AIRWAY MANAGEMENTVICTOR VIERSEN, ANESTHESIOLOOG

AIRWAY MANAGEMENT

▸ Eerste stap in resuscitatie is beoordeling van de luchtweg (A)

▸ Specifieke expertise van anesthesioloog maar de basic airway manoeuvres zou iedereen moeten kunnen

▸ Enkele specifieke overwegingen bij de traumapatient

WAT IS EEN BEDREIGDE LUCHTWEG?

▸ Anatomische obstructie (door trauma of zwelling)

▸ Verlies van beschermende reflexen (aspiratie risico)

BASIC AIRWAY MANOEUVRES

▸ Chin lift

▸ Jaw thurst

▸ Kapbeademing

GOUDEN STANDAARD AIRWAY MANAGEMENT

▸ Gouden standaard = Endotracheale intubatie

▸ Cuff sluit trachea af en beschermd tegen aspiratie

INDICATIE VOOR INTUBATIE

▸ Breder dan alleen bedreigde luchtweg (A)

▸ Ook voor bedreigde Oxygenatie / Ventilatie (B) zoals bij ribfracturen, longcontusie, fladderthorax

▸ Ook voor ernstige (hypovolemische) shock (C)

▸ Ook voor ernstig neurotrauma (D)

▸ Bij noodzaak voor algehele anesthesie bij niet meewerkende patiënt

WAT HEB JE NOU NODIG OM IEMAND VEILIG TE INTUBEREN?

VOORWAARDEN

▸ iemand die het kan!

▸ Algehele anesthesie

▸ Monitoring: ECG, SpO2, NIBP, EtCO2

▸ Uitzuig materiaal

▸ Beademingsmachine

POSITIONERING VOOR DIRECTE LARYNGOSCOPIE

the cricoid and the sternal notch. These rings arethe common location for elective tracheotomies.Urgent percutaneous access to the trachea ismore commonly achieved through the relativelyavascular and easily palpable cricothyroid mem-brane (Fig. 3–9). Located between the cricoid

and thyroid cartilages, the membrane is 22–30 mmwide and 9–10 mm high, in the average adult.This means that the maximal outer diameter of atube or cannula placed through the cricothyroidmembrane, as part of an emergent surgicalairway, should be no greater than 8.5 mm (the

24 CHAPTER 3

Figure 3–7 A, B. Alignment of oral and pharyngeal/tracheal axes (A) before and (B) after plac-ing the patient in the “sniff” position.

the cricoid and the sternal notch. These rings arethe common location for elective tracheotomies.Urgent percutaneous access to the trachea ismore commonly achieved through the relativelyavascular and easily palpable cricothyroid mem-brane (Fig. 3–9). Located between the cricoid

and thyroid cartilages, the membrane is 22–30 mmwide and 9–10 mm high, in the average adult.This means that the maximal outer diameter of atube or cannula placed through the cricothyroidmembrane, as part of an emergent surgicalairway, should be no greater than 8.5 mm (the

24 CHAPTER 3

Figure 3–7 A, B. Alignment of oral and pharyngeal/tracheal axes (A) before and (B) after plac-ing the patient in the “sniff” position.

outside diameter [OD] of a #4 tracheostomytube is 8 mm; the OD of a #6 tracheostomytube is 10 mm; and a 6.0 ID ETT has an OD of8.2 mm). The average distance between the mid-point of the cricothyroid membrane and thevocal cords above is only 13 mm. The lowerthird of the membrane is usually less vascularthan the upper third.

Emergency cricothyrotomies are performedafter failure to intubate, in conjunction witha failure to oxygenate by BMV or extraglotticdevice. Rarely, airway pathology may mandatea primary cricothyrotomy or tracheotomy. Itshould be noted that developmentally, the

cricoid cartilage initially lies immediatelybeneath the thyroid cartilage. For this reason,in the younger pediatric patient (i.e., up to age8), there is no well-defined cricothyroid mem-brane allowing easy access to the airway.

! AIRWAY INNERVATION

Knowledge of the innervation of the airway isimportant to the airway manager contemplatingapplication of airway anesthesia to facilitatean “awake” intubation. The posterior third ofthe tongue is innervated primarily by the

AIRWAY PHYSIOLOGY AND ANATOMY 25

Figure 3–8. Final alignment of the airway axes is achieved through tongue displacement andanterior lift of the mandible using a laryngoscope.

VOLGORDE VAN HANDELEN

HOE HET ER IN HET ECHT UITZIET!

TEKST

CASUS

▸ auto versus boom

▸ polytrauma en neurotrauma

▸ Snurkende ademhaling

▸ Algehele anesthesie

▸ bij laryngoscopie zie je…… —>

CORMACK AND LEHANE

VOORSPELBAARHEID MOEILIJKE LUCHTWEG

BIJ EEN TRAUMA….

