Difficult Airway (Adult)
🔹 Core concept
- Difficult
airway = difficulty in
- mask
ventilation
- SGA
ventilation
- laryngoscopy
- tracheal
intubation
👉 ภาวะนี้มีความเสี่ยงสูง
→ hypoxic brain injury /
death ภายในไม่กี่นาที
🔹 Definitions (สอบบ่อย)
- Difficult
mask ventilation →
ventilate ไม่ได้เพียงพอ
- Difficult
laryngoscopy → ไม่เห็น vocal cord
- Difficult
intubation → ใส่ ETT ไม่ได้หลังหลายครั้ง
🔹 Recognition (สำคัญมาก)
🔸 Predictors
1. Difficult mask ventilation
- obesity
- beard
- edentulous
- OSA
2. Difficult SGA
- limited
mouth opening
- obesity
- airway
pathology
3. Difficult intubation
- previous
difficult airway
- short
thyromental distance
- ↓ neck mobility
👉 ยิ่งมีหลาย
factor → risk ↑
🔹 Key principle
👉 Majority =
unanticipated
👉 ต้อง “prepare
ทุกเคส”
🔹 ASA Difficult Airway
Algorithm (core idea)
🔸 Decision Tree (จำง่าย 4 ข้อ)
1.
Difficult laryngoscopy?
2.
Difficult ventilation?
3.
Aspiration risk?
4.
Tolerate apnea?
👉 ใช้ตัดสินใจ
- Awake
vs after induction
🔹 Awake intubation
(high-yield)
✔ Indications
- difficult
intubation +
- difficult
ventilation
- aspiration
risk
- cannot
tolerate apnea
👉 รักษา spontaneous
breathing
🔹 Airway strategy
🔸 Option 1: After
induction
ใช้เมื่อ
- ventilation
OK
- intubation
likely success
🔸 Option 2: Awake
intubation
ใช้เมื่อ
- risk
สูง
🔹 Device selection
✔ Facemask
- basic
- ใช้ได้ short case
✔ SGA
- rescue
device
- primary
airway (low aspiration risk)
✔ ETT
- gold
standard
- best
airway protection
🔹 Preparation (critical)
- airway
assessment
- full
equipment
- backup
devices
- skilled
assistant
👉 Airway timeout
recommended
🔹 Preoxygenation
- 100%
O₂
- aim
EtO₂ >90%
👉 high-risk → apneic oxygenation
🔹 NMBA strategy (advanced
point)
🔸 Difficult mask
ventilation predicted
→ rapid
intubation (succinylcholine / rocuronium)
🔸 Difficult intubation
predicted
→
optimize intubation conditions
🔸 Both difficult
👉 Avoid NMBA → awake intubation
🔹 Rescue strategy
(critical)
Stepwise
1.
Mask ventilation
2.
SGA
3.
Intubation (advanced device)
4.
Surgical airway
👉 SGA = first rescue
most cases
🔹 Failed airway
Definition
👉 cannot intubate +
cannot ventilate
Management
- call
for help
- follow
algorithm
- emergency
surgical airway
🔹 Important rules
- ❗
limit attempts ≤3
- ❗
reoxygenate between attempts
- ❗
change technique each attempt
🔹 Extubation (often
overlooked)
- risk
สูงใน difficult airway
- ต้องมี reintubation plan
🔹 Clinical pearls
- anticipation
> skill
- algorithm
ลด mortality
- awake
intubation = safest in high risk
- SGA
= key rescue device
- VL =
preferred rescue after DL fail
- failed
airway = rare แต่ lethal
🔹 One-page summary (ใช้งานจริง)
If predicted difficult airway:
👉 ถ้า
- ventilation
difficult OR
- aspiration
risk OR
- cannot
tolerate apnea
➡️ Awake intubation
👉 ถ้า
- ventilation
OK
- low
risk
➡️ Induction → intubation
👉 ถ้า failed:
1.
Oxygenate (mask/SGA)
2.
Limit attempts
3.
Call help
4.
Surgical airway
ไม่มีความคิดเห็น:
แสดงความคิดเห็น