Airway management Second cause of mortality in anaesthesia in 1996 in France = 1/3 of the anaesthesia mortality. 600 deaths in UK in 1990 15 to 30% of the predictable difficult intubation was not identified.

A Clinical Case: The Reality in 2014 62 years old, male, with history of diabetes and hypertension controlled by medications 175 cm – 86 kg. ASA II Previous surgeries uneventful History of previous surgery / GA with intubation (no documentation of any airway difficulties) No predictive factor of difficult intubation or mask ventilation Mallampati II Posted for elective Cholecystectomy/ laparoscopy

Anaesthesia induction Post induction Pre oxygenation : MASK ON THE FACE Monitoring ; SPO2 NIBP SCOPE Exp CO2 DRUG INDUCTION Fentanyl = 50 mcg Lido IV = 60 mg Propofol = 100 mg Atracurium = 50 mg IMPOSSIBLE TO BAG THE PATIENT 1ST LARYNGOSCOPY = NO VISION Call for help Tried to bag the patient

Anaesthesia induction Pre oxygenation : MASK ON THE FACE Monitoring ; SPO2 NIBP SCOPE DRUG INDUCTION Fentanyl = 50 mcg Lido IV = 60 mg Propofol = 100 mg Atracurium = 50 mg IMPOSSIBLE TO VENTILATE IMPOSSIBLE TO INTUBATE

WHAT TO DO FIRST Patient still with a good SPO2 ASK FOR CRICOTHYROTOMY SET LARYNGOSCOPY LARYNGOSCOPY PLUS ELASTIC BOUGIE TREAT THE BRONCHOSPASM LMA INTUBATING LMA DO NOT DO ANY MANOEUVRES - MAKE ANESTHESIA DEEPER

THE REALITY LARYNGOSCOPY Blind intubation with Bougie TRIED CRICOTHYROTOMY by no air in the lung LMA = Cannot ventilate => REMOVED DRUGS FOR BRONCHOSPASM (Aminophylline Hydrocortisone...) INTUBATING LMA = IMPOSSIBLE Patient “Extreme” Bradycardia = START CPR Atropine adrenaline Ketamine 100 mg => Patient intubated back to SPO2 100% Transfert to ICU => patient Died

Airway management is still a main concern in 2015 Guidelines are there to improve outcomes of intubation Can we improve our airway assessment. Can we train our airway skills.