Awake intubation

Indications :
- Airway anomalies
- Any suspicion on difficulty intubating
- Facial trauma
- Significant hemodynamic instability
Advantages :
- Airway patency

Disadvantages :
- Trauma
- Increased blood pressure and intracranial
Introduction
During routine anaesthesia the incidence of difficult tracheal
intubation has been estimated at 3-18%.

Class I: the vocal cords are visible
Class II: the vocals cords are only partly visible
Class III only the epiglottis is seen
Class IV the epiglottis cannot be seen.

Cormack RS, Lehane J. "Difficult intubation
in obstetrics." Anaesthesia 1984;39:1105-11

Predicting Difficult Intubation (1)
"sniffing the morning air" position
History and examination
Specific Screening Tests to Predict Difficult Intubation.
View obtained during Mallampati test:
1. Faucial pillars, soft palate and uvula visualised
2. Faucial pillars and soft palate visualised, but uvula
masked by the base of the tongue
3. Only soft palate visualised
4. Soft palate not seen.

Samsoon GLT, Young JRB. "Difficult tracheal
intubation: a retrospective study."
Anaesthesia 1987;42:487-90
Predicting Difficult Intubation (2)
Thyromental distance
Grade 3 or 4 Mallampati who also had a thyromental distance
of less than 7cm were likely to present difficulty with
intubation
Frerk CM. "Predicting difficult intubation." Anaesthesia 1991;46:1005-8
Sternomental distance
A sternomental distance of 12.5cm or less predicted difficult
intubation
Savva D. "Prediction of difficult tracheal intubation." British Journal of
Anaesthesia 1994;73:149-53
Predicting Difficult Intubation (3)
Protrusion of the mandible
If the patient cannot get the upper and lower incisors into
alignment intubation is likely to be difficult.
Calder I, Calder J, Crockard HA. "Difficult direct laryngoscopy in patients
witH cervical spine disease." Anaesthesia 1995;50:756-63
X-ray studies
Various studies have been used to try to predict difficult
intubation by assessing the anatomy of the mandible on X-ray.
These have shown that the depth of the mandible may be
important, but they are not commonly used as a screening test.
Preoperative assessment
A combination of the above tests is better than using
only one. The modified Mallampati, thyromental
distance, ability to protrude the mandible and
craniocervical movement are probably the most
reliable.

Preparation for Intubation (1)
Anaesthetists should be ready to deal with difficulties in
intubation at any time. The correct equipment must be
immediately available. This will include:
laryngoscopes with a selection of blades
a variety of endotracheal tubes
introducers for endotracheal tubes (stylets or better, flexible
bougies)
oral and nasal airways
Preparation for Intubation (2)
a cricothyroid puncture kit (a 14 gauge cannula and jet
insufflation with high pressure oxygen is the simplest and
cheapest kit




reliable suction equipment
a trained assistant
laryngeal mask airways, sizes 3 & 4
After intubation
The anaesthetist should ensure that the patient is in the
optimal position for intubation and must be able to oxygenate
the patient at all times.
After intubation correct placement of the tube should be
confirmed by:
a stethoscope listening over both lung fields in the axillae
observing the tube pass through the cords
successful inflation of the chest on manual ventilation
Special techniques for intubation
Awake intubation under local anaesthesia
Oral intubation
Nasal intubation is the best method of awake intubation using a
fibreoptic bronchoscope or other intubating fibrescope via the nose.
Retrograde intubation (1)
is a technique first described in Nigeria
Waters DJ "Guided blind endotracheal intubation for patients with deformities of the upper
airway." Anaesthesia 1963;18:158-62

Retrograde intubation has recently been used successfully for
traumatised airways when conventional techniques had failed
Barriot P, Riou B. "Retrograde technique for tracheal intubation in trauma patients."Critical Care
Medicine. 1988;16:712-3

the membrane between the cricoid and first tracheal ring can
also been used.
Shanther TR. "Retrograde intubation using the subcricoid region." British Journal of
Anaesthesia. 1992;68:109-12

Retrograde intubation (2)

The Laryngeal Mask Airway
is a common device in anaesthesia and can often provide a
good airway in patients in whom intubation is difficult.
Following insertion the anaesthetist may use it to maintain
the airway during anaesthesia, or may use it as a route to
allow tracheal intubation.
The McCoy laryngoscope
is designed with a movable tip which allows the epiglottis to
be lifted and intubation often made easier








McCoy EP, Mirakhur RK. "The levering laryngoscope." Anaesthesia
1993;48:516-9
A light wand is a long flexible device which has a bright
light at the end and can be directed into the trachea with an
endotracheal tube mounted over it
Robelen GT, Shulman MS. "Use of the lighted stylet for difficult intubations
in adult patients (abstract)." Anesthesiology 1989;71:A439
The Combi-tube is a tube which may be inserted
blindly and used to ventilate the patient in an emergency
Frass M, Frenzer R. Zahler J, Lilas W, Leithner C. "Ventilation via the
esophageal tracheal combitube in a case of difficult intubation." Journal of
Cardiothoracic Anaesthesia 1987;1:565-8
Planning Anaesthesia
During general anaesthesia patients must never be given
muscle relaxants unless the anaesthetist can be certain of
being able to ventilate them.
When the anaesthetist faces unexpected difficulty in
intubation the priority is to ensure adequate mask
ventilation and oxygenation of the patient.
Multiple attempts at endotracheal intubation may result in
bleeding and oedema of the upper airway making the task
even more difficult. Often it is better to accept failure after a
few attempts and move on to a pre-planned failed intubation
sequence
King TA, Adams AP. "Failed tracheal intubation." British Journal of
Anaesthesia1990;65:400-414

