• Basic Airway Management Update

• Airway Adjuncts Application in ICU

• Main Airway Algorithm in ICU • Universal Emergency Airway Management Algorithm 張家昇 主任 • Management of Unrecognized Difficult • AirwayDifficult Airway Assessment

Characteristics of Patients In ICU Universal Unconscious, Emergency unreactive, near death • Unstable Hemodynamics • Poor Hypoxemia Tolerance Airway X V Management • Poor Oral Hygiene with Tubing Difficult Airway ? Crash Airway • Soft Tissue Edematous Change Algorithm Algorithm • Various Coagulopathy X V Fail • Various Enteric Paralytic illus … R S I Difficult Airway Failed Algorithm Airway • Electrolytes & Acid-Base Fluctuation Fail Algorithm Fail • N-M dystrophy with Various Organs dysfunction Failed Airway Failed Algorithm Airway Algorithm Walls, RM. The Emergency Airway Algorithms , 2004

Difficult Airway The clinic situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both. (ASA Task Force)

Difficult Mask Ventilation It is not possible for the unassisted anesthesiologist to maintain the SPO2>90%using 100% oxygen and positive pressure mask ventilation in a patient whose SPO2 was > 90% before anesthetic intervention; and /or it is not possible for the unassisted anesthesiologist to prevent or reverse signs of inadequate ventilation during positive pressure mask ventilation. (ASA Task Force)

1 Main Airway Need Intubation ? RSI (Medication) Management Unconscious, unreactive, near death • atropine – X V – blocks vagal response to airway stimulation, may be protective against Algorithm arrhythmias seen with Succinylcholine 預估為困難氣道嗎？ Crash • lidocaine Airway From Difficult Airway X V – IV if head injury suspected R S I Difficult Airway • sedative: – Thiopental (50 mg test dose, then 2-4 mg/kg ,onset: 1 min, effect: 10-30 插管成功嗎？ min) ; – Propofol X V – Midazolam: 2-10mg IV (onset: 1-2 min, effect: 2-4 hr) BMV? , SPO2>90% ? 做插管後的處理 – ketamine X V • good choice for patient with status asthmaticus; may raise IICP – morphine , fentanyl Failed 熟手經口插管 ≥3次 Airway • neuromuscular blocker: V Walls, RM. X – Succinylcholine: 1 mg/kg IV (onset 1 min, effect: 4-8 min) The Emergency Airway Algorithms Failed Airway – rocuronium (Esmeron): 0.6 mg/kg 2004

引導意識不清的鎮靜劑 Ketamine的作用

劑量(IV) 作用開始 藥效 口內分泌物 時間 期間 胃內壓 Thiopental 3-5 mg/kg 10-30秒 10-30分 腦內壓 Ketamine 1-2 mg/kg 1-2分 15-30分 血壓、心跳、心輸出量 Diazepam 0.25-0.4mg/kg 2-4分 30-90分 眼內壓 最大10mg 張力過強 Midazolam 0.1-0.2 mg/kg 1-2分 30-60分 最大 15mg 支氣管擴張 Fentanyl 2-10 μg/kg 1分 30-60分 緊急反應(emergency reaction)

肌肉鬆弛劑 Succinylcholine的禁忌 劑量(IV) 作用開始 藥效 時間 時間 • 使用SCH的禁忌症，它包括眼球 Succinylcholine 1.0-1.5 mg/kg(>10kg) 30-60秒 4-10分 穿刺傷、青光眼、神經肌肉疾 1.5-2.0mg/kg(<10kg) 病、惡性高體溫病史、壓性傷害 Rocuronium 0.6mg/kg(標準劑量 ) 60-90秒 45-60分 (Esmeron) 0.06mg/kg(去顫抖劑量) 2-3分 和超過48小時以上的創傷或燒 Pancuronium 0.1 mg/kg 2-5分 45-90分 傷。 0.01m/kg(去顫抖劑量 ) • 它的快速作用和短效作用可抵消 Atracurium 0.6mg/kg 2-4分 25-40分 它的不良影響。

2 Crash Airway

Crash BMV Most patients do not die from Airway 嘗試經口插管 Algorithm 成功？ X V failure to intubate, BMV 可以嗎？ 做插管後的處理 but from X V Failed Airway Succinylcholine 2 mg/kg IVP not stopping to 再次嘗試經口插管

成功？ try to intubate.

