Professional Documents
Culture Documents
Airway
management
Giedrius Laurinėnas
Airway management
Lithuania:
Go west
Airway management
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)
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...
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 •
spontaneous breathing
apnea
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 •
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 •
Faceshield (Microshield)
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 •
1139 prehospital
insertions of Combitube
8 Combitube-related subcutaneous emphysema
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
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 •
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
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)
Local algorithm
Difficult Airway Algorithm
• Exploring Lithuania •
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
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 •
Patient's drama
Circumstancies
Anesthesiologist's drama
Expected
difficult airway
A look back
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
As a As a
LMA failure definitive ventiliation temporary ventiliation
device device
F Rigid bronchoscopy
9 Availability.............................................................................8%
9 Nevertheless, nobody is experienced in rigid bronchoscopy.....50%
Fiberoptic intubation
Indications Contraindications and drawbacks
Important notes
Expected in an
Expected Unexpected
uncooperative patient
LMA as LMA as a
LMA failure definitive ventiliation temporary ventiliation
device device
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
LMA as LMA as a
LMA failure definitive ventiliation temporary ventiliation
device device
40 first-time
cricothyroidotomies
Surgical cricothyrotomy vs Seldinger technique
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
94%
It must have been a preventable disaster in....... 53%
2003 2004
Teaching airway skills
• Exploring Lithuania •
2005
A Year of Airway Management ?
2003 2004
The Happy End