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Airway Management:

An Introduction and Overview


&
Massive Hemoptysis
Division of Critical Care Medicine
University of Alberta

Airway Management

Outline

Overview
Normal airway
Difficult intubation
Structured approach to airway
management
Causes of failed intubation

Overview of the Airway

600 patients die per year from


complications related to airway
management
3 mechanisms of injury:
1.
2.
3.

Esophageal intubation
Failure to ventilate
Difficult Intubation

98% of Difficult Intubations may be anticipated by performing a


thorough evaluation of the airway in advance

Indications for Intubation

Ventilatory Support
Decreased GCS
Protection of Airway
Ensuring Airway patency
Anesthesia and surgery
Suctioning and Pulmonary Toilet
Hypoxic and Hypercarbic respiratory Failure
Pulmonary lavage

Endotracheal Intubation
Depends Upon Manipulation of:

Cervical spine
Atlanto-occipital Joint
Mandible
Oral soft tissues
Neck hyoid bone
Additionally:

Dentition
Pathology - Acquired
and Congenital

The Normal Airway

History of one or more easy intubations w/o


sequelae
Normal appearing face with regular features
Normal clear voice
Absence of scars, burns, swelling, infections,
tumour, or hematoma
No history of radiation of the head or neck
Ability to lie supine asymptomatically; no
history of snoring or sleep apnea

The Normal Airway

Patent nares
Ability to open mouth widely
with TMJ rotation and
subluxation (3 4 cm or two
finger breaths)
Mallampati Class I

Patient sitting straight up,


opening mouth as wide as
possible, with protruding
tongue; the uvula, posterior
pharyngeal wall, entire
tonsillar pillars, and fauces can
be seen

At least 6 cm (3 finger breaths)


from tip of mandible to thyroid
notch with neck extension
At least 9 cm from symphysis
of mandible to mandible angle

The Normal Airway

Slender supple neck w/o masses; full


range of neck motion
Larynx moveable with swallowing
and manually moveable laterally
(about 1.5 cm each side)
Slender to moderate body build
Ability to extend atlanto-occipital
joint (normal extension is 35)

Risk Factors For Difficult


Intubation

El-Canouri et al. - prospective study of 10,


507 patients demonstrating difficult
intubation with objective airway risk
criteria

Mouth opening < 4 cm


Thyromental distance < 6 cm
Mallampati grade 3 or greater
Neck movement < 80%
Inability to advance mandible (prognathism)
Body weight > 110 kg
Positive history of difficult intubation

Signs Indicative of a Difficult


Intubation

Trauma, deformity: burns, radiation therapy, infection,


swelling, hematoma of face, mouth, larynx, neck
Stridor or air hunger
Intolerance in the supine position
Hoarseness or abnormal voice
Mandibular abnormality

Decreased mobility or inability to open the mouth at least 3


finger breaths
Micrognathia, receding chin

Treacher Collins, Peirre Robin, other syndromes


Less than 6 cm (3 finger breaths) from tip of the mandible to
thyroid notch with neck in full extension

< 9 cm from the angle of the jaw to symphysis


Increased anterior or posterior mandibular length

Signs Indicative of a Difficult


Intubation

Laryngeal Abnormalities

Fixation of larynx to other structures of


neck, hyoid, or floor of mouth.

Macroglossia
Deep, narrow, high arched oropharynx
Protruding teeth
Mallampati Class 3 and 4

Signs Indicative of a Difficult


Intubation

Neck Abnormalities

Thoracoabdominal abnormalities

Short and thick


Decreased range of motion (arthritis, spondylitis, disk
disease)
Fracture (subluxation)
Trauma
Kyphoscoliosis
Prominent chest or large breasts
Morbid obesity
Term or near term pregnancy

Age 50 59
Male gender

Difficult Intubation - History

Previous Intubations
Dental problems (bridges, caps, dentures, loose
teeth)
Respiratory Disease (sleep apnea, smoking, sputum,
wheeze)
Arthritis (TMJ disease, ankylosing spondylitis,
rheumatoid arthritis)
Clotting abnormalities (before nasal intubation)
Congenital abnormalities
Type I DM
NPO status

Difficult Intubation - Diabetes


Mellitus

Difficult intubation 10 x higher in


long term diabetics
Limited joint mobility in 30 40 %
Prayer sign

Unable to straighten the interpharyngeal


joints of the fourth and fifth fingers

Palm Print

100% sensitive of difficult airway

Difficult Intubation - Physical


Exam

General:

