PHD Resident Airway Lecture

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PHD Resident Airway Lecture

• Alan I. Frankfurt, MD

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

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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.

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Airway Class Objective

• Use this airway training as your own Red Flag
  Exercise
• Training
• Lecture
• Hands on lab
• Visualization

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Airway Topics

• Relevant airway anatomy
• Innervation of the airway
• Anesthesia of the airway
• PUlt92 Concept
• Airway examination
• 6 Ds

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Airway Definitions and Concepts

• Jim Rich, CRNA
• Critical airway event ability to rescue the
  airway.
• CICMV
• Intubation difficulty
• Definition difficult airway
• SPO2lt92
• 100 Oxygen
• PPV
• Crash airway early recognition for patient
  salvage.
• PUlt92
• IRS
• Intubation
• Rescue breathing
• Surgical airway
• Airway Evaluation 6 Ds
• Difficulty airway options
• Intubation rescue options
• Law of insanity
• AB4CS

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Overview of Upper Airway AnatomyStructure and
Function
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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

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Pharynx

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

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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

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Larynx

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

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Laryngeal Anatomy
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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.

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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

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Airway Innervation 5-9-10
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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

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Anesthesia for the Mouth and Oropharynx CN 9

• Anatomy
• Glossopharyngeal nerve (CN9)

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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).

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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

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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.

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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

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Airway Local Anesthesia Drug Absorption

• Topical anesthetic absorption
• AlveoligtTracheobroncheal treegtPharynx

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Airway Anesthesia Medications

• Cocaine
• 4 and 10 solutions
• 3 mg/kg (200 mg maximum dose)
• 5ccs 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.

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Goal of Airway Anesthesia
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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

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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

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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
• Dont burn any airway bridges
• Reversible agents
• Lubrication
• The entire airway can be anesthetized topically
  with generous amounts of anesthetic jelly and
  ointment.

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Recurrent Laryngeal Nerve BlockAKA
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

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Recurrent Laryngeal Nerve BlockAKA
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.

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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.

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PU-92 Concept

• Crash Airway

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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.

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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.

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PU-92 Parameters

• Level of consciousness
• SpO2 level

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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 GCSlt9
• GCSlt9 immediate indication for intubation
• Patients SpO2 level
• SpO2lt92, despite
• Maximum airway efforts utilizing
• PPV
• manual airway opening techniques
• 100 oxygen ( if available).
• If SpO2 unavailable, use a RR lt10 or gt
  30/breathes per minute.
• Use of SpO2 in the field environment.
• Masimo
• Movement algorithm
• Low perfusion algorithm
• Co and MetHg

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PUlt92 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

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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

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ECT Esophageal Combitube Tube
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ECT Esophageal Combitube Tube
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ECT Esophageal Combitube Tube
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LMA
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King LT
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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 Ds
• Rescue ventilation
• If intubation fails or airway appears difficult
• SpO2gt92
• Yes-monitor airway and reassess need for
  definitive airway
• No-gt

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Airway Evaluation

• 6-D Method of Airway Assessment

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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.

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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.

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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.
• Patients anatomy
• Assessment
• Mallampati Classification
• Predicting airway disproportion problems
• Mallampati class 4 (3?)
• Swelling or protruding tongue
• Blunt or penetrating injury
• Receding mandible

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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.

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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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6-D Method of Airway Assessment

• Decreased thyromental distance
• Reflects an anterior larynx and decreased
  sub-mandibular space.
• Problem
• Unable to displace the tongue into the
  submandibular space, out of the view of the
  laryngoscopist.
• Predicting airway difficult resulting from
  decreased thyromental distance
• Thyromental distance lt7 cm (lt3 FB)
• Measured from the superior aspect of thyroid
  cartilage to the tip of the chin.
• Underdeveloped mandible

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6-D Method of Airway Assessment

• Decreased interincisor gap
• Reduced mouth opening
• Reduced ability of the oral cavity to accommodate
  airway instrumentation.
• Predicting airway difficulty secondary to
  decreased incisor gap distance
• Distance between the upper and lower incisors is
  lt4 cm ( 2 FB )
• Mandibular condyle fracture.
• Rigid cervical collar.
• TMJ dysfunction

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6-D Method of Airway Assessment

• Decreased range of motion in any or all of the
  joints of the airway.
• Atlanto-occipital joint, cervical spine and TMJ.
• Sniffing position.
• Predicting airway difficulty secondary to
  decreased ROM of joints involved in assuming the
  sniffing position
• Head extension lt 35 degrees
• Neck flexion lt 35 degrees
• Short, thick neck
• Cervical spine collar or C spine immobilization

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6-D Method of Airway Assessment

• Dental overbite
• Large angled teeth disrupt the alignment of the
  airway axes and possibly result in decreased
  interincisor opening.
• Predicting airway difficulty secondary to dental
  overbite
• Protruding maxillary incisors.

