Airway Management in Neurosurgery

AIRWAY MANAGEMENT IN NEUROSURGERY

1 The Philippine General Hospital (PGH)

2 University of the Philippines (UP)

3 UP-PGH

4 DIFFICULT AIRWAY MANAGEMENT IN NEUROSURGERY

GERALDINE RAPHAELA B. JOSE MD FPBA CLINICAL ASSOCIATE PROFESSOR DEPARTMENT OF ANESTHESIOLOGY UNIVERSITY OF THE PHILIPPINES PHILIPPINE GENERAL HOSPITAL

4TH ASIAN SOCIETY FOR NEUROANESTHESIA AND CRITICAL CARE (ASNACC)/ 22ND ANNUAL MEETING OF THE KOREAN SOCIETY FOR NEUROSCIENCE IN ANESTHESIOLOGY AND CRITICAL CARE BUSAN, KOREA APRIL 4, 2015

5 Lecture Objectives

• To review airway issues that might be encountered in the neurosurgical patient

1) Intracranial Dynamics and the airway 2) The “Anticipated Difficult Airway” clinical scenarios in Neuroanesthesia and their respective management options 3) The potential “Postoperative Airway- Related Risks” due to the Neurosurgical procedure

6 DISCLAIMER: This author has made every effort to ensure that the patient care recommended herein is in accord with current accepted standards and practice. In view of the changing nature of medical knowledge, this author warrants that the information and views contained herein may be controversial or with personal bias in the context of his own clinical practice experiences; thus, the lecturer disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained herein. Furthermore, the lecturer is neither sponsored/commissioned by nor in a commercial relationship with equipment manufacturers of equipment cited herein.

7 Neurosurgical Patient Airway Demographics PATIENT PROFILE

8 1) Patients expected/anticipated to have Difficult Airways: a) Acute cervical spine injury/instability with immobilization b) The patient’s head may be fixed in a Halo/Stereotactic head frame. c) Conditions with high incidence of difficult airway management or failed intubation i. The patient for pituitary surgery ii. Patients with Chronic Spine Disease with Myelopathy iii. Patients S/P occipito-cervical or cervical fusion iv. Patients S/P temporal neurosurgical procedures 9 1) Patients expected/anticipated to have Difficult Airways: d) Patients presenting for Functional Neurosurgery (“awake” cranial or spine procedures) or embolization procedures

d) Pediatric patients with Cranio-maxillo- facial dysmorphic syndromes, Cranio- spinal Dysraphisms, Congenital Hydrocephalus with Macrocephaly

10 2) The “UNPREPAREDNESS” in a failed airway or Unanticipated Difficult Airway situation becomes an even greater challenge in: a. Patients at risk for cerebral aneurysm rupture b. Patients at risk of herniation c. Head-injured patients d. Patients with “missed/undetected” myelopathy secondary to an underlying chronic cervical spine disease

11 3) Other challenges & considerations: a. the patient in the unusual positions during surgery (e.g., prone, sphinx, military, sit-up) b. extubation after a prolonged surgery c. Peculiar sensitivity of some patients with central nervous system (CNS) disease to the effects of hypnotic agents

12 Intracranial Dynamics and the Airway

PATIENT PROFILE

13 Unique challenges 1. Airway management in the face of intracranial hypertension or limited intracranial compliance 2. During the processes of achieving, maintaining, and/or rescuing the difficult neurosurgical airway, there is the need to: a) balance and maintain CNS hemodynamics

(CBF, CBV, CMRO2, CSF dynamics), b) avoid increases in ICP, yet c) maintain cerebral/spinal perfusion

Bekker AY, Mistry A, Ritter AA, et al: Computer simulation of intracranial pressure changes during induction of anesthesia: comparison of thiopental, propofol, and etomidate. J Neurosurg Anesthesiol 11:69–80, 1999. 14 • FACTS: • Airway obstruction and difficult Bag/Mask Ventilation may quickly lead to hypercarbia, hypoxemia, and increased CBF aggravating intracranial hypertension • Laryngoscopy and intubation result in acute increases in ICP and MAP (also undue cranio-cervical spine motion) • THE PRIMARY GOALS are to avoid: • further increases in ICP and • further neurologic injury.

Burney RG, Winn R: Increased cerebrospinal fluid pressure during laryngoscopy and intubation for induction of anesthesia. Anesth Analg 54:687–690, 1975. 15 General Airway Considerations in Patients for Craniotomy Is there an “ideal” technique? CLINICAL STRATEGIES

16 1) Airway Assessment (history and PE) of the neurosurgical patient requires similar considerations

a) A previous history of difficult airway management (mask ventilation, laryngoscopy, and/or intubation) warrants particular attention

17 b) Patients with signs and symptoms of Intracranial vascular insufficiency should receive special attention to neck position not only during tracheal intubation & surgery but also in the perioperative period. i. “Beauty parlor stroke syndrome” & “Adolescent stretch syncope” [vertebro-basilar insufficiency], ii. Transient ischemic attacks (TIA), iii. Stroke, and iv. Presence of carotid bruit

• Weintraub, et. al. (MRA flow analysis of 160 cases in 1998): “sustained neck hyperextension greater than 12 minutes appears to be a neglected potential hemodynamic factor that may play a pivotal role in the pathogenesis of perioperative stroke”

Stroke. 1998;29:1644-1649 18 MOUTHS Acronym (modified from Davis J, 1991) Components Description Assessment Activities Measure hyomental Length, subluxation distance (A) Mandible and anterior displacement A of mandible

Base, symmetry, Assess and measure mouth opening in Opening range centimeters or patient’s own 3-finger breadth.

0 Assess pharyngeal Visibility (to include structures and classify Uvula palatal configuration) [Mallampati Class]

Teeth Dentition Assess for presence of loose teeth and dental appliances, occlusion (bite), incisor prominence Flexion, extension, Assess all ranges of movement Head rotation of head/neck [Belhouse-Doré Grade, axial rotation, and cervical spine instability, sternomental distance]

Upper body AP Identify potential impact on airway control abnormalities by large breasts, buffalo hump, kyphosis, Silhouette (to include thyroid short (position of larynx to base of the cartilage tilt) tongue) & large neck circumference, etc. 19 HOWEVER, the limitations of difficult airway prediction via “bedside” screening tests are increasingly being recognized within anesthesia.

“ …we believe that attempts at prediction are much less important than knowing what to do when difficulty is encountered…the clinical value of these bedside screening tests for predicting difficult intubation remains limited.”

