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THE DIFFICULT AIRWAY MANAGEMENT IN ADULT CRITICAL CARE

THE DIFFICULT AIRWAY MANAGEMENT IN ADULT CRITICAL CARE. 5 MAY 2014 J MATSHE. AIRWAY MANAGEMENT. Obligatory & Necessary skill for ALLL Critical care practitioners

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THE DIFFICULT AIRWAY MANAGEMENT IN ADULT CRITICAL CARE

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  1. THE DIFFICULT AIRWAY MANAGEMENT IN ADULT CRITICAL CARE 5 MAY 2014 J MATSHE

  2. AIRWAY MANAGEMENT • Obligatory & Necessary skill for ALLL Critical care practitioners • FAILURE to maintain airway & provide adequate oxygenation=↑ patient morbidity & mortality; psychologically-distressing to attending registrar • ALL Critical Care patients-Initially viewed to have a potentially difficult airway & REMEMBER have less physiological reserves VS airway intervention @ elective surgery

  3. DEFINITION • DIFFICULT AIRWAY: Acc to ASA guidelines 2013=Clinical situation whereby conventionally trained anaesthetist experiences DIFFICULTY with either: • MASK VENTILATION or • TRACHEAL INTUBATION or • BOTH ( “CAN’T INTUBATE, CAN’T VENTILATE”) NB: AVOID AVOID AVOID!!!!!!!

  4. DIFFICULT MASK VENTILATION • Unassited anaesthetist cannot maintain arterial oxygen saturation ≥90% by mask ventilation using 100% Oxygen & positive pressure OR • Cannot reverse signs of inadequate ventilation eg. Absence of chest movement & exhaled CO2 OR Presence of cyanosis

  5. DIFFICULT LARYNGOSCOPY • Difficulty visualising any portion of vocal cords using a conventional laryngoscope: Cormack Lehane 3(epiglottis only)/4(soft palate only)

  6. DIFFICULT ENDO-TRACHEAL INTUBATION • › 3 Attempts @ inserting ET tube Or • › 10 minutes to perform using conventional equipment

  7. OUTLINE • INDICATIONS FOR INTUBATION • AIRWAY ASSESSMENT & PREDICTING DIFFICULT AIRWAY: • PRE-INTUBATION STRATEGY -Preparation -Pre-Oxygenation -Positioning -Premedication • PLANS & BACK UP PLANS • ADJUNCTS

  8. INDICATIONS FOR INTUBATION • Inadequate Oxygenation • Inadequate Ventilation • Anticipate development of inadequate oxygenation/ventilation • Airway protection

  9. PREDISPOSING FACTORS TO DIFFICULT INTUBATION • OPERATOR related: Unassisted junior trainee after-hours with no senior/specialist assistance • DISEASE related: All intubations EMERGENCIES • PATIENT related: EMERGENCY=Shortened preparation time;Recent previous intubation-predispose airway edema, subgottic inflammation & even stenosis & Operator Stress due to patient’s deteriorating condition

  10. AIRWAY ASSESSMENT History for airway assessment Potential Problems • Anaesthesia records All stages • Previous intubation trauma All stages • Previous surgery, radio-therapy to head/neck All stages • Airway disease process All stages • Systemic disease(rheum arthr, ankylosspondyl) Diff laryngoscopy • Sleep apnoea Loss of airway tone & Difficult laryngoscopy • Previous tracheostomy Difficult laryngoscopy and intubation • Gastro-oesophageal reflux Aspiration of gastric contents • Full stomach Aspiration of gastric contents

  11. AIRWAY ASSESSMENT Exam for A A Potential Problems • Stridor All stages • Obesity Loss of airway tone and difficult laryngoscopy • Short neck Difficult laryngoscopy • ↓ mouth opening Difficult laryngoscopy • Receding jaw Difficult laryngoscopy • Hamster mouth Difficult laryngoscopy • Buck teeth Difficult laryngoscopy • Missing upper teeth Difficult laryngoscopy • Respiratory difficulty Difficult laryngoscopy • Neck masses All stages • Position of larynx/ trachea and availability of cricothryroid membrane Difficult laryngoscopy and intubation

  12. BAG MASK VENTILATION

  13. BAG MASK VENTILATION • INTEGRAL component of Airway mx • If done correctly & successfully: Gives time to prepare for definitive airway mx • Entails 3 Principles: Patent Airway, Good mask seal & Proper ventilation

  14. IDENTIFYING DIFFICULT BMV M O A N S • Mask seal: Can’t approximate mask • Obesity:Redundant tissues impede airflow • Age ›55yrs: Loss of tissue elasticity • No teeth:Mask doesn’t sit properly • Stiff lungs/body:↑pressure needed

  15. OPENING AIRWAY MANOUVERE 1 HEAD TILT CHIN LIFT: 1ST HAND DOWNWARD PRESSURE TOFOREHEAD ; 2ND HAND INDEX & MIDDLE FINGERS LIFT CHIN

  16. OPENING AIRWAY MANOUVRE 2 JAW THRUST-UNSTABLE CERVICAL SPINE: PLACE HEELS OF HANDS ON PARIETO-OCCIPAL AREA & GRASP ANGLES OF MANDIBLE WITH FINGERS & DISPLACE JAW ANTERIORLY

  17. OPENING AIRWAY ADJUNCT 1 OROPHARYNGEAL: GUEDEL-SIZE CORRECTLY; INSERT-CURVE INVERTED, ROTATE 180˚ AS TIP REACHES POSTERIOR PHARYNX AVOID IN AWAKE PATIENT

