EMCOP airway management1 Airway management in morbid obese patients J P Mulier MD PhD Sint Jan...

EMCOP airway management 1

Airway management in Airway management in morbid obese patients morbid obese patients

J P Mulier MD PhDJ P Mulier MD PhD

Sint Jan Brugge-OostendeSint Jan Brugge-OostendeBariatric center of ExcellenceBariatric center of Excellence

www.publicationslist.org/jan.mulier www.publicationslist.org/jan.mulier

1150 1850 1947 1977 2010

EMCOP airway management

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Is mask ventilation safe in morbid Is mask ventilation safe in morbid obese patients?obese patients?

Intra abdominal pressure correlates with Intra abdominal pressure correlates with BMIBMI J P Mulier EJA 2009J P Mulier EJA 2009

Abnormal reflux scores correlates with BMIAbnormal reflux scores correlates with BMI Fisher B. Fisher B. Dig Dis Sci. 1999Dig Dis Sci. 1999

During abdominal compression, the rate of During abdominal compression, the rate of LES pressure increase is faster than that of LES pressure increase is faster than that of the gastric pressure, suggesting an active the gastric pressure, suggesting an active contraction at the esophagogastric junction contraction at the esophagogastric junction R Mittal R Mittal Am J Physiol Gastrointest Liver Am J Physiol Gastrointest Liver

PhysiolPhysiol 1990 1990


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BMI effect on abdominal P/V BMI effect on abdominal P/V relationrelation

Effect of BMI on PV0

-4

-2

0

2

4

6

8

10

0 10 20 30 40 50 60

BMI

PV

0 in

mm

Hg

Effect of BMI on E

0

0,002

0,004

0,006

0,008

0,01

0,012

0 20 40 60

BMI

E in

mm

Hg

/l

J Mulier ISPUB 2009J Mulier ISPUB 2009 Pressure volume relation is linearPressure volume relation is linear PV0 and E define each patientPV0 and E define each patient

J Mulier IFSO 2007J Mulier IFSO 2007


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Is mask ventilation safe in morbid Is mask ventilation safe in morbid obese patients?obese patients?

A deLeon Body position and esophageal sphincter pressures in obese patients during anesthesia

Acta Anesth Scand 2010


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Mask ventilationMask ventilationRapid sequence induction?Rapid sequence induction?

Awake intubation?Awake intubation? Safe to ventilate by mask?Safe to ventilate by mask?

Yes <-> No …Never if Yes <-> No …Never if High intra abdominal pressures PV0 up 12High intra abdominal pressures PV0 up 12 But LES prevents regurgitation …But LES prevents regurgitation …

High mask pressures neededHigh mask pressures needed Volutrauma risk post intubationVolutrauma risk post intubation

CPAP by mask before inductionCPAP by mask before induction non-invasive CPAP: the SUPER-non-invasive CPAP: the SUPER-

Boussignac Boussignac


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Is Sellick maneuver Is Sellick maneuver usefull?usefull?

Displacement of esophagusDisplacement of esophagus Lowering of LES = less Lowering of LES = less

protection?protection?


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Original Sellick maneuverOriginal Sellick maneuver

Hypoharynx and not esophagus Hypoharynx and not esophagus is compressed!is compressed!


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Help position: head Help position: head elevated laryngoscopy elevated laryngoscopy

positionposition J. Brodsky: obese patients: difficult in mask ventilation J. Brodsky: obese patients: difficult in mask ventilation No difference in difficult intubation if properly No difference in difficult intubation if properly

positioned.positioned.Brodsky, J. B. et al. Anesth Analg 2003;96:1841-1842-a

J. Brodsky A morbidly obese patient will be in position for direct laryngoscopy when an imaginary horizontal line can be drawn from the sternal notch to the external auditory meatus


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Copyright restrictions apply.

Intubation is not difficult if…Intubation is not difficult if…difficult mask ventilation = difficult difficult mask ventilation = difficult

intubationintubation

Proper positioning (help)Proper positioning (help) normalizes normalizes the risk of difficult intubation. the risk of difficult intubation. ( Brodsky)( Brodsky)

Trachea pharyngeal alignment byTrachea pharyngeal alignment by Head pillowHead pillow Thorax elevationThorax elevation

Use of an Use of an inflatable pillow, safety bird inflatable pillow, safety bird is simple and effective to rotate is simple and effective to rotate thoracic column.thoracic column.

