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Airway Management Instrumentation & Techniques NBCRNA Core Modules Supplemental Part 2 Airway Management Instrumentation & Amy Sheppard, CRNA, MSNA Techniques Getting your credits ❖ NBCRNA Core Module #1: Airway ❖ Series of 3 Airway lectures online: INCLUDED in conference fee ❖ CRNA Today is a recognized vendor for NBCRNA & Prior Approve by the AANA Getting your credits ❖ FIRST – Visit and Register at CRNAToday.com ❖ Enroll in the Airway: NBCRNA Core Module #1….At check out utilize your Coupon Code “1FL” followed by your AANA number. NO Leading zero. Click Update ❖ Online lecture ❖ Can be viewed on-demand…. ❖ 3 attempts to pass Post Test ❖ To get Class A Credit- A Post Test grade of 80% is required ❖ 3 Attempts ❖ Certificate is only available after passing ❖ All records submitted to the AANA monthly Objectives ❖ The Learner will demonstrate the appropriate steps in assessing an airway to develop the appropriate patient-specific plan that ensures safe management of the airway and facilitates continuity of care ❖ The Learner will identify the indications and contraindications associated with the use of airway equipment. ❖ The Learner will understand the associated malpractice claims arising from the management of the airway, using a closed claims analysis. ❖ The Learner will identify the complications associated with airway equipment History of Airway Management MurphyDräger Endotracheal “Pulmonator” Tube 1943 Morton Inhaler 1941 “Airway Management” A broad term used to describe the tools, techniques and procedures used to support and control oxygenation and ventilation as well as delivery of Alfredanesthetics. Kirstein Autoscope Getting started ❖ What factors need to be considered? • NPO status • Risk of aspiration • Patient factors • Surgeon factors • Type and length of surgery • Regional anesthesia • Provider competencies Preoperative Fasting Guidelines ❖ 2017: ASA updated recommendations for pre-operative fasting1 • 2 hours clear liquids • 4 hours breast milk • 6 hours solid foods, infant formula & non-human milk • 8 hours fried or fatty foods Preoperative Fasting Guidelines ❖ Gum, smokeless tobacco, hard candy2 • Not specifically addressed by the ASA guidelines • European Society of Anaesthesiology guidelines do NOT recommend delaying anesthesia Aspiration Prophylaxis ❖ Overall incidence of aspiration remains very low ❖ Incidence of anesthesia related fatal aspiration was only 1:350,000 (.0003%)3 ❖ In the NAP4 study, aspiration was responsible for 50% anesthetic deaths.3 ❖ Risk of aspiration is greater with higher patient Physical Status (ASA status) and emergency surgery3 Aspiration Prophylaxis ❖ The intended goal of aspiration prophylaxis is to decrease gastric volume and pH. ❖ Sodium Citrate, Metoclopramide, Ranitidine (or other H2 antagonist) The ASA guidelines do NOT recommend routine prophylaxis1 Aspiration Prophylaxis Indications: 4, 5 ❖ Full stomach ❖ GI obstruction ❖ Diabetic gastroparesis ❖ Hiatal hernia ❖ Symptomatic GERD ❖ Active N/V ❖ Pregnancy ❖ NG tube ❖ Emergency surgery ❖ Morbid obesity ❖ ESRD Aspiration Prophylaxis in Pregnancy After 20 weeks gestation, extra caution should be exercised with the unprotected airway to prevent aspiration29 Updated report from ASA task force on Obstetric Anesthesia & the Society for Obstetric Anesthesia and Perinatology6 For clear liquids: “The uncomplicated patient undergoing elective surgery (e.g. scheduled C/S, post partum tubal ligation) may have moderate amounts of clear liquids before induction of anesthesia.” For solids: “The patient undergoing elective surgery (e.g. scheduled C/S, post partum tubal ligation) should undergo a fasting period of 6-8 hours depending on the type of food ingested (e.g. fat content).” Before surgical procedures (e.g., cesarean delivery or post- partum tubal ligation) “The clinician should consider the timely administration of nonparticulate antacids, H2 antagonists, and/or metoclopramide for aspiration prophylaxis.” Aspiration Prophylaxis Strategies for reducing aspiration risk3 Reducing gastric Preoperative fasting, nasogastric aspiration, pro volume kinetic premedication Avoidance of general Is regional anesthesia an option? anesthesia Reducing pH of gastric Antacids, H2 antagonists, proton pump inhibitors contents Tracheal intubation, 2nd generation supra-glottic Airway protection airway devices Prevent regurgitation Rapid sequence induction Extubate only after awake and airway reflexes have Extubation returned Cricoid Pressure & Preventing Aspiration Is it time to LET GO of cricoid pressure? Cricoid Pressure & Preventing Aspiration ❖ Does cricoid pressure (CP) reduce the risk of aspiration? • Evidence to support that CP is effective is based almost exclusively on cadaver studies and case reports of regurgitation occurring after CP has been released. There