Case discussion A case of difficult intubation

2. Case discussionA case of difficult intubation Intern 嚴元鴻 Department of anesthesiology NTUH 2001/12/25

3. Brief history (1) • Name:邱X榮 Chart No:4099581 • Sex/Age:male , 59 y/o Bed No:9D-13-1 • Admission date:2001/12/4 • Past History: 1.DM , fresh case • 2.denied other systemic disease • 3.smoking and drinking when young • 4.denied any food and drug allergy • 5.no recent travel and trauma history

4. Brief history (2) • Posterior neck swelling without discharge initially since 11/19. • He visited our ER for discharge and tenderness of the wound on 11/29. • Low grade fever,leukocytosis and high CRP value were noted. • Unasyn,Metronidazole and Gentamicin were given with only minor improvement of lab data and clinical condition. • He was discharge under cellulitis and suggested OPD F/U. • Because of purulent discharge persisted,the patient visited our ER again on 12/4. • Deep neck infection was suspected ,he was admitted for further care and op evaluation.

5. Brief history (3) • PE: erythematous induration all over the posterior neck region ; mild tenderness. • CXR shows normal heart size with slightly increased lung markings. Tortuous aorta is noted. • SPINE CERVICAL AP. LAT showed marked degenerative change of C-spine with calcification of post. nuchal ligament. post. spur are noted at C5 6 7.

6. Brief history (4) • Neck CT without/with contrast enhancement shows • 1. soft tissue swelling with low density change at dorsal aspect of neck and occpital region symmetrically, the fat planes are blurred. there is indistinct interface of the swollen soft tissue with the posterior neck muscles (splenius capitus and probably semispinalis). infectious process is considered, probably cellulitis and myositis. • 2. the spine is intact • 3. no abnormal enlarged LAPs

7. Brief history (5) • Pre op : 59 y/o male with DM was diagnosed neck abscess s/p I&D. • Op method:Debridement on 12/7 • ASA class III • Neck movement decrease,extension(-) • short neck , small mandible • Risk of difficult intubation was explained to family.

8. Induction of general anesthesia followed by direct laryngoscopy and oral intubation. -> difficult intubation -> Flexible fiberoptic intubation --> IVG ; propofol infusion Anesthesia course (see record)

9. Prediction and Management of Difficult Tracheal Intubation • Introduction • Predicting Difficult Intubation • Preparation for Intubation • Planning Anaesthesia

10. Introduction • During routine anaesthesia the incidence of difficult tracheal intubation has been estimated at 3-18%. • Class I: the vocal cords are visible • Class II: the vocals cords are only partly visible • Class III only the epiglottis is seen • Class IV the epiglottis cannot be seen. • Cormack RS, Lehane J. "Difficult intubation • in obstetrics." Anaesthesia 1984;39:1105-11

11. Predicting Difficult Intubation (1) • "sniffing the morning air" position • History and examination • Specific Screening Tests to Predict Difficult Intubation. • View obtained during Mallampati test: • 1. Faucial pillars, soft palate and uvula visualised • 2. Faucial pillars and soft palate visualised, but uvula • masked by the base of the tongue • 3. Only soft palate visualised • 4. Soft palate not seen. • Samsoon GLT, Young JRB. "Difficult tracheal • intubation: a retrospective study." • Anaesthesia 1987;42:487-90

12. Predicting Difficult Intubation (2) • Thyromental distance • Grade 3 or 4 Mallampati who also had a thyromental distance of less than 7cm were likely to present difficulty with intubation • Frerk CM. "Predicting difficult intubation." Anaesthesia 1991;46:1005-8 • Sternomental distance • A sternomental distance of 12.5cm or less predicted difficult intubation • Savva D. "Prediction of difficult tracheal intubation." British Journal of Anaesthesia 1994;73:149-53

13. Predicting Difficult Intubation (3) • Protrusion of the mandible • If the patient cannot get the upper and lower incisors into alignment intubation is likely to be difficult. • Calder I, Calder J, Crockard HA. "Difficult direct laryngoscopy in patients witH cervical spine disease." Anaesthesia 1995;50:756-63 • X-ray studies • Various studies have been used to try to predict difficult intubation by assessing the anatomy of the mandible on X-ray. These have shown that the depth of the mandible may be important, but they are not commonly used as a screening test.

14. Preoperative assessment • A combination of the above tests is better than using only one. The modified Mallampati, thyromental distance, ability to protrude the mandible and craniocervical movement are probably the most reliable.

15. Preparation for Intubation (1) • Anaesthetists should be ready to deal with difficulties in intubation at any time. The correct equipment must be immediately available. This will include: • laryngoscopes with a selection of blades • a variety of endotracheal tubes • introducers for endotracheal tubes (stylets or better, flexible bougies) • oral and nasal airways

16. Preparation for Intubation (2) • a cricothyroid puncture kit (a 14 gauge cannula and jet insufflation with high pressure oxygen is the simplest and cheapest kit • reliable suction equipment • a trained assistant • laryngeal mask airways, sizes 3 & 4

17. After intubation • The anaesthetist should ensure that the patient is in the optimal position for intubation and must be able to oxygenate the patient at all times. • After intubation correct placement of the tube should be confirmed by: • a stethoscope listening over both lung fields in the axillae • observing the tube pass through the cords • successful inflation of the chest on manual ventilation

18. Special techniques for intubation • Awake intubation under local anaesthesia • Oral intubation • Nasal intubation is the best method of awake intubation using a fibreoptic bronchoscope or other intubating fibrescope via the nose.

