Combined Otolaryngology-Anesthesia-Emergency Medicine Difficult Airway Conference Dowling Amphitheater February 12, 2007.

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Presentation transcript:

Combined Otolaryngology-Anesthesia-Emergency Medicine Difficult Airway Conference Dowling Amphitheater February 12, 2007

Case A 60 year old man, (80 kg, 5’8”) suffered a hemorrhagic stroke shortly after a full meal. He was taken to a community hospital unconscious and with breathing difficulty. In the ER, endotracheal intubation with direct laryngoscopy was attempted several times unsuccessfully. A laryngeal mask airway (LMA) was inserted and somewhat adequate ventilation was achieved. The patient was transferred to Boston Medical Center with the LMA in place, unconscious.

Physical Exam Unresponsive (GCS < 6) but not paralyzed Hemodynamically stable Husky, short neck Mouth opening – difficult to evaluate LMA #4 in place Full dentition Distended tympanic epigastrium Distant breath sounds – ventilated with bag-valve Hgb O2 Sat: 98%

Challenge How should we manage the airway?

Considerations 1.Fiberoptic assessment of larynx through LMA? 2.How long can he remain apneic? 3.Do we sit the patient up? 4.Should neuromuscular blocking agents be used? 5.Should a nerve stimulator be used? 6.Insert NGT? 7.Remove LMA? 8.Attempt direct laryngoscopy again? 9.Intubate through LMA? 10.Cricoid pressure? 11.Surgical airway? 12.Control hemodynamics?

Conventional LMA

LMA is a conduit

Fiberoptic Exam Through LMA

Intubating LMA

ProSeal LMA

Combitube

CT of the cervical spine showing an over-inflated distal balloon of the combitube (solid arrow), placed in the esophagus, severely compressing and narrowing the adjacent trachea (dashed arrow). From: Portereiko: J Trauma, Volume 60(2).February Combitube

King L-T

Other Devices

Cutting the LMA Anesth Analg 2003;97:

Considerations Fiberoptic assessment of larynx through LMA? How long can he remain apneic? Do we sit the patient up? Should neuromuscular blocking agents be used? Should a nerve stimulator be used? Insert NGT? Remove LMA? Attempt direct laryngoscopy again? Intubate through LMA? Cricoid pressure? Surgical airway? Control hemodynamics?