TEKST

LEMON

▸ L: look externally

▸ E: evaluate 3-3-2

▸ M: mallampati

▸ obstruction

▸ Neck mobility

PLAN VAN AANPAK

▸ blijf kalm

▸ Haal hulp!

▸ Plan A, B, C

▸ communiceer

▸ organiseer je omgeving

IETS ANDERS!

WAT GAAN WE DOEN?

GUM ELASTIC BOUGIE (FROVA CATHETER, “DE BLAUWE VOERDER”)

VIDEO LARYNGOSCOOP

LARYNXMASKER (LMA)

INTUBATING LARYNGEAL MASK AIRWAY (ILMA)

MAAR WAT ALS DAT NOU ALLEMAAL NIET LUKT?

Unanticipated difficult tracheal intubation-during routine induction of anaesthesia in an adult patient

failed intubation

Tracheal intubation

Plan A: Initial tracheal intubation plan

Direct laryngoscopy - check:Neck flexion and head extensionLaryngoscope technique and vectorExternal laryngeal manipulation -by laryngoscopistVocal cords open and immobileIf poor view: Introducer (bougie) - seek clicks or hold-up and/or Alternative laryngoscope

Plan B: Secondary tracheal intubation plan

ILMATM or LMATM

Not more than 2 insertionsOxygenate and ventilate

failed oxygenation(e.g. SpO2 < 90% with FiO2 1.0)

via ILMATM or LMATM

Revert to face maskOxygenate and ventilateReverse non-depolarising relaxant1 or 2 person mask technique(with oral ± nasal airway)

failed ventilation and oxygenation

Plan D: Rescue techniques for"can't intubate, can't ventilate" situation

Difficult Airway Society Guidelines Flow-chart 2004 (use with DAS guidelines paper)

Not more than 4 attempts,maintaining:(1) oxygenationwith face mask and(2) anaesthesia

Verify tracheal intubation(1) Visual, if possible(2) Capnograph(3) Oesophageal detector"If in doubt, take it out"

Confirm: ventilation, oxygenation, anaesthesia, CVS stability and muscle relaxation - then fibreoptic tracheal intubationthrough IMLATM or LMATM - 1 attemptIf LMATM, consider long flexometallic,nasal RAE or microlaryngeal tubeVerify intubation and proceed with surgery

failed intubation via ILMATM or LMATM

Postpone surgeryAwaken patient

Directlaryngoscopy

Any problems

Call for help

Plan C: Maintenance of oxygenation, ventilation,postponement of surgery and awakening

succeed

succeed

succeed

RESCUETECHNIEKEN

NAALDCONIOTOMIE VS CHIRURGISCH• Slagingspercentages naaldconiotimie +/- 50% vs 80

tot 100% voor chirugische benadering

A key issue in simulation training is the transfer of simulatorlearning to clinical performance. To maximize this transfer,educational goals and learner ability should be aligned withthe type of simulator in order to reduce the gap between simu-lation and clinical reality. Research has repeatedly shown thatthe transfer of learning from one entity to another depends onthe overlapping conditions between those two entities.28 In arecent issue of the British Journal of Anaesthesia, Howes andcolleagues.1 describe the modification of a model to replicatea thick or burnt neck for PEAA training. In this example the edu-cational goal is to prepare anaesthetists to manage PEAAthrough a burnt or obese neck and transfer that learning tothe clinical environment. By modifying a simple cricothyroidot-omy model to create anatomical difficulty in the neck, thereality gap between the simulator and the patient has nar-rowed and, therefore, the transfer of learning from one set ofconditions (the simulator) to another (the patient) has beenenhanced.28 Obesity with increased neck circumference isassociated with decreased accuracy identifying the CTM.29 Ina cadaver study, identification of anatomical landmarks tookone third of the total mean time (37.5 seconds) to perform ascalpel bougie technique. Two out of 36 procedures failed inthis study as a result of an inability to identify the CTM. Both fail-ures occurred in cadavers with neck circumferences greaterthan 40 centimetres.24 Interestingly, an early report of the

scalpel bougie technique described the use of this techniqueas a solution for patients with fat necks.23 The next step, aftera failed scalpel bougie technique, is a longitudinal scalpelincision in the neck and blunt dissection to digitally identifyana-tomical landmarks, prior to a cricothyroidotomy or tracheot-omy. A simple non-anatomical model, or an anatomicallyincorrect, virtual reality simulator are unlikely to satisfy the edu-cational goal of this scenario, where anatomical knowledge andprocedural skill are crucial to a successful outcome.

