What equipment should be in your Difficult Airway Cart ?

1. What equipment should be in your Difficult Airway Cart ? Margaret Healy CNM 2 Anaesthesia University College Hospital Galway

2. What is a “Difficult Airway”? The difficult airway is defined as the clinical situation in which a conventionally trained anaesthetist experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both

4. Difficult Airway Society recommendations • Practitioners should be competent in a number of core airway skills. • Work in an appropriate environment (trained assistance, with access to a range of airway devices and techniques, appropriate monitoring during surgery and facilities for the appropriate level of post op care) • That equipment is stocked in dedicated trolleys. These should be regularly checked and stocked. The exact number and location of each trolley should be determined locally • All anaesthetists and anaesthetic assistants should be familiar with the contents and location of the trolley • Training should be provided in the use of equipment selected by each department • There should be a Consultant Airway Coordinator in each department, a training room and dedicated lists for airway training

5. CORE SKILLS • LMA for ventilation • FOI through LMA, Aintree or other airway • ILMA • Indirect laryngoscopes Glidescope, Airtraq etc • Emergency cricothyrotomy

6. Difficult Airway Trolley • A shelf and 5 Drawers that follow sequence of Difficult Airway Algorithm • Mobile • Robust • Clearly labelled • Easily cleaned • Attach DAS algorithms • Restocking list

7. Recommended equipment for management of unanticipated difficult intubation • DAS guidelines algorithm flowcharts • Equipment list for restocking • At least one alternative blade(e.g. straight, McCoy) • Intubating LMA (Size 3,4,5 with dedicated tubes and pushers) • Flexible fibreoptic laryngoscope (with portable/battery light source) • Aintree Intubation Catheter • Proseal LMA / Supreme LMA • Cricothyroid cannulae with High pressure jet ventilation system (Manujet) OR • Large bore cricothyroid cannulae (e.g. Cuffed Melker) OR • Surgical Cricothyroidotomy kit

8. Miller Blades (Straight) • The Miller blades are commonly used for infants. It is easier to visualize the glottis using these blades than the Macintosh blade in infants, due to the larger size of the epiglottis relative to that of the glottis.

9. Levering Laryngoscope (McCoy) • Hinged tip which facilitates elevation of the epiglottis • Less force required to intubate • Improves view at laryngoscopy • Useful in patients wearing cervical hard collars • Inexpensive • Steep learning curve

10. Supraglottic Devices • Supraglottic devices are the suitable alternative to endotracheal intubation, Useful when endotracheal intubation has failed • Suitable for use by those with limited experience with endotracheal intubation • Should be immediately available for every difficult airway situation • Various types available

11. Fastrach (Intubating LMA) Advanced version of the standard LMA, which allows a specifically designed ETT to be passed blindly into the trachea Useful in “can’t intubate, can’t ventilate” scenarios Allows fast insertion into correct position without moving patients head or neck Can be used alone or as a guide to intubation Facilitates ventilation between ILMA insertion and ETT insertion Available in 3 sizes, 3, 4 & 5 with dedicated ETTs available in 6 / 6.5 / 7 / 7.5 & 8mm

12. LMA Pro-Seal • Not necessarily a Difficult Airway Device, but is useful in situation where patient has not been fasting • May be useful in failed obstetric intubation • This has an extra tube which provides excess access to stomach contents • Protects against aspiration by providing an escape for unexpected regurgitation • Drain tube prevents against gastric insufflation

13. LMA Supreme™ • Quite new to the market, combines all the best features of all previous LMA except you can’t intubate through it • The SLMA is easily and rapidly inserted, providing a reliable airway and a good airway seal • Rates of failure, manipulations required and complications are very low. • Can be used when tracheal intubation fails in non-fasted patients • Can be used in CPR • Useful in “failed intubation” and the “can’t intubate-can’t ventilate” situation

