1. Lecture Title: Lecture Title: Airway Evaluation and Management Lecturer name: Dr. Massoun Taha Jasser Lecture Date: 17 /10 / 2014

2. Lecture Objectives.. Students at the end of the lecture will be able to: 1.Learn about basic airway anatomy 2.Conduct a preoperative airway assessment 3.Identify a potentially difficult airway 4.Understand the issues around aspiration and its prevention 5.Learn about the management of airway obstruction 6.Become familiar with airway equipment 7.Practice airway management skills including bag and mask ventilation, laryngeal mask insertion, endotracheal intubation 8.Learn about controlled ventilation and become familiar with ventilatory parameters 9.Appreciate the different ways of monitoring oxygenation and ventilation

3. Indications of intubation Resuscitation (CPR) Prevention of lung soiling Positive pressure ventilation (GA) Pulmonary toilet Patent airway (coma or near coma) Respiratory failure(CO2 retention )

4. Requirement of successful intbatin 1-Normal roomy mandible 2-Normal T-M, A-O, and C-spine

6. Requirements of successful intubation 3-Alignment of 3 axes or Assuming sniffing position -Any anomaly in these 3 joints A-O, T-M or C-spine can result In difficult intubation

7. Airway Evaluation  Take very seriously history of prior difficulty  Head and neck movement (extension) ◦ Alignment of oral, pharyngeal, laryngeal axes ◦ Cervical spine arthritis or trauma, burn, radiation, tumor, infection, scleroderma, short and thick neck

8. Airway Evaluation Jaw Movement – Both inter-incisor gap and anterior subluxation – <3.5cm inter-incisor gap concerning – Inability to sublux lower incisors beyond upper incisors Receding mandible Protruding Maxillary Incisors (buck teeth)

9. Thyromental Distance Have the patient extend their head fully. Measure from the mentum (chin) to the thyroid notch. Over 7 cm (around 3 fingerbreadths) is associated with easier intubation. Less than 6cm may mean a difficult airway because you would assume the patient has an anterior larynx and less space for the tongue to be compressed out of the way by the laryngoscopy blade

11. Airway gadgets

12. Requirement of successful intubation Proper equipment -Bag and mask,oxygen source -Airways oro and nasopharyngeal -Laryngosopes different blades -ETT different sizes -suction on

13. Management I-History: previous history of difficulty is the best predictor Inquire about:-Nature of difficulty -No of trials -Ability to ventilate bet trials -Maneuver used -Complications II-Snoring and sleep apnea( prdictors of DMV)

14. Examination -Look for any obvious anomaly  Morbid obesity(BMI)  Skull  Face  Jaw  Mouth,teeth  Neck

15. Examination I-The 3 joints movements  A-O joint(15-20 degrees) Presence of a gap bet the Occiput and C1 is essential  The cervical spine(range>90)  T.M joint:-interdental gap(3 fingers)  -subluxation (1 finger)

16. Examination II-Measurements of the mandible -Thyro-mental distance (head extended) Normally 6.5 cm Less than 6 cm=expect difficulty

17. Tests to predict difficulty Mallampatti test: Based on the hypothesis That when the base of the Tongue is disproportionally Large it will overshadow the larynx

19. MP Class I- Soft palate, tonsillar fauces, tonsillar pillars, and uvula MP Class II- Soft palate, tonsillar fauces, partial uvula MP Class III- Soft palate, base of uvula MP Class IV- Hard palate only MP III and MP IV are associated with greater likelihood of a difficult airway.

20. -Simple easy test,correlates with what is seen during laryngoscopy or Cormack-Lehene grades,but 1-moderate sensitivity and specificity(12% false +ve) 2-Inter observer variation 3-Phonation increases false negative view

22. II-Wilson test -Consists of 5 easily assessed factors  Body wight(n=0,>90=1,>110=2)  Head and neck movement  Jaw movement  Receding jaw  Buck teeth Each factor assigned as o,1,2 max is 10

23. Teeth Buck teeth and large incisors can interfere with blade placement. Loose teeth, loose crowns, cracked teeth, and chipped teeth must be documented beforehand. Ask if your patient has dentures, partials, or any other type of dental appliance that can be removed

24. Cervical Mobility Ask the patient to turn her head from side to side, and up and down. Some patients cannot be placed in the “sniffing position” secondary to neck trauma, cervical collar, musculoskeletal disorders like kyphosis and rheumatoid arthritis. This prevents to place the patients head in the appropriate alignment that would allow for the best visualization of the airway.

25. Neck Circumference & Body Mass Index (BMI) A neck circumference of greater than 45cm in an obese patient with a BMI of greater than 40kg/m^2 is likely to be a difficult intubation. women with large pendulous breasts add a degree of difficulty to an intubation because the provider may not be able to position the blade handle appropriately toward the chest.

26. Facial Hair facial hair can mask other signs of a difficult airway- like short thyromental distance. This is why you need to physically touch your patient’s neck when determining thyromental distance

27. Assess airway L- Look externally (facial trauma, teeth, facial hair, etc.) E- Evaluate thyromental distance M- Mallampati Class O- Obstruction (airway edema, tracheal mass, mediastinal mass, etc.) N- Neck mobility

31. Difficult airway Expected from history,examination Secure airway while awake under LA  Unexpected different options Priority for maintenance of patent airway and oxygenation

32. Airway gadgets

34. predictors of difficult mask ventilation

35. Beard Obese Old Age Toothless Snores

36. Needle cricothyroidotomy

37. Confirm tube position Direct visualization of ETT between cords Bronchoscopy ;carina seen Continuous trace of capnography 3 point auscultation Esophageal detector device Other as bilateral chest movement,mist in the tube,CXR

38. Rapid sequence induction Indications: – Full stomach, cesarean section. Acute abdomine – Gastric band --- Technique: -Preoxygenation -IV induction with sux -Cricoid pressure -Intubate, inflate the cuff,confirm position -Release cricoid and fix the tube

39. Complications of intubation 1-Inadequate ventilation 2-Esophageal intubation 3-Airway obstruction 4-Bronchospasm 5-Aspiration 6- Trauma 7-Stress response

40. Recommendations Adequate airway assessment to pick up expected D.A to be secured awake Difficult intubation cart always ready Pre oxygenation as a routine Maintenance of oxygenation not the intubation should be your aim Use the technique you are familiar with Always have plan B,C,D in unexpected D.A

49. Thank you