Airway Management Airway Management TechniquesTechniques

By Hwan Joo MDBy Hwan Joo MD

Airway PresentationAirway Presentation

Normal Airway ManagementNormal Airway Management Closed ClaimsClosed Claims Difficult Intubation and ToolsDifficult Intubation and Tools Difficult Ventilation and ToolsDifficult Ventilation and Tools Intubation tools for SurgeonsIntubation tools for Surgeons Overall goalsOverall goals

Teach surgeons about airway toolsTeach surgeons about airway tools Not necessarily how to intubateNot necessarily how to intubate

Indication for Tracheal Indication for Tracheal IntubationIntubation

Oxygenation and PeepOxygenation and Peep VentilationVentilation Airway protection from AspirationAirway protection from Aspiration Tracheal toilet and/lung washingsTracheal toilet and/lung washings Route for drug administrationRoute for drug administration

Airway AssessmentAirway Assessment

The Mallampati view The Mallampati view may be indicative of may be indicative of difficult airwaydifficult airway

Negative predictive Negative predictive value >99% for MP 1-2value >99% for MP 1-2

PPV for MP 4 only 40%PPV for MP 4 only 40% MP and laryngeal view MP and laryngeal view

not very correlativenot very correlative

Difficult Airway AssessmentDifficult Airway Assessment

History of difficult IntubationHistory of difficult Intubation Physical examinationPhysical examination TraumaTrauma

C-spine precautionC-spine precaution Blood in airwayBlood in airway Airway traumaAirway trauma

Morbid obesityMorbid obesity RSI makes it worse!RSI makes it worse!

Direct LaryngoscopyDirect Laryngoscopy

3# Mcintosh blade most 3# Mcintosh blade most commonly usedcommonly used

No change in design for No change in design for 60 years60 years

High success rates in High success rates in normal airways (99%)normal airways (99%)

However, difficult to learnHowever, difficult to learn >50 uses to be proficient>50 uses to be proficient Not so good with difficult Not so good with difficult

airwaysairways

Laryngeal Mask AirwayLaryngeal Mask Airway

Comes in sizes 3, 4, 5 Comes in sizes 3, 4, 5 (small, medium large)(small, medium large)

Great for ventilationGreat for ventilation Insertion easier if you have Insertion easier if you have

deep anesthesiadeep anesthesia Does not protect against Does not protect against

aspirationaspiration Not able to deliver high Not able to deliver high

pressure ventilationpressure ventilation Useful for difficult airways Useful for difficult airways

and failed laryngoscopyand failed laryngoscopy

Induction of for IntubationInduction of for Intubation

NothingNothing Patient already non-responsivePatient already non-responsive Medications contraindicatedMedications contraindicated

Topical lidocaineTopical lidocaine Midazolam, fentanylMidazolam, fentanyl EtomidateEtomidate±Sux±Sux KetamineKetamine±Sux±Sux PropofolPropofol±Sux±Sux

Closed Claims -Closed Claims -Caplan, Anesthesiology 1990Caplan, Anesthesiology 1990

Airway -Largest and most costly form of Airway -Largest and most costly form of injury (34% of all claims, $200,000+ US)injury (34% of all claims, $200,000+ US) Inadequate ventilation (34%)Inadequate ventilation (34%) Esophageal intubation (18%)Esophageal intubation (18%) Difficult intubation (17%)Difficult intubation (17%)

36% of claims against difficult intubation 36% of claims against difficult intubation cases considered preventablecases considered preventable

Closed Claims in CanadaClosed Claims in Canada

Between 1993-2003, 50% of all large CMPA Between 1993-2003, 50% of all large CMPA suits in anesthesia were airway relatedsuits in anesthesia were airway related Average settlement was $500,000Average settlement was $500,000 75% of patients suffered brain damage or deaths75% of patients suffered brain damage or deaths 50% were associated with difficult airways50% were associated with difficult airways

In half of these patients, difficult airway adjuncts were not In half of these patients, difficult airway adjuncts were not usedused

Therefore, there is room for improvementTherefore, there is room for improvement

ASA Difficult Airway AlgorithmASA Difficult Airway Algorithm

Recognized difficult airwayRecognized difficult airway intubation vs non-intubationintubation vs non-intubation

facemask, LMAfacemask, LMA regionalregional

Unrecognized difficult airwayUnrecognized difficult airway can ventilatecan ventilate

convert to spontaneous ventilation?convert to spontaneous ventilation? awake vs asleepawake vs asleep

cannot ventilatecannot ventilate emergency measures requiredemergency measures required

Difficult Intubation -Ventilation PossibleDifficult Intubation -Ventilation Possible

Awaken patientAwaken patient Asleep fiberoptic intubationAsleep fiberoptic intubation LMA without intubationLMA without intubation Intubation via LMA or ILMAIntubation via LMA or ILMA Lighted styletteLighted stylette CombitubeCombitubeTMTM

Video laryngoscopeVideo laryngoscope

Flexible Fiberoptic IntubationFlexible Fiberoptic Intubation

Awake fiberoptic intubation Awake fiberoptic intubation is the gold is the gold (Rose CJA 1994)(Rose CJA 1994)

Asleep FOI, successful but,Asleep FOI, successful but, It may be more difficult due It may be more difficult due

toto Airway obstruction or apneaAirway obstruction or apnea Blood in pharynxBlood in pharynx Limited time before oxygen Limited time before oxygen

desaturationdesaturation

Should be done with help!Should be done with help!

