Airway Management: An Introduction and Overview & Massive Hemoptysis Division of Critical Care Medicine Division of Critical Care Medicine University of

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  • Slide 1
  • Airway Management: An Introduction and Overview & Massive Hemoptysis Division of Critical Care Medicine Division of Critical Care Medicine University of Alberta
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  • Airway Management
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  • Outline Overview Overview Normal airway Normal airway Difficult intubation Difficult intubation Structured approach to airway management Structured approach to airway management Causes of failed intubation Causes of failed intubation
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  • Overview of the Airway 600 patients die per year from complications related to airway management 600 patients die per year from complications related to airway management 3 mechanisms of injury: 3 mechanisms of injury: 1. Esophageal intubation 2. Failure to ventilate 3. Difficult Intubation 98% of Difficult Intubations may be anticipated by performing a thorough evaluation of the airway in advance
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  • Indications for Intubation Ventilatory Support Ventilatory Support Decreased GCS Decreased GCS Protection of Airway Protection of Airway Ensuring Airway patency Ensuring Airway patency Anesthesia and surgery Anesthesia and surgery Suctioning and Pulmonary Toilet Suctioning and Pulmonary Toilet Hypoxic and Hypercarbic respiratory Failure Hypoxic and Hypercarbic respiratory Failure Pulmonary lavage Pulmonary lavage
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  • Endotracheal Intubation Depends Upon Manipulation of: Cervical spine Cervical spine Atlanto-occipital Joint Atlanto-occipital Joint Mandible Mandible Oral soft tissues Oral soft tissues Neck hyoid bone Neck hyoid bone Additionally: Additionally: Dentition Dentition Pathology - Acquired and Congenital Pathology - Acquired and Congenital
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  • The Normal Airway History of one or more easy intubations w/o sequelae History of one or more easy intubations w/o sequelae Normal appearing face with regular features Normal appearing face with regular features Normal clear voice Normal clear voice Absence of scars, burns, swelling, infections, tumour, or hematoma Absence of scars, burns, swelling, infections, tumour, or hematoma No history of radiation of the head or neck No history of radiation of the head or neck Ability to lie supine asymptomatically; no history of snoring or sleep apnea Ability to lie supine asymptomatically; no history of snoring or sleep apnea
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  • The Normal Airway Patent nares Patent nares Ability to open mouth widely with TMJ rotation and subluxation (3 4 cm or two finger breaths) Ability to open mouth widely with TMJ rotation and subluxation (3 4 cm or two finger breaths) Mallampati Class I Mallampati Class I Patient sitting straight up, opening mouth as wide as possible, with protruding tongue; the uvula, posterior pharyngeal wall, entire tonsillar pillars, and fauces can be seen Patient sitting straight up, opening mouth as wide as possible, with protruding tongue; the uvula, posterior pharyngeal wall, entire tonsillar pillars, and fauces can be seen At least 6 cm (3 finger breaths) from tip of mandible to thyroid notch with neck extension At least 6 cm (3 finger breaths) from tip of mandible to thyroid notch with neck extension At least 9 cm from symphysis of mandible to mandible angle At least 9 cm from symphysis of mandible to mandible angle
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  • Slender supple neck w/o masses; full range of neck motion Slender supple neck w/o masses; full range of neck motion Larynx moveable with swallowing and manually moveable laterally (about 1.5 cm each side) Larynx moveable with swallowing and manually moveable laterally (about 1.5 cm each side) Slender to moderate body build Slender to moderate body build Ability to extend atlanto-occipital joint (normal extension is 35) Ability to extend atlanto-occipital joint (normal extension is 35) The Normal Airway
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  • Risk Factors For Difficult Intubation El-Canouri et al. - prospective study of 10, 507 patients demonstrating difficult intubation with objective airway risk criteria El-Canouri et al. - prospective study of 10, 507 patients demonstrating difficult intubation with objective airway risk criteria Mouth opening < 4 cm Mouth opening < 4 cm Thyromental distance < 6 cm Thyromental distance < 6 cm Mallampati grade 3 or greater Mallampati grade 3 or greater Neck movement < 80% Neck movement < 80% Inability to advance mandible (prognathism) Inability to advance mandible (prognathism) Body weight > 110 kg Body weight > 110 kg Positive history of difficult intubation Positive history of difficult intubation
