Michael Schuster, MD Renee KoltesEdwards, MD

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Michael Schuster, MD Renee Koltes-Edwards, MD

• These presenters will not discuss any commercial
  product or service. Nor will the presentation
  include discussion of any off-label and/or
  investigational use of any products or services.
  This presenter will not use any trade names in
  his presentation. The presenter does not have
  any relationship with the commercial supporters
  of this program.
• The sponsoring unit will not include discussion
  of any commercial product or service, nor will
  they discuss any off-label and/or investigational
  use of any product or service. Trade names will
  not be used.

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Airway Management

• Mike Schuster, M.D.

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Goals

• Basic airway evaluation
• Recognize potential difficult airways
• Learn management of the difficult airway

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The most important thing to an Anesthesiologist?
AIRWAY, AIRWAY, AIRWAY(plus the A is first in
the ABCs of resuscitation for a reason)
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Airway Complications

• Death
• Brain Death
• Hypoxemia
• Hypercarbia
• Trauma
• Chipped Teeth

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Incidence of Difficult Intubation

• Multiple attempts 1-4
• Unable to Intubate
  .5-.35
• Severe Complications .0001-.02

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Incidence

• Lost airway -- 85 respiratory malpractice
• Anesthesia Deaths -- 30

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Important Airway Management Issues

• Careful History
• Careful Exam
• Review Pertinent Radiology and Lab Data
• Formulate a Plan
• Maintain Expertise in Special Techniques
• Always Monitor Oxygenation and Ventilation

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Airway Assessment

• Can I Intubate this patient safely?
• History of Difficult Intubation?
• Examination of Old Records
• Examination of Patient
• Effects of Disease and the Airway

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Physiologic Airway Considerations

• Bag Mask Airway
• Ventilation
• Oxygenation
• Full Stomach
• Reactive Airways
• Cardiovascular Status

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Basic Anatomy
http//www.oto-hns.northwestern.edu/voice/VOICEBOX
/Xsection.htm
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http//en.wikipedia.org/wiki/ImageGray955.png
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Airway Exam

• Mouth (Mallampati)
• Teeth
• Jaw Mobility
• Cervical Spine
• Thyromental Distance
• Laryngeal Mobility
• Effects of Disease
• Effects of Obesity

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Mallampati Sign

• Base of Tongue
• Soft Palate
• Uvula
• Assess the Relationship Between the Tongue and
  Oral Cavity

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Mallampati Classes

• Class 3-4 associated with more difficult airway

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Teeth
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Nares

• Assess patency of each nasal passage.
• Use the more patent side for nasal
  airway/fiberoptic intubation.
• Avoid nasal intubation in patients with
• Clotting abnormalities
• CSF leak
• Skull base fracture
• Nasal polyps

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Cervical Spine (atlanto-occipital) Mobility
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Thyromental Distance

• 6cm easier

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Effect of Disease

• Limited Cervical Mobility
• Limited Mouth Opening
• Limited Jaw Movement
• Fixed Airway Tissue
• Distorted Upper or Lower Airway Anatomy
• Decreased Upper Airway Space

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Head and Neck Tumors
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Facies

• Airway Often Abnormal
• Pierre Robin Syndrome
• Treacher Collins syndrome
• Klippel-Feil
• Aperts Syndrome
• Fetal Alcohol
• Downs Syndrome
• Cleft Palate

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Pierre Robin Syndrome
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Treacher Collins Syndrome
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Aperts Syndrome
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Downs Syndrome
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Obesity
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Enough talk, just put the tube in would you?
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Basic Airway Equipment

• Suction
• The Bag and Mask Airway
• Oral and Nasal Airway
• The Laryngoscope and Endotracheal tube

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THE BAG AND MASK AIRWAYMOTHER OF ALL AIRWAYS
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Bag Mask
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Oral and Nasal Airways
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Endotracheal Tubes
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Blades

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The Laryngoscope
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Blade Selection

• Proper function of both Miller and Mac blades is
  dependent on appropriate length of blade
• Macintosh
• blade must be long enough to put tension on the
  hyoepiglottic ligament to lift the epiglottis
• better blade when little upper airway room to
  pass the ETT - small narrow mouth, palate,
  oropharynx
• Miller
• must be long enough to trap the epiglottis
  against the tongue
• better blade with small mandibular space
  (anterior larynx), large incisors, long floppy
  epiglottis

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Miller, R.D. Basics of Anesthesia2000p153
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Alignment

• Tracheal Axis
• Oral Axis
• Pharyngeal Axis

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Alignment
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What you want to see(minus the labeling of
course)
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Cormack Grades
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All I see is tongue, now what?
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Clinical Airways

