Principles of Airway Management (eBook)

Brendan T. Finucane, MBBCh, FRCPC Professor Emeritus Department of Anesthesiology and Pain Medicine University of Alberta Edmonton, Alberta, Canada Dr. Finucane is also the editor of Complications of Regional Anesthesia, 2nd ed. (Springer, 2007). Albert H. Santora, MD Athens, GA USA Ban C.H. Tsui, Dip Eng, BSc(Math), B Pharm, MD, MSc, FRCPC Associate Professor Department of Anesthesiology and Pain Medicine University of Alberta Director, Regional Anesthesia and Acute Pain Service Stollery Children's Hospital / University of Alberta Hospital Edmonton, Alberta, Canada Dr. Tsui is also the author of Atlas of Ultrasound and Nerve Stimulation-Guided Regional Anesthesia (Springer, 2007).

Preface 6
Acknowledgements 10
Contents 12
Chapter 1: Anatomy of the Airway 24
Introduction 25
The Nose 25
Oral Cavity 27
Uvula 27
Tonsils 28
Tongue 29
Nerve Supply to the Tongue 29
Pharynx 30
Prevertebral Fascia 32
Retropharyngeal Space 32
Larynx 33
Laryngeal Cartilages 34
Single Cartilages 34
Epiglottis 34
Thyroid Cartilage 35
Cricoid Cartilage 35
The Paired Cartilages 36
Arytenoids, Corniculates and the Cuneiforms 36
The Hyoid Bone 36
Laryngeal Cavity 38
Piriform Sinus (Recess or Fossa) 38
Nerve Supply to the Larynx 39
Superior Laryngeal Nerve 39
Recurrent Laryngeal Nerve 39
Action of the Cricothyroid Muscle and the Intrinsic Muscles of the Larynx 40
Trachea and Bronchi 41
Main Divisions of the Bronchial Tree 43
Comparative Anatomy of the Adult and Infant Airways 44
Head 45
Nose 45
Tongue 45
Larynx 45
Cricoid Cartilage 46
Epiglottis 46
Trachea and Mainstem Bronchi 46
Summary 48
References 48
Chapter 2: Evaluation of the Airway 49
Introduction 50
The Normal/Abnormal Airway 51
Box 2.1Factors Characterizing the Normal Airway in Adolescents and Adults 51
Box 2.2Signs Indicative of an Abnormal Airway 52
Predictive Tests for Difficult Intubation 51
Elective Intubation 54
History Pertinent to Elective Airway Management 54
Diabetes Mellitus 54
NPO Status 55
Physical Examination 56
General 56
Facies 56
Nose 56
Temporomandibular Joint 56
Lips 60
Oral Cavity 60
Teeth 60
Tongue 62
Mandible and Floor of Mouth 64
Neck, Cervical Spine, and Hyoid Bone 65
Vocal Quality 68
Cardiorespiratory System 69
Patient History 69
Physical Examination 70
Cardiovascular System 70
Patient History 70
Physical Examination 71
Structured Approach 71
Bag/Valve/Mask Ventilation 72
Additional Information 74
Arterial Blood Gases 74
ENT Consultation 75
Radiologic Studies 75
Pulmonary Function Studies 75
Flow-Volume Loops 76
Difficult Airway Clinic 76
The “Awake Look” 77
Summary 78
References 78
Chapter 3: Basic Emergency Airway Management and Cardiopulmonary Resuscitation (CPR) 81
Emergency Airway Management 82
Importance of Basic Life Support 82
Adult Basic Life Support (BLS) 83
Chain of Survival 84
Changes in the 2005 and 2010 AHA Recommendations 84
The AHA Algorithm and Recommendations for Rescue Breaths, a Universal Compression-Ventilation Ratio, and Defibrillation 85
General Sequence for Lay Rescuer and HC Provider 85
Rescue Breaths 87
Chest Compressions 88
Defibrillation 88
Box 3.1Safety Considerations Before Performing Defibrillation 89
Techniques of CPR 90
Establishing Unresponsiveness and Positioning the Victim 90
Maneuvers for Opening the Airway 91
Head Tilt/Chin Lift 91
Jaw Thrust 93
Triple Airway Maneuver (Not Included in AHA Recommendations) 93
Mandibular Displacement (Not Included in AHA Recommendations) 93
Determining Breathlessness (Look, Listen, and Feel) 93
Rescue Breathing Technique 94
Box 3.2 Requirements of a Bag-Mask Device 96
Bag-Mask Ventilation 96
Advanced Airway Devices for Airway Control and Ventilation 97
Determining Pulselessness (HC Providers Only) 99
External Chest Compression Techniques 99
Compression-Only CPR 100
Special Situations 101
Drowning 101
Hypothermia 101
CPR Devices and Techniques 101