20 Summary of Pooled Sensitivity and Specificity of Commonly Used Methods of Airway Evaluation

EXAMINATION SENSITIVITY (%) SPECIFICITY (%) Mallampati classification 49 86 Thyromental distance 20 94 Sternomental distance 62 82 Mouth opening 46 89 Anterior tilt of larynx* 70 95 Data derived from Shiga T, Wajima Z, Inoue T et al: Predicting Difficult Intubation in Apparently Normal Patients: A Meta-analysis of Bedside Screening Test Performance. Anesthesiology 2005; 103: 429 * Roberts JT, Ali HH, Shorten GD. Using the bubble inclinometer to measure laryngeal tilt and predict difficulty of laryngoscopy. J Clin Anesth 1993;5:306–309

Shiga, et al. META-ANALYSIS: “…only poor to moderate sensitivity and moderate to fair specificity”

21 • In clinical practice, unexpected difficulties may occur in 25-30% of cases. . Approximately 50% of these had been labelled as “pseudo-difficulties” resulting from: 1) unskilled operators, 2) incorrect execution of maneuvers, or 3) lack of working guidelines/protocols

SIAARTI-DASG, 2005

22 2) In addition to the history and physical examination, preoperative • plain radiographs, • computed tomography (CT) or • magnetic resonance imaging (MRI), & • angiography may give valuable information of the patient’s intracranial status - signs of increased ICP presence of hemorrhage/infarct/vasospasm/edema

Bedford RF, Morris L, Jane JA: Intracranial hypertension during surgery for supratentorial tumor: correlation with preoperative tomography scans. Anesth Analg 61:430–433, 1982 23 “Copper beaten” skull • Signs of increased intracranial pressure on a skull plain x-ray – Increased vascular markings – Widening of the sella turcica – Erosion of the sella turcica – Gyri may make prominent markings on the inner table of the skull – The pineal gland is displaced from the midline. Tuite GF, Evanson J, Chong WK et-al. The beaten copper cranium: a correlation between intracranial pressure, cranial radiographs, and computed tomographic scans in children with craniosynostosis. Neurosurgery. 1996;39 (4): 691-9 24 T1 post-gadolinium

3-D DTI

Fluid Attenuated Proton Density Gradient Echo Diffusion Tensor Imaging Inversion Recovery 25 CT appearance of normal brain. CT scan appearance of tumor with edema and midline shift. Lesions associated with greater than 10 mm in midline shift or cerebral edema usually indicate intracranial hypertension

Acute Sub-acute Chronic

27 Branch of the Left PCA

Basilar Right Vertebral artery artery

VASOSPASM (CEREBRAL ANGIOGRAM) 28 3) For “Difficult Airway suspects” (2ry to extensive skull-base pathologies) due for elective cranio-facial procedures: PEAE 1 and airway UTZ 2 as adjunctive assessment tools may be valuable in the airway approach decision-making

1 Rosenblatt W, Ianus AI, Sukhupragarn W, Fickenscher A, Sasaki C. Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth Analg 2011; 112: 602-4.

2 Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiol Scand 2011;55: 1155-1173. 29 Routine Measures to achieve optimal airway control &/or “smooth” intubation include: 1) proper head positioning*, 2) preoxygenation, and 3) appropriate dosing of induction agents (hypnotics, opioids) and relaxants (with or without adjuvant agents)

* Ng I, Lim J, Wong HB: Effects of head posture on cerebral hemodynamics: its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation. Neurosurgery 54:593–597, 2004. 30 • Techniques currently being employed to “blunt” the sympathetic response to laryngoscopy and intubation: 1) an additional dose of thiopental or propofol &/or opioids, 2) use of beta-blockers or other antihypertensive agents, and 3) use of intravenous (IV) lidocaine

31 GENERAL PRINCIPLES IN THE ANESTHETIC MANAGEMENT TO AVOID INCREASED INTRACRANIAL PRESSURE Technique Precaution(s) Be vigilant to changes in degree of painful stimulation. Avoid marked Ensure adequate depth of anesthesia before intubation hypertension attempts or surgical/procedural attempts. Be vigilant of patient’s respiratory status. Avoid hypoxia Take precautions to avoid aspiration. Preoxygenation before induction of anesthesia or tracheal intubation. Be vigilant of patient’s respiratory status. Avoid hypercapnia Avoid undue sedation. Avoid severe neck Attempt to maintain neck in neutral position. rotation Be vigilant to head positioning of patient during surgery.

32 GENERAL PRINCIPLES IN THE ANESTHETIC MANAGEMENT TO AVOID INCREASED INTRACRANIAL PRESSURE Technique Precaution(s) Avoid compression of Consider avoiding internal jugular neck lines jugular veins when possible. If backup position not possible, use reverse Elevate head Trendelenburg (avoid hypotension). Decrease blood viscosity Avoid rapid infusion of mannitol, which may and intracerebral BV paradoxically increase intracranial pressure. Use maneuvers or pharmacologic agents to Avoid sustained avoid bucking, movement, and vomiting. increases in Avoid high ventilatory pressures when possible. intrathoracic pressure

Consider beta-blocker use to treat hypertension. Avoid cerebral Consider calcium channel blockers. venodilators Avoid nitroglycerine and nitroprusside, if possible. 33 Reminder

“RSI regimens with paralysis produced three-fold increases in peak ICP change compared with the sedation-only regimen. Pretreatment agents did not affect ICP changes.”

Bozeman WP, Idris AH. Intracranial pressure changes during rapid sequence intubation: a swine model. J Trauma. 2005 Feb;58(2):278-83

34 A. Traumatic Brain Injury CLINICAL STRATEGIES IN COMMON NSS DIFFICULT AIRWAY SCENARIOS

35 The anesthesiologist caring for the patient with TBI must understand that although primary mechanisms of injury (primary insults) are a large determinant of patient outcome, secondary insults can impact dramatically on morbidity, mortality, and quality of life of the TBI patient.

