difficultairway-110507131405-phpapp01.ppt

7/21/2019 difficultairway-110507131405-phpapp01.ppt

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MANAGEMENT OFMANAGEMENT OFDIFFICULTDIFFICULT

AIRWAY AIRWAY

ATUL KUMAR



DIFFICULT AIRWAY:DEFINITIONS

DIFFICULT AIRWAY:

• A clinical situation in which a convntionall!t"ain# anasthsiolo$ist %&"incs #i'cult!with (as) vntilation* #i'cult! with t"achalintu+ation o" +oth

Difcult airway: spectru

• Di'cult : S&ontanous,(as) vntilation

La"!n$osco&!

T"achal intu+ation

T"achosto(!-



DIFFICULT MASK VENTILATION –

• It is not possible for the unassisted anaesthesiologist to maintain

SPO2>90% using 100% O2 and positive pressure mas ventilation in a

patient !hose SPO2 !as > 90% before anaestheti" intervention and#or It is

not possible for the unassisted anesthesiologist to prevent or reverse signs

of inade$uate ventilation during positive pressure mas ventilation

A!se"t #r i"a$e%uate c&est #'ee"t(

A!se"t !reat& s#u"$s(

Gastric air e"try #r $ilatati#"(

Cya"#sis(

)ae#$y"aic c&a"*es $ue t# &yp#+ia #r

&ypercar!ia(

Decreasi"* #+y*e" saturati#"(

A!se"t #r i"a$e%uate e+&ale$ CO,

Signs of inadequate mask ventilat



."#icto"s o/ Di'cult Mas)0ntilation 1(n(onic 2ONES3

• &eard

•Obesit' !ith &(I > 2) g#m

2

• *o teeth

• +lderl' > ,,'ears

• Snorers

DIFFICULT LARYNGOSCOPY-

•It is not possible to visualize any potion o! t"e vo#al

#o$s %it" #onventional layn&os#opy'

DIFFICULT (NDOTRAC)(AL INTU*ATION +

•Usin& #onventional layn&os#opy, it euies./ atte0pts

to inset an (TT an$1o t"e insetion o! an (TT euies.

23 0in' usin& #onventional layn&os#opy



2EST ATTEM.TLARYN4OSCO.Y

• La"!n$osco&! &"/o"(# +!"asona+l! %&"inc#la"!n$osco&ist with th &t in o&ti(alsni5 &osition havin$ no si$ni6cant(uscl ton 7 th la"!n$osco&ist hasan o&tion o/ chan$ o/ +la# t!& 7

ln$th-



D$" o/ #i'cult (as)vntilation

8- Eas! chin li/t onl! 1 9"o3

- On &"son ;aw th"ust , (as) sal-

<- As a+ov = o"o&ha"!n$al o"naso&ha"!n$al ai"wa! o" +oth-

>- Two &"son ;aw th"ust , (as) sal-

?- Two &"son ;aw th"ust , (as) sal = ai"wa!-

@- I(&ossi+l (as) vntilation #s&it(a%i(al %t"nal 5o"t 7 /ull us o/ai"wa! 1in6nit3



D$" o/ #i'cult t"achalintu+ation

8- Eas! n#ot"achal intu+ation 1 9"o3

- On att(&t* inc"asin$ li/tin$ /o"c-

<- As a+ov = us +tt" sni5 &osition

>- Multi&l att(&ts*%t"nal la"!n$al &"ssu"an# (ulti&l +la#s-

?- As a+ov = (ulti&l att(&t +! thla"!n$osco&ist-

@- I(&ossi+l to intu+at #s&it a+ov (anuv"san# usin$ (ulti&l +la#s-1 in6nit3



I"$icati#" F#r I"terrupti#" O-Trac&eal I"tu!ati#"

• Intu+ation att(&t i/ %c#s <scon#s

• C!anosis o" &allo" i/ #vlo&s

• Chan$ in ha"t "h!th( i/ occu"s

• .atint i/ #vlo&# si$ni6cant h!&o%ia-



Causs o/ #i'cult

intu+ation• Anasthsiolo$ist : Ina#Buat &"o&"ativ

assss(nt

Ina#Buat Bui&(nt &"&a"ation In%&"inc

.oo" tchniBu

• EBui&(nt : Mal/unction , Unavaila+ilit!

• .atint : Con$nital 7 acBui"# causs-



CAUSES OF DIFFICULTINTU2ATION

.i"" Ro+in

S!n#"o(

Mic"o$"a&hia* Mac"o$lossia* Cl/t

so/t &alat

T"ach" Collins

S!n#"o(

Au"icula" 7 ocula" #/ct* (ola" 7

(an#i+ula" h!&o&lasia-

4ol#nha"sS!n#"o(

Au"icula" an# ocula" #/cts* (ola"an# (an#i+ula" h!&o&lasia

occi&itali9ation o/ atlas-

Downs S!n#"o( .oo"l! #vlo&# o" a+snt +"i#$

o/ th nos* (ac"o$lossia

Kil&&lFil

S!n#"o(

Con$nital /usion o/ a va"ia+l

nu(+" o/ c"vical v"t+"a

"st"iction o/ nc) (ov(nt-



ACUIRED

In/ctions

Su&"a$lottitis

C"ou&

A+scss

Lu#wi$s an$ina

La"!n$al o#(a

La"!n$al o#(a

Disto"tion o/ th ai"wa! an# t"is(us

Disto"tion o/ th ai"wa! an#

t"is(us-

A"th"itis

La"!n%*

Rhu(atoi#

A"th"itis

An)!losin$

s&on#!litis

TMG an)!losis* c"icoa"!tnoi#*

#viation o/ "st"ict# (o+ilit! o/

C"vical s&in-

An)!losis o/ c"vical s&in* lssco((onl! an)!losis o/ TMG lac) o/

(o+ilit! o/ c"vical s&in-

Tu(ou"

2ni$n Tu(o"

Mali$nant Tu(o"

Stnosis o" #isto"tion o/ th ai"wa!

