Difficult tracheal intubation

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Presentation transcript:

Difficult tracheal intubation Dr Tuan Pham Duc 06/2010

Plan Preintubation checklist. Intubation kit . RSI ( Rapid sequence intubation ) Predicting difficult tracheal intubation Bougie ( Eschmann stylet ) . Laryngeal mask airway-Fastrach ( Intubating LMA) Cricothyroidotomy Alternatives intubation techniques Confirmation of ETT placement . Miscellaneous Summary

Preintubation checklist

Intubation kit Laryngoscope ET Stylet Syringe 10ml Suction catheter Carbon dioxide detector Oral & nasal airways Ambu bag & mask attached to oxygen source

Rapid sequence intubation Endotracheal intubation using RSI is the cornerstone of emergency airway management . RSI: the administration of a potent induction agent followed immediately by a rapidly neuromuscular blocking agent to induce unconsciousness & motor paralysis for tracheal intubation

RSI 3 phases: pretreatment-induction-paralysis. Pretreatment : LOAD Lidocaine Opiod analgesics Atropine Defasciculating agents

Pretreatment medications

Induction medications

Paralytic medications

Predicting difficult tracheal intubation LEMON rule Look externally E Evaluate the 3-3-2 rule Mallampati scale Obstruction present ? Neck mobility

Difficult airway assessement Look externally : physical features such as a small mandible , large tongue , short bull neck & obesity , facial or mandibular fracture are all red flags for a difficult airway

Difficult airway assessement Mallampati classification

Difficult airway assessement Obstruction : 3 signs of upper airway obstruction are stridor , muffled voice,difficulty swallowing secretions. Neck mobility:cervical spine immobilization in trauma , medical condition such as ankylosing spondylitis or RA.

McCormack & Lehane grade

Bougie ( Eschmann stylet )

Bougie ( Eschmann stylet ) It can be beneficial in the following situations : Grade 3 view Poor grade 2 view As a general intubation aid

A bougie can be used on the 1st attempt intubation when DL has failed to yield an adequate view

LMA A laryngeal mask airway

LMA

Fastrach( Intubating LMA)

Intubating LMA sizes 1 (<5kg) 1,5 (10-20kg ) 2,4 ( 20-50kg )

Cricothyroidotomy Insertion of a tracheal tube through an incision in the cricothyroid membrane .

Alternatives intubation techniques Glottiscope ( Airtraq..) Special laryngoscopes Lighted stylet intubation Fiberoptic techniques. Esophageal-tracheal Combitube Retrograde intubation

Airtraq

Combitube

Confirmation of ETT placement Chest auscultation: bilateral breath sounds Detection of CO2 exhaled. Chest Xray :

A- Capnography B-C CO2 color change indicator

Miscellanous Cricoid pressure:Sellick’s maneuver External Laryngeal Manipulation or BURP Backward Upward Right Pressure maneuver ELM improved the laryngoscopic view by one whole grade in most pts initially rated 2 or 3 All pts presenting grade 3 view were converted to grade 1 or 2 with ELM

Summary Always be prepared for a difficult airway. No single airway assessment tool is sufficiently sensitive nor specific to reliably predict or rule out a difficult airway. In many cases features of the patient’s morphology & pathology enable prediction of a difficult airway