Context Sensitive Airway Management Orlando Hung Departments of Anesthesia and Surgery, Dalhousie...

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Transcript of Context Sensitive Airway Management Orlando Hung Departments of Anesthesia and Surgery, Dalhousie...

  • Context Sensitive Airway ManagementOrlando HungDepartments of Anesthesia and Surgery, Dalhousie University, Halifax, Nova Scotia

  • ObjectivesContext-sensitive Airway ManagementDevice-Dependent Airway management

  • Tracheal Intubation

  • FIGURE 3922 Difficult airway algorithm developed by ASA Task Force on Guidelines for Difficult Airway Management (Modified from American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice guidelines for the management of the difficult airway. Anesthesiology 78:597, 1993) Copyright 2000, 1995, 1990, 1985, 1979 by Churchill Livingstone

  • What if you are not in the OR environment?

  • FIGURE 3922 Difficult airway algorithm developed by ASA Task Force on Guidelines for Difficult Airway Management (Modified from American Society of Anesthesiologists Task Force on Management of the Difficult Airway: Practice guidelines for the management of the difficult airway. Anesthesiology 78:597, 1993) Copyright 2000, 1995, 1990, 1985, 1979 by Churchill Livingstone

  • These algorithms will work if: It is in the ORThere is timeThere is proper preparationThere are equipmentThere is assistance

  • Case Presentation

  • This morbidly obese patient is scheduled for an open appendectomyShe is otherwise healthy.She weighs 210 kg and is 158 cm tall (BMI 84.1).She takes no meds.She has no allergies.Apart from a big thick neck, she has no obvious predictors of difficult laryngoscopy.

  • What is your choice of anesthesia for the surgical procedure?Spinal anesthesia?Epidural anesthesia?GA using an LMA?GA with a tracheal tube?

  • How would you like to secure the airway?RSI with a Macintosh laryngoscope?Glidescope intubation under GA?Awake intubation using bronchoscope?

  • Would you do anything different if she is scheduled for a cystoscopy?Cancel the surgery?Consider doing the procedure under local and sedation?Consider regional anesthesia (spinal)?GA using an LMA?Awake tracheal intubation using a bronchoscope?

  • What if she is scheduled for the appendectomy and she is unco-operative?Cancel the surgery?Consider regional anesthesia (spinal)?Insisting awake tracheal intubation under sedation?Mask induction and tracheal intubation? Tracheal intubation using a video-laryngoscope under GA?

  • What if she is cooperative, but is also 18 weeks pregnant?Postpone surgeryRegional anesthesiaAwake intubation under sedationRSI with a video-laryngoscope

  • What if she is 18 weeks pregnant with bowel perforation, peritonitis and in septic shock?Regional anesthesiaAwake intubation using whateverRSI using a video-laryngoscopeSurgical airway awake

  • What if you are working in a community hospital in Rwanda?Regional anesthesiaAwake intubation using a bronchoscopeAwake intubation using a GlidescopeAwake intubation using direct laryngoscopy Blind nasal intubation RSI using direct laryngoscopy

  • Many factors can influence how we manage the airway of a patient: Can I ventilate the patient with a BMV, an extraglottic device, or through a tracheal tube?Failing that, can I get a surgical airway easily?Emergency? Cyanotic? Do I have time?Pregnant?A child? Co-operative?Aspiration risk?Any assistance?Available resources?Skills with the airway devices

  • Device Dependent Airway ManagementWhen we identify a potentially difficult laryngoscopic intubation, we must resist the inclination to persist with direct laryngoscopy.Similarly, we should not rely on a single intubation technique, such as the bronchoscopic intubation.With the currently available resources, airway practitioners should be able to choose an appropriate device or technique to effectively manage a difficult airway with alternative plans depending on the situation or environment as well as the skills of the practitioner.

  • Strategy to manage patients with a difficult airway:Plan APlan BPlan CPlan DThese plans should be modified or changed according to the environment or situations.

  • Principles of Airway Management

  • SummaryWe should focus on ventilation and oxygenation in airway managementPlans to manage the airway of a patient depend on many factors and situations and all airway practitioners should modify their approaches to meet these challenges.All airway practitioners should avoid relying on a single airway device or technique.

  • *******BMV, DL, bougie, LMA *****