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AIRWAY NIGHTMARE
YUSFADZRY YUSUF
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INTRODUCTION
Breathlessness, shortness of breath, or dyspnea isa difficult symptom for some patients to explainand quantify.
Tend to be subjective to some individual to furtherexplain.
It can be a natural consequence of strenuousphysical exercise.
Physiological or pathological cause in origin
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Defined as the sensation of uncomfortable breathing.
This breathing discomfort may reflect an increasedawareness of breathing or the sense that breathing isdifferent, difficult or inadequate.
Several factors may operate in an individual patientto produce breathlessness.
The clinical analysis of the breathless patientcomprises both an assessment of the severity ofbreathlessness and identification of its cause.
INTRODUCTION cont..
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Begin by assessing the patients stability.
If the patient unable to talk or complete a
full sentence without pausing for a deepbreath, move quickly to stabilize thepatient.
Return to the interview after the patient ismore comfortable.
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Common cause ofbreathlessness
MINUTES HOURS DAYS-WEEKS
Pneumothorax Asthma Pleural
effusionPulmonaryembolism
Pneumonia AECOAD
Pulmonaryoedema
Pulmonaryoedema
Pneumonia
Acute asthma Metabolicacidosis
Pulmonary TB
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Anaphylaxis 50% of patient will havedyspnea associated withanaphylaxis
Aspiration Dyspnea due to aspirationgenerally begins abruptlywithin hours of the event
Cardiac tamponade Tamponade is associatedwith dyspnea, chest pain &lightheadedness
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Acutepneumonia
Prevalence of pneumonia in healthypatient with acute cough approx- 6-7%, higher in population withcomorbid illness
Respiratorymuscleweakness
40% patient with Guillain Barre syndwill requires assisted ventilation d/tmuscle weakness
Spontaneous
pneumothorax
The lifetime risk in men is 12% for
heavy smoker &
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Chronic dyspnea
Cardiac: cardiomyopathies, MI, primarypulmonary hypertension, pericardial disease.
Pulmonary: Asthma, COPD, interstitial lung
disease, chronic pneumonia, chronic pulmonaryembolism, pulmonary neoplasm (primary/mets),pleural effusions.
Miscellaneous: Anemia, neuromuscular disorder
Psychiatric: Panic attack, anxiety disorder
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Need intubation?.....
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AIRWAY ASSESSMENT
Outlines of Presentation
Anatomy Terminology
History
Physical Examination Management of Difficult Intubation
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ANATOMY I- upperrespiratory system
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ANATOMY II- Lowerrespiratory system
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ANATOMY III- larynx
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ANATOMY IV
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TERMINOLOGY I
Difficult airway is said to occurWhen one experiences difficulty with mask
ventilation, difficulty with tracheal intubationor both
Difficult mask ventilationWhen it is not possible for the unassisted
anaesthesiologist to maintain the SpO2>90% using 100% oxygen and positivepressure mask ventilation in a patient
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TERMINOLOGY II
Difficult laryngoscopyWhen it is not possible to visualize any portion
of the vocal cords with conventionallaryngoscope
Difficult endotracheal intubation
When proper insertion of the tracheal tube
with conventional laryngoscopy requires morethan 3 attempts or more than 10 minutes
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HISTORY I
Taking an adequate history isnecessary to anticipate possible
complications.
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HISTORY II
Condition that may associated with difficultairway included
Obesity Pregnancy and labour
Increased risk of laryngeal eodema in preeclamsia
Anatomical abnormalities
Microanathia Macroglossia
Congenital syndromes (eg: Pierre-Robin, Treacher-Collin)
Burn contracture involving the head and neck
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Pierre Robin syndrome
Pierre Robin syndrome is a condition
present at birth marked by a very small
lower jaw (micrognathia).
The tongue tends to fall back and
downward (glossoptosis) and there is cleft
soft palate.
