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Upper airway assessment east iv
- 1. Emergency Airway Skill Training IV Course 2013 Assessment Of The Upper Airway NIK AHMAD SHAIFFUDIN BIN NIK HIM MD., MMed (Emerg.Med. USM), AMM Hospital Sultanah Nur Zahirah drnikahmad@gmail.com
- 2. Presentation Outline 1. Introduction 2. Airway Revisited – Adult vs Pediatric Airway 1. Approach to upper airway assessment – – General…. Recognizing difficult airway 4. Take Home Messages
- 3. Most of us already know this much On going learning and professional skills development After E.A.S.T. (hopefully) DISCLAIMER: Hold you horses! You ain’t getting a full license at the end of the course!
- 4. INTRODUCTION • Airway assessment & management ….. The single most important skill for ECP • “A” in the ABC of resuscitation…. Without a secure airway and adequate oxygenation the other resuscitative measures are doomed to failure • With the exception of immediate defibrillation in cardiac arrest patient….. No single resuscitative maneuver takes priority over the airway assessment & management!!
- 5. AIRWAY REVISITED Understanding The Airways Anatomical hollow canals that allow the passage of air into and outside the respiratory system Divided into upper and lower airways; the arbitrary border is the glottis • Upper airway has muscular, bony and cartilaginous part • Lower airways is almost all smooth muscle Upper Lower
- 6. Understanding The Airways Functional anatomy is important to expert airway management… A clear understanding will… o o o o Guide the choice of intubation Enhanced the best approach Basis for avoiding complications …..… early detection Upper Airway
- 8. Important distances in adult: Incisor teeth to vocal cords 15 cm Incisor teeth to carina 20 cm External nares to carina 30 cm *+/- 1 to 2 cm
- 9. Adults VS Pediatric Airway : Anatomy & Physiology The Pediatric Airway: “They’re not just little adults!”
- 11. Anatomical Differences…cont PHYSIOLOGICAL DIFFERENCES Infant 1. 2. 3. 4. 5. 6. Fewer alveoli Increase oxygen consumption Rate dependant Diaphragmatic dependant High airway resistance Infant is more vulnerable to respiratory muscle fatigue
- 12. Physiology • Kids desaturate fast!
- 13. Ron Walls, MD “Manual of Emergency Airway Management”
- 14. APPROACH TO UPPER AIRWAY ASSESSMENT
- 15. Purpose Of Airway Assessment…. 1. Look for potential or compromised airway 2. Need for basic airway adjuncts 3. Suitability for NIV 4. Candidacy for definitive airway or IPPV 5. Emergency surgical airway 6. Clues to diagnosis or etiology and its subsequent management
- 16. In emergency setting…. How do you know if the airway is patent…… When to secure it? Is your patient is going to be difficult for definitive airway…? …… and does it really matter?
- 17. Approach To Emergency Upper Airway Assessment…. General 1. SPEECH Speak to your patient !!! Patency & Adequacy What is your name ? Or Boleh saya bantu ? Response provides information both airway and neurological status!! ….. Suggestive the airway is patent and adequate for the time being!!!!
- 18. Approach To Emergency Upper Airway Assessment…. General 2. LOOK….. Consciousness - full, alternating, reduced Respiratory effort - normal, increased or reduced Do they just look difficult? •Dentition (prominent upper incisors, receding chin) •Distortion (edema, blood, vomits, tumor, infection) •Disproportion (short chin-to-larynx distance, bull neck, large tongue, small mouth) •Dysmobility (TMJ and cervical spine) •Distance ( Sternomental > 12 cm, Thyroidmental > 7 cm…) Oxygenation - Respiratory rate and SPO2 read together Capnograph…. 3. LISTEN… Phonation, snore, stridor, wheeze, gargles etc Try to get airway history…… if possible !!!
