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Review

Airway
management

Giedrius Laurinėnas
Airway management

A look back: what's learnt


from bitter experience

Future trends: a vision of a


'universal soldier'

Lithuania:
Go west
Airway management

A look back: what's learnt


from bitter experience
• Difficult airway is an interdisciplinary problem
• The diagnostics wasn't, isn't, and, apparently,
Future
won't be accurate
trends: a vision of a
'universal
• Updated knowledge, soldier'
vigilance, adequate monitoring
and standardization is the key for success:
- Standards of Safe Anesthesia Practice (ASA, 1986)
- Difficult Airway Algorithm (ASA, 1993)
Lithuania:
• Alternative airway devices revolutionized outcomes
• Ever growing Go westfor a proper education
interest
The Problem

Adverse respiratory events in anesthesia: A


closed claims analysis. Caplan RA, Posner KL,
Ward RJ Anesthesiology 75:828, 1990
•••

Adverse respiratory events


N = 1541 infrequently leading
Inadequate
to malpractice suits. A closed claims analysis.
ventilation 13%

Cheney FW, Posner KL, CaplanEsophageal


RA
Other claims
34%
Anesthesiology 75:932, 1991intubation 7%
••• Difficult
intubation 6%
ASA closed claims project database
Other respiratory
1985-2004 problems 8%
The Problem

Adverse respiratory events in anesthesia: A


closed claims analysis. Caplan RA, Posner KL,
N = 4459
Inadequate
Ward RJ Anesthesiology 75:828,ventilation
1990 7%
•••

Adverse 18% Esophageal


Other claimsrespiratory events infrequently leading
intubation 4.5%

to malpractice suits. A closed claimsDifficult


analysis.
intubation 6,4%
Cheney FW, Posner KL, Caplan RA
Anesthesiology 75:932, 1991
•••

ASA closed claims project database


2002
The Problem

Anesthesia-related deaths
and permanent brain damage
(ASA closed claims project database, 2002)

N= 1320 N= 570
Respiratory adverse events
1980-1990 Cardiovascular adverse events 1990-2000
Technical problems
A look back

Monitoring:
The Beginning of A New Era
A look back
Monitoring modalities and respiratory adverse events
(ASA closed claims project database)

Inadequate Esophageal Difficult


ventilation intubation intubation
Both SaO2 and EtCO2 unavailable

SaO2 monitoring only

SaO2 ir EtCO2 available

Mirtys ir CNS pakenkimas dėl anestezijos (ASA closed claims project database, 2004)
Monitoring of Ventilation
... Continuous evaluation of qualitative
clinical signs such as chest excursion,
observation of the breathing bag, and
auscultation is mandatory...

... When an ETT or LMA is inserted, its


correct positioning must be verified by
identification of carbon dioxide in the
expired gas. Continuous capnometry
should be used until extubation...

... Quantitative monitoring of the volume


of expired gas is strongly encouraged...

ASA Standards for basic Anesthetic Monitoring


Ventilation monitoring
• Exploring Lithuania •

9 OR fully equipped with capnography....................................10%


9 Hospitals without capnography............................................12%
9 Hospitals, where blood gas analysis is unavailable.................0%

F Capnometry in our operating rooms:


9 District hospitals..................................................................42%
9 Regional nonteaching hospitals.............................................55%
9 University hospitals..............................................................70%

F Capnometry in our ICUs:


9 ICUs, where capnography is used at least from time to time......8%

F Capnometry in our prehospital setting:


9 Ambulances equipped with capnometry devices..............not found
Ventilation monitoring
• Recent
• Kokybiniai advances
etCO2 •
detektoriai

2000 Qualitative end-tidal CO2 detectors

American Heart Association


Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care

Esophageal detectors
Ventilation monitoring
• Recent advances •

2004 ?
Microstream capnometry
Day case surgery
Sleep apnea monitoring
Extended cardiovascular uses of capnography
(CPR, electromechanic dissociation ...)
Pulmonology
Ventilation monitoring
• Other uses of capnometry •

One lung ventilation Fiberoptic bronchoscopy

spontaneous breathing

apnea

Needle cricothyrotomy Critical care


Monitoring of Oxygenation
... Adequate illumination and exposure of
the patient are necessary to assess
color...

... During all anesthetics, pulse oximetry


shall be employed...

... The concentration of oxygen in the


breathing system shall be measured with a
low FiO2 alarm in use...

