Airway

Managem
ent
Dr-Roc
 Difficult & Failed
Airway
Defined as:

0 Three failed attempts at oral intubation

0 Even when O2 saturation can be maintained

0 Failure to maintain acceptable O2 saturation

0 During or after one or more failed attempts at
laryngoscopy

Getting the tube in and/or maintaining

subsequent oxygenation
Consequences......
Hypoxia for longer than 3-5 minutes

irreversible cerebral and cardiac complications

DEATH
 Difficult Airway
Statistics
0 Difficult laryngoscopy: 1:50 100
0 Failed intubation in general population:
1:3000
0 Cant intubate cant ventilate: 1:5000

Failed intubation in pregnancy: 1:300

 Difficult Airway Statistics
-> Experience counts
1 intubation/week
One difficult
laryngoscopy per year
One failed intubation
every 60 years
One CICV every 100 years
*Key CICV
Cant Intubate Cant Ventilate
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25 intubations
per week
One difficult
laryngoscopy every 2
weeks [cf. one per year]
0 One failed intubation
every 2.5 years
[cf. one per 60 years]
0 One CICV every 4
years [cf. one per 100 years]
Difficult & Failed Airway
Benumofs definition of best attempt

0 Experienced endoscopist
0 Full paralysis
0 Optimal morning sniff position
0 OELM
0 A range of blade lengths
0 Different types of blade
(Magill curved; Miller straight)
Difficult & Failed Airway
Benumofs definition

The following can be added:

0 Extra padding for optimal positioning of

the patient
0 Or repositioning in failed intubation
0 The early use of a gum elastic boogie
0 Trained and experienced assistant
 Difficult Airway
Statistics
LMA provides rescue
ventilation in 95% of cases
of CICV
So, how do we pick up a
difficult airway ?
What are the factors ?
Technical 0Anatomical
ie positioning 0Immobility
the blade
- Buck teeth,
-
Absent Incisors,
- large breasts
The Difficult Airway : Anatomical factors
DISPROPORTION
0 The TONGUE TOO LARGE for the
MANDIBLE
0 The MANDIBLE TOO SMALL for
the TONGUE
Pierre Robin Syndrome
Angioneurotic Oedema
Sublingual Mass

Disproportion can be objectively

assessed with assessment of
- Mallampati Class
- The Thyromental Distance :
Normal > 7cm
- Submandibular Space : Normal > 3
fingers
The Difficult Airway : Immobility
A. SKELETAL FACTORS
Cervical Spine fractures
Rheumatoid Arthritis
Ankylosing Spondylitis
Arthritides
Cervical Fusion
B. NON - SKELETAL FACTORS
Obesity
Oedema
Tumour
Contractures Scarring due to
Burns, Radiatiotherapy

Disproportion can be
objectively assessed
with use of
- Mallampati Score
- The Thyromental
Disproportion - an
extreme case!!!!
Immobility
0Skeletal
c-spine injuries,
rheumatoid a

0Non-
skeletal
burns, contractures
 Difficult Airway
Assessment - history
0 Previous anaesthetic history of DA
0 Previous neck surgery, radiotherapy or burns
0 Diabetes mellitus glycosylation of tissue
proteins
0 TM joint, C-spine, arytenoids
0 Difficult intubation in 30% of diabetics
 Difficult Airway
Assessment - history
Rheumatoid arthritis, ankylosing spondylitis,
other auto-immune diseases:
0 Immune-mediated joint destruction
0 Chronic progressive synovial inflammation,
esp:
0 Cervical spine
0 Temporomandibular joint
 Difficult & Failed
Airway
Atlanto-axial subluxation

0 Protrusion of odontoid process into the

foramen magnum during intubation
0 Compromises vertebral blood flow
0 Compresses spinal cord or brainstem
Atlanto-axial subluxation
 Difficult & Failed
Airway
Crico-arytenoid arthritis narrowing of glottic
opening post-extubation airway obstruction
 Difficult Airway
Assessment - examination
0 Neck masses, scars
0 Small mouth
0 Recessed mandible
0 Protruding mandible
0 Loose teeth
0 Buck teeth
 Difficult & Failed
Airway
0 Large tongue
0 Bull neck
0 Morbid obesity
0 Large breasts
0 Passion gap
Difficult & Failed Airway
Clinical tests