Laryngeal MaskLaryngeal Mask

Airway for intubationAirway for intubation Success for intubation with conventional Success for intubation with conventional

LMA is variable (19-93%)LMA is variable (19-93%) Success may be improved by the use of a Success may be improved by the use of a

pediatric bronchoscope via the ETT in pediatric bronchoscope via the ETT in LMALMA

LMA removal may be difficult after LMA removal may be difficult after intubationintubation

Consider LMA without intubationConsider LMA without intubation

Lighted Stylette (TrachliteLighted Stylette (TrachliteTMTM))

With experienceWith experience Success rates reported to Success rates reported to

be up to 99% in patients be up to 99% in patients with difficult airway with difficult airway (Hung, (Hung, CJA 1995)CJA 1995)

Success rates for novices Success rates for novices 50% 50% (Wilk, Resuc 1997)(Wilk, Resuc 1997)

Success rates decreased Success rates decreased in patient with bull necks in patient with bull necks and obese patientsand obese patients

CombitubeCombitubeTMTM

Success rates by non-Success rates by non-anesthesiologist with combitube anesthesiologist with combitube has ranged (33-93%)has ranged (33-93%)

Average beginner success rates Average beginner success rates expected to be in the 80-90% expected to be in the 80-90% range (Anesthesia-trained)range (Anesthesia-trained)

May be associated with May be associated with esophageal injuries and esophageal injuries and mediastinitis mediastinitis (Vezina, CJA 1998)(Vezina, CJA 1998)

Video LaryngoscopesVideo Laryngoscopes Glidescope Glidescope

Rigid laryngoscope with Rigid laryngoscope with CCD CCD

View is very clear with no View is very clear with no foggingfogging

Blade angle 50-60 degBlade angle 50-60 deg Easy to useEasy to use

Very rapid learning curveVery rapid learning curve Can also be learned by ER Can also be learned by ER

physicians, Surgeonsphysicians, Surgeons

Glidescope in UseGlidescope in Use

Glidescope Success Rates with Glidescope Success Rates with Experience Experience Joo et alJoo et al

0102030405060708090

100

0 to 9 10 to 19 20 to 29 30 to 39 > 40

Success Rate

Glidescope with Disposable BladeGlidescope with Disposable Blade

McGrath VideolaryngoscopeMcGrath Videolaryngoscope

Similar to GlidescopeSimilar to Glidescope Disposable blade coverDisposable blade cover Beautiful all in one designBeautiful all in one design Optics not be as goodOptics not be as good

Narrow field of visionNarrow field of vision

More difficult?More difficult? More portableMore portable

More likely to disappearMore likely to disappear

Video LaryngoscopesVideo LaryngoscopesRES-Q-SCOPERES-Q-SCOPE

LCD ScreenLCD Screen Disposable bladeDisposable blade Much cheaper initial costMuch cheaper initial cost However, $50 per useHowever, $50 per use

AirtraqAirtraqWhat is wrong with this picture?What is wrong with this picture?

Ventilation Difficult or ImpossibleVentilation Difficult or Impossible

Failed intubation is disturbing Failed intubation is disturbing but…..but….. Failed ventilation is universally fatal!Failed ventilation is universally fatal! ChoicesChoices

LMA (will discuss ILMA later)LMA (will discuss ILMA later) CombitubeCombitube Transtracheal airwayTranstracheal airway

cricothryotomycricothryotomy transtracheal jet ventilationtranstracheal jet ventilation tracheostomytracheostomy

Laryngeal Mask AirwayLaryngeal Mask Airway

Success rates for ventilation as high asSuccess rates for ventilation as high as 95% after 1 attempt and 98% after 2 attempts95% after 1 attempt and 98% after 2 attempts

No decrease in success rates in patient’s No decrease in success rates in patient’s with difficult airwayswith difficult airways

Overwhelming data of uses in difficult Overwhelming data of uses in difficult airways and in failed ventilationairways and in failed ventilation may have saved 100’s of lives!may have saved 100’s of lives!

