Difficult intubation guidelines in ICU (ANN SNEHA).pptx

this slide includes various difficult intubation techniques and guidelines.

1. Difficult intubation guidelines in ICU BY ANN SNEHA VINCENT

2. Definition of difficult airway A difficult airway includes the clinical situation in which anticipated or unanticipated difficulty or failure is experienced by a physician trained in anesthesia care Facemask ventilation,larynogoscopy , ventilation using a supraglottic airway, tracheal intubation, extubation , or invasive airway

3. DEFINITION Difficult to ventilate: when sign of inadequate ventilation could not be resersved by mask ventilation or oxygen saturation could not be maintained above 90% Difficult to intubate: if a trained anaesthetist using conventional laryngoscope take’s more than 3 attempts Or More than 10 minute are required to complete tracheal intubation

4. CAUSES OF DIFFICULT INTUBATION Anaesthetist Inadequate preoperation assessment Experience not enough Poor technique Inexperience assistance Inadequate equipment Malfunctioning of equipment Patient Congenital causes Acquired causes

5. ANATOMICAL FACTORS AFFECTING LARYNGOSCOPY Neck Disturbing incisor teeth Long high arched palate Poor mobility Increase in either anterior depth or posterior depth of the mandilble decrease in atlanto occipital distance

6. Basic airway evaluation in all patients Previous anaesthetic problems General appearance of the neck, face, maxilla and mandibute Jaw movements Head extention and movements The teeth and oro-pharyngx The soft tissues of the neck Recent chest and cervical spine x-rays

7. FOUR TECHNICAL OPERATIONS OF THE DIFFICULT AIRWAY Difficult bag valve mask ventilation MOANS/BONES Difficult laryngoscopy and intubation LEMON Difficult supra- giottic device RODS Difficult cricothyrotomy SHORT

8. DIFFICULT BAG-MASK VENTILATION: MOANS Mask seal BONES Obstruction/obesity Beard obese Age>55 N o teeth B deny No teeth deep apnea Stiff lungs

9. DIFFICULT LARYNGOSCOPY AND INTUBATION: LEMON Look externally Evaluate 3-3-2 Mallampati score Obstruction /obesity Neck mobility

10. L: LOOK EXTERNALLY Obesity or very small Short muscular neck Prominent upper incisors (BUCK TEETH) Large breasts Receding (dentures) Burns Facial trauma Stridor macroglossia

11. DIFFICULT LARYNGOSCOPY AND INTUBATION: LEMON Evaluate 3-3-2 rule: relates the mouth opening to size of the mandible to the position of the larynx in the terms of likehood of the successful visualization of the glottis bt direct laryngoscopy

12. E- EVALUATE THE 3-3-2 3 finger fit in mouth 3 finger fit from mentum to hyoid cartilage 2 fingers fit from the floor of the mouth to the top of the thyroid cartilage

13. DIFFICULT LARYNGOSCOPY AND INTUBATION: LEMON First “3” Assesses for mouth opening 3 fingers between the upper and lower incisors

14. DIFFICULT LARYNGOSCOPY AND INTUBATION: LEMON Second “3” length of the mandibular space Menturn to hyoid

15. DIFFICULT LARYNGOSCOPY AND INTUBATION: LEMON “2” Position of the glottis in relation to the base of the tongue Space from chin-neck junction (hyoid) to and thyroid notch

16. DIFFICULT LARYNGODCOPY AND INTUBATION: LEMON Mallampati sitting up head in sniffing position open mouth, protrude tongue without phanation Class I-IV Class I & II = low intubation failure rate Class III & IV = intubation failure may be > 10%

17. M- Mallampati classification (LEMON)

18. DIFFICULT LARYNGOSCOPY AND INTUBATION: LEMON Obstruction/obesity Four cardinal signs of upper airway obstruction: - muffied voice -difficulty swallowing secretions -stridor -sensation of dyspnea

19. DIFFICULT LARYNGOSCOPY AND INTUBATION: LEMON Neck mobility - C spine immobilization may compound the effects of other difficult airway markers Trauma,ra , ankylosing spondylitis May require video laryngoscopy

20. DIFFICULT SUPRAGLOTIC DEVICE: RODS Restricted mouth opening Obstruction Disrupted or distorted airway Stiff lungs or cervical spine

21. DIFFICULT SUPRALOTTIC DEVICE: RODS Restricted mouth opening - allowing for oral access to insert device

22. DIFFICULT SUPRAGLOTTIC DEVICE: RODS Disrupted or distorted airway - seal/ seal compromised of the device

23. DIFFICULT SUPRAGLOTTIC DEVICE: RODS Stiff lungs or cervical spine - Increased airway resistance -severe asthma - Decreased pulmonary compliance -pulmonary ederna - Decreased cervical movement

24. DIFFICULT CRICOTHYROTOMY: SHORT Surgery or disrupted any way Hematoma (infection/abscess) Obesity Radiation Tumor

25. DIFFICULT CRICOTHYROTOMY: SHORT Tumor -extrinsic - intrinsic

26. PREPARATION FOR DIFFICULT AIRWAY MANAGEMENT The availability of equipment for airway management Informing the patient; / senior colleague/ expert help / assistance Preoxygenation ; Patient positioning ; Sedative administration ; Local anesthesia; Supplemental oxygen; Patient monitoring; and Human factors.##

27. MANAGEMENT PLAN OF ANTICEPATED DIFFICULT AIRWAY Discussion with colleagues in advance Equipment tested before Senior help backup Definite initial plan (A) for ventilation and intubation. Definite plan (B) than option of awake intrubation Ideal situation surgery team standby

28. PRE-OXYGENATION: HO MUCH IS ENOUGH? Two techniques common in use: Tidal volume breathing (TVB) of oxygen for 3-5 min Deep breath (DB) 4 times within 30sec Both are equally effective in increasing arterial oxygen tension (pao2)

29. CONSIDER THE MERITS AND FEASIBILITY Awake intubation vs intubation after induction of GA Non-invasive technique vs invasive technique for initial approach For initial approach Preservation of spontaneous vs abiation of spontan ventilation Ventilation

30. WHAT WE ARE GOING TO DO IF WE DON’T GET THE TUBE Plan “A” “B” and “C” Know this answer before you tube

31. PLAN “A”: ( ALERNATE) Different length of blade Different type of blade Different type position

32. PLAN B: ( BYM AND BLIND INTUBATION TECHNIQUES) Can you ventilate with a BVM ? (consider two person mask ventilation) Combi -tube? LMA an Option?

33. WHAT DO WE DO WHEN FACED WITH A CAN’T INTUBATE CAN’T VENTILATE SITUATION? Plan “c” : (CRIC) needle, surgical.

34. THANK YOU BY ANN SNEHA VINCET