2. Airway Management Mehdi Khosravi, MD Pulmonary/CCM Fellow Giuditta Angelini, MD Assistant Professor Jonathan T. Ketzler, MD Associate Professor Douglas B. Coursin, MD Professor Departments of Anesthesiology & Medicine University of Wisconsin, Madison

3. Slide 3 Global Assessment Assess underlying need for airway control –Duration of intubation –Permanent support –Temporary support

4. Slide 4 Global Assessment Pathophysiology of the respiratory failure –Hypoxic respiratory failure –Hypercapnic respiratory failure Assessment Code status should be clarified prior to proceeding.

5. Slide 5 Global Assessment Oxygenation –Respiratory rate and use of accessory muscles –Amount of supplemental oxygen –Pulse oximeter or arterial blood gas

6. Slide 6 Global Assessment Airway –Anatomy –Patency –Airway device in place

7. Slide 7 Oxygen Delivery Devices (In order of degree of support) Nasal Cannula Face tent Ventimask Nonrebreather mask

8. Slide 8 Oxygen Delivery Devices Noninvasive Positive Pressure CPAP is a continuous positive pressure BiPAP allows for an inspiratory and expiratory pressure to support and improve spontaneous ventilation

9. Slide 9 Oxygen Delivery Devices Noninvasive Positive Pressure Consider when to intubation Patient status Device considerations: –Some devices allow respiratory rate to be set. –Up to 10 L of oxygen can be delivered into the mask for 100% oxygen delivery. –Nasal or oral (full face) mask can be used; less aspiration potential with nasal.

10. Slide 10 Degree of Respiratory Distress Respiratory pattern Need for artificial airway Pulse oximetry Arterial blood gas

11. Slide 11 Temporizing Measures Naloxone for narcotic overdose –40 mcg every minute up to 200 mcg –0.4 - 2 mg of naloxone is indicated in patients with respiratory arrest and history suggestive of narcotic overdose –Caution in patients with history of narcotic dependence –Naloxone drip can be titrated starting at half the bolus dose used to obtain an effect

12. Slide 12 Temporizing Measures Flumazenil for benzodiazepine overdose Artificial airway for upper airway obstruction in patients with oversedation 100% oxygen and maintenance of spontaneous ventilation in patients with pneumothorax

13. Slide 13 Oral/Nasal Airways

14. Slide 14 Indications for Intubation Depressed mental status –Head trauma patients with GCS 8 or less is an indication for intubation –Drug overdose patients may require 24 - 48 hours airway control. Upper airway edema –Inhalation injuries –Ludwig’s angina –Epiglottitis

15. Slide 15 Underlying Lung Disease Chronic obstructive lung disease Pulmonary embolus Restrictive lung disease

16. Slide 16 Airway Anatomy - Difficult Intubation Length of upper incisors and overriding maxillary teeth Interincisor distance < 3 cm Thyromental distance < 7 cm Neck extension < 35 degrees Sternomental distance < 12.5 cm Narrow palate (less than three finger breaths) Mallampati score class III or IV Stiff joint syndrome Erden V, et al. Brit J Anesth. 2003;91:159-160. Prayer Sign

17. Slide 17 Mallampati Score Class I: Uvula/tonsillar pillars visible Class II:Tip of the uvula / pillars hidden by tongue Class III:Only soft palate visible Class IV: Only hard palate visible Den Herder, et al. Laryngoscope. 2005: 115(4): 735-739

18. Slide 18 Comorbidities Potential for aspiration requires rapid sequence intubation with cricoid pressure Potential for hypotension Organ failure

19. Slide 19 Induction Agents Sodium Thiopental –3 - 5 mg/kg IV Etomidate –0.1 - 0.3 mg/kg IV Propofol –2 - 3 mg/kg IV Ketamine –1 - 4 mg/kg IV, 5 - 10 mg/kg IM

20. Slide 20 Neuromuscular Blockers Succinylcholine –1 - 2 mg/kg IV, 4 mg/kg IM Rocuronium –0.6 - 1.2 mg/kg Vecuronium –0.1 mg/kg Cisatricurium –0.2 mg/kg

21. Slide 21 Rapid Sequence Intubation Preoxygenate for three to five minutes prior to induction Crycoid pressure should be applied from prior to induction until confirmation of appropriate placement. Succinylcholine 1 - 2 mg/kg Rocuronium 1.2 mg/kg Avoid mask ventilation after induction.

22. Slide 22 Y BAG PEOPLE (Reference #6)

23. Slide 23 Cricoid Pressure Cricoid is circumferential cartilage Pressure obstructs esophagus to prevent escape of gastric contents Maintains airway patency Koziol C, et al. AORN. 2000;72(6):1018-1030.

24. Slide 24 Sniffing Position Align oral, pharyngeal, and laryngeal axes to bring epiglottis and vocal cords into view. Hirsch N, et al. Anesthesiology. 2000;93(5):1366.

25. Slide 25 Mask Ventilation Mask ventilation crucial in patients who are difficult to intubate

26. Slide 26 Laryngoscope Blades and Endotracheal Tubes Miller blade: End of blade should be under epiglottis Mac blade: End of blade should be placed in front of epiglottis in valecula ETT for Fastrach LMA Pediatric uncuffed ETT ETT for blind nasal Standard ETT

27. Slide 27 Graded Views on Intubation Grade 1: Full glottis visible Grade 2: Only posterior commissure Grade 3: Only epiglottis Grade 4: No glottis structures are visible Yarnamoto K, et al. Anesthesiology. 1997;86(2):316.

