THE DIFFICULT AIRWAY

MANAGEMENT IN ADULT
CRITICAL CARE

5 MAY 2014 J MATSHE

AIRWAY MANAGEMENT
 Obligatory & Necessary skill for ALLL Critical care
practitioners
 FAILURE to maintain airway & provide adequate
oxygenation=↑ patient morbidity & mortality;
psychologically-distressing to attending registrar
 ALL Critical Care patients-Initially viewed to have a
potentially difficult airway & REMEMBER have less
physiological reserves VS airway intervention @
elective surgery
DEFINITION
 DIFFICULT AIRWAY: Acc to ASA guidelines
2013=Clinical situation whereby conventionally
trained anaesthetist experiences DIFFICULTY
with either:
 MASK VENTILATION or
 TRACHEAL INTUBATION or
 BOTH ( “CAN’T INTUBATE, CAN’T
VENTILATE”) NB: AVOID AVOID AVOID!!!!!!!
DIFFICULT MASK VENTILATION
 Unassited anaesthetist cannot maintain arterial
oxygen saturation ≥90% by mask ventilation using
100% Oxygen & positive pressure OR
 Cannot reverse signs of inadequate ventilation eg.
Absence of chest movement & exhaled CO2 OR
Presence of cyanosis
DIFFICULT LARYNGOSCOPY
 Difficulty visualising any portion of vocal cords
using a conventional laryngoscope: Cormack
Lehane 3(epiglottis only)/4(soft palate only)
DIFFICULT ENDO-TRACHEAL
INTUBATION
 › 3 Attempts @ inserting ET tube Or
 › 10 minutes to perform using conventional
equipment
OUTLINE
 INDICATIONS FOR INTUBATION
 AIRWAY ASSESSMENT & PREDICTING DIFFICULT
AIRWAY:
 PRE-INTUBATION STRATEGY

-Preparation
-Pre-Oxygenation
-Positioning
-Premedication
 PLANS & BACK UP PLANS

 ADJUNCTS
INDICATIONS FOR INTUBATION

 Inadequate Oxygenation
 Inadequate Ventilation
 Anticipate development of inadequate
oxygenation/ventilation
 Airway protection
PREDISPOSING FACTORS TO
DIFFICULT INTUBATION
 OPERATOR related: Unassisted junior trainee
after-hours with no senior/specialist assistance
 DISEASE related: All intubations EMERGENCIES
 PATIENT related: EMERGENCY=Shortened
preparation time;Recent previous intubation-
predispose airway edema, subgottic inflammation &
even stenosis & Operator Stress due to patient’s
deteriorating condition
AIRWAY ASSESSMENT
History for airway assessment Potential Problems
 Anaesthesia records All stages
 Previous intubation trauma All stages
 Previous surgery, radio-therapy to head/neck All stages
 Airway disease process All stages
 Systemic disease(rheum arthr, ankylos spondyl) Diff laryngoscopy

