Adult and Pediatric Intubation Alice A Tolbert Coombs MD MPA FCCP

Associate Professor Virginia Commonwealth University

Medical College of Virginia

No Disclosures Alice A Tolbert Coombs MD MPA FCCP

Associate Professor

Department of Anesthesiology and Critical Care Medicine

Medical College of Virginia

Medical Director, Critical Care Medicine Vibra Hospital

VCU Health Systems

Objectives

Discuss anatomy and physiology

Review Techniques and methods of Airway Management

Review Airway Cases

Discuss Complications of Airway management and how to avoid common problems

Airway Assessment

External Airway Evaluation “the Grocery Store Look”

• Mallampati Classification

• Oral Cavity-

• Mouth Opening, Teeth

• High Arched Palate

• Hypopharyngeal Masses , Large Tongue or Oral tumor , Enlarged Tonsils

• Skull and Facial Structures

• Maxillary Anatomy/Injury

• Mandibular Anatomy-Prominent CHIN or Receding CHIN Pierre-Robin

• Nasal Anatomy, Antrum

• Low Riding ears

• Ocular Assessment-Enucleation

• Neck

• Neck Mobility

• Masses

• Cervical Spine Anatomy

Internal Airway Evaluation

• Upper Lip Bite Test

• Saying “e” High Pitch” for evaluation of degree of swelling and RCL Nerve encroachment with angioedema , ACEI

Functional Assessment-

Date of download: 2/16/2019 Copyright © 2019 American Society of Anesthesiologists. All rights reserved.

Representative data screen for the online data collection tool used at the R Adams Cowley Shock Trauma Center (Baltimore, MD),

the Shock Trauma Airway Registry (STAR). OR = operating room.

Figure Legend:

From: Performance Assessment in Airway Management Training for Nonanesthesiology Trainees:An Analysis of 4,282

Airway Procedures Performed at a Level-1 Trauma Center

Anesthes. 2014;120(1):185-195. doi:10.1097/ALN.0000000000000064

From: Performance Assessment in Airway Management Training for Nonanesthesiology Trainees: An Analysis of 4,282 Airway Procedures Performed at a Level-1 Trauma Center

Anesthes. 2014;120(1):185-195. doi:10.1097/ALN.0000000000000064

Distribution of intubation attempts with corresponding success rate by week of rotation. *P < 0.05 for week 1 versus week 4.

Intubation of the Trachea with Trach

AIRWAY

Glottic Airway

Direct Laryngoscopy

Light Wand , etc

Video-Laryngoscopy

Blind

Surgical

Tracheostomy

Retrograde Intubation

Rigid Bronchoscopy

TongueSuture-Patient Positions

Airway Anatomy

Upper Airway

Lower Airway

Airway Position

Head-Sniff position

Jaw Thrust

Bag Mask Ventilation

Supraglottic Airway

Where are you managing the Airway?

Clinical scenario and choice of Airway

Airway Algorithms considerations

What are the Indications?

What are the contraindications to supraglottic airway

Video Laryngoscopy

Out of Hospital Arrest and Intubation

Patients do worse (mortality )if Intubated

Acad Emerg Med. 2010 Sep;17(9):918-25. doi: 10.1111/j.1553-2712.2010.00827.x.

The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients.

In-Hospital Cardiac Arrest

Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults

Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation. (Funded by Vanderbilt Institute for Clinical and Translational Research and others; PreVent ClinicalTrials.gov number, NCT03026322.)

February 28, 2019N Engl J Med 2019; 380:811-821

Patient’s difference in aspiration 2.5 vs 4.0 % P .41

IntubationsIndications

Apnea/Arrest

Hypoxia

Hypercarbia- relative indication , check for metabolic compensation

Acid Base Disturbances

Airway or massive trauma

Control Respiratory Rate

Low GCS 8 or less

Intracranial- Event -IPH IVH SAH

MVA

Airway Protection – Status Epilepsy

Cardiac/Hemodynamic Instability, Bleeding, MTP

Sepsis with Respiratory signs of respiratory Failure

Neuromuscular-for example ALS

Vocal cords laryngoscopy

Mallampati Classification

Neck Mobility

Lehane McCormack classification

MACCOCHA SCORE he MACOCHA score is a simple

tool, which can be performed within a very short time period and seems to be superior to Mallampati or Cormack

M Mallampatii

A APNEA SYNDROME

C CERVICAL SPJNE LIMITATION

O Mouth Opening

C Coma

H Hypoxia

A Anesthesiologist years of experience

Prepared Equipment

Planned and Prepare

1. Plan A Perfect

2. Plan B Deviations Obstacles that can be easily overcome with correct toolset

3. Plan C- The tough ones that make you good Prepare for the worse with all needed devices nearby and personnel!

Airway equipment:

Airways Mac 3 & 4, Miller 2 & 3 blades

Supraglottic Tookset Intubating LMA (Fast Track)

Various size endotracheal tubes

Video-laryngoscopy Device and /or Disposable fiberoptic bronchoscope,

Standard hemodynamic and Respiratory monitors available

Stethoscope

Ventilator

Capnography

Intravenous fluid and monitors attached,

Working Suction!

