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Adult and Pediatric Intubation Alice A Tolbert Coombs MD MPA FCCP
Associate Professor Virginia Commonwealth University
Medical College of Virginia
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No Disclosures Alice A Tolbert Coombs MD MPA FCCP
Associate Professor
Department of Anesthesiology and Critical Care Medicine
Medical College of Virginia
Medical Director, Critical Care Medicine Vibra Hospital
VCU Health Systems
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Objectives
Discuss anatomy and physiology
Review Techniques and methods of Airway Management
Review Airway Cases
Discuss Complications of Airway management and how to avoid common problems
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Airway Assessment
External Airway Evaluation “the Grocery Store Look”
• Mallampati Classification
• Oral Cavity-
• Mouth Opening, Teeth
• High Arched Palate
• Hypopharyngeal Masses , Large Tongue or Oral tumor , Enlarged Tonsils
• Skull and Facial Structures
• Maxillary Anatomy/Injury
• Mandibular Anatomy-Prominent CHIN or Receding CHIN Pierre-Robin
• Nasal Anatomy, Antrum
• Low Riding ears
• Ocular Assessment-Enucleation
• Neck
• Neck Mobility
• Masses
• Cervical Spine Anatomy
Internal Airway Evaluation
• Upper Lip Bite Test
• Saying “e” High Pitch” for evaluation of degree of swelling and RCL Nerve encroachment with angioedema , ACEI
Functional Assessment-
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Date of download: 2/16/2019 Copyright © 2019 American Society of Anesthesiologists. All rights reserved.
Representative data screen for the online data collection tool used at the R Adams Cowley Shock Trauma Center (Baltimore, MD),
the Shock Trauma Airway Registry (STAR). OR = operating room.
Figure Legend:
From: Performance Assessment in Airway Management Training for Nonanesthesiology Trainees:An Analysis of 4,282
Airway Procedures Performed at a Level-1 Trauma Center
Anesthes. 2014;120(1):185-195. doi:10.1097/ALN.0000000000000064
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From: Performance Assessment in Airway Management Training for Nonanesthesiology Trainees: An Analysis of 4,282 Airway Procedures Performed at a Level-1 Trauma Center
Anesthes. 2014;120(1):185-195. doi:10.1097/ALN.0000000000000064
Distribution of intubation attempts with corresponding success rate by week of rotation. *P < 0.05 for week 1 versus week 4.
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AIRWAY
Glottic Airway
Direct Laryngoscopy
Light Wand , etc
Video-Laryngoscopy
Blind
Surgical
Tracheostomy
Retrograde Intubation
Rigid Bronchoscopy
TongueSuture-Patient Positions
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Airway Anatomy
Upper Airway
Lower Airway
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Airway Position
Head-Sniff position
Jaw Thrust
Bag Mask Ventilation
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Supraglottic Airway
Where are you managing the Airway?
Clinical scenario and choice of Airway
Airway Algorithms considerations
What are the Indications?
What are the contraindications to supraglottic airway
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Out of Hospital Arrest and Intubation
Patients do worse (mortality )if Intubated
Acad Emerg Med. 2010 Sep;17(9):918-25. doi: 10.1111/j.1553-2712.2010.00827.x.
The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients.
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In-Hospital Cardiac Arrest
Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults
Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation. (Funded by Vanderbilt Institute for Clinical and Translational Research and others; PreVent ClinicalTrials.gov number, NCT03026322.)
February 28, 2019N Engl J Med 2019; 380:811-821
Patient’s difference in aspiration 2.5 vs 4.0 % P .41
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IntubationsIndications
Apnea/Arrest
Hypoxia
Hypercarbia- relative indication , check for metabolic compensation
Acid Base Disturbances
Airway or massive trauma
Control Respiratory Rate
Low GCS 8 or less
Intracranial- Event -IPH IVH SAH
MVA
Airway Protection – Status Epilepsy
Cardiac/Hemodynamic Instability, Bleeding, MTP
Sepsis with Respiratory signs of respiratory Failure
Neuromuscular-for example ALS
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Vocal cords laryngoscopy
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Mallampati Classification
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Neck Mobility
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Lehane McCormack classification
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MACCOCHA SCORE he MACOCHA score is a simple
tool, which can be performed within a very short time period and seems to be superior to Mallampati or Cormack
M Mallampatii
A APNEA SYNDROME
C CERVICAL SPJNE LIMITATION
O Mouth Opening
C Coma
H Hypoxia
A Anesthesiologist years of experience
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Prepared Equipment
Planned and Prepare
1. Plan A Perfect
2. Plan B Deviations Obstacles that can be easily overcome with correct toolset
3. Plan C- The tough ones that make you good Prepare for the worse with all needed devices nearby and personnel!
Airway equipment:
Airways Mac 3 & 4, Miller 2 & 3 blades
Supraglottic Tookset Intubating LMA (Fast Track)
Various size endotracheal tubes
Video-laryngoscopy Device and /or Disposable fiberoptic bronchoscope,
Standard hemodynamic and Respiratory monitors available
Stethoscope
Ventilator
Capnography
Intravenous fluid and monitors attached,
Working Suction!