is no evidence for or against the use of CP and there are no published randomized controlled trials comparing the incident of regurgitation on induction, with or without the use of CP. Additionally, CP has been shown to decrease LES tone thus potentially increasing the risk of aspiration.3 ❖ Is cricoid pressure properly applied? • Who is applying the CP? Have they been trained? Do YOU even know how to properly apply? ❖ Does properly applied cricoid pressure actually compress the esophagus? • The esophagus is laterally displaced relative to the midline of the vertebral body in 49%-53% of subjects without cricoid pressure being applied. When CP was applied, lateral displacement increased by 53%- 91%.7 ❖ Does cricoid pressure increase or decrease the quality of the laryngeal view? • Numerous articles have been published with contradictory results. However, it has been found that application of > 40N of force can compromise airway patency and cause difficulty with tracheal intubation.7 ❖ Is CP harmful? • Difficult laryngoscopy, esophageal rupture, cricoid fracture8 ❖ Are there any contraindications to use of CP? • Trauma to anterior neck, unstable C-spine, obstructing mass, active vomiting8 Cricoid Pressure & Preventing Aspiration Is it time to LET GO of cricoid pressure? Cochrane Anaesthesia, Critical and Emergency Care Group9 There is currently NO information available from published RCTs (randomized controlled trials) on clinically relevant outcome measures with respect to the application of cricoid pressure during RSI. Cricoid Pressure & Preventing Aspiration If you are going to do it, you should at least do it correctly. To correctly apply cricoid pressure, 30 - 40N (3 - 4 Kg) of force should be applied downward onto the cricoid cartilage.10 Just how good is your cricoid? Investigator Ok, please proceed with the application of cricoid pressure to the test fixture Just how good is your cricoid? Participant OK! Just how good is your cricoid? Investigator Are you applying cricoid pressure to the test fixture? Just how good is your cricoid? Participant Yes, of course Just how good is your cricoid? Investigator Something must be wrong. We’re not registering any pressure? You are pressing down on the cricoid, right? Just how good is your cricoid? Participant Oh no, I would never do that. I always “squeeze” the sides of the throat. Pushing down would obstruct the view of the person intubating. Just how good is your cricoid? Investigator And how long have you been applying cricoid pressure in this manner? Just how good is your cricoid? For 38 years! Participant Airway Assessment Airway Assessment Evaluating the Airway No single test has been devised that can predict a difficult airway 100% of the time; especially when tests are done by themselves. Modified Mallampati Classification • Originally described in 1983, Mallampati is an easy to perform, commonly used airway assessment tool. As a stand alone tool however, it is insufficient to predict the difficult airway.11 • In a meta analysis of over 177,000 patients, only 35% of patients with a difficult intubation were identified as Mallampati III or IV.11 • May be useful clinically when used in combination with other airway predictors11 • To properly perform, the neck should be neutral (not extended) and the patient should not phonate4 LEMON Test15 Evaluation Are there any physical Look externally attributes that stand out? Evaluate 3-3-2 3-3-2 rule Mallampati Facial trauma, edema, Obstruction/Obesity foreign body, obesity, large breasts? Neck mobility RA? Radiation? Burns? *Adapted with permission from The Difficult Airway Site (TheAirwaySite.com) & Walls RM & Murphy, MF:Manual of Emergency Airway Management, 4th ed Philadelphia, Lippincott, Williams and Wilkins, 2012 El-Ganzouri Multivariate Risk Index Test 12, 13 Score Mouth Opening 0 - 1 Mallampati 0 - 2 TM Distance 0 - 2 Neck Movement 0 - 2 Hx difficult intubation 0 - 2 Ability to prognath 0 - 1 Abdel Raouf Sayed Ahmed El-Ganzouri, M.D. Weight 0 - 2 TOTAL 0 - 12 A score ≥ 4 indicates potential difficulty when performing direct laryngoscopy Documenting EGRI 0 1 2 Mouth Opening ≥ 4 cm < 4 cm Mallampati 1 2 3, 4 TM Distance > 6.5 cm 6 - 6.5 cm < 6 cm Neck Movement > 90 80 - 90 < 80 Hx difficult intubation No Questionable Yes Ability to prognath Yes No Weight < 90 kg 90 - 110 kg > 110 kg Total =_______ A score ≥ 4 indicates potential difficulty when performing direct laryngoscopy Deciding How to Manage the Airway vs vs vs vs vs Positioning “Sniffing Position”: Neck flexion and head extension14 7-9cm Positioning Positioning of the obese patient14 Ideally, the external auditory meatus should be in horizontal alignment with the sternal notch. Capnography ❖ Continuously monitor ETC02 during controlled or assisted ventilation and any anesthesia
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