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The Difficult Airway

Eleni E. Pappas, DDS 10-17-06

Questions to Answer
1. 2.

3. 4. 5.

Must the airway be controlled? Must I stop the patient's reliance on his/her own physiologic ventilatory control and force dependence on the success of my own airway/breathing techniques? How dangerous might it be to attempt to take control of your patients airway/breathing? Will laryngoscopy be difficult? Can we visualize anything with endoscope? Is there an aspiration risk?

Physical Exam
single

most reliable method of detecting and anticipating difficulties in airway management


Is the patient able to sit and talk without becoming breathless? Is the patient able to swallow their own secretions? Is the patient pale or cyanotic, cachectic or acutely ill? Is the patient receiving chronic O2 therapy? Is the patient markedly obese? Review vital signs, particularly pulse oximetry. Will chest x-ray or spirometry be helpful?

Examine mouth and oral cavity noting the extent and symmetry of opening (3 fingerbreadths is optimal) Health/Position of the teeth loose, missing, cracked, protruding Presence of facial hair Presence of dental appliances Relative size of the tongue large tongue = more difficulty Arch of the palate high arch sometimes associated with difficulty in visualizing the larynx Mallampati Exam
I = Pharyngeal pillars, entire palate, uvula II = Pharyngeal pillars, soft palate, uvula obstructed by tongue III = Soft palate but pharyngeal pillars and uvula obstructed IV = only hard palate with soft palate, pillars, and uvula obstructed

Focused exam of the Airway

Mallampati Classification

Size of Mandible and TMJ Fxn


Thryomental

distance avg. = three fingerbreadths Short md body may suggest difficulty in visualizing the larynx TMJ Dysfxn =
may have asymmetry or limitations in opening in opening Popping clicking Manipulation during laryngoscopy may worsen symptoms post-op

Exam of Neck
Evidence

of prior surgeries (especially tracheostomy) Abnormal masses present or tracheal deviation Short or thick neck may prove problematic Patient especially obese FROM preparation of laryngosopy requires extension of the neck to facilitate visualization

Goal of DL = create line of sight from eye to glottis (glottic opening)

Patient

presents to ED with rapidly progressing infection CC: My lower right jaw is swollen and I am having some difficulty swallowing. Moderately healthy ASA II patient
PMH: EtOH use, sleep apnea PSH: none NKDA Medications: Amoxicillin for infection Family Hx: paternal - heart disease Slight Dyspnea in supine position

If physical exam leaves in question the ability to adequately ventilate and successfully intubate once the patient is anesthetized and paralyzed, serious consideration should be given to awake intubation.

Awake Intubation Technique


Discuss with patient Must be done in operative

monitors Topicalization with LA Intravenous sedatives Selection of oral and nasal airways available ET tubes Suction Fiberoptic endoscope Surgeon capable of creating surgical airway

suite with standard ASA

Pre-medication
Glycopyrrolate

secretions Versed mg slowly titrated so that the patient is not rendered obtunded, apneic, or unable to protect their airway

0.2 0.4mg useful to reduce

Topicalization

Plan for nasal intubation due to operative site 2% viscous lidocaine have patient swish for 5 minutes then swallow 4% lidocaine spray intranasally and orally Nasal trumpet with lidocaine ointment inserted gently

Trachea also needs to be anesthetized


How

do we do this? Transtracheal injection of lidocaine is performed via needle puncture of the cricothyroid membrane 1% lidocaine aspirating before injection

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Time for Intubation?


Once

an adequate level of sedation and topical anesthesia is achieved How do we know?

Fiberoptic Technique
ET tube loaded onto endoscope Endoscope gently lowered into nasal

passage and then directed past epiglottis through the larynx and down the trachea visualizing tracheal rings and carina ET tube passed into trachea and endoscope removed Connect ET to anesthesia machine and check for bilateral breath sounds and en-tidal CO2 confirmed Patient may then be fully anesthetized

Fiberoptic Intubation

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

What if we are unable to ventilate or intubate?


- LMA
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Combitube
QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Jet ventilation

QuickTime and a TIFF (Uncompressed) decompressor are needed to see this picture.

Reversal benzos and opoids

Thank you!

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