0 No single test predicts with certainty

0 Combining tests increases value
0 No combination of tests failsafe!
0 Mallampatti I can correlate with a Cormack &
Lehane grade III or IV!
Difficult & Failed Airway
Clinical tests

1. Ability to push out mandible:

0 Lower incisors brought edge to edge with

upper incisors
Difficult & Failed Airway
Clinical tests

2. Inter-incisor distance of less than three

centimetres

0 Cannot fit two finger-breadths into mouth

vertically
Difficult & Failed Airway
Clinical tests

3. Thyromental distance
of less than 6cm (3
finger breadths)
-- 75% positive
predictive value
Difficult & Failed Airway
Clinical tests

4. Two fingers from larynx

to thyroid cartilage
Difficult & Failed Airway
Clinical tests

0 Short fat (bull) neck

0 Range of motion of head and neck
Difficult & Failed Airway
Clinical tests

0 Disproportion
0 Mallampati score
0 Grade IV addition by Samsoon & Young
0 Ties in very closely with Cormack & LeHane
grading of vocal cord visualisation
Difficult & Failed Airway
Clinical tests

Affected by cricoid
pressure
 FRC
Important to consider the respiratory functional
reserve

(Functional Residual Capacity)

0 When a difficult or prolonged intubation is

anticipated
0 2 minutes no Oxygen vs 10 minutes with
preoxygenation
Difficult & Failed Airway
LEMON
Difficult & Failed Airway
LEMON

0 Look externally if it looks like a

difficult airway, it most likely will be
0 Evaluate 3-3-2:
0 Accommodate three fingers in mouth
0 Three fingers under mandible between tip
of mentum (chin) and hyoid bone
(6cm thyromental distance)
0 2 fingers to identify larynx to base of
tongue
Difficult & Failed Airway
LEMON

0 Mallampati score
0 Obstruction upper airway
0 Neck mobility

WARNING: LEMONS are

not quite so good!
not a fully
comprehensive checklist!
 Anticipated Difficult
Airway
Options

0 RSI with
0 Rescue airway devices on hand and
0 ENT surgeon scrubbed and ready
0 Patient prepared for emergency tracheostomy
 Anticipated Difficult
Airway
Options
0 Propofol quick-look
0 Inhalation induction
0 Classic LMA
0 Proseal LMA
0 Intubating LMA
0 Awake flexible fibre-optic nasal
intubation
0 Airtraq optical laryngoscope
0 Awake elective tracheostomy under
local anaesthetic
 Unanticipated difficult
and failed airway
0 ASA
0 UK DAS
0 Elective GA, not
EM application
0 Confusing and
intimidating at
first
Unanticipated difficult and
failed airway
Unanticipated difficult and
failed airway

Repeated laryngoscopy:
0Laryngeal oedema
0Bleeding
0Can evolve into CICV
Unanticipated difficult and
failed airway
0 Laryngoscopy should be limited

