Dr.

Gayathri Ramanathan
Associate Professor
SRM MEDICAL COLLEGE HOSPITAL &
RESEARCHCENTRE
08/01/16

OBJECTIVES
Causes of difficult intubation
Basic airway evaluation
Management plan for Anticipated difficult airway Plan A, Plan
B , Plan C & Plan D
Gallery of tools
The Expected & Unexpected Difficult Airway

08/01/16

DEFINITION
American society of Anesthesiologist (ASA)
suggested

(difficult to ventilate)
That when sign of inadequate ventilation
could not be reversed by mask ventilation
or
oxygen saturation could not be maintained
above 90%

DEFINITION
(difficult to intubate)
If a trained Anaesthetist using conventional
laryngoscope takes more than 3 attempts
or
more than 10 minute to complete tracheal
intubation

H
T
I
W
N
!
EVE PER
N
O
O
I
R
T
P
A
U
L
A
V
E

1550%

ARE ONLY PICKED UP

LT
U
C
I
DIFF
K
S
A
N
M
O
I
T
A
L
I
T
N
VE

DIFFICULT INTUBATION

EXTREMELY
DIFFICULT

ABANDON

GS 1 in 2000
OBG- 1 in 300

CAUSES OF
DIFFICULT INTUBATION

Pre-op assessment
Equipments

Anesthetist
Experience not
enough
Poor technique

Malfunctionin
g equipment
Inexperienced
assistance

CAUSES OF
DIFFICULT INTUBATION
Patient
1.
2.

Congenital causes
Acquired causes

Basic airway evaluation

in all patients
Dr. Binnions LEMON Law
BONES
The 4 Ds

Dr. Binnions Lemon Law: An

easy way to remember
multiple tests
L ook externally.
E valuate the 3-3-2 rule.
M allampati.
O bstruction?
N eck mobility.

L: Look Externally

Obesity

Short
muscular
neck

Buck
teeth

Recedin
g jaw
Denture
s

L: Look Externally

Macroglossia
Stridor
Facial
trauma

E:Evaluate the 3-3-2

rule

3 fingers fit in mouth- Inter incisor

distance

fingers fit from mentum

to hyoid cartilage

2 fingers fit from the floor

of the mouth to the top of

the thyroid cartilage

14

M: Mallampati classification

Class-I

soft palate, fauces;

uvula, anterior and
the posterior pillars.

Class-III soft palate and base of uvula

the soft palate, fauces Class-II

and uvula

Only hard palate Class-IV

O:
Obstruction?

Blood

Vomitus

Teeth

Epiglottis

Dentures

Tumors

N:Neck mobility
-Measurement of
Atlanto-Occipital Angle

Thyro- Mental Distance

Measure from upper edge of thyroid cartilage to chin with

the head fully extended.
A short thyromental distance = an anterior
larynx .

> 7 cm is usually = easy intubation

< 6 cm =

difficult airway
18

MANAGEMENT PLAN
OF
ANTICIPATED
DIFFICULT AIRWAY

08/01/16

19

Is mask ventilation going to

be difficult?
Cant ventilate
Defined by BONES
Beard
Obesity
No teeth
Elderly
Snoring

v
t

n
Ca

e
t
a
l
i
t
en

Is laryngeal visualization
going to be difficult?
Cant intubate
Defined by 4 Ds
1.Disproportion
2.Distortion
3.Dysmobility
4.Dentition

Disproportion

e
t
a
b
u
t
n
i

Achondroplasi
a

Pierre robin
sequence

Acromegal
y

n
a
C

Prognathis
m

t
Distortion
a
b
u
t
n
i
Burns contracture

Neurofibromatosis

n
a
C

Cystic hygroma

Dysmobility

TM joint Ankylosis

e
t
n
a
a
C tub
in
Klippel
Fiel

Dentitio
n

n
a
C

i
t

u
t
n

Edentulous

Buck teeth

e
t
a
b

Is cricothyroidotomy going
to be difficult?
Cant Rescue

Should assessment reveal a potentially

difficult airway the cricothyroid membrane

should be identified and marked, BEFORE an
intervention is undertaken

Possible Options!
Following airway assessment, the person
performing the intubation should be in a
position to decide between three possible
options
1.Awake intubation
2.Quick look
3.Induction and paralysis

1. Awake Intubation
The patient needs to be intubated awake
There is significant risk of complications if
sedatives and/or muscle relaxants are
administered prior to airway control.

2. Quick Look
The patient may be sedated for an attempt at
direct laryngoscopy WITHOUT muscle
relaxation
(Quick Look)
There is some risk of failed laryngoscopy
but
There should be a low risk of failed mask
ventilation.

3. Induction & Paralysis

The patient may be induced and paralyzed,
In this case the patient is assessed as having a
low risk of laryngoscopy and/or mask
ventilation

Pre-oxygenation: How
Much Is Enough?
Two techniques common in use:
1. Tidal volume breathing (TVB) of oxygen
for 35 min
2. Deep breaths (DB) 4 times within 0.5 min
Both are equally effective in increasing
arterial oxygen tension (Pao2).

Anesth Analg 1981; 60: 3135

Pre-oxygenation
m
o
r
f
y
a
r
e
e
n
v
p
o
a
c
e
d
r
e
s
c
y
l
u
u
t
o
d
n
e
n
e
i
i
n
n
i
c
a
e
t
b
n
ffi
o
n
i
l
l
u
o
g
s
o
o
e
Sp ylch ccur
s
m
o
e
h
n
h
i
o
w
t
c
t
c
n
s
o
t
u
e
n
s
.
c
v
e
d
y
e
j
r
ma to p n sub ssiste
i
y
a
l
t
k
n
c
o
o
i
i
n
t
u
a
s
q
r
i
u
n
t
o
a
i
s
t
e
a
l
Each subject
received
5
mg/kg
thiopental and 1 mg/kg succinylcholine.
d
i
t
n
e
v Anesthesiology 2001, 95: 754-759

What are we going to do if

we dont get the Tube?
Plans A, B ,C and plan D.
Know this answer before you tube.

Failure -Why does it

happens?
No critical discussion with colleagues about

proposed management plan

No request for experienced help
Exaggerated idea of personal ability
Ill-conceived plan A and/or plan B
Poorly executed plan A and/or plan B
Persisting with plan A too long, starting the
rescue plan too late
Not involving, and preparing, surgical
colleagues

GALLERY OF TOOLS
ILMA
Video laryngoscopes
Malleable video stillet- Levitan scope
Fibreoptic bronchoscope

ELECTIVE

EMERGENCY

ELECTIVE

Old case of Hemi-mandibulectomy with

forehead flap with trismus for block
dissection of neck nodes

Anesthesia of choice - G.A.

Intubating technique of
choice
?

MANAGEMENT PLAN
OF
UNANTICIPATED
DIFFICULT AIRWAY

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45

TheUnexpected
DifficultAirway
Experienced help may not be immediately
available
Special equipment may not be immediately
available
A general anaesthetic has usually been
administered
A long acting relaxant may have been given
Backup airway management plans may be
poorly thought out

46

Take home
message
Be familiar with the alternative methods of

intubating technique and use it regularly in

your day today practice e.g. ILMA, FOB,
Videolaryngoscopes,
cricothyroidotomy.
So that you wont fumble at the time of crisis

08/01/16

47

Challenges
may be
Waiting for you

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48

Thank