Schreiber M, Aoki N, Scott B, et al: Determinants of mortality in patients with severe blunt head injury. Arch Surg 137:285–290, 2002. 36 TRAUMATIC BRAIN INJURY • Improperly planned airway technique can severely compromise intracranial dynamics and increase morbidity and mortality • Predictors of mortality in adult brain- injured patients are: − Hypoxia (mortality rate doubles to 50%) − Hypercarbia (mortality rate increases to 67%) − Systemic hypotension resulting in cerebral Hypoperfusion/decreased CPP − Intracranial hypertension − Hypothermia Jeremitsky E, Omert L, Dunham CM, et al: Harbingers of poor outcome the day after severe brain injury: hypothermia, hypoxia, and hypoperfusion. J Trauma 54:312–319, 2003. 37 A reasonable CLINICAL estimate can be made in head injured patients who are not sedated: • Drowsy and confused (GCS 13-15): ICP = 20-30 mmHg • Severe brain swelling (GCS ≤ 8): ICP ≥ 30 mmHg

38 REMINDERS 1) Techniques minimizing head movement should be used in TBI. However, concern about a cervical inury should never take precedence over relieving hypoxemia. 2) It is of critical importance to ensure that appropriate monitoring is present throughout airway maneuvers. 3) Caution should be exercised in “blindly” inserting “devices/appliances” into the nasal cavity of patients with known or suspected basilar skull fractures and sinus injuries: a. A nasotracheal tube for airway control b. An NGT for gastric decompression or c. A Foley catheter for control of massive epistaxis.

39 ETT inside the Anterior Cranial Fossa after “blind” nasotracheal intubation in patient with basal skull fracture

Marlow, Troy J. et al. Intracranial placement of a nasotracheal tube after facial fracture: A rare complication. Journal of Emergency Medicine , Volume 15 , Issue 2 , 187 - 191 40 Foley Catheter Placed for Epistaxis Inside Anterior Cranial Fossa

41 REMINDERS Most of these patients are assumed to have a “full stomach,” so it is important to weigh the risk of aspiration during laryngoscopy and intubation vs. prior stomach decompression with Computed axial tomography showing NGT insertion pneumoencephalus and a localized intracranial NGT

Genú et al. Inadvertent Intracranial Placement of an NG Tube. J Oral Maxillofac Surg 2004. 42 REMINDERS 4) If intubation attempts fail and Face Mask/Supraglottic Airway ventilation becomes impossible & if the situation warrants , surgeons or appropriately trained anesthesiologists should be prepared to RAPIDLY perform invasive airway techniques.

43 B. Patient with Cervical Spine Problem – Acute Traumatic Cervical Spine Injury CLINICAL STRATEGIES IN COMMON NEUROSURGICAL DIFFICULT AIRWAY SCENARIOS

44 Epidemiology

1) Incidence of spinal injuries in polytrauma patients is approximately 13% to 30% • Cervical spine injury (CSI) represents about 0.9% to 3% of these. 2) The relative risk of having concomitant CSI is increased in the presence of severe head injury by a factor greater than 8. – if GCS score is 13-15, the incidence of CSI is 1.4% – if GCS score is <8, the incidence of CSI is 10.2%

Schmidt OI, Gahr RH, Gosse A, et al: ATLS and damage control in spine trauma. World J Emerg Surg 4:9, 2009. Goldberg W, Mueller C, Panacek E, et al: Group distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med 38:17–21, 2001. 45 Epidemiology

• If a CSI is missed or its detection delayed: – the incidence of secondary neurologic deficit increases from 1.4% to 10.5%. – almost one-third of patients may develop permanent neurologic deficit.

American College of Surgeons: Advanced trauma life support, Chicago, 2008, ACS, pp 157-169. 46 How then is the best way to “clear” the cervical spine in the trauma patient?

– Detection of CSI requires a variety of modalities that vary in sensitivity, including: • clinical evaluation, • plain radiography, • CT, • MRI, and • dynamic fluoroscopy.

47 Clinical Evaluation To clear the cervical spine clinically, the following criteria must be met: 1. GCS score of 15, with the patient alert and oriented 2. Absence of injuries that may draw attention away from a CSI 3. Absence of drugs or intoxicants that may interfere with the patient’s sensorium 4. Absence of signs or symptoms on examining the neck, specifically: a. No midline pain or tenderness b. Full range of active movement c. No neurologic deficit attributable to the cervical spine

Clinical Clearance of Cervical Spine Injury Karim Brohi, trauma.org 7:4, April 2002 48 Plain Radiography

• The cross-table lateral view alone, even if technically adequate and interpreted by an expert, will still miss 15% of cervical injuries. • BEST PRACTICE: A 3-view cervical series 1. cross-table lateral view, 2. open-mouth odontoid view, and 3. anteroposterior (AP) view

Nguyen GK, Clark R: Adequacy of plain radiography in the diagnosis of cervical spine injuries. Emerg Radiol 11:158–161, 2005. 49 In low-risk patients, plain radiography is an efficient diagnostic examination with specificity of 100%. Normal lateral In high-risk patients, plain cervical Normal AP radiography + CT scan = x-ray view cervical spine x- ray view sensitivity of 93.3% and specificity of 95%.

Normal odontoid cervical spine x- ray view

50 Computed Tomography

• CT scan of either the entire cervical spine or directed at areas missed by plain radiographs, provides a complementary approach when used in addition to the three-view cervical series, reducing the risk of missing a CSI to less than 1%. • The more costly Helical CT is the preferred initial screening test for detection of cervical spine fractures among moderate- to high-risk patients. – It reduces the incidence of paralysis resulting from false-negative imaging studies together with eventual institutional costs, when settlement costs are taken into account.

Grogan EL, Morris JA Jr, Dittus RS, et al: Cervical spine evaluation in urban trauma centers: lowering institutional costs and complications through helical CT scan. J Am Coll Surg 200:160–165, 2005. 51 AIRWAY TECHNIQUES FOR ELECTIVE PATIENTS WITH UNSTABLE CERVICAL SPINE

1. Awake flexible fiberoptic intubation 2. Nasal intubation (if without basal skull &/or sinus fractures) 3. Indirect rigid laryngoscopy: Bullard, Wu, Upsher & TruView laryngoscopes 4. Videolaryngoscopy [DCI (direct coupled interface)/CMOS/wireless systems; channeled/non-channeled] 5. Direct laryngoscopy with in-line stabilization 6. Fiberoptic intubation using appropriate SGAs as conduit (e.g. ILMA, ILA) 7. Lightwands (e.g. Trachlight) 8. Fiberoptic optical stylets [rigid/semi-rigid/”hybrids”]: Bonfils, Shikani, Clarus video system, SensaScope, StyletScope, IntubaidFlex 9. Retrograde intubation 10. Percutaneous/Surgical airway: Cricothyrotomy, Tracheostomy

Modified from Osborn IP, Ferrario L. The Difficult Airway in Neurosurgery. In BENUMOF AND HAGBERG’S AIRWAY MANAGEMENT, 3rd edition, 2013. Hagberg CA editor. 52 Alternative airway devices when the head must remain immobilized in an emergent setting

1. Video laryngoscopes 2. Indirect rigid laryngoscopes 3. Supraglottic airway as conduit for Fiberoptic Intubation 4. Fiberoptic stylets (rigid/malleable/”hybrid”) 5. “Invasive” Mosier JM, Stolz U, Chiu S, Sakles JC: Difficult airway management in the emergency department: GlideScope videolaryngoscopy compared to direct laryngoscopy. J Emerg Med 2011 53 • Retrograde intubation had been deemed as the alternative technique of choice in resource-constrained theatre complexes/settings provided that the care-giver is adept at the technique.

