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PHD Resident Airway Lecture

PHD Resident Airway Lecture . Alan I. Frankfurt, MD. Alan Frankfurt, M.D.; Gary Weinstein, M.D. Why Train?. “…my life flashed before my eyes.” Meaning? Initial response to any stressful/life threatening experience… Mental rolodex scanning

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PHD Resident Airway Lecture

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  1. PHD Resident Airway Lecture Alan I. Frankfurt, MD

  2. Alan Frankfurt, M.D.;Gary Weinstein, M.D.

  3. Why Train? • “…my life flashed before my eyes.” • Meaning? • Initial response to any stressful/life threatening experience… • Mental rolodex scanning • “Have I ever been in or seen a situation like this before?” • What worked then?” • What did not work? • Why train? • Populating your mental rolodex • Making the unfamiliar, familiar in a controlled environment.

  4. Training: USAF Experience • USAF Red Flag Training Exercise • 90% of all fighter pilots who died in combat, did so in their first 10 missions. • Learning curve: First ten missions. • Flying those first ten missions in a training environment. • Red Flag Training Exercise.

  5. Airway Class Objective • Use this airway training as your own Red Flag Exercise • Training • Lecture • Hands on lab • Visualization

  6. Airway Topics • Relevant airway anatomy • Innervation of the airway • Anesthesia of the airway • PU<92% Concept • Airway examination • 6 D’s

  7. Airway Definitions and Concepts • Jim Rich, CRNA • Critical airway event: ability to rescue the airway. • CICMV • Intubation difficulty • Definition: difficult airway • SPO2<92% • 100% Oxygen • PPV • Crash airway: early recognition for patient salvage. • PU<92 • IRS • Intubation • Rescue breathing • Surgical airway • Airway Evaluation: 6 D’s • Difficulty airway options • Intubation rescue options • Law of insanity • AB4C’S

  8. Overview of Upper Airway Anatomy:Structure and Function

  9. Nares: Nasal Turbinates • Turbinate bones • Superior • Inferior • Middle • Function • 10,000 L of ambient air pass through the nasal airway per day and • 1 L of moisture is added to the air during this process. • Inferior turbinate • Highly vascular membrane • Vasoconstriction prior to instrumentation • Nasotracheal tube • Nasopharyngeal airway

  10. Pharynx • Location • The pharynx situated between the nose and larynx. • 3 Divisions • Nasopharynx • Oropharynx • Hypopharynx (Laryngopharynx)

  11. The Pharyngeal Anatomic Divisions • Nasopharynx • Termination of the turbinates and nasal septum • Soft palate. • Oropharynx • Soft palate • Hyoid bone. • Hypopharynx • Hyoid bone • First tracheal ring • AKA Laryngopharynx

  12. Larynx • Base of the tongue (hyoid bone) -> first ring of the trachea. • Opposite C3-C6 • Function • Watchdog of the airway • Swallowing • Organ of phonation • Bones • Hyoid • Cartilages • Epiglottis • Thyroid • Cricoid

  13. Laryngeal Anatomy

  14. Cricoid Cartilage • Anatomic lower limit of the larynx. • Only complete cartilaginous ring in the upper airway. • Attaches to the thyroid cartilage by the cricothyroid membrane. • Laryngotracheal anesthesia • Surgical airway • Identification in the patient with poor anatomic landmarks.

  15. Cricothyroid artery • The superior thyroid artery • First anterior branch of the external carotid artery. • The cricothyroid artery • Branch of the superior thyroid artery • Runs in the upper portion of the cricothyroid membrane. • Surgical airway • Tracheal hook placement

  16. Airway Innervation: 5-9-10

  17. Innervation of the Nasal Passage and Nasopharynx: CN 5 • Anterior 1/3 of the nares. • Anterior ethmoidal nerve • Posterior 2/3 of the nares. • Greater and Lesser Palatine nerve

  18. Anesthesia for the Mouth and Oropharynx: CN 9 • Anatomy • Glossopharyngeal nerve (CN9)

  19. Anesthesia for the Mouth and Oropharynx: CN 9 • Poster 1/3 tongue, • Gag reflex • Vallecula, • Anterior surface of the epiglottis (lingual branch), • Posterior and lateral walls of the pharynx (pharyngeal branch), and • Tonsillar pillars (tonsillar branch).

  20. Laryngeal Innervation: CN 10 • CN X (Vagus) • Superior laryngeal nerve • Internal laryngeal nerve. • Posterior epiglottis to vocal cords. • Penetrates at the thyrohyoid membrane. • External laryngeal nerve. • Cricothyroid muscle

  21. Innervation of Trachea and Vocal Cords • Recurrent Laryngeal Nerve • Sensory innervation of the tracheobroncheal tree up to and including the vocal cords. • Intrinsic laryngeal musculature except cricothyroid muscle.