- 19. Predictors: Medical History • Joint disease • Acromegaly • Thyroid or major neck surgeries • Tumors, known abnormal structures • Genetic anomalies • Epiglottitis • Previous problems in surgery • Diabetes • Pregnancy • Obesity Ron Walls, MD, “Manual of Emergency Airway Management”
- 20. Difficult Airways… Look For Predictors & Risks – Believe the history of previous difficult airway management….. – All airway management techniques fail and this is often unanticipated !!!! – Never fail to prepare for failure – Even a thorough advance evaluation will help you identify difficult airways only about 50% of the time ACEP Ron Walls, MD, “Manual of Emergency Airway Management” M. Rosen & I.P.Latto 1984 , British Journal Of Anesthesia
- 21. Difficult Airway ….. Risk Assessment • Assessing & Identifying a potentially difficult airway is essential to preparing and developing a strategy for successful ETI and also preparing an alternate plan in the event of a failed ETI. Ron Walls, MD, “Manual of Emergency Airway Management”
- 22. Recognizing Difficult Airway 1. Difficult laryngoscopy & intubation 3. Difficult Extraglottic Device (EGD) Four Dimensions of Airway Difficulties 2. Difficult to ventilate with a BVM 4. Difficult to perform cricothyrotomy Ron Walls, MD, “Manual of Emergency Airway Management”
- 23. 1. Difficult Laryngoscopy & Intubation ……Quick Assessment Subjective clinical judgment can be highly specific (>90%), but severely insensitive (<20%) and so must be augmented by other evaluations Dr. Binnions Lemon Law: An easy way to remember multiple test • • • • • • Look externally. Evaluate the 3-3-2 rule. Mallampati. Obstruction? Neck mobility Scene & Situation Rosen's Emergency Medicine: Concepts and Clinical Practice, 6th ed., Copyright © 2006 Mosby, Inc
- 24. LOOK Externally • • • • • • • Facial or neck trauma Large incisors/ broken teeth Beards or facial hair Protruding tongue Short, fat neck Morbidly obese Dysmorphism LEMONS
- 25. EVALUATE 3-3-2 • • • Will patients mouth open wide enough to accommodate 3 fingers? Will 3 fingers fit between the mentum and hyoid bone? Will 2 fingers fit between the hyoid and thyroid notch? – If not, expect a difficult intubation LEMONS
- 26. Incisors distance ( Mouth opening) Distance -3 fingers? Hyoid-mentum ( Length of mandible) Distance -3 fingers? LEMONS
- 27. LEMONS Hyoid to the thyroid notch Distance- 2 fingers ? • • Patients who have a longer Hyoid to thyroid distance, greater then 2 finger widths, tend to be more difficult to intubate. A more caudal hyoid bone thus indicates a relatively caudal larynx.
- 28. Upper & Lower Face • Size upper face = lower face ….. • Lower face > upper face then you should anticipate some degree of difficulty lining up the structures. LEMONS
- 31. Obstruction • Laryngoscopy or intubation may be more difficult in the presence of an obstruction – – – – Anatomy Trauma Foreign body obstruction Edema (burns) LEMONS
- 32. Obstructions Laryngoscopic View Grades Grade 1: Grade 2: Grade 3: Grade 4: Full aperture visible Lower part of cords visible Only epiglottis visible Epiglottis not visible LEMONS
- 34. LEMONS Cormack & Lehane Grading Grade I = ↑ success & ease of intubation 10-30% <5% % listed = incidence <1%
- 35. Neck Mobility LEMONS • Ideally the neck should be able to extend back approximately 35° • Problems: – – – – Cervical Spine Immobilization Ankylosing Spondylitis Rheumatoid Arthritis Halo fixation
- 36. Scene and Situation (SEE) LEMONS • Scene safety • Environment – Do you have a reasonable chance to get the tube? – Space, positioning, access • Egress – Will 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?
