DIFFICULT AIRWAYDIFFICULT AIRWAYASSESSMENT ANDASSESSMENT AND

MANAGEMENTMANAGEMENTBYBY

DR AZHARDR AZHAR

DEFFINATIONDEFFINATION

American society of Anesthesiologist (ASA) American society of Anesthesiologist (ASA) suggested that when sign of inadequate suggested that when sign of inadequate

ventilation could not be reversed by mask ventilation could not be reversed by mask ventilation or oxygen saturation could not be ventilation or oxygen saturation could not be

maintained above 90% ormaintained above 90% or if a trained Anaesthetist usinig conventional if a trained Anaesthetist usinig conventional

larangoscope take’s more than 3 attempts or larangoscope take’s more than 3 attempts or more than 10 minute are required to complete more than 10 minute are required to complete

tracheal intubation tracheal intubation

Anatomy of oropharynex and larynxAnatomy of oropharynex and larynx

PREVALENCEPREVALENCE

Fact of the matter is even with proper evaluation Fact of the matter is even with proper evaluation only 15 to 50 % were picked up while only 15 to 50 % were picked up while

difficult face mask ventilation in general is difficult face mask ventilation in general is about 1:10,000 out of which again 15% proved about 1:10,000 out of which again 15% proved to be the difficult intubation ,while incidence to be the difficult intubation ,while incidence of extreme difficult or abandons intubation in of extreme difficult or abandons intubation in

general surgery patients are 1:2000 but in general surgery patients are 1:2000 but in obstetrics is 1:300 and of course most critical obstetrics is 1:300 and of course most critical

incidence is Hypoxiaincidence is Hypoxia

BASIC AIRWAY EVALUATIONBASIC AIRWAY EVALUATION

1.1. Previous anaesthetic problems and general Previous anaesthetic problems and general appearance of the patient. appearance of the patient.

2.2. Neck, face, maxilla and mandible with jaw Neck, face, maxilla and mandible with jaw movements.movements.

3.3. Head extension and movements, teeth, Head extension and movements, teeth, oropharanx and soft tissue of the neck .oropharanx and soft tissue of the neck .

Why does it happens ?Why does it happens ?

1.1. Exaggerated idea of personal ability.Exaggerated idea of personal ability.2.2. Not requesting for experienced help.Not requesting for experienced help.3.3. No discussion with colleagues about proposed No discussion with colleagues about proposed

management of the case .management of the case .4.4. Ill conceived plan (A) with no proper back up Ill conceived plan (A) with no proper back up

plan (B).plan (B).5.5. Even poorly conducted plan (A) or sticking Even poorly conducted plan (A) or sticking

extra time to the plan (A) other way delaying extra time to the plan (A) other way delaying the rescue plan late.the rescue plan late.

6.6. Last not the least not involving surgical Last not the least not involving surgical friends. friends.

CAUSES OF CAUSES OF DIFFICULT INTUBATIONDIFFICULT INTUBATION

Anaesthetist Anaesthetist 1.1. Inadequate preoperative assessment.Inadequate preoperative assessment.2.2. Inadequate equipments. Inadequate equipments. 3.3. Experience not enough.Experience not enough.4.4. Poor technique.Poor technique.5.5. Malfunctioning of equipment.Malfunctioning of equipment.6.6. Inexperience assistananceInexperience assistanance

Patient Patient

1.1. Congenital causes Congenital causes 2.2. Acquired causes Acquired causes

Anatomical factors affecting Anatomical factors affecting LarangoscopyLarangoscopy

1.1. Short Neck.Short Neck.2.2. Protruding incisor teeth.Protruding incisor teeth.3.3. Long high arched palate.Long high arched palate.4.4. Poor mobility of neck.Poor mobility of neck.5.5. Increase in either anterior depth or Posterior Increase in either anterior depth or Posterior

depth of the mandible decrease in Atlanto depth of the mandible decrease in Atlanto Occipital distance that's why role of Occipital distance that's why role of Radiology has increased in our specialty Radiology has increased in our specialty

ASSESSMENT OF AIRWAYASSESSMENT OF AIRWAY

Mallampati classification with Mallampati classification with larangoscopic view. larangoscopic view. Patil’s Test

Measurement of Measurement of Atlanto-Occepital AngleAtlanto-Occepital Angle

MANAGEMENT PLAN OF MANAGEMENT PLAN OF ANTICEPATED DIFFICULT ANTICEPATED DIFFICULT

AIRWAYAIRWAY1.1. Discussion with colleagues in advance.Discussion with colleagues in advance.

2.2. Equipment tested before.Equipment tested before.

3.3. Senior help backup.Senior help backup.

4.4. Definite initial plan (A) for ventilation and Definite initial plan (A) for ventilation and intubation.intubation.

5.5. Definite plan (B) than option of awake Definite plan (B) than option of awake intubation.intubation.

6.6. Ideal situation surgery team standby.Ideal situation surgery team standby.

UNEXPECTED DIFFICULT AIRWAY UNEXPECTED DIFFICULT AIRWAY ProblemsProblems

1.1. Unexpected encounter with difficult airway is mostly gone worse Unexpected encounter with difficult airway is mostly gone worse because mainly GA is already given including (NMB,S).because mainly GA is already given including (NMB,S).

2.2. Equipment may not be in hand.Equipment may not be in hand.3.3. Senior and back up plan not available so delay occur in active Senior and back up plan not available so delay occur in active

resuscitationresuscitation

TECHNIQUE OF MANAGEMENTTECHNIQUE OF MANAGEMENT

1.1. Manipulation of the patients airway.Manipulation of the patients airway.2.2. Laryngeal pressure.Laryngeal pressure.3.3. Nasal or oral airway.Nasal or oral airway.4.4. Different blades of larangoscope like Miller, Magill, Robershaw , Mackintosh and Different blades of larangoscope like Miller, Magill, Robershaw , Mackintosh and

relatively new laryngoscope McCoy. relatively new laryngoscope McCoy. 5.5. Bougies and stylet Bougies and stylet 6.6. LMA. LMA. 7.7. Combitube.Combitube.

1alternative

1alternative

2alternative

2alternative

3alternative

3alternative

4 alternative

4 alternative

1Manipulation of airway

different blade, bugie

2LMA, ILMA, Combitube

3Trantracheal Jet Ventilation

4Cricothireotomy, Tracheostomy

GALLERY OF TOOLSGALLERY OF TOOLS

GALLERY OF TOOLSGALLERY OF TOOLS

Bullard laryngoscope Fiber Bullard laryngoscope Fiber opticoptic

Mini TracheostomyMini Tracheostomy

Mini Tracheostomy (Cont.)Mini Tracheostomy (Cont.)

BLIND NASAL,BLIND NASAL,RETROGRADERETROGRADE

AND HIGH FREQUENCY VENTILATION AND HIGH FREQUENCY VENTILATION

Awake IntubationAwake Intubation

ASA ALLOGORYTHAMASA ALLOGORYTHAM

ASA ALLGORYTHAMASA ALLGORYTHAM

C-SPINE OAC-SPINE OA

THANK YOU THANK YOU VERY MUCHVERY MUCH FOR YOUR FOR YOUR ATTENTIONATTENTION