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Airway Endoscopy and Laser
Anesthetic considerations
Dr. Abdul-Hamid Samarkandi,
FFARCSI,KSUF
Chairman Anaesthesia Department
King Saud University Hospitals
King Khalid University Hospital
Objectives:
1- Airway assessment and patient
examination.
2- Mapping a plane for the perioperative
sequlae.
3- Requirements for save endoscopy.
4- Selection for reasonable anesthetic
technique.
5- Intraoperative challenges.
6- Postoperative recommendations.
7- Considerations for Laser surgery.
1- Airway assessment and
patient examination.
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Must be able to assess or anticipate the degree of
difficulty
Then select method most likely to succeed .
Clinical Airway Assessment
Airway examination:
- Indirect laryngoscope.
Radiographic studies
Lung reserves: flow-volume loop.
Reserving ICU bed for postop.respiratory care.
* Discusse the perioperative plan with the surgeon
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Historical features ( prior AW difficulty):
– Anesthesia record in old chart.
– Medical alert bracelet.
– Tracheostomy scar.
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Anatomical features:
– C-spine mobility
– External dimensions ( 3-3-2 rule)
* Mouth opening 3 fingers (TMJ).
* Mandible large enough to accommodate
tongue.
* 3 fingers from tip of chin to hyoid.
– Length of neck/position of larynx - 2 fingers
between top of thyroid and floor of jaw
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Teeth
– large or protruding incisors obstruct vision
– jagged teeth can lacerate balloon
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Oral dimensions
– narrow facial features and high arched
palates (decreased lateral space)
– Mallampatti classification
Mallampatti Classification
(Tongue to Pharyngeal Size)
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I - soft palate, uvula, tonsillar pillars
visible
– 99 % have grade I laryngoscopic view.
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II - soft palate, uvula visible.
III - soft palate, base of uvula.
IV - soft palate not visible
– 100% grade III or grade IV laryngoscopic
views.
Mallampatti Classification
Predictors of Difficult
Laryngoscopy
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Direct laryngoscopy intubation is difficult in 1%
- 4% and impossible in 0.05% - 0.35% of
patients who have seemingly normal airways.
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The unanticipated difficult laryngoscopy
intubation places patients at increased risk of
complications ranging from sore throat to serious
airway trauma.
Moreover, in some cases we may not be able to
maintain a patent airway, leading to severe
complications such as brain damage or death.
Predictors of Difficult
Laryngoscopy
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Short, thick, muscular neck.
Receding mandible.
Protruding maxillary incisors
– “Buck teeth”
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Poor TMJ mobility/ limited jaw opening
Limited head and neck movement
– ( including trauma )
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High, arched palate
Predictors of Difficult
Laryngoscopy
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Tumor, abscess or hematoma
Burns
Angioneurotic edema
Blunt or penetrating trauma
Rheumatoid arthritis, ankylosing spondylitis
Congenital syndromes
Neck surgery or radiation
Response to Unanticipated Difficulty
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Difficult laryngoscopy and intubation
– Can’t intubate but Can ventilate
– Can’t intubate and Can’t ventilate
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Difficult Mask Ventilation
Response to Unanticipated
Difficulty
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Bag the patient.
Maximize neck flex/ head extension.
Move tongue out of line of site.
Maximize mouth opening.
ID landmarks and adjust blade.
BURP maneuver
– (Backwards Upwards Rightwards Pressure on
Thyroid Cartilage)
Increasing lifting force.
Consider Miller blade.
Bag the patient.
Response to Unanticipated
Difficulty
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An optimal or best attempt at difficult
laryngoscopy should consist of :
– use of optimal sniffing position
– no significant muscle tone
– use of optimum external laryngeal
manipulation (BURP)
– one change in length of blade
– one change in type of blade
– a reasonably experienced laryngoscopist
Response to Unanticipated
Difficulty
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Remember, the first response to failure to
intubate should always be to Bag-MaskVentilate the patient.
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The first response to failure of bag-maskventilation is always better bag-maskventilation
Algorithm for Difficulty
“Bagging”
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Remove FB - Magill forceps.
