Olivier Langeron, MD, PhD

Department of Anesthesiology and Intensive CarePitié-Salpêtrière Hospital

Paris, France

Guidelines of difficult airway :

what’s new ?

Disclosures

BAXTER

COOK medical

COVIDIEN

Difficult airway management guidelines

SFAR difficult intubation : a collective expertise Ann Fr Anesth Réanim 1996, 2007 (2014)

ASA practice guidelines for management of the difficult airway Anesthesiology 1993, 2003, 2013

Canada the anticipated difficult airway with recommendations for management

Can J Anaesth 1998

UK difficult airway society guidelines for management of unanticipated difficult intubation

Anaesthesia 2004

Difficult airway issues

Anticipate it, to manage it !

How ?

difficult airway algorithms

difficult airway risk factors

Definition of DMV

1993

2003

2000

2005

2006

S

No universal definition

Simplification over time

2 main criteria despite lack of objectivity:

-Difficulties to maintain oxygenation

-Necessity of additional support to perform MV

El-Orbany M and Woehlck HJ Anesth Analg 2009

Definition of difficult intubation (DI)

ASA 2003 : DI if conventionnal laryngoscopy

> 3 attempts or >

10 minutes multiples attempts

SFAR 1996 : DI if conventionnal laryngoscopy > 2

attempts or > 10 minutes and/or alternative technique required after optimization of head position, with or without external laryngeal maneuver

2013 2006

Anticipated DMV

Impossible : - lingual tonsill hyperplasia (LTH) +++

Ovassapian A et al. Anesthesiology 2002

- increased risk after tracheal intubation failures (≥3) Mort T. Anesth Analg 2004

- laryngospasm / bronchospasm

Possible : prediction of DMV Langeron O et al. Anesthesiology 2000

Kheterpal S et al. Anesthesiology 2006

Hypertrophied Lingual Tonsil

Sagittal Sectionof normal Tongueand Larynx

From Jones DH et al. Anesth Analg 1993

Comparison of DMV prediction studies

Langeron 2000

Kheterpal 2006

DMV risk factors

http://www.sfar.org/cexpintubdifficile.html

Increasing risk if at least 2 of these factors:

• Age >55 yr• BMI >26kg/m2

• Jaw protrusion severely limited• Lack of teeth• Snoring• Beard

X 4 risk of difficult intubation with a DMV

0

0

88

Mask ventilation

Laryngoscopy - Intubation

easy impossibleCerebral damageDeath

Benumof JL Anesthesiology 1991

Definition of a difficult airway

Interaction

DMV could be a dynamic process

Multiple TI attempts

DMV prediction and number of risk factors

Kheterpal et al Anesthesiology 2006

Johnson JO et al Anesthesiology 1999

DMV risk factor and clinical relevance

Patient information +++

Ask to shave the beard ?

Optimization of mask ventilation

Better mask seal : appropriate face mask size, mask ventilation achieved by two persons with a two-handed mask ventilation technique

Use of large oral-pharyngeal / nasal-pharyngeal airways

One person assigned to O2 administration (flush valve…) and patient monitoring (SpO2 …)

DMV risk factor and clinical relevance

lower lip placement standard face mask ventilation

DMV risk factor and clinical relevance

lower lip placement standard face mask ventilation

Expired tidal volume (ml)

median value 0 ml (0–50ml) 400 ml (365–485 ml)

P < 0.001

DI risk factors

http://www.sfar.org/cexpintubdifficile.html

History of a DI ++++Recommended criteria (mandatory +++) :

Mallampati class >IITMD <65mmMO <35mm

Supplementary criteriaLimited jaw protrusion Limited cervical spine mobility

Criteria dependent on context BMI > 35kg/m2

OSA with neck circumference > 45.6cmNeck and/or facial pathologyPre-eclampsia

Strategy

Techniques

Algorithms

Strategy = Algorithms

Oygenation maintenance

Altenative techniques to control the airway

Rationale to use algorithms

To Analyze the difficult airway situation

To elaborate (local) solutions

To broadcast information

90 % ID solved with GEB

98 % patients intubated

100 % patients oxygenated

ANTICIPATED DIFFICULT INTUBATION

Strategic Options

DMV prediction

Oxygenation Maintenance ( LMA or ILMA usable ? Invasive tracheal approach ? )

Choice of the anesthestic technique : apnea or spontaneaous ventilation ?

SFAR 20062006

INTUBATION

FAILURE

ILMALMA <30 kg

FAILURE

FIBERSCOPE

FAILURE

Apnea possible Spontaneous Ventilation

Anticipated support

RecoveryTracheal access

If impossible

Mask ventilation efficientSFAR 2006

IntubationIntubation± fiberscope

Intubation

Recovery Recovery

Laryngoscopy 2 trials –

Gum elastic bougie

SFAR 20062006

Videoloaryngoscope

ILMALMA <30 kg

Transtracheal O2

Intubation

FAILURE Contre Indication

Recovery

Success

Others intubation techniques

Intubation

FAILURE

Failure

CRICOTHYROIDOTOMY TRACHEOTOMY

Recovery

OXYGENATIONMask ventilation and/or intubation failures

= SUPPORT IN ANY CASES

Recovery

2006

UNANTICIPATED DIFFICULT INTUBATION

Intubation

Failure ILMA LMA <30 kg

Mask Ventilation

= SUPPORTand DI trolley and Anesthesia maintenance +++

INTUBATION ALGORITHM

OXYGENATION ALGORITHM

efficient inefficient

Laryngoscopy 2 trials - Gum elastic bougie

Ventilation ILMA

inefficientefficient

SFAR 20062006

Videoloaryngoscope

ASA DIFFICULT AIRWAY ALGORITHM Anesthesiology 1993 / 2003 /

Consider attempt LMA

ASA DIFFICULT AIRWAY ALGORITHM Anesthesiology 2013

Videolaryngoscopes added

Algorithm Basic Rules

At each step : consider awaken patient option

Never go a “bridge too far”, never try the “last” option

Algorithm fitting with the patient case, local means and operator abilities

Logistics (material, human resources and task organization) are mandatory

Strategy to manage a difficult airway : what remains !!!

Algorithm (ASA /SFAR) :

Mask ventilation adequate or not ?

Intubation algorithm or oxygenation algorithm

The good question

The good option

Basic airway management

Preoxygenation, SpO2 monitoring

Chin lift and Jaw thrust

Oral / nasopharyngeal airway devices

Limited tracheal intubation attempts (<3)

Conclusion

DMV prediction is mandatory (SFAR guidelines for ex), and the patient should be informed about the risk and the solutions to decrease it

The main goal of airway management is patient oxygenation and not necessary endotracheal intubation

A strategy (including DMV prediction and anesthesia techniques) arising from guidelines and algorithms is always the first step in a difficult airway management

DMV

DI

Oxygenation maintenance

http://www.sfar.org/cexpintubdifficile.html