The document outlines assessment tools and algorithms for managing difficult airways. It describes the Mallampati classification system, Cormack-Lehane grading scale, and criteria for predicting difficult mask ventilation. Awake fiberoptic intubation is recommended as the primary approach, with local anesthesia techniques to anesthetize the airway. Alternative devices and techniques discussed include video laryngoscopy, supraglottic airways like LMAs, retrograde intubation, and surgical airways if needed.
The document outlines assessment tools and algorithms for managing difficult airways. It describes the Mallampati classification system, Cormack-Lehane grading scale, and criteria for predicting difficult mask ventilation. Awake fiberoptic intubation is recommended as the primary approach, with local anesthesia techniques to anesthetize the airway. Alternative devices and techniques discussed include video laryngoscopy, supraglottic airways like LMAs, retrograde intubation, and surgical airways if needed.
The document outlines assessment tools and algorithms for managing difficult airways. It describes the Mallampati classification system, Cormack-Lehane grading scale, and criteria for predicting difficult mask ventilation. Awake fiberoptic intubation is recommended as the primary approach, with local anesthesia techniques to anesthetize the airway. Alternative devices and techniques discussed include video laryngoscopy, supraglottic airways like LMAs, retrograde intubation, and surgical airways if needed.
• The ASA defines the difficult airway as the situation in which the “conventionally trained anesthesiologist experiences difficulty with intubation, mask ventilation or both. Airway assessment • Assessment include: 1. Mouth opening: an incisor distance of 3cm or greater is desirable in an adult. 2. Upper lip bite test: the lower teeth are brought in front of the upper teeth. The degree to which this can be done estimates the range of motion of the temperomandibular joints. 3. Mallampati classification: it examines the size of the tongue in relation to the oral cavity Mallampati classification
Class 1: the entire palatal arch, including the
bilateral faucial pillars, are visible down to their bases. Class 2: the upper part of the faucial pillars and most of the uvula are visible. Class 3: only the soft and hard palates are visible. Class 4: only the hard palate is visible. 4.Thyromental distance: a distance greater than 3 finger breadths is desirable.
5.Neck circumference : greater than 27inch is
suggestive of difficulties in visualization of the glottic opening. LARYNGOSCOPIC VIEW Cormack lehane • CLASS LARYNGOSCOPIC VIEW • 1 Entire glottic • 2 Posterior commisure • 3 Tip of epiglottis • 4 No glottic structure. Causes of difficult intubation AIRWAY EXAMINATION WHICH SUGGEST DIFFICULTY WITH INTUBATION 1. Long upper incisors 2. A prominent overbite 3. The patient cannot protrude the mandibular incisors anterior to maxillary incisors 4. Interincisor distance is less than 3cm when mouth is fully opened. 5. Uvula is not visible when tongue is protruded with patient in sitting position 6. Shape of palate is highly arched or very narrow 7. Mandibular space is noncompliant 8. Thyromental distance is less than three finger breadths 9. Neck is short or thick 10. Patient lacks normal range of motion of head and neck. Assessment and Predictability of Difficult Mask Ventilation Criteria for difficult mask ventilation 1. Inability for one anesthesiologist to maintain oxygen saturation >92% 2. Significant gas leak around face mask 3. Need for ≥4 Litres per minute gas flow (or use of fresh gas flow button more than twice) 4. No chest movement 5. Two-handed mask ventilation needed 6. Change of operator required Awake Airway Management
• Awake airway management remains mainstay of
