DIFFICULT AIRWAY DIFFICULT AIRWAY IN THE ICUIN THE ICU

Dr Anitha Shenoy

Professor and Head of Anaesthesiology

Kasturba Medical College, Manipal

Difficult Airway Difficult Airway In The ICUIn The ICU

Hypoxic Hypoxic patientpatient

Cardiac Cardiac arrestarrest

Equipment Equipment unavailabilityunavailability

Insufficient Insufficient trainingtraining

DefinitionsDefinitions

Ref: ASA Taskforce Anesthesiology 2003; 98:1269–77

Difficult airway

A clinical situation in which a

conventionally trained

anaesthesiologist experiences

difficulty with face mask ventilation,

tracheal intubation or both.

Difficult face mask ventilation

It is not possible for the anesthesiologist to

provide adequate face mask ventilation

due to :

inadequate mask seal

excessive gas leak or

excessive resistance to the ingress or

egress of gas.

Signs of inadequate face mask ventilation include:

Absent or inadequate chest movement / breath

sounds

Auscultatory signs of severe obstruction

Gastric air entry or dilatation

Decreasing or inadequate SpO2

Absent or inadequate exhaled CO2 and

Haemodynamic changes associated with

hypoxaemia or hypercarbia (e.g., hypertension,

tachycardia, arrhythmia).

Difficult laryngoscopy

It is not possible to visualize any portion of the vocal

cords after multiple attempts at conventional

laryngoscopy.

Difficult tracheal intubation

Tracheal intubation requires multiple attempts, in the

presence or absence of tracheal pathology.

Failed intubation

Placement of the endotracheal tube fails after multiple

intubation attempts.

AssessmentAssessment

ASSESSMENT OF AIRWAYASSESSMENT OF AIRWAY

• History and Physical examination: To detect

medical, surgical and anaesthetic factors hinting

a difficult airway. Previous anesthetic records

• The 1-2-3 test:

• One finger into the temporomandibular joint

• Two-finger breadths’ distance between the upper

and lower incisors

• Three-finger breadths’ distance from the chin to

the thyroid cartilage.

Modified Mallampati Classification of Modified Mallampati Classification of the airwaythe airway

• These classes roughly correlate with the following grades of laryngoscopic views.

• Difficult intubation is anticipated with Mallampati Class III and IV.

Modified Cormack and Lehane grading of Modified Cormack and Lehane grading of laryngoscopic viewlaryngoscopic view

Neck movementsNeck movements

Goniometer

Full range of neck movementsFull range of neck movements

> 90° - Normal

80 - 90° - Slight restriction

< 80° - Severe restriction

Neck ExtensionNeck Extension

Grade I : > 35° Normal

Grade II : 22°-34°

Grade III : 12°-21°

Grade IV : < 12°

Anticipated Difficult mask ventilationAnticipated Difficult mask ventilation

Anticipated Anticipated Difficult Difficult

IntubationIntubation

Anticipated difficult intubationAnticipated difficult intubation

Anticipated difficult intubation - AwakeAnticipated difficult intubation - Awake

Anticipated difficult intubationAnticipated difficult intubation

Anticipated difficult intubationAnticipated difficult intubation

Anticipated difficult intubation - AwakeAnticipated difficult intubation - Awake

Choices for intubation

Flexible fibreoptic intubation

Blind nasal intubation

Retrograde intubation

Tracheostomy (Take consent in advance)

Unanticipated difficult intubation - Unanticipated difficult intubation - AAnaesthetisednaesthetised Can ventilate, difficult to intubateCan ventilate, difficult to intubate

Essentially Same as Before !!!

Plan DPlan CPlan BPlan A

Anticipated difficult intubation - AAnticipated difficult intubation - Anaesthetisednaesthetised

Plan APlan A

Initial tracheal Initial tracheal intubation planintubation plan

Direct Direct LaryngoscopyLaryngoscopy

Tracheal Tracheal intubationintubation

SucceedFailed intubation

Plan BPlan B

Variety of Variety of laryngoscopes, laryngoscopes, endotracheal tube endotracheal tube guides, lighted styletsguides, lighted stylets

Anticipated difficult intubation - AAnticipated difficult intubation - Anaesthetisednaesthetised

Direct Rigid laryngoscopesDirect Rigid laryngoscopes

CLM Laryngoscope

Direct Rigid laryngoscopesDirect Rigid laryngoscopes

Glidescope

Indirect Rigid laryngoscopesIndirect Rigid laryngoscopes

Bullard LaryngoscopeBullard Laryngoscope

Upsher Laryngoscope

Endotracheal tube guides Endotracheal tube guides

Gum Elastic Gum Elastic BougieBougie

Frova IntroducerFrova IntroducerAintree Aintree

IntroducerIntroducer

Cook Airway Cook Airway Exchange Flextip Exchange Flextip

CatheterCatheter

Lighted styletsLighted stylets

TrachlightTrachlight

Bonfils

Shikani Optical Shikani Optical Stylet (SOS)Stylet (SOS)

Plan BPlan B

Secondary tracheal Secondary tracheal intubation planintubation plan

ILMA, LMAILMA, LMA

Confirm, FOB Confirm, FOB guided tracheal guided tracheal

intubationintubation

SucceedFailed oxygenation

Plan CPlan C

Variety of Variety of supraglottic supraglottic airwaysairways

Anticipated difficult intubation - AAnticipated difficult intubation - Anaesthetisednaesthetised