X V

熟手經口插管≥3次 做插管後的處理

X V Walls, RM. The Emergency Failed Airway Airway Algorithms , 2004

Failed Airway Criteria

等做氣管造口時可嘗試 BMV? , SPO2>90% ? LMA, Combitube 求救 X V Cricothyrotomy Failed Airway 考慮 Fiberoptic method , I- Algorithm LMA, Lighted stylet, supra-glottic airway

Time allows and successful? Walls, RM. The Emergency V X Airway Algorithms , 2004 Cuffed ETT Placed? Cricothyrotomy

V X 做插管後的處理 安排Definite Airway Management

Certain Difficult Airway Problems

• Limited mouth opening • Anterior larynx • Sternal space restriction • Small intraoral cavity • Immobile or unstable cervical spines

3 ‧如何依據各種情境選擇適當的呼吸道 (the “airway hierarchy”) ，包括下列︰ Supraglottic Ventilatory Devices –如何選擇適當並正確使用較具侵襲性的呼吸道: • Laryngeal mask airway (LMA) (Class Class IIa) • 喉罩與插管喉罩 • Esophageal-tracheal (Combitube) tube (Class IIa) Laryngeal mask airway (LMA) • Tracheal tube (well trained HCP, Class I) (well Intubating LMA (I-LMA) trained EMS, Class IIa) • 食道氣管聯合管 –如何確定tracheal tube放置的位置正確: Esophageal Tracheal Combitube • Physical exam criteria • 氣囊式口咽氣道 • End-tidal CO2 detection (Class IIa) (for Combitube, Cuffed oropharyngeal airway LMA (Class Indeterminate)) • 喉管 • Esophageal detector device (EDD) (Class IIa) Laryngeal tube –如何固定tracheal tube以防止其滑脫

Esophageal Tracheal Combitube (I) • Kendall Sheridan • A disposible double lumen tube • Combine a conventional ET and an esophageal obturator airway • Ventilation is possible with either tracheal or esophageal intubation

Esophageal Tracheal Combitube (II) Cuffed Oropharyngeal Airway (I) 氣囊式口咽氣道 • COPATM, Mallinkrodt Medical • Inserted blindly, or • First described by Greenberg in the early 1990s laryngoscopy to enhance placement • Inexpensive, disposible Single use device, no risk of cross • Should protect against aspiration • Modified Guedel’sairway • Especially useful --- Direct visualization An inflatable distal high volume, lower pressure cuff of the vocal cords is not possible A 15 mm proximal adapter • Insertion technique is the same as for a Guedel’sairway

4 Laryngeal Tube

Almost like a single lumen, shorten Combitube

Compared to the Combitube, easier to insert Can be attached directly to any breathing system Possibility of esophageal A “bridge to extubation” Not protect airway from rupture is increased if regurgitation and aspiration vomiting occur, as there is Contraindication for full stomach no esophageal vent Currently available in four size: 8, 9, 10, 11

History Where is the hole? First elective oral intubation

Vallecula

AE fold

Cuniform Corniculate

Arytenoid INTUBATION OF THE LARYNX.htm

Three primary laryngoscope blades

• Jackson laryngoscope blade • Miller laryngoscope blade • MacIntosh laryngoscope blade

5 Video Glidescope Modifications of Laryngoscopes Intubation Laryngoscope Rigid laryngoscopes – Flexible tip laryngoscopes McCoy levering laryngoscope Bullard Indirect rigid fiberoptic laryngoscopes – Bullard laryngoscope – WuScope system – AWS laryngoscope

Pentax-AWS

AWS WuScope

Endotracheal tube guides Lighted Stylet Intubation

A.K.A. : • Eschmann tracheal tube introducer Trachlite ®(Rusch), Trachlight ® (Laerdal), Surch-lite ® (Aaron Medical), "Lightwand" • Rüsch® Intubation stylet ® Introduction • Frova intubation introducer Lighted stylet guided intubation can be a useful technique • Arndt airway exchange catheter set for oral and nasal intubations in both asleep and awake patients (1,3). This type of intubation technique has a • Aintree airway exchange catheter reported success rate as high as 99% in experienced hands • Lighted Stylets (3). It can be used in anticipated and unexpected difficult Shikani Optical airways where conventional direct laryngoscopy has failed ™ Trachlight Stylet (2,7). It can be achieved as fast as conventional direct laryngoscopy by one skilled in its use (3,4,5).