Limitations and Complications of CPR 102
Airway Obstruction 102
Etiology of Upper Airway Obstruction 102
CNS Causes 103
Peripheral Causes 103
The Tongue as a Cause of Airway Obstruction 103
Foreign Body Airway Obstruction 104
Partial Obstruction 105
Complete Obstruction 105
Management of the Obstructed Airway: The Heimlich Maneuver 106
Conscious Victim 106
Unconscious Victim 107
Chest Thrusts 107
Finger Sweep 107
Recommendations for the Conscious Choking Victim Who Becomes Unconscious (AHA Sequence) 109
CPR and Precautions Against the Transmission of Disease 109
Transmission of Disease from CPR Mannequins 110
Summary 111
References 111
Chapter 4: Basic Equipment for Airway Management 114
Introduction 114
Oxygen Sources 115
Wall Oxygen 115
Tank Oxygen 116
Pulse Oximetry and Capnography 119
Vacuum Suction Apparatus 119
Oxygen Delivery Systems for Spontaneously Breathing Patients 121
Oxygenation and Ventilation Systems 125
Airways 126
Oral Airway 126
Nasal Airway 128
Anesthesia Masks and Resuscitation Bags 131
Masks 132
Manual Resuscitation Bags 133
Equipment for Endotracheal Intubation 136
Laryngoscope 136
Alternative Light Source 139
Endotracheal Tube 139
Stylet 141
Other Useful Airway Tools 142
Cleaning, Disinfecting, and Sterilizing Equipment 142
Equipment Problems 144
“The Dedicated Airway” and the “Ideal Airway Device” 145
Summary 145
References 145
Chapter 5: The Laryngeal Mask Airway (LMA™) and Other Extraglottic (Supraglottic) Airway Devices 150
Introduction 151
The “Ideal” Extraglottic Airway 152
Classification of Extraglottic (Supraglottic) Airway Devices 153
Description of Extraglottic Airways 154
Basic Extraglottic Airway Design and Function 154
Cleaning and Sterilization of Reusable LMA™ Products 156
Basic LMA™ Design Features 156
LMA™ Models 158
Ambu® Line of Extraglottic Airway Products 158
General Information Concerning Ambu® LMAs 158
Indications for Ambu® LMAs 159
Contraindications 159
Use of Ambu® LMAs for Resuscitation 159
Sizing of Extraglottic Airways 160
Descriptions of Extraglottic Airway Design and Features 160
Illustrations of Extraglottic Airway Devices 160
Insertion Techniques 174
Preinsertion Recommendations 174
LMA™ Insertion Recommendations 174
LMA™ Insertion 175
Index Finger Insertion Technique 176
Thumb Insertion Technique 178
LMA ProSeal™ Insertion Using the Introducer 180
Testing the LMA ProSeal™ for Proper Positioning: “Malpositioning Test” 184
LMA Fastrach™ Insertion and Intubation Through the Airway14 191
Intubation Through the LMA Fastrach™ 192
Removal of the LMA Fastrach™ While Leaving the Endotracheal Tube in Position 192
Intubation with a Fiberoptic Scope 198
Troubleshooting Problems Associated with LMA Fastrach™ Intubation 199
Insertion of Ambu® Mask Airways 199
Preparation 199
Insertion of the SLIPA™ SGA16 203
Indications for Use 203
Contraindications for Use 204
Sizes of SLIPA™ Airway 204
Preuse Checks 205
Preinsertion Preparation 205
Insertion of SLIPA™ Airway 205
Insertion of the King LT(S)-D® Airway17 207
Sizes 207
Insertion Technique 207
Modified Insertion Techniques 208
Use of the GEB (Gum Elastic Bougie) for LMA ProSeal.™ Insertion 209
Laryngoscope-Guided, GEB-Guided LMA ProSeal™ Insertion Technique2 (p. 521) 211
Removing the Extraglottic Airway 214
Further Comments on LMA™ Size 215
Ease of LMA™ Insertion and Airway Grading Systems 215
Comparison of Methods to Assess LMA™ Airway Sealing Pressures 216
LMA™ and Modalities of Ventilation 217
Use of the LMA™ with Pediatric Patients 218
Insertion Techniques for Pediatric Patients 218
Removal of the LMA™ in Pediatric Patients 219
Use of the LMA™ to Manage Patients with Congenital Airway Anomalies 219
LMA™ and Neonatal Resuscitation 220
Diagnostic Fiberoptic Bronchoscopy with LMA™ Assistance 220
Use of the LMA™ in Pediatric Surgical Patients with Upper Respiratory Tract Infections (URI’s) and Mild Bronchopulmonary Dyspl 220
