1. Airway Endoscopy and Laser Anesthetic considerations Dr. Abdul-Hamid Samarkandi, FFARCSI,KSUF Chairman Anaesthesia Department King Saud University Hospitals King Khalid University Hospital

2. Objectives: 1- Airway assessment and patient examination. 2- Mapping a plane for the perioperative sequlae. 3- Requirements for save endoscopy. 4- Selection for reasonable anesthetic technique. 5- Intraoperative challenges. 6- Postoperative recommendations. 7- Considerations for Laser surgery.

3. 1- Airway assessment and patient examination. Must be able to assess or anticipate the degree of difficulty Must be able to assess or anticipate the degree of difficulty Then select method most likely to succeed. Then select method most likely to succeed. Clinical Airway Assessment Clinical Airway Assessment Airway examination: Airway examination: - Indirect laryngoscope. - Indirect laryngoscope. Radiographic studies Radiographic studies Lung reserves: flow-volume loop. Lung reserves: flow-volume loop. Reserving ICU bed for postop.respiratory care. Reserving ICU bed for postop.respiratory care. * Discusse the perioperative plan with the surgeon * Discusse the perioperative plan with the surgeon

4. Historical features ( prior AW difficulty): Historical features ( prior AW difficulty): –Anesthesia record in old chart. –Medical alert bracelet. – Tracheostomy scar. Anatomical features: Anatomical features: – C-spine mobility – C-spine mobility – External dimensions ( 3-3-2 rule) – External dimensions ( 3-3-2 rule) * Mouth opening 3 fingers (TMJ). * Mouth opening 3 fingers (TMJ). * Mandible large enough to accommodate tongue. * Mandible large enough to accommodate tongue. * 3 fingers from tip of chin to hyoid. * 3 fingers from tip of chin to hyoid. – Length of neck/position of larynx - 2 fingers between top of thyroid and floor of jaw –

5. Teeth Teeth –large or protruding incisors obstruct vision –jagged teeth can lacerate balloon Oral dimensions Oral dimensions –narrow facial features and high arched palates (decreased lateral space) –Mallampatti classification

6. Mallampatti Classification (Tongue to Pharyngeal Size) I - soft palate, uvula, tonsillar pillars visible I - soft palate, uvula, tonsillar pillars visible –99 % have grade I laryngoscopic view. II - soft palate, uvula visible. II - soft palate, uvula visible. III - soft palate, base of uvula. III - soft palate, base of uvula. IV - soft palate not visible IV - soft palate not visible –100% grade III or grade IV laryngoscopic views.

7. Mallampatti Classification

8. Predictors of Difficult Laryngoscopy Direct laryngoscopy intubation is difficult in 1% - 4% and impossible in 0.05% - 0.35% of patients who have seemingly normal airways. Direct laryngoscopy intubation is difficult in 1% - 4% and impossible in 0.05% - 0.35% of patients who have seemingly normal airways. The unanticipated difficult laryngoscopy intubation places patients at increased risk of complications ranging from sore throat to serious airway trauma. The unanticipated difficult laryngoscopy intubation places patients at increased risk of complications ranging from sore throat to serious airway trauma. Moreover, in some cases we may not be able to maintain a patent airway, leading to severe complications such as brain damage or death. Moreover, in some cases we may not be able to maintain a patent airway, leading to severe complications such as brain damage or death.

9. Predictors of Difficult Laryngoscopy Short, thick, muscular neck. Short, thick, muscular neck. Receding mandible. Receding mandible. Protruding maxillary incisors Protruding maxillary incisors –“Buck teeth” Poor TMJ mobility/ limited jaw opening Poor TMJ mobility/ limited jaw opening Limited head and neck movement Limited head and neck movement –( including trauma ) High, arched palate High, arched palate

10. Predictors of Difficult Laryngoscopy Tumor, abscess or hematoma Tumor, abscess or hematoma Burns Burns Angioneurotic edema Angioneurotic edema Blunt or penetrating trauma Blunt or penetrating trauma Rheumatoid arthritis, ankylosing spondylitis Rheumatoid arthritis, ankylosing spondylitis Congenital syndromes Congenital syndromes Neck surgery or radiation Neck surgery or radiation

11. Response to Unanticipated Difficulty Difficult laryngoscopy and intubation Difficult laryngoscopy and intubation –Can’t intubate but Can ventilate –Can’t intubate and Can’t ventilate Difficult Mask Ventilation Difficult Mask Ventilation

12. Response to Unanticipated Difficulty Bag the patient. Bag the patient. Maximize neck flex/ head extension. Maximize neck flex/ head extension. Move tongue out of line of site. Move tongue out of line of site. Maximize mouth opening. Maximize mouth opening. ID landmarks and adjust blade. ID landmarks and adjust blade. BURP maneuver BURP maneuver –(Backwards Upwards Rightwards Pressure on Thyroid Cartilage) Increasing lifting force. Increasing lifting force. Consider Miller blade. Consider Miller blade. Bag the patient. Bag the patient.

