Difficult Airway Question

[militarymd]

Fat guy, sleep apnea...airway exam reveals...short fat neck....I would rate the likelihood of a successful DL at < 10%.

Case is a knee arthroscopy with a good surgeon....likely less than 15 minute case.

Anesthetic plan was GA with LMA as the airway device.

Patient is pre-oxygenated and induced with 300 mg of propofol (he's probably 130 kg).

The anesthesia team was unable to mask ventilate the patient, and they were unable to open the patient's mouth.....good mouth opening prior to induction.

What would you guys do next?

Would you give succinylcholine to "relax" the jaw?

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[InGasWeTrust]

Assuming you knew that this was going to be a "difficult airway" then you prolly should have plans A-E


I would prolly already have the intubating LMA, FOI, and bougie within arms reach.

First I would asses can you really not ventilate, I mean the 2 handed "yoke the jaw like trying to start a 10yr old lawn mower" with a nasal and oral airway in....(Is the chest rigid? or is it trsimus?)

No luck, with that then, I would try to intubate with DL( best blade, and yes splay the teeth open with blade), one look no luck then you gotta cut the neck

On A side note this is why I always try to position patient optimally for intubating regardless if the plan is for LMA or not, cuz you never know....

 

[UTSouthwestern]

Fat guy, sleep apnea...airway exam reveals...short fat neck....I would rate the likelihood of a successful DL at < 10%.

Case is a knee arthroscopy with a good surgeon....likely less than 15 minute case.

Anesthetic plan was GA with LMA as the airway device.

Patient is pre-oxygenated and induced with 300 mg of propofol (he's probably 130 kg).

The anesthesia team was unable to mask ventilate the patient, and they were unable to open the patient's mouth.....good mouth opening prior to induction.

What would you guys do next?

Would you give succinylcholine to "relax" the jaw?

Sux him. The propofol will be in effect longer than the sux will. Give yourself a chance to slide that LMA in. Call ENT for possible emergency trach, jet ventilate through an angiocath cric, etc. You can also slide in a large nasal airway, connect a 6.0 ETT connector to it, hook that up to your anesthesia machine, have someone hold cricoid pressure (real cricoid pressure, not cricoid pinching leading to airway obliteration), then hand bag through the nasal airway (occlude the other nare). This is just a temporizing measure until you can proceed with the next step you want to go towards.

 

[jwk]

Sux - 10-20mg, and I'll bet he magically opens up and all is well. Lots of folks tighten up at induction. Not usually a big deal.

Disagree with one look and then cut the neck - that's a panic move. If you've really pre-oxygenated well (denitrogenated as some will say ), you've got a little time. I'd go with FOB before the knife. Do it without ramming the tube through the nose and stirring up bleeding.

And remember - you can always wake them up. If you're truly in deep doodoo, don't keep adding drugs that make things worse. This is elective surgery.

 

[militarymd]

Interesting responses.


The patient wasn't adequately anesthetized....that was my assessment...kind of rigid...clenching jaw....preventing airway instrumentation.

The team gave sux...and mask ventilation became very easy.


I would have given more propofol....and proceed with LMA ...rather than giving a paralytic

 

[TofuBalls]

It seems like the LMA will work for just about everybody and the intubating LMA has saved me in at least one fat guy. But... have any of you experienced guys had a rescue LMA fail in a difficult airway/failed DL? If so, what were the specifics?

 

[UTSouthwestern]

Interesting responses.


The patient wasn't adequately anesthetized....that was my assessment...kind of rigid...clenching jaw....preventing airway instrumentation.

The team gave sux...and mask ventilation became very easy.


I would have given more propofol....and proceed with LMA ...rather than giving a paralytic

Problem is that you have already given 300 mg, 2.5 mg/kg at his non-ideal body weight. How much more would you give before you use sux and would it be too late by then. I think they gave more than enough propofol for induction, but maybe they tried to put in the LMA too quickly after the induction, then panicked.

 

[MTGas2B]

Interesting responses.


The patient wasn't adequately anesthetized....that was my assessment...kind of rigid...clenching jaw....preventing airway instrumentation.