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Treatment of Airway Loss Operator Skill and
Equipment Requirements.

• Causes of Airway Obstruction LIFT
• L-Level of consciousness
• Trauma or Medications.
• Loss of muscle tone
• Jaw lift
• Nasal trumpet
• I-Inflammation
• Burns
• Early intervention
• Advanced airway techniques
• Anaphylaxis
• F-Foreign body
• Blood clots, teeth, bone, food
• Finger sweep, positioning
• T-Trauma
• If it was pushed inpull it out.

• Treatment of Airway Obstruction AIR
• A-Assess for airway obstruction
• Recognition
• Signs and symptoms
• Dysphonia, noisy breathing, RRlt8 or gt30, use of
  accessory muscles.
• I-Improve the airway
• Positioning
• Position of comfort
• Recovery position
• Cervical spine precautions.
• Mechanical
• Jaw thrust,
• Chin lift
• Nasal trumpet(s)
• R-Remove any debris
• Finger sweep

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Indications for Tracheal Intubation

• Airway protection and risk for aspiration.
• Need for a definitive airway.
• Patient will be going to OR and has an unstable
  airway.
• Respiratory failure/arrest and in need of
  mechanical ventilation
• PEEP administration
• GCSlt9 or on AVPU scale a P or U
• ACLS drug administration
• Pulmonary toilet
• Hypoxemia refractory to oxygen therapy
• Uncontrolled seizure activity
• Depressed LOC in a trauma patient
• Combative patient with a compromised airway.

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Emergency Indications for Intubation

• Cant protect airway
• Gag reflex absent in 37 population
• Ability to swallow and manage secretions
• Cant maintain Ventilation/Oxygenation
• Inability to maintain SpO2gt92 on oxygen,
• PaCO2gt55 or 10 torr above baseline.
• RR lt8 or gt30/ minute
• Expected decline in clinical status.
• Deterioration/Impending compromise
• Transport

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Contraindication to RSI

• Evaluation of the patients airway reveals that
  laryngoscopy and intubation would not be
  successful
• 6 Ds
• Unfamiliarity with the technique
• Do what you do all the time.
• Lack of any rescue ventilation options
• Plan A, B, C.
• Other safer options
• Awake intubation under topical and nerve block
  anesthesia
• Cricothyrotomy under local anesthesia
• Local infiltration
• Transtracheal block
• Dont burn an airway bridge.
• A lousy airway is better than no airway.

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Direct Laryngoscopy Checklist

• Variety of laryngoscopy blades
• Variety of Endotracheal tube (ETT) sizes
• Stylett the ETT
• Boogie
• Test balloon on ETT
• Class 2a rescue ventilation device
• Adequate muscle relaxation if indicated
• Head position
• Suction
• Test IV patency
• Pre-treatment
• Oxygen
• Vagolytic
• Non particulate antacid
• RSI indicated?
• Assistant present as available
• Look for the epiglottis first
• Dont shotgun the laryngoscope
• Control the tongue

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Techniques to Rescue a Difficult Intubation

• Avoid the Law of Insanity

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Law of Insanity

• Doing the same thing over and over again while
  expecting a different result.

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Techniques to Rescue a Difficult Intubation

• Access
• Visualization
• Passage of the ETT

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Techniques to Rescue a Difficult Intubation Law
of Insanity

• AB4CS
• Axis
• Boogie
• BURP
• Blade size and type
• Block
• Cricoid pressure let up
• Stylet/Smaller ETT

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Techniques to Rescue a Difficult Intubation

• Sniffing Position
• Head extension
• Neck flexion
• Onto the shoulders
• 20-30 degree angle

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Aligning Axes of Upper Airway
Mouth

• A

B
A
B
C
C
Pharynx
Trachea
Extend-the-head-on-neck (look up) aligns axis
A relative to B Flex-the-neck-on-shoulders
(look down) aligns axis B relative to C
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External Laryngeal manipulation (ELM) BURP

• BURP
• Laryngoscopist hand placed on top of assistants
  hand.
• Backward, Upward, Rearward Pressure.
• Thyroid cartilage

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Gum Elastic Bougie
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Gum Elastic Bougie

• Most beneficial with a Grade III larygoscopic
  view.
• Works synergistic with other airway maneuvers
• ELM BURP airway manipulation
• Jaw thrust/chin lift.
• Indicators of successful tracheal placement of
  the bougie
• Tracheal clicking
• Hold up
• Leave the laryngoscope in place during ETT
  insertion with the bougie in place.
• Rotate the ETT counter clockwise 90 degree to
  prevent the tip of the ETT from hanging up on
  laryngeal structures during passage.