13. Response to Unanticipated Difficulty An optimal or best attempt at difficult laryngoscopy should consist of : An optimal or best attempt at difficult laryngoscopy should consist of : –use of optimal sniffing position –no significant muscle tone –use of optimum external laryngeal manipulation (BURP) –one change in length of blade –one change in type of blade –a reasonably experienced laryngoscopist

14. Response to Unanticipated Difficulty Remember, the first response to failure to intubate should always be to Bag-Mask- Ventilate the patient. Remember, the first response to failure to intubate should always be to Bag-Mask- Ventilate the patient. The first response to failure of bag-mask- ventilation is always better bag-mask- ventilation The first response to failure of bag-mask- ventilation is always better bag-mask- ventilation

15. Algorithm for Difficulty “Bagging” Remove FB - Magill forceps. Remove FB - Magill forceps. Triple maneuver if c-spine clear Triple maneuver if c-spine clear – Head tilt, jaw lift, mouth opening Nasal (NP) or oropharyngeal (OP) airways. Nasal (NP) or oropharyngeal (OP) airways. two-person, four-hand technique. two-person, four-hand technique. Generate as much positive pressure as possible without inflating the stomach Generate as much positive pressure as possible without inflating the stomach Do not abandon bagging unless it is impossible with two people and both an OP and NP airway

16. The Failed Intubation: Definition Three failed attempts to intubate Three failed attempts to intubate –by an experienced anesthetist. Inability to ventilate with BMV Inability to ventilate with BMV (Bag-Mask-Ventilation) (Bag-Mask-Ventilation) Inability to oxygenate Inability to oxygenate

17. The Failed Intubation If can’t intubate but can ventilate with BMV have time to consider options If can’t intubate but can ventilate with BMV have time to consider options –Light guided technique (Lighted stylet) –Combitube –LMA –Fiberoptic techniques –Retrograde intubation –Cricothyrotomy

18. Awake Oral Intubation Prepare patient psychologically Prepare patient psychologically Pre-oxygenate Pre-oxygenate Topical anesthesia if time permits Topical anesthesia if time permits Titrated sedation - avoid obtundation Titrated sedation - avoid obtundation Reassure patient throughout procedure Reassure patient throughout procedure

19. Difficult Airway Kit Multiple blades and ETTsMultiple blades and ETTs ETT guides (stylets, bougé, light wand)ETT guides (stylets, bougé, light wand) Emergency nonsurgical ventilation ( LMA, Combitube, TTJV )Emergency nonsurgical ventilation ( LMA, Combitube, TTJV ) Emergency surgical airway access ( cricothyroidotomy kit, cricotomes )Emergency surgical airway access ( cricothyroidotomy kit, cricotomes ) ETT placement verificationETT placement verification Fiberoptic and retrograde intubationFiberoptic and retrograde intubation

20. The Failed Intubation If can’t intubate, can’t ventilate, must act immediately If can’t intubate, can’t ventilate, must act immediately –Cricothyrotomy –Urgent Tracheotomy –Percutaneous Transtracheal Jet Ventilation –Combitube –LMA The last three are temporizing measures and not definitive airway management

21. Awake Oral Intubation Consider for anticipated can’t intubate, can’t ventilate situation Consider for anticipated can’t intubate, can’t ventilate situation distorted upper airway anatomy distorted upper airway anatomy (i.e., penetrating neck trauma) (i.e., penetrating neck trauma) Avoids ‘burning bridges” Avoids ‘burning bridges” maintains ventilation maintains ventilation maintains patient’s ability to protect airway maintains patient’s ability to protect airway May use to take quick look to assure that you can see enough for RSI May use to take quick look to assure that you can see enough for RSI

22. Difficult Airway Maxims “It is preferable to use superior judgment -- to avoid having to use superior skill”. “It is preferable to use superior judgment -- to avoid having to use superior skill”.

23. Difficult airway due to upper airway pathology Plan for tracheostomy before going to surgery (under LA)  Plan for tracheostomy before going to surgery (under LA)  Awake fibroptic laryngoscope,either nasal or oral  Awake fibroptic laryngoscope,either nasal or oral 

24. Anesthetic management of operative endoscopies Anesthetic management of operative endoscopies

25. Preoperative preparation Psychological preparation of patients and /or his relatives. Psychological preparation of patients and /or his relatives. Arrangement for ICU bed. Arrangement for ICU bed. Consent for tracheostomy. Consent for tracheostomy.