0 Best attempt early as possible to

0 Prevent a Difficult Airway from evolving into

CICV
Unanticipated difficult and
failed airway

CICV situation must be recognised as early as

possible

Rescue airway interventions must be

implemented immediately
 The failed emergency
airway
0 Patient should have been be pre-oxygenated
with gently assisted ventilation
0 Ideally, airway emergency should be
recognised before desaturation
0 *If* practitioner vigilant!
 The failed emergency
airway Facemask ventilation
0 Declare the situation
0 Call for assistance
0 Ensure head tilt, jaw thrust, chin lift
0 Consider OPA and NPA insertion
0 Consider two-person (two-handed) facemask
ventilation
The failed emergency
airway Facemask ventilation
The failed emergency
airway Facemask ventilation
0 Consider suctioning patient
0 Consider sedation with caution!
0 Consider paralysis with caution!
0 Consider LMA insertion
0 If difficult facemask seal
0 If patient sufficiently obtunded
The failed emergency
airway Failed intubation
0 Declare the situation
0 Call for assistance
0 Revert to facemask ventilation
0If difficult facemask ventilation,
revert to difficult facemask
ventilation drill
 The failed emergency
airway Failed intubation
0 Maintain cricoid pressure if RSI
0 Hand over to more experienced endoscopist
if present
0 Optimal positioning earlobe/sternal notch
0 Adequate sedation/relaxation
 The failed emergency
airway Failed intubation
0 Ensure OELM
0 Is cricoid pressure too much?
0 Is cricoid pressure not enough?
0 Consider applying cricoid pressure yourself
 The failed emergency
airway Failed intubation
0 Cant see epiglottis?
0May be too deep?
0May not be deep enough?
The failed
emergency
airway Failed
intubation
0 Can see epiglottis, cant see cords?
0 Consider more OELM
0 Consider blind introduction of gum elastic
bougie by feel
0 Consider railroading ETT
- Parker Flex-tip ETT (if available)
The failed emergency
airway Failed intubation
0 Consider LMA, Proseal, I-LMA
0 Consider King Laryngeal Tube
0 Consider needle cricothyroidotomy
0 Consider surgical cricothyroidotomy
The failed emergency
airway Failed intubation
Once airway established,
consider:
0I-LMA if available
0Airtraq optical laryngoscope
0Flexible fibre-optic
laryngoscopy
 The failed emergency
airway Failed intubation
Flexible FO laryngoscopy not a good first
option in failed RSI/CICV:
0 Precludes ventilation
0 Visualisation very difficult with blood and
secretions
 The failed
emergency airway
Failed intubation

0 I-LMA better option:

0Can ventilate
0Intubation blind
The graded approach.....

Tight fitting face mask

1. Position -sniffing
-Obesity ramp
2. Supraglottic device
- Oropharyngeal/
nasopharyngeal airway
-LMA, laryngeal tube
3. Laryngoscopic intubation,
- direct,
- indirect rigid/flexible
4. Blind intubation
- iLMA, bougie
5. Surgical
- retrograde, cricothyroidotomy, tracheostomy
 Categories
0 Assessment
0 Difficult Bag Mask Ventilation
0 Difficult laryngoscopy
0 Cant Intubate Cant Ventilate
 Assessment

0 Mass effect
0 Mobility
 Mass Effect
0 Supraglottic
0 Infraglottic
 Mobilty
0 TMJ
0 C-spine
0 Wilson Score
 Evaluation
0 Mallampati
0 Thyromental
0 LEMON
Difficult Bag Ventilation
0 Beard
0 Obesity
0 Age>55
0 Snoring
0 Teeth
 Difficult Laryngoscopy
0 Anticipated
0 Unanticipated
 Cant Intubate Cant
Ventilate
0 Rapid sequence
0 After 1st failure call for help in emergency
0 After 3rd attempt with elective
0 Optimize position
0 2 people
 Advanced Airway
Management
0 Blind
0 Direct laryngoscopy
0 Indirect laryngoscopy
0 Surgical
 Instruments
0 Supraglottic
0 Infraglottic - intubation
Supraglottic
Supraglottic
Laryngeal Mask Airway

Laryngeal Mask
Insertion
Insertion
Proseal LMA
The Many Types of LMA
AMBU LMA
i-gel
SLIPA
Position of SLIPA
Supraglottic
Supraglottic
Supraglottic
Combitube
Supraglottic
Supraglottic
Intubation
Technique
Placement
 Blind
0 Awake Nasal
0 Use of a Bougie
0 Light Wand
0 Intubating LMA
 Direct Laryngoscopy
0 Macintosh
0 Miller
0 McCoy
0 Polio
 Indirect laryngoscopy
0 RIGID
0 Glidescope
0 McGrath
0 Pentax AWS
0 Airtraq
0 Bullard Laryngoscope
0 Wuscope
Rigid Indirect
Rigid Indirect
 Indirect laryngoscopy
0 FLEXIBLE
0 Optical Stylet
0 Bonfils Retromandibular Optical Stylet
0 Fibreoptic bronchoscope
Flexible Indirect
laryngoscopy
Flexible Indirect
laryngoscopy
 Surgical
0 Elective - Retrograde
0 Emergency Needle, Surgical
Cricothyrodotomy
0 Tracheostomy
Needle vs Surgical
Jet Ventilation
Augustine Guide
Variants of Endotracheal
Tubes
0 RAE
0 Armoured
0 Double lumen
RAE
North RAE
Armoured
Armoured
Armoured
Double Lumen
Right vs Left