Transcript Some Interesting Airway Cases - Doyle-Airway

Some Interesting
Airway Cases
D. John Doyle MD PhD
Cleveland Clinic Foundation
Case 1
Case 1
Trauma
Image
Bank
Endotrol ETT
The Glidescope is a video laryngoscope with a TV camera built into the blade.
The views obtained can be quite striking, as with the case shown below.
Microminiature TV
camera and dual
LED light source
integrated into the
laryngoscope blade
Case 112
ETT Position
Confirmation
Devices
Portable Capnograph
Easy Cap Disposable
End-tidal CO2 Detector
Changes color from purple to yellow with expired CO2
Ambu Tubecheck - Bulb Model
Case 2
Case 2
Retrograde Intubation
Description: This technique utilizes a wire passed retrograde from a
puncture in the cricothyroid membrane to the mouth to allow passage
of an endotracheal tube into the trachea.
Advantages: Placement of the wire through the cricothyroid
membrane should ensure passage of the endotracheal tube into the
trachea. Does not require visualization of the larynx. May be
performed rapidly by skilled practitioner.
Disadvantages: May cause bleeding in the airway. The endotracheal
tube may not pass easily into the larynx, even when the wire is
correctly passed. This may occur when the endotracheal tube engages
the epiglottis or the glottic cartilaginous structures. It may also occur
if the wire kinks or bends during attempted passage of the
endotracheal tube.
http://www.gasnet.org/airway/opt10.htm
http://www.anes.med.umich.edu/intubation/images/topical1.jpg
http://www.anes.med.umich.edu/intubation/images/tracheal_injection.jpg
Waters DJ. Guided blind endotracheal intubation for patients with
deformities of the upper airway." Anaesthesia 1963;18:158-62
(Original description from Nigeria).
Sanchez, Tony F. Retrograde
intubation. Anesthesiology
Clinics of North America
1995 Jun; 13(2):439-450.
Synopsis of
Retrograde
Intubation
www.biodigital.org/voz2/W3M.htm
www.metrohealthanesthesia.com/edu/airway/retrograde.htm
Retrograde Nasal Intubation In A Case Of Subdural
Hematoma With Mandible Fracture: A Case Report
The Internet Journal of Anesthesiology.
2006 Volume 10 Number 2
Case 3
Case 3a
Case 3b
Fiberoptic Intubation
Ovassapian Airway
Patil-Syracuse Face Mask
The Parker Flex-TipTM tubes are available in
sizes 6.5, 7.0, 7.5, and 8.0mm ID.
The tapered, centered, flexible tip of the Parker
Flex-TipTM Endotracheal Tube is designed for:
•Better tip visibility
•Gentle sliding off of delicate anatomical
structures in the airway
•Easier insertion through narrow glottic openings
•Snag-free "railroading" along fiberoptic scopes
•Gentle "skiing" down tracheal walls
Case 4
Case 4
Trauma Image Bank
28 yr old male, motorcycle
collision, fall over pieces of
wood. The patient was
haemodynamically normal,
conscious, just demanding the
removal of the stick.
Nevertheless, he was submitted
to an emergent left
thoracotomy, and left
laparotomy. The piece of wood
was just located behind the
sternum and in front of the
heart with no major vascular or
cardiac injury found, only a
perforation of the diaphragm.
Intraabdominally, the piece
passed between the left lobe of
the liver and the spleen with no
further injury. We found this
almost unbelievable! Luis Filipe
Pinheiro, Viseu, Portugal
Case 5
Case 5
Case 6
Case 6
Case 7
Case 7
Case 8
Case 9
Case 9
From Trauma Imagebank at www.trauma.org
Case 10
Case 10
Refuses Awake
Intubation
A snarly and demanding 80 year old lady
issues an endless stream of demands to
her care givers. She is accustomed to
getting what she wants, coming from a
large family which she was the matriarch.
Refuses Awake Intubation
She presented with recurrent bowel
obstructions following a messy
appendectomy complicated by peritonitis.
