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