Fi%ation o/ la"!n% to a#;acnttissus-

T"au(a O#(a o/ ai"wa!* unsta+lH*

ha(ato(a

O+sit! Sho"t thic) nc)* sl& a&noa

Ac"o($al! Mac"o$lossia* ."o$nanthis(



Assss(nt o/ Di'cultAi"wa!

• isto"!

• 4n"al &h!sical %a(ination• S&ci6c tsts /o" assss(nt

– Di'cult (as) vntilation

– Di'cult la"!n$osco&!

– Di'cult su"$ical ai"wa! accss

• Ra#iolo$ic assss(nt



AIRWAY ANATOMY



ANATOMY OF LARYNJ



isto"!

• Con$nital ai"wa! a+no"(alitis: -$- .i"" Ro+in*Kli&&lFil* Downs s!n#"o(s

• AcBui"# – Rhu(atoi# a"th"itis* Ac"o($al!* 2ni$n an# (ali$nant

tu(o"s o/ ton$u* la"!n% tc-

• Iat"o$nic – O"al,&ha"!n$al "a#ioth"a&!* La"!n$al,t"achal

su"$"!* TMG su"$"!-

• R&o"t# &"vious anasthtic &"o+l(s – Dntal #a(a$* E("$nc! t"achosto(!* M#al"ts

/"o(

th &"vious "co"# tc-



GENERAL E.AMINATION• A$'erse a"at#ical -eatures: -$- s(all (outh*

"c#in$ chin* hi$h a"ch# &alat* la"$ ton$u* (o"+i#o+sit!

• Mec&a"ical liitati#": "#uc# (outh o&nin$* &ost"a#ioth"a&! 6+"osis* &oo" c"vical s&in (ov(nt

• .oo" $e"titi#": ."o(innt,loos tth

• O"tho&a#ic,o"tho#ontic e%uipe"t-

• /ate"cy o/ th nasal &assa$0asic cate*#ries

• Evaluation o/ ton$u si9 "lativ to &ha"!n%

• Man#i+ula" s&ac

• Asss(nt o/ $lottic o&nin$-

• Mo+ilit! o/ th ;oints

– TMG

– Nc) (o+ilit!

AIRWAY E1ALUATION



Ai"wa! assss(ntin#ics

8- In#ivi#ual in#ics-

- 4"ou& in#ics Wilsons sco"

2nu(o/s anal!sis

Sa$hi 7 sa/avi tst

L(on asss(nt

tc<- Ra#iolo$ical in#ics



MALLAM/ATI TE2TMALLAM/ATI TE2T• .atint in sittin$ &osition

• a# in nut"al &osition

• Ma%i(al ton$u &"ot"usion

• No &honation

2AM/2OON3YOUNG42 MODIFICATION 586

a### Class I0 an# co""lat# +,w a+ilit! to o+s"v int"ao"alst"ucu"s an# inci#nc o/ su+sBunt #i'cult intu+ations-

• 0isualisation o/ an! &a"t o/ &i$lottis #u"in$ MM.tst

• Associat# with as! la"!n$osco&!

• Di'cult ai"wa! &ossi+l la"$ &i$lottis hin#"

CLA22 7ERO MALLAM/ATI





SI4NIFICANCE OF MM. SCORE

• Class III o" I0: si$ni6s that th an$l +twnth +as o/ ton$u an# la"!n$al inlt is (o"acut an# not con#uciv /o" as! la"!n$osco&!

•Li(itations – .oo" int"o+s"v" "lia+ilit!

– Li(it# accu"ac!

• 4oo# &"#icto" in &"$nanc!* o+sit!* ac"o($al!



E1ALUATION OFE1ALUATION OFMANDI0ULAR 2/ACEMANDI0ULAR 2/ACE

T)YROMENTAL DI2TANCE 5/ATIL42TE2T6

• Distanc /"o( th ti& o/ th!"oi# ca"tila$ to th ti& o/

insi# o/ th (ntu(-• Nc) /ull! %tn## , (outh clos#

2i*"i8ca"ce

• N$ativ "sult th la"!n% is "asona+l! ant"io" toth +as o/ ton$u

9(; c( No &"o+l( withla"!n$osco&! 7 intu+ation

< (; c = Di'cultla"!n$osco&! +ut &ossi+l

P c =La"!n$osco&! (a! +i(&ossi+l



Liitati#"s

• Littl "lia+ilit! in &"#iction

• 0a"iation acco"#in$ to hi$ht* thnicit!

M#$i8cati#" t# ipr#'e t&e accuracy

• Ratio o/ hi$ht to th!"o(ntal #istanc 1RTMD3

• Us/ul +#si# sc"nin$ tst

• RTMD Q <-? v"! snsitiv &"#icto" o/#i'cult la"!n$osco&!