ASA Standards for basic Anesthetic Monitoring


Oxygenation monitoring
• Exploring Lithuania •
9 Hospitals, fully equipped with pulse oximetry.........................4%
9 Hospitals, where pulse oximetry is unavailable.......................0%

F Pulse oximetry in operating rooms:


9 District hospitals...................................................................59%
9 Regional nonteaching hospitals..............................................46%
9 University hospitals...............................................................73%

F Pulse oximetry in ICUs:


9 District hospitals...................................................................57%
9 Regional nonteaching hospitals..............................................51%
9 University hospitals...............................................................60%

F Pulse oximetry in the prehospital setting:


9 Ambulances, equipped with pulse oximeters.............a recent victory
Equipment Status Monitoring
... There shall be in continuous use a
device that is capable of detecting
disconnection of components of the
breathing system ...

... Anesthesia apparatus check-up is an


essential part of any anesthesia ...

... Unreliable and unsecure anesthesia


equipment should not be used ...
Equipment status monitoring
• Obsolescence criteria •

• Necessary and approved replacement parts are impossible to obtain


It's the responsibility of the
• No standard connections
• Evident leakage ASA
anesthesiologist to determine Guidelines
in the breathing system
• Absent oxygen supply alarm, no FiO detector
forO /NDetermining
2

if a machine’s
• Absent automatic 2 2
failure to meet
O ratio device, no "fail-safe" system

Anesthesia Machine
• Absent airway pressure (P-peak, PEEP, negative pressure) alarm*
newer
• Impractical equipment
equipment (e.g.,, no possibility standards
to utilize other vaporizers or to
perform a low flow anesthesia)*
• Arepresents Obsolescence
significant possibility a threat
of human to patient
error due to tremendous
differencies when compared with modern anesthesia machines*
technological

(...) safety
* Relative criteria
Anesthesia equipment
• Exploring Lithuania •

F Stationary anesthesia machines in the OR:


9 District hospitals...................................................................85%
9 Regional nonteaching hospitals..............................................89%
9 University hospitals...............................................................89%

F Newer (<5 years) anesthesia machines:


9 District hospitals...................................................................16%
9 Regional nonteaching hospitals..............................................16%
9 University hospitals................................................................9%

F Older (>10 years) anesthesia machines:


9 District hospitals....................................................................31%
9 Regional nonteaching hospitals...............................................25%
9 University hospitals................................................................13%
Ventilation equipment
• Exploring Lithuania •

F Provision with ventilators of our ICUs:


9 District hospitals...................................................................48%
9 Regional nonteaching hospitals..............................................49%
9 University hospitals...............................................................59%

F Newer (<5 years) ventilators in ICU:


9 District hospitals...................................................................26%
9 Regional nonteaching hospitals..............................................21%
9 University hospitals...............................................................40%

F Older (> 10 years) ventilators in ICU:


9 District hospitals...................................................................53%
9 Regional nonteaching hospitals..............................................17%
9 University hospitals...............................................................10%
A look back

Deaths and brain damage


related to difficult airway
(ASA closed claims project database, 2003)

100

50

0
Desperate attempts of Alternative airway
intubation only devices used
A look back

Searching for
a perfect one
A
ABCD
(Airway)
Alternative airway management devices
• Laryngoscopes •

Handles Blades

McCoy laryngoscope
Alternative airway management devices
• Laryngoscopes •

Flexiblade Bullard laryngoscope

Wu scope Upsher laryngoscope


Alternative airway management devices
• Intubation adjuncts •

Flexible stylets Lighted stylets

Guminis elastinis bužas


Gum elastic bougie ETT with controllable tip
Alternative airway management devices
• Supraglotic devices •

Nasopharyngeal airway Oropharyngeal airway

COPA (cuffed oropharyngeal Esophageal obturator airway


airway)
Alternative airway management devices
• Supraglotic devices •

Laryngeal mask airway (LMA) Intubation LMA (Fastrach)

Laryngeal tube Combitube


Alternative airway management devices
• Infraglotic devices •

Transtracheal jet ventilation Cricothyrotomy

Tracheostomy Translaryngeal tracheostomy


B
ABCD
(Breathing)
Ventilation devices
• Primary survey •

Faceshield (Microshield)

Pocket face mask


Ventilation devices
• Advanced •

Bag-valve device Demand valve Ventilation via Combitube

Ventilation via LMA Emergency transport ICU ventilators


ventilator
Searching for an ideal one
• What should I choose? •
EXPERIENCE
• It's the main factor influencing one's decision. Many alternative
techniques, however, could be relatively easily learnt.
• Intubation is still considered a "gold standard". One should maintain
acceptable intubation skills.
SITUATION
• Factors to consider: aspiration risk, possible ventilation difficulties, risks
associated with patient transportation
• LMA and Combitube are effective when one needs to establish airway
patency quickly, in nonstandard position or in case of difficult intubation
SURGICAL INTERVENTION
• LMA is the best known alternative airway device in elective as well as in
emergency anesthesiology
• Endotracheal intubation is preferred during prolonged procedures, in
case of nonstandard positioning of the patient
PATIENT
• The indications of alternative devices in airway management is only
partly defined. There are, however, well-established contraindications.
• Only few specific recommendations for suspected cervical spine injury,
presence of dangerous infections have been developed
Prehospital setting
• What should I choose? •

