PR Series 2 Slide Handouts 4.21.14

Course Materials

Professor’s Rounds 2014 Program 2 - PR20142 Approved for 1 contact hour of CRCE® credit per participant who successfully completes the test.

Management of the

Difficult Airway

© 2015 American Association for Respiratory Care

OVERVIEW

Management of the Difficult Airway AARC Professor’s Rounds 2014 – Program 2

Description

Various conditions can pose significant challenges in establishing a patent airway. This presentation will discuss these conditions, identify strategies to compensate for the challenges presented, and various adjuncts that are useful in establishing an effective airway in emergent situations.

Objectives

Learn to identify: Discuss basic approaches to endotracheal intubation. Examine advantages and disadvantages of using a laryngeal mask airway. Discuss the strengths and weaknesses of video laryngoscopy. Examine the role of airway adjuncts (stylets) in the management of the difficult airway.

Presenters

Professor William Hurford, MD, FCCM Professor and Chair, Department of Anesthesiology University of Cincinnati Cincinnati, OH

Moderator Douglas Laher, MBA, RRT, FAARC Associate Executive Director American Association for Respiratory Care Irving, TX

CRCE® Credit To earn 1 CRCE credit for participating in today’s program: • View entire presentation • Take the 10-question test (available from Proctor/Site Coordinator) • Answer at least 7 questions correctly • Enter your name and AARC member number on the Attendance and CRCE Log (Please do not enter your Social Security Number) • Receive Certificate of Completion from the Proctor/Site Coordinator

PROGRAM SLIDES and NOTES

Slide 1

Slide 2

Objectives 1. Discuss basic approaches to

endotracheal intubation

2. Examine advantages and disadvantages of using a laryngeal mask airway

Objectives 3. Discuss the strengths and

weaknesses of video laryngoscopy.

4. Examine the role of airway adjuncts (stylets) in the management of the difficult airway.

Slide 4

Slide 5

Common Problems Limited ability to examine the airway

Limited equipment and positioning

Limited “back-up”

Common Problems Inadequate; difficult pre-oxygenation • Non-invasive ventilation may be

useful

Presence of co-existing; life threatening conditions

Endotracheal Intubation Outside the OR

27 % had > 1 complication; n = 150

76% success rate on 1st attempt; 91% on second

Benedetto WJ et al., J Clin Anes 2007;19:20-24

Slide 7

Slide 8

impactednurse.com/pics3/big_airway.jpg

Evaluation Mouth opening

Mallampati score

Evaluation Head and neck

exam

www.ispub.com/.../nasal-fig2.jpg

Evaluation Tracheal

abnormalities

Courtesy Dr. Yash Patil

Slide 10

Slide 11

Evaluation Tracheal

abnormalities

Courtesy Dr. Yash Patil

Orotracheal Intubation Preparation

Be calm

• Bring your equipment

• Review the patient's history

• Position the patient

Orotracheal Intubation Preparation

Check for suction

Oxygen, oxygen, oxygen

Airway supplies

Pharmacy-IV access and drugs

Position

Slide 13

Slide 14

Positioning for Laryngoscopy Supine:

Pharyngeal and laryngeal axes not aligned

Sniffing: Head elevated neck extended

Positioning Controversies Patient on the floor • Left lateral decubitus

- Adnet F et al. '97,'98

Cervical Spine Injury • Most cervical displacement with mask

- Hauswald et al. '91 (fresh cadavers)

- Suderman et al. '91 Clinical series

Points to Consider Blade Selection Interventions to

improve the view: • Position • Cricoid/thyroid

pressure and tilt • Stylets

Slide 16

Slide 17

Anesthesia and Sedation for Endotracheal Intubation

1. Nothing at all

2. Awake intubation with topical anesthetic

3. Procedural sedation

4. General anesthesia with or without neuromuscular blockade

Awake Intubation Oxygenate

Explain calmly; proceed deliberately

Topical anesthetic spray (Lidocaine)

Superior laryngeal or recurrent laryngeal nerve blocks not recommended routinely

Intravenous Sedation Oxygenate

Combine with topical anesthesia

Gradually titrate midazolam / fentanyl

Use propofol, etomidate, dexmedetomidine if skilled and airway adequate

Slide 19

Slide 20

Anesthesia and Neuromuscular Blockade

Paralysis converts a spontaneously breathing patient into an apneic patient

Severe hypoxemia will occur before the succinylcholine is gone

Ability to gain surgical access to the airway must be present

Neuromuscular Blockers

Higher success rates during RSI

Lower rate of complications

Not just for the OR anymore?