Hodgson RE. Which airway devices should be on difficult intubation trolleys in resource-constrained settings? South Afr J Anaesth Analg 2011;17(1)

54 Immobilization Options 1. Manual in-line immobilization (not traction) 2. Immobilization of the head between two (2) sandbags 3. Rigid cervical collar and spinal board • Significant morbidity and mortality • Increase the difficult intubation and airway compromise • Risk of aspiration • Does not necessarily protect against movement at the occipito-cervical and cervico-thoracic junction

American College of Surgeons. Advanced Trauma Life Support for Doctors, 8th Edn. published by the American College of Surgeons 55 Manual In-Line Stabilization Techniques

From Austin N, Krishnamoorthy V, Dagal A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci 2014;4:50-6. 56 STUDIES OF VIDEO LARYNGOSCOPY ON INTUBATION PERFORMANCE FOR THE PATIENT MAINTAINED IN MANUAL IN-LINE STABILIZATION Outcome Author Device Control Sample Major Findings Assessed Malik et GlideScope DL 120 Laryngeal view Improved laryngeal view and IDS Slower intubation time al, 2008 (Verathon, IDS Bothell, WA) Intubation time No difference in success Success rate Maharaj et Airtraq (Prodol, DL 40 IDS Reduced number of intubation al, 2008 Vizcaya, Spain) Intubation attempts attempts. Improved IDS, improved Laryngeal view laryngeal view Smith et al, WuScope (Pentax, DL 87 IDS Improved IDS and laryngeal view 1999 Orange-burg, NY) Laryngeal view, No difference in success or number of intubation attempts attempts Malik et al, AWS (Pentax, DL 90 IDS, laryngeal view Improved IDS and laryngeal view 2009 Hoya, Japan) Enomoto et AWS DL 203 Laryngeal view, Improved laryngeal view al, 2008 intubation time, Increased success rate success rate Faster intubation time Liu et al, AWS Glide- 70 IDS, Intubation time, Faster intubation time 2009 Scope success rate within a Lower IDS, Improved laryngeal view defined time interval and higher intubation success with AWS IDS = Intubation Difficulty Scale AWS = Airway Scope DL = direct laryngoscopy

57 STUDIES OF CERVICAL MOTION WHILE USING VIDEO LARYNGOSCOPES Study Device Control Cervical Precautions Fluoroscopy Major Findings In selected patients Hastings et al, Bullard (Circon ACMI, (C0–C4) Reduced extension across DL None 1995 Stamford, CT) Angle finder used in (C0–C4) the entire sample Continuous C0–C5 Robitaille et al, No decrease in cervical GlideScope DL MILS during several time 2008 movement points Maruyama et al, DL and Reduced extension at AWS None C1/C2, C3/C4 2008 McCoy adjacent vertebra Hirabayashi et al, Reduced extension at all AWS DL None C0–C4 2007 segments GlideScope Reduced C2–C5 motion with Turkstra et al, Lightwand Glidescope DL MILS C0–C5 2005 (Trachlight, Laerdal, Reduced motion across all Armonk, NY) segments with Lightwand Watts, Gelb, One arm with MILS Reduced cervical extension in Bullard DL C0–C5 Bach, Pelz, 1997 One arm without the Bullard 1MILS arm Maruyama et al, Reduced cumulative cervical AWS DL MILS C0–C4 2008 motion No difference at C1–C2 Turkstra et al, Airtraq DL MILS C0-Thoracic segment, less extension at 2009 C2–C5, and C5-Thoracic

58 Section Summary 1. The problem with airway management in patients with CSI is that the techniques normally employed to secure the airway have the potential to cause movement and thereby risk causing secondary neurologic injury. • Effect of Direct Laryngoscopy (Mac 3 Blade) on cervical spine:  Occiput and C1, superior rotation  C2, remains neutral  C3-C5, mild inferior rotation  Atlanto-occipital and atlanto-axial joints - most significant movements • Chin lift – greater movement than intubation • Cricoid pressure – no significant cervical movement

59 Section Summary

2. It is essential to proceed in the most expedient manner with the techniques that the care-giver is familiar and proficient with. • Due to the emergent nature of management of these often multiply- injured patients, time constraint may not permit “clearing” the cervical spine to be performed. Therefore, a group of patients remain whose cervical spinal integrity is uncertain and who must be managed as if their cervical spine is, in fact, injured.

60 C. Patient with Cervical Spine Problem – Chronic Spine Disease with Myelopathy

CLINICAL STRATEGIES IN COMMON NEUROSURGICAL DIFFICULT AIRWAY SCENARIOS

61 • One of the problems in relation to this patient group is predicting difficulty with intubation, both by direct laryngoscopy and fiberoptic intubation.

Maktabi MA, Titler SS, Kadia S, et al: When fiberoptic intubation fails in patients with unstable craniovertebral junctions. Anesth Analg 108:1937–1940, 2009

• Difficult intubation (DI) is well recognized as more common in patients with cervical spine disease: – ankylosing spondylitis, – rheumatoid arthritis, and – Klippel-Feil abnormality/congenitally fused cervical vertebrae.

Stallmer ML, Vanaharam V, Mashour GA: Congenital cervical spine fusion and airway management: a case series of Klippel- Feil syndrome. J Clin Anesth 20:447–451, 2008. 62 Direct Laryngoscopy Problems with this group of patients: • There is reduced mobility of the atlanto- occipital and atlanto-axial joints or fusion of cervical vertebrae resulting in inability to assume the “sniff” position.