Supraglottic airway devicesSupraglottic airway devices

Intubating Laryngeal Mask Airway (ILMA)

ProSeal Laryngeal Mask Airway (PLMA)

Supraglottic airway devicesSupraglottic airway devices

Ambu Laryngeal Mask Airway

Supraglottic airway devicesSupraglottic airway devices

Combitube®

Supraglottic airway devicesSupraglottic airway devices

Laryngeal

Tube

Pharyngotracheal Lumen Airway

(PLA)

Plan CPlan C

Maintenance of Maintenance of oxygenation, ventilation, oxygenation, ventilation, postponement of surgery postponement of surgery and awakeningand awakening

Revert to face Revert to face mask, oxygenate mask, oxygenate

and ventilateand ventilate

Postpone Postpone surgerysurgery

Failed

oxygenationSucceed

Plan DPlan D

Variety of Variety of supraglottic supraglottic airwaysairways

Anticipated difficult intubation - AAnticipated difficult intubation - Anaesthetisednaesthetised

Plan DPlan D

Rescue techniques for Rescue techniques for ‘can’t intubate, can’t ‘can’t intubate, can’t ventilate’ situationventilate’ situation

LMALMA

Awaken patientAwaken patient

Improved oxygenation

Increasing hypoxaemia

CricothyroidotomyCricothyroidotomy

Variety of Variety of infraglottic infraglottic airwaysairways

Anticipated difficult intubation - AAnticipated difficult intubation - Anaesthetisednaesthetised

Unanticipated difficult intubation - Unanticipated difficult intubation - AAnaesthetisednaesthetised Cannot ventilate, cannot intubate

Failed intubation and difficult ventilation

Face mask

Oxygenate and ventilate

Maximum head extension

Maximum jaw thrust

Assistance with mask seal

Oral 6 mm nasal airway

Reduce cricoid force – If necessary

Call for help !!!

Unanticipated difficult intubation - Unanticipated difficult intubation - AAnaesthetisednaesthetised Cannot ventilate, cannot intubate

Failed oxygenation

with face mask ?

(SpO2 > 90%) with FIO2 = 1

Cannot intubate, cannot ventilate …Cannot intubate, cannot ventilate …

ILMA, LMA ILMA, LMA

Oxygenate and ventilate patientOxygenate and ventilate patient

Maximum 2 attempts at insertionMaximum 2 attempts at insertion

Reduce any cricoid force during insertionReduce any cricoid force during insertion

Succeed

Oxygenation Oxygenation satisfactory and stable: satisfactory and stable: Maintain oxygenation Maintain oxygenation and awaken patientand awaken patient

Cannot intubate, Cannot ventilate

Plan DPlan D

Plan D: Rescue techniques for ‘cannot intubate, Plan D: Rescue techniques for ‘cannot intubate, cannot ventilate’ situation cannot ventilate’ situation

CricothyroidotomyCricothyroidotomy

Needle

Cannula

Surgical

Increasing hypoxaemia

Variety of Variety of infraglottic infraglottic airwaysairways

Cannot intubate, cannot ventilate …Cannot intubate, cannot ventilate …

Infraglottic airway devicesInfraglottic airway devices

Enk Oxygen Flow Modulator

Infraglottic airway devicesInfraglottic airway devices

Melker Cricothyrotomy

Cannula

Arndt’s Cricothyrotomy set

Infraglottic airway devicesInfraglottic airway devices

Quicktrach

Unanticipated difficult intubation – Unanticipated difficult intubation – AAnaesthetised and full stomachnaesthetised and full stomach

Unanticipated difficult intubation – Unanticipated difficult intubation – AAnaesthetised and full stomachnaesthetised and full stomach

Plan APlan A

Initial tracheal Initial tracheal intubation planintubation plan

Direct Direct LaryngoscopyLaryngoscopy

Failed intubation

Tracheal Tracheal intubationintubation

Succeed

Plan C (Face mask)

Maintenance of Maintenance of oxygenation, ventilation, oxygenation, ventilation, postponement of surgery postponement of surgery and awakeningand awakening

No Plan BNo Plan BProSeal LMA ?ProSeal LMA ?

Unanticipated difficult intubation – Anaesthetised and full stomach

Plan DPlan D

Rescue techniquesRescue techniques

Increasing hypoxaemia

CricothyroidotomyCricothyroidotomy

Variety of Variety of infraglottic infraglottic airwaysairways

LMALMAImproved oxygenation

Awaken patientAwaken patient

Oxygenate

Visualisation

Ventilation

Intubation

Oxygenation

Chain of Chain of survival for the survival for the

airway airway

VIVOVIVO

Infraglottic airway Infraglottic airway

obstruction ??obstruction ??

Approach to Approach to Difficult Difficult AirwayAirway

Difficult Airway EquipmentDifficult Airway Equipment

Direct laryngoscopes

Indirect laryngoscopes

Endotracheal tube guides

Lighted stylets

Supraglottic airway devices

Infraglottic airway devices

Difficult airway cartDifficult airway cart

Difficult airway cartDifficult airway cart

Pulse oximetry

Capnography

Difficult airway trainersDifficult airway trainers

Sheep trachea

Critical Airway Management

Trainer

Medic Alert !!!