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  • Lets Revisit Awake Intubation

    Clifford Gonzales CRNA, PhD

    Wake Forest School of Medicine Nurse Anesthesia Program

  • Objectives

    After the presentation, participants will be able to:

    Identify physical assessments for ventilation and tracheal intubation.

    Describe the innervation of the airway.

    State the modalities of anesthetizing the airway.

  • Closed Claims

    1984- ASA Closed Claims Project

    Anesthesiol. 1999; 91:552-556

  • Closed Claims

    1970-2007 Closed claims analysis

    Best Pract Res Clin Anaesthesiol. 2011; 25:263-276

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    1970-1989

    1990-2007

  • Closed Claims

    1980-2011 Closed Claims Analysis

    10,093 closed claims

    Airway injuries from general anesthesia.

    https://depts.washington.edu/asaccp/pubs/herring-jc-posner-kl-domino-kb-airway-injuries-associated-general-anesthesia-closed-claims

  • Airway Management Closed Claims

    1980-2011 Closed Claims Analysis

    0%

    10%

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    Difficult Intubation (DI) Pharyngeal/Esophageal Perforation (P/EP)

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    1980-1999

    2000-2011

    https://depts.washington.edu/asaccp/pubs/herring-jc-posner-kl-domino-kb-airway-injuries-associated-general-anesthesia-closed-claims

  • Closed Claims

    Limitations of closed claims

    Inaccurate numerator and denominator

    Geographical representations

    Retrospective studies

  • Closed Claims

    Lessons from closed claims

    Securing an airway is a team effort

    Avoid haste with preparation (assessment, planning, communication)

    Anatomy and physiology, pharmacological, and equipment knowledge needs to be current

  • Airway Assessment

    Table 4a: Comparison of various predictive tests

    Assessment Sensitivity (%) Specificity (%) PPV (%) NPV (%)

    IIG 13.43 98.31 56.25 87.50

    HNM 07.46 93.95 16.67 86.22

    MMT 70.15 61.02 22.60 92.65

    TMD 07.46 98.06 38.46 86.72

    RHTMD 71.64 92.01 59.26 95.24

    ULBT 74.63 91.53 58.82 95.70

    IIG=Inter-incisor gap; HNM=Head and neck movement; MMT=Modified mallampatti test; TMD=Thyromental distance; RHTMD=Ratio of height to thyromental distance; ULBT=Upper lip bite test

    J Aenesthesiol Clin Pharmacol, 2013, 29(2): 191-195

  • Airway Assessment

    Assessment of ability to mask ventilate M O A N S

    Mask seal Obese Age Nose, no teeth, neck mobility stiffness

  • Airway Assessment

    Assessment of ability to intubate

    L E M O N

    Look externally Evaluate (TMD, RHTTMD, ULBT) Mallampati Obstruction Neck mobility

    Multivariate assessment to predict DI

  • Difficulty Airway Algorithm ASA Difficult Airway Algorithm

    1. Assess the likelihood and clinical impact of basic management problems:

    Difficulty with patient cooperation or consent

    Difficult mask ventilation

    Difficult supraglottic airway placement

    Difficult laryngoscopy

    Difficult intubation

    Difficult surgical airway access

    2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management.

    3. Consider the relative merits and feasibility of basic management choices:

    Awake intubation vs. intubation after induction of general anesthesia

    Non-invasive technique vs. invasive techniques for the initial approach to intubation

    Video-assisted laryngoscopy as an initial approach to intubation

    Preservation vs. ablation of spontaneous ventilation

    Anesthesiology 2013; 118:251-270

  • Difficulty Airway Algorithm ASA Difficulty Airway Algorithm

    Anesthesiology 2013; 118:251-270

  • Difficulty Airway Algorithm

    Unanticipated Difficulty Airway Algorithm

    Brit J of Anesthet, 2015; 115(6):827-848

  • Awake Intubation

    Indications

    Co-morbidities (cervical conditions, intolerance to apnea, etc.)

    Risk of aspirations

    Difficult airway assessment

    Emergency

  • Awake Intubation

    Explanation to patient Pharmacological Equipment Personnel

  • Awake Intubation

    Pharmacological Antisialagogue Dilators Sedation Topical anesthesia Emergency

  • Awake Intubation

    Equipment Airway visualization Adjuncts Monitors Emergency

  • Awake Intubation

    Personnel Other anesthesia providers Surgeon/s Nurses

  • Awake Intubation

    Various local anesthetics (LA) can be used for anesthetizing the airway.

    Lidocaine has an advantage because of:

    Availability of different formularies and preparation.

    Wider margin of safety

  • Awake Intubation

    Airway innervation Nasopharynx- Trigeminal nerve

    (opthalmic and maxillary branch) Oropharynx- CNIX

    (Glossopharyngeal nerve) Laryngopharynx- superior

    laryngeal nerve Larynx and trachea- recurrent

    laryngeal nerve

  • Common Methods of Anesthetizing the Airway

    Nasopharynx

    in of lidocaine 5% at each nares (50mg)

    OR

    2 ml Lidocaine 4% aerosol spray (80mg)

  • Common Methods of Anesthetizing the Airway

    Oropharynx Apply 2 inches of 5% Lidocaine ointment on a tongue depressor (200mg)

    OR Instruct patient to gurgle 5 ml of

    Lidocaine 4% topical solution (may need to do this twice) (200 mg or 400mg)

  • Common Methods of Anesthetizing the Airway

    Oropharynx

    OR Place in. of 5% lidocaine at a cotton tip

    applicator and apply it at the base of palatoglossal arch (5 min each side) (100 mg)

    OR Using a 22g spinal needle, administer 2% of

    Lidocaine injection solution to both bases of the palatoglossal arch (80mg)

  • Common Methods of Anesthetizing the Airway

    Laryngopharynx (Superior Laryngeal Nerve) Administer 5 ml of 4% lidocaine injection solution via nebulization (200 mg)

    OR Drip 5 ml of 2% lidocaine viscous solution to the back of the patients tongue (1-2 min) (200mg)

  • Common Methods of Anesthetizing the Airway

    Laryngopharynx (Superior Laryngeal Nerve) OR

    Using a 23 G needle, administer 3 ml of 2% lidocaine injection solution at both lateral sides of the neck between the thyroid cartilage and hyoid bone (120mg).

  • Common Methods of Anesthetizing the Airway

    Recurrent Laryngeal Nerve Lidocaine nebulization may suffice

    OR Using epidural cath through the fiberoptic,

    5ml of lidocaine 4% to the trachea (200mg) OR

    Using a 20 G needle, administer 5 ml of 4% lidocaine injection solution to the Cricothyroid membrane (200mg)

  • Awake Intubation

    Calculation of lidocaine total administered dose: 1. Nasopharynx (ointment)= 50mg 2. Glossopharyngeal nerve= 80mg 3. Superior Laryngeal nerve= 120mg 4. Recurrent Laryngeal nerve=200mg Total without nasopharynx = 400mg Total with nasopharynx = 450mg

  • Awake Intubation

    Lidocaine toxicity

    Legendary: 5mg/kg

    Normal therapeutic range for ventricular arrythmias: 2-5mcg/ml

    Various pharmacological factors affect lidocaine plasma level

  • Awake Intubation