The manner in which a


patient's airway is
maintained often influences
how effectively ventilation
and transportation is
accomplished
Prehospital setting
Despite constantly increasing selection of
alternatives, an ideal airway device for
prehospital airway does not yet exist

Difficult intubations are more common in


prehospital circumstancies. Poor intubation
experience, errors in tube position
diagnostics and lack of monitoring are
detrimental

Oxygenation and effective ventilation are


the main priorities
Prehospital setting
• Exploring Lithuania •

F Anesthesiologists in prehospital setting


it's a minority
F Fully equipped ambulances ('reanimobiles')

usually up to 100 km away


F Alternative airway devices available
9 Combitube..............................................................................rarity
9 Laryngeal mask...........................................................................no
9 Succinylcholine............................................................................no
Prehospital setting
• Endotracheal intubation issues •

FAILED PREHOSPITAL INTUBATIONS: AN ANALYSIS OF


EMERGENCY DEPARTMENT COURSES AND OUTCOMES
Henry E. Wang et al, Prehospital Emergency Care 2001;5:134–141

592 prehospital intubations


•••
AN ANALYSIS OF INVASIVE AIRWAY MANAGEMENT IN A
SUBURBAN EMERGENCY MEDICAL SERVICES SYSTEM
Prehosp Disaster Med 1992; 7:121-126

278 prehospital intubations


Prehospital setting
• Endotracheal intubation issues •
• Knowledge of indications for endotracheal intubation is of
paramount importance
• The incidence of difficult intubation subsides remarkably if
muscle relaxants are used. Although rare, potential
complications could be lethal. A great deal of experience is
required when using these pharmacological adjuncts.
• There is still no clearly defined and internationally
supported indications for their use in prehospital setting
• Intubation with iv sedation seems to be a reasonable
choice
• There is no clear consensus on the number of intubations
required to train prehospital personnel adequately and
maintain their skills. A figure of approximately 10 per year is
often cited.
Prehospital setting
• Ventilation priorities •
AHA Guidelines 2000
for cardiopulmonary resuscitation and emergency cardiac care

Emergency Pocket face Bag - mask


Demand valve
and transport mask ventilation
ventilators
Prehospital setting
• Ventilation priorities •

AHA Guidelines 2000


for cardiopulmonary resuscitation and emergency cardiac care

Combitube + Laringinė kaukė Bag-mask only


bag-mask + bag-mask
Combitube
An ideal option for
our ambulances?
Prehospital setting
• Combitube •

Use of the Esophageal Tracheal Combitube by basic emergency


medical technicians. Resuscitation 2002 Jan;52(1):77-83)

760 prehospital
insertions of Combitube
• insertion successful 95,4%
• ventilation successful 91,4%
No Combitube related injuries
• sucutaneous emphysema (18)
established at autopsy
• tension pneumothorax (5)
• pharyngeal bleeding (15)
• airway edema (3)
Combitube
Indications Advantages
• Difficult intubation (especially useful in • No experience is required
case of bleeding from upper airways and
• No 'sniffing' position is needed
gastrointestinal tract or profuse vomiting
as well) • No preparation is needed -
Combitube is ready for immediate use
• Quick establishment of airway is needed
(especially useful in prehospital setting) • Suitable in case of 'full stomac'.
Minimal aspiration risk if inserted
• Elective surgery, especially in case of
correctly
deformities of neck and face. Also
recommended for actors and singers • Fixation is unnecessary

Contraindications Disadvantages
• Conscious patient or the presence of gag • Requires ablation of consciousness
reflex
• Small (<1.52 m) adults • Its insertion can evoke cardiovascular
reactions
• Children (up to sixteen years old) ?
• Serious complications (esophageal
• Corrosive injuries of gastrointestinal
tract trauma, subcutaneous emphysema,
pneumomediastinum etc)
• Foreign bodies
• Difficulties if bronchoscopy is needed
• Tracheostomy
• Esophageal abnormalities
Prehospital setting
• Combitube •

Complications associated with the use of the Esophageal-


Tracheal Combitube. Vezina D et al. Can J Anaesth 1998

1139 prehospital
insertions of Combitube
8 Combitube-related subcutaneous emphysema

