Guidelines of difficult airway : what’s new ? Olivier Langeron, MD, PhD Department of Anesthesiology and Intensive Care Pitié-Salpêtrière Hospital Paris, France

Disclosures BAXTER COOK medical COVIDIEN

Difficult airway management guidelines SFAR difficult intubation : a collective expertise Ann Fr Anesth Réanim 1996, 2007 (2014) ASA practice guidelines for management of the difficult airway Anesthesiology 1993, 2003, 2013 Canada the anticipated difficult airway with recommendations for management Can J Anaesth 1998 UK difficult airway society guidelines for management of unanticipated difficult intubation Anaesthesia 2004

Difficult airway issues Anticipate it, to manage it ! How ? difficult airway risk factors difficult airway algorithms

Definition of DMV S 1993 No universal definition El-Orbany M and Woehlck HJ Anesth Analg 2009 1993 No universal definition Simplification over time 2 main criteria despite lack of objectivity: Difficulties to maintain oxygenation Necessity of additional support to perform MV 2000 2003 2005 2006

Definition of difficult intubation (DI) ASA 2003 : DI if conventionnal laryngoscopy > 3 attempts or > 10 minutes multiples attempts SFAR 1996 : DI if conventionnal laryngoscopy > 2 attempts or > 10 minutes and/or alternative technique required after optimization of head position, with or without external laryngeal maneuver 2013 2006

Anticipated DMV Impossible : - lingual tonsill hyperplasia (LTH) +++ Ovassapian A et al. Anesthesiology 2002 - increased risk after tracheal intubation failures (≥3) Mort T. Anesth Analg 2004 - laryngospasm / bronchospasm Possible : prediction of DMV Langeron O et al. Anesthesiology 2000 Kheterpal S et al. Anesthesiology 2006

Hypertrophied Lingual Tonsil From Jones DH et al. Anesth Analg 1993 Sagittal Section of normal Tongue and Larynx

Comparison of DMV prediction studies Langeron 2000 Kheterpal 2006

DMV risk factors Increasing risk if at least 2 of these factors: http://www.sfar.org/cexpintubdifficile.html Increasing risk if at least 2 of these factors: Age >55 yr BMI >26kg/m2 Jaw protrusion severely limited Lack of teeth Snoring Beard X 4 risk of difficult intubation with a DMV

Definition of a difficult airway Laryngoscopy - Intubation Mask ventilation 8 Cerebral damage Death easy Interaction impossible 8 Laryngoscopy - Intubation DMV could be a dynamic process Benumof JL Anesthesiology 1991

Multiple TI attempts

DMV prediction and number of risk factors Kheterpal et al Anesthesiology 2006

DMV risk factor and clinical relevance Johnson JO et al Anesthesiology 1999 Patient information +++ Ask to shave the beard ?

Optimization of mask ventilation Better mask seal : appropriate face mask size, mask ventilation achieved by two persons with a two-handed mask ventilation technique Use of large oral-pharyngeal / nasal-pharyngeal airways One person assigned to O2 administration (flush valve…) and patient monitoring (SpO2 …)

DMV risk factor and clinical relevance standard face mask ventilation lower lip placement

DMV risk factor and clinical relevance median value 0 ml (0–50ml) 400 ml (365–485 ml) Expired tidal volume (ml) P < 0.001 standard face mask ventilation lower lip placement

DI risk factors History of a DI ++++ http://www.sfar.org/cexpintubdifficile.html History of a DI ++++ Recommended criteria (mandatory +++) : Mallampati class >II TMD <65mm MO <35mm Supplementary criteria Limited jaw protrusion Limited cervical spine mobility Criteria dependent on context BMI > 35kg/m2 OSA with neck circumference > 45.6cm Neck and/or facial pathology Pre-eclampsia

Strategy Algorithms Techniques

Strategy = Algorithms Oygenation maintenance Altenative techniques to control the airway 20

Rationale to use algorithms To Analyze the difficult airway situation To elaborate (local) solutions To broadcast information

90 % ID solved with GEB 98 % patients intubated 100 % patients oxygenated

Oxygenation Maintenance SFAR 2006 ANTICIPATED DIFFICULT INTUBATION Strategic Options 2006 DMV prediction Oxygenation Maintenance ( LMA or ILMA usable ? Invasive tracheal approach ? ) Choice of the anesthestic technique : apnea or spontaneaous ventilation ?

Spontaneous Ventilation SFAR 2006 Anticipated support SFAR 2006 INTUBATION Mask ventilation efficient 2006 Spontaneous Ventilation Apnea possible FAILURE Laryngoscopy 2 trials – Gum elastic bougie FAILURE ILMA LMA <30 kg Videoloaryngoscope FIBERSCOPE Recovery Recovery FAILURE Recovery Tracheal access If impossible Intubation Intubation Intubation ± fiberscope

OXYGENATION ILMA Others intubation techniques Mask ventilation and/or intubation failures = SUPPORT IN ANY CASES 2006 Intubation ILMA LMA <30 kg Recovery FAILURE Contre Indication Transtracheal O2 Success Failure Others intubation techniques CRICOTHYROIDOTOMY TRACHEOTOMY FAILURE Recovery Recovery Intubation

UNANTICIPATED DIFFICULT INTUBATION OXYGENATION ALGORITHM = SUPPORT and DI trolley and Anesthesia maintenance +++ SFAR 2006 UNANTICIPATED DIFFICULT INTUBATION 2006 Mask Ventilation inefficient efficient Laryngoscopy 2 trials - Gum elastic bougie ILMA LMA <30 kg Failure Videoloaryngoscope Ventilation ILMA efficient inefficient INTUBATION ALGORITHM OXYGENATION ALGORITHM Intubation

ASA DIFFICULT AIRWAY ALGORITHM Anesthesiology 1993 / 2003 / Consider attempt LMA

ASA DIFFICULT AIRWAY ALGORITHM Anesthesiology 2013 Videolaryngoscopes added

Algorithm Basic Rules At each step : consider awaken patient option Never go a “bridge too far”, never try the “last” option Algorithm fitting with the patient case, local means and operator abilities Logistics (material, human resources and task organization) are mandatory

Strategy to manage a difficult airway : what remains !!! Algorithm (ASA /SFAR) : Mask ventilation adequate or not ? Intubation algorithm or oxygenation algorithm The good question The good option

Basic airway management Preoxygenation, SpO2 monitoring Chin lift and Jaw thrust Oral / nasopharyngeal airway devices Limited tracheal intubation attempts (<3)

Conclusion DMV prediction is mandatory (SFAR guidelines for ex), and the patient should be informed about the risk and the solutions to decrease it The main goal of airway management is patient oxygenation and not necessary endotracheal intubation A strategy (including DMV prediction and anesthesia techniques) arising from guidelines and algorithms is always the first step in a difficult airway management

DI Oxygenation maintenance DMV

http://www.sfar.org/cexpintubdifficile.html