An Introduction and Overview & Massive Hemoptysis

Division of Critical Care Medicine University of Alberta

Airway Management:

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

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

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

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

< 9 cm from the angle of the jaw to symphysis Increased anterior or posterior mandibular length

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

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 100% sensitive of difficult airway

Palm Print

Difficult Intubation - Physical Exam

General:

Facies:

LOC, facies and body habitus, presence or absence of cyanosis, posture, pregnancy 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:

Movements: rotational and advancement of condylar head Normal opening of mouth 5 6 cm

Rheumatoid arthritis Ankylosing spondylitis Psoriatic arthritis Degenerative join disease

Difficult Intubation - Physical Exam

Oral Cavity

Foreign bodies Long protruding teeth can restrict access Dental damage 25% of all anesthesia litigations Loose teeth can aspirate Edentulous state

Teeth:

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
Description
Length and subluxation Base, symmetry, range Visibility Dentition Flexion, extension, rotation of head/neck and cervical spine Upper body abnormalities, both anterior and posterior

Component

Assessment Activities
Measure hyomental distance and anterior displacement of mandible Assess and measure mouth opening in centimetres Assess pharyngeal structures and classify Assess for presence of loose teeth and dental appliances Assess all ranges and movement

Mandible Opening Uvula Teeth Head Silhouette

Identify potential impact on control of airway of large breasts, buffalo hump, kyphosis, etc.

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:

3 minutes of tidal volume breathing at 5 ml/kg 100% O2

Rapid

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 antlantooccipital 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 Grade Grade Grade

I - 99% II - 1% III - 1/2000 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.

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

Esophageal intubation Failure to ventilate Difficult Intubation

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

Tumors

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

Bronchogenic

Squamous

Necrotizing parenchymal cancer

Adenocarcinomas

Bronchial adenoma

Cardiovascular

Mitral Stenosis

Localized Bleeding

Pulmonary Vascular Problems

Trauma
Others

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

Broncholithiasis Sarcoidosis (cavitary lesions with mycetoma) Ankylosing spondylitis

Diffuse Bleeding

Drug and chemical Induced

Blood dyscrasias

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

Thrombotic thrombocytopenic purpura Hemophilia Leukemia Thrombocytopenia Uremia Antiphospholipid antibody syndrome

Pulmonary Renal Syndrome Goodpasture syndrome Wegener granulomatosis Pauci-immune vasculitis

Hemosiderosis

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

Pulmonary 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)

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

Tachypnea, respiratory distress Localized wheezing, rales, poor dentition Digital clubbing Hematuria

Frothy blood sputum mixture Bright red Alkaline

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

CT scan

Aspiration from distant source Chronic changes unrelated to acute event

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 life-threatening hemoptysis, or failure or recurrence after other interventions. Contraindications:

Mortality is higher if bleeding is acute

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

Late Surgical Treatment

Indicated for definitive treatment of underlying lesion, once bleeding subsided. Indications:

Mycetoma Resectable carcinoma Localized bronchiectasis

Prognosis

Factors likely affecting outcome

Mortality

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

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:

Primary goal is airway control followed by bleeding localization.

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