Big Airway Lecture- Students .pptx

Airway Anatomy Jennifer Oakes, PhD, DNAP, CRNA TCU, Anesthesia Essentials 1 Required Reading • Barash Chapter 28 2 Objectives • Students will identify anatomy of the nose, oral cavity and understand purpose of specific structures. • Students will understand separations of the pharynx and specif...

Airway Anatomy Jennifer Oakes, PhD, DNAP, CRNA TCU, Anesthesia Essentials 1 Required Reading • Barash Chapter 28 2 Objectives • Students will identify anatomy of the nose, oral cavity and understand purpose of specific structures. • Students will understand separations of the pharynx and specific structure and purposes. • Students will identify structure of larynx including cartilages • Students will describe the basic nerve innervations of the pharynx and larynx 3 Airway Anatomy 4 Nose • Warms and humidifies air • Resistance to airflow is twice that through the mouth • Accounts for 2/3 total airway resistance 5 Oral anatomy • • • • Soft palate Hard palate Uvula Palatine tonsil 6 7 Pharynx 8 Pharynx • Nasopharynx – Extends from base of skull to upper surface of soft palate – Contains adenoids, pharyngeal tonsils, lymph tissue, Eustachian tubes opening • Oropharynx – Extends from uvula to level of hyoid bone – Contains palatine tonsil, epiglottis, tongue, uvula • Hypopharynx (Laryngopharynx) – Inferior to epiglottis – Where common pathway diverges into larynx and esophagus pathways. 9 Larynx • Between third and sixth cervical vertebrae • Modulates sound • Separates trachea and esophagus during swallowing • Composed of muscles, ligaments, cartilages, glottis 10 11 You put the tube where? 12 Cartilages of the Larynx • Single – Thyroid – Cricoid – Epiglottis • Paired – Arytenoid – Corniculate – Cuneiform 13 Cartilage of the Larynx 14 Larynx • Vocal Cords are the narrowest portion of the adult airway • Anterior-posterior dimensions of the vocal cords is approximately 23 mm in men and 17 mm in women 15 From: Section III. Anesthetic Management Morgan &amp; Mikhail's Clinical Anesthesiology, 5e, 2013 Legend: Typical view of the glottis during laryngoscopy with a curved blade. (Modified and reproduced, with permission, from Barash PG: Clinical Anesthesia, 4th ed. Lippincott, 2001.) Date of download: 7/7/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved. 16 17 Cricoid Cartilage • From the Greek krikoeides meaning "ring-shaped“ • Only complete ring of trachea 18 Trachea • Begins at the sixth cervical vertebra and extends to the carina, which overlies the fifth thoracic vertebra • 16-20 horseshoeshaped cartilages • Only one full ring… the cricoid 19 Nerves • Glossopharyngeal • Vagus – Superior laryngeal – Internal laryngeal – Recurrent laryngea; 20 Glossopharyngeal • Sensory branch to pharyngeal mucosa and posterior 1/3 of the tongue (gag reflex) 21 Superior Laryngeal Nerve • Internal Branch – Sensory to both sides of the epiglottis and airway mucosa above the cords • External Branch – Motor innervation to the cricothyroid muscle 22 From: Section III. Anesthetic Management Morgan &amp; Mikhail's Clinical Anesthesiology, 5e, 2013 Legend: Sensory nerve supply of the airway. Date of download: 7/7/2014 Copyright © 2012 McGraw-Hill Medical. All rights reserved. 23 Recurrent Laryngeal Nerve • Sensory below Vocal Cords to the Trachea • Motor to all muscles of Larynx except Cricothyroid Muscle 24 25 Muscle innervation • Extrinsic muscle group moves the larynx as a group • Intrinsic muscles move the cartilages – Recurrent laryngeal nerve moves all the intrinsic muscles except the cricothyroid muscle • Abducts (only one) – Posterior Cricoarytenoid • Adducts – Lateral Cricoarytenoid (principle adductors) 26 Injured nerves • Recurrent Laryngeal Nerve – Unilateral= hoarseness – Bilateral = adduction of the cords results in stridor or occlusion 27 28 29 References • Miller, R. D. (2009). Miller's anesthesia (7th ed.). New York: Elsevier/Churchill Livingstone. • Barash, P. G. (2013). Clinical anesthesia (7th ed.). Philadelphia: Lippincott Williams & Wilkins. • Stoelting, R. K., & Miller, R. D. (2011). Basics of anesthesia (6th ed.). Philadelphia: Churchill Livingstone. • Butterworth, J. F., & Mackey, D. C. (2013). Morgan & Mikhail's clinical anesthesiology (5th ed.). New York: McGraw-Hill. 30 Airway Assessment