4 Combitube-related esophageal lacerations


Combitube
Where is the tip?
Bag ventilation via blue port

Chest rises, breath sounds are Chest does not rise, gurgitation Unable to ventilate via either
present, no gurgitation in epigastrium is heard port, no sounds heard

Deflate cuffs
Ventilation via blue port Ventilation via white port
Withdraw 2-3 cm
Gastric tube via white port Observe, listen, look
Reinflate
Drugs via blue port? Drugs via white port
Recheck

• Always use capnography, esophageal detectors or end-tidal If situation does not


carbon dioxide detectors. Recheck position during transportation changes, reinsert Combitube
• Do not overfill the distal cuff once more. If unsuccessful,
• Consider endotracheal intubation consider other airway devices
Prehospital setting
• Combitube •
Comparison of a conventional tracheal airway with the
Combitube in an urban emergency medical services system run
by physicians. Rabitsch W et al. Resuscitation, 2003;57(1):27

172 prehospital airway


emergencies
A: Endotracheal intubation B: Combitube insertion
• Successful 94% • 98% successful
• Failed 6% • 2% failed

Combitube and endotracheal intubation could act as a substitute of


each other. Intubation success rate increases, if these devices are
used concomitantly
Prehospital setting
• Combitube vs LMA •
• So far, there are no well-controlled, randomized, prospective studies
• Success rates for insertion of both the Combitube and the LMA depend
on adequate initial training and frequent practice. Those that were trained
in the OR had much higher success rates for insertion of the LMA

A choice of airway device for 12,020 cases of non-


traumatic cardiac arrest in Japan. Tanigawa K et al.
Prehosp Emerg Care 1998.

Overall successful insertion and ventilation rates


Combitube 73.5% vs 64% LMA

Both of these devices provide good options for airway


rescue in the event of failed intubation, but in prehospital
studies neither have consistently high success rates for
insertion and ventilation
Hospital setting

Hospital: An underused source of


knowledge and experience for the
prehospital care staff

Despite better equipment, monitoring, and


extensive experience of hospital staff,
perioperative respiratory adverse events are
still common

Noncompliance with standardized action


plan as well as the absence of preplanned
strategy in case of difficulties seems to be
the main problem
Hospital setting
• Suggested portable storage unit (ASA, 2003) •

Alternative laryngoscope blade (McCoy, Miller, Bullard)


Endotracheal tubes of assorted sizes
Tracheal tube guides (semirigid stylets, tube changer,
lighted stylet, Magill forceps)
Laryngeal mask airway of assorted sizes and types
Flexible fiberoptic intubation equipment
Retrograde intubation equipment
Noninvasive ventilation devices (Combitube, hollow jet
ventilation stylet, transtracheal jet ventilation)
Emergency invasive airway access (cricothyrotomy
equipment)
Exhaled carbon dioxide detectors
Hospital setting
• Exploring Lithuania •
F Availability of a portable kit for difficult airways

0%
F Hospitals equipped with all required devices

0%
F Hospitals without any alternative device
9 District hospitals....................................................................63%
9 Regional nonteaching hospitals...............................................33%
9 University hospitals................................................................12%
Hospital setting
• Exploring Lithuania •

F Most common alternative airway devices:


9 Laryngeal mask...............................................24%
9 Cricothyroidotomy kit.....................................18%
9 Fiberoptic bronchoscope.................................18%
9 Combitube.........................................................8%
9 Rigid bronchoscope...........................................8%
9 Alternative blades of laryngoscopes.................5%
9 COPA..................................................................4%
9 Intubating LMA..................................................2%
Laryngeal
mask
The essential tool
LMA
Currently available items

Classical LMA Disposable LMA Wire - reinforced LMA

Dual-lumen LMA Intubating LMA LMA accessoires


Laryngeal mask
ADVANTAGES
Easy insertion technique
Multifunctional device (a ventilatory device or conduit for tracheal intubation)
Placement success is not influenced by anatomic abnormalities
A first choice device in case intubation has failed
Minimal cardiovascular response after insertion
'Smooth' awakening
Minor vocal cord dysfunction
Well tollerated in awake patients
Reusable
DISADVANTAGES

Risk of aspiration
Risk of gastric distention
Risk of dislodgement
Isn't suitable in case of any gross laryngeal abnormality
Drug administration via LMA is a bit problematic
LMA performs
adequately even
when it is used
poorly.
Try it!
LMA
Failed insertion

0,4-6%
LMA
Failed insertion

Insufficient deflation Excessive deflation Wrong pressure direction

Entrapped epiglottis Folded mask Wrong LMA size


LMA
The role of LMA in case of difficult airway
....Chadwick IS et al. Anaesthesia for emergency caesarean section using the brain
laryngeal airway (letter). Anaesthesia 1989. McClune S et al. Laryngeal mask
airway for caesarean section. Anaesthesia 1990. Priscu V et al. Laryngeal mask for

