8/3/2016 Dr Abdollahi Afshar - PowerPoint Presentation

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8/3/2016

Dr

AbdollahiAfshar Hospital

Airway Assessment

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If

Endotracheal Intubation

fails, you must have a back-up plan

...8/3/2016

Combi-Tube

LMA

BVM

King-LTD

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Airway Assessment

History

Examination

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History

Previous difficulty

Medical conditions

RA

Ankylosing spondylitisCongenital problemsHead and neck tumoursPrevious surgery

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Purpose

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Review Airway Anatomy

Learn Advanced Airway Assessment Techniques 3-3-2

Laryngoscope View GradingMallampati ClassificationsBURP

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Airway Anatomy

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Airway Anatomy

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Airway Anatomy

Larynx

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Middle Airway

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Thyroid versus Cricoid Cartilage

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Thyroid cartilage used in “BURP” maneuver. Does not form a complete ring around the trachea.

Cricoid Cartilage used in Cricoid Pressure, does form a full ring around the trachea allowing for the compression of the esophagus.

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Some Predictors of a Difficult Airway

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C-spine immobilized trauma patient

Protruding tongueShort, thick neck

Prominent upper incisors (“buckteeth”)Receding mandibleHigh, arched palateBeard or facial hair

Dentures

Limited jaw opening

Limited cervical mobility

Upper airway conditions

Face, neck, or oral trauma

Laryngeal traumaAirway edema or obstruction

Morbidly obese 11

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Additional Predictors:

Medical History

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Joint disease Acromegaly

Thyroid or major neck surgeriesTumors, known abnormal structuresGenetic anomaliesEpiglottitis

Previous problems in surgery

Diabetes

Pregnancy

Obesity

Pain issues

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Objectives

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Predict a difficult airway using the following mnemonics:

MOANSLEMONS

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Airway Difficulties

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Difficult to ventilate with a BVM

Difficult to intubate14

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Triple Failure

Difficult

SGA

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Difficult Mask Ventilation

Difficult

Intubation

DANGER ZONE

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Difficult to Bag (MOANS)

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ask SealObesity or Obstruction

Age > 55No TeethStiff neck

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Mask Seal

Small Hands

Wrong Mask Size

Oddly Shaped FaceBushy BeardBlood/Vomit

Facial Trauma

MOANS

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Examination

Sometimes it’s pretty obvious…

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Examination

Obesity

Short thick neck

Neck movement

ScarsLarge breasts

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Examination

Jaw

Receding mandible

ProtrusionDentition

Loose teethProminent upper teethOverbiteDentures

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Examination

Beware the bearded man…

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Obesity or Obstruction

Obesity

Heavy chest

Abdominal contents inhibit movement of the diaphragmIncreased supraglottic airway resistance

Billowing cheeksDifficult mask sealQuicker desaturation

MOANS

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Obesity or Obstruction

3

rd

Trimester PregnancyIncreased body massQuick desaturationIncreased Mallampati Score

Gravid uterus inhibits movement of the diaphragm

MOANS

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Obesity or Obstruction

Obstructions

Foreign Body

AngioedemaAbscessesEpiglottitis

CancerTraumatic Disruption/Hematoma/Burns

MOANS

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Age > 55

Associated with BVM difficulty, possibly due to loss of tone in the upper airway

MOANS

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Difficulty mask ventilating

Age >55

BMI >26

History of snoringLack of teethBeard

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No Teeth

Face tends to “cave in”

Consider leaving dentures in for BVM and remove for intubation

MOANS

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Stiff

Refers to Poor Compliance

Reactive Airway Disease

COPDPulmonary Edema/Advance PneumoniaHistory of Snoring/Sleep Apnea

Also predicts a higher Mallampati score

MOANS

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Difficult Laryngoscopy & Intubation

LEMONS

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ook ExternallyEvaluate 3-3-2

Mallampati ScoreObstructionNeck Mobility

Scene and Situation

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LOOK

Externally

Beards or facial hair

Short, fat neckMorbidly obese patientsFacial or neck trauma

Broken teeth (can lacerate balloons)Dentures (should be removed)Large teethProtruding tongueA narrow or abnormally shaped face

LEMONS

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L

:

Look Externally

Receding jaw

Short muscular neck

Obesity

Buck teeth

Dentures

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L

:

Look Externally

Facial trauma

Stridor

Macroglossia

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E

:Evaluate the 3-3-2 rule

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3 fingers fit in mouth- Inter incisor distance 3 fingers fit from

mentum

to hyoid cartilage

2

fingers fit from the floor

of the mouth to the top of

the thyroid cartilage

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در صورتی که دهان بیمار کمتر از 3 ا نگشت باز شود و فاصله

thyromental کمتر از 3 ا نگشت باشد و mandibulohyoid کمتر از 2 ا نگشت باشد لوله گذاری راه هوایی مشکل خواهد بود

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Mouth opens at least 3 fingers width?

