Context Sensitive Airway Management Orlando Hung Departments of Anesthesia and Surgery, Dalhousie University, Halifax, Nova Scotia

Objectives Context-sensitive Airway Management Device-Dependent Airway management

Tracheal Intubation

FIGURE 39–22 Difficult airway algorithm developed by ASA Task Force on Guidelines for Difficult Airway Management (Modified from American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice guidelines for the management of the difficult airway. Anesthesiology 78:597, 1993) Copyright © 2000, 1995, 1990, 1985, 1979 by Churchill Livingstone

What if you are not in the OR environment?

FIGURE 39–22 Difficult airway algorithm developed by ASA Task Force on Guidelines for Difficult Airway Management (Modified from American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice guidelines for the management of the difficult airway. Anesthesiology 78:597, 1993) Copyright © 2000, 1995, 1990, 1985, 1979 by Churchill Livingstone

These algorithms will work if: It is in the OR There is time There is proper preparation There are equipment There is assistance

Case Presentation

This morbidly obese patient is scheduled for an open appendectomy She is otherwise “healthy”. She weighs 210 kg and is 158 cm tall (BMI 84.1). She takes no meds. She has no allergies. Apart from a big “thick” neck, she has no obvious predictors of difficult laryngoscopy.

What is your choice of anesthesia for the surgical procedure? Spinal anesthesia? Epidural anesthesia? GA using an LMA? GA with a tracheal tube?

How would you like to secure the airway? RSI with a Macintosh laryngoscope? Glidescope intubation under GA? Awake intubation using bronchoscope?

Would you do anything different if she is scheduled for a cystoscopy? Cancel the surgery? Consider doing the procedure under local and sedation? Consider regional anesthesia (spinal)? GA using an LMA? Awake tracheal intubation using a bronchoscope?

What if she is scheduled for the appendectomy and she is unco-operative? Cancel the surgery? Consider regional anesthesia (spinal)? Insisting awake tracheal intubation under sedation? Mask induction and tracheal intubation? Tracheal intubation using a video- laryngoscope under GA?

What if she is cooperative, but is also 18 weeks pregnant? Postpone surgery Regional anesthesia Awake intubation under sedation RSI with a video-laryngoscope

What if she is 18 weeks pregnant with bowel perforation, peritonitis and in septic shock? Regional anesthesia Awake intubation using whatever RSI using a video-laryngoscope Surgical airway awake

What if you are working in a community hospital in Rwanda? Regional anesthesia Awake intubation using a bronchoscope Awake intubation using a Glidescope Awake intubation using direct laryngoscopy Blind nasal intubation RSI using direct laryngoscopy

Many factors can influence how we manage the airway of a patient: Can I ventilate the patient with a BMV, an extraglottic device, or through a tracheal tube? Failing that, can I get a surgical airway easily? Emergency? Cyanotic? Do I have time? Pregnant? A child? Co-operative? Aspiration risk? Any assistance? Available resources? Skills with the airway devices

Device Dependent Airway Management When we identify a potentially difficult laryngoscopic intubation, we must resist the inclination to persist with direct laryngoscopy. Similarly, we should not rely on a single intubation technique, such as the bronchoscopic intubation. With the currently available resources, airway practitioners should be able to choose an appropriate device or technique to effectively manage a difficult airway with alternative plans depending on the situation or environment as well as the skills of the practitioner.

Strategy to manage patients with a difficult airway: Plan A Plan B Plan C Plan D These plans should be modified or changed according to the environment or situations.

Principles of Airway Management

Summary We should focus on ventilation and oxygenation in airway management Plans to manage the airway of a patient depend on many factors and situations and all airway practitioners should modify their approaches to meet these challenges. All airway practitioners should avoid relying on a single airway device or technique.