• Known difficult intubation
• Known easy intubation
• Unknown difficult airway

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ASA Difficult Airway Algorithm
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ASA Difficult Airway Algorithm 2002
Anesthesiology 2003 98(5)1269-1277
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ASA Difficult Airway Algorithm 2002
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Management of Known Difficult Airway

• Awake fiberoptic intubation
• Surgical airway
• Retrograde intubation
• Fastrack LMA

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Types of Unknown Difficult Airways

• Cant intubate and can ventilate
• Cant intubate and cant ventilate

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Management of Cant Intubate and Can Ventilate

• Wake up
• Fiberoptic
• Other airway

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Management of Cant Intubate and Cant Ventilate

• Call for help and optimize situation
• Try to achieve an airway
• Goal is always OXYGENATION
• Use PPV and airways
• LMA and Combitube
• Surgical airway

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Additional Airway Equipment

• Eschmann Stylet
• The Fiberoptic Bronchoscope
• Special Scopes
• The Laryngeal Mask Airway
• The Light Wand
• The Combitube
• Retrograde Intubation Kit
• The Jet Ventilator

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Eschmann Stylet

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Eschmann Stylet
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• Used as adjunct to direct laryngoscopy
• Most useful with grade 2-3 views

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Fiberoptic Bronchoscopes

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The Fiberoptic Bronchoscope (FOB)
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Advantages Disadvantages

• Direct visualization below the cords
• Flexible adaptable to airway, no need to align
  axes
• Less stimulating
• Oral and nasal routes
• ETT over scope

• Expensive equipment
• Easily obscured field
• Difficult to clean equipment
• Easy to break
• Technical skill

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Special Scopes

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Bullard Scope
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WuScope
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McGrath Video Laryngoscope
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AirTraq
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Pentax Airway Scope
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The Glidescope
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DL and View
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Tube Insertion
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Tube Advancement
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Tube In Place
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Light Wands

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The Light Wand
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Advantages Disadvantages

• Inexpensive
• Not affected by secretions/blood

• False negatives
• Difficulty removing stylet from ETT
• Difficult to see without lowering lights

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Retrograde Intubation
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• Wire passed percutaneously through Cricothyriod
  membrane retrograde out the mouth or nose
• ETT is then passed antegrade into trachea
• Useful when large amount of secretions/blood or
  anatomical variations are present

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Retrograde Equipment

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Retrograde Set
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Placing Retrograde Wire
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Placing Endotracheal Tube
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Retrograde Airway
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Laryngeal Mask Airway (LMA)

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Laryngeal Mask Airway

• Supraglottic airway
• Easy placement- high success rate
• Blind technique (not affected by secretions)
• Several different designs
• Reusable and disposable models
• Best airway advance in the last 20 years
  (personal opinion)

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The Laryngeal Mask Airway
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LMA Insitu
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FOB Examination of Glottis after cLMA Placement
J Oral Maxillofac Surg 621108-1113, 2004
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After LMA Placement in the Difficult Airway

• Do Nothing
• Use the LMA as the airway device
• Remember, cricoid pressure may impede LMA
  insertion
• Regurgitation is less likely if hypoxemia is
  reversed
• Aspiration morbidity and mortality is much less
  than that with hypoxemic organ injury
• Blind Wire, Stylet, or Endotracheal Tube via the
  LMA
• Cricoid pressure again may impede LMA insertion
• If impeded, transiently release cricoid pressure
• Success rate of blind passage of an ETT via a
  cLMA is only 50-60

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Regular vs LTS Endotracheal Tube
Note increased distance beyond the LMA with the
longer LTS ETT
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Classic LMA and the Fiberoptic Bronchoscope
Bronchoscope, with pre-threaded LTS ETT, passed
via the laryngeal mask
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FOB Wire-Guided Exchange Technique

• Definitive airway using the LMA until exchange
• Equipment needed
• Insitu LMA
• Pediatric bronchoscope
• Bronchoscopic port airway adaptor
• Allows ventilation via the LMA to continue during
  FOB
• 140 cm length guide wire that will fit through
  working channel port of bronchoscope
• 14 french hollow stylet/airway exchange catheter
  (AEC)
• Endotracheal tube
• Lubrication

