What equipment should What equipment should be in your Difficult be in your Difficult Airway Cart ?Airway Cart ?

Margaret HealyMargaret HealyCNM 2 AnaesthesiaCNM 2 AnaesthesiaUniversity College HospitalUniversity College HospitalGalwayGalway

What is a “Difficult What is a “Difficult Airway”?Airway”?

The difficult airway is defined as The difficult airway is defined as the clinical situation in which a the clinical situation in which a

conventionally trained conventionally trained anaesthetist experiences anaesthetist experiences

difficulty with mask ventilation, difficulty with mask ventilation, difficulty with tracheal intubation, difficulty with tracheal intubation,

or bothor both

Difficult Airway Society Difficult Airway Society recommendations recommendations

Practitioners should be competent in a number of Practitioners should be competent in a number of core airway skills.core airway skills.

Work in an appropriate environment (trained assistance, Work in an appropriate environment (trained assistance, with access to a range of airway devices and techniques, with access to a range of airway devices and techniques, appropriate monitoring during surgery and facilities for appropriate monitoring during surgery and facilities for the appropriate level of post op care) the appropriate level of post op care)

That equipment is stocked in dedicated trolleys. That equipment is stocked in dedicated trolleys. These should be regularly checked and stocked. These should be regularly checked and stocked. The exact number and location of each trolley The exact number and location of each trolley should be determined locallyshould be determined locally

All anaesthetists and anaesthetic assistants should be All anaesthetists and anaesthetic assistants should be familiar with the contents and location of the trolleyfamiliar with the contents and location of the trolley

Training should be provided in the use of equipment Training should be provided in the use of equipment selected by each departmentselected by each department

There should be a Consultant Airway Coordinator in There should be a Consultant Airway Coordinator in each department, a training room and dedicated lists for each department, a training room and dedicated lists for airway trainingairway training

CORE SKILLSCORE SKILLS

LMA for ventilationLMA for ventilation

FOI through LMA, FOI through LMA,

Aintree or other airwayAintree or other airway

ILMAILMA

Indirect laryngoscopes Indirect laryngoscopes

Glidescope, Airtraq etc Glidescope, Airtraq etc

Emergency Emergency

cricothyrotomycricothyrotomy

Difficult Airway TrolleyDifficult Airway Trolley

A A shelfshelf and and 5 Drawers5 Drawers that follow sequence that follow sequence of Difficult Airway of Difficult Airway AlgorithmAlgorithm

MobileMobile RobustRobust Clearly labelledClearly labelled Easily cleanedEasily cleaned Attach DAS algorithmsAttach DAS algorithms Restocking listRestocking list

Recommended equipment for Recommended equipment for management of unanticipated management of unanticipated difficult intubationdifficult intubation

DAS guidelines algorithm flowchartsDAS guidelines algorithm flowcharts Equipment list for restockingEquipment list for restocking At least one alternative blade(e.g. straight, At least one alternative blade(e.g. straight,

McCoy)McCoy) Intubating LMA (Size 3,4,5 with dedicated Intubating LMA (Size 3,4,5 with dedicated

tubes and pushers)tubes and pushers) Flexible fibreoptic laryngoscope (with Flexible fibreoptic laryngoscope (with

portable/battery light source)portable/battery light source) Aintree Intubation CatheterAintree Intubation Catheter Proseal LMA / Supreme LMAProseal LMA / Supreme LMA Cricothyroid cannulae with High pressure jet Cricothyroid cannulae with High pressure jet

ventilation system (Manujet) ventilation system (Manujet) OROR Large bore cricothyroid cannulae (e.g. Cuffed Large bore cricothyroid cannulae (e.g. Cuffed

Melker) Melker) OROR Surgical Cricothyroidotomy kitSurgical Cricothyroidotomy kit

Miller Blades Miller Blades (Straight)(Straight) The Miller blades are commonly used for The Miller blades are commonly used for

infants. It is easier to visualize the glottis infants. It is easier to visualize the glottis using these blades than the Macintosh blade using these blades than the Macintosh blade in infants, due to the larger size of the in infants, due to the larger size of the epiglottis relative to that of the glottis. epiglottis relative to that of the glottis.

Levering Laryngoscope Levering Laryngoscope (McCoy)(McCoy)

Hinged tip which facilitates elevation of the epiglottisHinged tip which facilitates elevation of the epiglottis Less force required to intubateLess force required to intubate Improves view at laryngoscopyImproves view at laryngoscopy Useful in patients wearing cervical hard collarsUseful in patients wearing cervical hard collars InexpensiveInexpensive Steep learning curveSteep learning curve

Supraglottic DevicesSupraglottic Devices

Supraglottic devices are the suitable Supraglottic devices are the suitable alternative to endotracheal intubation, alternative to endotracheal intubation, Useful when endotracheal intubation Useful when endotracheal intubation has failedhas failed

Suitable for use by those with limited Suitable for use by those with limited experience with endotracheal experience with endotracheal intubationintubation