Dr. Jennifer Oakes, DNAP, CRNA 31 Airway assessment Video • http://www.youtube.com/v/dtmPNKSAQR8 32 Patient History • Congenital conditions • Infections • Arthritis • Tumors • Trauma • obesity 33 Physical Examination • Mallampati Classification • Thyromental distance • Sternomental distance • Mouth opening • Head and neck movement • Ability to prognath • Dentition 34 Mallampati Classification • Mallampati is a classification of the oropharyngeal space • Head in neutral position • Opens mouth maximally • Protrudes the tongue without phonating 35 Mallampati Classification • Class I: The soft palate, uvula, and tonsil pillars are visible. • Class II: The soft palate, and partial uvula are visible. • Class III: The soft palate and base of the uvula are visible • Class IV: The soft palate is not visible 36 Cormack and Lehane 37 Cormack and Lehane • Laryngoscopy view • Grade I: Most of glottis is visible • Grade II: Only the posterior portion of the glottis is visible • Grade III: The epiglottis, but no part of the glottis can be seen • Grade IV: No airway structures are visualized 38 Real life views 39 Stoelting, fig 16-7, p 213; Barash, fig 29-10, p 766 Cormack & Lehane Score 40 Thyromental distance ●Thyromental Distance ○Less than three fingers (<6.5 cm)=difficult airway ○Micrognathia limits the ability to move tongue and tissue out of pharyngeal space=laryngeal structures positioned anterior 41 Thyromental distance • 6.5 cm is considered a normal airway • 6.0 cm or less often indicates difficulty moving the tongue anteriorly and visualizing the larynx • Some question degree of reliability due to variation in age and gender 42 Micrognathia 43 Sternomental distance • Sternomental Distance (SMD)distance from the tip of the chin (mentum) to the sternal notch 44 Mouth Opening • If less than 4-5 cm (two finger breaths) between the upper and lower incisors indicates a possible difficult airway • Shape of the palate • Highly arched and narrow • Can be misleading due to variation in finger size 45 Head and Neck Mobility 46 Inflammatory Disease 47 Prognathation • Upper lip bite-test • Class 1: lower incisors can bite above the vermillion border of the upper lip • Class 2: Lower incisors cannot reach vermillion border • Class 3: Lower incisors cannot bite upper lip 48 Hyomental Distance (HMD) • Measures the tip of the chin to the hyoid bone and gives information about the ability of the tongue to be moved anteriorly in the mandibular space. A difficult airway should be expected if the HMD is < 3.5 cm • The only measurement that is not effected by age or gender 49 Dentition 50 Incisors • Length of upper incisors • Relatively long • Relationship of the maxillary and mandibular incisors during normal jaw closure • Prominent overbite (max incisors anterior to mandibular incisors) • Relationship between the max incisors and mandibular incisors (bite lip test) • Patient cannot bring the mandibular incisors in front of the maxillary incisors 51 Obesity • Patients with BMI’s greater than 30 and neck circumference of greater than 40 cm have a 5% higher risk of difficult airways • Neck circumference greater than 60 cm have a 35% increase risk of difficult intubation • A mallampatti of 3 or 4 in these patients increases the risk of hypoxemia with laryngoscopy 52 Pediatric Airway • Mallampati is often not a good predictor in children. • There are fewer predictive tests for children and techniques used in adults may not be applicable to children. More likely to encounter congenital disorders which increase difficult airway problems. Comprehensive history may give best information. • Look at size of head, facial features, size of tongue, incisors, ROM • Signs of retraction-use of sternal or intercostals muscles-sign of obstruction 53 Pediatric Airway Differences • Epiglottis: larger, stiffer, more narrow in children • Until about 2 years of age • Very large tongue compared to oral cavity • Can’t “sweep” the tongue out of the way – one reason to use a miller • Glottis • Narrowest portion of adult airway • Used to believe that the cricoid cartilage is the narrowest portion of child’s airway but new studies indicate it is the glottis • Clinical implications: ok to use cuffed endotracheal tubes in children 54 55 L.E.M.O.N. • • • • • • • Goal: To determine