Triple maneuver if c-spine clear
– Head tilt, jaw lift, mouth opening
Nasal (NP) or oropharyngeal (OP) airways.
two-person, four-hand technique.
Generate as much positive pressure as possible
without inflating the stomach
Do not abandon bagging unless it is impossible with two
people and both an OP and NP airway
The Failed Intubation:
Definition
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Three failed attempts to intubate
– by an experienced anesthetist.
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Inability to ventilate with BMV
(Bag-Mask-Ventilation)
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Inability to oxygenate
The Failed Intubation
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If can’t intubate but can ventilate with
BMV have time to consider options
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Light guided technique (Lighted stylet)
Combitube
LMA
Fiberoptic techniques
Retrograde intubation
Cricothyrotomy
Awake Oral Intubation
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Prepare patient psychologically
Pre-oxygenate
Topical anesthesia if time permits
Titrated sedation - avoid obtundation
Reassure patient throughout procedure
Difficult Airway Kit
• Multiple blades and ETTs
• ETT guides (stylets, bougé, light
wand)
• Emergency nonsurgical ventilation
( LMA, Combitube, TTJV )
• Emergency surgical airway access
( cricothyroidotomy kit, cricotomes )
• ETT placement verification
• Fiberoptic and retrograde intubation
The Failed Intubation
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If can’t intubate, can’t ventilate , must act
immediately
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Cricothyrotomy
Urgent Tracheotomy
Percutaneous Transtracheal Jet Ventilation
Combitube
LMA
The last three are temporizing measures and not
definitive airway management
Awake Oral Intubation
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Consider for anticipated can’t
intubate, can’t ventilate situation
 distorted upper airway anatomy
 (i.e., penetrating neck trauma)
Avoids ‘burning bridges”
 maintains ventilation
 maintains patient’s ability to
protect airway
May use to take quick look to assure
that you can see enough for RSI
Difficult Airway Maxims
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“It is preferable to use superior
judgment -- to avoid having to use
superior skill”.
Difficult airway due to
upper airway pathology
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Plan for tracheostomy before going to surgery
(under LA) 
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Awake fibroptic laryngoscope ,either nasal or
oral
Anesthetic management of
operative endoscopies
Preoperative preparation
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Psychological preparation of patients
and /or his relatives .
Arrangement for ICU bed.
Consent for tracheostomy.
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Avoid sedation.
Anti-sialagouge :
Glycopyrrolate IV or IM
(Quaternary ammonium compound)
Atropine , Scopolamine
(Tertiary ammonium compounds)
 Nebulizing racemic epinephrine
 Nebulizing bronchodilators.
 Intravenous corticosteroid.
Intraoperative considerations
1- Maintaining surgical anesthesia levels:
- Continuous infusion of short acting
anesthetics (TIVA) :
Propofol ,Alfentanil,Remifentanil.
- Supplementary volatile anesthetics .
- Supplementation with:
* -antagonists e.g.; Esmolol.
* -agonist e.g.; Dexemedotomidine.
Intraoperative considerations
2-The use of muscle relaxants:
* Continues infusion of
SUX.or Intermittent boluses of short and
intermediate durations relaxants.
VS
* TIVA plus volatile anesthetics
3-Methods of ventilation
1- Conventional ETT anesthesia
using size 4.0-6.0 micro-laryngeal
tube.
2- Insufflation's ventilation
 with high flows of oxygen through a small
catheter placed in the trachea.
 better with spontaneously breathing
patients.
3- Intermittent apnea technique :
Periods of controlled ventilation via face mask
or ETT alternated with periods of apnea.
4- Manual Jet Ventilation :
 The jet injector is connected to a high pressure
source of oxygen and to the side port of the
laryngoscope.
 It ventilate the lungs during inspiration and allow
period for passive expiration.
5-High -Frequency Jet Ventilation:
Utilizes a tube in the trachea to inject small
volume of gas at a rate of 80-300 times/min.
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Manual intermediate- frequency jet
ventilation:
Use small bag (0.5 l) for delivering small
volume high rate , jet like ventilation (60150).
Uneventful course during endoscopy
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Difficulty to maintain ventilations.
