특집_김시오

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1 Focused Issue of This Month SiOh Kim, MD. Department of Anesthesiology and Pain Medicine, Kyungpook National University College of Medicine sokim@knu.ac.kr J Korean Med Assoc 2007; 50(12): Abstract Airway management is still perceived as the greatest patient safety issue and the key task that anesthesiologists perform. Management includes mask ventilation, use of a laryngoscope, and the endotracheal intubation and extubation of the patient. Difficulty can be encountered at any of these stages, and can be a major cause of anesthesiarelated morbidity and mortality. Competence in airway management requires knowledge of the anatomy and physiology of the airway, ability to access the patient's airway for the anatomic features that correlate with difficulties in airway management, skill with the many devices used in airway management, including a variety of recentlyintroduced airway tools, and the appropriate application of the sophisticated algorithm for difficult airway management. Development and clinical distribution of supraglottic airway devices and their enhancement, as well as the broad acceptance of awake fiberoptic intubation, has led to profound changes in the strategy for managing a difficult airway. Including the American Society of Anesthesiologists, many countries have developed their own airway management algorithm these days. Nevertheless, massive national and international deficits still exist in implementing these guidelines into practice as well as the implicated structural requirements with respect to education, reflection, team building and equipment concerning each individual institution. In regard to this situation, it is the recommendation of the author that our country develop and institute such a standardized system of airway management. Keywords : Airway management; Difficult airway; Intubation; Fiberoptic bronchoscope; Supraglottic airway devices 1048

2 Table 1. Disease states associated with difficult airway management Congenital PierrreRobin syndrome TreacherCollins syndrome Goldenhar's syndrome Mucopolysaccharidoses Achondroplasia Micrognathia Down's syndrome Acquired Morbid obesity Acromegaly Infections involving the airway (Ludwig's angina) Rheumatoid arthritis Obstructive sleep apnea Ankylosing spondylitis Tumours involving the airway Trauma (airway, cervical spine) Table 2. Components of the preoperative airway physical examination Airway examination component Nonreassuring findings 11. Length of upper incisors Relatively long 12. Relation of maxillary and mandibular Prominent 'overbite' (maxillary incisors incisors during normal jaw closure anterior to mandibular incisors) 13. Relation of maxillary and mandibular Patient mandibular incisors anterior to incisors during voluntary protrusion (in mandible front of) maxillary incisors 14. Interincisor distance Less than 3 cm 15. Visibility of uvula Not visible when tongue is protruded with patient in sitting position (e.g. Mallampati class II) 16. Shape of palate Highly arched or very narrow 17. Compliance of mandibular space Stiff, indurated, occupied by mass, or non resilient 18. Thyromental distance Less than three ordinary finger breadths 19. Length of neck Short 10. Thickness of neck Thick 11. Range of motion of head and neck Patient cannot touch tip of chin to chest or cannot extend neck 1049

3 Kim SO Figure 1. Mallampati classification. 1050

A) Classic LMA TM with different sizes. B) LMA Fastrack TM. C) LMA ProSeal TM (from www.lmana.com).

4 15mm connector Integral biteblock Airway tube Introducer strap Airway tube orifice Internal drain tube Drain tube orifice Handle Inflation line Laryngeal mark Epiglottic elevator Figure 2. Laryngeal Mask Airways. A) Classic LMA TM with different sizes. B) LMA Fastrack TM. C) LMA ProSeal TM (from Rigid anatomically curved airway 15mm standard connector accepts 8mm cuffed tube Drain tube Inflation tube Pilot balloon Valve Cuff A B C 1051

Kim SO A C Figure 3. Insertion of the laryngeal mask airway (LMA). A) The tip of the cuff is pressed upward against the hard palate by the index finger while the middle finger opens the mouth.