SPONDYLOTIC MYELOPATHY WITH CORD COMPRESSION IN RA

CERVICAL SPINE FUSION ANKYLOSING SPONDYLITIS WITH PSEUDOARTHROSIS Calder I, Calder J, Crockard HA: Difficult direct laryngoscopy in patients with cervical spine disease. Anaesthesia 50:756–763, 1995. 63 • Three especially relevant areas in which rheumatoid arthritis (RA) affects the airway and cervical spine are 1. cricoarytenoid arthritis, 2. temporomandibular arthritis, and 3. atlantoaxial instability and/or limited craniocervical junction extension.

Bandi V, Munnur U, Braman SS: Airway problems in patients with rheumatologic disorders. Crit Care Clin 18:749–765, 2002.

64 1) Laryngeal Involvement • prevalence of 45% to 88% • 59% of patients with RA show laryngeal involvement on PE • 14% show extrathoracic airway obstruction on spirometry • 69% show one or more signs of laryngeal involvement – 75% of these have symptoms of breathing difficulty • The greatest risk is after extubation. – Intubation, even if of brief duration, can lead to sufficient mucosal edema to cause postextubation stridor and airway obstruction – the incidence of postextubation stridor is much lower after FOI (1%) than after direct laryngoscopy (14%).

Kolman J, Morris I: Cricoarytenoid arthritis: a cause of acute airway obstruction in rheumatoid arthritis. Can J Anesth 49:729–732, 2002. 65 2) TMJ Involvement • Up to two thirds of patients with long- standing RA may have limited temporomandibular joint (TMJ) mobility with consequent limited mouth opening. • Of those with severe TMJ destruction, up to 70% may undergo episodes of airway obstruction similar to that seen in patients with micrognathia or obstructive sleep apnea syndrome

Horton WA, Fahy L, Charters P: Disposition of the cervical vertebrae, atlanto-axial joint, hyoid and mandible during x-ray laryngoscopy. Br J Anaesth 63:435–438, 1989 66 3) Atlanto-Cervical Instability • Present in about 25% of all patients with RA and is more likely in those with severe peripheral rheumatoid involvement. – 3 main patterns: atlanto-axial instability, cranial settling, and subaxial instability • Symptoms correlate poorly with radiologic findings (may be asymptomatic in 5%) – Patterns of neurologic involvement can include radiculopathy, myelopathy, and cranial nerve compromise • Vertical subluxation or cranial “settling” & upper cervical involvement impact on brainstem (lower cranial nerves) and respiratory muscle functions, respectively – impingement of the odontoid peg on the brainstem may occur

Paus AC, Steen H, Røislien J: High mortality rate in rheumatoid arthritis with subluxation of the cervical spine: a cohort study of operated and nonoperated patients. Spine (Phila Pa 1976) 33:2278, 2008 67 Section Summary • If with symptoms of cervical myelopathy, careful airway management to avoid further injury should be exercised. • Intubation techniques similar for the CSI patient are appropriate and best performed by experienced practitioners. – When possible, awake intubation followed by demonstration of extremity movement, is ideal and recommended. When this is not possible, an “asleep” technique that produces minimal head movement and airway maintenance is acceptable (e.g. SGA for ventilation & VL for intubation) – A rescue plan for intubation or ventilation failure must always be in place

68 A. Patients with Head-neck FIXATION Devices ANTICIPATED DIFFICULT AIRWAY

69 Patients with Halo Fixation

• CHALLENGE IN AIRWAY CONTROL: The halo frame prevents proper positioning for laryngoscopy by restricting atlanto- occipital extension. 1. IN THE NON-EMERGENT SETTING: “awake” intubation with a flexible intubating fiberscope is indicated. a. Other choices: video laryngoscopy, rigid/semi-rigid optical stylet, Bullard

Kang M, Vives MJ, Vaccaro AR: The halo vest: principles of application and management of complications. J Spinal Cord Med 26:186–192, 2003. 70 b. For patients who present for elective surgery in halo fixation, it is imperative that: i. clinicians involved have skills and equipment for alternative intubation techniques, ii. a neurosurgeon can safely remove the halo if necessary, and iii. a rescue plan is prepared in case of failed ventilation.

71 2. IN THE EMERGENT SETTING • Respiratory failure or airway obstruction in the patient wearing a halo frame becomes a serious emergency • Sims and Berger (2002) – almost half of 14 patients with halo fixation who required emergency airway control died in the attempts. • RESCUE TECHNIQUES: – Indirect laryngoscopy (Bullard) – Videolaryngoscopy – Invasive airway techniques

Sims CA, Berger DL: Airway risk in hospitalized trauma patients with cervical injuries requiring halo fixation. Ann Surg 225:280–284, 2002. 72 RECOMMENDATIONS FOR EARLY TRACHEOSTOMY IN TRAUMA PATIENTS WITH HALO FIXATION High cervical injury score History of cardiac disease Age >60 years Intubated on arrival Previous history of difficult intubation Anticipated length of intubation > 1 week Capability of surgical airway not available

Sims CA, Berger DL: Airway risk in hospitalized trauma patients with cervical injuries requiring halo fixation. Ann Surg 225:280–284, 2002. 73 Patient in Leksell frame for transport

Patients with Stereotactic

Headframes Leksell frame allows placement of LMA Supreme

74 AIRWAY MANAGEMENT TECHNIQUES FOR HEADFRAME PLACEMENT & SUBSEQUENT STEREOTACTIC PROCEDURE Spontaneous ventilation with oxygen supplementation Awake or asleep SGA Awake oral or nasal flexible fiberoptic intubation Blind nasal intubation with SV Awake or asleep fiberoptic intubation via SGA Awake or asleep optical stylet/lightwand intubation Awake or asleep videolaryngoscopy intubation

75 REMINDERS

• Patient cooperation is an important factor for “awake” placement of Halo/Stereotactic head frames under LA ± sedation. • Indications for general anesthesia: – pediatric patients, – obtunded/intoxicated/uncooperative patients, – obese patients prone to airway obstruction, and – those at risk for seizures

76 B. Patient for “Awake” Craniotomy or Embolization Procedures ANTICIPATED DIFFICULT AIRWAY

77 Functional Neurosurgery

• Indications: – Resection of a lesion (tumors, AVM) in the “eloquent” areas of the brain – Treatment of chronic pain (including cancer pain and failed back surgery syndrome), spasticity, movement disorders (Parkinson's disease, dystonia, tremors, etc), “refractory” psychiatric conditions, epilepsy, & even addiction. • Intraoperative complications with airway- related implications include: – restlessness and agitation – “loss of airway” due to excessive sedation

