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SSECOND ITERATION OF THE ASA DIFFICULT AIRWAY ALGORITHM: REVIEW AND CHANGES JONATHAN L. BENUMOF, MD UCSD MEDICAL CENTER
Jonathan L. Benumof, M.D.
THE ASA DIFFICULT AIRWAY ALGORITHM:
A. REVIEW THE ENTIRE ALGORITHM BRIEFLY
B. DISCUSS THE MAJOR CHANGES IN THE SECOND ITERATION
(1). PREOPERATIVE AIRWAY EVALUATION
(2). PREOXYGENATION
(3). USE OF LMA AS FIRST RESCUE OPTION
(4). CONFIRMATION OF TRACHEAL
INTUBATION OUTSIDE OF OR
ASA DIFFICULT AIRWAY ALGORITHM RECOGNIZED UNRECOGNIZED AWAKE
INTUBATION GENERAL
ANESTHESIA
± PARALYSIS CVCI
RESCUE
OPTIONS CONFIRM (1) (2) (3) (4) 5151
This is an overview of the positions at which these changes occur.
The 11-point airway exam is designed to convert more unrecognized difficult airways to difficult airways and put you in a position to solve this problem with an awake fiberoptic intubation.
The fact that you shall preoxygenate is likely the most important message of today and pertains not just to difficult airways but also to sick patients of any kind, as I will illustrate.
The fact that the LMA is now preferred as the initial rescue option for a cannot-ventilate-cannot-intubate situation is a function of our familiarity with the device as opposed to any of the other rescue options. If you think about how many combitubes you have inserted in the last 6 months or how many transtracheal jet ventilations or surgical airways you have done in your career, this choice becomes evident.
The fact that there are two nearly failsafe devices that allow confirmation of ETT placement in the field is very important and now a standard of care that you have to be familiar with.
DIFFICULT AIRWAY ALGORITHM RECOGNIZED UNRECOGNIZED PREOPERATIVE
AIRWAY
EVALUATION
(11 STEPS) GENERAL
ANESTHESIA
± PARALYSIS AWAKE
INTUBATION (1)
The 11 point airway exam should be performed in every patient in order to increase your yield of detecting a patient that has a difficult airway, so you can perform an awake fiberoptic intubation.
ASA DIFFICULT AIRWAY ALGORITHM 11 STEP PREOPERATIVE AIRWAY EVALUATION ALONG THE LINE OF SIGHT
T 3 F B
OR 6 CM 7. MANDIBULAR
SPACE LENGTH =
TMD = INDEX
OF A OR P
OF LARYNX
DIFFICULT AIRWAY PROPER
PREPARATION UNRECOGNIZED GENERAL
ANESTHESIA
± PARALYSIS AWAKE
INTUBATION
CHOICES FAIL SUCCEED SURGICAL
AIRWAY CANCEL CASE,
REGROUP REGIONAL
ANESTHESIA CONFIRM UNCOOPERATIVE PATIENT MASK VENT NONPROBLEMATIC RECOGNIZED
If you are not certain that a patient will be easy to intubate then you perform an awake fiberoptic intubation. This requires preparation. Specifically glycopyrrolate and 5 injections: Block of lingual branch of glossopharyngeal nerve and superior laryngeal nerve as well as transtracheal injection of 4% lidocaine. Besides that the patient inhales 4% nebulized lidocaine until he does not know that he has a neck anymore.
Local anesthetic toxicity is a real risk here but can be partially prevented by administration of a small dose of midazolam.
If successful, your difficult airway problem has gone away.
If not successful you have 5 options:
You could choose to perform the surgery under regional anesthesia recognizing that the difficult airway will not disappear and in fact may make a very untimely reappearance when you have no access to it. So don’t do a regional anesthetic if access to the airway is going to be a problem and if the procedure cannot be aborted once in progress.
You could cancel the case and come back another day.
You could place a surgical airway
You could do further preparation
You could convert to a general anesthetic if you are absolutely certain that mask ventilation is not going to be a problem
The two other circumstances in which you will find yourself giving a general anesthetic to a patient with a difficult airway
PATIENTS WHO NEED MAXIMAL PRE-02 PATIENTS WITH O2 TRANSPORT ABNORMALITIES (DESATURATE
THE FASTEST)
2. PATIENTS WITH DIFFICULT
AIRWAYS (MAY NEED MORE TIME
TO SOLVE A CVCI SITUATION)
CAUSES OF SUBMAXIMAL PRE-O2
INSUFFICIENT TIME OF
BREATHING FIO2 = 1.0
2. TAKING MASK ON AND OFF
FIO2 = 1.0 ROOM AIR
3. LEAK UNDER/AROUND MASK
FIO2 ROOM AIR
HOW DO YOU KNOW YOU ARE ACHIEVING MAXIMAL PRE-O2? MASK HELD CONTINUOUSLY TO FACE
I.E., HAND OR STRAPS = 3-5 MINUTES
2. RESERVOIR BAG MUST MOVE:
IN WITH EACH INHALATION
OUT WITH EACH EXHALATION
3. GOOD EXHALATION CAPNOGRAPHY
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