AirwayAirway

Evaluation and ManagementEvaluation and Management

Indications of intubationIndications of intubation

Resuscitation (CPR)Resuscitation (CPR) Prevention of lung soilingPrevention of lung soiling Positive pressure ventilation (GA)Positive pressure ventilation (GA) Pulmonary toiletPulmonary toilet Patent airway (coma or near coma)Patent airway (coma or near coma) Respiratory failure(CO2 retention )Respiratory failure(CO2 retention )

Requirement of successful Requirement of successful intbatinintbatin

1-Normal roomy 1-Normal roomy mandiblemandible

2-Normal T-M, A-O 2-Normal T-M, A-O , and C-spine, and C-spine

Requirements of successful Requirements of successful intubationintubation

3-Alignment of 3 axes or3-Alignment of 3 axes or

Assuming sniffing positionAssuming sniffing position

-Any anomaly in these 3 joints-Any anomaly in these 3 joints

A-O, T-M or C-spine can resultA-O, T-M or C-spine can result

In difficult intubationIn difficult intubation

Requirement of successful Requirement of successful intubationintubation

Proper equipmentProper equipment

-Bag and mask,oxygen source-Bag and mask,oxygen source

-Airways oro and nasopharyngeal-Airways oro and nasopharyngeal

-Laryngosopes different blades-Laryngosopes different blades

-ETT different sizes-ETT different sizes

-suction on-suction on

Airway gadgetsAirway gadgets

Management Management

I-History:I-History: previous history of difficulty is the best previous history of difficulty is the best

predictorpredictorInquire about:-Nature of difficultyInquire about:-Nature of difficulty -No of trials-No of trials -Ability to ventilate bet trials-Ability to ventilate bet trials -Maneuver used-Maneuver used -Complications-ComplicationsII-Snoring and sleep apnea( prdictors of II-Snoring and sleep apnea( prdictors of

DMV)DMV)

ExaminationExamination

-Look for any obvious anomaly -Look for any obvious anomaly Morbid obesity(BMI)Morbid obesity(BMI) SkullSkull FaceFace JawJaw Mouth,teethMouth,teeth Neck Neck

ExaminationExamination

I-The 3 joints movementsI-The 3 joints movements A-O joint(15-20 degrees)A-O joint(15-20 degrees)

Presence of a gap bet the Presence of a gap bet the

Occiput and C1 is essentialOcciput and C1 is essential The cervical spine(range>90)The cervical spine(range>90) T.M joint:-interdental gap(3 fingers)T.M joint:-interdental gap(3 fingers) -subluxation (1 finger)-subluxation (1 finger)

ExaminationExamination

II-Measurements of the mandibleII-Measurements of the mandible

-Thyro-mental distance (head -Thyro-mental distance (head extended)extended)

Normally 6.5 cmNormally 6.5 cm

Less than 6 cm=expect difficultyLess than 6 cm=expect difficulty

Tests to predict difficultyTests to predict difficulty

Mallampatti test:Mallampatti test:

Based on the hypothesisBased on the hypothesis

That when the base of theThat when the base of the

Tongue is disproportionallyTongue is disproportionally

Large it will overshadow theLarge it will overshadow the

larynxlarynx

-Simple easy test,correlates with what is seen during -Simple easy test,correlates with what is seen during laryngoscopy or Cormack-Lehene grades ,butlaryngoscopy or Cormack-Lehene grades ,but

1-moderate sensitivity and specificity(12% false +ve)1-moderate sensitivity and specificity(12% false +ve)

2-Inter observer variation2-Inter observer variation

3-Phonation increases false negative view3-Phonation increases false negative view

II-Wilson testII-Wilson test

-Consists of 5 easily assessed factors-Consists of 5 easily assessed factors Body wight(n=0 ,>90=1,>110=2)Body wight(n=0 ,>90=1,>110=2) Head and neck movementHead and neck movement Jaw movementJaw movement Receding jawReceding jaw Buck teethBuck teeth

Each factor assigned as o ,1 ,2 max is Each factor assigned as o ,1 ,2 max is 1010

Difficult airwayDifficult airway

Expected from history,examinationExpected from history,examination

Secure airway while awake under LASecure airway while awake under LA

Unexpected different optionsUnexpected different options

Priority for maintenance of patent Priority for maintenance of patent airway and oxygenationairway and oxygenation

Airway gadgetsAirway gadgets

Needle Needle cricothyroidotomycricothyroidotomy

Confirm tube positionConfirm tube position

Direct visualization of ETT between Direct visualization of ETT between cordscords

Bronchoscopy ;carina seenBronchoscopy ;carina seen Continuous trace of capnographyContinuous trace of capnography 3 point auscultation3 point auscultation Esophageal detector deviceEsophageal detector device Other as bilateral chest Other as bilateral chest

movement,mist in the tube,CXRmovement,mist in the tube,CXR

Rapid sequence Rapid sequence inductioninduction

IndicationsIndications Technique: Technique:

-Preoxygenation-Preoxygenation

-IV induction with sux-IV induction with sux

-Cricoid pressure-Cricoid pressure

-Intubate, inflate the cuff ,confirm -Intubate, inflate the cuff ,confirm positionposition

-Release cricoid and fix the tube-Release cricoid and fix the tube

Complications of Complications of intubationintubation

1-Inadequate 1-Inadequate ventilationventilation

2-Esophageal 2-Esophageal intubationintubation

3-Airway obstruction3-Airway obstruction

4-Bronchospasm4-Bronchospasm

5-Aspiration5-Aspiration

6- Trauma6- Trauma

7-Stress response7-Stress response

RecommendationsRecommendations

Adequate airway assessment to pick up Adequate airway assessment to pick up expected D.A to be secured awakeexpected D.A to be secured awake

Difficult intubation cart always readyDifficult intubation cart always ready Pre oxygenation as a routinePre oxygenation as a routine

Maintenance of oxygenation not the Maintenance of oxygenation not the intubation should be your aimintubation should be your aim

Use the technique you are familiar withUse the technique you are familiar with Always have plan B,C,D in unexpected D.AAlways have plan B,C,D in unexpected D.A