78 “Awake” Craniotomy

• “Asleep-awake-asleep” technique – Minimize patient’s discomfort – Provide better operating conditions for the surgeon – Technique: TIVA → scalp block - awakened intraoperatively → “testing/mapping” → options: • Insert SGA or • Patient remains awake up to end of surgery, if comfortable

79 Embolization Procedures • Indication: endovascular treatment of intracranial

aneurysm or arteriovenous Microcath malformation (AVM) • 2 most serious potential complications are: – cerebral infarction – hemorrhage • Technique: “immobile/ motionless” patient under GA with SGA or ETT (intubation via DL, VL, Optical Stylet) 80 • Airway options:

– While awake, on O2 binasal prongs with CO2 monitoring – IF complications arise: • (SGA) for ventilation • ILMA as intubation conduit • Video laryngoscope intubation

81 C. Patients with Acromegaly & Cushing’s Disease ANTICIPATED DIFFICULT AIRWAY

82 Patient Profile 1. Those with Cushing’s disease & syndrome are more prone to difficulties with mask ventilation and airway obstruction, but not difficult DL – Can be morbidly obese and have increased incidence of OSA resulting in rapid desaturation if with difficulty in airway management

Shipley JE, Schteingart DE, Tandon R, et al. Sleep architecture and sleep apnea in patients with Cushing’s disease. Sleep 1992;15:514-8.

2. Those with acromegaly are at increased risk of intubation failure. Aziz M. Airway management in neuroanesthesiology. Anesthesiology Clin 30 (2012) 229-240.

83 Multisystem Manifestations of Cushing’s Syndrome Organ Systems Affected Clinical Features Cardiorespiratory Hypertension Increased sensitivity to endogenous and exogenous vasopressors Left ventricular hypertrophy and strain Congestive cardiac failure Obstructive sleep apnea Electrolyte imbalance Hypokalemia, hypernatremia Endocrine Diabetes mellitus Musculoskeletal Osteoporosis Aseptic necrosis of the hip Vertebral crush fractures Proximal myopathy Capillary fragility Miscellaneous Obesity, Polycythemia, Decreased wound healing, Thin skin, gastroesophageal reflux

84 a) Acromegaly is a rare condition afflicting 3 to 4 per 1million people.

Melemed S: Acromegaly. N Engl J Med 322:966–975, 1990.

b) Compared with the non-acromegalic population, acromegalic patients have a higher incidence of: • difficult intubation (9-33% incidence) • unpredictable difficult airway • problematic mask ventilation • upper airway obstruction (16% - 30% incidence diagnosed by spirometry) • sleep apnea (obstructive and central)

Nemergut EC, Zuo Z: Airway management in patients with pituitary disease: a review of 746 patients. J Neurosurg Anesthesiol 18:73–77, 2006). Piper J, Dirks BA, Traynelis VC, et al: Perioperative management and surgical outcome of the acromegalic patient with sleep apnea. Neurosurgery 36:70–75, 1995. 85 AIRWAY CONSIDERATIONS IN PATIENTS WITH ACROMEGALY Prognathic jaw Macroglossia Osteophyte formation of cervical spine: decreased range of motion of neck Thickening of pharyngeal and laryngeal soft tissue Thickening of vocal cords Recurrent laryngeal nerve paralysis Decrease in width of cricoid arch Hypertrophy of arytenoepiglottic folds Hypertrophy of ventricular folds Richard Kiel “Jaws” Central sleep apnea

86 Airway Management Considerations

• While awake FOI remains the present standard of care for anticipated difficult airways, FOI may prove difficult or fail in acromegalic patients due to considerable redundant tissue and large tongues.

Hakala P, Randell T, Valli H: Laryngoscopy and fibreoptic intubation in patients with acromegaly. Br J Anaesth 80:345–347, 1998.

• If awake FOI is planned, the increased incidence of coronary artery disease/cardiomyopathy in some patients with acromegaly should also be considered.

Matta MP, Caron P: Acromegalic cardiomyopathy: a review of the literature. Pituitary 6:203–207, 2003.

87 Airway Management Considerations

• Other options: – For ventilation failure rescue: SGAs – For intubation: • Video laryngoscopy • Optical stylet intubation • SGA as conduit for FOI • ILMA (but with high failure rate of intubation*)

*Law-Koune JD, Liu N, Szekely B, et al: Using the intubating laryngeal mask airway for ventilation and endotracheal intubation in anesthetized and unparalyzed acromegalic patients. J Neurosurg Anesthesiol 16:11–13, 2004.

88 Intubation of acromegalic patient with McGrath Series 5 videolaryngoscope.

89 Postop Consideration

The propensity toward airway obstruction must also be considered in the immediate postop period, especially in the patient with bilateral nasal packing. – Postop negative pressure pulmonary edema has been described in acromegalic patients from partial obstruction after extubation.

Spiekermann BF, Stone DJ, Bogdonoff DL: Airway management in neuroanaesthesia. Can J Anaesth 43:820–834, 1996.

Scholtes FJ, Scholtes JL: Airway obstruction in acromegaly: A method of prevention. Anaesthesia and Intensive Care 16:491– 492, 1988. 90 D. Pediatric Patients with Congenital Hydrocephalus, Cranio-Facial Dysmorphic Syndromes and Cranio-Spinal Dysraphism ANTICIPATED DIFFICULT AIRWAY

91 CONGENITAL SYNDROMES ASSOCIATED WITH DIFFICULT AIRWAYS

Anatomical Syndrome Anomaly Location Head Hydrocephalus Macrocephaly Pierre-Robin Sequence Micrognathia Mandible Treacher-Collin’s Syndrome Mandibular hypoplasia

Mid-face Apert’s, Crouzon’s Maxillary hypoplasia Arthrogryposis Ankylosis TMJ Cocayane Syndrome Down’s Syndrome (Trisomy 21) Macroglossia Mucopolysaccharidosis Macroglossia Mouth and Freeman-Sheldon Syndrome Microstomia tongue Neurofibromatosis Masses obstructing airway Sturge-Weber Syndrome Masses obstructing airway Dental Cocayane Syndrome Protruding incisors Klippel-Feil Syndrome Limited mobility Cervical Spine Down’s Syndrome Instability Mucopolysaccharidoses Instability