laryngeal view to predict ease or difficulty of tracheal intubation L- Look externally at neck, incisors, mandible, dentition, facial trauma E- Evaluate (mandibular space) Upper lip bite test, TMD M-Mallampati (classification evaluation)/Mouth Opening O- Obstruction/Obese (present or absent) N- Neck (mobility) 56 References • Miller, R. D. (2009). Miller's anesthesia (7th ed.). New York: Elsevier/Churchill Livingstone. • Barash, P. G. (2013). Clinical anesthesia (7th ed.). Philadelphia: Lippincott Williams & Wilkins. • Stoelting, R. K., & Miller, R. D. (2011). Basics of anesthesia (6th ed.). Philadelphia: Churchill Livingstone. • Butterworth, J. F., & Mackey, D. C. (2013). Morgan & Mikhail's clinical anesthesiology (5th ed.). New York: McGraw-Hill. • Lang, S. A. The airway approach algorithm: practical airway assessment. Journal of Clinical Anesthesia, 404. 57 Airway Management Jennifer Oakes, DNAP, CRNA TCU, Anesthesia Essentials 58 Required Reading Barash Chapter 28 59 Objectives Student will identify various airway techniques and their appropriate uses Students will identify necessary equipment and steps to take to manage a patient’s airway Students will evaluate steps to prepare and improve patients outcomes when managing the airway Students will analyze complications of airway management and predict steps to decrease these complications Students will understand safe extubation criteria and management of complications associated with extubation 60 Difficult and failed airway management account for 2.3% of anesthetic deaths in the U.S. As anesthesia providers, we are nothing if not an AIRWAY EXPERT 61 Steps to improve success 1. 2. 3. 4. 5. Good airway history and assessment Consideration of RSI Formation of plans (Plan A, Plan B, Plan C) Weighing the risk of aspiration of gastric contents Estimating the relative risk of failed airway maneuvers 62 Airway Management Techniques Bag/mask Oral Endotracheal intubation Nasal Endotracheal intubation Supraglottic Airways Transtracheal 63 Definitive Airways Spontaneously Breathing Endotracheal Tube Nasal Endotracheal Tube Surgical Airway ◦ Cricothyrotomy ◦ Tracheotomy 64 FAILURE TO INTUBATE IS OFTEN NOT LIFE THREATENING: FAILURE TO VENTILATE AND OXYGENATE WILL BE 65 Pre-oxygenation (denitrogenation) DAWD: Duration of Apnea Without Desaturation Goal to achieve ETO2 >90% 3 minutes of 100% O2 or 8 deep breaths in 60 seconds A healthy patient can maintain SaO2 >90% for approximately 8.5 minutes! Obesity, pregnancy, pulmonary disease seriously decrease DAWD 66 Bag-Mask Ventilation Left Hand Fingers lift mandible into mask Not squish mask down Right hand on bag Ventilating pressure should be < 20 cm H2O 67 Indications of difficult mask Age (>55 years old) BMI >26 Facial hair Edentulous (no teeth) H/o snoring/sleep apnea Repeated attempts at laryngoscopy Mallampati Class III or IV Neck radiation Male gender Unable to prognath 68 69 Oral Airways Displaces tongue from the posterior pharyngeal wall May stimulate gag reflex 70 Nasal Airways Better tolerated in awake or lightly anesthetized patient Contraindicated in coagulation abnormalities, basilar skull fractures A bloody nose can ruin 71 Oral ETT Gold Standard in Airway management 72 Indications for ETT Provide a patent airway Prevent aspiration Need for frequent suctioning Facilitate positive-pressure ventilation Operative position other than supine Operative site near or involving the upper airway Airway maintenance by mask 73 Equipment 10 CC Syringe attached to appropriately sized ETT Stylet Laryngoscope tape Stethoscope Suction equipment ET C02 detector. 74 Basic Airway Set-up 75 Intubation video http://www.youtube.com/v/xuYzIgZ Uy_o 76 Systematic Steps for DVL (Direct visual laryngoscopy) 1. 2. 3. 4. 5. 6. 7. 8. 