On most occasions an N/G tube would do
the trick, but twice a laparotomy became
necessary.
Refuses Awake Intubation
The first time in, she was difficult to
intubate because her larynx was just too
anterior- despite a “BURP” maneuver
seemed to push things into position.
However, in the end a colleague got the
tube in using a Gum Elastic Bougie he
kept nearby for just this situation.
Refuses Awake Intubation
The next time around the anesthesia team
decided on awake fiberoptic intubation, but
it required quite a bit of coaxing, and the
experience was a terrible one for the
patient, remembering that awful choking
feeling whenever the scope was
introduced.
Refuses Awake Intubation
The old chart put the picture differently:
“Awake FOB intubation L nostril with 2%
lidocaine gel, midazolam 1 mg IV and
glycopyrrolate 0.2 mg IV. Difficult
procedure because of excessive
secretions with some bleeding, as well as
frequent swallowing and gagging”.
Refuses Awake Intubation
Now it is your turn to give the anesthetic to
allow the surgeons to unwrap her bowels
once again.
You explain about the awake intubation
business, but she’s not biting. She views
the whole process as barbaric and she
simply will not allow herself to be
subjected to awake intubation.
Refuses Awake Intubation
Just as firmly, she refuses to have any
kind of needle put into her back!
What should you do after you give up
trying to coax her?
Refuses Awake Intubation
Discussion
Options to consider include:
1. Stun her with just a little ketamine (or other
agent) and get on with the job of an “awake”
intubation, holding her down if necessary.
2. Get a psychiatrist to declare her
incompetent.
If s/he agrees, go to 1.
If s/he disagrees, go to 3, 4 or 5.
Refuses Awake Intubation
Discussion
3. Try your usual rapid sequence induction and
if you can’t get the airway, proceed as per the
ASA airway management algorithm.
4. Try your usual rapid sequence induction and
if you can’t get the airway, insert an LMA,
while continuing cricoid pressure throughout
the case.
5. Refuse to be her anesthetist.
Case 11
Case 11
Fetal Distress, Emergency
C/Section, Difficult Airway
A 19 year old woman 38 weeks pregnant
has had 4 previous operations for a
complex congenital cranio-facial
syndrome, all requiring fiberoptic
intubation.
You are now asked to provide an
emergency anesthetic for a C/Section for
fetal distress (profound bradycardia) for a
suspected prolapsed cord.
Fetal Distress, Emergency
C/Section, Difficult Airway
• What if a "stale" epidural (in need of
a top up) were in place?
• What if there was no epidural in place at
the time?
• Would you have agreed to an epidural in
this lady for routine labour and delivery?
• What is the role of the LMA?
Fetal Distress, Emergency
C/Section, Difficult Airway
Your objective in this case is to get the
baby out in as short a time as possible.
If an epidural is already in place with a
block adequate for surgery, the problem is
largely solved.
If the epidural had been unsatisfactory,
would you consider a spinal?
Fetal Distress, Emergency
C/Section, Difficult Airway
If the epidural is in need of a top-up, many
clinicians would choose to top up the
epidural while arrangements to transfer
her to the OR are being made.
Fetal Distress, Emergency
C/Section, Difficult Airway
Other clinicians may not be comfortable
giving a lot of epidural drugs under such
volatile conditions, or would worry about
what to do if the block didn't end up high
enough or was patchy.
Fetal Distress, Emergency
C/Section, Difficult Airway
If no epidural were in place the situation is
more complicated: there is no "right
answer".
Clinicians with a lot of experience with
spinals for c/sections point out how quickly
a spinal can be done, but is not a great
option if your experience with spinals for
C/Sections is limited.
Fetal Distress, Emergency
C/Section, Difficult Airway
Other options
• local anesthesia (prepare two 50 ml
syringes of 0.5% lidocaine with epi (= 5
mg/ml) and give up to 7 mg/kg [= 500 mg
(100 ml) in a 70 kg parturient]
• quick awake FO intubation
• quick blind nasal intubation
None of those options is especially satisfactory !