92 CONGENITAL HYDROCEPHALUS with Macrocephaly

93 FEATURES OF CONGENITAL SYNDROMES ASSOCIATED WITH DIFFICULT AIRWAYS Anomaly Syndrome 1) TMJ Ankylosis Arthrogryposis, Cockayne 2) AO instability Trisomy 21 3) Cleft lip and palate Pierre-Robin, Treacher-Collins 4) Craniofacial dysostosis (midface Apert, Crouzon, Pfeiffer hypoplasia, proptosis, high-arched palate, small nasal passages) 5) Glossoptosis Pierre-Robin 6) Jaw hyperplasia Ramon or cherubism 7) Limited cervical mobility (due to Klippel-Feil, Juvenile RA, Goldenhar’s, fused or hemivertebrae, neck Freeman-Sheldon, Trisomy 21 (AO contractures, joint instabilities) instability) 8) Macrocephaly Hydrocephalus 9) Macroglossia Trisomy 21, Beckwith-Wiedemann, congenital mucopolysaccharidosis, hypothyroidism, Hem-/lymphangioma 94 FEATURES OF CONGENITAL SYNDROMES ASSOCIATED WITH DIFFICULT AIRWAYS Anomaly Syndrome 10) Mandibular hypoplasia (often Pierre-Robin, Carpenter, Goldenhar, associated with reduced nose- Crouzon, Freeman-Sheldon, Treacher- pharynx space) and Collins (mandibulofacial dysostosis), micrognathia/retrognathia Stickler’s 11) Maxillary hypoplasia Apert’s, Treacher-Collins 12) Microsomia (craniofacial, vertebral) Goldenhar’s 13) Microstomia (reduced mouth Freeman-Sheldon (whistling face), opening) Hallermann -Streiff, oto-palato-digital syndromes 14) Obstructed airway from masses Neurofibromatosis, Sturge-Weber 15) Protruding incisors Cockayne Syndrome 16) Pharyngomalacia Trisomy 21 17) Vocal cord paralysis Arnold-Chiari, hydrocephalus, encephalocoele 18) Zygomatic hypoplasia Treacher-Collins 95 Summary of Issues that may arise when attempting mask ventilation or intubation with these malformations

Anomaly Implications Craniofacial dysostosis: high-arched Mouth breathing, obstructive apnea; palate, small nasal passages Options: preserve SV, use SGA Hemifacial hypoplasia or other Difficult FMV – use SGA distortions in facial structures Difficult DL & TI; Options: ILMA or Limited anterior mandibular space fiberoptics (flexible intubation fiberscope, relative to tongue size (e.g., Pierre- rigid indirect, VL, semi-rigid optical stylet, Robin, Treacher-Collins) RI, elective surgical airway) High Mallampati Class – FMV should not Tongue hyperplasia &/or be attempted; Options: curved blades mandibular/maxillary hypoplasia may allow DL; oral airway or SGA effective in maintaining airway patency; Bullard with bougie & optical stylet

96 Summary of Issues that may arise when attempting mask ventilation or intubation with these malformations

Anomaly implications Difficult FMV; Microsomia (e.g., Goldenhar’s) Options: SGA or nasal FIF Microstomia Difficult DL & TI; Options: NP airway, optical stylet, FIF Cervical spine & TMJ Difficult DL; movement limitation Options: nasal FIF, lightwand, VL Impossible DL; Glossopexy (tongue sutured to lip) Options: FIF, optical stylet Congenital mucopolysaccharidosis: Difficult FMV, DL & TI; macroglossia, soft tissue Options: preserve SV, ILMA with FIF thickening, blocked nasal passages

97 CRANIOFACIAL ANOMALIES 1. Difficult BMV &/or TI due to abnormal upper and lower airway anatomy & physiology – Midface retrusion brings the soft palate against the posterior pharyngeal wall resulting in breathing problems and sleep apnea 2. AO joint instability 3. Co-existing congenital conditions ( e.g. cardiopulmonary, renal, metabolic, etc.) 4. Neurological dysfunction and increased ICP 5. These patients usually present for: – VPS, cranio-maxillo-facial re-modelling (strip craniectomy), tracheostomy, release of TMJ ankylosis, or occipito-cervical fusion.

98 Sturge-Weber Pfeiffer

Trisomy 21 Pierre Robin Maroteaux- Lamy

Crouzon Morquio

Post-remodelling Crouzon’s with appliance

99 100 Airway Management

• Preoperative endoscopic airway evaluation (PEAE) may be essential • If with difficult FMV: SGA then DL intubation • If with difficult DL: optical stylet, VL • Early tracheostomy may be unavoidable! – obviate the need for an early midface advancement for airway control – reduces the risk of postoperative problems, such as aspiration pneumonia

101 • Positioning concerns – on induction

Patient with occipital encephalocoele. Head being supported by assistant

Child at edge of table with head supported by assistant 102 Challenging Airway: Craniopagus (Partial Angular) Conjoined Twins

103 Challenging Airway: Craniopagus (Partial Angular) Conjoined Twins

104 Positioning Issues

105 A. Airway-related Potential Risks POSTOPERATIVE CONSIDERATIONS

106 1. Postoperative “obtundation” jeopardizing the ability to maintain the airway due to: a) Intraoperative neurological events • seizure • herniation • hypoperfusion of an ischemic penumbral area (may also be due to vasospasm, NPBE) • infarct/“bleed”/”re-bleed”/edema b) Anesthesia management-related • residual effects of anesthetic drugs • hypoxia and hypercarbia • acid-base, fluid and electrolyte problems 2. Surgery-related airway injuries 3. Positioning-related airway complications

107 B. Specific Airway-related Risks due to Procedures POSTOPERATIVE CONSIDERATIONS

108 1. After Supratentorial Craniotomy

• Patients who have previously undergone fronto- temporal or pterional craniotomy may subsequently in the future suffer from limited mouth opening not evident at the original craniotomy consequent to restrictive scarring region of the temporalis muscle due to: – Non-resumption of normal eating and talking activities – Excessive pain on temporalis muscle use

Nitzan DW, Azaz B, Constantini S: Severe limitation in mouth opening following transtemporal neurosurgical procedures. J Neurosurg 76:623–625, 1992.

Kawaguchi M, Sakamoto T, Furuya H, et al: Pseudoankylosis of the mandible after supratentorial craniotomy. Anesth Analg 83:731–734, 1996.