 Sleep apnoea Loss of airway tone & Difficult laryngoscopy

 Previous tracheostomy Difficult laryngoscopy and intubation

 Gastro-oesophageal reflux Aspiration of gastric contents

 Full stomach Aspiration of gastric contents
AIRWAY ASSESSMENT
Exam for A A Potential Problems
 Stridor All stages
 Obesity Loss of airway tone and difficult laryngoscopy
 Short neck Difficult laryngoscopy
 ↓ mouth opening Difficult laryngoscopy
 Receding jaw Difficult laryngoscopy
 Hamster mouth Difficult laryngoscopy
 Buck teeth Difficult laryngoscopy
 Missing upper teeth Difficult laryngoscopy
 Respiratory difficulty Difficult laryngoscopy
 Neck masses All stages
 Position of larynx/ trachea and availability of cricothryroid membrane
Difficult laryngoscopy and intubation
BAG MASK VENTILATION
BAG MASK VENTILATION
 INTEGRAL component of Airway mx
 If done correctly & successfully: Gives time to
prepare for definitive airway mx
 Entails 3 Principles: Patent Airway, Good
mask seal & Proper ventilation
IDENTIFYING DIFFICULT BMV
M O A N S
 Mask seal: Can’t approximate
mask
 Obesity:Redundant tissues
impede airflow
 Age ›55yrs: Loss of tissue
elasticity
 No teeth:Mask doesn’t sit
properly
 Stiff lungs/body:↑pressure
needed
OPENING AIRWAY MANOUVERE 1
HEAD TILT CHIN LIFT:
1ST HAND DOWNWARD PRESSURE TOFOREHEAD ; 2ND HAND INDEX &
MIDDLE FINGERS LIFT CHIN
OPENING AIRWAY MANOUVRE 2
JAW THRUST-UNSTABLE CERVICAL SPINE:
PLACE HEELS OF HANDS ON PARIETO-OCCIPAL AREA & GRASP ANGLES
OF MANDIBLE WITH FINGERS & DISPLACE JAW ANTERIORLY
OPENING AIRWAY ADJUNCT 1
OROPHARYNGEAL: GUEDEL-SIZE CORRECTLY; INSERT-CURVE
INVERTED, ROTATE 180˚ AS TIP REACHES POSTERIOR PHARYNX
AVOID IN AWAKE PATIENT
OPENING AIRWAY ADJUNCT 2
NASOPHARYNGEAL AIRWAY
MASK VENTILATION TECHNIQUE 1
1 HAND: ALIGN PATIENT’S EXTERNAL AUDITORY MEATUS WITH
STERNAL NOTCH USING E-C METHOD FOR MASK SEAL & BAG WITH
OTHER HAND
MASK VENTILATION TECHNIQUE 2
2 HANDED: 1 PERSON HOLDS MASK WITH BOTH HANDS USING E-C
METHOD OR APPLY PRESSURE WITH THUMBS & LIFT JAW WITH FINGERS;
2ND PERSON BAGS
ENDOTRACHEAL INTUBATION
THE DIFFICULT INTUBATION
Failure to intubate can result in severe adverse
events such as:
 Airway trauma

 Aspiration

 Hypoxemia/Anoxic brain injury

 Hypotension

 Cardiac arrest & Death

BE PREPARED & HAVE A PLAN

IDENTIFYING THE DIFFICULT
INTUBATION
L E M O N
 LOOK

 EVALUATE 3-3-2

 MALLAMPATI

 OBSTRUCTION/OBESITY

 NECK MOBILITY
DIFFICULT INTUBATION
ASSESSMENT
“LOOK”
 Externally: Facial

trauma;
Unusual/Distorted
anatomy
 Internally: Foreign
body; Secretions;
Obstructing mass
DIFFICULT INTUBATION ASSESSMENT

EVALUATE: 3-3-2 RULE

Mouth opening Tip of mentum to hyoid bone Thyromental distance

Access to airway Can tongue be deflected Predicts location larynx to

and obtaining glottic to accomdate base of the tongue. If larynx high
view laryngoscope angles difficult
DIFFICULT INTUBATION
ASSESSMENT
DIFFICULT AIRWAY ASSESSMENT
OBESITY
 Redundant tissues in

upper airway may

obscure glottis
 Positioning imp:
Pillows under
shoulders
OBSTBUCTION
 Epiglottitis, Quisy
DIFFICULT AIRWAY ASSESSMENT
NECK MOBILITY

↓ Cervical spine
mobility: RA,DM,
Cervical immobility
→COMPROMISED
Sniffing position
PRE-INTUBATION STRATEGY
PREPARATION
PRE-OXYGENATION
POSITIONING
PREMEDICATION
PREPARATION
 ASSESS AIRWAY: Look for signs of possible
difficult bag mask ventilation/intubation OR both
 ASSEMBLE EQUIPMENT: Check functional
status
 PREPARE MEDICATION
 DEVELOP AIRWAY MANAGEMENT PLAN
WITH BACK UP PLANS
PREPARATION
S T O P M A I D