The Learning Curve for Use of the LMA™ on Pediatric Patients 222
Long-Term Use of the LMA™ on Pediatric Patients 222
The Use of the LMA ProSeal™ on Pediatric Patients 222
Innovative Uses of the LMA™ 223
Patient Position 224
Prone Position 224
Lateral Position 225
LMA™ Oropharyngeal Leak Pressure (OLP) and Head Position 226
Adjunctive Equipment to Aid Endotracheal Intubation Through the Extraglottic Airway 226
Extraglottic Airways and the “Difficult Airway” 226
Use of the LMA™ to Manage the Difficult Airway in Obstetric Patients 229
Use of the LMA™ and the Difficult Pediatric Airway 230
The LMA™ and the Morbidly Obese Patient 231
Use of the LMA™ in Patients with Cervical Spine Pathology 231
Cervical Pressure and Movement Associated with LMA™ Use 232
Role of the LMA Outside of the Operating Room (PreHospital and Emergency Room) 233
Problems Associated with the Use of Extraglottic Airway Devices 234
What to Do if the Patient Regurgitates with an Extraglottic Airway in Place 236
U.S. FDA Regulations Concerning the Introduction of Extraglottic Airway Devices to the Market: “510(k) Exempt” Classification 237
Is the Extraglottic Airway Device Interchangeable with the Endotracheal Tube in the Practice of Anesthesia? 238
Summary 244
References 244
Chapter 6: Advanced Airway Devices 253
Introduction 254
Supra and Infraglottic Devices 255
Supraglottic Devices 255
Laryngeal Masks 255
LMA Classic 255
LMA Unique and Portex Softseal (Single-Use Variants of LMA Classic) 256
LMA ProSeal 257
LMA Flexible (Wire-Reinforced Flexible LMA) 258
LMA Supreme 258
LMA Fastrach (Intubating LMA) 260
LMA CTrach 261
Laryngeal Tube and Laryngeal Tube S 262
I-Gel Airway 263
Cobra Perilaryngeal Airway (PLA) 264
Streamlined Liner of Pharyngeal Airway (SLIPA) 265
Infraglottic Devices 265
Combitube 265
Easy Tube 266
Laryngoscope Handles and Blades 267
Handles 267
Howland Adapter/Lock 268
Blades 269
Left-Handed Macintosh Blade 269
Polio Blade 269
Oxiport Blades 270
Siker Blade (Mirror Laryngoscope) 270
Belscope 271
Levering Laryngoscope Blades 271
McCoy Levering Laryngoscope 271
Pediatric McCoy 273
Dorges Universal 273
Viewmax 273
Fiberoptic Laryngoscopes 274
Truview EVO2 274
Heine FlexTip+ 275
Flipper 275
Bullard 277
WuScope 277
Video laryngoscopes 278
Storz DCI Video Intubating System 279
GlideScope 280
McGrath 283
Airway Scope (AWS-S100) 285
Airtraq 286
TrachView Intubating Videoscope 288
Comparisons of Indirect Laryngoscopes 289
Stylets and Light Wands 289
Conventional Stylets: Endotracheal Tube Introducers and Exchangers 289
Optical Stylets 292
Bonfils Intubation Fibrescope 292
Shikani (Seeing) Optical Stylet (SOS) 294
Levitan FPS (First-Pass Success) Scope 294
Airway Pocket Scope 296
Stylet Scope 296
Illuminating Stylets (Lightwands) 298
Trachlight 299
Endotracheal Tubes 301
Articulating 301
Armored or Wire-Reinforced 302
Double-Lumen Endobronchial 302
Polar RAE (Ring-Adair-Elwyn) 303
Uncuffed 304
Parker Flex-Tip 304
GlideRite 305
Brief Review of Other Tubes 305
Cricothyrotomy 306
Catheter-Over-Needle Technique 306
PCK Indicator-Guided Device 306
Nu-Trake 307
QuickTrach 307
Wire-Guided Technique 307
Minitrach II 308
Melker 308
Ultrasound Imaging of the Airway 309
Oral Cavity and Pharynx 310
Larynx 311
Cervical Trachea 311
Lung 312
Available Portable Ultrasound Systems 312
Airway Management Training Devices 313
Task/Skills Trainers 313
Manikins and Simulated Settings 314
Animal Models 316
Cadaver Models 316
Virtual Reality Simulators 316
References 317
Chapter 7: Indications and Preparation of the Patient for Intubation 329
Introduction 330
General Indications for Intubation 330
Box 7.1 Indications for Intubation 331
Ventilatory Support 330
Box 7.2 Objectives in Ventilatory Support 331
Hypoxia 332
Box 7.3 Classification of Hypoxia 332
Hypoxemia 332
Box 7.4 Common Causes of Hypoxemia 333
Decreased Oxygen Content of Inspired Air 333
Hypoventilation 333
