Airway management in special scenarios

Airway management in special scenarios

1. 1 Airway Management in special scenarios i.e. Cervical Trauma, Airway Trauma, Cervical Spine Disease --- DR ZIKRULLAH .

2. INTRODUCTION Injury is the third leading cause of death overall. WHO estimates that injury is the leading cause of death worldwide for both men and women from 15 to 44 years Hypoxia and airway mismanagement are the predominant cause of pre-hospital deaths (34%) in these patients Inability to oxygenate- permanent brain injury and death within 5 to 10 minutes. 2

3. 3 60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise. 20-50% concurrent brain injury. 1-4% cervical spine injuries. Airway injuries occur in 1% of trauma patients. 78% of them die within 1 hour if unattended hence the GOLDEN HOUR. The primary focus of ATLS is on the first hour of trauma management - rapid assessment and resuscitation

4. The initial assessment of the trauma patient should be done which should take 2–5 min and consists of the ABCDE sequence of trauma: A irway B reathing C irculation D isability E xposure. If the function of any of the first three systems is impaired, resuscitation must be initiated immediately.

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6. 6 Life threatening airway obstruction: Inhalation of tooth fragments Accumulation of blood & secretions Loss of control of tongue in unconscious CLEAR AIRWAY : suction, remove foreign bodies such as a broken denture or avulsed teeth, jaw thrust, cricoid pressure, nasal airway,

7. 7 A trauma patient is always considered to have a full stomach and to be at risk for aspiration Is the patient conscious- If so, the use of sedation or analgesics should be done cautiously since the airway can be lost following injudicious use of such drugs Is the patient breathing spontaneously- If so, there is time to arrive at the hospital, preferably to the operating room, and manage the airway under the best conditions and by the most experienced personnel Spontaneous breathing should be preserved

8. 8 Prehospital management – control ing airway, external hemorrhage, rapid transport All patients should be transported initially with supplemental oxygen. I mmobilization of the C-spine combination of a hard collar and sandbags on opposite sides of the head

9. 9 Prehospital airway management is a key component of emergency. Advanced airway management techniques involves placement of oropharyngeal airways such as the Laryngeal Mask Airway or endotracheal tube. Endotracheal tube placement success is a common measure of out‑of‑hospital airway management quality. In studies demonstrating poor outcomes related to prehospital attempted endotracheal intubation (ETI), both training and skill level of the provider are usually often low.

10. 10 Many systems may benefit from more input and guidance by the anesthesia department, which have extensive training and experience not just with training of airway management but also with different airway management techniques and adjuncts. Establishing and maintaining an airway is always the first priority. Establishing verbal contact with the patient - clear phonation by the patient establishes that the airway is patent. Further intervention depends on: neurologic stability adequacy of gas exchange and the potential for airway compromise

11. Simple maneuvers to manage airway compromise Head tilt/chin lift Jaw thrust 100% oxygen by face mask. Oral airway or nasopharyngeal airway 11

12. 12 Endotracheal intubation, whether performed in the prehospital environment or in the ED, must be confirmed immediately by capnometry . Esophageal intubation or endotracheal tube dislodgement are common and devastating if not promptly corrected. Patients in cardiac arrest may have very low end-tidal CO 2 values; direct laryngoscopy should be performed if there is any question about the location of the endotracheal tube

13. Neurological Stability brief neuro exam (done during the primary survey): A - A lert V - responds to V erbal stimuli P - responds to P ainful stimuli U - U nresponsive Glasgow Coma Scale (GCS): GCS < 8 requires definite airway intervention to prevent aspiration pneumonitis, to insure adequate oxygen delivery and to avoid hypercarbia. 13

14. 14 Simplified approach to definitive airway management in trauma patients

15. CERVICAL SPINE INJURY 2 to 4% of blunt trauma patients have cervical spine injuries. Common causes include high-speed motor vehicle accidents, falls, diving accidents, and gunshot wounds. Head injuries, especially those with low GCS and focal neurologic deficits, are likely to be associated with cervical spine injuries About 2 to 10% of blunt trauma-induced cervical spine injury patients develop new or worsening neurologic deficits after admission 15

16. 16 In conscious patients, neck pain, tenderness, and extremity paresthesias are strong indicators of spine injury. Five criteria increase the risk for potential instability of the cervical spine: (1) neck pain, (2) severe distracting pain, (3) any neurological signs or symptoms, (4) intoxication, and (5) loss of consciousness at the scene.

