AIRWAY NIGHTMARE

YUSFADZRY YUSUF

INTRODUCTION

Breathlessness, shortness of breath, or dyspnea is a difficult symptom for some patients to explain and quantify. Tend to be subjective to some individual to further explain. It can be a natural consequence of strenuous physical exercise.

Physiological or pathological cause in origin

INTRODUCTION cont..

Defined as the sensation of uncomfortable breathing. This breathing discomfort may reflect an increased awareness of breathing or the sense that breathing is different, difficult or inadequate. Several factors may operate in an individual patient to produce breathlessness.

The clinical analysis of the breathless patient comprises both an assessment of the severity of breathlessness and identification of its cause.

Begin by assessing the patients stability. If the patient unable to talk or complete a full sentence without pausing for a deep breath, move quickly to stabilize the patient. Return to the interview after the patient is more comfortable.

Common cause of breathlessness

MINUTES HOURS Pneumothorax Asthma Pulmonary embolism Pulmonary oedema Pneumonia Pulmonary oedema DAYSWEEKS Pleural effusion AECOAD Pneumonia Pulmonary TB

Acute asthma Metabolic acidosis

Anaphylaxis

50% of patient will have dyspnea associated with anaphylaxis Dyspnea due to aspiration generally begins abruptly within hours of the event Tamponade is associated with dyspnea, chest pain & lightheadedness

Aspiration

Cardiac tamponade

Acute pneumonia

Respiratory muscle weakness Spontaneous pneumothorax

Metabolic acidosis(DKA, lactic acidosis, aspirin overdose)

Prevalence of pneumonia in healthy patient with acute cough approx- 67%, higher in population with comorbid illness 40% patient with Guillain Barre synd will requires assisted ventilation d/t muscle weakness The lifetime risk in men is 12% for heavy smoker & <0.001% for non smokers

Severe metabolic acidosis compensate by hyperventilating. This may cause dyspnea 0r tachypnea without dyspnea.

Chronic dyspnea

Cardiac: cardiomyopathies, MI, primary pulmonary hypertension, pericardial disease. Pulmonary: Asthma, COPD, interstitial lung disease, chronic pneumonia, chronic pulmonary embolism, pulmonary neoplasm (primary/mets), pleural effusions. Miscellaneous: Anemia, neuromuscular disorder Psychiatric: Panic attack, anxiety disorder

Need intubation?.....

AIRWAY ASSESSMENT
Outlines of Presentation Anatomy Terminology History Physical Examination Management of Difficult Intubation

ANATOMY I- upper respiratory system

ANATOMY II- Lower respiratory system

ANATOMY III- larynx

ANATOMY IV

TERMINOLOGY I
Difficult

airway is said to occur

When one experiences difficulty with mask ventilation, difficulty with tracheal intubation or both When it is not possible for the unassisted anaesthesiologist to maintain the SpO2 >90% using 100% oxygen and positive pressure mask ventilation in a patient

Difficult mask ventilation

TERMINOLOGY II

Difficult laryngoscopy

When it is not possible to visualize any portion of the vocal cords with conventional laryngoscope

Difficult endotracheal intubation

When proper insertion of the tracheal tube with conventional laryngoscopy requires more than 3 attempts or more than 10 minutes

HISTORY I

Taking an adequate history is necessary to anticipate possible complications.

HISTORY II

Condition that may associated with difficult airway included

Obesity Pregnancy and labour

Increased risk of laryngeal eodema in preeclamsia

Microanathia Macroglossia Congenital syndromes (eg: Pierre-Robin, TreacherCollin) Burn contracture involving the head and neck

Anatomical abnormalities

Pierre Robin syndrome

Pierre Robin syndrome is a condition present at birth marked by a very small lower jaw (micrognathia). The tongue tends to fall back and downward (glossoptosis) and there is cleft soft palate.