RSI vs. Etomidate-Only Intubation in Air Medical Setting

Prospective crossover trial (n=49 pts ) of etomidate vs. succinylcholine

Acceptable conditions in 79% of RSI pts and 13% without paralysis

92% of RSI pts vs 25% of pts were successfully intubated

Boseman WP et al. Prehosp Emerg Care 2006; 10:8-13

Slide 22

Slide 23

Succinylcholine Succinylcholine provides

better intubating conditions than rocuronium under emergent conditions

Rocuronium vs. Succinylcholine for RSI

Sux superior to roc for intubating conditions

Succinylcholine should still be used as a first line

Rocuronium can be used but should only be used as a second line treatment

Perry JJ et al. Cochrane Database Syst Rev 2008; 16(2):CD002788

Nasotracheal Intubation Alternative to Tracheostomy

Intraoral pathology; intraoral maxillary fixation

Poor mouth opening

Difficult or impossible visualization with direct and/or fiberoptic laryngoscopy

Slide 25

Slide 26

Nasotracheal Intubation Longer time to intubate

• Airway uncontrolled

• Increased hypoxia possible

Nosebleeds can be disastrous • coagulopathies

• anticoagulants

• thrombolytics

Verification of Intubation: End-tidal Carbon Dioxide

A fool's gold standard? Not present if:

• pulmonary circulation absent - dead, poor CPR, massive PE

Present with esophageal intubation: • insufflated air, carbonated beverages • 0.2 - 2% CO2 in 33 - 45% of esophageal

intubations (Linko '83;Sum-Ping '89)

Supraglottic Airways

www.i-gel.com

www.indemed.com

www.kingsystems.com

Slide 28

Slide 29

LMA and the Difficult Airway Primary airway adjunct when mask ventilation is

difficult or impossible (case reports) Provide routine airway management with

anticipated difficult intubation • LMA placement successful in 29 of 30 pts with

known abnormal airways - Langenstein H. Anaesthetist 44:712, 1995

Aid to endotracheal intubation

Difficult Airways Managed with the LMA

Ankylosing spondylitis

Facial burns

Failed obstetric intubation

Limited mouth opening

Hemifacial microsomia

Percutaneous tracheostomy

Rhematoid arthritis

Obesity

Neck contractures

Motor vehicle accident

Multiple difficult intubations

Unstable neck

Cervical halo

Sitting and prone position

Comparison of Placement of LMA with ETT by Paramedics and Respiratory Therapists

Mean time to successful ventilation: • ETT 206 sec • LMA 39 sec (P < 0.001)

Failed placement (> 3 attempts) • ETT 10/19 (53%) • LMA 0 (P < 0.01)

Reinhart DJ and Simmons G. Ann Emerg Med 24:260, 1994

Slide 31

Slide 32

LMA as an Aid to Intubation Blind Insertion

• 6.0 ETT max (#3 & 4); 7.0 (#5) • Length of ETT and removal of

LMA are issues

LMA as an Aid to Intubation Intubating LMA (Fastrach):

success rate 70 - 98%

LMA as an Aid to Intubation Fiberoptic Placement

• Higher rate of success • Passage of fiberscope and ETT may be

difficult

Slide 34

Slide 35

The LMA and the ASA Algorithm

Combat Trauma Airway Management: Endotracheal Intubation vs. LMA vs. Combitube Use by Navy SEAL and

Reconnaissance Combat Corpsmen

12 Special Operations corpsmen evaluated in use of each device (randomized) during “live fire” combat conditions

Criterion was establishment of reliable airway within 40 sec

No failures occurred

Calkins MD & Robinson TD, J Trauma 46:927, 1999

Combat Trauma Airway Management: Endotracheal Intubation vs. LMA vs. Combitube Use by Navy SEAL and

Reconnaissance Combat Corpsmen

Mean time to insertion:

• ETT 36.5 sec

• Combi 40 sec

• LMA 22.3 sec (P < 0.05)