For IPPV use large LMA’sFor IPPV use large LMA’s

What is the Best Device for Failed What is the Best Device for Failed Ventilation? LMA vs. CombitubeVentilation? LMA vs. CombitubeTMTM

Success is dependent on more on the Success is dependent on more on the operator’s experience than to tooloperator’s experience than to tool

Majority of anesthesiologist have little or Majority of anesthesiologist have little or no experience with the Combitubeno experience with the Combitube

LMA should be the first choice for difficult LMA should be the first choice for difficult ventilation scenariosventilation scenarios

However, Combitube theoretically However, Combitube theoretically prevents aspirationprevents aspiration

Trans Trachea Airway Trans Trachea Airway FOR UPPER AIRWAY OBSTRUCTIONFOR UPPER AIRWAY OBSTRUCTION

TTJV (jet ventilation)TTJV (jet ventilation) difficult with multiple difficult with multiple

complicationscomplications

Needle cricothryotomyNeedle cricothryotomy High success rates using High success rates using

Seldinger techniqueSeldinger technique No need for jetNo need for jet

Slash or surgical Slash or surgical tracheotomytracheotomy Messy but may do the jobMessy but may do the job

Intubating Laryngeal Mask Intubating Laryngeal Mask Airway (ILMA)Airway (ILMA)

ILMA with FOBILMA with FOB

Things of interestThings of interest Elbow connectorElbow connector

Continuous ventilationContinuous ventilation

PVC TubePVC Tube Metal rings in silicone tube Metal rings in silicone tube

not compatible with FOBnot compatible with FOB

Better than C-Trach?Better than C-Trach? Better manipulationBetter manipulation Higher Success ratesHigher Success rates

What is this?What is this?

The view via ILMA is The view via ILMA is different from regular different from regular FOBFOB

The epiglottis is often The epiglottis is often distorteddistorted

Obviously blind Obviously blind intubation failedintubation failed

Larger ILMA requiredLarger ILMA required

LMA C TrachLMA C Trach

ILMA with LCD screenILMA with LCD screen Improved success rates for intubation over ILMA Improved success rates for intubation over ILMA Success on Success on normal airwaysnormal airways about 90-95% about 90-95%

based on limited studiesbased on limited studies However, need greater mouth opening compared to However, need greater mouth opening compared to

ILMA, 2.5cm versus 2.0 cmILMA, 2.5cm versus 2.0 cm

Same success rate for ventilationSame success rate for ventilation Less traumaLess trauma

Failed IntubationFailed IntubationWhat to do as a SurgeonWhat to do as a Surgeon

Awaken patient if possible/feasibleAwaken patient if possible/feasible Maintain ventilation and oxygenationMaintain ventilation and oxygenation

FacemaskFacemask LMALMA CombitubeCombitube

Call AnesthesiaCall Anesthesia Surgical AirwaySurgical Airway

Attempt ventilation throughoutAttempt ventilation throughout

Airway Tools Airway Tools notnot for Surgeons for Surgeons

FOBFOB Too much effort required to learnToo much effort required to learn Not good with secretions or bloodNot good with secretions or blood Not as useful in unplanned cases (ER)Not as useful in unplanned cases (ER)

Lighted StylettesLighted Stylettes Again, high learning curveAgain, high learning curve Not as useful in patients who are not paralyzedNot as useful in patients who are not paralyzed High incidence of esophageal intubationsHigh incidence of esophageal intubations

What is the Best Tool for What is the Best Tool for Surgeons?Surgeons?

LCD Laryngoscopes are the way of the LCD Laryngoscopes are the way of the futurefuture

Currently, Glidescope is the easiest to use Currently, Glidescope is the easiest to use with the most literature supporting itwith the most literature supporting it Must Practice on routine patientsMust Practice on routine patients

Use it get familiarityUse it get familiarity Bug the anesthesiologists to use it in the ORBug the anesthesiologists to use it in the OR

Gold standard, Glidescope + FOBGold standard, Glidescope + FOB

Glidescope FOB InsertionGlidescope FOB Insertion

Glidescope FOB IntubationGlidescope FOB Intubation

The FutureThe Future The future of intubation will be video assistedThe future of intubation will be video assisted

In the past, intubators In the past, intubators intubated in the dark intubated in the dark by themselvesby themselves

PRIVATE PRIVATE (Like masturbation!)(Like masturbation!)

The future will have The future will have everybody involved in everybody involved in the process of the process of intubation intubation

(ER Doc, Nurses, RT)(ER Doc, Nurses, RT)

PARTY!PARTY! Everyone is involvedEveryone is involved

Final RecommendationFinal Recommendation

When faced with a When faced with a difficult airway, stay difficult airway, stay on the beaten path ofon the beaten path of Practice, Practice…Practice, Practice… Use familiar but Use familiar but

advanced devices advanced devices Do not persist with Do not persist with

techniques that have techniques that have failedfailed Secure ventilationSecure ventilation

Practice in SimulationPractice in Simulation