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Wire Hollow Stylet/Tube Exchanger Kit
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FOB Wire-Guided Exchange via LMA
1.) Place Bronchoscopic Port Adaptor into circuit
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FOB Wire-Guided Exchange
2.) Pass bronchoscope through the LMA into the
trachea ventilation continues
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FOB Wire-Guided Exchange
3.) Pass guide wire through bronchoscope
into the trachea
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FOB Wire-Guided Exchange
4.) Remove bronchoscope leaving guide wire
in the trachea
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FOB Wire-Guided Exchange
5.) Pass the airway exchange catheter over
wire and through the LMA into trachea
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FOB Wire-Guided Exchange
Use the largest diameter AEC that will fit
through the desired endotracheal tube. Larger
diameter airway exchange catheters (AEC) increase
the success rate of advancing the ETT into the
trachea.
6.) Remove wire leaving the airway
exchange catheter in the trachea
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FOB Wire-Guided Exchange
7.) Remove LMA over immobilized airway
exchange catheter
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FOB Wire-Guided Exchange
8.) Pass ETT over airway exchange catheter
into the trachea
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FOB Wire-Guided Exchange
9.) Remove airway exchange catheter from
immobilized endotracheal tube
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FOB Wire-Guided Exchange
10.) Connect ETT to circuit and ventilate.
Confirm placement of ETT (BSs, ETCO2, FOB
Inspection)
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Increasing Successful Passage of ETT over AEC

• Consider laryngoscopy to clear the supraglottic
  pathway the ETT must take over the airway
  exchange catheter
• May be able to visualize what is preventing
  passage of the ETT
• Use as large of diameter of AEC as possible to
  minimize the ETT getting hung-up and or the ETT
  kinking the AEC

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Increasing Successful Passage of ETT over AEC

• Failure of the ETT tip to pass the laryngeal
  inlet usually occurs secondary to the ETT tip
  engaging the right vocal cord or arytenoid
• Rotate the ETT 90 degrees counter-clockwise to
  rotate the tip of the ETT from the three oclock
  position to the twelve oclock position
• Consider starting with the endotracheal tube
  pre-rotated

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Aintree Intubation Catheter (AIC)

• The Aintree catheter (Length 56 cm) is a
  semirigid intubation catheter designed to enable
  fibreoptic-guided intubation via an insitu LMA
• Internal diameter 4.8 mm
• Accommodates a 4.0 mm fiberscope to guide
  placement
• External diameter of 6.5 mm
• Allows a tracheal tube of 7.0 mm to be placed
  over it

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Aintree Intubation Catheter

• Blunt tip of catheter is atraumatic to internal
  structures
• Centimeter marks facilitate accurate placement
  with shortened endotracheal tubes
• Use of a removable airway circuit adapters allow
  ventilation during exchange procedures
• Through-lumen design of catheter with distal side
  ports ensures adequate air flow

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Aintree Intubation Catheter

• The distal 3 cms (maneuverable portion) of
  bronchoscope extends beyond the end of the AIC

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AIC Insertion via a LMA using FOB
Fiberscope and AIC inserted into trachea via the
LMA (pLMA, in this model)
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Fastrach LMA-iLMA (Intubation, tracheostomy)
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iLMA

• Rigid, anatomically curved, airway tube that
• Is wide enough to accept an 8.0 mm cuffed ETT
• Is short enough to ensure passage of the ETT cuff
  beyond the vocal cords
• Optimizes alignment with glottic opening
• Rigid handle to facilitate
• One-handed insertion
• Removal
• Adjustment of the device's position to enhance
  oxygenation and alignment with the glottis

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Euromedical Endotracheal Tube

• Silicone, wire-reinforced cuffed endotracheal
  tube
• Has low volume cuff (but high pressure cuff) to
  minimize damage to cuff when passing though the
  metal shaft of the Fastrach
• Tube is straight, not pre-curved like standard
  ETT
• Sizes 6.0, 6.5, 7.0, 7.5, 8.0 mm ID
• The tube tip is curved to facilitate advancement
• The tip is much softer than a polyvinyl chloride
  (PVC) endotracheal tube and is specially molded
  to avoid trauma to the vocal cords

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iLMA and Euromedical Endotracheal Tube

• Epiglottic elevating bar (at red arrow) in the
  mask aperture elevates the epiglottis as the ETT
  is passed through
• This ramp effect directs the soft tipped ETT
  centrally and anterior, reducing the risks of
  arytenoid trauma or esophageal placement

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iLMA-Insertion
Insertion is possible from any position. No head
or neck manipulation is required. With the mask
fully deflated, rub lubricant over the anterior
palate with the device in the position shown here.
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iLMA-Insertion

• The mask is swung into position in a singular
  movement while pressure is maintained against the
  palate and palatopharyngeal curve.