Thyromental DistancePATIL’S TEST



)YO MENTAL DI2TANCE)YO MENTAL DI2TANCE

• Distanc +twn(ntu( an# h!oi# +on

• 4"a# I : Q @c(• 4"a# II: > @c(

• 4"a# III : P >c(

I(&ossi+l la"!n$osco&!7 Intu+ation



2TERNOMENTAL DI2TANCE2TERNOMENTAL DI2TANCE52A11A TE2T652A11A TE2T6

• Distanc /"o( th u&&" +o"#" o/ th (anu+"iu(

to th ti& o/ (ntu(* nc) /ull! %tn##* (outh

clos#

• Mini(al acc&ta+l valu 8-? c(

• Single best predictor o/ #i'cult la"!n$osco&! an#

intu+ation 1 as hi$h snsitivit! 7 s&ci6cit!3-



CORMAC> 3 LE)ANE4"a#in$ at #i"ct la"!n$osco&!

• 4"a# 8: Full %&osu" o/ $lottis 1ant"io" = &ost"io"co((issu"3

4"a# : Ant"io" co((issu" not visualis#

4"a#<: E&i$lottis onl!

4"a# >: No $lottic st"uctu" visi+l-



A22E22MENT OF TM?A22E22MENT OF TM?



A22E22MENT OF TM?A22E22MENT OF TM?FUNCTIONFUNCTION

TM ;oint %hi+its /unction-

8- Rotation o/ th con#!l in th s-cavit!-

- Fo"wa"# #is&lac(nt o/ th con#!l-

Fi"st (ov(nt is "s&onsi+l /o" <c( (outh o&nin$ 7th scon# is "s&onsi+l /o" /u"th" <c( (outh

o&nin$-

In#% 6n$" is &lac# in /"ont o/ th t"a$us 7

th thu(+ is &lac# in /"ont o/ th th low" &a"to/ th (astoi# &"ocss- &atint is as)# to o&nhis (outh as wi# as &ossi+l- In#% 6n$" in/"ont o/ th t"a$us can + intnt# in its s&acan# th thu(+ can /l th sli#in$ (ov(nt o/th con#!l as th con#!l o/ th (an#i+l sli#s

2U0LU.ATION OF T)E2U0LU.ATION OF T)EMANDI0LEMANDI0LE



INTER3INCI2ORGA/

• Int"inciso" #istanc with (a%i(al (outho&nin$

• No"(al valu Q ? c( , a#(its < 6n$"s-

Signicance :

• .ositiv "sults: Eas! ins"tion o/ a < c( #&an$ o/ th la"!n$osco& +la#

• P < c(: #i'cult la"!n$osco&!• P c(: #i'cult LMA ins"tion

• A5ct# +! TMG an# u&&" c"vical s&in (o+ilit!



Significance-

Class B and C: difficult laryngoscopy



U//ER LI/ 0ITE@CATC) TE2T

• Class I: Low" inciso"s can +it th u&&" li&a+ov v"(ilion lin

• Class II: can +it th u&&" li& +low v"(ilion

lin

• Class III: cannot +it th u&&" li&

2i*"i8ca"ce

• Assss(nt o/ (an#i+ula" (ov(nt an# #ntala"chitctu"

• Lss int" o+s"v" va"ia+ilit!



Evaluation o/ Nc) Mo+ilit! .atint is as)# to hol# th ha# "ct* /acin$

#i"ctl! to th /"ont (a%i(al ha# %tnsion an$l t"av"s# +! th

occlusal su"/ac o/ u&&" tth1 can also(asu"# +!

$onio(t"3-

Mini(u( <?

%tnsion is

&ossi+l at

AOG in no"(alin#ivi#uals-

Attlanto.Occipital.Extension

Gra$i"* #- re$ucti#" i" A O E+te"si#"



rade !eduction of A.O.Extension

" none # One t$ird

% T&o t$ird

' co(plete Grades 3 and 4 : Difcult la

Gra$i"* #- re$ucti#" i" A(O(E+te"si#"

4"a# I : Q <?

4"a# II : <> 4"a# III : 88 4"a# I0 : P 8



A22E2MENT OF A(O( E.TEN2ION

• Flexion movement o the cervical spine can+ assss# +! as)in$ th &atint to touch his(anu+"iu( st"nii with his chin- I/ #on* tha+ov (anuv" assu"s a nc) %ion o/ ? <?#$"- Fl%ion an# th %tnsion (ov(nt i/

within th no"(al "an$ *th" a%is

can also + #on +! as)in$ th &atint toloo) at th oo" an# at wall a/t" /ull! %in$

an# 6%in$ th nc) as shown

War"i"* si*" #-



War"i"* si*" #-DELI>AN

.lac th in#% 6n$" o/ ach han#* on un#"nath th

chin an# on un#" th in/"io" occi&ital &"o(innc with

th ha# in nut"al &osition- Th &atint is as)# to /ull!

%tn# th ha# on nc)- I/ th 6n$" un#" th chin is

sn to + hi$h" than th oth"* th" woul# a&&a" to

+ no #i'cult! with intu+ation- I/ lvl o/ +oth 6n$"s"(ains sa( o" th chin 6n$" "(ains low" than th

oth"* inc"as# #i'cult! is &"#ict#-



/ALM /RINT /RAYER 2IGN

/al pri"t si*":

.atints 6n$"s an# &al(s &aint# with +lu in) an#&"ss# 6"(l! a$ainst a whit &a&"

• 4"a# 8 all &halan$al a"as visi+l

• 4"a# #6cint int"&halan$al a"as o/ >th an#?th #i$its

• 4"a# < #6cint int"&halan$al a"as o/ n# to?th #i$its

• 4"a# > onl! ti&s sn-

/rayer si*"(Li(it#(o+ilit! ;oint s!n#"o( 1sti5;oint s!#"o(3 <

T!& I #ia+tics &ositiv &"a!" si$nX- TM ;oint an# Cs atlantoocci&ital ;oint3 (a! + involv#