LOC, facies and body habitus, presence or absence of cyanosis,


posture, pregnancy

Facies:

Abnormal facial features

Nose:

Pierre Robin
Treacher Collins
Klippel Feil
Aperts syndrome
Fetal Alcohol syndrome
Acromegaly

For nasal intubation


Patency

Pierre Robin

Treacher Collins

Difficult Intubation - Physical


Exam

TMJ Joint articulation and movement


between the mandible and cranium
Diseases:

Rheumatoid arthritis
Ankylosing spondylitis
Psoriatic arthritis
Degenerative join disease

Movements: rotational and advancement


of condylar head
Normal opening of mouth 5 6 cm

Difficult Intubation - Physical


Exam

Oral Cavity

Foreign bodies

Teeth:

Long protruding teeth can restrict access


Dental damage 25% of all anesthesia litigations
Loose teeth can aspirate
Edentulous state

Rarely associated with difficulty visualizing airway

Tongue:

Size and mobility

Mallampati Classification

Class I: soft palate, tonsillar fauces, tonsillar


pillars, and uvuala visualized
Class II: soft palate, tonsillar fauces, and uvula
visualized
Class III: soft palate and base of uvula visualized
Class IV: soft palate not visualized
Class III and IV

Difficult to Intubate

Mallampati Classification

Structured Approach to
Airway Management

MOUTHS

Componen
t

Description

Assessment Activities

Mandible

Length and subluxation

Measure hyomental distance


and anterior displacement of
mandible

Opening

Base, symmetry, range

Assess and measure mouth


opening in centimetres

Uvula

Visibility

Assess pharyngeal structures


and classify

Teeth

Dentition

Assess for presence of loose


teeth and dental appliances

Head

Flexion, extension,
rotation of head/neck
and cervical spine

Assess all ranges and


movement

Silhouett

Upper body
abnormalities, both

Identify potential impact on


control of airway of large

Bag/Valve/Mask Ventilation

Always need to anticipate difficult mask ventilation


Langeron et al. 1502 patients reported a 5% incidence of
difficult mask ventilation
5 independent risk factors of difficult mask ventilation:

Two of these predictors of DMV

Beard
BMI > 26
Edentulous
Age > 55 years of age
History of snoring (obstruction)

Sensitivity and specificity > 70%

DMV

Difficult Intubation in 30% of cases

Intubation Technique

Preparation:

Equipment Check
100% oxygen at high flows (> 10 Lpm)
during bask/mask ventilation
Suction apparatus
Intubation tray

Two laryngoscopic handles and blades


Airways
ET tubes
Needles and syringes
Stylet
KY Jelly
Suction Yankauer
Magill Forceps
LMAs

Pre - oxygenation

Traditional:

Rapid

3 minutes of tidal volume breathing at 5 ml/kg


100% O2

8 deep breaths within 60 seconds at 10 L/min

Always ensure pulse oximetry on


patient

Positioning

Optimal Position sniffing position

Flexion of the neck and extension of the


antlanto-occipital joint

Mandible and Floor of


Mouth

Optimal position:

flexing neck and extending the


atlantooccipital joint

Positioning

Positioning

Factors that Interfere with


Alignment

Large teeth or
tethered tongue
Short mandible
Protruding upper
incisors
Pathology in floor
of mouth
Reduced size of
intra and sub
mandibular space

Practical Note: Thyromental distance 6 cm or 3 finger breaths should show


Normal mandible

Visualization

Visualization

Insert blade into mouth


Sweep to right side and
displace tongue to the left
Advance the blade until it
lies in the valeculla and
then pull it forward and
upward using firm steady
pressure without rotating
the wrist
Avoid leaning on upper
teeth
May need to place
pressure on cricoid to
bring cords into view

Visualization

Visualization

Laryngoscopy Grade

Grade I - 99%
Grade II - 1%
Grade III - 1/2000
Grade IV - 1/ 10,000

Insertion

Insert cuff to ~ 3 cm beyond cords


Tendency to advance cuff too far

Right mainstem intubation

Cuff Inflation

Inflate to 20 cm H2O
Listen for leak at patients mouth
Over inflation can lead to ischemia of trachea

Confirmation ETT Position

Continuous CO2 monitoring or capnometry

Gold standard

Must have at least 3 continuous readings


without declining CO2

False Negative Results

Tube in Trachea, Capnogram Suggests


Tube in Esophagus

Concurrent PEEP with ETT cuff leak


Severe Airway obstruction
Low Cardiac Output
Severe hypotension
Pulmonary embolus
Advanced pulmonary disease

False Positive Results

Tube NOT in trachea, capnogram


suggests tube in trachea

Bag/valve/mask ventilation prior to


intubation
Antacids in stomach
Recent ingestion of carbonated
beverages
Tube in pharynx

False Positive Results

Other Methods to Determine


Placement of ETT tube

Auscultation
Visualization of tube through cords
Fiberoptic bronchoscopy
Pulse oximetry not improving or worsening
Movement of the chest wall
Condensation in ET tube
Negative Pressure Test
CXR

Airway Maneuvers

BURP Improves visualization of


airway
1.