Decreased Diffusion Capacity 334
Ventilation/Perfusion Inequality 335
True or Anatomic Shunt 335
Protection of the Airway in a Patient with Impaired Laryngeal Reflexes 335
Ensuring Airway Patency in a Patient with Abnormal Pathology or Depressed Level of Consciousness 336
Anesthesia and Surgery 336
Specific Indications 336
Suctioning 337
Selecting the Route of Intubation 337
Orotracheal Intubation 337
Contraindications 337
Nasotracheal Intubation 338
Surgical Field Avoidance 338
Poor Oral Access 338
Prolonged Ventilation 338
Contraindications 338
Transtracheal Intubation 339
Endobronchial Intubation 339
Box 7.5 Indications for Endobronchial Intubation 339
Preparation of the Patient for Intubation Outside the Operating Room4 339
Patient Interview 340
Sedation 340
When It Is Needed 340
How It Is Done 340
How the Patient Should Be Monitored 342
When It Is Adequate 342
Local Anesthetic Techniques 342
General Anesthesia 342
Cerebral Injury 343
Acute Epiglottitis 343
Uncooperative Patient 343
Neuromuscular Blocking Drugs 343
Depolarizing Drug: Succinylcholine 344
Box 7.6 Disadvantages of Succinylcholine (Classified by Mechanism of Action) 345
Nondepolarizing Drugs 346
Methods of Administering a Neuromuscular Blocking Drug 347
Reversal of Neuromuscular Blockade 347
Summary 348
References 349
Chapter 8: Techniques of Intubation 351
Introduction 352
Intubation Methods 353
Orotracheal Intubation by Direct Vision in an Adult (Macintosh Blade) 353
Preparation 354
Positioning 355
Exposure 359
Visualization 359
Insertion 359
Cuff Inflation 360
Confirmation 363
Box 8.1 False/Negative Results (Tube in Trachea, Capnogram Suggests That Tube Is in Esophagus) 365
Box 8.2 False-Positive Results (Tube Not in Trachea, Capnogram Suggests Tube Is in Trachea) 365
Box 8.3 Suspicion of Esophageal Intubation: Indications for Extubation 367
Box 8.4 Actions for Suspected Esophageal Intubation 367
Stabilization 368
Orotracheal Intubation by Direct Visionin an Adult (Miller Blade) 369
Nasotracheal Intubation by Direct Visionin an Adult (Macintosh Blade) 369
Preparation 370
Positioning 371
Tube Insertion 371
Exposure 372
Visualization 372
Tube Placement 373
Confirmation 375
Stabilization 375
Blind Nasotracheal Intubation 375
Technique 375
Summary 376
Airway Maneuvers 376
BURP 377
OELM 377
Sellick’s Maneuver (Cricoid Pressure) 377
Failed Intubation (Normal Anatomy) 378
Summary 378
References 379
Chapter 9: The Difficult Airway 381
Introduction 382
Definitions 382
Mask Ventilation 384
Incidence of the Difficult Airway 385
Etiology of Difficult Intubation 390
Limited Access to the Oropharynx or Nasopharynx 390
Inability to See the Larynx 390
Diminished Cross-Sectional Area of the Larynx or Trachea 390
Practice Guidelines and the ASA Difficult Airway Algorithm 391
Difficult Airway Kit 394
Basic Essentials of an Airway Kit 394
Structured Approach to the Difficult Airway in the Operative Room 394
Failed Awake Intubation for Elective Surgery 395
Unanticipated Difficult Airway in Elective Surgery 396
Unanticipated Difficult Intubation in Emergency Surgery 398
Anticipated Difficulty in Elective or Emergency Surgery 399
Loss of the Airway: “Cannot Intubate, Cannot Ventilate” 399
Difficult Airway in Special Circumstances 401
Emergency Room 401
Difficult Airway Prediction: Mnemonics to Use in Emergency Situations 401
Head and Neck Injury 402
Incidence and Etiology 402
Management 402
Cervical Spine Injury 403
Incidence and Etiology 403
Management 403
Cervical Spine Clearance 404
Airway Management 408
Airway Burns 409
Incidence and Etiology 409
Management 409
Ventilation Considerations in the Patient with Airway Burns 410
Facial Trauma 411
Incidence and Etiology 411
Management 411
Securing and Maintaining the Airway 412
Cardiac Arrest 413
Intensive Care Unit (ICU) 413
Incidence and Etiology 413
Management 414
Operating Room 415
Obesity 415