The team gave sux...and mask ventilation became very easy.


I would have given more propofol....and proceed with LMA ...rather than giving a paralytic

How about this option...

If you decided to give sux, you could also try this:
Sux,
Half-a$$ DL, just enough to get in the mouth and around the tounge
Bougie into the esophagus
Place pro-seal LMA over the bougie (bougie through the gastric port)
Slide it on down.
Works slick, plus you can postive pressure ventilate to higher pressures with the pro-seal than you can with the standard LMAs.

 

[MTGas2B]

Why would you do all that if you can get the LMA in after sux?

Three reasons I can think of
1. You've pumped his stomach full of air and you want to empty it once you secure the airway.

2. Couldn't get the plain LMA to work

3. You can positive pressure ventilate up to 30 cmH2O with pro-seal lma, even if you get the plain LMA in place you may still be in a tough spot riding out the sux and propofol

 

[militarymd]

Problem is that you have already given 300 mg, 2.5 mg/kg at his non-ideal body weight. How much more would you give before you use sux and would it be too late by then. I think they gave more than enough propofol for induction, but maybe they tried to put in the LMA too quickly after the induction, then panicked.

YES

 

[Laryngospasm]

No luck, with that then, I would try to intubate with DL( best blade, and yes splay the teeth open with blade), one look no luck then you gotta cut the neck

....

You would chose to knock out the guys teeth before using sux or more propofol, and then you would "cut the neck"?,Have you ever done a cricothyrotomy on a really fat guy with a short neck? Im guessing you never have, I havent either.

 

[johankriek]

Sux - 10-20mg, and .

if you are gonna use a dose of anectine.. use a full dose... whiy half ass it



cant ventilate... need best attempt.. and that best attempt is with anectine


i would have put a spinal in him...

or if general i would have intubated him awake with a fiberoptic

 

[johankriek]

How about this option...

If you decided to give sux, you could also try this:
Sux,
Half-a$$ DL, just enough to get in the mouth and around the tounge
Bougie into the esophagus
Place pro-seal LMA over the bougie (bougie through the gastric port)
Slide it on down.
Works slick, plus you can postive pressure ventilate to higher pressures with the pro-seal than you can with the standard LMAs.

say what?

 

[MTGas2B]

say what?

1: Br J Anaesth. 2006 Feb;96(2):238-41. Epub 2005 Nov 25. Links
Bougie-guided insertion of the ProSeal laryngeal mask airway has higher first attempt success rate than the digital technique in children.Lopez-Gil M, Brimacombe J, Barragan L, Keller C.
Department of Anaesthesia and Reanimation, Maranon University Hospital, Madrid, Spain.

BACKGROUND: We tested the hypothesis that bougie-guided insertion of the ProSeal laryngeal mask airway (ProSeal LMA) has higher success rate than the digital technique in children. METHODS: One hundred and twenty children (ASA I-II, aged 1-16 yr) were randomly allocated for ProSeal LMA insertion using the digital or bougie-guided technique. The digital technique was performed according to the manufacturer's instructions. The bougie-guided technique involved priming the drain tube with a bougie, placing the bougie in the oesophagus under direct vision and railroading the ProSeal LMA into position. Unblinded data were collected about ease of insertion (number of attempts and time taken to provide an effective airway), efficacy of seal, ease of gastric tube placement, haemodynamic responses and blood staining. Blinded data were collected about postoperative airway morbidity. RESULTS: The first attempt success rate was higher for the bougie-guided technique (59/60 vs 52/60, P=0.015), but effective airway time was longer (37 vs 32 s, P<0.001). There were no differences in efficacy of seal, ease of gastric tube placement, haemodynamic responses, blood staining or postoperative airway morbidity. CONCLUSION: We conclude that bougie-guided insertion of the ProSeal LMA has a higher first attempt success rate than the digital technique in children.

PMID: 16311278 [PubMed - indexed for MEDLINE]


There are other papers describing the technique, but this is the only one I could find that studied it systematically.