  22. Airway Anesthesia • Airway manipulations issue without adequate anesthesia. • Patient comfort • Hemodynamic response • Valsalva • Airway anesthesia options • “Spray and Pray”: Topicalization of the airway with local anesthesia • Entire airway may be anesthetized using topical anesthesia • Nerve block • ? Glossophyngeal nerve • Superior laryngeal nerve • “Transtracheal nerve block”

  23. Airway Local Anesthesia Drug Absorption • Topical anesthetic absorption • Alveoli>Tracheobroncheal tree>Pharynx

  24. Airway Anesthesia Medications • Cocaine • 4% and 10% solutions • 3 mg/kg (200 mg maximum dose) • 5cc’s in a 70kg person. • Benzocaine • Rapid onset and short duration (10 minutes) • Cetacaine • Bezocaine, Tetracaine • Methemoglobinemia • Cyanosis, fatigue, weakness, headaches, dizziness and tachycardia • Massimo pulse oximeter • Lidocaine • 1%, 2% and 4% solutions • 4% lidocaine/Afrin mixture • Rare to see toxic reactions within the context of airway anesthesia. • Lidocaine 5% ointment • Lidocaine 2% jelly • Loaded in a syringe • Viscous lidocaine. • Swish and swallow • Tetracaine • Toxicity 100mg (40mg)

  25. Goal of Airway Anesthesia

  26. Airway Preparation for Awake Airway Manipulation • First: Never sacrifice patient safety for patient comfort. • What are the systemic effects of inadequate airway anesthesia? • Coughing, straining, valsalva • Hypertension and Tachycardia • Myocardial oxygen consumption • Increased ICP • Increased IOP • How to prepare for success prior to anesthetizing the airway. • Maintain the ability to communicate with the patient. • Dry the airway. • Maximize effectiveness of the LA applied to the airway. • Dilution of LA concentration by oral secretions • Decreases LA effectiveness • Comfortable patient is a cooperative patient: • Sedation/analgesia/anesthesia • Intravenous medications • Transmembrane medication administration

  27. Patient Preparation for Anesthesiaof the Airway • Antisialogogues (Drying Agents) • Robinal 0.2-0.4 mg IV • Atropine 0.5-1.0 mg IV • Vasoconstrictor • Afrin spray • Phenylephrine 1% spray • Anxiolytics and Analgesia • Versed • Flumazenil • Fentanyl • Naloxone • Monitors • Pulse Oximetry • Supplemental oxygen

  28. Key Airway Anesthesia Principles: Timing, Positioning and Lubrication • Timing • Give your preparation drugs time to work. • Anticholinergic • Vasoconstriction agents • Positioning • Position yourself to succeed. • Go slow • Monitor the patient • Masimo pulse oximetry • Don’t burn any airway bridges • Reversible agents • Lubrication • The entire airway can be anesthetized topically with generous amounts of anesthetic jelly and ointment.

  29. Recurrent Laryngeal Nerve Block:AKA Transtracheal Block • Indications • Anesthesia for the laryngotracheal mucosa. • Awake intubation, • Retrograde intubation, • Cricothyrotomy (surgical or percutaneous), • Abolishment of gag reflex or hemodynamic response associated with intubation. • Medications • 4% Lidocaine • 1-2% Lidocaine

  30. Recurrent Laryngeal Nerve Block:AKA Transtracheal Block • Patient positioning • Supine in the “sniffing” position • Technique • Cricothyroid membrane identification. • Local anesthesia skin wheal: Conscious verse Unconscious Patient • 2-3cc of 4% Lidocaine drawn into a 5cc syringe • 20G Angiocath needle. • Identification of the airway • Loss of resistance • Air bubbles signals entry into the larynx.

  31. How I Do It: • Robinal • Afrin/Afrin and 4% Lidocaine cocktail. • Nasal manipulation. • Sedation +/- • Nebulized 4% Lidocaine 2-3cc • Prior to the application of gels or ointments. • 4% Lidocaine in a syringe dribbled down the nares. • (Viscous Lidocaine swish and swallow). • Oral airway/Nasal trumpet with 5% Lidocaine gel. • CN9 gag reflex: posterior tongue. • Transtracheal block with 4% Lidocaine with 22G-25G needle or 20 G Angiocath. • Above and below vocal cord anesthesia.

  32. PU-92 Concept Crash Airway

  33. Crash Airway Concept: Walls, R. • Teaching Goal: To identify patients in extremis. • Patients who are going to die unless you intervene quickly and decisively. • Who are these patients? • Altered mental status with airway compromise. • Lethal combination: M/M increased 50-75% • Unconscious • Apneic or having agonal respirations. • Arrested or near death. • Anticipated to be unresponsive and tolerant to laryngoscopy.