9. Hyper-oxygenate the patient with 100% oxygen for 2 minutes. Open the patient’s mouth with the right hand, and remove any dentures. Grasp the laryngoscope in the left hand. Spread the patient’s lips, and insert the blade between the teeth, being careful not to break a tooth. Pass the blade to the right of the tongue, and advance the blade into the hypopharynx, pushing the tongue to the left. Lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords. Pass the tube through the vocal cords. Verify Placement Secure ETT 77 Laryngoscope Blade Most common for adults: ◦ Macintosh (Mac) #3-#4 : curved blade ◦ Miller (straight blade) #2-#3 Might see with Pediatrics ◦ Miller #1, Mac #1-2, Phillips, WisHipple 78 79 Laryngoscopy blade in left hand enter mouth on right no pressure on teeth move blade to left displacing tongue depression or lateral movement of thyroid cartilage may improve view Curved blade (Macintosh) place in vallecula Straight blade (Miller) place beneath epiglottis Stoelting, fig 16-12, p 218 80 Endotracheal Tubes Size is based on internal diameter (ID) ◦ Marked on each tube ◦ Available in 0.5mm diameter increments Lengthwise cm markings to measure length at patients lip Clear polyvinyl chloride ◦ Warms and softens with patients body heat Radiopaque to measure position of tip in relation to carina with x-ray 81 Endotracheal Tubes Always have 1 size smaller & 1 size larger than anticipated Can use cuffed or uncuffed tubes for infants & small children -must make sure cuff pressure is monitored to avoid subglottic edema and postextubation croup 82 83 Confirm ETT placement  Sustained presence of ETCO2 (3 to 5 consecutive breaths)  Bilateral chest movement  Bilateral breath sounds and absence of sound over stomach  “feel” on the reservoir bag & expiratory refilling of the bag  Condensation of H2O in tube lumen (breath fogging) 84 Something wrong? DOPE: Displaced (usually right mainstem, pyreform fossa, etc.) Obstruction (kinked or bitten tube, mucous plug, etc.) Pneumothorax (collapsed lung) Esophagus 85 Cricoid Pressure AKA “Sellick’s” maneuver Assistant exerts downward external pressure with thumb and index finger on the cricoid cartilage. Compresses esophagus against cervical vertebrae Pressure of 30-40 Newtons (3-5 kg) Should be applied before 86 87 When do you release Cricoid Pressure? When you are absolutely sure the ETT is correctly placed. Ideally after ETT is secured. 88 89 Nasal ETT 90 NETT Indications Dental procedures Intraoral/oropharyngeal surgeries Questionable cervical spine stabilty Limited mouth opening (jaw wired shut) 91 Contraindications Midface instability Coagulopathy Suspected basilar skull fractures Relative contraindications Suspected nasal foreign bodies Recent nasal surgery h/o frequent epistaxis 92 https://www.youtube.com/v/vXKaB cC9VT0 93 NETT Equipment Small ETT or Nasal Rae ETT Magill forceps Lidocaine jelly or water-soluble lubricant Nasal vasoconstrictor (Afrin or phenylephrine) Syringe to inflate cuff Suction Laryngoscope or glide-scope Nasal airway (for dilating) 94 Steps to NETT Spray vasoconstrictor Insert lubricated nasal airway (optional) Insert lubricated pre-warmed ETT into nares at right angle to the face Apply gentle, firm pressure until ETT passes nasopharynx Insert laryngoscope into mouth Advance tube under DVL Magill forceps may be needed to guide tube through the vocal cords. An assistant advances the tube 95 96 Complications of Laryngoscopy Dental trauma ◦ 1 in every 4500 pts ◦ Dislodged tooth should be recovered, if not recovered then x-ray Systemic hypertension & tachycardia ◦ Usually transient Lip lacerations Retropharyngeal dissection 97 Complication of ETT Bronchospasm Obstruction of tube by secretions or kinking Endo-bronchial intubation (Right Main-stem Bronchus) Extubation Tube migration ◦ Lateral head rotation moves tracheal tube ~ 0.7 cm ◦ Extension or Flexion (on pillows) of a patient’s head may move the tube toward or away from the carina 98 Bougie Useful for Epiglottis-only view (Grade 3) 60 cm long Angled 40 degree distal end Non-latex Flexible but maintains shape Tip can be felt “bouncing” off tracheal rings as it advances ETT is thread over bougie and advanced after bougie is in place 9 Aspiration Mendelson’s Syndrome - *pH=2.5 or greater than 25 ml of gastric content Aspiration phneumonitis 10 0 Risks of Aspiration Pregnancy Acute GI disease i.e. small bowel obstruction, ileus, esophageal disease Trauma DM Obesity Narcotics Full stomach 10 1 RSI- Rapid Sequence Induction Preoxygenation Rapid-onset neuromuscular blockade (Succinylcholine) Cricoid pressure Absence of positive pressure mask ventilation 10 2 Improve your chances for Success! Equipment ◦ Oral/nasal airways ◦ Difficult airway equipment ◦ Various sizes of ETT Assistant personnel Patient position Oral/nasal airways