Case discussion
A case of difficult intubation
Intern 嚴元鴻
Department of anesthesiology
Brief history (1)
Brief history (1)
Name:
邱 X 榮 Chart
No:4099581
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
11/29.
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
7.
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
intubation
--> IVG ; propofol
infusion
Prediction and Management
Prediction and Management
of Difficult Tracheal Intubation
of Difficult Tracheal Intubation
Introduction
Predicting Difficult Intubation
Preparation for Intubation
Introduction
Introduction
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 visible Class 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" position History and examination
Specific Screening Tests to Predict Difficult Intubation.
View obtained during Mallampati test:
1. Faucial pillars, soft palate and uvula visualised 2. Faucial pillars and soft palate visualised, but uvula masked by the base of the tongue
3. Only soft palate visualised 4. 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
intubation
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
reliable.
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
bougies)
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 aRetrograde 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 canalso 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
A
light wand
light wand
is a long flexible device which has a brightlight 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
The
Combi-tube
Combi-tube
is a tube which may be insertedblindly 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
tracheostomy.
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!!