  34. Getting Your Arms Around The Crash Airway: PU-92 • Crash airway • Meant to convey an unmistakable sense of urgency. • Circling the drain! • From conceptual idea to clinical action. • PU-92 concept • PU-92: • Reflects the lethal combination of a cerebral insult (ischemic or traumatic) and hypoxia. • Critical nature of early airway support in the face of brain injury. • Airway compromise in a patient with compromised cerebral circulation may DOUBLE mortality. • Provides a quick and reliable tool to recognize these patients early and intervene.

  35. PU-92 Parameters • Level of consciousness • SpO2 level

  36. PU-92 Parameters: LOC and SpO2 • Level of consciousness using the AVPU system • Alert, Voice response, Pain response only or Unresponsive • McKay et al: • P or U response corresponds to a GCS<9 • GCS<9 immediate indication for intubation • Patients SpO2 level • SpO2<92%, despite: • Maximum airway efforts utilizing: • PPV • manual airway opening techniques • 100% oxygen ( if available). • If SpO2 unavailable, use a RR <10 or > 30/breathes per minute. • Use of SpO2 in the field environment. • Masimo • Movement algorithm • Low perfusion algorithm • Co and MetHg

  37. PU<92: Now What? The Crash Airway Response • Patients require immediate improvement in Ventilation and Oxygenation • Treatment options: IRS • Intubation • Rescue Ventilation • Surgical airway • Treatment options are decided upon after an Airway Evaluation • Airway Evaluation reveals: • No difficulty anticipated • One attempt at direct laryngoscopy and Intubation (I). • Failed intubation fall back to Rescue Ventilation (R) • Class 2a agent • Surgical airway (S) • Difficulty anticipated • Rescue Ventilation • Surgical airway

  38. Rescue Ventilation • Positive Pressure Ventilation with Class 2a adjunctive airway device. • Class 2a: therapeutic option for which the weight of evidence is in favor of its usefulness and efficacy. • ETC: Esophageal-tracheal Combitube • LMA • (King LT) • Class 2a devices are supraglottic devices which do not address obstruction of the airway at the glottic or subglottic level. • Endotracheal tube • Cricothyrotomy • Airway literature reveals that rescue ventilation is often effective in providing ventilation and oxygenation in the following conditions • CMVCI • Failed intubation

  39. ECT: Esophageal Combitube Tube

  40. ECT: Esophageal Combitube Tube

  41. ECT: Esophageal Combitube Tube

  42. LMA

  43. King LT

  44. Summary: Crash Airway • Confirm a crash airway exist: • Patient in extremis. • PU-92. • Call for help. • Maximize airway support • Manual maneuvers • Airway devices: OA and NT • PPV with 100% O2 as available • Identify possible difficulty airway • Pay the “IRS” • Intubation attempt • Only if airway appears easy to intubate • Airway evaluation • 6 D’s • Rescue ventilation • If intubation fails or airway appears difficult • SpO2>92 • Yes-monitor airway and reassess need for definitive airway • No-> • Surgical airway

  45. Airway Evaluation 6-D Method of Airway Assessment

  46. 6-D Method of Airway Assessment • 6-D method of airway assessment is meant to assist health care providers in remembering the six signs that can be associated with a difficult intubation. • Each sign begins with a D. • The potential for airway difficulty is generally proportional to the number of signs observed.

  47. 6-D Method of Airway Assessment • 1. Disproportion. • 2. Distortion. • 3. Decreased thyromental distance (3). • 4. Decreased interincisor gap (2). • 5. Decreased range of motion in any or all joints of the airway (1). • 6. Dental overbite.

  48. 6-D Method of Airway Assessment • Disproportion • Size of tongue in relation to the oropharyngeal size. • Obstructed laryngoscopic view of airway. • Airway trauma (blunt or penetrating) with resultant swelling. • Patient’s anatomy • Assessment • Mallampati Classification • Predicting airway disproportion problems: • Mallampati class 4 (3?) • Swelling or protruding tongue • Blunt or penetrating injury • Receding mandible

  49. Mallampati Airway Classification System • Class 1: • soft palate, uvula, anterior and posterior pillars are visible. • Class 2: • soft palate and uvula are visible • Class 3: • only soft palate and base of uvula visible. • Class 4: • hard palate visible, but not the soft palate.

  50. 6-D Method of Airway Assessment • Distortion • Etiology: • Neck mass, neck hematoma, neck abscess, previous surgery or trauma. • Predicting airway distortion problems: • Voice change • Subcutaneous emphysema • Laryngeal immobility • Non palpable thyroid and/or cricoid cartilage. • Neck asymmetry • Tracheal deviation • Subcutaneous emphysema

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