- 37. 2. Difficult to Bag & Mask Ventilation (MOANS) “The clinical situation where using 100% oxygen and bag/valve/mask ventilation, an unassisted anesthesiologist is unable to maintain oxygen saturation greater than 90% in a person who was capable of doing so before intervention” Estimated that up to 28% of all anaesthetic related deaths are secondary to the inability to mask ventilate or intubate. • • • • • Mask Seal Obesity or Obstruction Age > 55 No Teeth Stiff Practice Guidelines for Management of the Difficult Airway. ASA Taskforce. Anesthesiology 2003; 98:1269-1277
- 38. Mask Seal • • • • • • Oddly Shaped Face Bushy Beard Blood/Vomit Facial Trauma Small Hands Wrong Mask Size MOANS
- 39. Obesity or Obstruction • Obesity – – – – Increased supraglottic airway resistance Billowing cheeks Difficult mask seal Abdominal contents inhibit movement of the diaphragm – Quicker desaturation – Heavy chest MOANS
- 40. Obesity or Obstruction MOANS • 3rd Trimester Pregnancy – – – – Increased Mallampati Score Gravid uterus inhibits movement of the diaphragm Quick desaturation Increased body mass
- 41. Obesity or Obstruction • Obstructions – – – – – – Foreign Body Angioedema Abscesses Epiglottitis Cancer Traumatic Disruption/Hematoma/Burns MOANS
- 42. Age > 55 MOANS • Associated with BVM difficulty, possibly due to loss of tone in the upper airway
- 43. No Teeth MOANS • Face tends to “cave in” • Consider leaving dentures in for BVM and remove for intubation
- 44. Stiff • Refers to Poor Compliance – – – – Reactive Airway Disease COPD Pulmonary Edema/Advance Pneumonia History of Snoring/Sleep Apnea • Also predicts a higher Mallampati score MOANS
- 45. Difficult EGD RODS RO- Restricted mouth opening Obstruction : Obstruction at the level of larynx or below EGD will not pass this obstruction D - Disrupted or distorted airway : Fail to “seat & seal” SStiff lungs or cervical spine: Ventilation difficult due to airway resistance, poor lungs compliance and difficult insertion due to limited neck movements.
- 46. Difficult Cricothyrotomy SHORT • No absolute contraindications to performing emergency cricothyrotomy… • Time is “SHORT” when cricothyrotomy is indicated!! S - Surgery H - Hematoma O - Obesity R - Radiation T - Tumor
- 47. Difficult Cricothyrotomy • The evidence is clear that….. When emergency surgical airway is required, it is not the procedures that kills the patients, but delaying or not doing it causes harm !! • Do what you can do BUT do not do what you cannot do. Ask for help !!!.... Airway management should suit the patient NOT the Dr, Nurse or Paramedics !! Dr Cook & Dr MacDouglass-Davis , British Journal of Anesthesia
- 48. “BURP” – a.k.a. “External Laryngeal Manipulation” • Backward, Upward, Rightward Pressure: manipulation of the trachea • 90% of the time the best view will be obtained by pressing over the thyroid cartilage Differs from the Sellick Maneuver
- 49. TAKE HOME MESSAGES 1. Upper airway assessment is a critical part of the RSI process …. Assess every airway for difficulty !!! 2. Believe the history of difficult airway management 3. Assess for the unexpected !!!. Hypoxia is the killer… avoid it.
- 50. TAKE HOME MESSAGES 4. If your assessment suggest risk for difficult airway and are frantically looking for a difficult airway equipment/ device you ought to be looking (or calling) for your consultant quickly too. 5. ETCO2 post-intubation was mandatory since 10 years ago! Please use. 6. Arterial blood gas values are rarely helpful in the emergence decision to intubate and may be misleading …..
- 51. TAKE HOME MESSAGES 7. If assessment anticipated deterioration & compromised airway of the critically ill or injured ……intubate early before it occurs!! 8. It is better to err by identifying an airway as potentially difficult, only to subsequently find it is not….. than the other way around !!! 9. While this criteria helps identify difficult airways, it does not guarantee an easy intubation — Be Prepared !!!!
- 52. “ Good Judgment may come from experience but experience comes from bad judgment “..… Mark Twain
- 53. Any questions?
- 54. Its spot the difficult airway patient time!
- 55. Look at you partner now. Difficult?