Case 12
Case 12
High Dose Fentanyl and
Pancuronium Induction
An otherwise healthy 67 year old man with
unstable angina underwent an uneventful
induction with fentanyl 5000 g and
pancuronium 10 mg for a planned 3-vessel
CABG.
High Dose Fentanyl and
Pancuronium Induction
At laryngoscopy the view is terrible - only the
epiglottis is visible. (Grade III)
Three attempts at intubation are unsuccessful,
despite use of a stylet, “BURP” and careful head
positioning - the larynx is just too anterior. The
ETT ends up in the esophagus with each
attempt.
What now?
High Dose Fentanyl and
Pancuronium Induction
The use of high-doses of a narcotic with
high doses of long-acting muscle relaxant
remains a common anesthetic technique
for cardiac surgery.
The technique is valued because of its
hemodynamic stability.
High Dose Fentanyl and
Pancuronium Induction
The key disadvantage of this technique is
that neither the narcotic component nor
the relaxant component of the anesthetic
is readily reversible.
High Dose Fentanyl and
Pancuronium Induction
“Waking” the patient using naloxone and
neostigmine is not a particularly viable
option (although I have heard of it being
done after a long period of ventilation by
face mask).
High Dose Fentanyl and
Pancuronium Induction
• Probably the best thing to do is to
maintain positive pressure ventilation by
mask, while calling for a fiberoptic
bronchoscope and another pair of
skilled hands.
• Use of a mask designed for
bronchoscopy (Patil-Syracuse mask)
allows BVM ventilation to continue.
High Dose Fentanyl and
Pancuronium Induction
• The intubating laryngeal mask airway
(ILMA) is also potentially useful in this
setting.
• In many cases it is easier to ventilate a
patient with an LMA than with a face
mask.
Case 13
Laryngospasm Under
Mask Anesthesia
• A 22 year old woman undergoes a
fentanyl/nitrous oxide/sevoflurane
anesthetic for a D&C.
• She is breathing well until the dilator is
introduced - then she develops
laryngospasm that won't break with
sustained airway pressure.
• The pulse oximeter reading has dropped
to 92% from 98%.
Laryngospasm Under
Mask Anesthesia
• What would you do now?
• How would you treat persistent
laryngospasm in a patient believed to
be MH susceptible?
Definition
Laryngospasm is closing of the larynx via
contracture of the intrinsic muscles of the
larnyx.
It commonly occurs in anesthesia when
the larnyx is stimulated by secretions or
airway instrumentation, especially in
combination with light anesthesia.
Laryngospasm Notch
The laryngospasm notch is located just behind the earlobe. It
is bordered by the base of the skull superiorly, the mastoid
process posteriorly, and the ramus of the mandible anteriorly.
Stimulation of laryngospasm notch can break a laryngospasm
and also assist the anesthetist in initiating spontaneous
respirations in the sedated patient. When performed properly,
the index or middle fingers should be placed in the notch with
pressure applied in a medial and cephalad direction. This
opens the airway by sliding the mandible forward and
produces an extremely painful stimulus, usually resulting in a
deep breath. [From Wikipedia]
See also Larson. Anesthesiology. 89(5):1293-1294, November 1998.
Treatment consists of applying pressure on both sides of the head, simultaneously, on the depression located
behind the ear lobes, which is limited anteriorly by the ascending ramus of the mandible adjacent to the
condilus, posteriorly by the mastoid process of the temporal bone, and superiorly by the base of the skull,
while at the same time dislocating the mandible anteriorly. An essential component of the treatment is the
severe pain that the patient experiences because of the firm pressure that is applied to the ramus of the
mandible, the facial nerve, and perhaps the deep lobe of the parotid gland. [Larson]
http://www.scielo.br/pdf/rba/v58n6/en_08.pdf
http://www.scielo.br/pdf/rba/v58n6/en_08.pdf
Laryngospasm Under
Mask Anesthesia
There are several ways to break
laryngospasm, but succinylcholine (in my
experience) is the most effective agent
(usually 10 mg will do the trick)
Laryngospasm Under
Mask Anesthesia
Obviously, if the patient is MH susceptible, don’t
attempt to break the laryngospasm with
succinylcholine unless all other maneuvers fail
and the patient is in extremis.