14. Fibreoptic Bronchoscope

15. Fiberoptic Intubation (FBI) • The use of a flexible bronchoscope to intubate • The endotracheal tube is passed directly over the bronchoscope into the trachea • Uses: - Patients with difficult airways - Pre-operative assessment - Extubation assessment • Advantages: • This technique allows direct visualization of the airway • Direct confirmation of ETT placement • Can be done awake • Disadvantages: • Expensive, difficult, requires care and skill • View may be hampered by blood or secretions • Requires detailed decontamination / traceability

16. Berman Airway • Berman, an American anaesthetist , designed airways to aid blind intubation • Useful to aid oral fibreoptic intubation • Also useful as a bite block

17. Aintree Intubation Catheter • Hollow bougie which fits over a standard intubating fibrescope • Aids intubation through a dedicated airway such as a laryngeal mask • Place LMA, load Aintree onto fibrescope, pass fibrescope to the carina and slide off the aintree. Remove the fibrescope and LMA and intubate over the Aintree • Possible to ventilate via this catheter if necessary, throughout the intubation procedure

18. Surgical Techniques • A cricothyrotomy is only indicated when all other devices and techniques have failed or are not available • Final step for CICV in all airway algorithms • Quicker than a tracheotomy • Life saving • Convert to definitive airway asap • Must be provided on all carts

19. Surgical Airway Technique 3 different techniques • Needle Cricothyrotomy +TTJV (Manujet) • Large Cannulae Cricothyrotomy (Melker / Quicktrach) • Surgical Cricothyrotomy

20. 1.Needle Cricothyrotomy (Manujet III with Jet Ventilation Catheter) • Useful for elective or emergency TTJV • Perc puncture of cricothyroid ligament • It consists of an injector with pressure gauge and adjustable driving pressure (0-4 BAR) • Catheters available in 3 sizes Adult 13g, Child 14g and Baby 16g

21. 1.Transtracheal Jet Ventilation (TTJV) • Jet ventilation using either specialized ventilator or high pressure driven valve circuit via a catheter passed through the cricothyroid membrane • Similar technique to previous • Disadvantages • Requires high pressure gas source • May cause subcutaneous emphysema, pneumo-mediastinum, pneumothorax or other types of barotrauma • Uses: • Emergency ventilation in the can’t intubate can’t ventilate scenario

22. 2. Cricothyrotomy Catheter (Melker cuffed/ Quicktrach) • Syringe • 18g Introducer Needles (5cm & 7cm) • Guidewire • Curved Dilator • Airway Catheter

23. 2. Large Cannulae Cricothyrotomy • Used for emergency airway access when conventional ETT intubation cannot be performed • Percutaneous entry ( Seldinger ) technique via cricothyroid membrane • Dilate the tract and tracheal entrance site to permit passage of the emergency airway • Cuffed catheter to protect and control airway

24. 3.Surgical Cricothyrotomy Requirements: • No 11 blade • Size 6 Shiley tracheostomy ( OR small ETT size 5.0-6.0) • Small artery forceps

25. Technique: • Head fully extended • longitudinal incision is made through the skin and subcutaneous fat over the thyroid and cricoid cartilages • Tissue bluntly dissected • Cricothyroid ligament is transversely incised • Tracheal tube inserted

26. Accessories • Fibreoptic Bronchoscopy accessories – suction adaptor, irrigation valve, camera head, light cable, Leak tester, mouth guard, • Berman airway • Endoscopy masks • Airway anaesthesia – nebuliser, atomiser, • Xylocaine Spray , Xylocaine 4% topical, Co-Phenylcaine • Battery Light Source

27. Documentation • D.A.S. guidelines • Set up instructions • Decontamination Instructions • Checking / Restocking List

28. Conclusion • Lack of clear instructions • Technology is changing quickly • Core skills are vital • Difficult Airway devices should be used in routine cases to ensure familiarity • ?? Standard Difficult Airway Cart nationally