Patient especially obesePatient especially obese

FROMFROM preparation ofpreparation oflaryngosopylaryngosopy requiresrequiresextension of the neck to facilitateextension of the neck to facilitatevisualizationvisualization


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Goal of DL = createGoal of DL = create line of sightline of sight

from eye to glottis (from eye to glottis (glotticglotticopening)opening)


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Patient presents to ED with rapidly progressingPatient presents to ED with rapidly progressing

infectioninfection CC: My lower right jaw is swollen and I amCC: My lower right jaw is swollen and I am

having some difficulty swallowing.having some difficulty swallowing.

Moderately healthy ASA II patientModerately healthy ASA II patient PMH:PMH: EtOHEtOH use, sleep apneause, sleep apnea

PSH: nonePSH: none

NKDANKDA

Medications: Amoxicillin for infectionMedications: Amoxicillin for infection

FamilyFamily HxHx: paternal: paternal -- heart diseaseheart disease

SlightSlight DyspneaDyspnea in supine positionin supine position


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If physical exam leaves in questionIf physical exam leaves in question

the ability to adequately ventilatethe ability to adequately ventilateand successfullyand successfully intubateintubate once theonce the

patient is anesthetized andpatient is anesthetized and

paralyzed, serious considerationparalyzed, serious consideration

should be given to awake intubation.should be given to awake intubation.


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Awake Intubation TechniqueAwake Intubation Technique Discuss with patientDiscuss with patient

Must be done in operative suite with standard ASAMust be done in operative suite with standard ASAmonitorsmonitors

TopicalizationTopicalization with LAwith LA

Intravenous sedativesIntravenous sedatives

Selection of oral and nasal airways availableSelection of oral and nasal airways available

ET tubesET tubes

SuctionSuction

FiberopticFiberoptic endoscopeendoscope Surgeon capable of creating surgical airwaySurgeon capable of creating surgical airway


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PrePre--medicationmedicationGlycopyrrolateGlycopyrrolate 0.20.2 0.4mg useful to reduce0.4mg useful to reduce

secretionssecretions

Versed mgVersed mg slowly titrated so that theslowly titrated so that the

patient is not rendered obtunded,patient is not rendered obtunded, apneicapneic, or, orunable to protect their airwayunable to protect their airway


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TopicalizationTopicalization Plan for nasal intubationPlan for nasal intubation

due to operative sitedue to operative site 2% viscous lidocaine have2% viscous lidocaine have

patient swish for 5 minutespatient swish for 5 minutes

then swallowthen swallow

4% lidocaine spray4% lidocaine spray

intranasallyintranasally and orallyand orally

Nasal trumpet withNasal trumpet with

lidocaine ointment insertedlidocaine ointment insertedgentlygently


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Trachea also needs to beTrachea also needs to be

anesthetizedanesthetized

How do we do this?How do we do this?

TranstrachealTranstracheal injectioninjectionof lidocaine isof lidocaine is

performed via needleperformed via needle

puncture of thepuncture of thecricothyroidcricothyroid membranemembrane

1% lidocaine1% lidocaine

aspirating beforeaspirating beforeinjectioninjection


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QuickTime and aTIFF (Uncompressed) decompressor

are needed to see this picture.


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Time for Intubation?Time for Intubation?Once an adequate level of sedation andOnce an adequate level of sedation and

topical anesthesia is achievedtopical anesthesia is achievedHow do we know?How do we know?


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FiberopticFiberoptic TechniqueTechnique ET tube loaded onto endoscopeET tube loaded onto endoscope

Endoscope gently lowered into nasal passage andEndoscope gently lowered into nasal passage andthen directed past epiglottis through the larynxthen directed past epiglottis through the larynxand down the tracheaand down the trachea visualizing tracheal ringsvisualizing tracheal ringsand carinaand carina

ET tube passed into trachea and endoscopeET tube passed into trachea and endoscoperemovedremoved

Connect ET to anesthesia machine and check forConnect ET to anesthesia machine and check forbilateral breath sounds and enbilateral breath sounds and en--tidal CO2tidal CO2confirmedconfirmed

Patient may then be fully anesthetizedPatient may then be fully anesthetized


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FiberopticFiberoptic IntubationIntubation


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What if we are unable toWhat if we are unable to

ventilate orventilate or intubateintubate??-- LMALMA

-- CombitubeCombitube

--

Jet ventilationJet ventilation

-- ReversalReversal benzosbenzos andand opoidsopoids








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Thank you!Thank you!

difficult airway pap pas 20061017

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