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Difficult airway management for nursing staff
- 1. Difficult Intubation & Difficult Airway Trolley Rashid M Khan Sr. Consultant National Trauma Centre Muscat, Sultanate of Oman
- 2. Objectives of this talk • Introduction to the difficult airway for the nurse assistants. • How to assess, manage & assist with difficult airway! • The algorithm and its purpose! • The difficult airway trolley! • Understanding of different airway devices!
- 3. Airway management is really easy… …except when it isn’t…
- 4. To Maximize Success… …recognize and predict difficult airway …choose appropriate technique and equipment …possess technical skills to assist intubation, drugs, and devices
- 5. The anesthesia nurses role! • Should Predict the difficult airway! • Provide assistance & support! • Has equipment/drugs ready! • Has experience to offer!
- 6. Predicting the Difficult Airway …if you have time
- 7. LEMON Law Look at patient’s head & neck anatomy Examine the airway Mallampati Obstructions Neck mobility
- 8. Look at Head & Neck Anatomy • Obesity: rapid desaturation, difficult intubation, ventilation • Facial hair: hides small chin, can make bagging difficult / impossible • Large teeth: hide airway, obscure tube passage • Jagged teeth: lacerate balloon
- 9. Look at Facial Anatomy
- 10. Look at Oropharyngeal Anatomy • Narrow face, high-arched palate: decreased side-to-side diameter • Large tongue: hides airway • False teeth: help bagging, remove for intubation
- 11. Examine the Airway The 1 – 2 – 3 rule 1. Ability to invaginate index finger in front of the tragus as patient opens mouth
- 12. Examine Airway • Mouth open: 2 fingers – Allows insertion of tube, laryngoscope • Mentum to hyoid: 3 fingers – Predicts ability to compress tongue into submandibular space
- 13. Mallampati Score • With patient seated: extend neck open mouth stick out tongue • Visualize base of tongue, faucial pillars, uvula, pharynx
- 14. Mallampati Score Difficulty None None Moderate Severe
- 15. Airway Obstructions • Foreign body • Angioedema? • Hematoma? • Dentures? • Epiglottis?
- 16. Neck Mobility Restriction Prior condition • Surgery • Rheumatoid arthritis • Osteoarthritis • Others
- 17. Being Prepared is Good Assistance Keep SOAPME Ready: •Suction •Oxygen •Airway •Pharmacological agents •Monitors •Equipment
- 18. The Difficult Airway Cart
- 19. Difficult Airway Cart • A shelf and 5 Drawers • Mobile • Robust • Clearly labelled • Easily cleaned • Attach DAS algorithms • Restocking list
- 20. What should be in the Difficult Airway Cart? •Top Shelf •Cricothyrotomy Kit, wide bore Intracath 12 or 14 G. •The Side •BVM, Jet Ventilator + connector •Bougie •Draw 1 •LMA •Oral & Nasopharyngeal airways •Draw 2 •Video-laryngoscopes: Cmac, Truview PCD •Draw 3 •Regular & alternative laryngoscope blades: Curved & Straight, Mc Coy •ETT •Draw 4 •Tracheostomy Tubes •Draw 5 •Intubating LMA, Trachlight, Fiberoptic scope
- 21. The Difficult Airway Cart
- 22. Always start with Pre-oxygenation • Provides oxygen reservoir within lungs, blood and body tissues. • Allows for several minutes of apnea without desaturation. • Nitrogen washout. • Use NRB, BVM or NIV for 3-5 mins.
- 23. Helping Preoxygenation and mask ventilation prior to intubation • Keep appropriate size oral airway or nasal trumpet ready. • Leave dentures. • In bearded patients, apply water-soluble lubricant or opsite to get good seal, especially if lots of facial hair
- 24. Apneic Oxygenation • New Concept! • Involves maintaining Nasal Prongs patent upper airway passage & oxygenation during apneic period. • Use Nasal prongs @ 15l 02.
- 25. Always start intubation attempts: • After a good preoxygenation. • Using technique with which you are most experienced and comfortable. • Don’t repeat the same technique more than twice, you will not get a different result.
- 26. Endotracheal intubation Basic instruments that you should keep ready Magill’s Forceps Laryngoscope Styleted ETT
- 27. Role of the nurse anesthetist during laryngoscopic attempts: • Providing adequately checked laryngoscope & ETT. • Providing cricoid pressure, if full stomach. • Applying BURP maneuver to facilitate laryngeal visualization. • Inflating the cuff and ETT fixation after ascertaining correct tracheal intubation.
