1. Sedation course 2011By Dr Moutasem Al Mashour

2. Objectives: To refresh the basic knowledge about airway anatomy Assess and Recognize signs of a threatened airway Assess airway on emergency / elective basis Describe manual techniques for establishing an airwayand for mask ventilation with and without suspectedcervical spine injury. Hands on airway adjuncts such as LMA and ET 3. Airway ManagementThe primary goalPatent airway and ability to support gas exchange. The A in your ABCs. Secondary goalscardiovascular stability and prevention of aspiration during airway management. Establishing and maintaining a patent airway is equally important and often more difficult. Health care providers must be skilled in manually supporting the airway and providing the essential process of oxygenation and ventilation 4. Airway Nasal and oral cavities Pharynx Larynx Trachea and large bronchi 5. The oral cavity 6. Difficult AirwaysThe difficult airway is something one anticipates; the failed airway is something one experiences. -Walls 2002 7. Is difficult airway common in population ? 8. PREVALENCEWith proper evaluation only 15 to 50 % were picked upWhile difficult face mask ventilation in general is about1:10,000 out of which again 15% proved to be the difficult intubation , While incidence of extreme difficult or abandons intubation in general surgery patients are 1:2000 but in obstetrics is 1:300 and of course most critical incidence is Hypoxia 9. ASA Closed Claims Review Adverse Respiratory EventsThe average settlement payment for adverse respiratory events equaled$200,000, with a range from $1,000 to $6,000,000. 10. Why does it happens ?1. Exaggerated idea of personal ability.2. Not requesting for experienced help.3. No discussion with colleagues about proposed management of the case .4. Ill conceived plan (A) with no proper back up plan (B).5. Even poorly conducted plan (A) or sticking extra time to the plan (A) other way delaying the rescue plan late. 11. Causes of difficult airway Congenital Acquired 12. Congenital CausesPierre-Robin syndrome Micrognathia, macroglossia, cleft soft palateTreacher-CollinsAuricular and ocular defects, malar and syndrome mandibular hypoplasiaGoldenharssyndromeDowns syndrome Poorly developed or absent bridge of the nose,macroglossiaKippel-Feil syndromeCongenital fusion of cervical vertebrae,restriction of neck movementGoiterCompression of trachea, deviation oflarynx/trachea 13. Acquired Causes Short, thick neck Prominent upper incisors (buckteeth), Dentures Receding mandible Limited jaw opening, cervical mobility High, arched palate Face, neck, or oral trauma, Laryngeal trauma Airway edema or obstruction Acromegaly Epiglottitis Pregnancy Obesity 14. Airway management Assess (recognize)Back-upPlan (prepare)Manage (act)Every caseEvery place 15. Airway AssessmentHistory Known potentially difficult airway Prior GA PMH Meds Allergies Recent respiratory illness NPO (number of hours) 16. Physical examination General appearance Obesity syndrome features and beard Receding mandible Vital signs 17. Assessment General assessment Primary assessment----- ABCD Secondary assessment----- SAMPLE Tertiary assessment------investigations 18. Assessment General appearancePosition, speech/cry, look/gazeCervical instabilityFull stomach---- anti reflux meds Work of breathing Increase (nasal flaring, retractions) Decrease / absent respiratory efforts Abnormal sound 19. Four Ds also suggest a difficult airway Dentition (prominent upper incisors, receding chin) Distortion (edema, blood, vomitus, tumor, infection) Disproportion (short chin-to-larynx distance, bull neck, large tongue, small mouth) Dysmobility (TMJ and cervical spine) 20. Advanced Airway Assessment Techniques 3 3 2 Teeth Examination Mallampati Classifications Laryngoscope View Grading 21. Evaluate 3-3-2 Will patients mouth open wide enough to accommodate 3 fingers? Will 3 fingers fit between the mentum and hyoid bone? Will 2 fingers fit between the hyoid and thyroid notch?If not, expect a difficult intubation 22. Mouth opens at least 3 fingers width? 23. Thyromental Distance-3 fingers? 24. Mandibulohyoid Distance- 3 fingers? Measured from thementum to the top of thehyoid bone. The epiglottis arises fromthe thyroid and remainsdorsal to the hyoid bone. Therefore, the position ofthe hyoid bone marks theentrance to the larynx. 25. Upper & Lower Face Measure the size of the upper face as compared to the lower face. Should be roughly the same. If the lower face is longer than the upper face then you should anticipate some degree of difficulty lining up the structures. 26. Upper and lower face equal? 27. Upper and lower face equal? 28. Teeth Protruded teeth Dentures Crowns ,bridges loose, Chipped and cracked teeth Missing teeth 29. Sensitivity: 44% - 81% , Specificity: 60% - 80% 30. Mallampati Score Roughly corresponds to Cormack and Lehanes laryngoscopy views 31. Secondary assessment S----- signs and symptoms A----- allergies M----- medication P----- PMH L----- last meal E----- events 32. Tertiary assessment Lab data CBC, basic screen, ABG&VBG Radiology- chest x-ray ECG Consultation Flow volume loops 33. Focused Airway Assessment This picture representsa Mallampati ClassOne airway. The entire uvula andtonsillar pillars areseen. This individual shouldbe easy to maskventilate or to intubatewith a laryngoscopeand endotracheal tube. 34. Focused Airway Assessment This picture represents aMallampati Class Threeairway. None of the uvula ortonsillar pillars are seen. This individual may hardto mask ventilate, andquite difficult to intubate. 35. Focused Airway Assessment This image is representative of an extremely short thyromental distance, indicating tremendous difficulty in tracheal intubation, and possible difficulty establishing a satisfactory mask seal 36. Focused Airway Assessment The patient undergoing conscious sedation should have athorough airway assessment focusing on mouth opening airway class thyromental distance (distance from chin to thyroid) range of motion of the neck For more information:http://www.vh.org/Providers/ClinGuide/ProceduralSedation/AirwayAssessment.html 37. THANK YOUQuestions & Discussion