DIFFICULT AIRWAY ASSESSMENT AND MANAGEMENT BY DR AZHAR

more than 10 minute are required to complete tracheal intubation DEFFINATION American society of Anesthesiologist (ASA) suggested that when sign of inadequate ventilation could not be reversed by mask ventilation or oxygen saturation could not be maintained above 90% or if a trained Anaesthetist usinig conventional larangoscope take’s more than 3 attempts or more than 10 minute are required to complete tracheal intubation

Anatomy of oropharynex and larynx

PREVALENCE Fact of the matter is even with proper evaluation only 15 to 50 % were picked up while difficult face mask ventilation in general is about 1:10,000 out of which again 15% proved to be the difficult intubation ,while incidence of extreme difficult or abandons intubation in general surgery patients are 1:2000 but in obstetrics is 1:300 and of course most critical incidence is Hypoxia

BASIC AIRWAY EVALUATION Previous anaesthetic problems and general appearance of the patient. Neck, face, maxilla and mandible with jaw movements. Head extension and movements, teeth, oropharanx and soft tissue of the neck .

Why does it happens ? Exaggerated idea of personal ability. Not requesting for experienced help. No discussion with colleagues about proposed management of the case . Ill conceived plan (A) with no proper back up plan (B). Even poorly conducted plan (A) or sticking extra time to the plan (A) other way delaying the rescue plan late. Last not the least not involving surgical friends.

CAUSES OF DIFFICULT INTUBATION Anaesthetist Inadequate preoperative assessment. Inadequate equipments. Experience not enough. Poor technique. Malfunctioning of equipment. Inexperience assistanance Patient Congenital causes Acquired causes

Anatomical factors affecting Larangoscopy Short Neck. Protruding incisor teeth. Long high arched palate. Poor mobility of neck. Increase in either anterior depth or Posterior depth of the mandible decrease in Atlanto Occipital distance that's why role of Radiology has increased in our specialty

Mallampati classification with larangoscopic view. ASSESSMENT OF AIRWAY Mallampati classification with larangoscopic view. Patil’s Test

Measurement of Atlanto-Occepital Angle

MANAGEMENT PLAN OF ANTICEPATED DIFFICULT AIRWAY Discussion with colleagues in advance. Equipment tested before. Senior help backup. Definite initial plan (A) for ventilation and intubation. Definite plan (B) than option of awake intubation. Ideal situation surgery team standby.

UNEXPECTED DIFFICULT AIRWAY Problems Unexpected encounter with difficult airway is mostly gone worse because mainly GA is already given including (NMB,S). Equipment may not be in hand. Senior and back up plan not available so delay occur in active resuscitation TECHNIQUE OF MANAGEMENT Manipulation of the patients airway. Laryngeal pressure. Nasal or oral airway. Different blades of larangoscope like Miller, Magill, Robershaw , Mackintosh and relatively new laryngoscope McCoy. Bougies and stylet LMA. Combitube.

Manipulation of airway different blade, bugie 1 Manipulation of airway different blade, bugie 2 LMA, ILMA, Combitube 3 Trantracheal Jet Ventilation 4 Cricothireotomy, Tracheostomy

GALLERY OF TOOLS

Bullard laryngoscope Fiber optic GALLERY OF TOOLS Bullard laryngoscope Fiber optic

Mini Tracheostomy

Mini Tracheostomy (Cont.)

BLIND NASAL, RETROGRADE AND HIGH FREQUENCY VENTILATION

Awake Intubation

ASA ALLOGORYTHAM

ASA ALLGORYTHAM

C-SPINE OA

THANK YOU VERY MUCH FOR YOUR ATTENTION