 

[jwk]

if you are gonna use a dose of anectine.. use a full dose... whiy half ass it



cant ventilate... need best attempt.. and that best attempt is with anectine


i would have put a spinal in him...

or if general i would have intubated him awake with a fiberoptic

Because then you've burned a bridge you might not want to burn. A little sux might help and probably won't hurt. A lot of sux, and if you truly can't ventilate, you're totally screwed.

 

[UTSouthwestern]

Because then you've burned a bridge you might not want to burn. A little sux might help and probably won't hurt. A lot of sux, and if you truly can't ventilate, you're totally screwed.

I'd argue that in this situation, you aren't losing much given that a full induction dose of propofol has been given and isn't going to wear off before the sux does.

A little sux may do absolutely nothing and then you've wasted more time.

 

[johankriek]

Because then you've burned a bridge you might not want to burn. A little sux might help and probably won't hurt. A lot of sux, and if you truly can't ventilate, you're totally screwed.

No you are in the same place you were before..

but with anectine on board.. and now at least you can have a best attempt at intubation before you are in cant ventilate cant intubate situation..


If you truly cannot ventilate.. at that point you should try to intubate and you have to have th eBEST ATTEMPT and that is with standard dose of anectine.. and if you cannot intubate then you can proceed down the algorhuthm to the 2 supraglottic or 2 subglottic choices..


I hate the teaching that paralysis is bad... anectine is your friend not your enemy.. it WILL help you..

 

[militarymd]

..


I hate the teaching that paralysis is bad... anectine is your friend not your enemy.. it WILL help you..

except when the jaw locks up......or when the patient remains paralzyed for a long, LONG, time....and that happened to me one time.....that's one too many for me....I was fortunately able to tube that fat lady.

 

[HomerSimpson]

Hindsight is 20/20 right? In this case I probably would have positioned the patient properly then done an awake look with the appropriate blade with the patient sedated to see if there even is a possible view. If I could visualize epiglottis and arytenoids I would proceed with induction and LMA if indicated. If then I couldn't open up the mouth post induction to put the LMA in, I would have some level of confidence that relaxing the patient would lead to intubation and not a cric-tubation. If my awake look is not satisfactory then it's truly a difficult airway i'd probably do awake FOI through nose. that's just me though... I know the practical implications of performing a 15 min awake intubation and a lot of trouble for a short 15 min case.

 

[jwk]

No you are in the same place you were before..

but with anectine on board.. and now at least you can have a best attempt at intubation before you are in cant ventilate cant intubate situation..


If you truly cannot ventilate.. at that point you should try to intubate and you have to have th eBEST ATTEMPT and that is with standard dose of anectine.. and if you cannot intubate then you can proceed down the algorhuthm to the 2 supraglottic or 2 subglottic choices..


I hate the teaching that paralysis is bad... anectine is your friend not your enemy.. it WILL help you..

Sounds like mil and I agree - experience is the best teacher.

Like I said before - lots of people get a little tight at induction. This is exactly what happened in mil's case. A little minimal intervention and all was well. No major pucker, no broken teeth, no cut necks.

I never said paralysis is bad - I said give sux. We just differ on the dose. In his case, they didn't even intubate the patient.

If you truly can't ventilate, then start down the algorithm road. You will find that there are VERY FEW patients that you can't tube/can't ventilate. I've had two in 25 years.

 

[Fah-Q]

Assuming you knew that this was going to be a "difficult airway" then you prolly should have plans A-E


I would prolly already have the intubating LMA, FOI, and bougie within arms reach.

First I would asses can you really not ventilate, I mean the 2 handed "yoke the jaw like trying to start a 10yr old lawn mower" with a nasal and oral airway in....(Is the chest rigid? or is it trsimus?)

No luck, with that then, I would try to intubate with DL( best blade, and yes splay the teeth open with blade), one look no luck then you gotta cut the neck

On A side note this is why I always try to position patient optimally for intubating regardless if the plan is for LMA or not, cuz you never know....

I don't know if your view would be very good to begin with but after knocking his teeth out I doubt it would get any better.

I trach is much less morbid than busted/aspirated teeth.

 

[VentdependenT]

Sounds like mil and I agree - experience is the best teacher.

