Case Discussion - A Case of Difficult Intubation



Case discussion

A case of difficult intubation

Intern 嚴元鴻

Department of anesthesiology


Brief history (1)

Brief history (1)


邱 X 榮 Chart


Sex/Age:male , 59 y/o Bed No:9D-13-1

Admission date:2001/12/4

Past History: 1.DM , fresh case

2.denied other systemic disease

3.smoking and drinking when young

4.denied any food and drug allergy


Brief history (2)

Brief history (2)

Posterior neck swelling without discharge initially since 11/19.

He visited our ER for discharge and tenderness of the wound on


Low grade fever,leukocytosis and high CRP value were noted.

Unasyn,Metronidazole and Gentamicin were given with only minor

improvement of lab data and clinical condition.

He was discharge under cellulitis and suggested OPD F/U.

Because of purulent discharge persisted,the patient visited our ER

again on 12/4.

Deep neck infection was suspected ,he was admitted for further Deep neck infection


Brief history (3)

Brief history (3)

PE: erythematous induration all over the posterior

neck region ; mild tenderness.

CXR shows normal heart size with slightly increased

lung markings. Tortuous aorta is noted.

SPINE CERVICAL AP. LAT showed marked

degenerative change of C-spine with calcification

of post. nuchal ligament. post. spur are noted at C5 6



Brief history (4)

Brief history (4)

Neck CT without/with contrast enhancement shows

1. soft tissue swelling with low density change at dorsal

aspect of neck and occpital region symmetrically, the fat

planes are blurred. there is indistinct interface of the

swollen soft tissue with the posterior neck muscles

(splenius capitus and probably semispinalis). infectious

process is considered, probably cellulitis and myositis.

2. the spine is intact


Brief history (5)

Brief history (5)

Pre op : 59 y/o male with DM was diagnosed neck

abscess s/p I&D.

Op method:Debridement on 12/7

ASA class III

Neck movement decrease,extension(-)

short neck , small mandible


Anesthesia course (see record)

Anesthesia course (see record)

Induction of general

anesthesia followed by

direct laryngoscopy and

oral intubation.

-> difficult intubation

-> Flexible fiberoptic


--> IVG ; propofol



Prediction and Management

Prediction and Management

of Difficult Tracheal Intubation

of Difficult Tracheal Intubation


Predicting Difficult Intubation

Preparation for Intubation




During routine anaesthesia the incidence of difficult tracheal

intubation has been estimated at 3-18%.

Class I: the vocal cords are visible

Class II: the vocals cords are only partly visibleClass III only the epiglottis is seen

Class IV the epiglottis cannot be seen.

Cormack RS, Lehane J. "Difficult intubation


Predicting Difficult Intubation (1)

Predicting Difficult Intubation (1)

"sniffing the morning air" positionHistory and examination

Specific Screening Tests to Predict Difficult Intubation.

View obtained during Mallampati test:

1. Faucial pillars, soft palate and uvula visualised2. Faucial pillars and soft palate visualised, but uvula masked by the base of the tongue

3. Only soft palate visualised4. Soft palate not seen.

Samsoon GLT, Young JRB. "Difficult tracheal intubation: a retrospective study."


Predicting Difficult Intubation (2)

Predicting Difficult Intubation (2)

Thyromental distance

Grade 3 or 4 Mallampati who also had a thyromental distance

of less than 7cm were likely to present difficulty with intubation

Frerk CM. "Predicting difficult intubation." Anaesthesia 1991;46:1005-8

Sternomental distance

A sternomental distance of 12.5cm or less predicted difficult


Savva D. "Prediction of difficult tracheal intubation." British Journal of


Predicting Difficult Intubation (3)

Predicting Difficult Intubation (3)

Protrusion of the mandible

If the patient cannot get the upper and lower incisors into

alignment intubation is likely to be difficult.

Calder I, Calder J, Crockard HA. "Difficult direct laryngoscopy in patients

witH cervical spine disease." Anaesthesia 1995;50:756-63

X-ray studies

Various studies have been used to try to predict difficult

intubation by assessing the anatomy of the mandible on X-ray. These have shown that the depth of the mandible may be


Preoperative assessment

Preoperative assessment

A combination of the above tests is better than using

only one. The modified Mallampati, thyromental

distance, ability to protrude the mandible and

craniocervical movement are probably the most



Preparation for Intubation (1)

Preparation for Intubation (1)

Anaesthetists should be ready to deal with difficulties in

intubation at any time. The correct equipment must be

immediately available. This will include:

laryngoscopes with a selection of blades a variety of endotracheal tubes

introducers for endotracheal tubes (stylets or better, flexible



Preparation for Intubation (2)

Preparation for Intubation (2)

a cricothyroid puncture kit (a 14 gauge cannula and jet insufflation

with high pressure oxygen is the simplest and cheapest kit

reliable suction equipment a trained assistant


After intubation

After intubation

The anaesthetist should ensure that the patient is in the

optimal position for intubation and must be able to oxygenate the patient at all times.