19. Retrograde intubation (1) • is a technique first described in Nigeria • Waters DJ "Guided blind endotracheal intubation for patients with deformities of the upper airway." Anaesthesia 1963;18:158-62 • Retrograde intubation has recently been used successfully for traumatised airways when conventional techniques had failed • Barriot P, Riou B. "Retrograde technique for tracheal intubation in trauma patients."Critical Care Medicine. 1988;16:712-3 • the membrane between the cricoid and first tracheal ring can also been used. • Shanther TR. "Retrograde intubation using the subcricoid region." British Journal of • Anaesthesia. 1992;68:109-12

20. Retrograde intubation (2)

21. The Laryngeal Mask Airway • is a common device in anaesthesia and can often provide a good airway in patients in whom intubation is difficult. Following insertion the anaesthetist may use it to maintain the airway during anaesthesia, or may use it as a route to allow tracheal intubation.

22. The McCoy laryngoscope • is designed with a movable tip which allows the epiglottis to be lifted and intubation often made easier • McCoy EP, Mirakhur RK. "The levering laryngoscope." Anaesthesia 1993;48:516-9

23. A light wandis a long flexible device which has a bright light at the end and can be directed into the trachea with an endotracheal tube mounted over it • Robelen GT, Shulman MS. "Use of the lighted stylet for difficult intubations in adult patients (abstract)." Anesthesiology 1989;71:A439 • The Combi-tubeis a tube which may be inserted blindly and used to ventilate the patient in an emergency • Frass M, Frenzer R. Zahler J, Lilas W, Leithner C. "Ventilation via the esophageal tracheal combitube in a case of difficult intubation." Journal of Cardiothoracic Anaesthesia 1987;1:565-8

24. Planning Anaesthesia • During general anaesthesia patients must never be given muscle relaxants unless the anaesthetist can be certain of being able to ventilate them. • When the anaesthetist faces unexpected difficulty in intubation the priority is to ensure adequate mask ventilation and oxygenation of the patient. • Multiple attempts at endotracheal intubation may result in bleeding and oedema of the upper airway making the task even more difficult. Often it is better to accept failure after a few attempts and move on to a pre-planned failed intubation sequence • King TA, Adams AP. "Failed tracheal intubation." British Journal of Anaesthesia1990;65:400-414

25. Failed intubation • If intubation proves impossible the anaesthetist should consider whether to allow the patient to wake up and carry on surgery with regional anaesthesia, or whether to abandon the surgery altogether. In situations where surgery is of an urgent nature it may be prudent to carry on the general anaesthetic under face mask anaesthesia if the airway is easy to maintain. • If the airway is impossible to maintain and the patient is becoming hypoxic, an emergency cricothyroidotomy is required. If time allows an emergency tracheostomy can be considered.

26. Difficult airway algorithm (ASA) • Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 1993 Mar;78(3):597-602.

27. ASA Algorithm Part 1

28. ASA Algorithm Part 2

29. Awake Intubation Pathway

30. Non-surgical techniques for awake intubation include laryngoscopy, fiberoptic bronchoscopy and retrograde intubation. Surgical access may be secured by awake tracheostomy. • Awake intubation requires patient cooperation and should be performed with local anesthesia. See Local Anesthesia for more information. • If awake intubation efforts fail, the patient is unlikely to have compromised ventilation. Consider canceling the case, other intubation options or surgical access to the airway.

31. Intubation After Induction Pathway

32. After induction of anesthesia, if the initial intubation attempts are unsuccessful, consider returning to spontaneous ventilation, awakening the patient and calling for help. • If mask ventilation is adequate, go to the Non-Emergency Pathway. If mask ventilation is inadequate go to the Emergency Pathway. • If mask ventilation becomes inadequate at any time while following the Non-Emergency Pathway, go to the Emergency Pathway

33. Non-Emergency Pathway

34. Follow the Non-Emergency Pathway when the patient is anesthetized, intubation is unsuccessful and mask ventilation is adequate. If mask ventilation becomes inadequate go directly to the Emergency Pathway. • Consider alternative approaches including fiberoptic intubation, intubation stylet, blind intubation, light wand and retrograde intubation. • If failure after multiple attempts, consider awakening the patient, surgical airway or surgery under mask anesthesia.

35. Emergency Pathway

36. Follow the Emergency Pathway when the patient is anesthetized, intubation is unsuccessful and mask ventilation is inadequate. • Time is critical. Call for help. Do one more intubation attempt or emergency non-surgical airway ventilation or emergency surgical airway. • Do not continue to attempt a previous unsuccessful technique. • Emergency non-surgical airway ventilation techniques include: transtracheal jet ventilation, intratracheal jet stylet, laryngeal mask, oral and nasopharyngeal airways, two person mask ventilation, and rigid ventilating bronchoscope. • Emergency non-surgical airway ventilation techniques are temporizing measures. Establish a definitive airway as soon as possible.

41. Thanks for your attention!!