Video laryngoscopy must be availableVideo laryngoscopy must be available


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Video laryngoscopyVideo laryngoscopy


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intubationintubation


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Sterno mental distance without safety Sterno mental distance without safety birdbird

Sterno mental distance

Normal positionUse of inflatable pillow

•Mulier J.P., Dillemans B. Intubation time with and without inflatable intubation device Eur J Anesthesia 2007 Suppl


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Effect of safety birdEffect of safety bird Trachea – pharyngeal angleTrachea – pharyngeal angle

> 30°> 30° < 30°< 30°

No safety birdNo safety bird with safety with safety birdbird•Mulier J.P., Dillemans B. CT analysis of the safety bird in mobid obese patients

Obes Surg 2008 18:444


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IntubationIntubation

Prediction of difficult intubation Prediction of difficult intubation Not BMI or obesityNot BMI or obesity based on neck circumference > 50 cmbased on neck circumference > 50 cm

Good Positioning is importantGood Positioning is important Risk not higher if properly positionedRisk not higher if properly positioned Help position (J Brodsky)Help position (J Brodsky) Safety bird (JPMulier)Safety bird (JPMulier)

Awake Bronchoscopic intubation?Awake Bronchoscopic intubation? Not needed anymore?Not needed anymore?

Video laryngoscopy must be availableVideo laryngoscopy must be available


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Knowledge test among Anesthesiologist & Knowledge test among Anesthesiologist & IntensivistsIntensivists

Hyperinflation of the cuff can lead Hyperinflation of the cuff can lead to…to…

Courtesy S Blot et al. 2009


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Knowledge testKnowledge testCuff pressure is determined most accurately by Cuff pressure is determined most accurately by

means of...means of...



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Practice testPractice testCuff pressure is controlled byCuff pressure is controlled by


Finger palpationFinger palpation

Manometer control Manometer control every 8 hoursevery 8 hours

Continous Continous monitored and monitored and automatic adaptedautomatic adapted

Most often in Most often in anesthesiaanesthesia

Most often at Most often at intensive careintensive care

Minority of intensive Minority of intensive care unitscare units


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Microaspiration: also with Microaspiration: also with perfect cuff pressureperfect cuff pressure

Migration of supraglottic material past the Migration of supraglottic material past the ETT cuff into the respiratory tract.ETT cuff into the respiratory tract.

Pictured: inadvertent microaspiration of contrast media after a barium swallow examination in an intubated patient

Reproduced from Macrae et al. Br Med J. 1981 (Clin Res Ed);283:1220 with permission from BMJ Publishing Group Ltd.


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A A B CB C

Runs througwghRuns througwgh stop on top stop on top runs runs & stop& stop

In vitro testsIn vitro tests


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Taperguard is a good indication in Taperguard is a good indication in bariatric surgery to prevent silent bariatric surgery to prevent silent

aspirationaspiration

Bronchoscopic evaluation in morbid obese Bronchoscopic evaluation in morbid obese patients ventilated at > 5 cm H20 peeppatients ventilated at > 5 cm H20 peep

No leakNo leakH

i con

tour

M

allin

ckro

dt

Hi c

onto

ur

Mal

linck

rodt

w

ith K

Y g

el

Tap

erG

uard

M

allin

ckro

dt

19 9 3113 2 0

Bronchoscopic visualized methylene blue leak

0

5

10

15

20

25

30

35

Hi contourMallinckrodt

Hi contourMallinckrodt with KY

gel

TaperGuard Mallinckrodt

nu

mb

er o

f p

atie

nts leak

no leak


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SOS: ComplicationsSOS: Complicationsmeasured in 1164 surgery patientsmeasured in 1164 surgery patients

Postoperative complications: 13 %

pulmonary complications 6.1 % other complications 4.8

leakage, abscess 2.1wound complications 1.8thrombosis, embolism 0.8bleeding 0.5

Complications required reoperation in 2.2 % of the patients.

Reoperations and conversions over 10 years:

Banding 31 %VBG 21Gastric bypass 17

Sjostrom Sjostrom N Engl J Med 2007


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Per-operative silent Per-operative silent aspirationaspiration

Normal cuffs leak!Normal cuffs leak! Peep is not protectingPeep is not protecting

To do:To do: Gel, microcuff or taperguard cuffGel, microcuff or taperguard cuff

Gel not 100% protectionGel not 100% protection Cuff pressure monitoring and Cuff pressure monitoring and

stabilisation at 30 cmH20stabilisation at 30 cmH20 Subglottic suctioningSubglottic suctioning


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VentilationVentilation

Peep Peep never interrupt, keep minimum 5 cmH2Onever interrupt, keep minimum 5 cmH2O

PCV vs VCVPCV vs VCV PCV risk for volutraumaPCV risk for volutrauma No outcome differenceNo outcome difference

PCV only when high airway pressures?PCV only when high airway pressures? Only when low saturation?Only when low saturation?