.RAYER SI4N

A &ositiv &"a!" si$n can +licit#

on %a(ination with th &atintuna+l

to a&&"o%i(at th &al(a" su"/acso/

th &halan$al ;oints whil &"ssin$

thi" han#s to$th" this "&"snts

c"vical s&in i((o+ilit! an# th

&otntial /o" a #i'cult n#ot"achal

intu+ation-



.al( ."int as a ."#icto" o/Di'cult Ai"wa! in DM



B( 2AG)EI 2AFA1I42

• Wi$ht

• Ton$u &"ot"usion

• Mouth o&nin$• U&&" inciso" ln$th

• Malla(&ati class

• a# %tnsion

An! < in#ics i/ &"snt

Q)$

P <-c(

P?c(Q8-?c(

Q8

P #$"

."olon$# la"!n$osco&!

Group indices



,(LEMON Assesse"t

L Loo) %t"nall! 1/acial t"au(a* la"$inciso"s*

+a"#* la"$ ton$u3

E Evaluat << "ul< Int" inciso" $a&

< !o(ntal #istanc

Distanc +twn th!"oi# ca"tila$ an#

oo" o/ th (outh-

M MM. sco"

O O+st"uction 1&i$lottitis* Buins!3

N Nc) (o+ilit!.

WIL2ON 2CORING



( WIL2ON 2CORING2Y2TEM, fa"tors - .eight/ upper "ervi"al spine mobilit'/ a! movement/ re"eding

mandible/ bu" teeth

• +a"h fa"tor s"ore 0-2• otal s"ore 3 , – +as' lar'ngos"op'

) to 4 - (oderate diffi"ult'

> 4 - Severe diffi"ult'

Parameter Risk 0 1 2

Weight (kg) ) *+ *+ , ""+ - ""+

Head & neck movement - *+ *+ ) *+

IID (cm)

SL

- /

- +

/

+

) /

) +

Receding mandible 0one 1oderate se2ere

!ck teeth 0one 1oderate se2ere

IID 4 Intein#iso Gap

SL 4 5a6i0al Fo%a$ Potusion o! Lo%e in#isos beyon$ uppe in#isos'



( 0ENUMOF42 BB /ARAMETERANALY2I2 /araeter

8- U&&" incio"s ln$th

- 2uc) tth

<- Su+lu%ation

>- Int"inciso" $a&

?- .alat con6$u"ation

@- Malla(&ati class

Mi"iu accepta!le

'alue

P8-?c(

A+snt

Ys

Q<c(

No a"chin$,na""ownss

P- TM #istanc

- SMS co(&lianc

- Nc) thic)nss8- Ln$th o/ nc)

88- a# ,nc) (vt

Q ?c(

So/t to &al&ation-

ualitativ 1 Q<<c( DI3 Qc(

No"(al "an$

/o" (an#i+ula" s&a< /o" nc) %a(inati

3,3,3 rule

> /o" tooth

/o" insi# o/ (outh



Rule #- B3,3• 8 6n$" +"a#th /o" su+lu%ation o/ (an#i+l-

• 6n$" +"at#h /o" a#Buac! o/ (outh o&nin$-

• < 6n$" +"ath# /o" h!o(ntal #istanc- In ("$nc! situation* a+ov tst can + "a&i#l! &"/o"(#

within 8?sc to assss th TMG /unction*(outh o&nin$ an#SM S&ac- Si$ni6cant #i'cult! in o" (o" o/ thsco(&onnts "Bui"s #tail# %a(ination-

• > 6n$" +"ath /o" th!"o(ntal #istanc

• ? (ov(nts a+ilit! to % th nc) u&to th (anu+"iu(st"ni* %tnsion at th AOG* "otation o/ th ha# alon$ with"i$ht 7 l/t (ov(nt o/ th ha# to touch th shoul#"-

Rule #- B3,333;

• < 6n$" in th int"#ntal s&ac-

• < 6n$" +twn (ntu( an# h!oi# +on-

• < 6n$" +twn th!"oi# ca"tila$ 7 st"nu(-

RULE OF T)REE2

ADIO4RA.

IC .REDICTORSADIO4RA.IC .REDICTORS



B( .3Ray "ecH 5lateral 'iew6 :

• Occi&ut C8 s&inous &"ocss

#istancP ?((-

• Inc"as in &ost"io" (an#i+l#&th Q -?c(-

• Ratio o/ 5ctiv (an#i+ula"

ln$th to its &ost"io" #&th

P<-@-

• T"achal co(&"ssion-

ADIO4RA.IC .REDICTORSADIO4RA.IC .REDICTORS

, CT 2



,( CT 2ca":

• Tu(o"s o/ oo" o/ (outh* &ha"!n%* la"!n%

• C"vical s&in t"au(a* ina((ation

• M#iastinal (ass

( )elical CT 5D3rec#"structi#"6:

• E%act location an# #$" o/ ai"wa! co(&"ssion

• Flow volu( loo&

• Acoustic "s&ons (asu"(nt

• Ult"a soun# $ui##

• CT , MRI

• Fl%i+l +"onchosco&

A34A0CE3 I03ICESA34A0CE3 I03ICES

A2A TA2> FORCE ONA2A TA2> FORCE ON



A2A TA2> FORCE ONA2A TA2> FORCE ONMANAGEMENT OF DIFFICULTMANAGEMENT OF DIFFICULT

AIRWAY AIRWAY

• Basic preparation

– In/o"(

– Asc"tain hl&

– ."o%!$nation – 2upplee"tal

#+y*e"ati#"t&r#u*&#ut

Portable storage unit

• Ri$i# la"!n$osco& +la#s

• ETTs

• ETT $ui#s,+ou$i

• LMAs• FOI Bui&(nts

• Rt"o$"a# intu+ation )it

• E("$nc! non invasiv ai"wa!vntilation #vic-

• E("$nc! invasiv ai"wa!accss

• E%hal# CO #tcto"



.lan XA: 1ALTERNATE3

• Di5"nt ln$th o/ +la#

• Di5"nt t!& o/ +la#

• Di5"nt &osition

• 2ou$i o" li$htwan# $ui##• Call /o" hl&

• 2st att(&t la"!n$osco&!

Plans 5A67 5B6 and 5C6

8$at are &e going to do if &e don’t get t$e

Tu9e place(ent

/la" 0: 501M a"$ #t&er



/la" 0 : 501M a"$ #t&er'e"tilati#" Tec&"i%ues 6

• Can w 0ntilat with a 20MZ1Consi#" two N.As o" a O.A* $ntl0ntilation3

• Two &"son vntilationZ

• LMA an O&tionZ O" oth"su&"a$lottic ai"wa! Z

• ILMAZ

• Co(+iTu+Z

• Rt"o$"a# Intu+ationZ

w shoul# hav an assistant at thissta$

What #o w #o whn /ac#



What #o w #o whn /ac#with a Cant Intu+at*Cant

0ntilat situationZ

/la" C

• N#l* Su"$ical c"icoth!"oi#cto(!• TTG0

• T"achosto(!

ry to !a"e up the patient rom thetime !e ail intubation#





MANAGEMENT OF DIFFICULT INTUBATION :

Correct position of t$e patient

; A pillo& <"+ c(= s$ould 9e placed under t$e $ead 9ut not under t$es$oulders.

; 1orton and colleagues <"*>*= defined t$is position as lo&er nec?flexion %/o and extension of t$e plane of face "/o <9ot$ angles relati2e to $ori@ontal plane=



SI5PL( T(C)NI7U(S



SI5PL( T(C)NI7U(S +

i5 Pressure on "ri"oth'roid#th'roid "artilage or +6ternal lar'ngeal manipulation- 7nill postulated &a"!ard/ 8p!ard and ight!ard pressure no!n as *URP to the th'roid "artilage !hen the lar'n6 is anteriol' pla"ed for

improving the vie!ii8 Stylet + - +longated metal or plasti" rod !ith a smooth surfa"e and no

sharp edges over !hi"h an + "an be passed- Should be stiff and fle6ible enough to "hange the shape

and "urve of the +- :a"ilitate intubation b' dire"ting the tube tip

to!ards the glottisiii8 Gue$el Ai%ays

iv8 Gu0 elasti# *ou&ie or ube "hangers-used b' Sir obert (a"intosh;19<=5

- +longatedfle6ible/soft and smooth rods over !hi"h the + "an bepassed but these "an not alter the shape of +

- 8seful !hen the posterior portion of the lar'n6 is barel' visible for theepiglottis "an not be elevated It is important to bend the distal end for!ardafter it has been passed through the tra"heal tube he bougie "an then beadvan"ed blindl' to!ards the "ords and then the tube "an be rail-roadedover the bougie

- ?ollo! bougies are also available for atta"hment to o6'gen

X2UR. 7 XE%t"nal



X2UR. 7 XE%t"nalLa"!n$al Mani&ulation

• 0acHwar$ Upwar$Ri*&twar$/ressure:a"ipulati#" #- t&e

trac&ea• JK #- t&e tie t&e

!est 'iew will !e#!tai"e$ !ypressi"* #'er t&et&yr#i$ cartila*e

Differs from the Sellick ManeuverDiffers from the Sellick Maneuver



2= Magill force! : 3ou9le angled forceps $a2e grasping ends in t$e axis ofETT and $andle at t$e rig$t angle.

2i= T"#e #en$er force! %Aillon force!& : T$ese $a2e uneual li(9s &$ic$

can 9end t$e distal end of t$e ETT in t$e desired direction.

2ii= Fle'i#le l"(en fin$er %Fle'g"i$e& : It is designed to 9e used &it$ rig$t$and after insertion t$roug$ t$e ETT. It $as a $andle t$u(9 ring7 inner rodand notc$ed outer tu9e. T$e distal tip of t$e tu9e can 9e (anoeu2red &it$t$e $elp of t$e proxi(al t$u(9 ring.

)iii& Sc*roe$er S+,le+ :ix= Laryngoscope 9lade and $andles :

Bo@@oni in2ented first laryngoscope in ">+/. In "*+ ac?son designed a D;s$aped laryngoscope &it$ t$e ai( to

di2ert force a&ay fro( upper teet$. T&o co((only used designs , t$e cur2ed <Macin+o!*= and t$e

straig$t <Miller= 9lades. It is essential t$at t$e force applied to t$e laryngoscope $andle isdirected along t$e long axis of $andle.



Specialised cur2ed 9lades

"; Left $anded 1acintos$ 9lade ; for left $anded laryngoscopists

; or anato(ical a9nor(alities on t$e rig$t side of t$e face (out$ and

oral ca2ity.