- As a complications during airway
surgery:
- Laryngeal stenosis (edema,
bleeding)
- Laser surgery (fire, small size ETT)
- As a complications after airway
surgery.
- Bleeding, edema.
- Pneumothorax.
Endoscopy under local anesthesia
1-Rigid bronchoscope:
- As rigid bronchoscopy requires straight
line between object and operator for
visualization. - It always done under GA.
Endoscopy under local anesthesia
2- Fiberoptic Bronchoscope
- It Does not require straight line for image
visualization.
- It could be done under LA:
I. Topical Application of LA
II. Nerve block
III. Nebulization of LA
I. Topical Application of LA
Step 1: Prepare the nose with vasoconstrictor
and ribbon gauze soaked with LA .
Step 2: Apply LA to the base of the
tongue, posterior pharyngeal wall
anterior tonsillar pillars & tonsils
Step 3: With the help of tongue depressor
apply LA to side walls of pharynx
and each pyriform fossa
Step 4: Do Laryngoscopy and apply LA to
Vallecullae,epiglottis and keep soaked gauze
to each pyriform fossa for 30 seconds to
block superior laryngeal nerve
Step 5: SAYGO (Spray As You GO) to lower airway
II. Nerve block
1- Glossopharyngeal nerve block
Inject 2 ml of Lignocaine 2% to the
anterior pillar of the tonsil at site 1 cm
above the lower pole of the tonsil at the
depth of 8mm (on each side)
II. Nerve block
2- Superior Laryngeal Nerve block
Infiltrate 2ml of Lignocaine 2% into the
thyro-hyoid membrane at site in between
the greater cornu of hyoid bone and
superior cornu of thyroid cartilage.
II. Nerve block
3- Transtracheal block :
(Recurrent laryngeal nerve block)
Insert 22 gauge canula into trachea through
cricothyroid membrane or in between
tracheal rings, remove the trocar, aspirate
air for .Forcefully Inject 4 ml of
Lignocaine 2% at the end of inspiration.
Post-endoscopy care
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Oxygen by face-mask.
Close monitoring for homodynamic and
respiratory parameters (PACU) before shifting.
NPO for 4 - 6 hrs.
Good hydration ( IV fluids).
Racemic epinephrine or normal saline
Nebulization.
Post bronchoscopy X-Ray chest.
Non-narcotics pain killers.
Lidocaine added to a tracheostomy tube cuff
reduces tube discomfort
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Tracheostomy tube cuffs were inflated with 5 ml
lidocaine 4% solution and air at 20 cmH2O .
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Lidocaine diffusion across the tracheostomy tube
cuff reduces tube discomfort e.g.: patients
undergoing oral cancer surgery
Laser surgery and precautions
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Characteristics: - Monochromatic.
- Coherent.
- Collimated.
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Advantages:
pain.
- Excellent hemostasis.
- Minimal edema and
Laser
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Hazards:
It depends on the medium in which laser
beam is generated ( wavelength).
CO2 Laser (10.600 nm ).is more
localised,less penetrated
YAG Laser (1.060 nm ).less absorbed by
water ,deep penetration
Laser
A. Anesthetic precautions:
 Suction of Laser fumes.
 Eye protection for all members inside the
theatre including the patient's eye.
 Avoidance of ETT fire:
- Use of inflammable ETT .
e.g.; Metal, red rubber, silicon rubber
- Use intermittent apnea technique or
jet ventilation.
Laser
4-Use low inspired O2 concentration.
5-Replace N2O by air or Helium.
6-Inflate ETT cuff with mixture of lidocaine
and saline( 1:2).
Laser
B-Surgical precautions:
1- Limit the duration and intensity of the
Laser beam as possible.
2-Saline soaked pledgets to be placed in the
airway to limit risk of ignition.
3-A 60 ml syringe filled with water to be
standby for fire control.
Airway-fire protocol
1- Stop ventilation, Remove ETT, Turn off
O2, and disconnect the circuit from the
machine.
2-Submerge the ETT in water.
3-Ventilate with Ambu bag and reintubate
with regular ETT.
4-Assess the airway damage (bronchoscope,
ABGs).
5- Consider steroids and bronchial lavage.
Thank You