Airway ManagementAirway Management

Dr. Omar OthmanDr. Omar Othman

Emergency MedicineEmergency Medicine

OutlineOutline

OverviewOverview Normal airwayNormal airway Difficult intubationDifficult intubation Structured approach to airway Structured approach to airway

managementmanagement Causes of failed intubationCauses of failed intubation

What we knowWhat we know

Air is goodAir is good Pink is goodPink is good Blue is badBlue is bad Air goes in Air goes in Air goes outAir goes out

Overview of the AirwayOverview of the Airway

600 patients die per year from 600 patients die per year from complications related to airway complications related to airway managementmanagement

3 mechanisms of injury:3 mechanisms of injury:1.1. Esophageal intubationEsophageal intubation2.2. Failure to ventilateFailure to ventilate3.3. Difficult IntubationDifficult Intubation

98% of Difficult Intubations may be anticipated by performing a thorough evaluation of the airway in advance

Indications for IntubationIndications for Intubation

Ventilatory SupportVentilatory Support Protection of AirwayProtection of Airway Hypoxic and Hypercarbic respiratory FailureHypoxic and Hypercarbic respiratory Failure

Endotracheal Intubation Endotracheal Intubation Depends Upon Manipulation of:Depends Upon Manipulation of:

Cervical spineCervical spine Atlanto-occipital JointAtlanto-occipital Joint MandibleMandible Oral soft tissuesOral soft tissues Neck hyoid boneNeck hyoid bone

Additionally:Additionally: DentitionDentition Pathology - Acquired and Pathology - Acquired and

CongenitalCongenital

Risk Factors For Difficult Risk Factors For Difficult IntubationIntubation

El-Canouri et al. - prospective study of 10, El-Canouri et al. - prospective study of 10, 507 patients demonstrating difficult 507 patients demonstrating difficult intubation with objective airway risk criteriaintubation with objective airway risk criteria Mouth opening < 4 cmMouth opening < 4 cm Thyromental distance < 6 cmThyromental distance < 6 cm Mallampati grade 3 or greaterMallampati grade 3 or greater Neck movement < 80%Neck movement < 80% Inability to advance mandible Inability to advance mandible Body weight > 110 kg Body weight > 110 kg Positive history of difficult intubationPositive history of difficult intubation

Signs Indicative of a Difficult Signs Indicative of a Difficult IntubationIntubation

Trauma, deformity: burns, radiation therapy, infection, Trauma, deformity: burns, radiation therapy, infection, swelling, hematoma of face, mouth, larynx, neckswelling, hematoma of face, mouth, larynx, neck

Stridor or air hungerStridor or air hunger Intolerance in the supine positionIntolerance in the supine position Hoarseness or abnormal voiceHoarseness or abnormal voice Mandibular abnormalityMandibular abnormality

Decreased mobility or inability to open the mouth at least 3 Decreased mobility or inability to open the mouth at least 3 finger breathsfinger breaths

Micrognathia, receding chinMicrognathia, receding chin Treacher Collins, Peirre Robin, other syndromesTreacher Collins, Peirre Robin, other syndromes Less than 6 cm (3 finger breaths) from tip of the mandible to thyroid Less than 6 cm (3 finger breaths) from tip of the mandible to thyroid

notch with neck in full extensionnotch with neck in full extension < 9 cm from the angle of the jaw to symphysis< 9 cm from the angle of the jaw to symphysis Increased anterior or posterior mandibular lengthIncreased anterior or posterior mandibular length

Neck AbnormalitiesNeck Abnormalities Short and thickShort and thick Decreased range of motion (arthritis, spondylitis, disk Decreased range of motion (arthritis, spondylitis, disk

disease)disease) Fracture (subluxation)Fracture (subluxation) TraumaTrauma

Thoracoabdominal abnormalitiesThoracoabdominal abnormalities KyphoscoliosisKyphoscoliosis Prominent chest or large breastsProminent chest or large breasts Morbid obesityMorbid obesity Term or near term pregnancyTerm or near term pregnancy

Age 50 – 59Age 50 – 59 Male genderMale gender

Signs Indicative of a Difficult Signs Indicative of a Difficult IntubationIntubation

Pierre RobinPierre Robin

TMJ Joint – articulation and movement TMJ Joint – articulation and movement between the mandible and craniumbetween the mandible and cranium

Diseases:Diseases: Rheumatoid arthritisRheumatoid arthritis Ankylosing spondylitisAnkylosing spondylitis Psoriatic arthritisPsoriatic arthritis Degenerative join diseaseDegenerative join disease

Movements: rotational and advancement of Movements: rotational and advancement of condylar headcondylar head

Normal opening of mouth 5 – 6 cmNormal opening of mouth 5 – 6 cm

Difficult Intubation - Physical Difficult Intubation - Physical ExamExam

Difficult Intubation - Physical Difficult Intubation - Physical ExamExam

Oral Cavity Oral Cavity Foreign bodiesForeign bodies

Teeth:Teeth: Long protruding teeth can restrict accessLong protruding teeth can restrict access Dental damage 25% of all anesthesia litigationsDental damage 25% of all anesthesia litigations Loose teeth can aspirateLoose teeth can aspirate Edentulous stateEdentulous state

Rarely associated with difficulty visualizing airwayRarely associated with difficulty visualizing airway Tongue:Tongue:

Size and mobilitySize and mobility

Mallampati ClassificationMallampati Classification

Class I: soft palate, tonsillar fauces, tonsillarClass I: soft palate, tonsillar fauces, tonsillar

pillars, and uvuala visualizedpillars, and uvuala visualized Class II: soft palate, tonsillar fauces, and uvula Class II: soft palate, tonsillar fauces, and uvula

visualizedvisualized Class III: soft palate and base of uvula visualizedClass III: soft palate and base of uvula visualized Class IV: soft palate not visualizedClass IV: soft palate not visualized