Failed intubation
If intubation proves impossible the anaesthetist should
consider whether to allow the patient to wake up and carry on
surgery with regional anaesthesia, or whether to abandon the
surgery altogether. In situations where surgery is of an urgent
nature it may be prudent to carry on the general anaesthetic
under face mask anaesthesia if the airway is easy to maintain.
If the airway is impossible to maintain and the patient is
becoming hypoxic, an emergency cricothyroidotomy is
required. If time allows an emergency tracheostomy can be
considered.

ASA Algorithm Part 1

ASA Algorithm Part 2

Awake Intubation Pathway

Non-surgical techniques for awake intubation include
laryngoscopy, fiberoptic bronchoscopy and
retrograde intubation. Surgical access may be secured
by awake tracheostomy.
Awake intubation requires patient cooperation and
should be performed with local anesthesia. See Local
Anesthesia for more information.
If awake intubation efforts fail, the patient is unlikely to
have compromised ventilation. Consider canceling
the case, other intubation options or surgical access to
the airway.

Intubation After Induction Pathway

After induction of anesthesia, if the initial intubation
attempts are unsuccessful, consider returning to
spontaneous ventilation, awakening the patient and
calling for help.
If mask ventilation is adequate, go to the Non-
Emergency Pathway. If mask ventilation is inadequate
go to the Emergency Pathway.
If mask ventilation becomes inadequate at any time
while following the Non-Emergency Pathway, go to the
Emergency Pathway

Non-Emergency Pathway

Follow the Non-Emergency Pathway when the patient is
anesthetized, intubation is unsuccessful and mask
ventilation is adequate. If mask ventilation becomes
inadequate go directly to the Emergency Pathway.
Consider alternative approaches including fiberoptic
intubation, intubation stylet, blind intubation, light
wand and retrograde intubation.
If failure after multiple attempts, consider awakening the
patient, surgical airway or surgery under mask
anesthesia.




Emergency Pathway


Follow the Emergency Pathway when the patient is
anesthetized, intubation is unsuccessful and mask
ventilation is inadequate.
Time is critical. Call for help. Do one more intubation
attempt or emergency non-surgical airway ventilation or
emergency surgical airway.
Do not continue to attempt a previous unsuccessful
technique.
Emergency non-surgical airway ventilation techniques
include: transtracheal jet ventilation, intratracheal jet
stylet, laryngeal mask, oral and nasopharyngeal
airways, two person mask ventilation, and rigid
ventilating bronchoscope.
Emergency non-surgical airway ventilation techniques
are temporizing measures. Establish a definitive
airway as soon as possible.

Succinylcholine
Side Effects & Clinical Considerations
Succinylcholine is a relatively safe drugassuming that its
many potential complications are understood and avoided.
Because of the risk of hyperkalemia, rhabdomyolysis, and
cardiac arrest in children with undiagnosed myopathies,

succinylcholine is considered contraindicated in the routine
management of children and adolescent patients. In the
absence of a difficult airway or full stomach, many clinicians
have also abandoned the routine use of succinylcholine for
adults.
Cardiovascular
Succinylcholine not only stimulates nicotinic
cholinergic receptors at the neuromuscular junction,
it stimulates all ACh receptors. Succinylcholine's
cardiovascular actions are therefore very complex.
Stimulation of nicotinic receptors in parasympathetic
and sympathetic ganglia and muscarinic receptors in
the sinoatrial node of the heart can increase or
decrease blood pressure and heart rate.
Low doses of succinylcholine can produce negative
chronotropic and inotropic effects, but higher doses
usually increase heart rate and contractility and
elevate circulating catecholamine levels
Children are particularly susceptible to profound
bradycardia following administration of
succinylcholine. Bradycardia typically occurs in
adults only if a second bolus of succinylcholine is
administered approximately 38 min after the first
dose.
A succinylcholine metabolite, succinylmonocholine,
appears to sensitize muscarinic cholinergic receptors
in the sinoatrial node to the second dose of
succinylcholine, resulting in bradycardia.
Intravenous atropine (0.02 mg/kg in children, 0.4 mg
in adults) is normally given prophylactically to
children prior to the first dose and always before a
second dose of succinylcholine
Fasciculations
Hyperkalemia
Muscle pains
Intragastric Pressure Elevation
Intraocular Pressure Elevation
Masseter Muscle Rigidity
Malignant Hyperthermia
Intracranial Pressure
Conditions Causing Susceptibility to
Succinylcholine-Induced Hyperkalemia
Burn injury
Massive trauma
Severe intraabdominal infection
Spinal cord injury
Encephalitis
Stroke
Guillain-Barr syndrome
Severe Parkinson's disease
Tetanus
Prolonged total body immobilization
Ruptured cerebral aneurysm
Polyneuropathy
Closed head injury
Hemorrhagic shock with metabolic acidosis
Myopathies (eg, Duchenne's dystrophy)