the ASA's difficult airway algorithm • Its advantages are 1. maintenance of spontaneous ventilation in the event that the airway cannot be secured rapidly, 2. increased size and patency of the pharynx, 3. relative forward placement of the base of the tongue, 4. posterior placement of the larynx, and 5. patency of the retropalatal space. • Awake state confers some maintenance of upper and lower esophageal sphincter tone, thus reducing the risk of reflux. • In the event that reflux occurs, the patient can close the glottis and/or expel aspirated foreign bodies by cough. • Contraindications to elective awake intubation include patient refusal or inability to cooperate (e.g., child, profound mental retardation, dementia, intoxication) or allergy to local anesthetics • appropriate explanation, medication can also be used to allay anxiety. • Small doses of benzodiazepines (diazepam, midazolam, lorazepam) are commonly used to alleviate anxiety without producing significant respiratory depression. • Opioid receptor agonists (e.g., fentanyl, alfentanil, remifentanil) can also be used in small, titrated doses for their sedative and antitussive effects, although caution must be taken. A specific antagonist (e.g., naloxone) should always be immediately available. • Ketamine, droperidol, and dexmedetomidine have also been popular . • Dexmedetomidine, a highly selective centrally acting α2-adrenergic agonist, has been used for sedation and analgesia without respiratory depression in patients who underwent awake fiberoptic intubation, cervical spine problems, and inability to cooperate with awake intubation. • Dexmedetomidine may cause hypotension, which can be corrected by phenylephrine or ephedrine. • Administration of antisialagogues is also important. • The commonly used drugs atropine (0.5 to 1 mg intramuscularly or intravenously) and glycopyrrolate (0.2 to 0.4 mg intramuscularly or intravenously). • Vasoconstriction of the nasal passages is required if there is to be instrumentation of this part of the airway. Oxymetazoline is a potent and long- lasting vasoconstrictor. • Local anesthetics are a cornerstone of awake airway control techniques • Cocaine is a popular topical agent. It is a highly effective local anesthetic, and also it is a potent vasoconstrictor. It is commonly available in a 4% solution. • Lidocaine, an amide local anesthetic. Topically applied, peak onset is within 15 minutes. • Tetracaine has a longer duration of action than either cocaine or lidocaine. • Benzocaine is popular because of its very rapid onset (<1 minute) and short duration (approximately 10 minutes). • It has been combined with tetracaine to prolong the duration of action. • There are three anatomic areas to which the clinician directs local anesthetic therapy: 1. the nasal cavity/nasopharynx, 2. the pharynx/base of tongue, and 3. the hypopharynx/larynx/trachea • Nerve supply:The oropharynx is innervated by branches of the vagus, facial, and glossopharyngeal nerves. • The glossopharyngeal nerve has three branches supplying sensory innervation to the posterior third of the tongue, the vallecula, the anterior surface of the epiglottis (lingual branch), the walls of the pharynx (pharyngeal branch), and the tonsils (tonsillar branch). • To block this nerve, a spinal needle is inserted at the base of the anterior tonsillar pillar , just lateral to the base of the tongue. • The internal branch of the superior laryngeal nerve, which is a branch of the vagus nerve, provides sensory innervation to the base of the tongue, epiglottis, aryepiglottic folds, and arytenoids. • The external branch, supplies motor innervation to the cricothyroid muscle. • The recurrent laryngeal nerves supply all of the intrinsic muscles of the larynx (with the exception of cricothyroid). • To block superior laryngeal nerve 3 landmarks are used : superior cornu of hyoid , superior cornu of the thyroid cartilage and superior notch of thyroid cartilage. • Translaryngeal or transtracheal block provides anesthesia of the trachea and vocal cords. • This is useful in situations where a neurologic examination is needed after intubation. • It makes the presence of the ETT in the trachea more comfortable. Alternative approaches to intubation • It includes video assisted laryngoscopy, • Alternative laryngoscope blades, • SGA • Fiberoptic intubation • Intubating stylet or tube changer • Light wand • Blind oral or nasal intubation. Invasive airway access • It includes • Surgical or percutaneous airway, • Jet ventilation • And retrograde intubation Other options • Face mask or supraglottic airway • Local anesthesia infiltration, • Regional nerve blockade. Awaken the patient: consider re preparation of the patient for awake intubation or cancelling the surgery. Fiberoptic bronchoscope • A flexible bronchoscope allows indirect visualization of the larynx in situation in which awake intubation is planned. • The insertion tube contains two bundles of fibers. One bundle transmits light from the