Treacher Collins Syndrome

Treacher Collins Syndrome, also called mandibulofacial dysostosis, affects the head and face. Characteristics include: down-slanting eyes notched lower eyelids underdevelopment or absence of cheekbones and the side wall and floor of the eye socket lower jaw is often small and slanting forward fair in the sideburn area underdeveloped, malformed and/or prominent ears

HISTORY III

Evidence of airway obstruction

Tumour

or oedema involving upper airway Large goitre Acute epiglottitis Maxillofacial injury Airways burns

Cervical spine problem

Fracture-dislocation

cervical spine Ankylosing spondylitis, rheumatoid arthritis

or subluxation or

HISTORY IV

History of upper airway compromise during sleep History of radiotherapy head and neck region History of difficult intubation during previous anaesthetics

HISTORY V

Past Medical History

Bronchiol COPD Electrolytes

Asthma

imbalance Myasthenia gravis HPT DM

Allergy History
Drugs/food

PHYSICAL EXAMINATION I

Body weight and general status

Expect difficulty in
obese

patients (body weight > 90kg or > 20% above ideal weight) Pregnant ladies particularly those in third trimester of pregnancy

PHYSICAL EXAMINATION II

Inspection in anterior and lateral views

Inspect the facial features for bony or soft tissue abnormalities:

Small

receding chin, Mandibular or maxillary fractures, tumour and oedema

Examine the neck for swelling, goitre, scarring, tracheal deviation and position of thyroid cartilage

Inspection in anterior and lateral views

Noted the pattern of respiration for presence of stridor, tachypnoea, respiratory distress and paradoxical respiration.

PHYSICAL EXAMINATION III

Mouth Opening

Modified Mallampati Classification Inter-incisor gap (expect difficulty if< 3cm) Any intra oral cavity swelling:

Eg ; adenotonsillar hypertrophy.
Protruding incisors, loose or missing teeth Orthodontic work with cap, crown or dentures

Dentition

Position of lower teeth in relation to upper teeth

PHYSICAL EXAMINATION IV

Neck Movement

Neck movement-flexion,extension,rotation Excluded cervical spondylosis- any pain in the neck, or neurological symptoms in the arm Thyromental distance- Should be > 6.5cm. If less expect difficulty Sternomental distance >12.5cm, If less,expect difficulty

PHYSICAL EXAMINATION V

Indirect laryngscope

Relevant in laryngael tumour or thyroid enlargement scheduled for surgery

Radiological examination
Chest x-ray Cervical x-ray

To

look for fracture dislocation of cervical spines

Modified Mallampati Classification

Mallampati reported a correlation between the visibility of oropharyngeal structures and the degree of difficulty of glottic exposure on direct laryngoscope Laryngoscopy was difficult in Class III and IV The test is performed at the patients bedside with the patient sitting up and the observer at eye level. The patient is asked to open the mouth fully and protrude the tongue.

Visualization and identification of pharyngeal structures is made without phonation.

Modified Mallampati Classification

Class I: Soft palate, uvula,tonsillar pillars visible Class II: Soft palate, uvula visible, tonsillar pillars not visible Class III: Only soft palate visible Class IV: No pharyngeal structures except hard palate visible

Cormack and Lehane Classification

Grade I Visualization of the entire laryngeal aperture Grade II Visualization of the posterior portion of laryngeal aperture Grade III Visualization of the tip of epiglottis Grade IV Visualization of the soft palate only

In Grade III and IV, intubation is considered to be difficult

MANAGEMENT
MANAGEMENT OF KNOWN DIFFICULT AIRWAY

Inform senior colleague, specialist in charge and discuss options available for patient

Regional anaesthesia Local anaesthesia GA with spontaneous respiration via facial mask or laryngeal mask airway

MANAGEMENT

Ensure Empty Stomach and decreased gastric acidity

Implementation of fasting guidelines Use antacids or H2 receptor antagonist

Inform surgeon about

Potential airway problem Option of tracheostomy

MANAGEMENT

Difficult

Intubation Equipment should be checked and there are in good working order

Laryngoscopes of different types and sizes

ET tubes with various types and sizes

Stylet and gum elastic bougie

Laryngeal mask airway (LMA) of various sizes, intubating LMA, LMA Proseal, Trachlight,

Ambu bag

Airway adjunct such as

oesohageal-tracheal laryngeal Fibreoptic

Combitube,

tube laryngoscope and its

accesories

Invasive

means of airway: cricothyrotomy or minitracheostomy

MANAGEMENT

Preoxygenation with 100% oxygen for 3-5 minutes prior to induction of anaesthesia

Establish monitors consisting ECG, BP, pulse oximetry, capnography,

MANAGEMENT

Ensure that the intubating condition are optimal

Sniffing the morning air position

MANAGEMENT

Consider using alternative laryngoscope blade and handle

Macoy blade to retract the epiglottis Straight blade in patient with receding chin, prominent incisors or if epiglottis is long and floppy Short handle in a patient with short neck and pendulous breast

Thank You..