Category Archives: airway

Anticipated Difficult Airway

Remember to consider – to get an idea of what you are dealing with.

Thoughts. Which of the following are anticipated to be difficult and what is the plan for each:

  • Mask ventilation
  • LMA insertion/use
  • Endotracheal intubation
  • Front of neck access

 

Options to consider:

  • AFOI
  • Inhalational induction vs IV induction
  • Spontaneous vs controlled ventilation (+/- muscle relaxant)
  • Mask ventilation with guedel + two person technique
  • THRIVE
  • Direct laryngoscopy
  • Video laryngoscopy
  • Asleep FOI
  • Front of neck: surgical cricothyroidotomy by us vs ENT trache (awake?)

Unanticipated difficult intubation – DAS guidelines 2015

Updates & take-home messages:

  • Laryngoscopy -> SAD -> FM ventilation -> cricothyroidotomy
  • If poor view at laryngoscopy remove cricoid under direct vision + suction at hand
  • Use second generation SAD device
  • Removed cricoid for SAD insertion
  • Successful SAD = ‘stop and think’ moment
  • CICO -> paralyse, continue supraglottic O2 attempts -> front-of-neck
  • Laryngeal handshake
  • Front-of-neck = scalpel (No.10, broad blade), bougie, 6.0mm COETT

 

  • Limit the number of airway interventions
  • DO NOT REPEAT SAME TECHNIQUE
  • First attempt is the best. Make it so.
  • Use apnoeic oxygenation in high risk patients
  • Neuromuscular blockade (rocuronium)

https://www.das.uk.com/guidelines/das_intubation_guidelines

Airtraq tips

In a situation where the view is good but difficulty is encountered passed ETT between the cords consider the following:

Manoeuvring Airtraq (+/- head/airway) e.g. ‘drop’ it into pharynx to align angles better

Positioning of the glottis ‘target’ towards bottom right of screen

Use of bougie or wide bore NG tube (with ETT railroaded)

Alternative ETT e.g. standard instead of RAE

Paediatric airway surgery recipe

e.g. laryngo-tracheo-bronchoscopy

Standard induction (IV or gas)

Maintenance using TIVA:

  • propofol 400 -> 300 -> 100 mcg/kg/min
  • remi 0.2 – 0.1 mcg/kg/min

Laryngoscopy:

  • Use to judge adequate depth of anaesthesia
  • insert nasal uncuffed (standard) ETT to level just proximal to cords
  • Spray larynx/cords/distally – take max allowed dose of lignocaine 10%, dilute to make up to desired volume, spray using MAD/atomiser

Ventilation:

  • Aim for spontaneous ventilation of oxygen enriched air while applying PEEP with bag
  • Can hand ventilate if mouth is closed (but risks insufflation of stomach)

Emergence of spontaneously breathing patient with NPA

– KP @ LRI

AFOI topicalisation

1. Glycopyrolate 200-400mcg IV/IM ASAP
2. Sedation EARLY

Topicalise:
Spray co-phenylcaine to nostrils
Gargle 4x5ml of Instilagel
Spray Xylocaine (10% lignocaine) to oropharynx -> distally

+/-
Spray-as-you-go with epidural catheter (2ml 1% lig)
Cricothyroid puncture (2ml 1%lig)

Alternatives/adjuvants:
Instilagel+soft NPA to nostril NB risk of bleeding -> bad view/problems
4% lignocaine squirt to nostril using teat
4% lignocaine squirt to oropharynx
‘nebulised’ lignocaine using cannula + 1% lignocaine