- 28. Failed Tracheal Intubation?
- 29. Always Keep Plan – B Ready
- 31. 1. Laryngeal Mask Airway Available in 8 sizes: 1, 1.5, 2, 2.5, 3, 4, 5, & 6
- 32. Proseal LMA Available in 8 sizes: 1, 1.5, 2, 2.5, 3, 4, 5, & 6
- 33. Usage
- 34. Usage
- 35. LMA Take-Home Points for Nurses • Always test cuff before use • Don’t lubricate anterior mask • Insert only in comatose patient • Keep cuff inflated until patient awake • Don’t throw out!! Used 40 – 50 times
- 36. 2. Combitube®
- 37. 2. Combitube® Available in 2 sizes: 37 & 41 French G
- 38. No .2 15 ml No .2 N o. 1 N o. 1 100 m l 2. Combitube®
- 39. 2. Combitube® • Double lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tube • Insert blindly 90% esophageal • Inflate proximal balloon: 100 mL • Inflate distal balloon: 5 –15mL
- 40. 2. Combitube® • Seals oropharyngeal and nasopharyngeal cavities • Ventilate through blue port – Good breath sounds and no air in stomach continue ventilating – No breath sounds and air in stomach use white tube
- 41. Indications of LMA, Combitube • Routine / emergency procedures • Known / unknown difficult airway • During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible
- 42. Contraindications of LMA, Combitube …has limited mouth opening …has not fasted, except in emergency …has lung compliance …is not profoundly unconscious …has oropharyngeal growth, trauma
- 43. Always keep Alternative Intubation Aids at Easy & Known Locations
- 45. 3. Intubating LMA Available in 3 sizes, 3, 4 & 5 with dedicated ETTs available in 6 / 6.5 / 7 / 7.5 & 8mm
- 47. 4. Flexible Fiberoptic Scope
- 48. 4. Flexible Fiberoptic Scope Advantages • Allows direct airway visualization • Causes little hemodynamic stress • Nasotracheal or orotracheal route • Can be done in all age groups • Requires minimal neck movement
- 49. 4. Flexible Fiberoptic Scope Disadvantages • Expensive • Expertise requires practice • Delicate equipment needs careful maintenance • Visual field easily impaired by blood and secretions
- 50. 4. Flexible Fiberoptic Scope
- 52. 5. Lightwand (Trachlight) Advantages • Minimal neck movement • Useful adjunct to laryngoscopy • Portable and inexpensive • Usable in bloody airway • Provides definitive airway
- 53. 5. Lightwand (Trachlight) Disadvantages • Blind technique • May damage airway • Usually requires darkened room • Expertise requires practice
- 54. 6. Intubating Stylet (Bougie)
- 55. 6. Intubating Stylet (Bougie) • Gum elastic – use as guidewire Advantages • Aids placement of definitive airway • Easy to learn • Inexpensive • Can be used blindly
- 56. 6. Intubating Stylet (Bougie) • Gum elastic – use as guidewire Disadvantages • Expertise requires practice • Not recommended in “can’t intubate / can’t ventilate” scenario
- 57. When you fail to secure the airway and patient is rapidly desaturating!!!
- 58. 7. Transtracheal Jet Ventilation
- 59. 7. Transtracheal Jet Ventilation Advantages • Surgical airway of choice if 8 years or younger • Effective • Can serve as temporary airway before permanent airway • Relatively simple procedure
- 60. 7. Transtracheal Jet Ventilation Disadvantages • Significant complications if misplaced • Need proper equipment • Need high-pressure oxygen • Does not protect against aspiration
- 62. 8. Cricothyrotomy • Life-saving technique • Surgical vs. needle / Seldinger vs. percutaneous kit • You must know this procedure before starting rapid sequence
- 63. 8. Cricothyrotomy • Final common pathways for all cannot intubate / cannot ventilate scenarios • “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen
- 64. BURP your patient – grab the larynx and give… …Backward …Upward …Rightward …Pressure
- 66. Conclusions • Recognize the difficult airway – How much time do you have? – Who else is around? – What is your backup procedure • Know both old and new methods • Choose backups based on skills
- 67. Thank You Who is ready for this patient?
Editor's Notes
- An adequately stocked Difficult Airway Cart, that can be quickly wheeled in is an absolute must! The dedicated trolley must be mobile, robust ,contain everything you may need to manage various difficult airway situations and it must be capable of facilitating fibreoptic bronchoscopy. Also, don’t forget it needs to pass the standards of Infection Control Manager!!