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  • Signs Indicative of a Difficult Intubation Trauma, deformity: burns, radiation therapy, infection, swelling, hematoma of face, mouth, larynx, neck Trauma, deformity: burns, radiation therapy, infection, swelling, hematoma of face, mouth, larynx, neck Stridor or air hunger Stridor or air hunger Intolerance in the supine position Intolerance in the supine position Hoarseness or abnormal voice Hoarseness or abnormal voice Mandibular abnormality Mandibular abnormality Decreased mobility or inability to open the mouth at least 3 finger breaths Decreased mobility or inability to open the mouth at least 3 finger breaths Micrognathia, receding chin Micrognathia, receding chin Treacher Collins, Peirre Robin, other syndromes Treacher Collins, Peirre Robin, other syndromes Less than 6 cm (3 finger breaths) from tip of the mandible to thyroid notch with neck in full extension Less than 6 cm (3 finger breaths) from tip of the mandible to thyroid notch with neck in full extension < 9 cm from the angle of the jaw to symphysis < 9 cm from the angle of the jaw to symphysis Increased anterior or posterior mandibular length Increased anterior or posterior mandibular length
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  • Laryngeal Abnormalities Laryngeal Abnormalities Fixation of larynx to other structures of neck, hyoid, or floor of mouth. Fixation of larynx to other structures of neck, hyoid, or floor of mouth. Macroglossia Macroglossia Deep, narrow, high arched oropharynx Deep, narrow, high arched oropharynx Protruding teeth Protruding teeth Mallampati Class 3 and 4 Mallampati Class 3 and 4 Signs Indicative of a Difficult Intubation
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  • Neck Abnormalities Neck Abnormalities Short and thick Short and thick Decreased range of motion (arthritis, spondylitis, disk disease) Decreased range of motion (arthritis, spondylitis, disk disease) Fracture (subluxation) Fracture (subluxation) Trauma Trauma Thoracoabdominal abnormalities Thoracoabdominal abnormalities Kyphoscoliosis Kyphoscoliosis Prominent chest or large breasts Prominent chest or large breasts Morbid obesity Morbid obesity Term or near term pregnancy Term or near term pregnancy Age 50 59 Age 50 59 Male gender Male gender Signs Indicative of a Difficult Intubation
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  • Previous Intubations Previous Intubations Dental problems (bridges, caps, dentures, loose teeth) Dental problems (bridges, caps, dentures, loose teeth) Respiratory Disease (sleep apnea, smoking, sputum, wheeze) Respiratory Disease (sleep apnea, smoking, sputum, wheeze) Arthritis (TMJ disease, ankylosing spondylitis, rheumatoid arthritis) Arthritis (TMJ disease, ankylosing spondylitis, rheumatoid arthritis) Clotting abnormalities (before nasal intubation) Clotting abnormalities (before nasal intubation) Congenital abnormalities Congenital abnormalities Type I DM Type I DM NPO status NPO status Difficult Intubation - History
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  • Difficult Intubation - Diabetes Mellitus Difficult intubation 10 x higher in long term diabetics Difficult intubation 10 x higher in long term diabetics Limited joint mobility in 30 40 % Limited joint mobility in 30 40 % Prayer sign Prayer sign Unable to straighten the interpharyngeal joints of the fourth and fifth fingers Unable to straighten the interpharyngeal joints of the fourth and fifth fingers Palm Print Palm Print 100% sensitive of difficult airway 100% sensitive of difficult airway
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  • Difficult Intubation - Physical Exam General: General: LOC, facies and body habitus, presence or absence of cyanosis, posture, pregnancy LOC, facies and body habitus, presence or absence of cyanosis, posture, pregnancy Facies: Facies: Abnormal facial features Abnormal facial features Pierre Robin Pierre Robin Treacher Collins Treacher Collins Klippel Feil Klippel Feil Aperts syndrome Aperts syndrome Fetal Alcohol syndrome Fetal Alcohol syndrome Acromegaly Acromegaly Nose: Nose: For nasal intubation For nasal intubation Patency Patency
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  • Pierre Robin
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  • Treacher Collins
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  • TMJ Joint articulation and movement between the mandible and cranium TMJ Joint articulation and movement between the mandible and cranium Diseases: Diseases: Rheumatoid arthritis Rheumatoid arthritis Ankylosing spondylitis Ankylosing spondylitis Psoriatic arthritis Psoriatic arthritis Degenerative join disease Degenerative join disease Movements: rotational and advancement of condylar head Movements: rotational and advancement of condylar head Normal opening of mouth 5 6 cm Normal opening of mouth 5 6 cm Difficult Intubation - Physical Exam
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  • Oral Cavity Oral Cavity Foreign bodies Foreign bodies Teeth: Teeth: Long protruding teeth can restrict access Long protruding teeth can restrict access Dental damage 25% of all anesthesia litigations Dental damage 25% of all anesthesia litigations Loose teeth can aspirate Loose teeth can aspirate Edentulous state Edentulou