26. Avoid sedation. Avoid sedation. Anti-sialagouge : Glycopyrrolate IV or IM Anti-sialagouge : Glycopyrrolate IV or IM (Quaternary ammonium compound) (Quaternary ammonium compound) Atropine, Scopolamine Atropine, Scopolamine (Tertiary ammonium compounds) (Tertiary ammonium compounds)  Nebulizing racemic epinephrine  Nebulizing racemic epinephrine  Nebulizing bronchodilators.  Nebulizing bronchodilators.  Intravenous corticosteroid.  Intravenous corticosteroid.

27. Intraoperative considerations 1- Maintaining surgical anesthesia levels: - Continuous infusion of short acting anesthetics (TIVA) : - Continuous infusion of short acting anesthetics (TIVA) : Propofol,Alfentanil,Remifentanil. Propofol,Alfentanil,Remifentanil. - Supplementary volatile anesthetics. - Supplementary volatile anesthetics. - Supplementation with: - Supplementation with: *  -antagonists e.g.; Esmolol. *  -antagonists e.g.; Esmolol. *  -agonist e.g.; Dexemedotomidine. *  -agonist e.g.; Dexemedotomidine.

28. Intraoperative considerations 2-The use of muscle relaxants: * Continues infusion of * Continues infusion of SUX.or Intermittent boluses of short and intermediate durations relaxants. SUX.or Intermittent boluses of short and intermediate durations relaxants. VS VS * TIVA plus volatile anesthetics * TIVA plus volatile anesthetics

29. 3-Methods of ventilation 1- Conventional ETT anesthesia using size 4.0-6.0 micro-laryngeal tube. using size 4.0-6.0 micro-laryngeal tube. 2- Insufflation's ventilation with high flows of oxygen through a small catheter placed in the trachea. with high flows of oxygen through a small catheter placed in the trachea. better with spontaneously breathing patients. better with spontaneously breathing patients.

30. 3- Intermittent apnea technique : Periods of controlled ventilation via face mask or ETT alternated with periods of apnea. Periods of controlled ventilation via face mask or ETT alternated with periods of apnea. 4- Manual Jet Ventilation : The jet injector is connected to a high pressure source of oxygen and to the side port of the laryngoscope. The jet injector is connected to a high pressure source of oxygen and to the side port of the laryngoscope. It ventilate the lungs during inspiration and allow period for passive expiration. It ventilate the lungs during inspiration and allow period for passive expiration.

31. 5-High -Frequency Jet Ventilation: Utilizes a tube in the trachea to inject small volume of gas at a rate of 80-300 times/min. Utilizes a tube in the trachea to inject small volume of gas at a rate of 80-300 times/min. Manual intermediate- frequency jet ventilation: Manual intermediate- frequency jet ventilation: Use small bag (0.5 l) for delivering small volume high rate, jet like ventilation (60- 150). Use small bag (0.5 l) for delivering small volume high rate, jet like ventilation (60- 150).

32. Uneventful course during endoscopy Difficulty to maintain ventilations. Difficulty to maintain ventilations. - As a complications during airway surgery: - As a complications during airway surgery: - Laryngeal stenosis (edema, bleeding) - Laryngeal stenosis (edema, bleeding) - Laser surgery ( fire, small size ETT) - Laser surgery ( fire, small size ETT) - As a complications after airway surgery. - As a complications after airway surgery. - Bleeding, edema. - Bleeding, edema. - Pneumothorax. - Pneumothorax. Intractable bronchospasm. Intractable bronchospasm.

35. Endoscopy under local anesthesia 1-Rigid bronchoscope: - As rigid bronchoscopy requires straight line between object and operator for visualization. - It always done under GA. - As rigid bronchoscopy requires straight line between object and operator for visualization. - It always done under GA.

36. Endoscopy under local anesthesia 2- Fiberoptic Bronchoscope - It Does not require straight line for image visualization. - It Does not require straight line for image visualization. - It could be done under LA: - It could be done under LA: I. Topical Application of LA I. Topical Application of LA II. Nerve block II. Nerve block III. Nebulization of LA III. Nebulization of LA

37. I. Topical Application of LA Step 1: Prepare the nose with vasoconstrictor Step 1: Prepare the nose with vasoconstrictor and ribbon gauze soaked with LA. and ribbon gauze soaked with LA. Step 2: Apply LA to the base of the Step 2: Apply LA to the base of the tongue, posterior pharyngeal wall tongue, posterior pharyngeal wall anterior tonsillar pillars & tonsils anterior tonsillar pillars & tonsils Step 3: With the help of tongue depressor apply LA to side walls of pharynx apply LA to side walls of pharynx and each pyriform fossa and each pyriform fossa Step 4: Do Laryngoscopy and apply LA to Vallecullae,epiglottis and keep soaked gauze Vallecullae,epiglottis and keep soaked gauze to each pyriform fossa for 30 seconds to to each pyriform fossa for 30 seconds to block superior laryngeal nerve block superior laryngeal nerve Step 5: SAYGO (Spray As You GO) to lower airway