17. 17 A cervical spine fracture must be assumed if any one of these criteria is present, even if there is no known injury above the level of the clavicle. Immobilization of the neck in neutral position is indicated in all acute trauma patients suspected to have cervical spine injury based on mechanism and clinical presentation Stabilization of the cervical spine will generally occur in the prehospital environment eg, MILS, axial traction, sandbags, forehead tape, soft collar, Philadelphia [hard] collar

18. 18 Jaw-thrust maneuver is the preferred means of establishing an airway , t o avoid neck hyperextension . Oral and nasal airways may help maintain airway patency A patient who arrives in the hospital with a rigid collar and other neck-stabilizing devices, but not in need of emergency airway management, should be evaluated for cervical spine injury. Clearance of the neck should be performed at the earliest possible time Not necessarily to facilitate airway management, but to minimize the risk of pressure ulceration by the collar.

19. C ERVICAL SPINE EVALUATION Clinical examination: NEXUS or Canadian criteria in awake patients Radiological modalities: awake and low GCS X-ray: AP , open mouth view , Lateral CT MRI 19

20. Early intubation is almost universally required for patients with cervical spine fracture and quadriplegia. Ventilatory support is absolutely required for patients with a deficit above C4 Patients with levels from C6 to C7 may still need support Spontaneous ventilation and extubation are possible after surgical stabilization and resolution of neurogenic shock.

21. 21 Unconscious patients with major trauma - increased risk for aspiration, Secure airway as soon as possible E ndotracheal tube or T racheostomy Avoid n eck hyperextension and excessive axial traction Apply MILS

22. 22 When cervical spine instability present Minimize force applied across unstable segments Minimize cervical spine motion Maintain neck in neutral position

23. MANUAL IN-LINE STABILIZATION Direct Laryngoscopy and orotracheal intubation with manual in-line stabilization Best accomplished by having two operators in addition to the physician managing the airway. The first operator stabilizes and aligns the head in neutral position without applying cephalad traction, and the second operator stabilizes both shoulders by holding them against the table or stretcher. 23

24. 24 The anterior portion of the hard collar, which limits mouth opening, may be removed after immobilization Preoxygenation and cricoid pressure (“full stomach”) Sedatives/anesthetics & paralytics as indicated Assistant applies force(s) equal & opposite to those of DL to keep the head/neck in neutral position

25. 25 CRICOID PRESURE Worsen the laryngoscopic view, Impair bag-valve mask (BVM) ventilation efficiency Not reduce the incidence of aspiration Removed as a level 1 recommendation Reduces successful insertion of LMA (94% to 67%) To be applied throughout induction and attempts at intubation in trauma patients To be removed to ease intubation or insertion of LMA, should take precedence over the potential risk of aspiration.

26. 26 Acc. To recent studies, MILS  Impaired glottic view  cause application of increased pressure The pressure is transferred to the cervical tissues causing cranio -cervical motion and instability of the pathologic cervical spine In patients with otherwise normal airways, MILS increases the tracheal intubation failure rate and intubation time, and worsens laryngeal visualization during direct laryngoscopy .

27. ROUTES OF INTUBATION: NASAL VS ORAL S ome clinicians prefer nasal intubation in spontaneously breathing patients with suspected CSI Easier path to intubation Higher risk of pulmonary aspiration. A voided in patients with midface or basilar skull fractures Increased risk for sinusitis in the ICU if the patient is not extubated at the end of the procedure.

28. 28 Oral intubation is likely to be more challenging technically Better if the patient remains mechanically ventilated

29. 29 ALTERNATIVE TECHNIQUES Awake fiberoptic intubation. Blind nasal intubation Transillumination with a lighted stylet , Intubating lma , GlideScope Bullard laryngoscope The clinician is advised to use the equipment and techniques that are most familiar.