#; I(pro2ed 2ision 1acintos$ 9lade

%; olio Bla$e , T$e angle 9et&een t$e 9lade and t$e $andle is (adeo9tuse.

; It is useful in situations &$en t$e antero;posterior dia(eter oft$e c$est is suc$ t$at insertion of t$e laryngoscope into t$e (out$ isdifficult or i(possi9le.



"# Laryngosco$e %ith st!nted' or short handle : useful in o9ese

patients and in patients &it$ large 9reast.

# *i$ort +acintosh , It $as an oxygen port in t$e 9lade allo&ing

oxygen insufflation during intu9ation atte(pts.

-# T!ll +acintosh , T$is 9lade $as a suction port.

.# Siker blade , $as stainless steel (irrored surface &$ic$ per(its

2isualisation of an 5anterior6 larynx. It gi2es an in2erted i(age.

>. H!//man Prism , I(ages are real. ;

Pris( s$ould 9e placed in &ar( &ater for %+ sec on anti;fog solution

to pre2ent fogging



9. Bullard Laryngoscop ! his is a fiber-opti" lar'ngos"ope !ith a

built in rigid 900 "urved blade It is batter' operated +'e pie"e is atta"hed

to the main bod' of the s"ope at <,0

angle- 8seful in mid-fa"ial h'poplasia s'ndrome and unstable "ervi"al

spines

http://vam.anest.ufl.edu/airwaydevice/bullard/index.html



23' McCoy l"r#ng Laryngoscop – he tip of the (a"intosh

blade is hinged ;appro6 2, "m from the blade tip5 and the angle of

the hinged portion "an be altered b' a lever atta"hed to the handle

Shucman-Pro

LeveringLaryngoscope



11. U!*er fi#reco+ic lar,ngo!coe , co(9ines fi9reoptic round t$e

corner 2ie&ing &it$ (aneu2era9ility.

; T$e tip of 9lade is ad2anced until it co(es to rest close to t$e

cords.T$e tu9e sits in t$e se(i;enclosed space in t$e 9lade.

; T$e 2aria9le focus eye piece ena9les t$e operator

to o9tain uninterrupted

2ie& of t$e procedure. T$e eye piece can 9e attac$ed to T.4. Ca(era for

teac$ing purposes.



-12. Blscop – @ong angulated blade !ith <,0 bend at midpoint and a

deta"hable prism

- It minimiAes damage to teeth/ due to angulation – the blade sta's

a!a'from upper teeth

- It gives a good vie! of lar'n6 !hen the ma"intosh blade gives grade =

vie!"%. Specialised straig$t 9lades

.ac/-Allen 9lade7 C*oi 9lade7

Bel!coe 9lade7 Bain+on 9lade7 G"e$el 9lade7

Benne++ 9lade7 *i+e*ea$ 9lade7 Flagg 9lade7

E)er!ole 9lade7 Sno& 9lade.

WU SCOPE

i " lid L i $ id

http://www.achi.com/products/productlist.htm

http://www.achi.com/products/productlist.htm



ruvie! evo"Laryngoscope

lidescope L &it$ 2ideo

intu9ating syste(

I di i id l



AI!T!ACF•Indirect rigid laryngoscopy

•1ini(u( (out$ opening reuired

•Less $e(odyna(ic sti(ulation co(pared

to con2entional L



•8tilises the paraglossal te"hni$ue of intubation•&O*:I@S retromolar intubation fibres"ope is a ,mm opti"al/ distall' "urved st'let

!hi"h "an a""ommodate a )mm or larger + tube•Permits "ontinous o6'gen insufflation•@ight supplied via remote Benon sour"e•Can be atta"hed to a module !ith image displa'



LI0D 01S1L I0T21TI0 : can 9e perfor(ed in anaest$etised or

a&a?e patients.

; Position ; sniffing t$e (orning air position

; A &ell lu9ricated nasal tu9e is gently passed t$roug$ t$e (ost patentnostril.; T$e nasal (ucous (e(9rane s$ould 9e constricted 9y t$e use of

2asoconstrictor <xylo(eta@oline or any ot$er nasal decongestant=.; T$e 9e2el of t$e tu9e s$ould 9e pointing laterally so as to a2oid trau(a to

c$onc$a. T$e opposite nostril s$ould 9e occluded &it$ t$e (out$ s$ut

and t$e c$in lifted for&ard.; T$e tu9e is t$en ad2anced &$ile listening to t$e 9reat$ sounds7

(anipulation of t$yroid cartilage and at ti(es of $ead facilitates t$e

align(ent of t$e tu9e.

; At ti(es acute flexion of nec? (ay 9e reuired if t$e o9struction occurs

during passage of t$e tu9e.

; T$e tip of t$e tu9e (ay get placed at fi2e positions , "; Into t$e trac$ea #. Against t$e anterior co((issure %. In t$e

2allecula at t$e 9ase of tongue. '. Laterally into pyrifor( recess. /. In

t$e Oesop$agus.



Awa) Intu+ation

SP(CIALI9(D T(C)NI7U( +



SP(CIALI9(D T(C)NI7U( +

1 @ight !and it has batter' handle and "opper st'let ;about <,

"ms5 "overed in !hite plasti" Ds it enters tra"hea/ transilluminated light is

seen as bright/ "ir"ums"ribed belo! "ri"oid "artilage if it enters esophagus/light is not easil' seen

- On"e position of light !and is "onfirmed then the tube is threaded

and guided through it

2 &ron"hos"opes &oth rigid and fibreopti" bron"hos"opes have



rincile

G Internal reflection ; Bea( of lig$t entering one

end of glass rod

&ill repeated internally reflex off t$e

&alls of rod7 e2entually e(erging fro( ot$er end.