Always, Always, Always have a plan B and C! 10 3 Sniffing Position Laryngoscopy requires distortion of the normal anatomic planes of the upper airway to produce a line of direct visualization from the anesthetist’s eye to the larynx Trying to create a new visual axis through alignment of the axes of the oral and pharyngeal cavities to displace the tongue. ◦ OA=oral axis ◦ PA=pharyngeal axis ◦ LA=Laryngeal axis 10 4 Sniff Position Controversial-some believe moving tongue and epiglottis out of the way play a greater role in ability to intubate Sniff position - improves pharyngeal patency in patients with sleep apnea Extension-facilitates mouth opening, laryngoscope placement, and view of the larynx 10 5 Sniffing position 10 6 A: head neutral position no alignment of OA, PA, or LA B: head on pad, neck flexed LA & PA better, but not OA Stoelting, fig 16-8, p 214 10 7 C: head on pad, neck flexed, head extended on neck OA, PA, LA aligned “sniffing” position D: head not on pad, extension of head on neck without elevation of head Stoelting, fig 16-8, p 214 10 8 Positioning Raise patient’s head for sniffing position: to optimize the LA and PA raise head (about 10 cm) Positioning obese patients in the sniffing position can be difficult-d/t fat pad on back –will need to “ramp” the patient Place blankets under shoulders to lift pad at the back of the neck off the OR tablecan then position head to move anteriorly 10 9 11 0 Ramping 11 1 Ramping 11 2 Prepare for Extubation Initial Plan: “Deep” extubation or “Awake” extubation Patient position plan Bite block in place Throat pack removed Pre-oxygenation (100%) Suction pharynx 11 3 Criteria for Extubation Adequate Oxygenation Adequate ventilation Hemodynamically stable Neurologically intact ◦ Intact gag/cough reflex ◦ Follows commands (i.e. opens eyes, takes a deep breath) ◦ Normothermic 11 4 Extubation Criteria Ensure full reversal of muscle relaxation Sustained tetany Train of four ratio >0.9 (four strong twitches) Sustained head lift for 5 seconds 11 5 Complication of Extubation Miller’s, Anesthesia (2009) 11 6 Laryngospasm Larynx spasms shut- air doesn’t move in or out Lightly anesthetized patient is at most risk- make sure they are either awake, or deep Secretions irritate Larynx (make sure you suction) 11 7 Laryngospasm Break the laryngospasm: Succinylcholine (0.1 mg/kg IV) Positive Pressure through facemask Forward displacement of mandible 11 8 11 9 References     Miller, R. D. (2009). Miller's anesthesia (7th ed.). New York: Elsevier/Churchill Livingstone. Barash, P. G. (2013). Clinical anesthesia (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Stoelting, R. K., & Miller, R. D. (2011). Basics of anesthesia (6th ed.). Philadelphia: Churchill Livingstone. Butterworth, J. F., & Mackey, D. C. (2013). Morgan & Mikhail's clinical anesthesiology (5th ed.). New York: McGraw-Hill. 12 0 Supraglottic Airways Jennifer Oakes, DNAP, CRNA TCU, Anesthesia Essentials 121 Objectives • Students will compare and contrast various SGA devices • Students will understand indications and contraindications of SGA devices • Students will synthesize appropriate uses for SGA devices • Students will Understand uses for SGA in emergency situations and conclude appropriate uses. • Students will analyze potential complications, rationale and evaluate risks 122 History • In 1988, Dr. Archie Brain introduced the first supraglottic airway- the LMA 123 Supraglottic Airways • All are designed to form a seal in the pharynx between the respiratory and digestive tracts • All are inserted blindly • Supraglottic means “above the glottis” or “above the larynx”. 124 LMA • LMA – Classic – Unique – Fastrach: facilitates ETT passing through LMA device – ProSeal: has gastric tube to decompress the stomach – Supreme • All have 3 main components: mask, airway tube, and inflation line 125 Advantages/Disadvantage Compared to face mask Advantages • Hands-free operation • Better seal in bearded patients • Less cumbersome in ENT surgery • Often easier to maintain airway • Protects against airway secretions • Less facial nerve and eye trauma • Less operating room pollution Disadvantages • More invasive • More risk of airway trauma • Requires new skill • Deeper anesthesia required • Requires some TMJ mobility • N2O diffusion into