Airway Management

Ahmad Hunainui I1A007018

Pembimbing: dr. Mahendratama, Sp.An

Anatomy

Equipment
Oral & nasal airway Face mask LMA Esophageal-Tracheal combitube Tracheal tube Rigid laryngoscope

Equipment
Oral & nasal airway
Maintain the opening airway Awake or lightly anesthetized patients may cough or even develop laryngospasm during airway insertion if laryngeal reflexes are intact. Nasal airway: risk of epistaxis, should not be used in basilar skull fracture, better tolerated than oral airway.

Face mask
Facilitate delivery of oxygen or of an anesthetic gas from a breathing system to a patient by creating an airtight seal with the patient's face Transparent masks observation of exhaled humidified gas and immediate recognition of vomiting Black rubber masks pliable enough to adapt to uncommon facial structures

 Effective ventilation requires both a gas-tight mask fit and a patent airway. Improper face mask technique deflation of the anesthesia reservoir bag when the adjustable pressure-limiting valve is closed indicating a substantial leak around the mask.

The McCoy Laryngoscope

Rigid Laryngoscope

LMA

Combitube

Specialized laryngoscopic blades

Flexible fiberoptic bronchoscope

Kheterpal S. Han R, Tremper RK, et al. Incidence and Predictors of Difficult and Impossible Mask Ventilation. Anesthesiology 2006; 105:88591

Spesific test for assessment A. Anatomical criteria

1. Relative to tongue/pharyngeal size Mallampatti test

Class I : Visualization of the soft palate, fauces; uvula, anterior and the posterior pillars. Class II : Visualization of the soft palate, fauces and uvula. Class III : Visualization of soft palate and base of uvula. Class IV: Only hard palate is visible. Soft palate is not visible at all.

2. Atlanto occipital joint (AO) extension feasibility to make sniffing or Magill position for intubation, measured by simple visual estimate or goniometer

Grade I Grade II Grade III Grade IV

: > 35 : 22-34 : 12-21 : <12

3. Mandibular space i. Thyromental (T-M) distance (difficult: <3 finger or <6 cm; less difficult: 6-6.5 cm; normal: >6,5 cm) ii. Sterno-mental distance (difficult intubation: <12 cm) iii. Mandibular-hyoid distance (N: 4 cm/ 3 finger) iv. Inter-incisor distance ( N: 4,6 cm / more)

Lemon Airway Assessment

The score with a maximum of 10 points is calculated by assigning 1 point for each of the following LEMON criteria: L = Look externally (facial trauma, large incisors, beard or moustache, large tongue) E = Evaluate the 3-3-2 rule (incisor distance-3 finger breadths, hyoid-mental distance-3 finger breadths, thyroidto-mouth distance-2 finger breadths) M = Mallampati (Mallampati score > 3). O = Obstruction (presence of any condition like epiglottitis, peritonsillar abscess, trauma). N = Neck mobility (limited neck mobility) Patients in the difficult intubation group have higher LEMON scores.
Gupta S, Sharma R, Jain D. AIRWAY ASSESSMENT : PREDICTORS OF DIFFICULT AIRWAY. Indian J Anaesth 2005; 49 (4): 257-262.

B. Direct laryngoscopy and fibreoptic bronchoscopy

Grade I Visualization of entire laryngeal aperture. Grade II Visualization of only posterior commissure of laryngeal aperture. Grade III Visualization of only epiglottis. Grade IV Visualization of just the soft palate. Grade III and IV predict difficult intubation

C. Radiographic assessment
1. Skeletal films 2. Fluoroscopy (cord mobility, airway malacia, emphysema) 3. Oesophagogram (inflammation, foreign body, extensive mass or vascular ring) 4. Ultrasonography (anterior mediastinal mass, lymphadenopathy, differentiates cyst from mass and cellulitis from abcess) 5. CT/MRI (congenital anomalies, vascular airway compression) 6. Video-optical intubation stylets

Visite Pre operatif

KU : Baik Batuk/pilek/demam : -/-/Gigi goyang/gigi palsu : -/R/ HT/DM/asma : -/-/R/ alergi makanan/obat : -/R/ operasi dengan GA : Merokok : + (berhenti 1 minggu yg lalu)

Pemeriksaan Fisik
Keadaan umum: Baik Kesadaran: Komposmentis GCS : 4-5-6 TD : 120/90 mmHg N : 84 x/menit RR : 20 x/menit BB : 64 kg Mallampati : 3

Kesulitan ventilasi pada kasus

 Cervical spine dbn Neck anatomy thick poor flexion-extension mobility of the head on neck. Mallampati classification III Full beard No Dentition normal Large tongue

Intraoperatif
Pethidin, propofol dan muscle relaksan sdh diinjeksikan apnea kesulitan ventilasi dengan face mask saturasi turun pasang guedel (untuk mempertahankan airway) saturasi tetap tidak meningkat pasang LMA.

Difficult Airway
Difficult airway : the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both.

Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. ANESTHESIOLOGY 2003; 98:126977

Difficult ventilation
(a) It is not possible for the anesthesiologist to provide adequate face mask ventilation due to one or more of the following problems: inadequate mask seal, excessive gas leak, or excessive resistance to the ingress or egress of gas. (b) Signs of inadequate face mask ventilation: 1. absent or inadequate chest movement, 2. absent or inadequate breath sounds, 3. auscultatory signs of severe obstruction, 4. cyanosis, 5. gastric air entry or dilatation, 6. decreasing or inadequate oxygen saturation (SpO2), 7. absent or inadequate exhaled carbon dioxide, 8. absent or inadequate spirometric measures of exhaled gas flow 9. hemodynamic changes associated with hypoxemia or hypercarbia (e.g., hypertension, tachycardia, arrhythmia).
Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. ANESTHESIOLOGY 2003; 98:1269 77

Predict difficult mask ventilation (OBESE)

Difficult intubation
Difficult intubation has been defined by the need for more than three intubation attempts or attempts at intubation that last > 10 min. Such patients in stable circumstances can usually tolerate 10 min of attempted intubation without adverse sequelae.

Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. ANESTHESIOLOGY 2003; 98:126977

Predict difficult intubation

a. Poor flexion-extension mobility of the head on neck b. A receding mandible and presence of prominent teeth c. A reduced atlanto-occipital distance, a reduced space between C1 and the occiput. d. Large tongue size- related more to the ratio of the anterior length of the chin or mandible

If a difficult airway is known or suspected:

1. Inform the patient (or responsible patient) of the special risk and procedures pertaining to management of the difficult airway 2. Ascertain that there is at least one additional individual who is immediately available to serve as an assistant in difficult airway management 3. Administer face mask preoxygenation before initiating management of the difficult airway. The uncooperative or pediatric patient may impede opportunities for preoxygenation 4. Actively pursue opportunities to deliver supplemental oxygen throughout the process of the difficult airway management

Difficult airway algorithm

Retrograde intubation