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- 61. TQ…
Notes de l'éditeur
- {"16":"In most pre-hospital cases the airway needs managing regardless of the level of difficulty, and the provider is expected to do that, regardless of difficulty ….so what is the benefit of knowing a fancy system?\n","22":"The four dimensions of difficult airways.\n","39":"More dead space in cheeks\nLower residual volumes\n","6":"Upper Airway\nThe face and the facial skeleton and are considered components of upper the airway. The upper airway heats, humidifies and conducts air into the lower airways. Problems can arise from obstructions, fractures and soft tissue injuries.\n","34":"Grade I: full aperture is visible\nGrade II: Lower portion of cords visible\nGrade III: Epiglottis only visible\nGrade IV: Epiglottis not visible\nGrades III & IV are rare. So, if you frequently see Grade III or IV – consider revisiting your technique.\n","29":"Pt should be sitting, head in neutral position, mouth wide open, and tongue extended out as far as possible. The number classification is based on the structures that are visible.\nA Class I view is a Grade I Intubation 99% of the time\nA Class IV view is a Grade III or IV intubation 99% of the time\nClass IV: <1% prevalence (hard palate only visible) Severe Difficulty Intubating\nClass III: <13% prevalance (soft palate, base of uvula visible) Moderate Difficulty Intubating\nClass II: 40% prevalence (soft palate, uvula, fauces visible) No Difficulty Intubating\nClass I: 46% prevalence (soft palate, uvula, fauces, pillars visible) No Difficulty Intubating\n","7":"Middle Airway\nThe middle airway consists primarily of the larynx. It is fairly well protected but is susceptible to injury. The larynx is comprised of cartilage and contains the vocal cords. Because it is narrow, edema, secretions, or foreign bodies can quickly cause problems.\nThe rigid laryngeal structures are the hyoid bone, thyroid cartilage, cricoid cartilage and arytenoid cartilage. Inferior to the cricoid cartilage are tracheal cartilages. The cricoid cartilage is a complete ring and can be used to prevent passive reflux of stomach using cricoesophageal pressure (Sellick’s Maneuver)\nLaryngeal Cartilages\nThe Cricothyroid artery is a small branch of the superior thyroid artery. It travels along the inferior border of the thyroid cartilage and becomes smaller as it reaches the midline. Cricothyroid puncture in the midline, inferior part of the membrane above the cricoid cartilage is least likely to produce bleeding.\nThe large superior and inferior thyroid arteries supply the thyroid gland. The gland is highly vascular. A pyramidal lobe may extend to the hyoid bone. Puncture below the cricoid cartilage has increased risk of bleeding. Palpate the puncture site carefully and avoid any masses (Engel et al, 2001).\n","24":"http://library.thinkquest.org/5029/badbite2.jpg\n","19":"Rheumatoid Arthritis\nAnkylosing Spondylitis: Painful Stiffening of the joint \nCervical Fixation Devices\nKlippel-Fiel Syndrome: Short wide neck, reduction in number of cervical vertebrae, and possible fusion of vertebrae. \nThyroid or major neck surgeries\nPierre Robin Syndrome: Small Jaw, cleft Palate, No Gag reflex, downward displacement of tongue\nAcromegaly: Thickening of Jaw, Soft tissue structures of the face, associated with middle age\n","14":"Upper Airway\nThe face and the facial skeleton and are considered components of upper the airway. The upper airway heats, humidifies and conducts air into the lower airways. Problems can arise from obstructions, fractures and soft tissue injuries.\n","48":"90% of the time the best view will be obtained by pressing over the thyroid cartilage – because, anatomically, the vocal cords are connected here.\n“BURP”-backwards, upwards, right, pressure\nMay help with difficult intubation\n","21":"The American Society of Anesthesiology (AMA) has noted:\n“… there is strong agreement among consultants that preparatory efforts enhance success and minimize risk.”\nAnd “…the literature provides strong evidence that specific strategies facilitate the management of the difficult airway “\nWell, many Anesthesiologists have the option to “Abort” induction, or to work through a problem with as much assistance as needed.\nIn the REAL WORLD of EMS that is seldom the case. \nHowever many of the BASIC principles are valid in the clinical evaluation of patients, and thus valuable in our education as medics. \nKnowing these principles will improve our decision making process and Patient Care;.\n"}