Difficult Airway. Predicting Difficult Mask Ventilation

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1 Predicting Difficult Mask Ventilation Difficult mask ventilation can be a serious threat to a patient if difficult intubation occurs, and the patient cannot be properly ventilated by mask Five factors were found to be independently associated with difficult mask ventilation o Age > 55 o BMI > 26 o Lack of teeth o Presence of beard o History of snoring Patient with active airway obstruction (tumor, abscess, laryngeal edema) will also likely be difficult to ventilate Presence of two of these factors is 72% Sensitive and 73% Specific for difficult mask ventilation Predicting Difficult Intubation History of difficult intubation is the most important risk factor Mallampati class o Patients head in neutral position, mouth opened maximally, tongue protruded without phonation o Can predict ability to have full laryngoscopic view of the airway o Class I = % Grade 1 view, Class IV = % Grade 3-4 view Cormack and Lehane grades of laryngoscopic view

2 Atlanto-occipital extension (facilitates visualization of the cords, less than 35 degrees may be predictive of difficult intubation Thyromental distance less than 6 to 7 cm o Straight distance from the thyroid notch to the chin with the patients head fully extended and their mouth closed o Can be estimated as 3 normal fingerbreadths Interincisor Gap less than 3 cm o Can be estimated as 2 fingerbreadths Mandibular Protrusion o A = can protrude lower incisors anterior to upper incisors o B = can touch upper incisors with lower incisors o C = cannot touch incisors together Prominent or long incisors High arched palate or long narrow palate ASA suggestions for contents of portable difficult airway management cart 1. Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic laryngoscope 2. Tracheal tubes of assorted sizes 3. Tracheal tube guides. Examples include (but are not limited to) semirigid stylets, ventilating tube changer, light wands, and forceps designed to manipulate the distal portion of the tracheal tube 4. Laryngeal mask airways of assorted sizes; this may include the intubating laryngeal mask airway and the LMA-Proseal (LMA North America, Inc., San Diego, CA) 5. Flexible fiberoptic intubation equipment 6. Retrograde intubation equipment 7. At least one device suitable for emergency noninvasive airway ventilation. Examples include (but are not limited to) an esophageal tracheal Combitube (Kendall-Sheridan Catheter Corp., Argyle, NY), a hollow jet ventilation stylet, and a transtracheal jet ventilator 8. Equipment suitable for emergency invasive airway access (e.g., cricothyrotomy) 9. An exhaled CO2 detector

3 If a difficult airway is known or suspected, the anesthesiologist should 1. Inform the patient (or responsible person) of the special risks and procedures pertaining to management of the difficult airway. 2. Ascertain that there is at least one additional individual who is immediately available to serve as an assistant in difficult airway management. 3. Administer face mask preoxygenation before initiating management of the difficult airway. The uncooperative or pediatric patient may impede opportunities for preoxygenation. 4. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management. Opportunities for supplemental oxygen administration include (but are not limited to) oxygen delivery by nasal cannulae, face mask, laryngeal mask airway (LMA), insufflation, or jet ventilation during intubation attempts; and oxygen delivery by face mask, blow-by, or nasal cannulae after extubation of the trachea. Techniques for Difficult Airway Management Techniques for Difficult Intubation Alternative laryngoscope blades Awake intubation Blind intubation (oral or nasal) Fiberoptic intubation Intubating stylet or tube changer Laryngeal mask airway as an intubating conduit Light wand Retrograde intubation Invasive airway access Techniques for Difficult Ventilation Esophageal tracheal Combitube Intratracheal jet stylet Laryngeal mask airway Oral and nasopharyngeal airways Rigid ventilating bronchoscope Invasive airway access Transtracheal jet ventilation Two-person mask ventilation This table displays commonly cited techniques. It is not a comprehensive list. The order of presentation is alphabetical and does not imply preference for a given technique or sequence of use. Combinations of techniques may be employed. The techniques chosen by the practitioner in a particular case will depend upon specific needs, preferences, skills, and clinical constraints. Extubation of patients with difficult airways Recommendations. The anesthesiologist should have a preformulated strategy for extubation of the difficult airway. This strategy will depend, in part, on the surgery, the condition of the patient, and the skills and preferences of the anesthesiologist.