SOAP

Equipment Preparation Including Drugs! 6 Ps

Technique Laryngoscopy Intubation-Starts with Positioning

IntubationWhich Blade?Miller or Mac or ?

Open Mouth Scissoring

Insert Laryngoscope on the right then maneuver

Pass ET through Cords

Confirm Proper Placement of ET Tubes

Chest Auscultation BS ET CO2Auscultation over ABDCXR/ FluoroBronchoscopy

Endotracheal Tubes

?

AIRWAY Measurement Trachea Length 11-13cm

Trachea width 2.5 cm

Intubating the TracheostomyIssues?

TracheostomyTrachea Stoma post Laryngectomy

Decreasing the sensations of Intubation

Intravenous analgesia

Topicalization

Airway Nerve Block

Gauze soaked

Nebulized Xylocaine

Nasal airway topicalization

Innervation of the Larynx

Vagus

Superior Laryngeal Nerve-sensory above cords and Crico-Thyroid

Recurrent Laryngeal Nerve –Sensory below Cords, VC Muscles not cricothyroid

SOAP

SOAP Don’t leave Home without it

S Suction

O Oxygen

A Airway Tools

P Pressures and Pharmacology

Airway algorithmThe Airway Bible-Guide

Case42-year-old Mozambican male presents for removal of extensive keloid scar tissue.

9 years prior to his presentation: Small scar from an injury in the center of his chest progress to cover his anterior chest wall encircling this neck bilaterally

The scar eventually involved the patient’s ears, superior portion of his chin and borders of his mandible and lower lip.

He was scheduled for a partial resection of the neck portion of the constricting keloid with(GETA)

With a difficult airway: Analysis

The supraglottic airway device reliably provided a good airway and allowed blind intubation in nearly 80% of patients. It is thus a reasonable initial approach to airway control. Muscle relaxation can be used safely when unparalyzed leak pressure is adequate. (Anesthesiology 2017; 127:307-16)

Blind Intubation through Self-pressurized, Disposable

Supraglottic Airway Laryngeal Intubation Masks An

International, Multicenter, Prospective Cohort Study

Kurt Ruetzler, et.al.

Blind Intubation through Self-pressurized, Disposable Supraglottic Airway Laryngeal Intubation MasksKurt Ruetzler, M.D., Sandra Esther Guzzella, M.D., David Werner Tscholl, M.D.et.al, .

1,000 adults having elective surgery with endotracheal intubation

The supraglottic airway device reliably provided a good airway and allowed blind intubation in nearly 80% of patients. It is thus a reasonable initial approach to airway control

What’s that?

What is your plan for intubation?

Case # 3This Patient has been on Lisinopril for 5 years. O2 Sat 91% on RA

When things go bad!

•Hemodynamic Instability

•Poor Mask

•Hypoxia/hypercarbia

•Aspiration Pneumonia

•Laryngospasm

•Bronchospasm

•Secretions

Burning bridges

Too much Juice

Taking away Spontaneous respiration

Know what you don’t have

Bleeding Swelling –is bad news

Choosing a surgical airway in the wrong patient with a leather skin!

Airway Physiology

Laryngoscopy View

Laryngoscopy Another Look

A B

F

C

ED

Airway Algorithm

with a Difficult Airway: An Analysis from the Multicenter Registry

Blind Intubation through Self-pressurized, Disposable Supraglottic Airway Laryngeal Intubation Masks An International, Multicenter, Prospective Cohort StudyKurt Ruetzler, et.al.

The supraglottic airway device reliably provided a good airway and allowed blind intubation in nearly 80% of patients. It is thus a reasonable initial approach to airway control. Muscle relaxation can be used safely when unparalyzed leak pressure is adequate. (Anesthesiology 2017; 127:307-16)

Airway Devices The Instruments

Non-Surgical

Oral and/or Nasal Airway

Supraglottic Airway

Esophageal/Supraglottic Airway

Endotracheal Intubation

Surgical Airway

Cricothyroidotomy

Tracheostomy-traditional

Clinical Scenario

GI Bleeding

Instrument Iatrogenesis

Airway trauma during difficult intubation… from the frying pan into the fire?

Sriraam Kalingarayar, et.al

CASE REPORT

A 46-year-old male, with no preexisting lung or heart ailments, diagnosed with severe cervical myelopathy, was posted for anterior cervical corpectomy and fusion. History of mild mitral stenosis (mitral valve area = 2 cm2) and mitral regurgitation, His airway examination revealed modified Mallampati class III. Neck mobility was not assessed because of his disc prolapse.