2.

3.

4.

Posterior pressure on the larynx against


cervical vertebrae (Backward)
Superior pressure on the larynx as far as
possible (Upward)
Lateral pressure on the larynx to the right
(Right)
With pressure (Pressure)

Causes of Failed Intubation

Poor positioning of the head


Tongue in the way
Pivoting laryngoscope against upper teeth
Rushing
Being overly cautious
Inadequate sedation
Inappropriate equipment
Unskilled laryngoscopist

Summary

600 patients die per year from complications related to airway


management
3 mechanisms of injury:
1.
2.
3.

Esophageal intubation
Failure to ventilate
Difficult Intubation

Indication for intubation:


1.
Ventilatory Support
2.
Decreased GCS
3.
Protection of Airway
4.
Ensuring Airway patency
5.
Anesthesia and surgery
6.
Suctioning and Pulmonary Toilet
7.
Hypoxic and Hypercarbic respiratory Failure
8.
Pulmonary lavage

Massive Hemoptysis

Massive Hemoptysis

More than 300 to 600 ml of blood in


12 to 24 hours.
Difficult to assess the actual amount.
Life threatening bleeding into the
lung can occur without actual
hemoptysis.

Causes of Hemoptysis and


Pulmonary Hemorrhage

Localized bleeding

Diffuse Bleeding

Localized Bleeding

Infections

Bronchitis
Bacterial Pneumonia
Streptococcus and
Klebsiella
Tuberculosis
Fungal Infections
Aspergillus
Candida
Bronchiectasis
Lung Abscess
Leptospirosis

Tumors

Bronchogenic

Necrotizing
parenchymal cancer

Squamous

Adenocarcinomas

Bronchial adenoma

Cardiovascular

Mitral Stenosis

Localized Bleeding

Pulmonary
Vascular Problems

Pulmonary AV
malformations
Rendu-Osler-Weber
Syndrome
Pulmonary embolism with
infarction
Behcet syndrome
Pulmonary artery
catheterization with
pulmonary artery rupture

Trauma

Others

Broncholithiasis
Sarcoidosis
(cavitary lesions
with mycetoma)
Ankylosing
spondylitis

Diffuse Bleeding

Drug and chemical


Induced

Anticoagulants
D-penicillamine (seen
with treatment of
Wilsons disease)
Trimellitic anhydride
(manufacturing of
plastics, paint, epoxy
resins)
Cocaine
Propylthiouracil
Amiodarone
Phenytoin

Hemosiderosis

Blood dyscrasias

Thrombotic
thrombocytopenic purpura
Hemophilia
Leukemia
Thrombocytopenia
Uremia
Antiphospholipid antibody
syndrome

Pulmonary Renal
Syndrome
Goodpasture syndrome
Wegener
granulomatosis
Pauci-immune vasculitis

Diffuse Bleeding

Vasculitis

Pulmonary capillaritis
With or without connective tissue disease
Polyarteritis
Churg-Strauss syndrome
Henoch-Schonlein Purpura
Necrotizing vasculitis
Connective Tissue diseases
Systemic lupus erythematosus
Rheumatoid arthritis
Mixed connective tissue disease
Scleroderma (rare)

Key Major Etiologies

Tuberculosis
Bronchiectasis
Cancer
Mycetoma
Iatrogenic causes
Alveolar Hemorrhage
Trauma
Vascular malformation
Pulmonary embolism
Other Infectious Causes

Pathophysiology

Bronchial circulation

High (systemic) pressure circulation


Drains into the right atrium (extrapulmonary
bronchi)
Also drains into pulmonary veins
(intrapulmonary bronchi)
Anterior spinal artery may originate from
bronchial artery (5% of cases)

Pulmonary circulation

Low-pressure circulation
Multiple anastomoses exist between bronchial
and pulmonary circulations

Clinical Findings

Hemoptysis, Dyspnea, Cough, Anxiety


Fever, weight loss
Smoking and Travel history
Bloody sputum

Frothy blood sputum mixture


Bright red
Alkaline

Tachypnea, respiratory distress


Localized wheezing, rales, poor dentition
Digital clubbing
Hematuria

Differential Diagnosis

Upper GI Bleeding

Dark blood
Food particles
Acid pH

Consider endoscopy

Upper airway bleeding

Examine mouth, nose, and pharynx.