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Treacher Collins Syndrome
Treacher Collins Syndrome, alsocalled mandibulofacial dysostosis,affects the head and face.Characteristics include:
down-slanting eyes
notched lower eyelids
underdevelopment or absenceof cheekbones and the side walland floor of the eye socket
lower jaw is often small andslanting
forward fair in the sideburnarea
underdeveloped, malformedand/or prominent ears
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HISTORY III
Evidence of airway obstruction
Tumour or oedema involving upper airway
Large goitre
Acute epiglottitisMaxillofacial injury
Airways burns
Cervical spine problem
Fracture-dislocation or subluxation orcervical spine
Ankylosing spondylitis, rheumatoid arthritis
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HISTORY IV
History of upper airway compromise duringsleep
History of radiotherapy head and neckregion
History of difficult intubation duringprevious anaesthetics
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HISTORY V
Past Medical HistoryBronchiol Asthma
COPDElectrolytes imbalance
Myasthenia gravis
HPT
DM
Allergy HistoryDrugs/food
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PHYSICAL EXAMINATION I
Body weight and general status
Expect difficulty in
obese patients (body weight > 90kg or >
20% above ideal weight)Pregnant ladies particularly those in third
trimester of pregnancy
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PHYSICAL EXAMINATION II
Inspection in anterior and lateralviews
Inspect the facial features for bony or
soft tissue abnormalities:Small receding chin,
Mandibular or maxillary fractures, tumourand oedema
xam ne e nec or swe ng go re
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xam ne e nec or swe ng, go re,scarring, tracheal deviation and
position of thyroid cartilage
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Inspection in anterior and
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Inspection in anterior andlateral views
Noted the pattern of respiration forpresence of stridor, tachypnoea,
respiratory distress and paradoxicalrespiration.
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PHYSICAL EXAMINATION III
Mouth Opening
Modified Mallampati Classification
Inter-incisor gap (expect difficulty if< 3cm) Any intra oral cavity swelling:
Eg ; adenotonsillar hypertrophy.
Dentition
Protruding incisors, loose or missing teeth Orthodontic work with cap, crown or dentures
Position of lower teeth in relation to upperteeth
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PHYSICAL EXAMINATION IV
Neck Movement Neck movement-flexion,extension,rotation
Excluded cervical spondylosis- any pain in theneck, or neurological symptoms in the arm
Thyromental distance- Should be > 6.5cm. Ifless expect difficulty
Sternomental distance >12.5cm, If less,expect
difficulty
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PHYSICAL EXAMINATION V
Indirect laryngscope
Relevant in laryngael tumour or thyroidenlargement scheduled for surgery
Radiological examination Chest x-ray
Cervical x-ray
To look for fracture dislocation of cervicalspines
Modified Mallampati
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Modified MallampatiClassification
Mallampati reported a correlation between the visibility oforopharyngeal structures and the degree of difficulty ofglottic exposure on direct laryngoscope
Laryngoscopy was difficult in Class III and IV
The test is performed at the patients bedside with the patientsitting up and the observer at eye level. The patient is askedto open the mouth fully and protrude the tongue.
Visualization and identification of pharyngeal structures ismade without phonation.
Modified Mallampati Classification
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Modified Mallampati Classification
Class I: Soft palate, uvula,tonsillar pillars visibleClass II: Soft palate, uvula visible, tonsillar pillars notvisible
Class III: Only soft palate visibleClass IV: No pharyngeal structures except hard palate
visible
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Cormack and LehaneClassification
Grade I Visualization of the entire laryngeal aperture Grade II Visualization of the posterior portion of laryngeal
aperture Grade III Visualization of the tip of epiglottis Grade IV Visualization of the soft palate only
In Grade III and IV, intubation is considered to be difficult
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MANAGEMENT
MANAGEMENT OF KNOWN DIFFICULTAIRWAY
Inform senior colleague, specialistin charge and discuss optionsavailable for patient
Regional anaesthesia Local anaesthesia
GA with spontaneous respiration via facialmask or laryngeal mask airway
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MANAGEMENT
Ensure Empty Stomach anddecreased gastric acidity Implementation of fasting guidelines
Use antacids or H2 receptor antagonist
Inform surgeon about Potential airway problem
Option of tracheostomy
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MANAGEMENT
Difficult Intubation Equipment
should be checked and there arein good working order
Laryngoscopes of different
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Laryngoscopes of differenttypes and sizes
ET tubes with various types
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ET tubes with various typesand sizes
Stylet and gum elastic bougie
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Stylet and gum elastic bougie
Laryngeal mask airway (LMA) of various
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Laryngeal mask airway (LMA) of varioussizes, intubating LMA, LMA Proseal,
Trachlight,
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Ambu bag
Airway adjunct such as
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Airway adjunct such as
oesohageal-tracheal Combitube,
laryngeal tube
Fibreoptic laryngoscope and its
accesories
Invasive means of airway:cricothyrotomy or minitracheostomy
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MANAGEMENT
Preoxygenation with 100%oxygen for 3-5 minutes prior toinduction of anaesthesia
Establish monitors consisting ECG, BP,pulse oximetry, capnography,
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MANAGEMENT
Ensure that the intubating conditionare optimal
Sniffing the morning air position
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MANAGEMENT
Consider using alternativelaryngoscope blade andhandle
Macoy blade to retract the
epiglottis
Straight blade in patient withreceding chin, prominentincisors or if epiglottis is long
and floppy
Short handle in a patient withshort neck and pendulousbreast
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ThankYou..