1. DIFFICULT AIRWAY MANAGEMENT
Dr.Gayathri Ramanathan
Associate Professor
SRM MEDICAL COLLEGE HOSPITAL & RESEARCHCENTRE
4/20/2017

2. OBJECTIVES Causes of difficult intubation Basic airway evaluation
Management plan for Anticipated difficult airway – Plan A, Plan B , Plan C & Plan D
Gallery of tools
The Expected & Unexpected Difficult Airway
4/20/2017

3. DEFINITION American society of Anesthesiologist (ASA) suggested
(difficult to ventilate)
That when sign of inadequate ventilation could not be reversed by mask ventilation or
oxygen saturation could not be maintained above 90%

4. DEFINITION (difficult to intubate)
If a trained Anaesthetist using conventional laryngoscope takes more than 3 attempts or
more than 10 minute to complete tracheal intubation

5. EVEN WITH PROPER EVALUATION !
15- 50%
ARE ONLY PICKED UP

6. DIFFICULT MASK VENTILATION
1 in 10,000
15%
DIFFICULT INTUBATION

7. EXTREMELY DIFFICULT
ABANDON
GS – 1 in 2000
OBG- 1 in 300

8. CAUSES OF DIFFICULT INTUBATION
Pre-op assessment
Equipments
Anesthetist
Experience not enough
Poor technique
Malfunctioning equipment
Inexperienced assistance

9. CAUSES OF DIFFICULT INTUBATION
Patient
Congenital causes
Acquired causes

10. Basic airway evaluation in all patients
Dr. Binnion’s LEMON Law
BONES
The 4 D’s

11. Dr. Binnions Lemon Law: An easy way to remember multiple tests…
L ook externally.
E valuate the rule.
M allampati.
O bstruction?
N eck mobility.

12. L: Look Externally Obesity Buck teeth Short muscular neck Receding jaw
Dentures

13. L: Look Externally
Macroglossia
Stridor
Facial trauma

14. E:Evaluate the rule
3 fingers fit in mouth- Inter incisor distance
3 fingers fit from mentum
to hyoid cartilage
2 fingers fit from the floor
of the mouth to the top of
the thyroid cartilage

15. M: Mallampati classification
soft palate, fauces;
uvula, anterior and
the posterior pillars.
the soft palate, fauces
and uvula
Class-I
Class-II
soft palate and base of uvula
Class-III
Only hard palate
Class-IV

16. O: Obstruction? Blood Vomitus Teeth Epiglottis Dentures Tumors
Impacted Objects

17. N:Neck mobility -Measurement of Atlanto-Occipital Angle

18. Thyro- Mental Distance
Measure from upper edge of thyroid cartilage to chin with the head fully extended.
A short thyromental distance = an anterior larynx .
> 7 cm is usually = easy intubation
< 6 cm = difficult airway

19. MANAGEMENT PLAN OF ANTICIPATED DIFFICULT AIRWAY
4/20/2017

20. Is mask ventilation going to be difficult?
Can’t ventilate
Defined by “BONES”
Beard
Obesity
No teeth
Elderly
Snoring
Can’t ventilate

21. Is laryngeal visualization going to be difficult?
Can’t intubate
Defined by 4 D’s
Disproportion
Distortion
Dysmobility
Dentition

22. Can’t intubate Disproportion Achondroplasia Pierre robin sequence
Acromegaly
Prognathism

23. Can’t intubate Distortion Burns contracture Neurofibromatosis
Cystic hygroma

24. Dysmobility
TM joint Ankylosis
Can’t intubate
Klippel Fiel

25. Dentition
Can’t intubate
Edentulous
Buck teeth

26. Is cricothyroidotomy going to be difficult?
Can’t Rescue
Should assessment reveal a potentially difficult airway the cricothyroid membrane should be identified and marked, BEFORE an intervention is undertaken

27. Possible Options!
Following airway assessment, the person performing the intubation should be in a position to decide between three possible options
Awake intubation
Quick look
Induction and paralysis

28. The patient needs to be intubated awake
1. Awake Intubation
The patient needs to be intubated awake
There is significant risk of complications if sedatives and/or muscle relaxants are administered prior to airway control.

29. 2. Quick Look
The patient may be sedated for an attempt at direct laryngoscopy WITHOUT muscle relaxation
(“Quick Look”)
There is some risk of failed laryngoscopy
but
There should be a low risk of failed mask ventilation.

30. The patient may be induced and paralyzed,
3. Induction & Paralysis
The patient may be induced and paralyzed,
In this case the patient is assessed as having a low risk of laryngoscopy and/or mask ventilation

31. Pre-oxygenation: How Much Is Enough?
Two techniques common in use:
Tidal volume breathing (TVB) of oxygen for 3–5 min
Deep breaths (DB) 4 times within 0.5 min
Both are equally effective in increasing arterial oxygen tension (Pao2).
Anesth Analg 1981; 60: 313–5

32. Each subject received 5 mg/kg thiopental and 1 mg/kg succinylcholine.
Pre-oxygenation
Spontaneous recovery from succinylcholine-induced apnea may not occur sufficiently quickly to prevent hemoglobin desaturation in subjects whose ventilation is not assisted.
Each subject received 5 mg/kg thiopental and 1 mg/kg succinylcholine.
Anesthesiology 2001, 95:

33. What are we going to do if we don’t get the Tube?
Plans “A”, “B” ,“C” and plan “D”.
Know this answer before you tube.

35. Failure -Why does it happens?
No critical discussion with colleagues about proposed management plan
No request for experienced help
Exaggerated idea of personal ability
Ill-conceived plan A and/or plan B
Poorly executed plan A and/or plan B
Persisting with plan A too long, starting the rescue plan too late
Not involving, and preparing, surgical colleagues

36. GALLERY OF TOOLS ILMA Video laryngoscopes
Malleable video stillet- Levitan scope
Fibreoptic bronchoscope

40. ANTICIPATED DIFFICULT AIRWAY ELECTIVE EMERGENCY

41. ANTICIPATED DIFFICULT AIRWAY
ELECTIVE EMERGENCY

42. ELECTIVE
Old case of Hemi-mandibulectomy with forehead flap with trismus for block dissection of neck nodes

43. Anesthesia of choice - G.A.
Intubating technique of choice ?

45. MANAGEMENT PLAN OF UNANTICIPATED DIFFICULT AIRWAY
4/20/2017

46. TheUnexpected DifficultAirway
Experienced help may not be immediately available
Special equipment may not be immediately available
A general anaesthetic has usually been administered
A long acting relaxant may have been given
Backup airway management plans may be poorly thought out

47. Take home message
Be familiar with the alternative methods of intubating technique and use it regularly in your day today practice e.g. ILMA, FOB, Videolaryngoscopes, cricothyroidotomy…………….
So that you won’t fumble at the time of crisis
4/20/2017

48. Challenges may be Waiting for you
GOOD LUCK
Challenges may be Waiting for you
4/20/2017

49. The whole world is made up of mistakes and people Forgive the mistakes and love the people
Thank you