Difficult airway in patients with

COVID-19

Ricardo Poveda Jaramillo

Anestesiólogo Cardiovascular & Torácico
Clínica Las Vegas & Clínica del Norte
 ¿Qué es vía aérea difícil?
1. Difficult facemask or supraglottic airway ventilation is not
possible.
2. SGA placement requires multiple attempts, in the presence
or absence of tracheal pathology.
3. It is not possible to visualize any portion of the vocal cords
after multiple attempts at conventional laryngoscopy.
4. Tracheal intubation requires multiple attempts, in the
presence or absence of tracheal pathology.
5. Placement of the endotracheal tube fails after multiple
attempts.
Apfelbaum JL, Hagberg CA, Caplan RA, et al; 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. 2013 Feb;118(2):251-70.
 Predictores de vía aérea difícil
Incisivos superiores largos

"Sobremordida” (incisivos superiores anteriores a incisivos inferiores)

El paciente no puede llevar incisivos inferiores adelante de incisivos superiores

Distancia interincisivos menor de 3 cm

Úvula no visible cuando la lengua sobresale con el paciente sentado (Mallampati> 2)

Paladar altamente arqueado o muy estrecho

Distancia tiro-mentoniana menor de tres anchos de dedo

Cuello corto

Cuello grueso

El paciente no puede tocar la punta de la barbilla con el pecho o no puede extender el cuello

Apfelbaum JL, Hagberg CA, Caplan RA, et al; 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. 2013 Feb;118(2):251-70.
Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in
patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care
Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020;75(6):785-799.
 La laringoscopia difícil ocurre con frecuencia en
pacientes críticos.

La visión laríngea difícil está asociada con múltiples

intentos de intubación; se asocia con hipoxia severa,
hipotensión, intubación esofágica y paro cardíaco.

Los intentos repetidos de pasar un tubo traqueal están

asociados con trauma, deterioro de las vías respiratorias y
progresión a una situación de ‘can’t intubate, can’t
oxygenate’ (CICO) situation.
Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth.
2018;120(2):323-352.
Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in
patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care
Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020;75(6):785-799.
 “The principle that anaesthetists
should have back-up plans in place
before performing primary
techniques still holds true”.

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 ¿Qué es clave?

1. Limiting the number of airway intervention

attempts
2. Encouraging declaration of failure by placing
a supraglottic airway device (SAD) even
when face-mask ventilation is possible
3. Recommending a time to stop and think
about how to proceed

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 “The complexities of difficult airway
management cannot
be distilled into a single algorithm, and even the
best anaesthetic
teams supported by the best guidelines will still
struggle to perform optimally if the systems in
which they operate are flawed”.

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Factores humanos que llaman al desastre

• Poor communication
• Poor training and teamwork
• Deficiencies in equipment
• Inadequate systems and processes

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 PLAN A
Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 “Mechanical drainage by nasogastric
tube should be considered in order to reduce
residual gastric volume in patients with severely
delayed gastric emptying or intestinal
obstruction”.

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 ¿Maniobra de Sellick?

• Paciente
inconsciente: 30 N
• Paciente consciente:
10 N

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Posición

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Preoxigenación

1–2
min 8 min
Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 “Recomendamos usar CPAP de 5-10
cmH2O si la oxigenación está
deteriorada”

Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth.
2018;120(2):323-352.
 Mask ventilation: paradigm shift

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Passive oxygenation during the apnoeic
period (apnoeic oxygenation)

15 litres/min of oxygen through nasal cannulae

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Inductor ideal

¿?
Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Intubación de secuencia rápida

¿Suxamethonium
Vs rocuronium?
Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Elección del laringoscopio

Videolaryngoscopes are
now the first choice or default device for some
anaesthetists

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Elección del laringoscopio

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Elección del tubo

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
BURP
 Uso del bougie o estilete luminoso

Blind bougie insertion is associated with trauma

and is not recommended in a grade 3b or 4 view

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Confirmación de la intubación traqueal

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 A maximum of
three attempts at intubation; a fourth
attempt by a more experienced
colleague is permissible

If unsuccessful, a failed intubation

should be declared and Plan B implemented.

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 PLAN B
Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Selección de dispositivos
supraglóticos

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Retirar presión
cricoidea

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 “Stop & think”

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 1. Despertar al paciente
2. Intubación a través del
dispositivo
Nuestras supraglótico
3. Realizar cirugía con el
opciones dispositivo
en este supraglotico/Esperar
momento que llegue un experto
en via aérea
4. Realizar traqueostomía
o cricotiroidotomía
 Even supraglottic
airways can fail!
Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 If oxygenation through a SAD
cannot be achieved after a
maximum
of three attempts…

Plan C should be implemented

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 PLAN C
Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 If face-mask ventilation results in
adequate oxygenation, woke the
patient up!

PLAN
C
Declare If it is not possible to maintain oxygenation using
CICO and
start Plan D a face mask, ensuring full paralysis

Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
“This is a can’t intubate, can’t
oxygenate situation”
 PLAN D
Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
 Seguimiento
① Pharynx and oesophagous are damaged most
commonly during difficult intubation.
② Pharyngeal and oesophageal injury are difficult to
diagnose, with pneumothorax, pneumomediastinum, or
surgical emphysema present in only 50% of patients.
③ Mediastinitis after airway perforation has a high
mortality, and patients should be observed carefully for
the triad of pain (severe sore throat, deep cervical pain,
chest pain, dysphagia, painful swallowing), fever, and
crepitus.
Frerk C et al; Difficult Airway Society intubation guidelines working group.. Difficult Airway Society 2015 guidelines for management of
unanticipated difficult intubation in adults. Br J Anaesth. 2015 Dec;115(6):827-48.
…qué dice la ASA?
 The will to win, the desire to
succeed, the urge to reach your full
potential…these are the keys to
unlock the door to personal
excellence. Confucius

Gracias