Difficult Airway Management J OSEPH C. G ABEL P ROFESSOR & C HAIR ∣ D EPT . OF A NESTHESIOLOGY T HE U NIVERSITY OF T EXAS M EDICAL S CHOOL AT H OUSTON M EDICAL D IRECTOR ∣ P ERIOPERATIVE S ERVICES M EMORIAL H ERMANN H OSPITAL , H OUSTON , TX C ARIN A. H AGBERG , MD Current Concepts
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Difficult Airway Management
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JOSEPH C. GABEL PROFESSOR & CHAIR ∣ DEPT. OF ANESTHESIOLOGY THE UNIVERSITY OF TEXAS MEDICAL SCHOOL AT HOUSTON
MEDICAL DIRECTOR ∣ PERIOPERATIVE SERVICES MEMORIAL HERMANN HOSPITAL, HOUSTON, TX
CARIN A. HAGBERG, MD
Current Concepts
Sir Robert Reynolds Macintosh
3 ingredients of a good anesthetic...
GOOD AIRWAY
GOOD AIRWAY
GOOD AIRWAY
Perhaps the most
fundamental principle in all
of anesthesiology
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Scope of the Problem
Local: 25k GA’s performed
- 250-75 possible unanticipated DA/DIs per yr
National: 46k ASA members
- 46k DIs per yr
- Doesn’t consider other clinical settings/nonmember care providers
International: HUGE problemIn patients undergoing GA, 1-3% incidence of
unanticipated DA
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Prospective Study All major airway events
over a 1yr period Anesthesia, ICU, ED
Important insights regarding airway management
complications
Elective ASA I-II, <60 Obese ENT Obstructive lesions
Case Types
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Deficiencies in airway assessment Underutilization of awake intubation Inappropriate use of SGA Poor planing
Outcomes
Most frequent cause of anesthesia-related mortality 56% SGA complications
Other options include (not limited to): surgery utilizing face mask or SGA anesthesia (LMA, ILMA, laryngeal tube), local anesthesia infiltration or regional nerve blockade. Pursuit of these options usually implies that mask ventilation will not be problematic. Therefore, these options may be of limited value if this step in the algorithm has been reached via the Emergency Pathway.
Invasive airway access includes surgical or percutaneous airway, jet ventilation, & retrograde intubation.
Alternative DI approaches include (not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (LMA, ILMA) as an intubation conduit (w/ or w/out fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation.
Consider re-preparation of the patient for awake intubation or canceling surgery.
Emergency non-invasive airway ventilation consists of a SGA.
Anesthesiology 2013 118:251-70.
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Langeron O, MD, PhD, Masso E, MD, Huraux C, MD, Guggiari M, Bianchi A, MD, Coriat, MD, Riou B, MD, PhD Anesthesiology 2009; 92:1229-36
Prediction of Difficult Mask Ventilation ‣ Prospective study
- 1,502 pts - French university hospital
‣ DMV: inability to maintain O2 sat >92% or prevent/reverse signs of inadequate ventilation during PPMV under GA
Specialist intubation techniques are likely required
restricted difficult
grade 2b
grade 3a
grade 3b
grade 4
In current anesthetic practice, there are a myriad of devices & techniques to ensure
that the airway is patent.
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1988-1998 Decade of SGA
Anesth Analg 2010;110:Cover
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2001-2011 Decade of Video Laryngoscopy
Anesth Analg 2010;110:Cover
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Original Research Telemedicine & Telepresence for Prehospital & Remote Hospital Tracheal Intubation Using a GlideScope™ Videolaryngoscope: A Model for Tele-Intubation
Intubation bot lets doctors safely shove tubes down unconscious human throats By Michael Gorman, Apr 16th 2011http://www.engadget.com/2011/04/16/intubation-bot-lets-doctors-safely-shove-tubes-down-unconscious/
!!!
Dr. Thomas M. Hemmerling from McGill University
Health Centre has created the world’s first intubation
robot, called the Kepler Intubation System (KIS), a robotic arm with a video
Inferior view/longer time or failure to secure airway
Recommended by ATLS guidelines
No outcome data demonstrating inferior
Benefits should be balanced against potential for hypoxic
damage
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Video Laryngoscopy
Does VL reduce cervical motion compared to DL in
patients w/ known or suspected CSI?
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Is there improved intubation success rate in the trauma
patient?
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!‣ Common problems
- Hemodynamic instability - Time pressure - Lack of patient cooperation - Risk of aspiration - Need for cervical spine protection - Facial injuries - Limited options (can’t wake up/