A clear understanding of both the educational goal of thelearning exercise and the skill level of the learner helps to de-termine the necessary fidelity of the simulator. If the educa-tional goal is to teach novices PEAA on normal anatomy, avery simple model will suffice. Friedman and colleagues com-pared the cricothyroidotomy performance of two groups of an-aesthetic trainees using either a high fidelity full-scaleSim-Man (Laerdal Medical, Stavanger, Norway) or a home-made model made out of tape and anaesthetic circuit. A sub-sequent cricothyroidotomy performed by both groups on acadaver with normal anatomy found no difference in perform-ance between the two groups.30 Simple models are particularlyhelpful to the novice learner to establish basic skills, but do notimprove learning curves or skill retention for more advancedprocedures such as an obese or distorted neck.31 Furthermore,advanced learners will benefit more from higher fidelity simu-lators, which can reproduce more complex tasks.32 Therefore,the experience of the learner and the associated educationalgoal should match the fidelity of the simulator.

The fidelity of many commercially available airway manikinshas come under scrutiny.33 While nominally, airway manikinsare based on normal anatomy, anatomical dimensions of theupper airway deviate significantly from human anatomy.33

These issues highlight the need to improve the fidelity of PEAAsimulators, to mimic our real-life patients, as done by Howesand co-workers,1 to meet the educational goals of instructorsandenhancetheexpertiseandlearningopportunitiesoftrainees.

The concept of regular compulsory training for clinical com-petence requires robust assessment to ensure an adequatestandard of comprehension and performance. Each clinicalfundamental should be teachable, learnable and measurablebut a training programme, which does not close the loop bybeing measurable, potentially exposes patients to suboptimalcare. In the case of CICV, this could result in brain damage ordeath. The Australian and New Zealand College of Anaesthe-tists (ANZCA) recently introduced a new competency-basedmedical education curriculum which includes a CICV modulethat must be repeated at regular intervals. A minimum oftwo of these modules must be completed, per triennium. Pro-cedural skill will inevitably decay without regular practice, butthe rate of skill decay and the interval between cricothyroidot-omy training, needs to be determined. Limited research hasbeen directed toward these questions but studies suggestthat cricothyroidotomy skill could be retained for at least oneyear.34 Simple attendance at a course does not guaranteelearning and performance. If performance during training isto become a requirement for on-going certification, it is essen-tial that a valid and reliable form of assessment is used.

Cannot intubate, cannotventilate

Always attempt to identify the cricothyroid membranebefore induction of anaesthesia

Can you identify thecricothyroid membrane?

Make a longitudinalmidline scalpel neck

incision. Use digital bluntdissection. Palpate thecricothyroid membrane

or trachea

Ventilate through a size6.0 mm ET tube with aventilation bag or ananaesthetic circuit

YES

Use a horizontal scalpelstab incision through thecricothyroid membrane,stabilise with a hook or

a bougie, advance a6.0 mm cuffed ET tube

NO

Fig 1 Flowchart for performance of the default percutaneousemergency airway access.

Editorials BJA

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TRAUMA VAN DE LUCHTWEG ▸ bloed

▸ zwelling

▸ structuren onherkenbaar

TRAUMA VAN DE LUCHTWEG ZELF

▸ Wakkere tracheotomie onder lokale verdoving is een optie

LARYNXFRACTUUR

▸ oorzaken: suicide, verkeersongevallen, geweld, val van hoogte etc.

▸ Symptomen: pijn (70%), heesheid (18%) hemoptysis (14%) , subcutaan emphyseem (9%)

INHALATIETRAUMA

▸ inhalatie van hete lucht, gassen, (water)damp, rook, chemicaliën

▸ Hitte, Materie, Asphyxie, systemische toxiciteit (CO, cyanide)

▸ Zwelling van bovenste en onderste luchtwegen

▸ Heesheid, benauwdheid, hypoxie, CO intoxicatie

PREHOSPITAL AIRWAY MANAGEMENT

▸ In essentie zijn de indicaties en technieken hetzelfde

▸ Omgeving is de uitdaging!weinig licht, beknelling, opstelling apparatuur

▸ Vaak ernstig zieke patienten

▸ In NL door de traumaheli’s (MMT)—> mn anesthesiologen

CONCLUSIE

▸ Airway management is een specialistische handeling die niet zonder risico’s is

▸ Airway management bij trauma patient is per definitie moeilijk

▸ Verwacht ellende! plan A,B,C, ….

WWW.URGENTIEGENEESKUNDE.COM

VRAGEN??

Victor Viersen, Anesthesioloog AMC

http://www.slideshare.net/VictorViersen

http://www.urgentiegeneeskunde.com/emergency-airway-management.html

Airway management after major traumaJulius Cranshaw et al. Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 3 2006