Beach chair and abdominal modelBeach chair and abdominal model Improves total thoraco pulmonary Improves total thoraco pulmonary

compliancecompliance Permissive hypercapniaPermissive hypercapnia


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HypercapniaHypercapnia

Permissive hypercapnia?Permissive hypercapnia? et CO2 is higher in morbid obese patientset CO2 is higher in morbid obese patients

Increases cardiac outputIncreases cardiac output Less wound infectionsLess wound infections

Increases blood pressureIncreases blood pressure Prevent post operative bleedingPrevent post operative bleeding

Pressure support easier or needed?Pressure support easier or needed? Breathing against ventilator possibleBreathing against ventilator possible

Contra indication:Contra indication: pulmonary pulmonary hypertensionhypertension


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Can anesthesiology help to Can anesthesiology help to prevent post op bleeding? prevent post op bleeding?

YesYes

110/57 145/78110/57 145/78

J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin J.P.Mulier, B Dillemans, G Vandrogenbroek, F Akin The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric The effect of systolic arterial pressure on bleeding of the gastric stapling during laparoscopic gastric

bypass surgery. bypass surgery. Obes Surg 2007; 17: 1051 Obes Surg 2007; 17: 1051


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PSV is possible even with PSV is possible even with full muscle relaxationfull muscle relaxation

Diaphragm Diaphragm remains active, remains active, enough to trigger enough to trigger ventilator at 0,6 ventilator at 0,6 L/min sensitivityL/min sensitivity

Extra dose of Extra dose of Morfine stops PSV Morfine stops PSV indicating no auto indicating no auto trigger phenomentrigger phenomen

PSVPro during esmeron infusion

-5

0

5

10

15

20

25

time

0

20

40

60

80

100

120

EtCO2

NMT count

RR(CO2)

PTCount

SpO2

PROFOUND MUSCLE RELAXATION DOES NOT DISTURB PROFOUND MUSCLE RELAXATION DOES NOT DISTURB PRESSURE SUPPORT VENTILATION. PRESSURE SUPPORT VENTILATION.

Mulier J, Blacoe D PGA 2009Mulier J, Blacoe D PGA 2009


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PSV allows pain therapy PSV allows pain therapy optimalisationoptimalisation

Before Before after extra sufentanil after extra sufentanil bolusbolus


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Weaning with PSV Weaning with PSV

Stimulates own breathingStimulates own breathing Possible during muscle relaxationPossible during muscle relaxation Maximum morfine loading possibleMaximum morfine loading possible Continue peep and cpap in spont Continue peep and cpap in spont

breathingbreathing Never hypoventilation and hypoxiaNever hypoventilation and hypoxia

Allow rise in et CO2, Allow rise in et CO2, less muscle relaxation needed at the end less muscle relaxation needed at the end Not breathing against ventilatorNot breathing against ventilator Not disturbing laparoscopic workspace and Not disturbing laparoscopic workspace and

viewview


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Post op gastric tube aspiration testPost op gastric tube aspiration test

Empty stomach pouch to prevent Empty stomach pouch to prevent aspirationaspiration

Treat if new red blood is detectedTreat if new red blood is detected


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ExtubationExtubation

Aspiration before extubation is Aspiration before extubation is importantimportant Oral cavityOral cavity

Prevent post extub aspirationPrevent post extub aspiration Gastric pouchGastric pouch

Detect intraluminal bleedingDetect intraluminal bleeding Prevent nausea, vomitingPrevent nausea, vomiting

Supra glottisSupra glottis Ctu ? Prevent silent aspirationCtu ? Prevent silent aspiration

Extubation during aspiration risk of Extubation during aspiration risk of atelectasisatelectasis better under positive airway pressurebetter under positive airway pressure


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OSA OHSOSA OHS

OSA obstructive sleep apneaOSA obstructive sleep apnea OHS obesity hypoventilation OHS obesity hypoventilation

syndromesyndrome

See lecture tomorrowSee lecture tomorrow


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President President

Jan P MulierJan P Mulier

Vice-President Vice-President

Yigal LeykinYigal Leykin

Secretary Secretary

Luc De baerdemaekerLuc De baerdemaekerTreasurer Treasurer

Nick KennedyNick Kennedy

www.publicationslsit.org/www.publicationslsit.org/ESPCOPESPCOP

www.espcop.org

Become member ESPCOP Become member ESPCOP

http://www.espcop.org/


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Second Second ESPCOP ESPCOP Scientific Scientific meeting meeting

MultidisciplinarMultidisciplinarityity

Pordenone, Pordenone, Italy 18 sept Italy 18 sept

20102010

EMCOP airway management1 Airway management in morbid obese patients J P Mulier MD PhD Sint Jan...

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