An endless
failed intubation in emergency caesarean section (letter). Can J Anaesth 1992; De
Mello WF et al. The laryngeal mask in failed intubation (letter). Anaesthesia 1990
Storey J et al. The laryngeal mask for failed intubation at caesarean section (letter).
Anaesth Intensive Care 1992; Williams AR et al. The laryngeal mask airway--
suboptimal availability, a cause for concern (letter). Anaesthesia 1992. Denny NM et

evidence in all
al. Laryngeal mask airway for emergency tracheostomy in a neonate (letter).
Anaesthesia 1990. Wheatley RS et al Intubation of a one-day old baby with the
pierre-robin syndrome via a laryngeal mask (letter). Anaesthesia 1994; Myles PS,
Venema HR, Lindholm DE: Trauma patient managed with the laryngeal mask
airway and percutaneous tracheostomy after failed intubation (letter). Med J

age groups
Australia 1994. Brain AIJ: The laryngeal mask airway--a possible new solution to
airway problems in the emergency situation. Arch Emer Med 1984; Brain AIJ: Three
cases of difficult intubation overcome by the laryngeal mask airway. Anaesthesia
1985; Calder I, Ordman AJ, Jackowski A, Crockard HA: The brain laryngeal mask
airway: An alternative to emergency tracheal intubation. Anaesthesia 1990; Lim W,
Wareham C, de Mellow WF, Kocan M: The laryngeal mask in failed intubation
(letter). Anaesthesia 1990; Owen G, Browning S, Davies CA, Saunders M, Thomas
TA: The laryngeal mask (letter). BE Med J 1993; Gature PS, Hughes JA: The
laryngeal mask airway in obstetrical anaesthesia. Canadian J of Anaesth 1995....
Difficult Airway Algorithms
• In the world •
Universal algorithm
(ASA, 1993 - 2004)

National algorithm
(Italy, France etc)

National database
(Austria)

Difficult Airway Clinic


(Michigan, USA, 1987)

Local algorithm
Difficult Airway Algorithm
• Exploring Lithuania •

F Approved algorithms for difficult airway:


9 Local hospitals......................................................................43%
9 Regional nonteaching hospitals..............................................50%
9 University hospitals...............................................................83%

F Algorithms adopted:
9 ASA 'Difficult Airway Algorithm (1993-2004)...........................10%
9 Local algorithms...................................................................38%
9 Algorithms are under development..........................................2%
9 No algorithm available..........................................................50%
Difficult airway algorithms

Most of difficult intubations could be


foreseen

Awake airway management is a


mainstay of all difficult airway
algorithms

Oxygenation is the highest priority


Difficult airway algorithms

Established indications and priority


range for alternative airway devices

Portable unit for difficult airway is highly


recommended

A difficult intubation should be


communicated to the patient.
Appropriate records are made as well.
Difficult Airway Algorithm
• Incidence •

• Official statistics is contradictory


9 0,5-20% depending on type of surgery, skills and facilities
9 3rd degree laryngoscopy 0,05% (1:2000)
9 4th degree laryngoskopy < 0,05%
9 Failed intubation -?
9 Failed mask ventilation - ?
9 Cannot ventilate, cannot intubate 0,01% (1:10000)

• Unofficial statistics: 15-30%


9 90% of cases are preventable with more careful airway status
assessment
Difficult Airway Algorithm
• Problem 1: Poor sensitivity •

Lingual tonsil hyperplasia:


an unexpected
catastrophe
Difficult Airway Algorithm
• Problem 2: Nonstandardized technique •

Effects of posture, phonation and observer on Mallampati


classification. Tham EJ et al. Br J Anaesthesia, 1992
Difficult Airway Algorithm
• Problem 3: Predictors of difficult mask ventilation ? •
Definition
• Necessity to increase flow up to 15 l/ min or to use a
• Air leak is evident by-pass button more than twice
• No chest rise • Persistent hypoventilatrion
• SaO2 < 90% when ventilating with 100% O2 • Necessity to constantly change patient's positioning

Incidence
• 0,07 % El-Ganzouri AR. Anesth Analg 1996
• 0,9 % Rose DK. Can J Anaesth 1994
• 1,4 % Asai T. Br J Anaesth 1998
• 5 % Francon D. AFAR 97, Langeron O. Anesthesiology 2000
• 15 % Williamson JA. Anaesth Intens Care 1993

Predictors
• Deformities, burns, scars, trauma • Obesity
• Beard • Snoring
• Absence of teeth • Advanced age
• Obstructive sleep apnea
Difficult Airway Algorithm
• Problem 3: Predictors of difficult mask ventilation •

