1. Difficult Airways! Difficult Airways! Dr Mike Entwistle Consultant Anaesthetist, Royal Lancaster Infirmary NWTS Study Day 18/10/12

2. Difficult airways What is a difficult airway? How are they managed? Practice some airway skills

3. Definition “The clinical situation in which a conventionally trained anaesthetist experiences difficulties with facemask ventilation, tracheal intubation, or both”

4. Airway vectors

5. Laryngoscopy

6. Laryngoscopic view

7. Airway assessment Mouth opening Protruding teeth Size of tongue Presence of soft tissue masses Mandibular size Neck mobility History of previous problems

8. Mallampati score

9. In life what you see is not always what you get….

10. In paediatric airways it frequently is….

11. Difficult airways in kids Congenital Acquired Under 1 year

12. Congenital Hypoplastic mandible (micrognathia) Midface hypoplasia Large tongue (macroglossia)

13. Hypoplastic mandible Pierre Robin Treacher Collins GoldenharSyn

14. Midface hypoplasia Crouzon Syn Apert Syn

15. Large tongue Mucopolysaccharidoses Beckwith-Wiedemann Syn Downs Syn

16. Acquired Acute obstruction Chronic obstruction

17. Acute obstruction Infection – croup, epiglottitis, tracheitis Foreign body aspiration Trauma Anaphylaxis

18. Chronic obstruction Tonsillar hypertrophy Haemangioma Subglottic stenosis

19. Activity 67/932 airway related referrals

20. Difficult airway management Anticipated Unanticipated

21. Anticipated difficult airway 1 Have a plan! Phone a friend – ENT support nearby Maintain spontaneous ventilation – inhalation induction Direct layngoscopy Indirect laryngoscopy

22. Anticipated difficult airway 2 LMA with fibreoptic scope

23. Unanticipated difficult airway Difficult intubation -in healthy kids0.08% (1 in 1250) -in under ones0.24% (1 in 400) Difficult mask ventilation 0.02% (1 in 5000) Can’t intubate/can’t ventilate (CICV) -adults 1 in 5-10000 -children ?less unless obese

24. DAS/APA guidelines 2012 3 guidelines -Difficult mask ventilation -Unanticipated difficult intubation -CICV

28. Cannula cricothyroidotomy is rescue technique recommended by APLS Attempted 19 times, failed 12 times (63% failure) in adults Likely much more difficult in small children

29. Emergency surgical airway needed in 5 children 1 child died on transfer to theatre for emergency tracheostomy 4 attempted -3 emergency tracheostomies by surgeons succeeded -1 needle cric, by anaesthetist, failed

30. Cannula Cricothyroidotomy

31. Summary Many major paediatric airways difficulties are predictable Unanticipated airways difficulties can occur ENT support is invaluable if airways difficulty is predicted Needle cricothyroidotomy has a high failure rate Children with congenital abnormalities can be extremely challenging to manage