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PSU Airway Management Excellent CenterAirway Assessment and Difficult Airway
ManagementNalinee Kovitwanawong, MD.Department of Anesthesiology
Faculty of MedicinePrince of Songkla University
Scope of Problem
Approximate 20-25 million patients per year in the US are
intubated for surgical procedures
1-3% incidence of unanticipated difficult airway
UK : approximate 3 million patients per year for GA.
Almost half : tracheal intubation
2.2% was expected difficult airway
International : HUGE problem
First phase of NAP4. BJA2011; 106(2):266-71
A Closed Claims Analysis 1961-1996
- Airway injury during GA is a significant source of morbidity
for patient and liability for anesthesiologist
- 4,460 claims : 6% were airway injury claims
39% of airway injury claims associated with
difficult intubation
- No different in ASA status, proportion of obese patients
- 8% result in death
Anesthesiology 1999; 91: 1703-11
National Health Service Litigation Authority data in UK 1995-2007
claims related to airway management :
5th Most common reason for anesthesia related litigation
BJA 2011; 106(2): 266-71
ASA Closed Claims 1976-2007
no. of claims
Permanent br. damage 867
Airway injury 581
Difficult intubation 466
Spinal cord injury 417
Medication Errors 283
Central venous cath injury 183
Best Practice & Research Clinical Anaesthesiology 2011; 25: 263-76
ASA Closed Claims 1976-2007
Esophageal intubation has nearly disappeared
Inadequate O2 or ventilation has declined in OR not out OR
setting
Difficult intubation remains a concern 27% of adverse
respiratory events
Pulmonary aspiration 3rd most common respiratory event
Best Practice & Research Clinical Anaesthesiology 2011; 25: 263-76
PSU Data : AirwayTechniques
Teachniques 2012 2013 2014 2015Endotracheal/tracheostomy 9,111 9,980 8,433 9,824
Awake intubation blind nasal 7 9 6 0
Awake intubation by oral 17 28 49 42
Awake intubation by fiberoptic 39 59 61 71
I gel insertion 533 218 153 42
Laryngeal mask anesthesia 1,794 1,465 1,503 1,527
Laryngeal tube 12 0 10 0Glidescope Technique 306 275 266 537
Difficult Airway
American Society of Anaesthesiologists Task Force definitions
The difficult airway is “the clinical situation in which a conventionally trained Anesthesiologist experiences difficulty with facemask ventilation, difficulty in supraglottic device ventilation, difficulty in tracheal intubation or all three”
o difficulty with facemask ventilation is the inability of an unassisted anesthesiologist a) to maintain oxygen saturation, measured by pulse oximetry 92%.b) to prevent or reverse signs of inadequate ventilation during positive-pressure mask ventilation under general anesthesia.
o Difficulty in SGA ventilation : poor device placement or inability to adequately ventilate with device successfully placed.
o Difficult laryngoscopy occurs when it is not possible to visualize any portion of the vocal cords with conventional laryngoscopy after 2 attempts. This typically corresponds to a Cormack and Lehane Grade IV laryngoscopy view
o Difficult endotracheal intubation occurs when “proper insertion of the tracheal tube with conventional laryngoscopy requires more than 2 attempts”
o Difficult surgical airway : may be cause by anatomical abnormality.