Anaesthesia was induced after confirming mask ventilation. Laryngoscopy, with minimal neck extension, revealed Cormack-Lehane grade 3a view of the vocal cords with external laryngeal manipulation. Portex ™ single use 15 Fr 700 mm coude tip bougie was first introduced up to 25 cm mark, without eliciting tracheal click or hold up signs. Portex ™ ETT size 8 mm I.D. was railroaded over the bougie without much difficulty and the ETT cuff inflated. On removal of the bougie, the tip was blood stained.

There was a gush of blood from the ETT. Suctioning was done through the ETT, and its position was checked. Ventilation was not achieved, and auscultation did not reveal bilateral air entry and end-tidal CO2 could not be recorded, as there was blood in the sampling line. Repeat suctioning through the ETT was done and auscultation again did not reveal air entry. Since the oxygen saturation started dropping to 80% and the position of ETT could not be confirmed, the ETT was removed and the patient was ventilated with a face-mask. Mask ventilation was difficult and a classic laryngeal mask airway size 4 was inserted. There was no chest rise, and auscultation revealed no air entry and SpO2 dropped further to 60%.

Repeat laryngoscopy was attempted, and airway was secured with Portex ™ 8 mm I.D. ETT with the help of the Portex ™ bougie again. No injury was visualised in the oral cavity and supraglottic area during laryngoscopy. There was still blood inside the ETT, but with repeat suctioning and lavage with dilute epinephrine (1:100,000) the bleeding was controlled. Injection tranexamic acid 1 g and injection dexamethasone 8 mg I.V. were administered. Auscultation revealed extensive wheeze and the peak airway pressure was 45 cm H2O and SpO2 increased to 95%.

An emergency bronchoscopy revealed bleeding from the right main bronchus. After instillation of topical tranexamic acid and repeated lavage, the bleeding was localised to be from the right middle bronchus [Figure 1]. The bleeding was controlled eventually. No definitive injuries could be visualised anywhere along the tracheobronchial tree while withdrawing the ETT till the vocal cords over the fibreoptic bronchoscope.

After bronchoscopy, it was decided to proceed with posterior decompressive laminectomy in the prone position. The decision was taken considering the possibility of rebleed during surgery and better drainage of the blood through ETT in the prone position. The rest of the intraoperative course was uneventful. After surgery, the patient was turned supine, neuromuscular blockade was reversed and trachea extubated. Postoperatively, the SpO2 maintained above 95% with 6 L/min oxygen flow through a facemask.

Boogie Bougie

Indian J Anaesth. 2017 May; 61(5): 437–439.

Bleeding Patient34 y/o coughs up blood

and then passes out as he is attempting to sign in to the ER . He develops apnea and hypo

The patient is intubated and Bronchoscopy

His ET tube is taped at 20 and filled

Hemoptysis

Obesity

Key to Large BMI Go Slow

Case Presentation35y/o nursing home patient with diagnosis of TBI has pulled out his tracheostomy and he arrives in the ER with an O2 Sat of 89% on face Mask O2

35 Y/o

Airway Management in a this Patient ?

All the ENT Docs have left town for a meeting.

Foreign Body

When things go bad !You’re Stuck!

Hemodynamic Instability

Poor Mask

Hypoxia/hypercarbia

Aspiration Pneumonia

Laryngospasm

Bronchospasm

Secretions

Cardiac Arrest/Arrythmias

Nasal and oral bleeding

Soft tissue/AW injury

VC Complications

Burning Bridges Too much large Juice

Neuromuscular Blockers

Missing Anatomic Warnings

Taking away Spontaneous respiration

Know what you don’t haves

Repeated attempts at intubation leading to trauma

Bleeding Swelling –is bad news

Choosing a surgical airway in the wrong patient with a leather

Risk of Complications-Difficult Intubation-Obesity -Critically Ill-Underlying Pathology -Location of Intubation-Provider Circumstances*

Complications

Airway Injury

Airway damage

Mainstem Intubation

Soft Tissue damage- Soft palette, Uvula and tongue

Dental

Hyoid Bone Fracture

Laryngeal , Arytenoid Dislocation, Nerve, Vocal Cord hematoma , VC Paralysis, Tracheal, bronchial injury

Systemic

Hypotension

Tachycardia, arrhythmia

Response to Mechanical Ventilation Asynchrony

Cardiac Arrest

Summary

Reviewed patients’ history

Prepare Airway equipment and Devices

Evaluate airway, assess Difficulty

Use acceptable Protocol

Improve Preoxygenate, 100% O2 Consider using CPAP

Measure ET CO2 , Capnogram

RSI-( Assume everyone coming to the ED is a “full Stomach)