Should be immediately available for Should be immediately available for every difficult airway situationevery difficult airway situation

Various types availableVarious types available

Fastrach (Intubating Fastrach (Intubating LMA)LMA)

Advanced version of the Advanced version of the standard LMA, which allows a standard LMA, which allows a specifically designed ETT to be specifically designed ETT to be passed blindly into the tracheapassed blindly into the trachea

Useful in “can’t intubate, can’t Useful in “can’t intubate, can’t ventilate” scenariosventilate” scenarios

Allows fast insertion into Allows fast insertion into correct position without correct position without moving patients head or neckmoving patients head or neck

Can be used alone or as a Can be used alone or as a guide to intubation guide to intubation

Facilitates ventilation between Facilitates ventilation between ILMA insertion and ETT ILMA insertion and ETT insertioninsertion

Available in 3 sizes, 3, 4 & 5 Available in 3 sizes, 3, 4 & 5 with dedicated ETTs available with dedicated ETTs available in 6 / 6.5 / 7 / 7.5 & 8mmin 6 / 6.5 / 7 / 7.5 & 8mm

LMA Pro-SealLMA Pro-Seal

Not necessarily a Difficult Not necessarily a Difficult Airway Device, but is useful Airway Device, but is useful in situation where patient in situation where patient has not been fastinghas not been fasting

May be useful in failed May be useful in failed obstetric intubationobstetric intubation

This has an extra tube This has an extra tube which provides excess which provides excess access to stomach contentsaccess to stomach contents

Protects against aspiration Protects against aspiration by providing an escape for by providing an escape for unexpected regurgitationunexpected regurgitation

Drain tube prevents against Drain tube prevents against gastric insufflationgastric insufflation

LMA Supreme™LMA Supreme™

Quite new to the market, Quite new to the market, combines all the best features of combines all the best features of all previous LMA except you can’t all previous LMA except you can’t intubate through itintubate through it

The SLMA is easily and rapidly The SLMA is easily and rapidly inserted, providing a reliable inserted, providing a reliable airway and a good airway sealairway and a good airway seal

Rates of failure, manipulations Rates of failure, manipulations required and complications are required and complications are very low. very low.

Can be used when tracheal Can be used when tracheal intubation fails in non-fasted intubation fails in non-fasted patients patients

Can be used in CPRCan be used in CPR

Useful in “failed intubation” and Useful in “failed intubation” and the “can’t intubate-can’t the “can’t intubate-can’t ventilate” situationventilate” situation

  

Fibreoptic Fibreoptic BronchoscopeBronchoscope

Fiberoptic Intubation Fiberoptic Intubation (FBI)(FBI) The use of a flexible bronchoscope to intubate The use of a flexible bronchoscope to intubate

The endotracheal tube is passed directly over the bronchoscope into the The endotracheal tube is passed directly over the bronchoscope into the tracheatrachea

Uses: Uses: - Patients with difficult airways - Patients with difficult airways

- Pre-operative assessment- Pre-operative assessment

- Extubation assessment- Extubation assessment

Advantages:Advantages:

– This technique allows direct visualization of the airwayThis technique allows direct visualization of the airway

– Direct confirmation of ETT placementDirect confirmation of ETT placement

– Can be done awake Can be done awake

Disadvantages:Disadvantages:

– Expensive, difficult, requires care and skillExpensive, difficult, requires care and skill

– View may be hampered by blood or secretionsView may be hampered by blood or secretions

– Requires detailed decontamination / traceabilityRequires detailed decontamination / traceability

Berman AirwayBerman Airway

Berman, an American anaesthetist , Berman, an American anaesthetist , designed airways to aid blind intubationdesigned airways to aid blind intubation

Useful to aid oral fibreoptic intubationUseful to aid oral fibreoptic intubation Also useful as a bite blockAlso useful as a bite block

Aintree Intubation Aintree Intubation CatheterCatheter

Hollow bougie which fits over a standard intubating fibrescopeHollow bougie which fits over a standard intubating fibrescope Aids intubation through a dedicated airway such as a Aids intubation through a dedicated airway such as a

laryngeal masklaryngeal mask Place LMA, load Aintree onto fibrescope, pass fibrescope to Place LMA, load Aintree onto fibrescope, pass fibrescope to

the carina and slide off the aintree. Remove the fibrescope the carina and slide off the aintree. Remove the fibrescope and LMA and intubate over the Aintreeand LMA and intubate over the Aintree

Possible to ventilate via this catheter if necessary, throughout Possible to ventilate via this catheter if necessary, throughout the intubation procedurethe intubation procedure

Surgical TechniquesSurgical Techniques

A cricothyrotomy is only indicated when A cricothyrotomy is only indicated when all other devices and techniques have all other devices and techniques have failed or are not availablefailed or are not available

Final step for CICV in all airway Final step for CICV in all airway algorithmsalgorithms