ETT considered preferable

Calkins MD & Robinson TD, J Trauma 46:927, 1999

Slide 37

Slide 38

Video Laryngoscopy

Kaplan MB, jepm.org

Many Products – More on the Way

Glidescope

McGrath

Stortz DCI

Bonfils

Wu

Bullard

Res-Q-Scope

Coopdech C-scope VLP-100

Stortz C-Mac

Pentax AWS

RIFL

AirTraq

Dozens more…

Types Stylets

Guide channels

Modified laryngoscope blade

Slide 40

Slide 41

Bonfils Stylet Retromolar oral insertion

technique – useful when mouth opening is limited

Fixed 40° distal angle

Camera adaptor

Continuous oxygen via tube adapter

https://www.karlstorz.com/

Guide Channel Laryngoscopes

Bullard

Wu

Res-Q-Scope

AirTraq

Pentax AWS

Pentax AWS Fits standard ET

tubes size 6.5 mm and larger

Powered by two lithium CR-123 batteries

135° tip www.ambuusa.com

Slide 43

Slide 44

Pentax AWS Fits standard ET

tubes size 6.5 mm and larger

Powered by two lithium CR-123 batteries

135° tip www.ambuusa.com

Macintosh Modifications Coopdech VLP-100

McGrath

Storz DCI

Storz C-Mac

GlideScope

Many others

GlideScope

Slide 46

Slide 47

C-Mac Video Laryngoscope

https://www.karlstorz.com/

McGrath

Comparison of Direct and Video-assisted Views of the Larynx During Predicted Difficult Intubation

112 patients with predicted difficult intubation received direct laryngoscopy followed by GlideScope

% of Grade I and II views increased from 63 to 90%

Intubation successful in 98% of cases

Stroumpoulis K et al. Eur J Anaesthesiol 2009; 26:218-22

Slide 49

Slide 50

DL vs. GlideScope in Untrained Personnel

20 volunteers attempted 5 intubations with either technique in pts scheduled for surgery

DL used in 217 (78%); GlideScope in 63 (22%) – not randomized

Overall success rate • GlideScope: 93% • Direct: 51% (P < 0.01)

Time to intubation • GlideScope: 63 + 30 sec • Direct: 89 + 35 sec (P < 0.01)

Nouruzi-Sedeh P et al. Anesthesiology 2009:110:32-7

Summary Supraglottic airways, such as the

LMA, are easy and safe alternatives

Video laryngoscopy is the best first alternative to direct laryngoscopy

Summary Sedation makes intubation easier;

neuromuscular blockade even better (if mask ventilation is possible)

Succinylcholine is preferred, but rocuronium is acceptable, for neuromuscular blockade

Slide 52

Other CRCE® Credit Opportunities with AARC

The AARC offers a variety of other programs for CRCE Credit. Visit these sites for details.

More Professor’s Rounds topics www.aarc.org/education/professors_rounds/

Meetings www.aarc.org/education/meetings/

Webcasts www.aarc.org/education/webcast_central/

Online courses www.aarc.org/education/aarc_crce/

Benefit for AARC Members!

Webcasts and many of the online courses are free for AARC Members.

Four Axioms for Endotracheal Intubation

1. Expect the intubation to be difficult until proven otherwise

2. A patient may not tolerate even short periods of apnea or hypoxia

Four Axioms for Endotracheal Intubation

3. A patient in extremis requires much less (if any) anesthesia

4. A patient who breathes is better than one that does not

TEST


Mark the Corresponding Box for your Response to each Question

7 Correct Out of 10 is Passing Name: __________________ _____________________ AARC Mbr #: _______________ (first) (last) Email Address:___________________________________ Date: _____________________ (required for nonmembers) 1. Approximately 1/3 of emergent endotracheal intubations outside the operating room are

complicated or difficult. True False

2. Ventilation with a laryngeal mask airway is often more difficult than using a traditional face mask

for inexperienced personnel. True False

3. Endotracheal intubation may be accomplished through an LMA. True False 4. LMAs may be used to manage some airways that cannot be intubated with a traditional

endotracheal tube. True False

5. The LMA is an integral part of the American Society of Anesthesiologists difficult airway algorithm.

True False 6. Video laryngoscopes offer a similar field of view to traditional direct laryngoscopy.

True False 7. Stylet laryngoscopes may be useful when a patient’s mouth opening is limited.

True False 8. Guide channel video laryngoscopes may be effective when direct laryngoscopy is difficult.

True False 9. Video laryngoscopes are not very portable and their use is limited to the operating room.

True False 10. The success rates of endotracheal intubation with the Glidescope is similar to direct laryngoscopy

when intubation is predicted to be difficult. True False

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PR Series 2 Slide Handouts 4.21.14

Documents

Transcript of PR Series 2 Slide Handouts 4.21.14