Cannot Ventilate, Cannot Intubate Situation

• Insertion of LMA • Insertion of the combitube • Insertion of transtracheal jet ventilation • Creation of a surgical airway

6 Fiberoptic Intubation Special Airway Techniques • Oral vs nasal approach • Under general anesthesia • Under rapid sequence Induction & intubation • Flexible fiberoptic intubation • Fiberoptic intubation aided by rigid • Retrograde intubation laryngoscopy • Transtracheal jet ventilation • Fiberoptic intubation through LMA or • Cricothyrotomy combitube • Percutaneous dilatation tracheostomy • Fiberoptic and retrograde intubation

Physiological Changes to Fiberoptic Intubation Fiberoptic Intubation

• Respiratory effect Hypopharynx – glossopharyngeal N –laryngeal 1.2% unsuccessful attempts spasm (1) inability to visualize the larynx (2) inability to advance the tube over Laryngeal surface of the epiglottis, larynx, the fiberoptic bronchoscope bronchial tree – vagus N – bronchial spasm (3) inability to direct the tube towards the larynx • Cardiovascular effect Ovassapian et al: Anesth Analg 1983; 62: 692-695 Sympathoadrenal response depend on the technique, intubation time, smoothness of intubation, size of the fiberscope and ET tube

Retrograde Intubation 氧氣和通氣的方法 • 氣管穿刺導管 • Through cricothyriod membrane • A blind technique • Useful in patients with cervical injury or airway trauma • As a adjunct for fiberoptic intubation • Arndt airway exchange catheter

7 Recurrent 氧氣和通氣的方法 lung CA s/p stenting • 環甲狀膜切開術 with • 氣管切開術 granulation bronchial obstructin and stent deherence

Manual Jet Needle cricothyrotomy ventilator

Transtracheal Jet Ventilation (TTJV)

Temporizing means of rescue ventilation

Jet ventilator

8 Difficult Airway Predicted

SPO2>90% ? 求救 Difficult X Y BMV? , SPO2>90% ? Airway X Algorithm BMV可成功 Failed Airway Y X 插管可能成功

Y X RSI Awake technique

Go to Main Algorithm X Y 預估 SPO2可>90% ? 做插管後的處理 X Y Blind nasaltracheal, Failed Airway cricothyrotomy, fiberoptic, I-LMA,lighted stylet

Difficult Airway Pre-intubation Airway Exam (1) 1. Head anomalies 5. Laryngeal anomalies a. laryngomalacia 2. Facial anomalies b. epigottitis a. maxillary and mandibular diseases c. congenital glottic lesions b. disease • Length of upper Incisors d. laryngeal papillomatosis 3. Mouth and anomalies e. laryngeal granalomas a. f. congenital and acquired subglottic • Involuntary: Maxillary Teeth Anterior to b. tongue disease disease 4. Nasal, palatal and pharyngeal 6. Tracheobronchial tree anomalies Mandibular Teeth anomalies a. tracheomalasia a. choanal atresia b. croup • Voluntary: Protrusion of Mandibular Teeth b. nasal masses c. bacterial tracheitis c. palatal anomalies d. mediastinal masses Anterior to the Maxillary Teeth d. enlarged adenoids e. vascular malformations e. tonsillar disease f. foreign body aspiration f. pharyngeal diseases 7. Neck and spine anomalies • Inter-cisor Distance g. retropharyngeal and parapharyngeal a. neck diseases b. limited cervical spine mobility • Oropharyngeal Class h. pharyngeal bullae or scarring c. congenital and acquired cervical spine instability

Pre-intubation Airway Exam (2)

• Narrowness of • Mandibular Space Length (thyromental distance) • Mandibular Space (MS) Compliance • Length of Neck • Thickness of Neck • Range of Motion of Head and Neck

9 如何確定氣管內管的位置？ 2005年的準則已經取消所謂的次級評估 也就是全部都是屬於初級評估 2005 ACLS Primary Secondary Primary

1992 E.C.C 2000 ACLS gold standard EDD ETCO Bronchoscopy 2 (觀看氣管軟骨)

Bulb Capnography CxR 理學檢查 & 觀察 (緩不濟急) type Detector

Tracheal Tube Holders: Adult and Infant (市售的專用固定器) •Secure the endotracheal tube with tape or a commercial device (Class I). •These devices may be considered during patient transport (Class IIb).

救人為快樂之本

Suggest Contents of Special Unit for Difficult Airway Management • Rigid laryngoscpe blades - alternate design & size • Endotracheal tubes of assorted sizes • Endotracheal tube guides • Various supraglottic airway devices- LMA/COMBITUBE • Fiberoptic intubation equipment • Retrograde intubation equipment • Equipments for transtracheal jet ventilation • Equipments suitable for emergency surgical airway access-cricothyrotomy • An exhaled CO2 detector

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