28. Slide 28 Confirmation of Placement Direct visualization Humidity fogging the endotracheal tube End tidal CO2 which is maintained after > 5 breaths Refill in 5 seconds Symmetrical chest wall movement Bilateral breath sounds Maintenance of oxygenation by pulse oximetry Absence of epigastric auscultation during ventilation

29. Slide 29 Additional Considerations Additional personnel and an experienced provider as backup Suction available No a muscle relaxant if difficult mask ventilation is demonstrated or expected Awake intubation should be considered

30. Slide 30 American Society of Anesthesiologists www.asahq.org

31. Slide 31 Alternative Methods Blind nasal intubation Eschmann stylet Fiber optic bronchoscopic intubation Laryngeal mask airway Light wand Retrograde intubation Surgical tracheostomy Combitube

32. Slide 32 Eschman Stylet Use if Grade III view achieved Perform direct laryngoscopy Place Eschman where trachea is anticipated Feel tracheal rings against stiffness of stylet Thread 7.0 or 7.5 ETT over stylet with laryngoscope in place

33. Slide 33 Fiberoptic Scope Fiberoptic Scope is used For bronchoscopy To thread an endotracheal tube into the trachea Via laryngeal mask airway in place

34. Slide 34 The Laryngeal Mask Airway (LMA)

35. Slide 35 LMA Placement LMA Placement: Guide along the palate Position underneath the epiglottis, in front of the tracheal opening, with the tip in the esophagus FOB placement through LMA positions in front of trachea Martin S, et al. J Trauma Injury, Infection Crit Care. 1999;47(2):352-357.

36. Slide 36 The FastrachTM Laryngeal Mask Airway Reinforced LMA allows for passage of ETT without visualization of trachea. 10% failure rate in experienced hands 20% failure rate in inexperienced

37. Slide 37 The Light Wand Light wand: Transillumination of trachea Minimal complication Contraindications: tumors, trauma, or foreign bodies of upper airway

38. Slide 38 Retrograde Intubation Puncture of the cricothyroid membrane with retrograde passage of a wire to the trachea Endotracheal tube guided endoscopically over the wire through the trachea Wesler N, et al. Acta Anaes Scan. 2004;48(4):412-416.

39. Slide 39 Combitube Use: Emergency airway Confirmation of Ventilation: blind blue tube white (clear) tube with patent distal end

40. Slide 40 Combitube Prevent airway edema/trauma: Changed to endotracheal tube (ETT) or tracheostomy Problems: Located in esophagus Failed exchange attempt

41. Slide 41 Tracheostomy Surgical airway through the cervical trachea Risks Caution Sharpe M, et al. Laryngoscope. 2003;113(3):530-536.

42. Case Studies The following are case studies / review questions that can be used for review of this presentation Cases Studies Skip All Review Questions

43. Slide 43 Case Scenario #1 The patient is 70 kg with a 20-year history of diabetes. On exam, the patient has intercisor distance of 4 cm, thyromental distance is 8 cm, neck extension is 45 degrees, and mallampati score is 1. Your staff wants to use thiopental and pancuronium. Do you have any further questions for this patient or would you proceed with your staff?

44. Slide 44 Case Scenario #1 - Answer A diabetic for 20 years needs assessment for stiff joint syndrome. You should have the patient demonstrate the prayer sign. If the patient is unable to oppose their fingers, you should not give pancuronium. You may want to proceed with an LMA and FOB at your disposal. If the patient has a history of gastroparesis, you may want to consider an awake FOB.

45. Slide 45 Case Scenario #2 43-year-old patient with HIV, likely PCP pneumonia who had been prophylaxed with dapsone RR is 38, oxygen saturation is 90% on 100% NRB mask The patient is on his way to get a CT scan. Is it appropriate to proceed without intubation?

46. Slide 46 Case Scenario #2 - Answer Dapsone will produce some degree of methemoglobinemia. Therefore, some degree of desaturation may not be overcome. The patient is in significant respiratory distress and will be confined in an area without easy access. Intubation should be considered as an extra measure of safety, especially as this patient is likely to get worse.

47. Slide 47 Case Scenario #3 40-year-old, 182-kg man has a history of sleep apnea and systolic ejection fraction of 25%. He has a Strep pneumonia in his left lower lobe and progressive respiratory insufficiency. He extends his neck to 50 degrees and has a mallampati score of 2. Would you proceed with an awake FOB?

48. Slide 48 Case Scenario #3 - Answer The patient’s airway anatomy is not suggestive of difficulty. However, with supine position, subcutaneous tissue may impair your ability to visualize or ventilate. Use of gravity, including a shoulder roll, extreme sniffing position, and reverse trendelenburg may be helpful with asleep DL. Prudent to have some accessory equipment, including an LMA and FOB, for back up

49. Review Questions The following are case studies / review questions that can be used for review of this presentation Cases Studies Skip Review Questions

51. Slide 51 References Caplan RA, et al. Practice guidelines for management of the difficult airway. Anesthesiology. 1993;78:597-602. Langeron O, et al. Predictors of difficult mask ventilation. Anesthesiology. 2000;92:1229-36. Frerk CM, et al. Predicting difficult intubation. Anaesthesia. 1991;46:1005-08. Tse JC, et al. Predicting difficult endotracheal intubation in surgical patients scheduled for general anesthesia. Anesthesia & Analgesia. 1995;81:254-8. Benumof JL, et al. LMA and the ASA difficult airway algorithm. Anesthesiology. 1996;84:686-99. Reynolds S, Heffner J. Airway management of the critically ill patient. Chest. 2005;127:1397-1412.