Laboratory Tests

No specific tests
CBC, diff, INR, PTT, platelet count
Electrolytes, BUN, Cr
Sputum culture and AFB
Urinalysis
ECG
ABGs
Type and Screen

Imaging Studies

Chest X-ray

Normal suggests endobronchial or


extrapulmonary source.
Potentially misleading

Aspiration from distant source


Chronic changes unrelated to acute event

CT scan

Useful in stable patients


Can detect bronchiectasis

Stabilization

Ensure adequate ventilation and


perfusion.
Most common cause of death is
asphyxia.
Place patient in Trendelenburg position
to facilitate drainage.
Lateral decub Bleeding side down

Prevent contamination of good lung.

Treatment

General Measures:
1.
2.
3.
4.
5.
6.

Place bleeding lung down to prevent


aspiration into good lung
Supplemental oxygen
Avoid Sedation
Correct coagulopathy and thrombocytopenia
Consult pulmonary, critical care, and thoracic
surgery
Consider early involvement of anesthesia
and interventional radiology

Primary Goal is Airway


Control

Asphyxiation, not blood loss, is the cause


of death.
Only stable patients with ability to protect
and clear their own airway should be
managed without intubation.
Intubation:

Performed by experienced personnel.


Large bore tube for bronchoscopy and
suctioning.
Consider bronchial blocker or double lumen
tube if bleeding site is known.

Secondary Goal is Localization


of Bleeding

Bronchoscopy required.
Intubate prior to bronchoscopy.
Rigid bronchoscopy

May facilitate better suctioning.


Inability to visualize beyond main stem
bronchi and need thoracic surgeon.

Bronchoscopic Interventions

Bronchial blocker or Fogarty balloon catheter


to occlude bleeding lung, lobe, or segment.
Topical coagulants:

Fibrin or fibrinogen-thrombin solution.


Topical transexamic acid

Consider Nd:YAG laser coagulation,


electrocautery, or argon plasma coagulation.
Lavaged iced saline
Topical epinephrine

Unilateral Lung Ventilation

Single lumen tube advanced into main stem


bronchus.
Double lumen tube:

Protects non-bleeding lung.


Use left sided tube to prevent occlusion of Right upper
lobe.
May be difficult to position.
Individual lumens too small for standard bronchoscope.
Airway obstruction frequent problem.
Displacement can lead to sudden asphyxiation.
Patient should be therapeutically paralyzed and not
moved.

Bronchial Arteriography and


Embolization

Favored initial approach if facilities and expertise


available.
High success rate: approximately 90% when a
bleeding vessel is identified.
Recurrence rate: 10 27%
10% of patients bleed from the pulmonary
circulation (TB or mycetoma).
Serious complications:

Occlusion of the anterior spinal artery with paraplegia.


Embolic infarction of distal organs.

Early Surgical Treatment

Offers definitive treatment.


Indicated for lateralized massive lifethreatening hemoptysis, or failure or
recurrence after other interventions.
Contraindications:

Poor baseline respiratory function.


Inoperable lung carcinoma.
Inability to localize bleeding site.
Diffuse lung disease (relative) eg. CF.

Mortality is higher if bleeding is acute

Late Surgical Treatment

Indicated for definitive treatment of


underlying lesion, once bleeding
subsided.
Indications:

Mycetoma
Resectable carcinoma
Localized bronchiectasis

Prognosis

Factors likely affecting outcome

Etiology of hemoptysis
Underlying co-morbid illnesses
Surgical vs. medical treatment

Mortality

Medical mortality: 17 85%


Estimated early surgical mortality: 0 50%
Most case series reports preceded the
development of angiographic embolization.

Conclusion

More than 300 to 600 ml of blood in 12 to


24 hours.
Major causes:

Tuberculosis
Bronchiectasis
Cancer
Mycetoma
Iatrogenic causes
Alveolar Hemorrhage
Trauma
Vascular malformation
Pulmonary embolism

Primary goal is airway control followed by


bleeding localization.

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