38. II. Nerve block 1- Glossopharyngeal nerve block Inject 2 ml of Lignocaine 2% to the anterior pillar of the tonsil at site 1 cm above the lower pole of the tonsil at the depth of 8mm (on each side) Inject 2 ml of Lignocaine 2% to the anterior pillar of the tonsil at site 1 cm above the lower pole of the tonsil at the depth of 8mm (on each side)

39. II. Nerve block 2- Superior Laryngeal Nerve block Infiltrate 2ml of Lignocaine 2% into the Infiltrate 2ml of Lignocaine 2% into the thyro-hyoid membrane at site in between the greater cornu of hyoid bone and superior cornu of thyroid cartilage. thyro-hyoid membrane at site in between the greater cornu of hyoid bone and superior cornu of thyroid cartilage.

40. II. Nerve block 3- Transtracheal block : (Recurrent laryngeal nerve block) (Recurrent laryngeal nerve block) Insert 22 gauge canula into trachea through cricothyroid membrane or in between tracheal rings, remove the trocar, aspirate air for.Forcefully Inject 4 ml of Lignocaine 2% at the end of inspiration. Insert 22 gauge canula into trachea through cricothyroid membrane or in between tracheal rings, remove the trocar, aspirate air for.Forcefully Inject 4 ml of Lignocaine 2% at the end of inspiration.

42. Post-endoscopy care Oxygen by face-mask. Oxygen by face-mask. Close monitoring for homodynamic and respiratory parameters (PACU) before shifting. Close monitoring for homodynamic and respiratory parameters (PACU) before shifting. NPO for 4 - 6 hrs. NPO for 4 - 6 hrs. Good hydration ( IV fluids). Good hydration ( IV fluids). Racemic epinephrine or normal saline Nebulization. Racemic epinephrine or normal saline Nebulization. Post bronchoscopy X-Ray chest. Post bronchoscopy X-Ray chest. Non-narcotics pain killers. Non-narcotics pain killers.

43. Lidocaine added to a tracheostomy tube cuff reduces tube discomfort Tracheostomy tube cuffs were inflated with 5 ml lidocaine 4% solution and air at 20 cmH2O. Tracheostomy tube cuffs were inflated with 5 ml lidocaine 4% solution and air at 20 cmH2O. Lidocaine diffusion across the tracheostomy tube cuff reduces tube discomfort e.g.: patients undergoing oral cancer surgery Lidocaine diffusion across the tracheostomy tube cuff reduces tube discomfort e.g.: patients undergoing oral cancer surgery

44. Laser surgery and precautions Characteristics: - Monochromatic. Characteristics: - Monochromatic. - Coherent. - Coherent. - Collimated. - Collimated. Advantages: - Excellent hemostasis. Advantages: - Excellent hemostasis. - Minimal edema and pain. - Minimal edema and pain.

45. Laser Hazards: Hazards: It depends on the medium in which laser beam is generated ( wavelength). It depends on the medium in which laser beam is generated ( wavelength). CO2 Laser (10.600 nm ).is more localised,less penetrated CO2 Laser (10.600 nm ).is more localised,less penetrated YAG Laser (1.060 nm ).less absorbed by water,deep penetration YAG Laser (1.060 nm ).less absorbed by water,deep penetration

46. Laser A. Anesthetic precautions: Suction of Laser fumes. Suction of Laser fumes. Eye protection for all members inside the theatre including the patient's eye. Eye protection for all members inside the theatre including the patient's eye. Avoidance of ETT fire: Avoidance of ETT fire: - Use of inflammable ETT. - Use of inflammable ETT. e.g.; Metal, red rubber, silicon rubber e.g.; Metal, red rubber, silicon rubber - Use intermittent apnea technique or jet ventilation. - Use intermittent apnea technique or jet ventilation.

47. Laser 4-Use low inspired O2 concentration. 5-Replace N2O by air or Helium. 6-Inflate ETT cuff with mixture of lidocaine and saline( 1:2).

48. Laser B-Surgical precautions: 1- Limit the duration and intensity of the Laser beam as possible. 2-Saline soaked pledgets to be placed in the airway to limit risk of ignition. 3-A 60 ml syringe filled with water to be standby for fire control.

49. Airway-fire protocol 1- Stop ventilation, Remove ETT, Turn off O2, and disconnect the circuit from the machine. 2-Submerge the ETT in water. 3-Ventilate with Ambu bag and reintubate with regular ETT. 4-Assess the airway damage (bronchoscope, ABGs). 5- Consider steroids and bronchial lavage.

50. Thank You