Difficult Airway Management in ICU

Main AirwayManagementAlgorithmFrom Difficult AirwayFailedAirwayWalls, RM.The Emergency Airway Algorithms2004XXX預 估 為 困 難 氣 道 嗎 ?XVR S I插 管 成 功 嗎 ?BMV? , SPO2>90% ?V熟 手 經 口 插 管 ≥3 次VXFailed AirwayNeed Intubation ?Unconscious, unreactive, near deathVDifficult AirwayV做 插 管 後 的 處 理CrashAirwayRSI (Medication)• atropine –– blocks vagal response to airway stimulation, may be protective againstarrhythmias seen with Succinylcholine• lidocaine– IV if head injury suspected• sedative:– Thiopental (50 mg test dose, then 2-4 mg/kg ,onset: 1 min, effect: 10-30min) ;– Propofol– Midazolam: 2-10mg IV (onset: 1-2 min, effect: 2-4 hr)– ketamine• good choice for patient with status asthmaticus; may raise IICP– morphine , fentanyl• neuromuscular blocker:– Succinylcholine: 1 mg/kg IV (onset 1 min, effect: 4-8 min)– rocuronium (Esmeron): 0.6 mg/kg引 導 意 識 不 清 的 鎮 靜 劑ThiopentalKetamineDiazepamMidazolamFentanyl劑 量 (IV)3-5 mg/kg1-2 mg/kg0.25-0.4mg/kg最 大 10mg0.1-0.2 mg/kg最 大 15mg2-10 μg/kg作 用 開 始時 間10-30 秒1-2 分2-4 分1-2 分1 分藥 效期 間10-30 分15-30 分30-90 分30-60 分30-60 分Ketamine 的 作 用口 內 分 泌 物胃 內 壓腦 內 壓血 壓 、 心 跳 、 心 輸 出 量眼 內 壓張 力 過 強支 氣 管 擴 張緊 急 反 應 (emergency reaction)SuccinylcholineRocuronium(Esmeron)PancuroniumAtracurium肌 肉 鬆 弛 劑0.6mg/kg劑 量 (IV)1.0-1.5 mg/kg(>10kg)1.5-2.0mg/kg(

‧ 如 何 依 據 各 種 情 境 選 擇 適 當 的 呼 吸 道 (the“airway hierarchy”) , 包 括 下 列 ..– 如 何 選 擇 適 當 並 正 確 使 用 較 具 侵 襲 性 的 呼 吸 道 :• Laryngeal mask airway (LMA) (Class Class IIa)• Esophageal-tracheal (Combitube) tube (Class IIa)• Tracheal tube (well trained HCP, Class I) (welltrained EMS, Class IIa)– 如 何 確 定 tracheal tube 放 置 的 位 置 正 確 :• Physical exam criteria• End-tidal CO 2 detection (Class IIa) (for Combitube,LMA (Class Indeterminate))• Esophageal detector device (EDD) (Class IIa)– 如 何 固 定 tracheal tube 以 防 止 其 滑 脫Supraglottic Ventilatory Devices• 喉 罩 與 插 管 喉 罩Laryngeal mask airway (LMA)Intubating LMA (I-LMA)• 食 道 氣 管 聯 合 管Esophageal Tracheal Combitube• 氣 囊 式 口 咽 氣 道Cuffed oropharyngeal airway• 喉 管Laryngeal tubeEsophageal Tracheal Combitube (I)• Kendall Sheridan• A disposible doublelumen tube• Combine aconventional ET andan esophagealobturator airway• Ventilation is possiblewith eithertracheal or esophagealintubationEsophageal Tracheal Combitube (II)• Inserted blindly, orlaryngoscopy to enhance placement• Should protect against aspiration• Especially useful --- Direct visualizationof the vocal cords is not possibleCuffed Oropharyngeal Airway (I)氣 囊 式 口 咽 氣 道• COPA TM , Mallinkrodt Medical• First described by Greenberg in the early 1990s• Inexpensive, disposibleSingle use device, no risk of cross infection• Modified Guedel’s airwayAn inflatable distal high volume, lower pressure cuffA 15 mm proximal adapter• Insertion technique is the same as for a Guedel’sairway4

Almost like a single lumen,shorten CombitubeLaryngeal TubeCan be attached directly to any breathingsystemA “bridge to extubation”Not protect airway fromregurgitation and aspirationContraindication for full stomachCurrently available in four size: 8, 9, 10, 11Compared to theCombitube, easier toinsertPossibility of esophagealrupture is increased ifvomiting occur, as there isno esophageal ventWhere is the hole?HistoryFirst elective oral intubationValleculaAE foldCuniformCorniculateArytenoidINTUBATION OF THE LARYNX.htmThree primary laryngoscope blades• Jackson laryngoscope blade• Miller laryngoscope blade• MacIntosh laryngoscope blade5

Modifications of LaryngoscopesRigid laryngoscopes– Flexible tip laryngoscopesMcCoy levering laryngoscopeIndirect rigid fiberoptic laryngoscopes– Bullard laryngoscope– WuScope system– AWS laryngoscopeBullardVideoIntubationLaryngoscopePentax-AWSGlidescopeAWSWuScopeEndotracheal tube guides• Eschmann tracheal tube introducer• Rüsch ® Intubation stylet• Frova intubation introducer• Arndt airway exchange catheter set• Aintree airway exchange catheter• Lighted StyletsTrachlightShikani OpticalStyletLighted Stylet IntubationA.K.A. :Trachlite ®(Rusch), Trachlight ® (Laerdal), Surch-lite ® (Aaron Medical), "Lightwand"®IntroductionLighted stylet guided intubation can be a useful techniquefor oral and nasal intubations in both asleep and awakepatients (1,3). This type of intubation technique has areported success rate as high as 99% in experienced hands(3). It can be used in anticipated and unexpected difficultairways where conventional direct laryngoscopy has failed(2,7). It can be achieved as fast as conventional directlaryngoscopy by one skilled in its use (3,4,5).Cannot Ventilate, CannotIntubate Situation• Insertion of LMA• Insertion of the combitube• Insertion of transtracheal jet ventilation• Creation of a surgical airway6