Incidence and Etiology 415
Anatomical Factors 415
Physiological Factors 415
Management 416
Preparation, Medicating, and Securing the Airway 416
Obstructive Sleep Apnea 419
Incidence and Etiology 419
Signs 419
Management 419
Preoperative Evaluation 420
Preoperative Management 420
Intraoperative Management 420
Postoperative Management 421
Specifics of Tracheal Intubation 421
Obstetrical Airway 422
Incidence and Etiology 422
Management 423
Summary 426
References 427
Chapter 10: Pediatric Airway Management 435
Section A: Basic and Difficult Airway Management 437
Introduction 437
The Pediatric Airway: Anatomy and Function 437
Susceptibility to Obstruction 437
Distinct Relationship Between the Tongue, Pharynx, and Larynx in the Infant 438
Susceptibility to Respiratory Failure 440
Difficulty During Tracheal Intubation 441
Basic Airway Management and CPR in Infants and Children 441
Opening the Airway 442
Use of Airway Adjuncts 442
Basic Life Support 443
Recommended Sequence for Basic Life Support 444
Resuscitation of the Neonate 446
2005 and 2010 American Heart Association Neonatal Resuscitation Guidelines28, 31 448
Initial Steps in Stabilization 448
Ventilation 449
Chest Compressions 450
Box 10.1 451
Medications or Volume Expansion 450
The Neonatal Resuscitation Program 451
Airway Equipment 453
Face Masks 453
Airways 453
Laryngeal Mask Airway (LMA) and Other Supraglottic Devices 454
T-Piece 455
Intubation Equipment 456
Blade Selection 456
ETT Selection 457
Flexible Fiberoptic Bronchoscope 458
Rigid Bronchoscopes 458
Light Wand 458
Other Devices for Intubation 459
Techniques For Bag-Valve-Mask Ventilation 459
Techniques of Routine Endotracheal Intubation in Infants and Children 459
Premedication and Induction of Anesthesia 460
Position 460
Exposure 460
Visualization 460
Tube Placement 461
Confirmation 461
Stabilization and Monitoring 462
Summary 462
Laryngospasm 462
Intubation Trauma 464
Difficult Pediatric Airway 465
Definition and Classifications 465
Congenital or Acquired Abnormalities Associated with Airway Difficulty 466
Anesthetic Management and Induction Technique 468
Induction Technique 468
Clinical Strategies for Difficult Ventilation and Intubation 469
Strategies to Overcome Difficulties with Failed Mask Ventilation 469
Strategies to Overcome Difficulties with Tracheal Intubation 470
Fiberoptic Intubation Techniques 471
Extubation Considerations for the Difficult Airway 472
Airway Obstruction in the Child 473
Clinical Presentation 473
Etiology 474
Congenital 474
Laryngomalacia 474
Congenital Vocal Cord Paralysis 475
Congenital Subglottic Stenosis 475
Miscellaneous 476
Acquired 476
Foreign Body Airway Obstruction 476
Obstructive Sleep Apnea 477
“Kissing Tonsils” and Sleep Apnea Syndrome 477
Subglottic Cysts and Hemangiomas 478
Acute or Recurrent Infections 478
Peritonsillar Infections 478
Acute Epiglottitis 478
Acute Laryngotracheitis (Viral Croup) 479
Acute Bacterial Laryngotracheobronchitis (Bacterial Croup) 480
Retropharyngeal Abscess 480
Recurrent Respiratory Papillomatosis 482
Allergic 482
Laryngeal Edema 482
Other 483
Spasmodic Croup 483
Acquired Subglottic Stenosis 483
Neoplasms 483
Inhalation Burn Injury 483
Managing Foreign Body Airway Obstruction (FBAO) 484
Complete FBAO 484
Incomplete FBAO 485
Treating Epiglottitis and Croup 489
Epiglottitis 489
Croup 491
Management of the Child with Impending Complete Airway Obstruction 492
Intubation Procedure 493
Heliox in Pediatric Airway Management 494
Tracheostomy in the Child 494
Preparation 495
Technique 495
Complications 495
Summary 496
Section B: Advanced Airway Management for Endoscopic (ENT) Procedures 497
Introduction 497
Description of Basic Endoscopic Procedures 497
Flexible Endoscopy 497
Rigid Bronchoscopy 498
Microlaryngoscopy 499
Anesthetic Considerations for Endoscopic Procedures 499
Goals of the Anesthesiologist during Pediatric ENT Procedures 500