G Optical lenses , Lig$t t$at is internally reflectedis co(pletely 9lurred. it is focused &it$ a series of

optical lenses.G old standard for anticipated difficult intu9ation

, any age7 any position.

G !euires good experience.

o " os"opes ot g d a d b eopt " b o " os"opes a e

been used as an aid to intubation

Fle6ible !ibeopti# intubation It "onsists of –

D Insertion tube – :le6ible part e6tending from "ontrol

se"tion to distal tip of s"ope& Control se"tion – Contain the tip "ontrol nob !hi"h

"ontrols movement of insertion tube

C +'e pie"e se"tion

E @ight transmission "ord – from e6ternal light sour"e to

hand of fibers"ope

+ @ight sour"e

ADUNCTS TO DIFFICULT AI.A MANAGEMENT 3



". Na!o*ar,ngeal air4a,

#. Oe!o*ageal O#+"ra+or Air4a, ,By 3on 1ic$ael and ordon in "*H>. Consist

of t&o parts first %+ c(s plastic oesop$ageal tu9e occluded at distal end.

; T$ere are perforation in t$e tu9e &$ic$ are intended to 9e located in $ypop$arynx.

A large 9alloon is located at distal end to create a seal in t$e oesop$agus.

; Second part of t$e de2ice is face (as? &it$ ap inflata9le cuff designed to (a?e a

tig$t seal &it$ t$e face. After lu9rication tu9e is inserted 9lindly &it$out

laryngoscope.

Connell’s Nasopharyngeal Airway

Esophageal O#turator $ir!ay

%. a+il! !,rac"!e oral air4a,- allo&s fi9reoptic intu9ation

http://www.allmed.net/catalog/showitem.php/2554

http://www.allmed.net/catalog/showitem.php/2554



%. a+il! !,rac"!e oral air4a, allo&s fi9reoptic intu9ation

'. O)a!!aian fi#ero+ic in+"#a+ing air4a, , Acco((odates

trac$eal tu9e upto * (( dia(eter.

/. COA %C"ffe$ Oro*ar,ngeal air4a, &-

3isposa9le de2ice t$at co(9ines a guided air&ay &it$ an inflata9le

distal $ig$ 2olu(e lo&pressure cuff and a proxi(al "/(( adapter. ;

distal tip s$ould 9e 9e$ind 9ase of tongue



-# Pharyngo3tracheal l!men air%ay 3 it is dou9le lu(en tu9e consisting

of a long tu9e &it$ a distal cuff <"/ cc= designed to 9e inflated in

esop$agus and s$orter tu9e t$at protrudes t$roug$ t$e larger tu9e and

past alarge proxi(al cuff <"++ cc= to 2entillate t$e lungs.

.# eso$hageal tracheal combi t!be (T4) , ;



$ g ( )

3isposa9le dou9le lu(en tu9e &it$ a lo& 2olu(e inflata9le distal cuff

and a larger proxi(al cuff. ; 3istal

cuff - Oesop$agus Proxi(al cuff - Orop$arynx ;

4entilation is possi9le &it$eit$er trac$eal or esop$ageal intu9ation. If itenters oesop$agus <co((on= , 4entilation is t$roug$ (ultiple proxi(al

apertures situated a9o2e distal cuff. Bot$ cuffs $a2e to 9e inflated. ; If it

enters trac$ea ,2entillation is t$roug$ distal lu(en as &it$ a standard trac$eal

tu9e.

'.



@(D "lassi" ;standard @(D5



SU.REME



; L1A uniue <disposa9le=



• Is a non cuffed

supraglottic de2ice &it$ t$e

s$ape of t$e L1A

• 3isposa9le

• (ade of gel 7softer

• $as a gastric drain

<ProSeal L1A;li?e=

• 9ite 9loc?

• and an epiglottis

9loc?er

"+. I GEL



22' P"ayn&eal ai%ay :pess – Curved tube !ith anatomi"all'

shaped gilled distal tip/ large orophar'ngeal "uff and an open

hooded !indo! that allo!s ventilation (ore effe"tive seal than@(D

“Pharyngeal

Express” Airway

nw t!& o/ SLA #vic that #os not hav a cu5* "ath"* it



!&has a &"/o"(# &lastic that 6ts anato(icall! to th sha& o/th &ha"!n%- This #vic allows on to $iv &ositiv &"ssu"vntilation to th &atint without cu5- This #vic also

contains a cha(+" 1a+out ? (ls3 as sto"a$ /o" "$u"$itantui#s to collct-

"#.



Trans$rac%al Tc%n#&us - 8suall' a small IF "annula ;1<#1)5 is re$uired It is advisable to

eep this fitted !ith usual 1, mm "onne"tor of =, mmendotra"heal tube

- he patients should be positioned to a"hieve ma6imum

e6tension of ne" h'roid and "ri"oid "artilages are identified and the

sin overl'ing the "ri"oth'roid membrane is fi6ed D 1< IF needle is

inserted through the membrane into the tra"hea and dire"ted to!ards

"arina he "orre"t intratra"heal position is verified b' free aspiration ofair through a s'ringe "ontaining saline

- &egin !ith , psi and in"rease in in"rements of , psi until

ade$uate "hest e6"ursion o""urs

- *o more than 2, psi and no more than half a se"ond inspirator'

time

E'rgncy $rac%os$o'y !- It is al!a's better to o6'genate the patient via transtra"heal IF

"annula !hile also performing tra"heostom'

- Per"utaneous dilatational tra"heostom' ;PCE5 taes time and

is usuall' not re"ommended !here urgen"' is there –



; 1initrac$eosto(y is preferred. A single 2ertical incision %;/ (( in lengt$

o2er cricot$yroid (e(9rane is (ade and t$en t$roug$ o9turator t$e ' ((

uncuffed trac$eal tu9e is guided.