4 The preformulated extubation strategy should include 1. A consideration of the relative merits of awake extubation versus extubation before the return of consciousness. 2. An evaluation for general clinical factors that may produce an adverse impact on ventilation after the patient has been extubated. 3. The formulation of an airway management plan that can be implemented if the patient is not able to maintain adequate ventilation after extubation. 4. A consideration of the short-term use of a device that can serve as a guide for expedited reintubation. This type of device is usually inserted through the lumen of the tracheal tube and into the trachea before the tracheal tube is removed. The device may be rigid to facilitate intubation and/or hollow to facilitate ventilation. Follow up care for patients with difficult airways Recommendations. The anesthesiologist should document the presence and nature of the airway difficulty in the medical record. The intent of this documentation is to guide and facilitate the delivery of future care. Aspects of documentation that may prove helpful include (but are not limited to) 1. A description of the airway difficulties that were encountered. The description should distinguish between difficulties encountered in face mask or LMA ventilation and difficulties encountered in tracheal intubation. 2. A description of the various airway management techniques that were employed. The description should indicate the extent to which each of the techniques served a beneficial or detrimental role in management of the difficult airway. Selected Pathologic States That Influence Airway Management Pathologic State Infectious epiglottis Abscess (submandibular, retropharyngeal, Ludwig s angina) Croup, bronchitis, pneumonia (current or recent) Difficulty Laryngoscopy may worsen obstruction. Distortion of airway renders mask ventilation or intubation extremely difficult. Airway irritability with tendency for cough, laryngospasm, bronchospasm

5 Pathologic State Papillomatosis Tetanus Traumatic foreign body Cervical spine injury Basilar skull fracture Maxillary/mandibular injury Laryngeal fracture Laryngeal edema (postintubation) Soft tissue, neck injury (edema, bleeding, emphysema) Neoplastic upper airway tumors (pharynx, larynx) Lower airway tumors (trachea, bronchi, mediastinum) Radiation therapy Inflammatory rheumatoid arthritis Ankylosing spondylitis Difficulty Airway obstruction Trismus renders oral intubation impossible Airway obstruction Neck manipulation may traumatize spinal cord Basal intubation attempts may result in intracranial tube placement Airway obstruction, difficult mask ventilation, and intubation; cricothyroidotomy may be necessary with combined injuries Airway obstruction may worsen during instrumentation. Endotracheal tube may be misplaced outside larynx and mayworsen the injury Irritable airway, narrowed laryngeal inlet Anatomic obstruction of airway Airway obstruction Inspiratory obstruction with spontaneous ventilation Airway obstruction may not be relieved by tracheal intubation. Lower airway distorted Fibrosis may distort airway or make manipulations difficult Mandibular hypoplasia, temporomandibular joint arthritis, immobile cervical spine, laryngeal rotation, cricoarytenoid arthritis all make intubation difficult and hazardous Fusion of cervical spine may render direct laryngoscopy impossible Temporomandibular joint syndrome Severe impairment of mouth opening o True ankylosis o False ankylosis (burn, trauma, radiation, temporal craniotomy) Scleroderma Tight skin and temporomandibular joint involvement make mouth opening difficult

6 Pathologic State Sarcoidosis Angioedema Endocrine/metabolic acromegaly Diabetes mellitus Hypothyroidism Thyromegaly Obesity Difficulty Airway obstruction (lymphoid tissue) Obstructive swelling renders ventilation and intubation difficult Large tongue, bony overgrowths May have reduced mobility of atlanto-occipital Large tongue; abnormal soft tissue (myxedema) make ventilation and intubation difficult Goiter may produce extrinsic airway compression or deviation Upper airway obstruction with loss of consciousness Tissue mass makes successful mask ventilation unlikely Adapted from: Stone, DJ, Gai, TJ. Airway management. In Miller, R.D., ed. Anesthesia, vol. 2, New York: Churchill Livingstone: 1994; (4):1407. References: Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2003; 98(5): Laneron O, et al. Prediction of difficult mask ventilation Anesthesiology 2000; 92: Mallampati SR, et al. A clinical sign to predict difficult tracheal intubation: A prospective study. Canadian Anesthetists Society Journal. 1985; 32: Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: Stone, DJ, Gai, TJ. Airway management. In Miller, R.D., ed. Anesthesia, vol. 2, New York: Churchill Livingstone: 1994; (4):1407

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