light source, whereas the other provides a high-resolution image. Esophageal Tracheal Combitube: • The Combitube is inserted “blindly. • Advantages of the Combitube include 1. rapid airway control, 2. airway protection from regurgitation, 3. ease of use by the inexperienced operator, 4. no requirement to visualize the larynx, 5. and the ability to maintain the neck in a neutral position. Supraglottic airways • It include devices that are blindly inserted into the pharynx to provide a patent conduit for ventilation, oxygenation without the need for tracheal intubation. • it is well tolerated by the patient. • It is a blind technique not hindered by blood, secretions, debris, and edema from previous attempts at laryngoscopy. LMA • It is helpful in patients with difficult airway because of its ease of insertion and relatively high success rate (95–99%) • An LMA consists of a wide-bore tube whose proximal end connects to a breathing circuit , and whose distal end is attached to an elliptical cuff that can be inflated through a pilot tube. The deflated cuff is lubricated and inserted blindly into the hypopharynx , and it is inflated to form a low-pressure seal around the entrance to the larynx. Video laryngoscopes • Video or optically based laryngoscopes have either a video chip or a lens/mirror at the tip of the intubation blade to transmit a view of the glottis to the operator. • They generally improve visualization of laryngeal structures. Retrograde intubation • The retrograde technique of intubation consists of percutaneously passing a narrow flexible guide into the trachea from a site below the vocal cords and advancing this guide through the larynx and out the mouth or nose. • In the basic technique, the tracheal tube is then passed over the guide into the upper part of the trachea, the guide is removed, and the tube is advanced into the trachea. Other Devices
Lighted Stylets: These devices rely on
transillumination of the airway. • A light source introduced into the trachea will produce a well-circumscribed glow of the tissues over the larynx and trachea. • The same light placed in the esophagus will produce no light or a diffuse light. Airway Bougie: Airway bougies encompass a series of solid or hollow, semimalleable stylets that maybe be blindly manipulated in to the trachea. • An ETT is then “threaded” over the bougie and into the trachea Percutaneous airways It includes • transtracheal jet ventilation, • cricothyrothomy, • and tracheostomy. Transtracheal jet ventilation • It is an invasive technique. • Inspiration during TTJV is achieved by insufflation of pressurized oxygen through a cannula placed by cricothyrotomy. • It should not be performed in patients with sustained direct damage to the cricoid cartilage or larynx or in patients with complete upper airway obstruction. Cricothyroidotomy • It is emergent invasive technique for establishing an air passage through the cricothyroid membrane. • The cricothyroid membrane is a fibroelastic membrane, lying over the tracheal mucosa. It is attached to the inferior border of the thyroid cartilage and superior edge of the cricoid cartilage. • Cricothyrotomy is contraindicated in neonates and children younger than 6 years of age, and in patients with laryngeal fractures. • The two most common techniques for performing a cricothyrotomy are the percutaneous dilational cricothyrotomy and surgical cricothyrotomy . • The most preferred technique is percutaneous technique. • The patient neck is extended, and the cricothyroid groove is identified. • An 18 gauge needle catheter attached to a fluid filled syringe is passed through the incision at a 45 degree angle in caudal direction with continous aspiration. • Aspiration of free air confirms passage through the cricothyroid membrane. • The catheter is advanced over the needle into the trachea. • The needle is removed, and the catheter is left in place. • The guidewire is inserted caudally to a depth of approximately 2 to 3 cm. • The catheter is removed, and the curved dilator with the airway cannula is threaded over the guidewire. • The dilator and cannula unit is advanced while maintaining control of the guidewire. • The dialator and guidewire are removed together while cannula remains in place. • The cuff is inflated, and ventilation is attempted. • Proper placement is confirmed by capnography, and the airway cannula is secured in place. THANK YOU