Consider deepening the patient with IV propofol
or using rocuronium.
Case 14
Case 14
• Imagine that the laryngospasm in Case 13
was so bad that it lasted quite a while, so
that intubation was necessary.
• What if following intubation, pink froth is
seen to be collecting in the ETT?
“To our knowledge, this condition is
previously unreported in English literature.
We presume that the pathogenesis is
related to alveolar and capillary damage,
induced by the severe negative pressure
generated by attempting to inspire against
the closed upper airway.”
Post Obstructive Pulmonary
Edema
Postobstructive pulmonary edema is a
well-recognized complication of upper
airway obstruction. The mechanisms of
edema formation are unclear and may be
due to increased hydrostatic forces
generated by high negative inspiratory
pressure or (less likely) by increased
permeability of the alveolar capillary
membrane.
Laryngospasm has been reported to be the cause in >
50% of cases of postobstructive pulmonary edema.
Other reported causes of postobstructive pulmonary
edema include the following: strangulation; epiglottitis;
foreign-body aspiration; hypothyroidism; inspissated
tracheal secretions; hiccups; croup; thyroid goiter ;
temporomandibular joint arthroscopy; difficult
intubation; hematoma; upper airway tumor;
oropharyngeal surgery; Ludwig angina; obesity;
acromegaly; obstructive sleep apnea; mediastinal
tumor; and biting the endotracheal tube or laryngeal
mask.
Patients in whom postobstructive pulmonary edema
develops generally have an uncomplicated hospital
course followed by the rapid resolution of the
pulmonary edema and short hospital stays.
Pathophysiology of
the development of
postobstructive
pulmonary edema
Case 15
Case 15
•
•
•
•
58-year old female patient
Recurrent head and neck cancer
Limited mouth opening
Very difficult to intubate using a
fiberoptic bronchoscope (even ENT
had considerable trouble).
• Stridor on extubation
• Patient starting to get agitated
The stridor was treated by two doses of
8 mg dexamethasone (one administered
pre extubation), two doses of nebulized
racemic epinephrine (0.5 ml of 2.25%
epinephrine added to 2.5 ml saline), and
assisted mask ventilation with the patient
sitting up at 60 degrees.
On standby we had available almost
every airway gadget ever manufactured,
an experienced ENT surgeon, a variety
of experienced anesthesiologists, and
everything needed for a surgical airway.
• Unfortunately, the patient did not
improve and was starting to tire.
• Reintubation would have been even
more difficult than it had been earlier.
• A surgical airway was starting to look like
our only way out.
What Now?
Treatment
• What saved us was a
mixture of Helium (70%)
and Oxygen (30%)
delivered using a
nonrebreathing face
mask at 10 lpm.
• Within 5 to 10 breaths
the stridor vanished and
the patient’s work of
breathing became
manageable.
Treatment
• The patient was then brought to
the recovery room with a large
Heliox tank in tow and with full
monitoring.
• She was then weaned off the
Heliox over several hours.
Discussion
Airway obstructing conditions
such as epiglottitis or tracheal
stenosis may be viewed as
breathing through an orifice
(defined as involving flow
through a tube whose length is
smaller than its radius).
Discussion
• Gas flow through an orifice is always
somewhat turbulent.
• Under such conditions, the approximate flow
across the orifice varies inversely with the
square root of the gas density.
• This is in contrast to laminar flow conditions,
where gas flow varies inversely with gas
viscosity.
Discussion
Note that while the
viscosity values
for helium and
oxygen are
similar, their
densities are very
different.