Class III and IV Class III and IV Difficult to IntubateDifficult to Intubate

Mallampati ClassificationMallampati Classification

Bag/Valve/Mask VentilationBag/Valve/Mask Ventilation

Always need to anticipate difficult mask ventilationAlways need to anticipate difficult mask ventilation Langeron et al. 1502 patients reported a 5% incidence of Langeron et al. 1502 patients reported a 5% incidence of

difficult mask ventilationdifficult mask ventilation 5 independent risk factors of difficult mask ventilation:5 independent risk factors of difficult mask ventilation:

BeardBeard BMI > 26BMI > 26 EdentulousEdentulous Age > 55 years of ageAge > 55 years of age History of snoring (obstruction)History of snoring (obstruction)

Two of these predictors of DMVTwo of these predictors of DMV Sensitivity and specificity > 70%Sensitivity and specificity > 70%

DMV Difficult Intubation in 30% of casesDMV Difficult Intubation in 30% of cases

Intubation TechniqueIntubation Technique Preparation:Preparation:

Equipment CheckEquipment Check 100% oxygen at high flows (> 10 Lpm) 100% oxygen at high flows (> 10 Lpm)

during bask/mask ventilationduring bask/mask ventilation Suction apparatusSuction apparatus Intubation trayIntubation tray

Two laryngoscopic handles and bladesTwo laryngoscopic handles and blades AirwaysAirways ET tubesET tubes Needles and syringesNeedles and syringes StyletStylet KY JellyKY Jelly Suction YankauerSuction Yankauer Magill ForcepsMagill Forceps LMA’sLMA’s

Pre - oxygenationPre - oxygenation

Traditional:Traditional: 3 minutes of tidal volume breathing at 5 ml/kg 3 minutes of tidal volume breathing at 5 ml/kg

100% O100% O22

RapidRapid 8 deep breaths within 60 seconds at 10 L/min8 deep breaths within 60 seconds at 10 L/min

Always ensure pulse oximetry on Always ensure pulse oximetry on patientpatient

1818

Pre-TreatmentPre-Treatment

analgesicsanalgesics

Sedative Sedative

Muscle relaxant Muscle relaxant

PositioningPositioning Optimal Position – “sniffing position”Optimal Position – “sniffing position”

Flexion of the neck and extension of the Flexion of the neck and extension of the antlanto-occipital jointantlanto-occipital joint

Mandible and Floor of Mandible and Floor of MouthMouth

Optimal position:Optimal position: flexing neck and extending the flexing neck and extending the

atlantooccipital jointatlantooccipital joint

PositioningPositioning

PositioningPositioning

Factors that Interfere with Factors that Interfere with AlignmentAlignment

Large teeth or Large teeth or tethered tonguetethered tongue

Short mandibleShort mandible Protruding upper Protruding upper

incisorsincisors Pathology in floor of Pathology in floor of

mouthmouth Reduced size of Reduced size of

intra and sub intra and sub mandibular spacemandibular space

Practical Note: Thyromental distance 6 cm or 3 finger breaths should show Normal mandible

VisualizationVisualization

VisualizationVisualization Insert blade into mouthInsert blade into mouth Sweep to right side and Sweep to right side and

displace tongue to the leftdisplace tongue to the left Advance the blade until it Advance the blade until it

lies in the valeculla and lies in the valeculla and then pull it forward and then pull it forward and upward using firm steady upward using firm steady pressure without rotating pressure without rotating the wristthe wrist

Avoid leaning on upper Avoid leaning on upper teethteeth

May need to place pressure May need to place pressure on cricoid to bring cords on cricoid to bring cords into viewinto view

VisualizationVisualization

VisualizationVisualization

Ped and Adult Normal Trachea0

InsertionInsertion

Insert cuff to ~ 3 cm beyond cordsInsert cuff to ~ 3 cm beyond cords Tendency to advance cuff too farTendency to advance cuff too far

Right mainstem intubationRight mainstem intubation

Cuff InflationCuff Inflation Inflate to 20 cm HInflate to 20 cm H22OO Listen for leak at patients mouthListen for leak at patients mouth Over inflation can lead to ischemia of tracheaOver inflation can lead to ischemia of trachea

Confirmation ETT PositionConfirmation ETT Position Continuous COContinuous CO22 monitoring or capnometry monitoring or capnometry

Gold standardGold standard Must have at least 3 continuous readings Must have at least 3 continuous readings

without declining COwithout declining CO22

Other Methods to Determine Other Methods to Determine Placement of ETT tubePlacement of ETT tube

AuscultationAuscultation Visualization of tube through cordsVisualization of tube through cords Fiberoptic bronchoscopyFiberoptic bronchoscopy Pulse oximetry not improving or worseningPulse oximetry not improving or worsening Movement of the chest wallMovement of the chest wall Condensation in ET tubeCondensation in ET tube Negative Pressure TestNegative Pressure Test CXRCXR

Causes of Failed IntubationCauses of Failed Intubation

Poor positioning of the headPoor positioning of the head Tongue in the wayTongue in the way Pivoting laryngoscope against upper teethPivoting laryngoscope against upper teeth RushingRushing Being overly cautiousBeing overly cautious Inadequate sedationInadequate sedation Inappropriate equipmentInappropriate equipment Unskilled laryngoscopistUnskilled laryngoscopist

GALLERY OF TOOLSGALLERY OF TOOLS

GALLERY OF TOOLSGALLERY OF TOOLS

Bullard laryngoscope Fiber Bullard laryngoscope Fiber opticoptic