Quicker than a tracheotomyQuicker than a tracheotomy Life savingLife saving Convert to definitive airway asapConvert to definitive airway asap MustMust be provided on all carts be provided on all carts

Surgical Airway Surgical Airway TechniqueTechnique

3 different techniques3 different techniques Needle Cricothyrotomy +TTJVNeedle Cricothyrotomy +TTJV

(Manujet)(Manujet) Large Cannulae Cricothyrotomy Large Cannulae Cricothyrotomy

(Melker / Quicktrach)(Melker / Quicktrach) Surgical CricothyrotomySurgical Cricothyrotomy

1.Needle 1.Needle Cricothyrotomy Cricothyrotomy ((Manujet III with Jet Ventilation Manujet III with Jet Ventilation Catheter)Catheter) Useful for elective or emergency TTJVUseful for elective or emergency TTJV Perc puncture of cricothyroid ligament Perc puncture of cricothyroid ligament It consists of an injector with pressure gauge It consists of an injector with pressure gauge

and adjustable driving pressure (0-4 BAR)and adjustable driving pressure (0-4 BAR) Catheters available in 3 sizes Adult 13g, Child Catheters available in 3 sizes Adult 13g, Child

14g and Baby 16g14g and Baby 16g

1.Transtracheal Jet 1.Transtracheal Jet Ventilation (TTJV)Ventilation (TTJV) Jet ventilation using either specialized ventilator or high Jet ventilation using either specialized ventilator or high

pressure driven valve circuit via a catheter passed pressure driven valve circuit via a catheter passed through the cricothyroid membranethrough the cricothyroid membrane

Similar technique to previousSimilar technique to previous

DisadvantagesDisadvantages– Requires high pressure gas sourceRequires high pressure gas source

– May cause subcutaneous emphysema, pneumo-May cause subcutaneous emphysema, pneumo-mediastinum, pneumothorax or other types of mediastinum, pneumothorax or other types of barotraumabarotrauma

Uses:Uses:– Emergency ventilation in the can’t intubate can’t Emergency ventilation in the can’t intubate can’t

ventilate scenarioventilate scenario

2. Cricothyrotomy 2. Cricothyrotomy Catheter Catheter (Melker cuffed/ (Melker cuffed/ Quicktrach)Quicktrach) SyringeSyringe 18g Introducer 18g Introducer

Needles (5cm & Needles (5cm & 7cm)7cm)

GuidewireGuidewire Curved DilatorCurved Dilator Airway CatheterAirway Catheter

2. Large Cannulae 2. Large Cannulae CricothyrotomyCricothyrotomy

Used for emergency airway access when Used for emergency airway access when conventional ETT intubation cannot be conventional ETT intubation cannot be performedperformed

Percutaneous entry ( Seldinger ) technique Percutaneous entry ( Seldinger ) technique via cricothyroid membranevia cricothyroid membrane

Dilate the tract and tracheal entrance site Dilate the tract and tracheal entrance site to permit passage of the emergency to permit passage of the emergency airwayairway

Cuffed catheter to protect and control Cuffed catheter to protect and control airwayairway

3.Surgical 3.Surgical CricothyrotomyCricothyrotomy

RequirementsRequirements:: No 11 blade No 11 blade Size 6 Shiley tracheostomySize 6 Shiley tracheostomy

( OR small ETT size 5.0-6.0)( OR small ETT size 5.0-6.0) Small artery forcepsSmall artery forceps

Technique:Technique:

• Head fully extended • longitudinal incision is made

through the skin and subcutaneous fat over the thyroid and cricoid cartilages

• Tissue bluntly dissected• Cricothyroid ligament is

transversely incised• Tracheal tube inserted

AccessoriesAccessories

Fibreoptic Bronchoscopy accessories – Fibreoptic Bronchoscopy accessories – suction adaptor, irrigation valve, camera suction adaptor, irrigation valve, camera head, light cable, Leak tester,head, light cable, Leak tester,mouth guard,mouth guard,

Berman airwayBerman airway Endoscopy masksEndoscopy masks Airway anaesthesia – nebuliser, atomiser, Airway anaesthesia – nebuliser, atomiser, Xylocaine Spray , Xylocaine 4% topical, Xylocaine Spray , Xylocaine 4% topical,

Co-Phenylcaine Co-Phenylcaine Battery Light SourceBattery Light Source

DocumentationDocumentation

D.A.S. guidelinesD.A.S. guidelines Set up Set up

instructionsinstructions Decontamination Decontamination

InstructionsInstructions Checking / Checking /

Restocking ListRestocking List

ConclusionConclusion

Lack of clear instructions Lack of clear instructions Technology is changing quicklyTechnology is changing quickly Core skills are vitalCore skills are vital Difficult Airway devices should be Difficult Airway devices should be

used in routine cases to ensure used in routine cases to ensure familiarityfamiliarity

?? Standard Difficult Airway Cart ?? Standard Difficult Airway Cart nationally nationally