Gas
Density @ 20° C
Air
1.293 g/L
Nitrogen
1.250 g/L
N2 0
1.965 g/L
Helium
0.178 g/L
Oxygen
1.429 g/L
Take Home Message
Heliox for delivery with a
nonrebreathing face
mask should be readily
available in every
operating room suite.
What is Stridor?
• Stridor is noisy inspiration from
turbulent gas flow in the upper
airway; it is often seen in upper
airway obstruction.
• Stridor is potentially serious and
always commands attention.
Causes of Stridor
“Stridor is a symptom, not a diagnosis or
disease, and the underlying cause must
be determined.”
emedicine.com
Causes of Stridor
Photograph of an electrical
wire stuck in the larynx of
infant at the level of the
vocal cords. The wire was
removed at laryngoscopy.
Interestingly, the child
presented with minimal
stridor. From the University of
Bristol’s Foreign Body Hall of Fame.
Causes of Stridor
Subglottic stenosis in a child.
Treatment options include
watchful waiting,
tracheotomy, anterior cricoid
split, laryngotracheal
reconstruction, and
cricotracheal resection.
From http://www.meei.harvard.edu/shared/oto/pedi2.php
Causes of Stridor
The triangular aperture
of the normal infant
larynx is about 7 mm x 4
mm, an area of 14 mm2.
When intubation or an
upper respiratory tract
infection causes one
millimeter of edema, the
cross-sectional area is
reduced to 5 mm2, only
35% of normal.
From www.childsdoc.org/spring98/stridor/ stridor.asp
Intubation
• The first issue is stridor
whether or not intubation
is immediately necessary.
• If intubation can be
delayed a number of
potential options can be
considered, depending on
the severity of the
situation and other clinical
details.
Nonintubation Options I
Expectant management with full
monitoring, oxygen by face mask, and
positioning the head of the bed for
optimum conditions (e.g., 45 - 90
degrees)
Nonintubation Options II
Use of nebulized racemic
epinephrine (0.5 to 0.75 ml of
2.25% racemic epinephrine
added to 2.5 to 3 ml of
normal saline) in cases where
airway edema may be the
cause of the stridor. (Cocaine
in a dose not exceeding 3
mg/kg may also be used, but
not together with racemic
epinephrine.)
Nonintubation Options III
Use of dexamethasone
(Decadron) 4 - 8 mg IV q
8 - 12 h in cases where
airway edema may be the
cause of the stridor; note
that some time (in the
range of hours) may be
need for dexamethasone
to work fully.
Nonintubation Options IV
Use of Heliox
(70% helium,
30% oxygen)
The effect is
almost
instantaneous
Causes of Stridor
Wherever possible,
attempts should be made
to immediately establish
the cause of the stridor
(e.g., foreign body, vocal
cord edema, tracheal
compression by tumor,
functional laryngeal
dyskinesia, etc.)
Diagnosis
• Stridor is usually
diagnosed on the basis
of history and physical
examination, with a view
to revealing the
underlying problem or
condition.
• Chest and neck x-rays,
CT-scans, and / or
MRIs may reveal
structural pathology.
Epiglottis with “thumb shaped” epiglottis
Diagnosis
Flexible fiberoptic
bronchoscopy can
also be very helpful,
especially in
assessing vocal cord
function of in looking
for signs of
compression or
infection.
http://www.tracheostomy.com
This stridor was recorded over the trachea of a 15 month old girl with croup.