109 2. After Anterior Cervical Spine Surgery a. Anterior cervical spinal surgery may result in recurrent laryngeal nerve injury or hematoma, causing airway obstruction after extubation. – Most common cause of vocal cord paralysis is compression of the RLN within the endolarynx – Monitoring of ETT cuff pressure and release after retractor placement may prevent injury to the recurrent laryngeal nerve.

Apfelbaum RI, Kriskovich MD, Haller JR: On the incidence, cause and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine 25:2906–2912, 2000.

110 2. After Anterior Cervical Spine Surgery b. Upper airway edema due to surgical retraction may also develop. – In contrast to problems associated with recurrent laryngeal nerve injury (angioedema or hematoma), which tend to occur early, this edema may not develop for 2 to 3 days postoperatively. – Common features in these patients who require re-intubation are: • an increasing number of levels manipulated • higher operated levels • longer surgery • greater intraoperative blood loss.

111 c. Swallowing difficulties and dysphonia d. Migration of the bone or synthetic graft or plate into the airway or compressing the airway with resultant obstruction may also occur

J Anaesthesiol Clin Pharmacol. 2012 Jan-Mar; 28(1): 139–140. 112 e. If with concomitant occipito-cervical and cervical fusion • Difficulty in assuming the “sniff” position for DL and TI if patients had to be re-intubated postoperatively for respiratory compromise Occipitocervical fixation • Options: VL or optical supplemented by vertebrectomy with an anterior cage and plate stylet fixation for a patient who required decompressive cervical laminectomies.

113 3. After Posterior Fossa Surgery a. Surgery-related – Because of the position of the lower cranial nerves in relation to the posterior fossa, the patient’s ability to maintain the airway may be compromised postoperatively. – Because of the proximity of the brainstem, further hazards are presented postoperatively because central control of respiration may be jeopardized.

Kimovec MA, Ambrose J: Predictors of airway and respiratory complications after posterior fossa craniotomies. J Neurosurg Anesthesiol 4:315, 1992.

Howard R, Mahoney A, Thurlow AC: Respiratory obstruction after posterior fossa surgery. Anaesthesia 45:222–224, 1990 114 b. Intraoperative positioning-related (esp. prone & sit-up) • Facial edema • Macroglossia • Oro-pharyngeal edema • Spinal cord infarction (in the sitting position)/quadriplegia

Howard R, Mahoney A, Thurlow AC: Respiratory obstruction after posterior fossa surgery. Anaesthesia 45:222–224, 1990.

Sinha A, Agarwal A, Gaur A, Pandey CK: Oropharyngeal swelling and macroglossia after cervical spine surgery in the prone position. J Neurosurg Anesthesiol 13:237–239, 2001.

Morandi X, Riffaud L, Amlashi SF, Brassier G: Extensive spinal cord infarction in the sitting position: case report. Neurosurgery 54:1512–1515, 2004. 115 Positioning and Ventilation Mechanics: Airway Management Goes Beyond the Larynx

116 Clinical Pearls SUMMARY

117 Clinical Pearls 1. In addition to airway assessment, a neurologic examination and/or communication with the surgeon are invaluable before induction of anesthesia. • Elective patients who demonstrate neurologic symptoms of the extremities with neck flexion or extension should have awake, topicalized endotracheal intubation.

118 Clinical Pearls

2. During the processes of achieving, maintaining, and/or rescuing the neurosurgical airway, the goals are: a. To avoid hypoxia and hypercarbia b. To maintain intracranial/spinal hemodynamics and cerebral/spinal perfusion (avoiding hypotension and further increases in ICP when there is limited intracranial compliance)

119 Clinical Pearls 3. Patients with an unstable cervical spine may be unable to cooperate with an awake fiberoptic intubation because of intoxication, hypoxia, or head injury. Thus, the need for a CSI patient’s airway to be secured “asleep” is often urgent. 4. A rigid cervical collar may make airway management difficult, impeding mouth opening and application of cricoid pressure. Therefore, with MILS, the front part of the collar should be removed or opened before attempted intubation.

120 Clinical Pearls 5. Patients with acromegaly and obese Cushing’s disease frequently have OSA and should be induced and ventilated well. Direct laryngoscopy and video laryngoscopy are the most effective intubation techniques. 6. Become familiar with alternative airway devices and techniques; however, practice in normal airways before treating patients with difficult airways.

121 Clinical Pearls 7. Be attentive and inspect the degree of neck flexion in patients positioned prone, lateral, or in any head fixation device. 8. Pediatric patients with macrocephaly, cranio-maxillo-facial dysmorphism, & cranio-spinal dysraphism pose unique airway challenges. 9. A cuff leak test may be helpful before extubation after prolonged surgery in the prone position; always have re- intubation strategies and plans.

122 123 Art-Skill-Technology

• Not all difficult airway cases are one and the same - patient factors (anatomical differences) - surgical factors - critical care factors • The approach to airway management are distinctly different in more ways than one.

124 Art-Skill-Technology

• Timing is of the essence…..

125 Art-Skill-Technology

• The art of intubation need not be surrendered to technology but to

• the understanding of the basic anatomical differences of the airway • The physiology of the mechanics of ventilation (e.g. influence of positioning)

126 Art-Skill-Technology

• The art of intubation need not be surrendered to technology but to

• the pathophysiology of the disease process in relation to the consequences of airway management • the influence of the neurosurgical procedure and critical care on the airway

127

Art-Skill-Technology

• The art of intubation need not be surrendered to technology but to

• the appropriate usage of the basic airway devices (e.g. laryngoscope) in specific difficult airway situations

128 Art-Skill-Technology

• Airway technology must not replace good planning and management approach for every difficult airway scenario

129 Art-Skill-Technology

• Learning the science of basic airway skills takes time… it is a process…it demands mastery…it is an art…there is beauty in it… • It must not be replaced by technology but instead, be aided by it

130 Art-Skill-Technology

• There are no short cuts…”we can only break rules once we have mastered them” • Skill and technology of airway management must go hand in hand if you will, not be replaced by it

131 Principal Elements of Difficult Airway Management Always remember ......

“SOMETHINGDevices ManageONE ANTICIPATES Airways, THE Do DIFFICULTNot & Will AIRWAY Not IS; SOMETHING– ONEAirway EXPERIENCES Managers, THE Do FAILED & Will AIRWAY IS.”

133 Experience Matters! “Good decisions come from experience, unfortunately experience often comes from bad decisions.”

69 THANK YOU!

Ask QUESTIONS you must.

135