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Euromedical Endotracheal Tube

• Designed for blind or FOB directed advancement
  into trachea
• Blind passage failure rate is higher when
  compared to fiberoptic and lightwand guided
  techniques
• Success rate of blind intubation with the iLMA
  can reach 95-97
• Reusable
• 10 use lifetime for the ETT
• 40 uses for the iLMA
• ALWAYS TEST INFLATE the cuff before each use!!
• Reusable device
• Cuff may not inflate properly
• Cuff may not hold a cuff pressure

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iLMA Removal Over An ETT
Remove the ETT connector and place it in the
circuit (avoids losing it). Gently ease the LMA
out over the ETT into the oral cavity. Use
stabilizer rod to "hold" ETT in position as iLMA
is withdrawn over tube (Figure 3)
Remove the stabilizer rod and hold onto the ETT
at the level of the incisors (Figure 4). (Some
use an appropriately sized endotracheal as a
stabilizer so ventilation isnt interrupted)
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iLMA FOB Guided ETT Tube Insertion

• Lubricate desired size ETT
• Pre-thread over FOB
• Adjust the iLMA to optimal ventilation
• Advance Silicone ETT to the 15 cm mark
• At this depth the ETT tip lifts esophageal
  elevator bar and ease passage of the bronchoscope
  preventing damage to the bronchoscope tip

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iLMA FOB Guided ETT Tube Insertion

• Visually pass the FOB into trachea
• May be facilitated by using the metal handle to
  gently lift anteriorly (not tilting) the LMA-i2-5
  cms away from the posterior pharyngeal wall
• Advance ETT into trachea, remove FOB (under
  visualization to see the ETT tip in the trachea),
  and Confirm Ventilation and ETT Placement

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FOB ETT Tube Insertion via the iLMA

• Consider fiberoptic bronchoscopy to guide the ETT
  initially or when difficulties encountered with
  blind ETT passage

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Proseal LMA
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LMA ProSeal (Regurgitation risk, positive
pressure ventilation, prone position,
laparoscopic surgery)

• Low profile, flexible airway tube
• Larger and deeper bowl with no grill
• Higher sealing pressures than a cLMA
• Removable introducer allows insertion without the
  need to place fingers in mouth
• Drainage tube exiting at mask tip

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Proseal LMA and Stylet
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Proseal LMA Back Cuff
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CTrach Laryngeal Mask Airway
Modified intubating LMA Contains light and return
image fiberoptic bundles Located ventrally on
mask Attachable viewing screen Contains the video
processor and the power and light sources
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CTrach Laryngeal Mask Airway
Unique opening in the epiglottis elevating bar
allows visualization of glottis and vocal
cords Allows either spontaneous or controlled
ventilation to occur concurrently with
visualization of the glottis Facilitates passage
of the endotracheal tube Optimal glottic
alignment achieved prior to ETT passage Watch
ETT pass through vocal cords Redirect ETT in
real-time
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CTrach Grading of Laryngeal View
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Combitube

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Combitube

• Easy Airway Placement
• Separates Airway from GI system
• Minimal Skills

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The Combitube
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Laryngeal Tube
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Indications for Emergency Surgical Airway

• Cant intubate, cant ventilate, cant oxygenate
• Other airway methods have failed

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Devices for a Surgical Airway

• IV catheter
• Wire-guided Seldinger kits
• Direct needle kits
• Surgical trays

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Goals of Cricothyrotomy

• Provide an AIRWAY
• Provide OXYGENATION
• Ventilation

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I.V. Cricothyrotomy Jet Ventilation
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Air Contrast TechniqueLOOKING FOR THE AIR
VESSEL!!!
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LOR Technique
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Catheter in Place
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The Jet Ventilator
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Jet Ventilator Connection
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Jet Ventilator
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Jet Ventilator On 50 psi!!
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Useful Clinical Endpoints

• End-tidal CO2
• Oxygenation
• Breath Sounds
• Gas egression out of the airway

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Jet Ventilation Complications

• Barotrauma
• Puncture of other tissues or organs
• Hemorrhage
• Subcutaneous or mediastinal emphysema

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Anesthesia Machines are not Jet Ventilators

• Use oxygen flush button
• Will oxygenate
• Driving pressure will vary

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Cricothyrotomy Kits
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Air Contrast Puncture
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Seldinger Wire In Place
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Cricothyrotomy
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Air Contrast Technique

• Air Contrast Needle
• Seldinger Technique
• Similar to placing a Central Line
• 15mm Airway Connector
• 4 mm and 6mm ID
• Cuffed 6 mm

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Cricothyriod Puncture
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Catheter In Place
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Wire Placement
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Wire In Place
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Melker Placement
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Skin Incision
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Obturator Removal
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Ready For Ventilation
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Best Airway

• Situation dependant
• Allows for oxygenation
• Allows for ventilation (though secondary to O2)
• Clinical situations are fluid, and so the best
  airway may change

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• Evaluate airway to reduce risk of unanticipated
  difficult airway
• Call for help early and often
• Use equipment you have available and have
  practiced using

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Now Lets Play!