General Anesthetic Approaches 501
Planning 501
Managing Uncooperative Children 502
Induction and Maintenance of General Anesthesia 502
Local Anesthesia of the Airway 503
Anesthetic Options During the Airway Procedure (Box 10.2) 503
Box 10.2 Anesthetic Options for Airway Procedures 504
Spontaneous vs. Controlled Ventilation 503
Intubation 504
Insufflations 506
Intermittent Apnea 506
Jet Ventilation 506
Emergence and Extubation 506
Clinical Scenarios 507
Upper Airway Pathology 508
Micro-/Retrognathia 508
Recurrent Respiratory Papilloma 511
Subglottic Stenosis/Hemangioma 513
Laryngomalacia (LM) 515
Laryngeal Paralysis 517
EXIT Procedure 519
Lower Airway Pathology 520
Foreign Body Aspiration 520
Tracheal Stenosis 524
Respiratory Failure or Failure to Extubate ICU Children: Children with Known Cardiac, or Neurological Pathology, vs. Virgin Cas 525
References 526
Chapter 11: Fiberoptically Guided Airway Management Techniques 534
Introduction 535
Applications 535
Implementation: Learning the Technique 536
Indications 537
Equipment 538
Intubating Airways 538
Masks/Adapters 540
Endotracheal Tubes 541
Light Source 542
Fiberoptic Endoscope 544
Fiberoptic Cart 546
Techniques of Fiberoptic Intubation 548
Awake Fiberoptic Intubation 549
Selecting the Route of Fiberoptic Intubation 549
Educate the Patient 549
Educate Assistants 550
Monitoring the Patient 550
Oxygen Insufflation Through the Fiberoptic Endoscope 551
Administer Antisialagogues 551
Administer Vasoconstrictors 551
Administer Sedatives and Hypnotics 552
Administer Topical Anesthetics (Upper Airway Anesthesia) 553
Nebulized (Aerosolized) Lidocaine 553
Topical Anesthetic Sprays and Ointments 553
Sec25_11 554
Applying Topical Anesthetics 554
Administration of Superior Laryngeal Nerve Blocks 555
Tracheal Anesthesia 555
Transtracheal Injection 556
Author’s Method 556
Awake Intubation Techniques 559
Manipulating the Scope 561
Prepare the Scope and Endotracheal Tube 562
Awake Nasotracheal Fiberoptic Intubation 564
Awake Orotracheal Fiberoptic Intubation 565
Confirming Proper Endotracheal Tube Placement 567
Fiberoptic Intubation for an Anesthetized Patient 567
Success Rate of Fiberoptic Intubation 568
Causes of Failed Fiberoptic Intubation 568
Difficulty Passing the Endotracheal Tube Off the Fiberoptic Scope: Causes and Solutions 569
Right Arytenoid Cartilage Impediment to Endotracheal Tube Passage over Endoscope 569
Rotation of the Endotracheal Tube 570
Alternate Endotracheal Tube Tip Designs 570
Tube Size and Fiberoptic Scope Diameter 571
Conclusions 572
Complications of Fiberoptic Intubation 572
Special Uses of the Fiberoptic Endoscope 573
Endobronchial Tube Placement 574
Retrograde Wire-Guided Intubation 574
Endotracheal Tube Change 575
Case Report 575
Techniques to use in the ICU 576
Pediatric Use 577
Fiberoptic Endoscopy and Adjunctive Airway Devices 577
COPA (Cuffed Oropharyngeal Airway) 577
LMA (Laryngeal Mask Airway) 578
Other Devices 578
Fiberoptic Endoscope and Jet Ventilation 580
Fiberoptic Endoscopy in the Difficult/Emergent Airway Scenario 580
Optical Intubating Stylets 581
Summary 582
References 582
Chapter 12: Surgical Options in Airway Management 587
Introduction 588
Oxygenation vs. Ventilation 588
Airway Algorithms 589
Preparing to Manage the Surgical Airway 589
Surgical Options in Airway Management 590
Techniques 590
Needle/Catheter Cricothyroidotomy 591
Objective of the Technique 591
Equipment 591
Technique 592
Comments on Catheter Insertion and Function 594
Oxygenation Through the Catheter 594
Expiration of Gases 594
Low-Pressure Oxygenation Systems 594
Spontaneous Ventilation 595
Apneic Oxygenation 595
Resuscitation Bag and Circle System Bag on an Anesthesia Machine 595
High-Pressure Systems 597
Anesthesia Machine Flush Valve 598
Equipment Needed 599
High-Pressure “Jet” Ventilation 599
Efficacy of the Technique 600
Obtaining a Formal Airway 601