30. Direct Laryngoscopy Most rapid route DL invariably involves muscle relaxation (induced or intrinsic), hypnotic induction and re-alignment of the airway; Can all be profoundly dangerous in cases of extensive maxillofacial trauma. 30

31. Aids to direct laryngoscopy Airway exchange catheter [AEC]or Jet stylet Serves dual function: to ventilate the lungs and to act as a guide for reintubation . AEC [Cook’s] has been used: (1) to assist with endotracheal tube exchanges, difficult intubations, and reintubation . (2) to monitor end-tidal CO2 levels after extubation . (3) to act as a conduit for jet ventilation and oxygen insufflation . 31

32. Fiberoptic intubation Most useful instrument in skillful hands. Pros: Good visualization Minimal neck motion Can be used in partially occluded airway Cons: Availability Operator dependent Relatively slow 32

33. Difficulties Encountered during Fiberoptic Intubation Lack of patient cooperation Acute airway obstruction/ distorted anatomy of airway Prescence of secretions and blood Extensive pharyngeal edema or tissue rearrangement Inadequate topical anaesthesia Fogging of the lens Difficulty advancing ETT into glottis despite fibreoptic in trachea 33

34. Videolaryngoscope like McGrath,Glidescope,C -Mac Pros: Minimizes neck movement Good at visualizing glottis when neck unable to be moved or mouth unable to be opened wide Cons: Difficult to pass tube Availability 34

35. C Mac Kings Vision Mcgrath Glidescope Mcgrath Video Laryngoscopes

36. The Bullard Laryngoscope 36

37. The Bullard Laryngoscope Potential Advantages Can be faster than fiberoptics Neck can be maintained in neutral position Better glottic visualization with MILS Incorporates a working for oxygen insufflation / suction Notes of Caution Not evaluated in patients with unstable spines Successful intubation not “a sure thing” 37

38. The WuScope 38 Potential Advantages Neck can be maintained in neutral position Better glottic visualization with MILS Notes of Caution Not evaluated in patients with unstable spines Not a “sure thing”

39. The Intubating LMA (ILMA) 39 Can be inserted with head & neck neutral Designed to allow rapid blind orotracheal intubation Fiberoptic guided intubation also possible

40. 40 Allows ventilation during intubation. No or minimal movement of cervical spine. Can serve as a good conduit for fibreoptic intubation in patients with blood/secretions Cannot be inserted if the inter dental distance is less than 2 cm. Can be inserted in lateral position .

41. Lighted Stylet (Light-Guided Intubation) The term “lighted stylet ” may be used to describe any device that uses a bright light within the tip of a endotracheal tube as a guide to facilitate tracheal intubation. The technique depends on interpretation of the light transmitted through the skin of the neck to indicate the position of the tip of the endotracheal tube. When the tip is at the larynx, the light should be in the midline, and its position in the longitudinal plane indicates its position in relation to the laryngeal cartilage. 41

42. 42 As the light passes more distally, a localized glow in the center indicates a tracheal position and a diffuse glow indicates an esophageal position.

43. Role of Supraglottic Airway Devices: CVCI Laryngeal Mask Airway Proseal Laryngeal Mask Airway Combitube Laryngeal Tube {King’s airway}

44. RETROGRADE INTUBATION pass a narrow flexible guide, percutaneously , into the trachea from a site below the vocal cords and advance this guide through the larynx and out the mouth or nose. In the basic technique, the tracheal tube is then passed over the guide into the upper part of the trachea, the guide is removed, and the tube is advanced into the trachea 44

45. SURGICAL AIRWAY Cricothyrotomy Tracheostomy

46. Cricothyrotomy Surgical or needle technique Incision through cricothyroid membrane Indicated when oral or nasotracheal intuation by other means fails and when BVM ineffective facilitates rapid restoration of ventilation and oxygenation in the “cannot intubate , cannot ventilate” situation. 46

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48. Risk-benefit analysis Direct laryngoscopy with orotracheal intubation and manual in-line stabilization 48 Risk of exacerbating cervical spine injury Risk of anoxic brain injury from failed intubation A failed airway is a bad outcome !