Difficult ventilation predicts


difficult intubation
•••
Ventilation is more complex in
difficult intubations
Difficult Airway Algorithm
• Everybody is involved •

Patient's drama

Circumstancies

Anesthesiologist's drama
Expected
difficult airway
A look back

Anesthesia-related deaths and brain damage


(ASA closed claims project database, 2004)

100

50

0
Unexpected difficult Expected difficult
airway airway
Expected difficult airway
• General considerations •
• An informed consent is mandatory
• Awake intubation techniques are employed. Sedation monitoring is highly
recommended (Ramsay 3)
• Techniques: FOB, intubation in local anesthesia, retrograde witre
intubation. A new alternative: intubating LMA, Bullard laryngoscope
• Uncooperative patient is a great problem. FOB is relatively
contraindicated, elective surgical airway seems to be a reasonable choice
• Risky: regional anesthesia, mask anesthesia without any back-up plan in
case the necessity of intubation ensues
• Not recommended: classical LMA, blind intubation through the LMA, FOB
in general anesthesia
• If failed:
9consider re-preparation of the patient for awake intubation or cancel case
9use different blades, LMA as a FOB conduit, retrograde intubation, face
mask and other anesthesia methods
9surgical airway (elective or emergency)
Expected difficult airway
ASA Difficult Airway Algorithm
Difficult airway

Expected in an
Expected Unexpected
uncooperative patient

Induction of general anesthesia


Proper preparation
Failed intubation
Awake intubation
Call for help. Ventilation via face mask

Failed Ventilation Ventilation


ineffective effective

Alternative noninvasive approaches


LMA (bronchoscopy, retrograde intubation...)

As a As a
LMA failure definitive ventiliation temporary ventiliation
device device

Combitube A conduit for fiberoptic intubation

Noninvasive and surgical airway access techniques


Flexible
fiberoptic
intubation
Bronchoscopy
• Exploring Lithuania •

F Availability of fiberoptic bronchoscopes


9 Local hospitals......................................................................10%
9 Regional nonteaching hospitals..............................................64%
9 University hospitals...............................................................75%

F If available, FOB service is provided by


9 Anesthesiologists....................................................................47%
9 Other physicians....................................................................35%
9 Nobody is experienced in FOB................................................18%

F Rigid bronchoscopy
9 Availability.............................................................................8%
9 Nevertheless, nobody is experienced in rigid bronchoscopy.....50%
Fiberoptic intubation
Indications Contraindications and drawbacks

• Expected difficult • Uncooperative patient


intubation
• Hypoxia
• Unexpected difficult
intubation in a non hypoxic • Obscure view anticipated
patient (incontrollable secretions
• Airway obstruction etc)
(foreign bodies, neoplasm..)
• Profuse bleeding if
• Unstable or immobile uncontrollable with active
cervical spine suctioning
• Endobronchial intubation
• Hypersensitivity to local
• Aspiration anesthetics (for an awake
• Airway hygiene patient)
• Tracheostomy •Inexperience of the
(percutaneous, surgical) operator
Flexible fiberoptic intubation
The most common problems
• Toxicity of local anesthetics
• Complications of oxygen insufflation
• Absence of any back-up plan in case of failure / complications
• No alternative airway device available
• Hang-up (inability to pass an ETT through the vocal cords)
• ETT placed too deep
• Lost landmarks due to inexperience
• Obstructing base of tongue or epiglottis
• Reflex closure of the glottis, bronchospasm, vomiting, severe
cardiovascular reaction
• Inadequate sedation of the awake patient
• Hypersecretion, epistaxis
• Fogging of the FOB
Retrograde
wire intubation
An underused alternative
Retrograde wire intubation
Indications Contraindications and drawbacks
• An alternative to FOB in case of • A hypoxic patient
expected difficult airway • Difficulties in identifying the
• Poor visualization of anatomic cricothyroid (obesity, neck trauma and
structures (blood, hypersecretion, tumors etc)
deformities etc) in a nonhypoxic • Laryngotracheal stenosis
patient
• Disorders of bleeding
• Infection
Complications
• Hoarseness (14)
• Bleeding (11)
• Subcutaneous emphysema, pneumomediastinum, pneumothorax (6)
• Esophageal trauma
• N. trigeminus injury (1)
Retrograde wire intubation

