Difficult Airways! Difficult Airways! Dr Mike Entwistle Consultant Anaesthetist, Royal Lancaster Infirmary NWTS Study Day 18/10/12.

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Presentation transcript:

Difficult Airways! Difficult Airways! Dr Mike Entwistle Consultant Anaesthetist, Royal Lancaster Infirmary NWTS Study Day 18/10/12

Difficult airways What is a difficult airway? How are they managed? Practice some airway skills

Definition “The clinical situation in which a conventionally trained anaesthetist experiences difficulties with facemask ventilation, tracheal intubation, or both”

Airway vectors

Laryngoscopy

Laryngoscopic view

Airway assessment Mouth opening Protruding teeth Size of tongue Presence of soft tissue masses Mandibular size Neck mobility History of previous problems

Mallampati score

In life what you see is not always what you get….

In paediatric airways it frequently is….

Difficult airways in kids Congenital Acquired Under 1 year

Congenital Hypoplastic mandible (micrognathia) Midface hypoplasia Large tongue (macroglossia)

Hypoplastic mandible Pierre Robin Treacher Collins GoldenharSyn

Midface hypoplasia Crouzon Syn Apert Syn

Large tongue Mucopolysaccharidoses Beckwith-Wiedemann Syn Downs Syn

Acquired Acute obstruction Chronic obstruction

Acute obstruction Infection – croup, epiglottitis, tracheitis Foreign body aspiration Trauma Anaphylaxis

Chronic obstruction Tonsillar hypertrophy Haemangioma Subglottic stenosis

Activity 67/932 airway related referrals

Difficult airway management Anticipated Unanticipated

Anticipated difficult airway 1 Have a plan! Phone a friend – ENT support nearby Maintain spontaneous ventilation – inhalation induction Direct layngoscopy Indirect laryngoscopy

Anticipated difficult airway 2 LMA with fibreoptic scope

Unanticipated difficult airway Difficult intubation -in healthy kids0.08% (1 in 1250) -in under ones0.24% (1 in 400) Difficult mask ventilation 0.02% (1 in 5000) Can’t intubate/can’t ventilate (CICV) -adults 1 in children ?less unless obese

DAS/APA guidelines guidelines -Difficult mask ventilation -Unanticipated difficult intubation -CICV

Cannula cricothyroidotomy is rescue technique recommended by APLS Attempted 19 times, failed 12 times (63% failure) in adults Likely much more difficult in small children

Emergency surgical airway needed in 5 children 1 child died on transfer to theatre for emergency tracheostomy 4 attempted -3 emergency tracheostomies by surgeons succeeded -1 needle cric, by anaesthetist, failed

Cannula Cricothyroidotomy

Summary Many major paediatric airways difficulties are predictable Unanticipated airways difficulties can occur ENT support is invaluable if airways difficulty is predicted Needle cricothyroidotomy has a high failure rate Children with congenital abnormalities can be extremely challenging to manage