  18. OPENING AIRWAY ADJUNCT 2 NASOPHARYNGEAL AIRWAY

  19. MASK VENTILATION TECHNIQUE 1 1 HAND: ALIGN PATIENT’S EXTERNAL AUDITORY MEATUS WITH STERNAL NOTCH USING E-C METHOD FOR MASK SEAL & BAG WITH OTHER HAND

  20. MASK VENTILATION TECHNIQUE 2 2 HANDED: 1 PERSON HOLDS MASK WITH BOTH HANDS USING E-C METHOD OR APPLY PRESSURE WITH THUMBS & LIFT JAW WITH FINGERS; 2ND PERSON BAGS

  21. ENDOTRACHEAL INTUBATION

  22. THE DIFFICULT INTUBATION Failure to intubate can result in severe adverse events such as: • Airway trauma • Aspiration • Hypoxemia/Anoxic brain injury • Hypotension • Cardiac arrest & Death BE PREPARED & HAVE A PLAN

  23. IDENTIFYING THE DIFFICULT INTUBATION L E M O N • LOOK • EVALUATE 3-3-2 • MALLAMPATI • OBSTRUCTION/OBESITY • NECK MOBILITY

  24. DIFFICULT INTUBATION ASSESSMENT “LOOK” • Externally: Facial trauma; Unusual/Distorted anatomy • Internally: Foreign body; Secretions; Obstructing mass

  25. DIFFICULT INTUBATION ASSESSMENT • EVALUATE: 3-3-2 RULE • Mouth opening Tip of mentum to hyoid boneThyromental distance Access to airway and obtaining glottic view Can tongue be deflected to accomdate laryngoscope Predicts location larynx to base of the tongue. If larynx high angles difficult

  26. DIFFICULT INTUBATION ASSESSMENT

  27. DIFFICULT AIRWAY ASSESSMENT OBESITY • Redundant tissues in upper airway may obscure glottis • Positioning imp: Pillows under shoulders OBSTBUCTION • Epiglottitis, Quisy

  28. DIFFICULT AIRWAY ASSESSMENT NECK MOBILITY • ↓ Cervical spine mobility: RA,DM, Cervical immobility →COMPROMISED Sniffing position

  29. PRE-INTUBATION STRATEGY PREPARATION PRE-OXYGENATION POSITIONING PREMEDICATION

  30. PREPARATION • ASSESS AIRWAY: Look for signs of possible difficult bag mask ventilation/intubation OR both • ASSEMBLE EQUIPMENT: Check functional status • PREPARE MEDICATION • DEVELOP AIRWAY MANAGEMENT PLAN WITH BACK UP PLANS

  31. PREPARATION S T O P • Suction • Tools(Laryngoscope) • Oxygen • Position/Plan M A I D • Monitors(Bp,Sats,Cap) • Ambu-bag,Airw devic • Iv access • Drugs

  32. INFLUENCE OF LARYNGOSCOPES • Macintosh -No difference compared to Miller

  33. LARYNGOSCOPES • Miller

  34. LARYNGOSCOPES • McCoy -Has an angulated tip -Improves visualisation with less force; in neutral position

  35. LARYNGOSCOPES • Bullard/Airtraq -Rigid fibre-optic laryngoscope -Alignment of axes not required

  36. PREOXYGENATION • Establish oxygen reservoir -Replace nitrogenous room air mixture with 100% oxygen • Challenge in ICU -Head of bed elevation -NIPPV • Challenge in Obesity & Critically ill patients -Desaturate much quicker

  37. POSITIONING • SUPINE -Access to airway obstructed • SNIFFING -Head elevated, Neck extended -Imaginary horizontal line from external auditory meatus to sternal notch -Access to airway improved

  38. PREMEDICATION ICU pts-require very little or no drugs L O A D Lidocaine: Reactive airways & ↑ICP Opioids: Blunt sympathetic response & ↑BP Atropine: Bradycardia in kids particularly Defasciculating agent-↓dose competitive neuromuscular blockade: ↑ICP

  39. INDUCTION AGENTS • KETAMINE: Sedation & Analgesia; No hypotension; Bronchodilatory effect; Respiratory drive preserved; ↑ICP & BP. Dose: 1-2mg/kg iv • PROPOFOL: Rapid onset; No analgesia; Hypotension. Dose: 1.5-3mg/kg iv • MIDAZOLAM: Time to effect › 15min ; Hypotension. Dose: 0.1-0.3mg/kg iv • ETOMIDATE: Rapid onset; No analgesia/Hypotension. Dose: 0.3mg/kg

  40. MUSCLE RELAXANTS SUXAMETHONIUM ROCURONIUM • Onset 45-60sec; DOA 6-10min. • Dose: 1-1.5mg/kg iv; • C/I-Rhabdomyolysis, Hyperkalemia, Burns › 72hrs & Hx Malignant HT • Onset 60min; Longer DOA than Sux. • Dose 0.8 - 1.2mg/kg iv

  41. LARYNGOSCOPY TECHNIQUE

  42. BIMANUAL LARYNGOSCOPY

  43. CRICOID PRESSURE • Avoid regurgitation of gastric contents by occluding upper end of oesophagus • May worsen glottic view • BURP: Improve glottic view by manipulating thyroid cartilage

  44. LARYNGOSCOPY

  45. INSERTING ET TUBE

  46. CONFIRM ET TUBE PLACEMENT

  47. AIRWAY ADJUNCTS BOUGIE VIDEO LARYNGOSCOPE LMA CRICOTHYROID CANNULA SURGICAL CRICOTHYROIDOTOMY KIT

  48. BOUGIE

  49. VIDEO LARYNGOSCOPY

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