;Co(pared &it$ I.4. cannula t$e (initrac$ $as larger dia(eter and is 9etter

for et 2entilation and e2en for assisted spontaneous respiration for a s$ort

period.

MINI TRAC)EO2TOMY



MINI TRAC)EO2TOMY 5CONT(6

C i t& t



Cric#t&yr#t#y

• uicHtrac& IStan#a"#St

Availa+l /o" a#ults 1I-D- >((

• chil#"n 1I-D- ((3 an#• in/ants 1I-D- 8-?((3

uicHtrac& II wit& cu St with cu5 T$in cuff seals trac$ea and allo&s efficient 2entilation &it$ aspiration

protection. Stopper and safety clip reduce t$e ris? of posterior trac$eal

&all inury. Anato(ically s$aped cannula adusts to t$e trac$ea due to

5(e(ory effect6. A2aila9le for adults <I.3. '((=

Con6"( th ai"wa!



Con6"( th ai"wa!

echnologyechnology

Based Based

ETCOETCO1(onito"31(onito"3

EDD 1+ul+3EDD 1+ul+3 Colo"(t"icColo"(t"ic

1ca&31ca&3

.uls O%.uls O%

MET(ODS OFMET(ODS OFCONFI)MATION CONFI)MATION

raditional raditional

Di"ctDi"ct0isuali9ation0isuali9ation

Lun$ Soun#sLun$ Soun#s

Tu+ Tu+Con#nsationCon#nsation

Causs o/ #i'culti + i i



intu+ation in

/REGNANCY 8\-- MM. Class < o" >

\-Su&"a$lottic an# $lottic a"as o#(a-

<\-La"$ +"asts-

>\-Full #ntition-

?\-Mucosal con$stion o/

nos* &ha"!n%*tc- @\-Enla"$(nt o/ton$u-

\-Fat #&osition in o"o&ha"!n$al "$ion-

\-Elvation o/ h!oi# +on-

\--Wi$ht $ain-

8\I(&"o&"l! a&&li# c"icoi# &"ssu"-

88\I(&"o&"l! a&&li# hi& w#$ causs#c"as# chin chst #istanc-



Di'cult ai"wa! :O0E2ITY

• Di'cult s&ontanous vntilation in o+st"uctivsl& a&na

• 2MI Q @ &"#icts #i'cult (as) vntilation

• Di'cult intu+ation &"#icto"s

MM. Sco" Q<

Nc) ci"cu(/"nc Q 8@inchs

sitionin$ /o" (o"+i#l! o+s &ati



sitionin$ /o" (o"+i#l! o+s &ati

Whlan Calicott



Whlan Calicott&osition

AIRWAY MANA4EMENT IN TRAUMA



AIRWAY MANA4EMENT IN TRAUMA• RSI involvs > %&"inc# &"sonnl

• AM/LE histo"!

– All"$is – M#ication

– .ast (#ical histo"!

– ti( o/ Last (al

– Evnts la#in$

• No #6nition o/ sa/ c"vical s&in (ov(nt• EBui&(nt o&tion #&n# on o&"ato" %&"inc 7 s)ill

• Manual inlin sta+ili9ation• Ai"wa! int"vntions "Bui"in$ lss nc) (ov(nt

– Gawth"ust 1vntilation3

– A#;unctiv #vic ILMA* co(+itu+

– C"icoth!"oto(!

• Last (ov(nt 1-8 ((3 with 6+" o&tic nasal intu+ation

CER1ICAL 2/INE IN?URY: MANAGEMENTO/TION2

Ai"wa! (ana$(nt in t"au(a



E.TU0ATION 2TRATEGIE2



E.TU0ATION 2TRATEGIE2

$u% lea" test

• ."/o"(# in a s&ontanousl! vntilatin$ &atint at

"is) o/ o+st"uction a/t" %tu+ation- Ci"cuit

#isconnct# occlusion o/ ETT n# an# #ation

o/ cu5 a+ilit! to +"ath a"oun# th ETT-

• Convntional awa) %tu+ation

• E%tu+ation ov" a +ou$i-

• E%tu+ation ov" a 6+"o&tic +"onchosco&-

• En#ot"achal vntilation an# %chan$catht"s -$-

– Coo)s ai"wa! %chan$ catht"

Do]s in th (ana$(nt o/



$#i'cult ai"wa!

• Us antisialo$u in &"(#ication-• As&i"ation &"o&h!la%is-

• ET o/ asso"t# si9-

• LMA o/ asso"t# si9-• T"achosto(! st-

• Chc) s&cial ai"wa! Bui&(nt-

• K& hl& o/ snio" anasthsiolo$ist-• ."o%!$nat &atint , En# ti#al CO

#vic-

Dont]s in th (ana$(nt o/



$#i'cult ai"wa!

• Dont &"o#uc #& &lan o/ anasthsia-

• Dont us tchniBu that !ou a" not /a(ilia"-

• Avoi# (ulti&l att(&ts-

• Dont "n#" th &atint a&noic* unlss !ou a"

c"tain that (as) vntilation can +(aintain#

TANK YOU



TANK YOU

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