Airway Management Techniques By Hwan Joo MD

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Airway Management TechniquesBy Hwan Joo MD
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Airway Presentation

• Normal Airway Management
• Closed Claims
• Difficult Intubation and Tools
• Difficult Ventilation and Tools
• Intubation tools for Surgeons
• Overall goals
• Teach surgeons about airway tools
• Not necessarily how to intubate

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Indication for Tracheal Intubation

• Oxygenation and Peep
• Ventilation
• Airway protection from Aspiration
• Tracheal toilet and/lung washings
• Route for drug administration

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Airway Assessment

• The Mallampati view may be indicative of
  difficult airway
• Negative predictive value gt99 for MP 1-2
• PPV for MP 4 only 40
• MP and laryngeal view not very correlative

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Difficult Airway Assessment

• History of difficult Intubation
• Physical examination
• Trauma
• C-spine precaution
• Blood in airway
• Airway trauma
• Morbid obesity
• RSI makes it worse!

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Direct Laryngoscopy

• 3 Mcintosh blade most commonly used
• No change in design for 60 years
• High success rates in normal airways (99)
• However, difficult to learn
• gt50 uses to be proficient
• Not so good with difficult airways

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Laryngeal Mask Airway

• Comes in sizes 3, 4, 5 (small, medium large)
• Great for ventilation
• Insertion easier if you have deep anesthesia
• Does not protect against aspiration
• Not able to deliver high pressure ventilation
• Useful for difficult airways and failed
  laryngoscopy

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Induction of for Intubation

• Nothing
• Patient already non-responsive
• Medications contraindicated
• Topical lidocaine
• Midazolam, fentanyl
• EtomidateSux
• KetamineSux
• PropofolSux

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Closed Claims -Caplan, Anesthesiology 1990

• Airway -Largest and most costly form of injury
  (34 of all claims, 200,000 US)
• Inadequate ventilation (34)
• Esophageal intubation (18)
• Difficult intubation (17)
• 36 of claims against difficult intubation cases
  considered preventable

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Closed Claims in Canada

• Between 1993-2003, 50 of all large CMPA suits in
  anesthesia were airway related
• Average settlement was 500,000
• 75 of patients suffered brain damage or deaths
• 50 were associated with difficult airways
• In half of these patients, difficult airway
  adjuncts were not used
• Therefore, there is room for improvement

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ASA Difficult Airway Algorithm

• Recognized difficult airway
• intubation vs non-intubation
• facemask, LMA
• regional
• Unrecognized difficult airway
• can ventilate
• convert to spontaneous ventilation?
• awake vs asleep
• cannot ventilate
• emergency measures required

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Difficult Intubation -Ventilation Possible

• Awaken patient
• Asleep fiberoptic intubation
• LMA without intubation
• Intubation via LMA or ILMA
• Lighted stylette
• CombitubeTM
• Video laryngoscope

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Flexible Fiberoptic Intubation

• Awake fiberoptic intubation is the gold (Rose CJA
  1994)
• Asleep FOI, successful but,
• It may be more difficult due to
• Airway obstruction or apnea
• Blood in pharynx
• Limited time before oxygen desaturation
• Should be done with help!

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Laryngeal MaskAirway for intubation

• Success for intubation with conventional LMA is
  variable (19-93)
• Success may be improved by the use of a pediatric
  bronchoscope via the ETT in LMA
• LMA removal may be difficult after intubation
• Consider LMA without intubation

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Lighted Stylette (TrachliteTM)

• With experience
• Success rates reported to be up to 99 in
  patients with difficult airway (Hung, CJA 1995)
• Success rates for novices 50 (Wilk, Resuc 1997)
• Success rates decreased in patient with bull
  necks and obese patients

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CombitubeTM

• Success rates by non-anesthesiologist with
  combitube has ranged (33-93)
• Average beginner success rates expected to be in
  the 80-90 range (Anesthesia-trained)
• May be associated with esophageal injuries and
  mediastinitis (Vezina, CJA 1998)

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Video Laryngoscopes Glidescope

• Rigid laryngoscope with CCD
• View is very clear with no fogging
• Blade angle 50-60 deg
• Easy to use
• Very rapid learning curve
• Can also be learned by ER physicians, Surgeons