49. Loss of an airway kills more quickly than does the loss of the ability to breathe or circulatory problems

50. AIRWAY TRAUMA Death from trauma has a trimodal distribution: seconds to minutes minutes to hours GOLDEN HOUR several days or weeks 50

51. DIRECT AIRWAY TRAUMA Direct trauma to the airway can be classified into broad categories of blunt and penetrating trauma Each of these can be considered in the context of direct injury to the airway itself versus compromise or threat to the airway caused by the proximity of the injury in the neck. 51

52. Penetrating Neck Trauma For the purposes of classification of penetrating injury, the neck is divided into three zones. 52

53. 53 Zone 1 injuries are relatively infrequent (less than 10% of penetrating neck injuries) but are often associated with major vascular injuries or injuries to the dome of the lung Zone 2 is a most common location for penetrating neck injuries. Zone 2 injuries require emergency airway intervention in approximately one third of cases, with a large proportion of the remainder undergoing subsequent intubation related to evaluation or surgical repair. Zone 3 injuries are uncommon (less than 10% of all penetrating neck injuries)

54. Blunt Neck Trauma Inability to localize injury precisely and the injury is usually more diffuse. Initial evaluation of the patient with blunt neck trauma should include identification of any bruising or ecchymosis related to the external injury. The oropharynx should be inspected to ensure that there is no injury to the tongue or dentition. The external neck should then be palpated carefully from the mandible to the clavicle. 54

55. 55 Infrequently, direct blunt neck trauma can cause laryngeal fracture or tracheal transsection . Bag-mask ventilation may produce profound subcutaneous emphysema and accelerates the patient's deterioration. Prompt transfer to the operating room for surgical exploration of neck and establishment of the airway by tracheostomy distal to the transection . Often, however, airway management must be undertaken before the surgery.

56. Maxillofacial trauma Fractures of the facial skeleton are commonly seen after assault, road traffic accidents, falls, and sporting injuries in a ratio of mandibular : zygoma : maxillary- 6 :2 : 1.1 56

57. 57 FRACTURES OF THE FACIAL SKELETON Divided into: Upper third( above the eyebrow) Middle third( above the mouth) Lower third( the mandible)

58. THE MIDDLE THIRD Three predominant types were described. Le Fort I : usually involves the inferior nasal aperture Le Fort I I : usually involve the inferior orbital rim Le Fort I I I : along the floor of the orbit along the inferior orbital fissure 58

59. Mandibular dislocation The mandible can be dislocated: Anterior 70% Posterior Lateral Superior Dislocations are mostly bilateral. 59

60. 60 Coronal CT is the investigation of choice for facial injuries Plain radiograph with waters view and submental -vertical view can also be done OrthoPentoGram (OPG) is done for mandibular fractures Advanced airway management (such as endotracheal intubation, cricothyrotomy, or tracheostomy) is indicated if there is cardiac arrest, apnea,

61. 61 persistent obstruction, severe head injury, maxillofacial trauma, a penetrating neck injury with an expanding hematoma, or major chest injur y(flail chest), inability to maintain spo2 >90% by facemask

62. Oral and nasal airways may help maintain airway patency. Unconscious patients are at risk for aspiration airway must be secured as soon as possi ble - endotracheal tube or tracheostomy. N asal intubation should be avoided in patients with midface or basilar skull fractures. Laryngeal trauma makes a complicated situation worse.

63. Open injuries may be associated with bleeding, obstruction, subcutaneous emphysema, and cervical spine injuries. Closed laryngeal trauma is less obvious but can present as neck crepitations, hematoma, dysphagia, hemoptysis, or poor phonation. An awake intubation under direct laryngoscopy or fiberoptic bronchoscopy with topical anesthesia , if the larynx can be well visualize d and patient is cooperative. If facial or neck injuries preclude endotracheal intubation, tracheostomy under local anesthesia should be considered.