After intubation correct placement of the tube should be

confirmed by:

a stethoscope listening over both lung fields in the axillae observing the tube pass through the cords


Special techniques for intubation

Special techniques for intubation

Awake intubation under local anaesthesia

Oral intubation

Nasal intubation

is the best method of awake intubation using a


Retrograde intubation (1)

Retrograde intubation (1)

is a technique first described in Nigeria

Waters DJ "Guided blind endotracheal intubation for patients with deformities of the upper

airway." Anaesthesia 1963;18:158-62

Retrograde intubation has recently been used successfully for

traumatised airways when conventional techniques had failed

Barriot P, Riou B. "Retrograde technique for tracheal intubation in trauma patients."Critical Care

Medicine. 1988;16:712-3

the membrane between the cricoid and first tracheal ring can

also been used.

Shanther TR. "Retrograde intubation using the subcricoid region." British Journal of Anaesthesia. 1992;68:109-12


Retrograde intubation (2)


The Laryngeal Mask Airway

The Laryngeal Mask Airway

is a common device in anaesthesia and can often provide a

good airway in patients in whom intubation is difficult.

Following insertion the anaesthetist may use it to maintain

the airway during anaesthesia, or may use it as a route to allow tracheal intubation.


The McCoy laryngoscope

The McCoy laryngoscope

is designed with a movable tip which allows the epiglottis to

be lifted and intubation often made easier

McCoy EP, Mirakhur RK. "The levering laryngoscope." Anaesthesia



light wand

light wand

is a long flexible device which has a bright

light at the end and can be directed into the trachea with an

endotracheal tube mounted over it

Robelen GT, Shulman MS. "Use of the lighted stylet for difficult intubations

in adult patients (abstract)." Anesthesiology 1989;71:A439




is a tube which may be inserted

blindly and used to ventilate the patient in an emergency

Frass M, Frenzer R. Zahler J, Lilas W, Leithner C. "Ventilation via the

esophageal tracheal combitube in a case of difficult intubation." Journal of Cardiothoracic Anaesthesia 1987;1:565-8


Planning Anaesthesia

Planning Anaesthesia

During general anaesthesia patients must never be given muscle

relaxants unless the anaesthetist can be certain of being able to ventilate them.

When the anaesthetist faces unexpected difficulty in intubation the

priority is to ensure adequate mask ventilation and oxygenation of the patient.

Multiple attempts at endotracheal intubation may result in bleeding

and oedema of the upper airway making the task even more

difficult. Often it is better to accept failure after a few attempts and move on to a pre-planned failed intubation sequence

King TA, Adams AP. "Failed tracheal intubation." British Journal of


Failed intubation

Failed intubation

If intubation proves impossible the anaesthetist should

consider whether to allow the patient to wake up and carry on surgery with regional anaesthesia, or whether to abandon the surgery altogether. In situations where surgery is of an urgent nature it may be prudent to carry on the general anaesthetic under face mask anaesthesia if the airway is easy to maintain.

If the airway is impossible to maintain and the patient is

becoming hypoxic, an emergency cricothyroidotomy is

required. If time allows an emergency tracheostomy can be considered.


Difficult airway algorithm (ASA)

Difficult airway algorithm (ASA)

Practice guidelines for management of the difficult airway. A report

by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 1993 Mar;78(3):597-602.


ASA Algorithm Part 1


ASA Algorithm Part 2


Awake Intubation Pathway


Non-surgical techniques for awake intubation include

laryngoscopy, fiberoptic bronchoscopy and retrograde intubation. Surgical access may be secured by awake


Awake intubation requires patient cooperation and should

be performed with local anesthesia. See Local Anesthesia for more information.

If awake intubation efforts fail, the patient is unlikely to

have compromised ventilation. Consider canceling the

case, other intubation options or surgical access to the


Intubation After Induction Pathway


After induction of anesthesia, if the initial intubation

attempts are unsuccessful, consider returning to

spontaneous ventilation, awakening the patient and calling for help.

If mask ventilation is adequate, go to the

Non-Emergency Pathway. If mask ventilation is inadequate go to the Emergency Pathway.

If mask ventilation becomes inadequate at any time

while following the Non-Emergency Pathway, go to the


Non-Emergency Pathway


Follow the Non-Emergency Pathway when the patient is

anesthetized, intubation is unsuccessful and mask ventilation is adequate. If mask ventilation becomes

inadequate go directly to the Emergency Pathway.

Consider alternative approaches including fiberoptic

intubation, intubation stylet, blind intubation, light wand and retrograde intubation.

If failure after multiple attempts, consider awakening the

patient, surgical airway or surgery under mask


Emergency Pathway


Follow the Emergency Pathway when the patient is anesthetized,

intubation is unsuccessful and mask ventilation is inadequate.

Time is critical. Call for help. Do one more intubation attempt or

emergency non-surgical airway ventilation or emergency surgical airway.

Do not continue to attempt a previous unsuccessful technique.Emergency non-surgical airway ventilation techniques include:

transtracheal jet ventilation, intratracheal jet stylet, laryngeal mask, oral and nasopharyngeal airways, two person mask ventilation, and rigid ventilating bronchoscope.

Emergency non-surgical airway ventilation techniques are temporizing


Thanks for your attention!!





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