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Glidescope

• Need to use introducer with ETT (60 bend)
• Easy to view vocal cords
• But sometimes difficult to navigate ETT into
  trachea
• May still fail in some patients
• Need to practice ETT manipulation under video
• Expected success 80-95

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Glidescope in Use
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Glidescope Success Rates with Experience Joo et
al
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Glidescope with Disposable Blade
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McGrath Videolaryngoscope

• Similar to Glidescope
• Disposable blade cover
• Beautiful all in one design
• Optics not be as good
• Narrow field of vision
• More difficult?
• More portable
• More likely to disappear

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Video LaryngoscopesRES-Q-SCOPE

• LCD Screen
• Disposable blade
• Much cheaper initial cost
• However, 50 per use

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AirtraqWhat is wrong with this picture?
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Ventilation Difficult or Impossible

• Failed intubation is disturbing but..
• Failed ventilation is universally fatal!
• Choices
• LMA (will discuss ILMA later)
• Combitube
• Transtracheal airway
• cricothryotomy
• transtracheal jet ventilation
• tracheostomy

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Laryngeal Mask Airway

• Success rates for ventilation as high as
• 95 after 1 attempt and 98 after 2 attempts
• No decrease in success rates in patients with
  difficult airways
• Overwhelming data of uses in difficult airways
  and in failed ventilation
• may have saved 100s of lives!
• For IPPV use large LMAs

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What is the Best Device for Failed Ventilation?
LMA vs. CombitubeTM

• Success is dependent on more on the operators
  experience than to tool
• Majority of anesthesiologist have little or no
  experience with the Combitube
• LMA should be the first choice for difficult
  ventilation scenarios
• However, Combitube theoretically prevents
  aspiration

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Trans Trachea Airway FOR UPPER AIRWAY OBSTRUCTION

• TTJV (jet ventilation)
• difficult with multiple complications
• Needle cricothryotomy
• High success rates using Seldinger technique
• No need for jet
• Slash or surgical tracheotomy
• Messy but may do the job

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Intubating Laryngeal Mask Airway (ILMA)
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ILMA with FOB

• Things of interest
• Elbow connector
• Continuous ventilation
• PVC Tube
• Metal rings in silicone tube not compatible with
  FOB
• Better than C-Trach?
• Better manipulation
• Higher Success rates

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What is this?

• The view via ILMA is different from regular FOB
• The epiglottis is often distorted
• Obviously blind intubation failed
• Larger ILMA required

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LMA C Trach

• ILMA with LCD screen
• Improved success rates for intubation over ILMA
• Success on normal airways about 90-95 based on
  limited studies
• However, need greater mouth opening compared to
  ILMA, 2.5cm versus 2.0 cm
• Same success rate for ventilation
• Less trauma

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Failed IntubationWhat to do as a Surgeon

• Awaken patient if possible/feasible
• Maintain ventilation and oxygenation
• Facemask
• LMA
• Combitube
• Call Anesthesia
• Surgical Airway
• Attempt ventilation throughout

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Airway Tools not for Surgeons

• FOB
• Too much effort required to learn
• Hard to maintain in ER expensive!
• Not as useful in unplanned cases (ER)
• Lighted Stylettes
• Again, high learning curve
• Not as useful in patients who are not paralyzed
• High incidence of esophageal intubations

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What is the Best Tool for Surgeons?

• LCD Laryngoscopes are the way of the future
• Currently, Glidescope is the easiest to use with
  the most literature supporting it
• Must Practice on routine patients
• Use it get familiarity
• Bug the anesthesiologists to use it in the OR
• Cost of acquisition about 6000 with 20-30/use
  for disposable blade

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Video (LCD) Laryngoscope

• Glidescope
• Verathon
• McGrath
• Vitaid Medical
• Airtraq
• ? But available in Canada

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The Future The future of intubation will be
video assisted

• In the past, intubators intubated in the dark by
  themselves
• PRIVATE (MASTURBATION!)

• The future will have everybody involved in the
  process of intubation
• (ER Doc, Nurses, RT)
• PARTY!
• Everyone is involved

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Final Recommendation

• When faced with a difficult airway, stay on the
  beaten path of
• Practice, Practice
• Use familiar but advanced devices
• Do not persist with techniques that have failed
• Secure ventilation