5 Kim SO A C Figure 3. Insertion of the laryngeal mask airway (LMA). A) The tip of the cuff is pressed upward against the hard palate by the index finger while the middle finger opens the mouth. B) The LMA is pressed backward in a smooth movement. Notice that the nondominant hand is used to extend the head. C) The LMA is advanced until definite resistance is felt. D) Before the index finger is removed, the nondominant hand presses down on the LMA to prevent dislodgment during removal of the index finger. The cuff is subsequently inflated, and outward movement of the tube is often observed during this inflation. (from B D 1052

of just the posterior portion of the laryngeal aperture, grade III is visualization of

6 Figure 4. Four grades of laryngoscopic view. Grade I is visualization of the entire laryngeal aperture, grade II is visualization of just the posterior portion of the laryngeal aperture, grade III is visualization of only the epiglottis, and grade IV is visualization of just the soft palate. A B Figure 5. Combitube (A) and Light wand (B). 1053

7 Kim SO 11. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: A closed claims analysis. Anesthesiology 1990; 72: American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: Rocke DA, Murray WB, Rout CC, Gouws E. Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 1992; 77:

8 15. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL. A clinical sign to predict difficult tracheal intubation: a prospective study. Can J Anaesth 1985; 32: Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, Riou B. Prediction of difficult mask ventilation. Anesthesiology 2000; 92: Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anaesth 1994; 41: Williamson JA, Webb RK, Szekely S, Gillies ER, Dreosti AV. Difficult intubation: an analysis of 2000 incident reports. Anaesth Intensive Care 1993; 21: Yildiz TS, Solak M, Toker K. Comparison of laryngeal tube with laryngeal mask airway in anaesthetized and paralysed patients. Eur J Anaesthesiol 2007; 24: Joshi GP, Inagaki Y, White PF, TaylorKennedy L, Wat LI, Gevirtz C, McCraney JM, McCulloch DA. Use of the laryngeal mask airway as an alternative to the tracheal tube during ambulatory anesthesia. Anesth Analg 1997; 85: Parmet JL, ColonnaRomano P, Horrow JC, Miller F, Gonzales J, Rosenberg H. The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated difficult tracheal intubation along with difficult mask ventilation. Anesth Analg 1998; 87: Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: Knill RL. Difficult laryngoscopy made easy with a BURP. Can J Anaesth 1992; 40: Adnet F, Borron SW, Lapostolle F, Lapandry C. The three axis alignment theory and the sniffing position: perpetuation of an anatomic myth? Anesthesiology 1999; 91: Chou HC, Wu TL. A reconsideration of the three axes alignment theory and sniffing position. Anesthesiology 2002; 97: Adnet F, Baillard C, Borron SW, Denantes C, Lefebvre L, Galinski M, Martinez C, Cupa M, Lapostolle F. Randomized study comparing the sniffing position with simple head extension for laryngoscopic view in elective surgery patients. Anesthesiology 2001; 95: Mercer MH, Gabbott DA. Insertion of the Combitube airway with the cervical spine immobilized in a rigid cervical collar. Anaesthesia 1998; 53: Agrò F, Hung OR, Cataldo R, Carassiti M, Gherardi S. Lightwand intubation using the Trachlight. Can J Anaesth 2001; 48: Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the Intubating LMAFastrach in 254 patients with difficulttomanage airways. Anesthesiology 2001; 95: Benemof JL. Management of the difficult adult airway with special emphasis on awake tracheal intubation. Anesthesiology 1991; 75: Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth 1998; 80: Barron FA, Ball DR, Jefferson P, Norrie J. 'Airway Alerts' How UK anaesthetists organize, document and communicate difficult airway management. Anaesthesia 2003; 58: Kerridge RK, Crittenden MB, Vutukuri VL. A multiplehospital anaesthetic problem register: establishment of a regionally organized system for facilitated reporting of potentially recurring anaestheticrelated problems. Anaesth Intensive Care 2001; 29: Rosenblatt WH,Wagner PJ, Ovassapian A, Kain ZN. Practice patterns in managing the difficult airway by anesthesiologists in the United States. Anesth Analg 1998; 87:

9 Kim SO Peer Reviewer Commentary 1056

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untitled 대한마취과학회지 2008; 55: 190~6 Korean J Anesthesiol Vol. 55, No. 2, August, 2008 임상연구 대한민국의 마취통증의학 임상실습 현황 연세대학교 의과대학 마취통증의학교실 및 마취통증의학연구소 장동진ㆍ안소운ㆍ안지원ㆍ김종훈 The current status of anesthesiology clerkship in Korea