64. 64 Acute obstruction from upper airway trauma may require emergency cricothyrotomy or percutaneous or surgical tracheostomy . RSI is reserved for an uncooperative patient needing definitive airway management Equipment to facilitate difficult intubation should be readily available wherever emergency airway management is performed The gum elastic bougie , or intubating stylet , is an inexpensive and easily mastered adjunct for management of a difficult airway.

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67. CERVICAL SPINE DISEASE It includes Rheumatoid arthritis of cervical spine Ankylosing spondylitis of cervical spine 67

68. Rheumatoid arthritis Rheumatoid arthritis (RA) is a chronic inflammatory form of arthritis, which affects about 1% of adults RA is characterized by persistent joint synovial tissue inflammation leading to bone erosion, destruction of cartilage, and loss of joint integrity The diagnosis of RA is primarily clinical. Patients commonly present with pain and stiffness in multiple joints. 68

69. 69 Airway management can be particularly challenging in RA patients because of involvement of cervical spine, temporomandibular joints and cricoarytenoid joints. Arthritis of the cervical spine is common in patients with RA nearly 85 % in long standing cases. Anterior subluxation of C1 on C2 ( atlantoaxial subluxation ) may occur in 40% of patients with RA, with symptoms of progressive neck pain, headaches, and myelopathy .

70. 70 Flexion of the head in the presence of atlantoaxial instability could result in the displacement of the odontoid process into the cervical spine and medulla and compression of the vertebral arteries .This may precipitate quadriparesis , spinal shock, and death. TMJ is affected in nearly 50% patients. Synovitis of the TMJ may significantly limit mandibular motion and mouth opening in these patients. Cricoarytenoid joints involvement occur in about 60 % patients.

71. Atlantoaxial dislocation.   Lateral view of the cervical spine 71

72. 72 Arthritic damage to the cricoarytenoid joints may result in diminished movement of the vocal cords, resulting in a narrowed glottic opening; this is manifested preoperatively as hoarseness and stridor . During laryngoscopy , the vocal cords may appear erythematous and edematous , and the reduced glottic opening may interfere with passage of the endotracheal tube. There also is an increased risk of cricoarytenoid dislocation with traumatic endotracheal intubations

73. 73 Awake fibreoptic intubation with MILS for cervical spine stablization is the technique of choice for airway management. Involvement of other systems may also add to the difficulty in management Other means of securing airway in these patients are ILMA Videolaryngoscope

74. 74 Bullard laryngoscope/ Airtraq Conventional laryngoscopy with MILS Retrograde intubation Intubation with lightwand Cricothyrotomy / Tracheostomy

75. 75 Restrictive lung changes due to costochondral joint involvement may lead to ventilation perfusion mismatch with the resultant decreased arterial oxygenation. These patients may show rapid desaturation during laryngoscopy despite adequate preoxygenation . Pericarditis , arteritis of coronary arteries , pericardial effusion,cardiac valve fibrosis may complicate the management.

76. Ankylosing spondylitis Ankylosing spondylitis is a chronic inflammatory arthritic disease that results in fusion of the axial skeleton. Ankylosing spondylitis involves ossification of the axial ligaments progressing from the sacral lumbar region cranially, resulting in a significant loss of spinal mobility. Reduced movement of their cervical spines and their TMJ. In most cases, awake fiberoptic endotracheal intubation is required for general anesthesia . 76

77. 77 Other means of securing airway in these patients are ILMA Videolaryngoscope Bullard laryngoscope Conventional laryngoscopy with MILS Retrograde intubation Intubation with lightwand Cricothyrotomy / Tracheostomy

78. lateral view of the upper cervical spine in ankylosing spondylitis patient(arrow).This is very early syndesmophyte formation. 78

79. Strict attention to intraoperative positioning is needed to avoid fracture of the fused spine with concomitant spinal cord trauma. 79

80. Extubation should be deferred until normal anatomy is restored or at least until the edema subsides. Close and continuous monitoring . Preparation for re-intubation . Steroids. Wire cutters.

81. 85 Thank You