Challenges in Airway Management

Operating Room Nurses Chapter of Singapore

30 Mar 2013

Dr Lim Yvonne
Consultant Anesthesiologist
M.B,B.S; M.Med(Anesth)

Challenges in Airway Management

1) Airway Management: Is it a problem?
2) Difficult Airway Guidelines
ASA Task Force : Practice Guidelines for Management of the Difficult
Airway (Anesthesiology 2003)
Airway Approach Algorithm (Anesth & Analg 2003)
Obstetrics Difficult and Failed Intubation Drill (IJOA 1997)

3) Difficult Airway Devices: Whats New?

4) Summary: Take home message

Airway Management:
Is it really a problem?

Difficult
Airways

Mallampati Classification

Airway Management:
Is it really a problem?

Cormack and Lehane Grades

Cormack and Lehane Grades

The Difficult Airway:

Incidence of Failed intubation
General population: 1 in 2230 (0.004%)
Obstetric population: 1 in 300 (0.3%)
Patient's Anatomy (upper airway oedema, full
dentition, head positioning)
Cricoid pressure
Stress on anaesthetist / anesthetic nurse
Failed intubation drill
Difficult and failed intubation in obstetrics.
Int J Obstet Anesth. Harmer. 1997.

Anaesthesia: Maternal Mortality

Confidential Enquiry Maternal Deaths
(UK 2000-2002)

90% cesarean section performed under Regional Anesthesia

10% cesarean section performed under General Anesthesia
7 maternal deaths directly due to Anesthesia
All 7 deaths involved General Anesthesia

Cricoid Pressure

Difficult Airway Guidelines

Difficult Airway Guidelines

National Society Guidelines
American Society of Anesthesiologists Task Force: Practice Guidelines for
Management of the Difficult Airway (2002)
Canadian Airway Focus Group: Management of unanticipated difficult airway
Difficult Airway Society: Guidelines for management of the unanticipated difficult
intubations
Italian Society of Anaesthesia, Resuscitation and Intensive Therapy (SIAARTI)
Fench Society of Anaesthesia and Intensive Care
German Soceity of Anaesthesiology and Intensive Care Medicine (GAI)
Institutional Guidelines
Airway Approach Algorithm (Rosenblatt, et al. 2003)
Failed Intubation Drill in Obstetrics (Harmer M. 1997)

Definitions
Difficult Airway
Trained anesthesiologist experiences difficulty with mask
ventilation, difficulty with tracheal intubation, or both

Difficult Ventilation
Require 2 persons effort
Use of an oropharyngeal and/or nasopharyngeal airway

Practice Guidelines for Management of the Difficult Airway. ASA Task for
on Difficult Airway Management. Amended 2002.

Difficult Ventilation

Difficult Intubation
Insertion of the tracheal tube requires more >3 attempts or > 10
min, by 2 experienced operators, 2 type of blade
patient in an optimal position
optimal external laryngeal manipulation

Difficult Intubation

Stylet

Gum elastic Bougie

ASA Task Force :

Practice Guidelines for Management of the Difficult
Airway

ASA Task Force :

Practice Guidelines for Management of the Difficult
Airway

Practice
Guidelines for
Management of
the Difficult
Airway. ASA Task
for on Difficult
Airway
Management.
Amended 2002

Unable to Intubate & Ventilate Drill

Difficult Airway Algorithm

Controlled human studies &computer
simulations demonstrate that desaturation
occurs rapidly after onset of apnoea
Preoxygenated, healthy adult: 5 - 9 min
Child : 2 - 4 min
Obesity, pregnancy, illness & inadequate
preoxygenation contribute to premature
desaturation

Difficult Airway Devices:

Whats New?

Difficult Airway Devices:

Whats New?
Supraglottic airways
Laryngeal Mask Airway (LMA) /Unique
Proseal LMA/ Supreme
Intubating Laryngeal Mask

Videolaryngoscope
Glidescope
C-trach
C-MAC
Pentax-AWS
Airtraq

Other Supreglottic Devices

1.
2.
3.
4.

Laryngeal mask airway (LMA)

Airway management device (AMD)
Combitube
Cuffed oropharyngeal airway
(COPA)
5. Streamlined Liner of the Pharynx Airway
(SLIPA)

Difficult Airway Devices:

Whats New?
The LMA vs ProSeal & Supreme
LMA with drain tube
Drain tube inserted to remove gastric contents, prevent gastric
insufflation, channel any regurgitated material

LMA in ASA Airway Algorithm

The ASA difficult airway algorithm recommends
using the LMA in unexpected Difficult Airway
allow ventilation and oxygenation while waiting for
patient to wake up
assist in ventilation for patient with difficult mask
ventilation
allow surgery to proceed
act as conduit for ETT insertion
act as conduit for bougie/fibreoptic assisted intubation
ventilate patient while surgical airway is perform

LMA: Life-saver Most Anesthetist

LMA in Difficult Airway

Advantages:
familiar equipment
easily available
always in difficult airway trolley
high incidence of successful insertion
allow insertion without need to re-paralyse patient
maintain patent airway until patient is fully awake

Disadvantages:
no airway protection
may need to release cricoid pressure to position LMA

Difficult Airway Devices:

Whats New?

Supreme LMA was used in 700 women undergoing elective LSCS

Mean time of insertion was 19.5sec
98% first insertion success rate
Good ventilation and oxygenation
No evidence of aspiration

Videolaryngoscope Devices
1.
2.
3.
4.
5.

Glidescope
Airtraq
C-trach
C-Mac
Pentax

Laryngoscope vs. Videolaryngoscope

Another Videolaryngoscope:
GlideScope

Application of Videolaryngoscope in
Difficult Airway
Routine elective intubation:
Decrease trauma
Improve laryngeal view
Supervision and documentation of laryngoscopy
Assessment of the oropharynx and quality of cricoid
pressure applied
Assists laryngeal manipulation to improve coordination for
tracheal intubation
Decrease haemodynamic changes

Application of Videolaryngoscope in
Difficult Airway
Anticipated difficult airway:
Awake videolaryngoscopy
Potentially easier learning curve then FOB
No restriction to the type and size of ETT that can be placed
Wider field of view than fibreoptic scope
Anti-fogging mechanism & less affected by secretions
Less expensive more durable than fibreoptic scope

Unanticipated difficult airway

Rapidly accessible for immediate use & easier to set up
Improve C/L grading
Assist in nasogastric/orogastric tube placement

Offer an advantage patients with infective conditions

Summary
Difficult airway continues to contribute to morbidity and
mortality, even in developed countries
Difficult airway management algorithm & failed intubation
drills are essential to prevent adverse outcomes
Supraglottic airway devices can be used as an airway
rescue device in unanticipated difficult airway

New videolaryngoscope systems can assist in

anticipated/unanticipated difficult airway

Summary:
Difficult Airway Algorithm
Anticipated:
Regional anaesthesia
Awake fibreoptic intubation/ Videolaryngoscope intubation

Unanticipated:
Can ventilate:
Wake patient, perform RA or awake intubation
Supraglottic airway (Proseal LMA) confirm placement & proceed with
surgery

Cant ventilate:
Supraglottic airway (Proseal LMA)
Cricothyroidotomy or surgical airway

Life is about the journey, not the destination.

Pelican Nebula

Thank You