 Suction  Monitors(Bp,Sats,Cap)
 Tools(Laryngoscope)  Ambu-bag,Airw devic
 Oxygen  Iv access
 Position/Plan  Drugs
INFLUENCE OF LARYNGOSCOPES

 Macintosh
-No difference
compared to Miller
LARYNGOSCOPES
 Miller
LARYNGOSCOPES
 McCoy
-Has an angulated tip
-Improves visualisation
with less force; in
neutral position
LARYNGOSCOPES
 Bullard/Airtraq
-Rigid fibre-optic
laryngoscope
-Alignment of axes not
required
PREOXYGENATION
 Establish oxygen reservoir
-Replace nitrogenous room air mixture with 100%
oxygen
 Challenge in ICU

-Head of bed elevation

-NIPPV
 Challenge in Obesity & Critically ill patients

-Desaturate much quicker

POSITIONING
 SUPINE
-Access to airway
obstructed
 SNIFFING

-Head elevated, Neck

extended
-Imaginary horizontal line
from external auditory
meatus to sternal notch
-Access to airway
improved
PREMEDICATION
ICU pts-require very little or no drugs
L O A D
Lidocaine: Reactive airways & ↑ICP
Opioids: Blunt sympathetic response & ↑BP
Atropine: Bradycardia in kids particularly
Defasciculating agent-↓dose competitive
neuromuscular blockade: ↑ICP
INDUCTION AGENTS
 KETAMINE: Sedation & Analgesia; No
hypotension; Bronchodilatory effect; Respiratory
drive preserved; ↑ICP & BP. Dose: 1-2mg/kg iv
 PROPOFOL: Rapid onset; No analgesia;
Hypotension. Dose: 1.5-3mg/kg iv
 MIDAZOLAM: Time to effect › 15min ;
Hypotension. Dose: 0.1-0.3mg/kg iv
 ETOMIDATE: Rapid onset; No
analgesia/Hypotension. Dose: 0.3mg/kg
MUSCLE RELAXANTS

SUXAMETHONIUM ROCURONIUM

 Onset 45-60sec; DOA  Onset 60min; Longer

6-10min. DOA than Sux.
 Dose: 1-1.5mg/kg iv;  Dose 0.8 - 1.2mg/kg iv
 C/I-Rhabdomyolysis,
Hyperkalemia, Burns ›
72hrs & Hx Malignant
HT
LARYNGOSCOPY TECHNIQUE
BIMANUAL LARYNGOSCOPY
CRICOID PRESSURE
 Avoid regurgitation of
gastric contents by
occluding upper end
of oesophagus
 May worsen glottic
view
 BURP: Improve
glottic view by
manipulating thyroid
cartilage
LARYNGOSCOPY
INSERTING ET TUBE
CONFIRM ET TUBE PLACEMENT
AIRWAY ADJUNCTS
BOUGIE
VIDEO LARYNGOSCOPE
LMA
CRICOTHYROID CANNULA
SURGICAL CRICOTHYROIDOTOMY KIT
BOUGIE
VIDEO LARYNGOSCOPY
VIDEO LARYNGOSCOPES
 GLIDESCOPE
VIDEO LARYNGOSCOPES
 C-MAC
LMAs

CLASSIC LMA INTUBATING LMA/FASTRACK

NEEDLE CRICOTHYROIDOTOMY
SURGICAL
CRICOTHYROIDOTOMY
THE PLAN
AND BACK UP PLANS.....
REFERENCES
 Critical care medicine.2008;36(7):2163-2173
 Anaesthesiology.2013;118:Practice guidelines for
manangement of the difficult airway
 Critical care and resuscitation.2003;5:43-52
 Endotracheal intubation in ICU by Dr D Oxman
2013