SOAP
Equipment Preparation Including Drugs! 6 Ps
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Technique Laryngoscopy Intubation-Starts with Positioning
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IntubationWhich Blade?Miller or Mac or ?
Open Mouth Scissoring
Insert Laryngoscope on the right then maneuver
Pass ET through Cords
Confirm Proper Placement of ET Tubes
Chest Auscultation BS ET CO2Auscultation over ABDCXR/ FluoroBronchoscopy
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AIRWAY Measurement Trachea Length 11-13cm
Trachea width 2.5 cm
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Intubating the TracheostomyIssues?
TracheostomyTrachea Stoma post Laryngectomy
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Decreasing the sensations of Intubation
Intravenous analgesia
Topicalization
Airway Nerve Block
Gauze soaked
Nebulized Xylocaine
Nasal airway topicalization
Innervation of the Larynx
Vagus
Superior Laryngeal Nerve-sensory above cords and Crico-Thyroid
Recurrent Laryngeal Nerve –Sensory below Cords, VC Muscles not cricothyroid
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SOAP
SOAP Don’t leave Home without it
S Suction
O Oxygen
A Airway Tools
P Pressures and Pharmacology
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Airway algorithmThe Airway Bible-Guide
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Case42-year-old Mozambican male presents for removal of extensive keloid scar tissue.
9 years prior to his presentation: Small scar from an injury in the center of his chest progress to cover his anterior chest wall encircling this neck bilaterally
The scar eventually involved the patient’s ears, superior portion of his chin and borders of his mandible and lower lip.
He was scheduled for a partial resection of the neck portion of the constricting keloid with(GETA)
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With a difficult airway: Analysis
The supraglottic airway device reliably provided a good airway and allowed blind intubation in nearly 80% of patients. It is thus a reasonable initial approach to airway control. Muscle relaxation can be used safely when unparalyzed leak pressure is adequate. (Anesthesiology 2017; 127:307-16)
Blind Intubation through Self-pressurized, Disposable
Supraglottic Airway Laryngeal Intubation Masks An
International, Multicenter, Prospective Cohort Study
Kurt Ruetzler, et.al.
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Blind Intubation through Self-pressurized, Disposable Supraglottic Airway Laryngeal Intubation MasksKurt Ruetzler, M.D., Sandra Esther Guzzella, M.D., David Werner Tscholl, M.D.et.al, .
1,000 adults having elective surgery with endotracheal intubation
The supraglottic airway device reliably provided a good airway and allowed blind intubation in nearly 80% of patients. It is thus a reasonable initial approach to airway control
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What’s that?
What is your plan for intubation?
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Case # 3This Patient has been on Lisinopril for 5 years. O2 Sat 91% on RA
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When things go bad!
•Hemodynamic Instability
•Poor Mask
•Hypoxia/hypercarbia
•Aspiration Pneumonia
•Laryngospasm
•Bronchospasm
•Secretions
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Burning bridges
Too much Juice
Taking away Spontaneous respiration
Know what you don’t have
Bleeding Swelling –is bad news
Choosing a surgical airway in the wrong patient with a leather skin!
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Airway Physiology
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Laryngoscopy View
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Laryngoscopy Another Look
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Airway Algorithm
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with a Difficult Airway: An Analysis from the Multicenter Registry
Blind Intubation through Self-pressurized, Disposable Supraglottic Airway Laryngeal Intubation Masks An International, Multicenter, Prospective Cohort StudyKurt Ruetzler, et.al.
The supraglottic airway device reliably provided a good airway and allowed blind intubation in nearly 80% of patients. It is thus a reasonable initial approach to airway control. Muscle relaxation can be used safely when unparalyzed leak pressure is adequate. (Anesthesiology 2017; 127:307-16)
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Airway Devices The Instruments
Non-Surgical
Oral and/or Nasal Airway
Supraglottic Airway
Esophageal/Supraglottic Airway
Endotracheal Intubation
Surgical Airway
Cricothyroidotomy
Tracheostomy-traditional
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Clinical Scenario
GI Bleeding
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Instrument Iatrogenesis
Airway trauma during difficult intubation… from the frying pan into the fire?
Sriraam Kalingarayar, et.al
CASE REPORT
A 46-year-old male, with no preexisting lung or heart ailments, diagnosed with severe cervical myelopathy, was posted for anterior cervical corpectomy and fusion. History of mild mitral stenosis (mitral valve area = 2 cm2) and mitral regurgitation, His airway examination revealed modified Mallampati class III. Neck mobility was not assessed because of his disc prolapse.