Special Airway Techniques• Flexible fiberoptic intubation• Retrograde intubation• Transtracheal jet ventilation• Cricothyrotomy• Percutaneous dilatation tracheostomyFiberoptic Intubation• Oral vs nasal approach• Under general anesthesia• Under rapid sequence Induction & intubation• Fiberoptic intubation aided by rigidlaryngoscopy• Fiberoptic intubation through LMA orcombitube• Fiberoptic and retrograde intubationPhysiological Changes toFiberoptic Intubation• Respiratory effectHypopharynx – glossopharyngeal N –laryngealspasmLaryngeal surface of the epiglottis, larynx,bronchial tree – vagus N – bronchial spasm• Cardiovascular effectSympathoadrenal response depend on thetechnique, intubation time, smoothness ofintubation, size of the fiberscope and ET tubeFiberoptic Intubation1.2% unsuccessful attempts(1) inability to visualize the larynx(2) inability to advance the tube overthe fiberoptic bronchoscope(3) inability to direct the tube towards the larynxOvassapian et al: Anesth Analg 1983; 62: 692-695Retrograde Intubation• Through cricothyriod membrane• A blind technique• Useful in patients with cervical injury orairway trauma• As a adjunct for fiberoptic intubation• Arndt airway exchange catheter氧 氣 和 通 氣 的 方 法• 氣 管 穿 刺 導 管7

氧 氣 和 通 氣 的 方 法• 環 甲 狀 膜 切 開 術• 氣 管 切 開 術Recurrentlung CAs/p stentingwithgranulationbronchialobstructinand stentdeherenceNeedle cricothyrotomyManual JetventilatorTranstracheal Jet Ventilation(TTJV)Temporizing means of rescue ventilationJet ventilator8

DifficultAirwayAlgorithmDifficult Airway PredictedSPO2>90% ?求 救XY BMV? ,SPO2>90% ?XBMV 可 成 功 Failed AirwayYX插 管 可 能 成 功YRSIXAwake techniqueGo to Main AlgorithmXY預 估 SPO2 可 >90% ?做 插 管 後 的 處 理XYBlind nasaltracheal, Failed Airwaycricothyrotomy, fiberoptic,I-LMA,lighted styletDifficult Airway1. Head anomalies2. Facial anomaliesa. maxillary and mandibular diseasesb. temporomandibular joint disease3. Mouth and tongue anomaliesa. microstomiab. tongue disease4. Nasal, palatal and pharyngealanomaliesa. choanal atresiab. nasal massesc. palatal anomaliesd. enlarged adenoidse. tonsillar diseasef. pharyngeal diseasesg. retropharyngeal and parapharyngealdiseasesh. pharyngeal bullae or scarring5. Laryngeal anomaliesa. laryngomalaciab. epigottitisc. congenital glottic lesionsd. laryngeal papillomatosise. laryngeal granalomasf. congenital and acquired subglotticdisease6. Tracheobronchial tree anomaliesa. tracheomalasiab. croupc. bacterial tracheitisd. mediastinal massese. vascular malformationsf. foreign body aspiration7. Neck and spine anomaliesa. neckb. limited cervical spine mobilityc. congenital and acquired cervical spineinstabilityPre-intubation Airway Exam (1)• Length of upper Incisors• Involuntary: Maxillary Teeth Anterior toMandibular Teeth• Voluntary: Protrusion of Mandibular TeethAnterior to the Maxillary Teeth• Inter-cisor Distance• Oropharyngeal ClassPre-intubation Airway Exam (2)• Narrowness of Palate• Mandibular Space Length (thyromentaldistance)• Mandibular Space (MS) Compliance• Length of Neck• Thickness of Neck• Range of Motion of Head and Neck9

如 何 確 定 氣 管 內 管 的 位 置 ?Primary2005 年 的 準 則 已 經 取 消 所 謂 的 次 級 評 估也 就 是 全 部 都 是 屬 於 初 級 評 估Secondary2005ACLSPrimary1992 E.C.Cgold standard理 學 檢 查 & 觀 察2000 ACLSEDD ETCO 2Bronchoscopy( 觀 看 氣 管 軟 骨 )BulbtypeCapnographyDetectorCxR( 緩 不 濟 急 )Tracheal Tube Holders: Adult and Infant( 市 售 的 專 用 固 定 器 )•Secure the endotracheal tube with tape or a commercial device (Class I).•These devices may be considered during patient transport (Class IIb).救 人 為 快 樂 之 本Suggest Contents of Special Unitfor Difficult Airway Management• Rigid laryngoscpe blades - alternate design & size• Endotracheal tubes of assorted sizes• Endotracheal tube guides• Various supraglottic airway devices-LMA/COMBITUBE• Fiberoptic intubation equipment• Retrograde intubation equipment• Equipments for transtracheal jet ventilation• Equipments suitable for emergency surgicalairway access-cricothyrotomy• An exhaled CO2 detector10