PSU Data : Difficult Airway
AirwayFrequency
2013 2014 2015
1. Suspected difficult airway 434 544 474
2. Anticipated difficult airway 30 46 22
3. Unanticipated difficult airway 0 0 0
4. Failed intubate 0 1 1
Incidence
• incidence of difficult airways is poorly defined, and varies according to the setting
• incidence of failed intubation (Cook and MacDougall-Davis, 2012)
• ~ 1 in 1–2000 in the elective setting
• ~ 1 in 300 during rapid sequence intubation in the obstetric setting
• ~ 1 in 50–100 in the emergency department (ED), intensive care unit (ICU), and pre-hospital settings
Difficult airway management
• Team and equipments preparation
• Airway assessment
• Call for help
• Oxygenation
• Aware airway trauma
• Aware cannot intubate/cannot ventilate
• Plan for extubation
• Follow up
Prediction of difficult airway
Unrecognized
difficult airway
25-30 %
Hypoxia
Dead
Adenoid
Polyp
Tumor
maxillar
Tongue
Mandible
Tonsil
Buccal mucosa
Cervical
spine
Larynx
Subglottic
Thyroid
Trachea
Esophagus
Airway assessment
• History
• physical examination
• Investigation
: chest x- ray
: computed tomography (CT)
: magnetic resonance imaging (MRI)
History taking
• Snoring, OSA, difficult intubation
• Chart
• Congenital anormaly
• Nose, mouth, neck pathologies
• Previous surgery
• Airway disease
Congenital anormaly andAirway disease
Down’s syndrome
Pierre Robin syndrome
Cystic hygroma Lymphangioma
Supraglottitis, croup,
epiglottitis
Retropharyngeal abscess
Ludwig’s angina
Papillomatosis
CA tongue, CA larynx
Tumor of oral cavity
Thyroid gland disease
Head, facial, cervical spine injury
Laryngeal trauma
Acute burn
Burn scar
Rheumatoid arthritis
Temporomandibular joint
ankylosis
C-spine immobility
Diabetic mellitus
Stiff joint syndrome at cervical joint
or TM jointSalzarulo HH,1986, Warner ME,1998
McAnulty GR, et al.2000
Ankylosing spondylitis
Morbid obesity
edentulous
Airway Assessment
6-D Method of Airway Assessment
6-D Method of Airway Assessment
Proc(Bayl Univ Med Cent).2005 Jul 18(3): 220-227.
6-D Method of Airway Assessment
Accuracy of Risk Factors in Predicting Difficulty with Tracheal Intubation
Bedside predictors of difficult tracheal intubation are imperfect !!
NAP4 study : major complications related to airway management
Led to death
Brain damage
Need for emergency surgical airway
Unanticipated ICU admission
Prolongation of ICU stay
T.M.Cook et al.BJA 2011; 106(5): 617-42
Recommendation
• Strong recommendation for : most patients
should receive the intervention
• Weak recommendation for : most patients
would want the suggested course of action,
but some would not
• Strong recommendation against : most
patients should not receive the intervention
• Weak recommendation against : most
patients would not want the suggested
course of action, but some would
Level of evidence
Level of evidence A (High) : systematic
reviews of RCTs
Level of evidence B (Moderate) : RCTs
with limitations, observational studies
with sig therapeutic effect
Level of evidence C (Low) : RCTs with sig
limitations, observational studies, case
series, expert opinion
Management of the difficult and failed airway in the
unconscious/induced patient (RSI)
https://www.das.uk.com/guidelines/das_intubation_guidelines
Positioning during intubation
Positioning during intubation
Difficult direct laryngoscope
Proper positioning of patient and
laryngoscope blade tip
External laryngeal pressure (strong
recommendation for, level B)
Blade change (little evidence) : specific
anatomy finding during initial DL
Tracheal tube introducer (strong
recommendation for, level B)
cricoid pressure (weak recommendation
against, level C)
Limit to tracheal intubation attempts
Patient morbidity increases with the
number of attempts
aspiration
hypoxemia
hypotension
trauma
etc.
Three failed attempts : indication to
declare “failed intubation”
VDO Laryngoscope
Difficult VDO laryngoscope
3 independent tasks
Namely
Laryngeal exposure
Delivery of ETT to laryngeal inlet
Non-channeled blades
Preload stylet with a curvature matching
Channeled blades
Suction prior to insertion
SAD
Difficult face mask ventilation
Placement of appropriately size
oro/nasopharyngeal airway
Two-handed mask hold
Exaggerated head extension
(strong recommendation for, level C)
Release of cricoid pressure (weak
recommendation for, level C)
After corrective maneuvers : SAD, ETT
Tracheal intubation confirmation
Capnographic confirmation (strong
recommendation for, level B)
ongoing continuous wave form
capnographic monitoring during the
duration of intubation (strong
recommendation for, level C)
continuous wave form capnographic
monitoring has also been recommended in
deep sedation patient
Documentation
Appropriate documentation should be
completed following every airway intervention
(strong recommendation for, level C)
Medical record
Informing the patient
Patient’s surgeon
Letter to primary care provider
Bracelets
local or national database
Education in difficult airway management
Technical skills : specific medical knowledge
: procedural ability required for
managing the airway
Non-technical skill : leadership, teamwork,
situational awareness, task management and
decision making
There is no “magic number” for competence,
weaken with time
International WS for Airway Management 2012
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Top 5 oral presentation
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Thank You
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