cuff • Multiple contraindications 126 Advantages/Disadvantages Compared to ETT Advantages • Less invasive • Very useful in difficult intubations • Less tooth and laryngeal trauma • Less laryngospasm/ bronchospasm • Dos not require muscle relaxation • Does not require neck mobility Disadvantages • Increased risk of gastric aspiration • Less safe in prone or jackknife positions • Limits maximum PPV • Less secure airway • Greater risk of gas leak and pollution • Can cause gastric distention 127 Contraindications Absolute contraindications (in all settings, including emergent) • Cannot open mouth • Complete upper airway obstruction 128 Relative contraindications (in the elective setting) Increased risk of aspiration Prolonged bag-valve-mask ventilation Morbid obesity Second or third trimester pregnancy Full stomach Upper gastrointestinal bleed Suspected or known abnormalities in supraglottic anatomy • Need for high airway pressures (*pressure should not exceed 20 mm H2 O*) 129 • • • • • • • LMA Classic • Flexible • Silicone rubber mask • Lateral edges rest in the piriform sinuses • Proximal end seats under base of tongue • Distal tip sits at upper esophageal sphincter • Size selection is determined by weight 130 LMA Fastrach • Allows for blind intubation through LMA • Anatomically curved stainless steel tube • Has attached handle to aid insertion of device and to assist in ETT insertion • Many require specifically designed ETT and advancer 131 LMA ProSeal • Modification of LMA classic • Second lumen that parallels airway tube but opens at distal tip • Acts as esophageal vent • Protects against aspiration ONLY if it is optimally seated • Not a guarantee to prevent aspiration 132 LMA Supreme • Single usedisposable • Gastric port/tube • Minimizes gastric insufflation • Decreases risk of aspiration but no guarantee 133 134 Insertion Technique 1. Deflate the cuff against a flat surface with index finger and middle finger on either side of the bowl 2. Hold the LMA like a pen, with index finger at the junction of the tube and mask 3. Insert the LMA into the mouth and advance, following the palate and posterior pharyngeal wall until resistance is met 4. Let go of the mask and tube 5. Inflate the cuff, allowing the device to move into correct position 135 Complications Aspiration of gastric contents *** Local irritation Upper airway trauma Pressure-induced lesions Nerve palsies Mild sympathetic response Complications associated with improper placement Obstruction • Laryngospasm • Bronchoconstriction • • • • • • 136 Sizes and Volumes 137 Role in Difficult Airway Algorithm • Factors related to difficult tracheal intubation do not correlate with difficult LMA placement • Therefore, the incidence of experiencing difficulty with both ETT and LMA placement is very low. Miller’s, Anesthesia 138 139 Other SAD Combitube  Double-lumen  Can function as either an endotracheal device or esophageal obturator  Passed blindly or with laryngoscope  Inflate oropharyngeal cuff first  Inflate distal cuff second  Ventilate through the longer (blue) lumen  If no breath sounds are heard, try other lumen 140 King Laryngeal tube • Ability to pass Gastric tube through distal port • Specific anatomically shaped tube • Blind insertion 141 References • http://www.lmaco.com/catalogue_main.php?catID=57 99 • Miller, R. D. (2009). Miller's anesthesia (7th ed.). New York: Elsevier/Churchill Livingstone. • Barash, P. G. (2013). Clinical anesthesia (7th ed.). Philadelphia: Lippincott Williams & Wilkins. • Stoelting, R. K., & Miller, R. D. (2011). Basics of anesthesia (6th ed.). Philadelphia: Churchill Livingstone. • Butterworth, J. F., & Mackey, D. C. (2013). Morgan & Mikhail's clinical anesthesiology (5th ed.). New York: McGraw-Hill. • www.kingsystems.com 142 Advanced Airway Management Jennifer Oakes, DNAP, CRNA TCU, Anesthesia Essentials 143 Objectives • Students will explain the ASA Difficult Airway Algorithm • Students will identify steps to take in an anticipated difficult airway • Students will identify various techniques for managing difficult airways • Students will explain techniques used for emergency airway management • Students will compare/contrast management techniques including indications, contraindications and complications. • Students will synthesize plans for specific difficult airway scenarios 144 Required Reading • Barash Chapter 28 145 146 Anticipated Difficult Airway • • • • Develop Plan A, B, and C Good Airway Assessment Have Equipment ready Know the Algorithm! 