Diagnosis
The respirosonogram provides a visual
representation of the content of the
respiratory sound recording. Time is
shown on the horizontal and
frequency on the vertical axis. Sound
intensity is indicated on a color scale,
ranging from red (loud) over yellow
and light green (medium) to dark
green and gray (low). The breathing
signal from Respitrace shows the rib
cage [RC] movement at the top and
the abdominal [AB] movement at the
bottom (inspiration = up, expiration =
down). Note: there is asynchronous
movement of chest and abdomen
during inspiration, clinically apparent
as "indrawing".
http://www.rale.ca
Case 16
Airway
obstruction
following a
severe burn
Case 17
http://www.trauma.org/imagebank/imagebank.html
Wisdom from GASNet
19 Jan 2004
Sandy Hancock
“I had a great one a few years back. The patient had been stabbed
in the back - 6 inch blade solidly embedded in his spine - spinal
cord transected. We intubated him on his side because it was
impossible to put him on his back. “
“ …The same goes for prone inductions. Although when I did it
recently at the academic hospital spine unit I got the impression it
hadn't been seen there....”
Sandy Hancock, Adelaide, Australia
Wisdom from GASNet
19 Jan 2004
William Loskota
We had a guy come in with a big kitchen knife sticking out of his
back (apparently he had complained about her cooking and the
missus didn't take kindly to his criticism).... Surgeon insisted that
we intubate (rapid sequence) in the lateral position.which we did
most readily... THEN the surgeon says: "Bring in another OR
table... I can't operate with him on his side!" He then places the
tables side by side, patient supine with the knife handle sticking
down between the tables! (and during the case he climbs under the
OR tables and pulls the knife out from below!).... I just
laughed...(and wished I had thought of that) Just another day at the
office... WM J LOSKOTA, PhD, MD
Wisdom from GASNet
21 Jan 2004
Sandy Hancock
“Inducing prone and inserting an LMA is counter-intuitive, and it
took me some time before I convinced myself it might be worth
trying. I don't do it often, but it is easy, elegant and completely
removes the risks of rolling an unconscious patient into the prone
position. In addition, a paralyzed, intubated prone patient is
arguably at more risk if the airway is lost than a spontaneously
breathing one with an LMA. There are pros and cons for most
techniques in anesthesia. It's all about finding your own balance.”
Sandy Hancock, Adelaide, Australia
Case 18
• A 22 year old 980 pound (445kg)
Caucasian male, 65 inches, BMI 163
• Admitted to the ICU for respiratory
failure.
• A tight-fitting CPAP / BIPAP system set
for 20 cm H20.
• PaCO2 76 mm Hg → 107 mm Hg (pH
7.13), requiring 100% oxygen.
• Urgent tracheostomy
Technique
• IV access was established in the forehead
– ultrasound image guided searches were
unsuccessful to assist in central line placement
• Unsuccessful oral fiberoptic and nasal
intubations
• LMA ProSeal placed without IV drugs.
• Anesthetized with Sevoflurane
• End-tidal CO2 levels 100 → 70 mmHg
Technique con’t
• Aintree stylette placed
over fiberoptic
bronchoscope, both
placed through the LMA
• FOB was removed,
followed by the LMA
• Parker size 7.5 ETT
placed over the Aintree
catheter
• Chin debulking procedure
prior to tracheotomy
• 7.5 mm ID armored ETT
placed in trachea
Fiberoptic bronchoscope (FOB) placed through
the Aintree catheter. The two are then passed
through an LMA™.
Note: The last 3 cm of the FOB are exposed
allowing its tip to be manipulated.
Step 1. Introduce a Laryngeal
Mask Airway (LMA)™ in the
usual manner.
Step 2. Next, a fiberoptic bronchoscope placed through an Aintree
Intubation Catheter, is introduced into the LMA™.
Step 3. The fiberoptic bronchoscope is advanced through the
LMA™, through the vocal cords, and into the trachea.
Step 4. Once visualization of the tracheal rings is confirmed, the
fiberoptic bronchoscope is removed while the Aintree catheter is
left behind.
Step 5. The LMA™ is carefully removed, taking care
not to displace the catheter.
Step 6. One can now “railroad” an endotracheal tube over the Aintree
Intubation Catheter into the patient’s trachea.
Step 7. After the catheter is removed, inflate the endotracheal tube cuff
and begin ventilation. Be sure to check for bilateral air entry and an
appropriate capnogram.
The End