Complications of Needle/Catheter Cricothyroidotomy1,2,30 602
Be Prepared to Perform a Needle/Catheter Cricothyroidotomy 602
Retrograde Catheter-Assisted Intubation 602
Objective of the Technique 602
Equipment 603
Methods 603
Minitracheostomy 606
Objective of the Technique 606
Complications and Problems with Minitracheostomies 609
Contraindications for Use of Minitracheostomy Techniques 610
Percutaneous Dilational Tracheostomy (PDT) 612
Objective of the Technique 612
General Comments 613
Cost Considerations 613
Complications Associated with PDT 613
Prospective Studies and PDT Complication Rates 617
Conclusions Regarding PDT-Related Complications 619
Comparisons Between the Ciaglia PDT and Open Tracheostomy 619
Debate over the Best Method to Establish an Elective Surgical Airway Continues 620
Comparisons of Different PDT Techniques 620
Percutaneous Dilatational Tracheostomy Devices 622
Adjunctive Equipment and Techniques Used to Facilitate PDT Placement and other Surgical Airway Management Options 631
Fiberoptic Bronchoscope 631
Video-Assisted Endoscopy 634
Laryngeal Mask Airway (LMA) 634
Lightwand (Trachlight, Laerdal Medical Inc., Wappingers Falls, NY) 635
Endotracheal Tube Exchangers 635
Ultrasound Guidance of PDT 636
Rigid Bronchoscope 636
Chest Radiographs After PDT 637
Capnography During Transtracheal Needle Cricothyrotomy 637
Fiberoptic Bronchoscope to Aid Retrograde Wire–Directed Intubation 638
Learning Percutaneous Tracheostomy 639
Clinical Patterns of PDT Utilization 639
Teaching Surgical Airway Techniques 640
Contraindications to Performing Percutaneous Tracheostomy 640
Emergency Percutaneous Tracheostomy 641
Emergency Surgical Cricothyrotomy 641
Anatomy of the Cricothyroid Space 641
General Comments 642
Outcome Studies 643
Prehospital Airway Management Including Cricothyroidotomy 644
Emergency Cricothyroidotomy Techniques 645
Standard Technique 645
Rapid 4-Step Technique173 646
Alternative Techniques 647
Complications of Emergency Cricothyroidotomy16,174 648
Contraindications to Emergency Cricothyrotomy 648
Cricothyrotomy and the Unstable Cervical Spine 648
Seldinger Technique Emergency Cricothyroidotomy vs. Standard Surgical Cricothyroidotomy 649
Formal Tracheostomy 649
Indications and Advantages of Tracheostomy178 649
Complications of Tracheostomy 650
Rigid Bronchoscopy 650
Summary 650
References 651
Chapter 13: Mechanical Ventilation and Respiratory Care 659
Introduction 660
Description of a Mechanical Ventilator 661
Commonly Utilized Modes of Ventilation1 661
Siemens Servo Ventilator 662
General Description 662
Control Unit 662
Patient Unit 662
Technical Specifications of the Servo 300/300A 663
Initial Ventilator Settings 664
Ventilatory Orders (Adult) 665
Comments on the Modality of Ventilation 665
Pediatric and Neonatal Ventilation 665
Ventilator Orders for the Infant Under 10 kg 667
Weaning the Patient from Mechanical Ventilation 667
Extubation Criteria 668
Troubleshooting Ventilator Problems 668
Current Strategies and Practices in Mechanical Ventilation and Respiratory Care 669
ALI/ARDS (Acute Lung Injury/Acute Respiratory Distress Syndrome) 671
Rating Systems for Scientific Evidence and Recommendations8 672
Rating System for Quality of Evidence 672
Rating System for Recommendations 672
Conclusions from McIntyre et al 673
Current Ventilation Strategies 673
Recruitment Maneuvers 674
Alternative Modalities of Ventilation 676
New Weaning Strategies 676
Complications of Mechanical Ventilation 677
Ventilator Associated Pneumonia 678
Closed-Circuit Suctioning 679
Portable Ventilators 679
Hyperbaric Oxygenation 680
Ethical Considerations of Mechanical Ventilation 680
Future ALI/ARDS Research 680
Summary 680
References 681
Chapter 14: Extubation Strategies: The Extubation Algorithm 684
Introduction 684
Purpose of an Algorithm 685
Purpose of an Extubation Algorithm 685
Extubation Criteria1 685
