Download presentation
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
Similar presentations
© 2025 SlidePlayer.com. Inc.
All rights reserved.