Difficult Airway Management

Dr. Adel Hammodi ,MRCP (UK)

M.Sc. Anesthesia (Alex. EGY)
Assistant Consultant A-ICU
Flexible endoscopic intubation
Video laryngoscopy
Cricothyrotomy
Introduction
30% percent were rated as easy,
47% as moderately difficult and
23% as difficult.

Every intubation in the ICU setting should be considered
potentially difficult.
A training program for alternative methods of airway
management for difficult intubations should be established.


Incidence of difficult intubation in intensive care patients: analysis
of contributing factors. Anaesth. Intensive Care. 2012
Mar;40(2):351
Flexible endoscopic intubation
Design / parts
Flexible fibreoptic parts.
A. Insertion tube Flexible part extending from control section to distal
tip of scope.
B .Control section Contain the tip control knob which
controls movement of insertion tube.
C. Eye piece section.
D. Light transmission cord from external light source to hand of fiberscope.
E. Light source
Flexible endoscopic intubation
Indications
Anticipated difficult intubation (upper airway abnormality).
Endotracheal intubation when neck extension is not desirable
(cervical spine injury, rheumatoid arthritis.
Advantages
Excellent airway visualization.
Minimal hemodynamic stress.
Gold standard for anticipated difficult intubation any age,
any position.
Requires good experience.
Technique

Oral route preferable
Topical anesthesia with 2% lidocaine on a base of
the tongue, hypopharynx and vocal cords
(aerosolized 10% lidocaine may also be used)
Sedation with midazolam (adult dose 1 to 2.5 mg
IV) and fentanyl (adult dose 25-100 mcg IV)
"Jaw thrust" maneuver improve visualization
Technique
Apply oral airway or "bite block" to protect the equipment.
Apply 100% oxygen via face mask (oxygen may also be
delivered via bronchoscope channel)
After the bronchoscope is lubricated and loaded with an
endotracheal tube it is introduced strictly in the midline
following the base of the tongue, pass the uvula, behind the
epiglottis and between the vocal cords. (see video on the left
below).
Once the main carina is visualized endotracheal tube is
introduced by rotating movement over the bronchoscope.
Proper position (3-5 cm above the carina) is evaluated and
the tube secured.
Technique

Most anesthesiologists
prefer to stand at the
head of the patient, as
they do for direct
laryngoscopy.

The advantage of this
position is that
anatomical structures are
visualized as accustomed
Technique
Fiberoptic bronchoscopy requires a clear visual
pathway. Blood and secretions prevent visualization of
the laryngeal structures.
Administration of an antisialogogue prior to the start
of the procedure is therefore essential (0.2 mg of
glycopyrrolate).
Repeated airway manipulation causes edema and
bleeding, both of which impair visualization through
the bronchoscope.
The possibility of a fiberoptic technique should
therefore be kept in mind, and employed before
blood and secretions have rendered this technique
unusable.

Contraindications
Inability to oxygenate
Major bleeding.
Disadvantages
Costs associated with the need for special equipment
and skill.
Complications
Oxygen desaturation.
Bronchospasm (inadequate local anesthesia).
Trauma (especially lower airway).

Video laryngoscopy
Advantages
Improved laryngeal Less force used than during direct laryngoscopy
Less cervical spine movement
Short learning curve
Improved portability and cost compared to flexible fiber optic laryngoscopes
Useful teaching tools
Generally higher success rate, especially in difficult situations.
Disadvantages
Passage of the ETT may be difficult despite good view or higher POGO score;
often stylet is needed
Fogging and secretion may obscure the view.
Loss of depth perception.
No single videoscope is ideal.
Video laryngoscopy
Video Laryngoscopes Glidescope
Rigid laryngoscope with CCD
View is very clear with no fogging
Blade angle 50-60 deg
1.The operator should always begin in
the midline of the mouth,
following the uvula as the GlideScope
enters.
If the blade is turned sideways for a
small mouth opening or large chest,
re-orient to the midline.
2.Obtain the best view possible by
withdrawing the blade in the vallecula
to reveal the epiglottis, vocal cords and
arytenoid cartilages.

Glidescope in Use
technique
Glidescope with Disposable Blade
McGrath Videolaryngoscope
Similar to Glidescope
Disposable blade cover
Optics not be as good
Narrow field of vision
More portable
More likely to disappear

Video Laryngoscopes RES-Q-SCOPE
LCD Screen
Disposable blade
Much cheaper
Airtraq

The Future
The future of intubation will be video assisted
In the past,
intubators intubated
in the dark by
themselves



PRIVATE
The future will have
everybody involved
in the process of
intubation
(ER Doc, Nurses, RT)


PARTY!

Video Laryngoscope Uses:


First intubation attempt (Oral or Nasal)
Known difficult DL (Awake or RSI)
Unanticipated unsuccessful DL
Confirmation of function of recurrent laryngeal
nerve
Placement of NGT, ETT, or ECHO probe
Ancillary Departments: ER, ICU, Pediatrics, NICU,
Telemedicine, Air Medical, and Academics
Adjunct with tracheotomy

Miscellaneous Applications of Video Laryngoscopy
Passage of nasogastric, orogastric, or enteral feeding tubes
Advancement of dilating bougie for esophageal procedures
Passage of a transesophageal echocardiography probe
Placement of upper gastrointestinal endoscopy equipment
Foreign body extraction (eg bridgework, tooth, crown, filling)
Evaluation of the oral cavity, oro- and hypopharyngeal
structures for trauma,
infections, healing
Visualize laryngeal function


Hirabayashi Y. GlideScope-assisted insertion of a transesophageal echocardiography
probe. J Cardiothorac Vasc Anesth. 2007;21(4):628.
Lai HY, Wang PK, Yang YL, Lai J, Chen TY. Facilitated insertion of a nasogastric tube in
trachel intubated patients using the GlideScope.Br J Anaesth. 2006;97(5):749-750.
Cricothyrotomy
Quicktrach I
- Available for adults (I.D. 4mm
Quicktrach II with cuff
- Set with cuff
Thin cuff seals trachea and
allows efficient ventilation with
aspiration protection.
Stopper and safety clip reduce
the risk of posterior tracheal wall
injury.
Anatomically shaped cannula
adjusts to the trachea due to
memory effect. Available for
adults (I.D. 4mm)
minitrach
A single vertical incision 3-5 mm in length over cricothyroid
membrane is made and then through obturator the 4 mm
uncuffed tracheal tube is guided.
Compared with I.V. cannula the minitrach has larger diameter
and is better for jet ventilation and even for assisted
spontaneous respiration for a short period.
CRICOTHYROTOMY
Complications

1. Barotrauma.
2. Trauma.
3. Subcutaneous / mediastinal emphysema.
4. Tracheal stoma granulation.
5. Persistent stoma.
6. Tracheal stenosis.
7. Dysphonia.
8. Vocal cord paresis.
9. Wound infection.

Glidescope Success Rates with Experience
Joo et al
0
10
20
30
40
50
60
70
80
90
100
0 to 9 10 to 19 20 to 29 30 to 39 > 40
Success Rate