LEMONS

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Examination

Mouth opening

Bad if <3cm

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Thyromental

Distance

If the

thyromental distance is short, <3 finger widths, the laryngeal axis makes a more acute angle with the pharyngeal axis and it will be difficult to achieve alignment.

Less space to displace the tongue.

LEMONS

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Thyromental Distance

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Mandibulohyoid

Distance- 2 fingers?

Measured from the mentum to the top of the hyoid bone.

The epiglottis arises from the thyroid and remains dorsal to the hyoid bone.Therefore, the position of the hyoid bone marks the entrance to the larynx.

LEMONS

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Mandibulohyoid Distance

LEMONS

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Mandibulohyoid

Distance

Patients who have a longer mandibulohyoid distance, greater then 2 finger widths, tend to be more difficult to intubate.

A more caudal hyoid bone thus indicates a relatively caudal larynx.

LEMONS

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Upper & Lower Face

Measure the size of the upper face as compared to the lower face.

Should be roughly the same.

If the lower face is longer than the upper face then you should anticipate some degree of difficulty lining up the structures.

LEMONS

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Upper and lower face equal?

LEMONS

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Upper and lower face equal?

LEMONS

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Mallampati ?

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Mallampati

Score

LEMONS

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Mallampati

Score

Have patient sit up, and stick out tongue without phonating

May be unable to properly assess this in an emergent field situationModified version is to use a laryngoscope blade like a tongue blade to visualize the oropharynx – (not as sensitive or specific)

LEMONS

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M-

Mallampati classification

Class-I

Class-II

Class-III

Class-IV

soft palate,

fauces

;

Uvula, pillars

.

the soft palate,

fauces

and uvula

soft palate and base of uvula

Only hard palate

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Mallampati

Classification

LEMONS

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Obstruction

Laryngoscopy or intubation may be more difficult in the presence of an obstruction

Anatomy

TraumaForeign body obstructionEdema (burns)

LEMONS

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O

: Obstruction?

Blood

Vomitus Teeth

Epiglottis

Dentures

Tumors

Impacted Objects

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Obstructions

Laryngoscopic

View Grades

Grade 1: Full aperture visible

Grade 2: Lower part of cords visible

Grade 3: Only epiglottis visible

Grade 4: Epiglottis not visible

LEMONS

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Cormack & Lehane Grading

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Obstructions

Laryngoscopic

View Grades

A severe grade III or IV view with failed endotracheal intubation occurs in 0.05-0.35% of patients

LEMONS

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Cormack & Lehane Grading

Grade I =

 success & ease of intubation

<1%

<5%

10-30%

% listed = incidence

LEMONS

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Neck Mobility

Ideally the neck should be able to extend back approximately 35

°

Problems:Cervical Spine ImmobilizationAnkylosing SpondylitisRheumatoid ArthritisHalo fixation

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Atlanto-Occipital Angle

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Estimates the angle traversed by the occluded surface of the upper teeth

Grade I --- > 35°

Grade II –- 22-34°

Grade III – 12-21°

Grade IV -- < 12°

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Scene and Situation

(SEE

)

Scene safetyEnvironmentDo you have a reasonable chance to get the tube?Space, positioning, accessEgressWill you be able to ventilate during egress?A respiratory rate of 4 is better than a rate of 0!Enough meds for a long extrication?

LEMONS

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BURP” –

“External Laryngeal Manipulation”

B

ackward, Upward, Rightward

Pressure: manipulation of the trachea90% of the time the best view will be obtained by pressing over the thyroid cartilage

Differs from the Sellick Maneuver

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To Summarize

Airway assessment is a critical part of the

intubation processThe difficult airway assessment must be performed prior to ALL attempts.While this criteria helps identify difficult airways, it does not guarantee an easy intubation—Be Prepared!

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