Like I said before - lots of people get a little tight at induction. This is exactly what happened in mil's case. A little minimal intervention and all was well. No major pucker, no broken teeth, no cut necks.

I never said paralysis is bad - I said give sux. We just differ on the dose. In his case, they didn't even intubate the patient.

If you truly can't ventilate, then start down the algorithm road. You will find that there are VERY FEW patients that you can't tube/can't ventilate. I've had two in 25 years.

Agreed,

All roads lead to LMA, unless there is a true anatomic anomaly. And if thats the case it should have been recognized by the anesthesiologist and dealt with before slamming in induction agents and paralytics.

UT, I like that nasal airway/mech vent idea. Will tuck it away.

If the jaw is tight in general then you have four possibilities (perhaps more, I aint the sharpest tool in the shed): TMJ (but you should be able to translate that jaw somehow), massater spasm (not a big deal from what I have read, just keep an eye on your end tidal co2 and perhaps flip off yer inhalation agent), malignant hyperthermia (not an issue in this case as only propofol was given), not waiting till the peak of you induction agent/light anesthesia (sounds like the case here).

Lastly I'd like to mention the awake fiberopotic. You really cant go wrong here people. Yeah its a pain in the ass for a 15 minute case but if anatomy calls for it seriously consider it. All your wicked DL skills wont save your ass for a cant ventilate/intubate in a morbidly obese short necked OSA patient.

 

[militarymd]

Here's a trick....works GREAT.


Nasal trumpet in place.

Jet ventilate into nasal trumpet.

No need for cricoid.

 

[VentdependenT]

Here's a trick....works GREAT.


Nasal trumpet in place.

Jet ventilate into nasal trumpet.

No need for cricoid.

HEY mmd how the hell do you rig up jet ventillation to yer standard machine? I know we've discussed this somewhere but I don't feel like digging.

I've fooled around with tubing a syringe and a 14 gauge but I'll damned if I can figure it out.

 

[militarymd]

Jet ventilator is something that is not a part of your regular machine. It is essentially a pressure regulator that connects to high pressure oxygen...up to 60 psi...it has a pressure regulator on it along with a hand adjustable valve that releases upto 60 psi of oxygen....essentially wall pressure....with flows up to 50+ liter per minute.

 

[VentdependenT]

Jet ventilator is something that is not a part of your regular machine. It is essentially a pressure regulator that connects to high pressure oxygen...up to 60 psi...it has a pressure regulator on it along with a hand adjustable valve that releases upto 60 psi of oxygen....essentially wall pressure....with flows up to 50+ liter per minute.

I thought you could jury-rig something up to the fresh gas flow port (that sucker is wall pressure) of the machine until somebody finds that device.

 

[UTSouthwestern]

I thought you could jury-rig something up to the fresh gas flow port (that sucker is wall pressure) of the machine until somebody finds that device.

A faster way is to bypass the anesthesia machine altogether as follows:

Take O2 tubing and connect it to any wall O2 outlet regulator or the one on your machine meant for nasal cannulas, etc.

Attach a 3 way stopcock to the other end (make sure it is secured very tightly).

Place your angiocath through the cricothyroid membrane.

Attach the stopcock to it and open the stopcock to all three ports.

Open the wall outlet regulator and keep turning the knob counterclockwise until it completely stops turning. You have now gone past the 15 PSI regulation point, but a little known secret is that if you continue to turn the dial, the pressure keeps going up until you reach the max outflow pressure (wall pressure of 50 PSI).

With everything attached, and the cannula securely taped into place, you cover the port of the stopcock that isn't attached to anything with your thumb to force the O2 flow into the patient's trachea for inhalation, then uncover it to vent the intrapulmonary pressure (exhalation).

Have used this technique five times on medicine and orthopedic floors at Parkland where a code was not called in code situations and multiple individuals had failed to intubate a patient, leaving me with a bloody, swollen mess that even a combitube could not allow ventilation through. Also used it once in the ER of St. Paul University Hospital on a patient with complete angioedema.

 

[VentdependenT]

my man ut comes through again.