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BURP Maneuver

• Difficult intubation rescue option
• Improve visualization of the larynx by at least
  one grade.
• Knill RL Can J Anesth 199340279-82
• BURP maneuver results in displacement of the
  larynx in three specific directions to place the
  vocal cords in view of the operator
• Backward-Thyroid cartilage displacement dorsally
  (backward) as to abut the larynx against the
  bodies of the cervical vertebrae.
• Upward-Thyroid cartilage is moved cephlad about 2
  cm until mild resistance is met.
• Rightward-laterally to the right approximately
  0.5-2.0 cm.
• Pressure
• Employing the BURP maneuver, the assistant moves
  the larynx until mild resistance is met.

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BURP Maneuver Mechanism of Action

• As a result of the BURP maneuvers, the glottis is
  moved directly into the line of vision. Lets
  examine why this is true
• The laryngoscope enters the oral cavity from the
  right and displaces the tongue toward the left.
• Tongue attached to larynx.
• Hence the larynx is moved leftward as well.
• Resulting visual pathway is somewhat to the right
  side of the oral cavity midline.
• BURP maneuver may improve visualization of the
  glottis by moving the larynx more into the line
  of vision.

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Effect of BURP on Visualization
Grade Initial Inspection After BURP
Grade 1 0 231
Grade 2 181 38
Grade 3 80 4
Grade 4 12 0
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Surgical Airway

• Cricothyrotomy
• Rapid Access to the Airway or Not.

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Indications for Surgical Airway

• Clinical
• Mid face trauma
• Blunt vs. Penetrating
• Airway obstruction above the level of the cricoid
  cartilage.
• Anaphylaxis/Anaphylactoid reaction
• Burn
• Failed intubation and failed rescue ventilation

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Cricothyrotomy Rapid 4 Step Technique

• Instruments Rapid 4 Step Technique
• Scalpel with a no.20 blade, tracheal hook, no. 6
  Shiley tracheostomy tube.

• Instruments Std Technique
• Scalpel with no.11 blade, Trousseau dilator,
  hemostats, tracheal hook, no. 6 Shiley
  tracheostomy tube.

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Cricothyrotomy Standard Technique

• Steps
• Identification of the cricoid membrane
• Palpation
• Sternal notch
• Dissection
• 4 cm vertical skin incision over the cricoid
  membrane.
• Short horizontal stab wound over the lower
  portion of the cricoid membrane.
• Never remove scalpel blade until tracheal in
  place.
• Stabilization of the larynx with a tracheal hook
  at the inferior aspect of the thyroid cartilage.
• Dilation of the ostomy with a curved hemostat.
• Placement of the Shiley tube/Endotracheal tube.

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Cricothyrotomy Rapid 4 Step Technique

• Steps
• Identification of the cricothyroid membrane by
  palpation.
• Horizontal stab wound through the skin and
  cricothyroid membrane with the scalpel.
• Non-palpable anatomy skin incision
• Stabilization of the larynx with the tracheal
  hook at the inferior aspect of the ostomy (on the
  cricoid cartilage), providing caudal traction.
• Placement of the Shiley tube in the trachea.

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Cricothyrotomy Modified Technique

• Identification of the cricoid cartilage.
• Easy
• Hard
• Non palpable and non visualized
• Sternal notch and work your way upward.
• Anesthesia?
• Local infiltration
• Transtracheal block
• 2-4 cm vertical incision overlying the cricoid
  membrane.
• Not a cosmetic procedure.
• Use the entire incision
• Define your anatomy
• No. 20 blade attached to a scalpel for cricoid
  membrane puncture.
• Puncture made at the superior aspect of the
  cricoid cartilage.

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Cricothyrotomy Modified Technique

• Tracheal hook applied to the superior surface of
  the cricoid cartilage.
• The cricoid cartilage is delivered out of the
  wound.
• Stabilizes the larynx.
• Prevents blood from pooling in the wound.
• Not working in a deep hole.
• Kelly clamp used to dilate the ostomy.
• 5-6 ETT/6 Shiley placed in the ostomy
• Bougie
• Confirmation of tracheal intubation
• CO2 detection
• Capnography
• Colorimetric
• SIB (Self inflating bulb)

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Questions?