Possible ways: a small ETT-over-a guidewire, a guidewire-through- Murphy


Eye, a guidewire-through-a FOB

Important notes

• A local anesthesia of the trachea, nasal and oral cavity is recommended,


if time allows
• The needle is advanced over the mid-cricothyroid membrane at an angle
of 45° to the chest while maintaining neck extension
• J - shaped introducer is at least 2,5 times the length of a standard ETT
(typically 1,1-1,2m)
• Coughing typically heralds caudad travelling of the wire
• Obstruction is usually overcome if the position of head and neck is
changed
Unexpected
difficult airway
Unexpected difficult airway
• Priorities •
• Oxygenation is the first priority. Reevaluate the oxygenation status
before any subsequent attemp. Ventilation status should be constantly
surveyed as well.
• If mask ventilation becomes inadequate, the aspiration issues are not
considered
• It's highly recommended to refer to Cormack-Lehane laryngoscopy
scale.
• Persistent attempts of intubation are detrimental. Three attempts are
usually allowed, but try once in case of the most difficult laryngoscopy
grade
• LMA and Combitube is the first choice devices if ventilation becomes
ineffective. Do not defer the insertion of LMA. Later, it will be of little
value due to progressive posttraumatic edema. If failed, consider
transtracheal oxygenation.
• FOB should be immediately available. It is used when the patient
awakes.
• Blind intubation through the LMA and blind nasal intubation is no
longer recommended
Unexpected difficult airway
ASA Difficult Airway Algorithm
Difficult airway

Expected in an
Expected Unexpected
uncooperative patient

Induction of general anesthesia


Awaken
Proper preparation
Failed intubation
Cancel
Awake case
intubation
Call for help. Ventilation via face mask
Postpone case
Failed Ventilation Ventilation
ineffective effective

Alternative noninvasive approaches


LMA (bronchoscopy, retrograde intubation...)

LMA as LMA as a
LMA failure definitive ventiliation temporary ventiliation
device device

Combitube A conduit for fiberoptic bronchoscope

Noninvasive and surgical airway access techniques


Intubating
laryngeal mask
Intubating LMA
Its role in the management of difficult airway

Use of the Intubating LMA-


Fastrach™ in 254 Patients with
Difficult-to-manage Airways
Anesthesiology, 2001

The overall success rates for blind and fiberoptically guided


intubations through the LMA-Fastrach™at three attempts were

96,5 - 100%
Intubating LMA
Advantages
• One of the most effective airway devices in case of difficult intubation and/or extubation
• Hypersecretion, blood, edema usually do not influence the success rate
• Positioning of physician is an unimportant issue
• One hand remains free
• Safe in case of suspected unstable cervical spine (no 'sniffing' position is needed)
• No contact with a dangerous infection
• Accomodation of large-lumen ETT (8,0 mm)
• Very suitable for bronchoscopy

Disadvantages
• Special endotracheal tubes are needed for intubation
• Complicated ILMA removal
• No suitable for prolonged procedures
• Possibility of trauma and dislodgement if patient's position is changed
• Contraindicated in case of pharyngolaryngeal abnormalities
• Possible difficulties if mouth opening is reduced
Intubating LMA
The place of LMA in ASA Difficult Airway Algorithm
Difficult airway

Expected in an
Expected Unexpected
uncooperative patient

Induction of general anesthesia


Proper preparation
Failed intubation
Awake intubation
Call for help. Ventilation via face mask

Failed Ventilation Ventilation


ineffective effective

Alternative noninvasive approaches


Intubating LMA (bronchoscopy, retrograde intubation...)

LMA as LMA as a
LMA failure definitive ventiliation temporary ventiliation
device device

Combitube ILMA as a conduite for FOBi

Noninvasive and surgical airway access techniques


The Last
Chance
Difficult Airway Algorithm
• Cannot intubate, cannot ventilate •

• Consider LMA, Combitube, rigid bronchoscope. If failed,


percutaneous cricothyrotomy is the procedure of choice.
• Decision to do it should not be delayed or postponed.
Most physicians hesitate at potentialy grave risk to the
patient
• Tracheostomy is never an emergency procedure. If
indicated (eg., a laryngeal neoplasm-related obstruction), it
is performed electively using a local anesthesia
• Every anesthesiologist should be familiar with basic
transtracheal oxygenation techniques. Practicing on
mannequins is shown to be effective and therefore it's
strongly recommended
Cannot ventilate, cannot intubate
1. Percutaneous cricothyroidotomy
1. If difficult intubation is expected, potential
puncture site should be identified, dressed and
anesthetized
2. The right-handed clinician stands on the right
side of patient, the trachea is fixated with
nondominant hand.
3. Needle is advanced at right angle in the
caudad third of the membrane. Constant
aspiration is applied until the trachea is entered.