147 The Awake Patient 148 Miller, 2009 The Awake Patient 149 Miller, 2009 Awake Fiberoptic Intubation • http://www.youtube.com/v/bDRTzmuwMnQ 150 Indications for Fiberoptic • Anticipated difficult tracheal intubation/ ventilation • Confirm ETT position • Diagnosis of malfunction of a supraglottic airway device • Cervical spine instability • Positioning of double-lumen tube and bronchial blocker • Assessment of swelling or trauma after difficult airway • Tracheal tube change • Aspiration of secretions and confirmation of 151 Fiberoptic laryngoscopy prep • Drying agent • Topical anesthetic • Equipment checked • Tracheal tube mounted and oral airway inserted • Position patient • Full explanation 152 Fiberoptic technique • Insert cord kept straight and scope maneuvered in three planes • Secretions aspirated • White-out, red-out, or loss of targetwithdraw, identify structures, readvance • Targets kept in center of view while advancing • Advance to close to the carina • Tracheal tube passed over the flexible fiberoptic laryngoscope • Tube position confirmed and secured • Anesthesia induced 153 Contraindications/ Complications • No absolute contraindications • Cannot be performed without patient cooperation • Unlikely to work if airway bleeding • Arytenoid cartilage can be displaced • Laryngeal damage • Complete airway obstruction usually due to heavy sedation 154 Nerve BlocksTranslaryngeal Translaryngeal Block • Anesthetizes below the cords • Stimulates cough (good) • 20 gauge or smaller • 3-5 cm plastic catheter over a needle is introduced midline • The inner steel cannula is withdrawn • Aspiration of air confirms placement • 3-5 ml of 4% lidocaine injected rapidly 155 Superior Laryngeal Nerve • Patient supine • Hyoid bone is displace laterally toward side to be blocked • 25 gauge, 2.5 cm needle is walked off the greater cornu of the hyoid bone inferiorly and advanced 2-3 mm. • As needle passes through membrane, loss of resistance is felt • 3 ml of local anesthetic is injected • Repeat on opposite side • Anesthetizes inferior aspect of epiglottis to vocal cords 156 Intraoral approach to Glossopharyngeal Nerve block • 5 mL of local anesthetic into base of each posterior tonsillar pillar • Careful aspiration before injection • Close Proximity to carotid artery 157 Blind Nasal Intubation • http://www.youtub e.com/v/8PG42Jl9M _g 158 Bougie • Useful for Epiglottis-only view (Grade 3) • 60 cm long • Angled 40 degree distal end • Non-latex • Flexible but maintains shape • Tip can be felt “bouncing” off tracheal rings as it advances • ETT is thread over bougie and advanced after bougie is in place 159 Cook Catheter • Can be used as an exchange catheter • Can ventilate through using jet ventilator 160 Lighted Stylet • Tip of Stylet uses bright light to visualize location through the skin of the neck • Localized glow indicates tracheal position • Diffuse glow indicates esophageal position • Obesity or skin pigmentation may alter results 161 Lighted Stylet video • http://www.youtube.com/v/9Op_iSDqrsE 162 Glidescope • Fog-resistant high-resolution video camera embedded in a reusable laryngoscope blade • Ability to see “around a corner” • Good in patients with limited neck extension or anterior airways • Easier to learn/use than FFL 163 Glidescope video • http://www.youtube.com/v/7jb2tbqQ6VQ 164 McGrath • Similar to Glidescope • Enhanced direct laryngoscope • Portable video camera attached to handle 165 • http://www.youtube.com/v/Ql2yPxha7CQ 166 Bullard • Rigid Indirect Laryngoscope • Good for minimal neck movement and/or small mouth opening • Indicated for unstable cervical spine if FFL not available • http://www.youtube.com/v/PDwN0VSzxxE • http://www.youtube.com/v/NEhkRk4oc9Y 167 Bullard Technique Technique • Start position with the Bullard handle close to the chest and the tip within the mouth • Midway through rotation of the Bullard laryngoscope • Rotation of the Bullard laryngoscope is complete, with the tip lying on the posterior pharyngeal wall and the handle vertical • The ETT is threaded through the glottis 168 Bullard 