Extubation Criteria Following a Difficult Intubation 686
Strategies to Extubate a Patient with a Difficult Airway 687
American Society of Anesthesiologists Task Force on the Management of the Difficult Airway: Strategy for Extubation of the Di 687
Difficult Airway Extubation Algorithms 688
Hagberg et al. Extubation Algorithm (Fig. 14.1) 688
Extubation Algorithm for Patients with Difficult Airways (Fig. 14.2) 690
Performing the Leak Test Prior to Extubation 690
Preoxygenation 690
Airway Anesthesia Prior to Extubation 690
Patient Education Prior to Extubation 691
Option A: Extubation over an Airway Guide 692
Option B: Extubation with Fiberoptic Guidance 692
Option C: Extubation with Video Laryngoscopic Guidance 694
Combined Extubation Options 696
Summary 697
References 698
Chapter 15: Complications of Airway Management 699
Introduction 701
Complications Arising During Intubation 701
Trauma 701
Eyes 701
Upper Lip 701
Mucous Membranes of the Oropharynx 702
Teeth 702
Laryngeal Injuries 703
Pharyngeal Injuries 704
Esophageal Trauma 704
Tracheal/Bronchial Injuries 704
Lung 705
Hypoxemia 705
Acute Hypoxic Encephalopathy 705
Failure of Oxygen at the Source 706
Failure of Oxygen at the Delivery Site 706
Improper Procedure 706
Inability to Intubate or Ventilate 707
Vomiting and Aspiration 707
Preventative Measures 710
Complications Arising Immediately After Intubation 711
Hypoxemia 711
Accidental Esophageal Intubation 711
Ingestion of Laryngoscope Lightbulb 712
Accidental Endobronchial Intubation 713
Bronchospasm 713
Difficulty with Ventilation 714
Laryngeal Intubation 714
Accidental Extubation 715
Rupture of the Trachea or Bronchus 715
Tension Pneumothorax 716
Hypertension, Tachycardia, and Arrhythmias 716
Elevated Intracranial Pressure 716
Complications Arising upon Removal of Endotracheal Tube 717
Hypoxemia 717
Laryngospasm 717
Incidence 717
Clinical Features 719
Airway Obstruction 721
Vomiting and Aspiration 721
Sore Throat 721
Temporomandibular Joint Dysfunction 722
Vocal Cord Injury 722
Postintubation Croup 722
Difficult Extubation 722
Arytenoid Dislocation 723
Cord Avulsion 724
Neural Injury 724
Recurrent Laryngeal Nerve Injury 724
Lingual, Hypoglossal, and Mental Nerve Damage 725
Mental Nerve 725
Complications Arising from Long-Term Intubation 725
Ulceration of the Mouth, Pharynx, Larynx, and Trachea 726
Granuloma Formation 726
Formation of Synechiae and Webs 726
Tracheal Stenosis 726
Complications Occurring Specifically in Relation to Nasotracheal Intubation 727
Epistaxis 727
Submucosal Dissection 727
Middle Turbinectomy 727
Trauma to the Posterior Pharyngeal Wall 728
Trauma to the Adenoids 728
Pressure Necrosis in the Nose 728
Obstruction of the Eustachian Tube 728
Maxillary Sinusitis 728
Complications of Laser Surgery 728
Summary 729
Airway Management Complications Summarized from Anesthesiology Morbidity Studies 729
American Society of Anesthesiologists Closed Claims Study 730
Limitations of the Closed Claims Study 730
Respiratory System 731
Management of the Difficult Intubation in Closed Malpractice Claims 731
Aspiration in Closed Malpractice Claims57 732
Gas Delivery Equipment and Closed Malpractice Claims58 732
Ambulatory and Office-Based Anesthesia and Closed Claims59,60 733
Airway Injury During Anesthesia 733
Australian Incident Monitoring Study (AIMS) 734
Monitors and the AIMS (1993: 2,000 Incidents)67-69 737
AIMS and Obstetric Anesthesia70 737
Deaths Attributed to Anesthesia in New South Wales: 1984–199071 738
The Pediatric Perioperative Cardiac Arrest Registry (POCA)72 739
NCEPOD (National Confidential Enquiry into Perioperative Deaths) 739
NCEPOD 1996/1997 Report 740
SAMS (Scottish Audit of Surgical Mortality) 741
Danish Morbidity Study: 1994–199877 741
Outcomes 742
Difficult Endotracheal Intubation 742
Complaints Related to Uncomplicated Endotracheal Intubation 742
Conclusions 742
Summary 743
References 743
Index 747