Anaesthesia was induced after confirming mask ventilation. Laryngoscopy, with minimal neck extension, revealed Cormack-Lehane grade 3a view of the vocal cords with external laryngeal manipulation. Portex ™ single use 15 Fr 700 mm coude tip bougie was first introduced up to 25 cm mark, without eliciting tracheal click or hold up signs. Portex ™ ETT size 8 mm I.D. was railroaded over the bougie without much difficulty and the ETT cuff inflated. On removal of the bougie, the tip was blood stained.
There was a gush of blood from the ETT. Suctioning was done through the ETT, and its position was checked. Ventilation was not achieved, and auscultation did not reveal bilateral air entry and end-tidal CO2 could not be recorded, as there was blood in the sampling line. Repeat suctioning through the ETT was done and auscultation again did not reveal air entry. Since the oxygen saturation started dropping to 80% and the position of ETT could not be confirmed, the ETT was removed and the patient was ventilated with a face-mask. Mask ventilation was difficult and a classic laryngeal mask airway size 4 was inserted. There was no chest rise, and auscultation revealed no air entry and SpO2 dropped further to 60%.
Repeat laryngoscopy was attempted, and airway was secured with Portex ™ 8 mm I.D. ETT with the help of the Portex ™ bougie again. No injury was visualised in the oral cavity and supraglottic area during laryngoscopy. There was still blood inside the ETT, but with repeat suctioning and lavage with dilute epinephrine (1:100,000) the bleeding was controlled. Injection tranexamic acid 1 g and injection dexamethasone 8 mg I.V. were administered. Auscultation revealed extensive wheeze and the peak airway pressure was 45 cm H2O and SpO2 increased to 95%.
An emergency bronchoscopy revealed bleeding from the right main bronchus. After instillation of topical tranexamic acid and repeated lavage, the bleeding was localised to be from the right middle bronchus [Figure 1]. The bleeding was controlled eventually. No definitive injuries could be visualised anywhere along the tracheobronchial tree while withdrawing the ETT till the vocal cords over the fibreoptic bronchoscope.
After bronchoscopy, it was decided to proceed with posterior decompressive laminectomy in the prone position. The decision was taken considering the possibility of rebleed during surgery and better drainage of the blood through ETT in the prone position. The rest of the intraoperative course was uneventful. After surgery, the patient was turned supine, neuromuscular blockade was reversed and trachea extubated. Postoperatively, the SpO2 maintained above 95% with 6 L/min oxygen flow through a facemask.
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Boogie Bougie
Indian J Anaesth. 2017 May; 61(5): 437–439.
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Bleeding Patient34 y/o coughs up blood
and then passes out as he is attempting to sign in to the ER . He develops apnea and hypo
The patient is intubated and Bronchoscopy
His ET tube is taped at 20 and filled
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Hemoptysis
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Obesity
Key to Large BMI Go Slow
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Case Presentation35y/o nursing home patient with diagnosis of TBI has pulled out his tracheostomy and he arrives in the ER with an O2 Sat of 89% on face Mask O2
35 Y/o
Airway Management in a this Patient ?
All the ENT Docs have left town for a meeting.
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Foreign Body
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When things go bad !You’re Stuck!
Hemodynamic Instability
Poor Mask
Hypoxia/hypercarbia
Aspiration Pneumonia
Laryngospasm
Bronchospasm
Secretions
Cardiac Arrest/Arrythmias
Nasal and oral bleeding
Soft tissue/AW injury
VC Complications
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Burning Bridges Too much large Juice
Neuromuscular Blockers
Missing Anatomic Warnings
Taking away Spontaneous respiration
Know what you don’t haves
Repeated attempts at intubation leading to trauma
Bleeding Swelling –is bad news
Choosing a surgical airway in the wrong patient with a leather
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Risk of Complications-Difficult Intubation-Obesity -Critically Ill-Underlying Pathology -Location of Intubation-Provider Circumstances*
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Complications
Airway Injury
Airway damage
Mainstem Intubation
Soft Tissue damage- Soft palette, Uvula and tongue
Dental
Hyoid Bone Fracture
Laryngeal , Arytenoid Dislocation, Nerve, Vocal Cord hematoma , VC Paralysis, Tracheal, bronchial injury
Systemic
Hypotension
Tachycardia, arrhythmia
Response to Mechanical Ventilation Asynchrony
Cardiac Arrest
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Summary
Reviewed patients’ history
Prepare Airway equipment and Devices
Evaluate airway, assess Difficulty
Use acceptable Protocol
Improve Preoxygenate, 100% O2 Consider using CPAP
Measure ET CO2 , Capnogram
RSI-( Assume everyone coming to the ED is a “full Stomach)