169 Case Study • • • • • 15 year old female H/o burns to face, neck and chest Elective reconstructive surgery of neck Virtually no range of motion in neck Small mouth opening due to scarring 170 Cannot Intubate, Cannot Ventilate • Noninvasive techniques fail • May develop rapidly • Often occurs after repeated unsuccessful attempts at intubation • Follow the Algorithm! Did you try SAD? Two person facemask? Oral/nasal airway? • Weigh the risk of invasive rescue technique against that of hypoxic brain damage or death • Severe hypoxemia when associated with bradycardia in an indication for imminent insertion of percutaneous airway 171 Percutaneous Airway • Necessary only when noninvasive techniques fail to relieve the “cannot intubate, cannot ventilate” situation • Tracheotomy (Surgeon performs) • Usually takes > 3 minutes to perform • Many possible complications • Surgical Cricothyrotomy • Seldinger Cricothyrotomy • Needle Cricothyrotomy 172 Surgical Cricothyrotomy • Advantageous to Thracheotomy d/t superficial nature of membrane being relatively avascular. • Equipment: No. 20 scalpel, Cuffed tracheal or trach tube with 6 or 7 mm diameter 173 Surgical Cric- Technique Miller, 2009 174 Retrograde Intubation/ Seldinger Cricothryotomy • Uses guidewire through cricothyroid membrane to pass through glottis, through oropharynx and allow ETT to over guidewire • Kinking of the guidewire can be a serious problem • Studies show this takes longer than the surgical technique to restore the airway 175 Needle Cricothyrotomy http://www.youtube.com/v/aPiQA2XKk cs 176 Miller, 2009 177 Percutaneous translaryngeal jet ventilation (PTJV) • Needle Cric is performed using above mentioned • • • • • • • technique Attach oxygen source Low pressure systems cannot provide enough flow to expand the chest adequately Wall O2 is pressure of 50 psi Connectors are available to down-regulate to 15-30 psi Insufflation of 1-1.5 seconds at a rate of 12 insufflation per minute A 14 gauge catheter will deliver a tidal volume of 400700 mL Pressure valve is a one-way only valve; therefore, you must allow 3-4 seconds between insufflation for passive egress of air. 178 Jet Ventilator 179 Case Study • • • • • 686 lbs (311 kg), 5’6 BMI 110.7 Large neck Beard Emergency EGD for Food bolus obstruction is distal esophagus 180 Conclusion “If your patient can’t breath, Nothing else matters” “As an Anesthesia provider, You are nothing if not an airway expert” 181 References • Miller, R. D. (2009). Miller's anesthesia (7th ed.). New York: Elsevier/Churchill Livingstone. • Barash, P. G. (2013). Clinical anesthesia (7th ed.). Philadelphia: Lippincott Williams & Wilkins. • Stoelting, R. K., & Miller, R. D. (2011). Basics of anesthesia (6th ed.). Philadelphia: Churchill Livingstone. • Butterworth, J. F., & Mackey, D. C. (2013). Morgan & Mikhail's clinical anesthesiology (5th ed.). New York: McGraw-Hill. 182 Pathologic Airway Jennifer Oakes, CRNA, DNAP TCU, Anesthesia Essentials Pierre Robin syndrome • Micrognathi a • Macroglossi a • Glossoptosi s • Cleft soft palate Treacher Collins syndrome • Auricular and ocular defects • Malar and mandibular hypoplasia • Microstomia • Choanal atresia Goldenhar syndrome • Auricular and ocular defects • Malar and mandibular hypoplasia • Occipitalization of atlas Down syndrome • Poorly developed or absent bridge of the nose • Macroglossia • Microcephaly • Cervical spine abnormalities Klippel-Feil syndrome • Congenital fusion of a variable number of cervical vertebrae • Restriction of neck movement Alpert syndrome • Maxillary hypoplasia • Prognathism • Cleft soft palate • Tracheobronchial cartilaginous anomalies Beckwith syndrome • macroglossia Cherubism • Tumorous lesion of mandibles and maxillae with intraoral masses Cretinism • Absent thyroid tissue or defective synthesis of thyroxine • Macroglossia • Goiter • Compression of trachea • Deviation of larynx/trachea Meckel syndrome • Microcephaly • Micrognathia • Cleft epiglottic Von Recklinghausen disease • Increased incidence of pheochromocytoma • Tumors may occur in the larynx and right ventricle outflow tract Hurler/Hunter syndrome • Stiff joints, upper airway obstruction due to infiltration of lymphoid tissue • Abnormal tracheobronchial cartilages Pompe disease • Muscle deposits • macroglossia