• Large - bore (3.5-6 mm) access


Ventilation and oxygenation with
low-pressure system is adequate. A
1-1,5 cm vertical skin incision is
needed. Insertion direction is 45°
caudad. A Seldinger technique may
be used to pass a dilator with the
catheter
Cannot ventilate, cannot intubate
1. Percutaneous cricothyroidotomy

• Low pressure system


Ambu bag or anesthesia circuit is
used. This cannot provide enough
flow to expand the chest
adequately, but it's a temporary
oxygenation mean while a more
definitive airway is secured.
• High pressure system
Jet ventiliator or "O2 flush" is used.
Vt 400-700 ml is achievable via a
16G catheter. Insufflations 1-1,5 sec
every 5 sec. Mouths and nose
closure is often needed during
insufflation (but not exhalation)
Cannot ventilate, cannot intubate
2. Surgical emergency airway access

• Complication rate is 20-40% higher when compared


to transtracheal jet ventilation
• Reported complications: laryngeal stenosis, voice
changes (10-15%), bleeding (up to 8%), tube
misplacement
Cannot ventilate, cannot intubate
3. Teaching problem
Comparison of Cricothyrotomy Methods Performed by Inexperienced
Clinicians. Eisenburger et al. Anesthesiology, March 2000

40 first-time
cricothyroidotomies
Surgical cricothyrotomy vs Seldinger technique

Successful placement 70% Successful placement 60%


Failure due to subcutaneous, Failure due to kinking of
paratracheal and esophageal guidewire
tube placement .
Cannot ventilate, cannot intubate
3. Teaching problem
What Is the Minimum Training Required for Successful
Cricothyroidotomy?: A Study in Mannequins.
Wong DT et al. Anesthesiology, 2003

102 anesthesiologists
performing cricothyroidotomies on mannequins

.
By the fifth attempt, 96% of participants were able to
successfully perform the cricothyroidotomy in 40 s or less
Difficult Airway
The problem of teaching

Training Guidelines in Anaesthesia of the


European Board of Anaesthesiology,
Reanimation and Intensive Care (2001)

• For most manual skills, a necessary number of cases per procedure


has been determined to achieve an optimal rate of success. As
concernes difficult airway situations, no prospective study has
established the minimum number of training sessions required.
• Nevertheless, European Academy of Anesthesiology strongly
suggests the use of anesthesia simulators and mannequins during the
training process.
• Prehospital and emergency medicine is an important advance in
contemporaneous residency training program.
Teaching airway skills
• Exploring Lithuania •

Survey of sixteen ex-residents


(2001-2004)
Teaching airway skills
• Exploring Lithuania •

F Experience of difficult intubation with a


compromised oxygenation

94%
It must have been a preventable disaster in....... 53%

F What guides you in case of difficulties?


9 Local algorithm of difficul intubation....................................14%
9 My own experience.............................................................20%
9 ASA Difficult Airway Algorithm ............................................66%
Teaching airway skills
• Exploring Lithuania •

F Airway techniques performed


9 LMA..........................................................................................100%
9 Endobronchial intubation..............................................................87%
9 Awake intubation........................................................................75%
9 Nasal intubation..........................................................................69%
9 Modified laryngoscopes (McCoy, Miller etc)...................................56%
9 Tracheostomy.............................................................................50%
9 Combitube..................................................................................13%
9 Fiberoptic intubation....................................................................13%
9 Retrograde wire intubation (incl. on a mannequin)..........................6%
9 Cricothyrotomy (incl. on a mannequin)...........................................6%
9 Lighted stylet (incl. on a mannequin)..............................................6%
9 Gum elastic bougie or similar device...............................................0%
Teaching airway skills
• Exploring Lithuania •

F Evident lack of experience


9 Fiberoptic intubation.............................................................100%
9 Gum elastic bougie and other stylets.......................................87%
9 Nasal intubation.....................................................................69%
9 Modified laryngoscopes (McCoy, Miller blades etc)....................44%
9 Awake intubation...................................................................19%
9 LMA......................................................................................13%
9 Combitube.............................................................................13%

F Gaps in the residency program


9 Fiberoptic intubation..............................................................100%
9 Alternative airway devices.......................................................87%
9 Simmulators and mannequins..................................................50%
Difficult Airway
Room for improvement

• Better knowledge of an appropriate plan / algorithm


• Being prepared to perform awake intubation more
often
• More practice in fiberoptic intubation
• Always having an appropriate sized LMA
immediately available
• All anesthesiologists knowing, and practicing on
mannequins, how to oxygenate via the cricothyroid
membrane
• All anesthesiologists knowing that a difficult
intubation should be communicated to the patient
Teaching airway skills
• Exploring Lithuania •

2003 2004
Teaching airway skills
• Exploring Lithuania •

2005
A Year of Airway Management ?
2003 2004
The Happy End