Addis Ababa University

Faculty of Medicine, Department of

Anesthesia

Difficult Air Way Management

By : Elleni Tamire
May 2013
 Content
• Introduction
• Air way management, Definitions, Terms
• Air way Anatomy
• Difficult air way
- difficult air way incidence
• Difficult air way assessment
-Air way equipment
• Difficult airway management
- Alternative techniques, Algorithm
- Emergency algorithms
- strategy for extubation of difficult air way
- Follow up care
• Case
• Summary
 Introduction
AIRWAY MANAGEMENT  
• Airway management is the maintenance of adequate
oxygenation and ventilation, and protection of the
airway from aspiration
• plan for the airway management is required before
providing sedation, and during general and regional
anesthesia. 
• An anesthetist may not be proficient in all airway
techniques
• But they sould be confident with some of the
alternatives.
 Anatomy
The anesthetist must be able to recognize the anatomy
of the laryngeal inlet.
With a perfect view the anesthetist can see the white
vocal cords in their triangular orientation beneath
the epiglottis.
Anatomy cont ….
 Difficult air way

Definition : the clinical situation in which a

conventionally trained anesthetists experiences
difficulty with facemask ventilation of the upper airway,
or
difficulty with tracheal intubation,
or
both.
• is a complex interaction between patient factors, the
clinical setting, and the skills of the practitioner.
• Analysis of this interaction requires precise collection
and communication of data.
 Difficult air way incidence
• Study shows that
• The incidence of difficult mask ventilation requiring
two-person is 1.4%
• Incidence of impossible mask ventilation was 0.16%
(22,660 cases).
•  Grade 3 laryngoscopic views, requiring multiple
attempts at intubation, occur in 1-13 % of all patients
• Severe Grade 3 to 4 views making intubation extremely
difficult, are estimated to be 0.05-0.09 %
• Impossible intubation in 0.05% - 0.35% and
• Dangerous situation of can’t intubate, can’t ventilate
(CICV) to occur in 0.0001% - 0.02% of patients.
 Difficult airway assessment
  Should not be restricted to assessing only the ease of
laryngoscopy and endotracheal intubation.
• It must also evaluate the ease/difficulty of bag mask
ventilation, supraglottic airway ventilation and performing a
surgical airway.  
 The anesthetist’s primary responsibility is to oxygenate the
unconscious patient.
 During any assessment, ask yourse
 Is mask ventilation is possible ?
 Will a supraglottic airway work ?
 Is tracheal intubation is possible and whether or not a surgical
airway is feasible.
 
 Difficult airway assessment cont …
 Failure to properly evaluate the airway and to
predict difficulty is the most important factor
leading to a failed airway.

 The view of the larynx is commonly graded using the
Cormack and Lehane classification:-
 Grade I– all of the vocal cords seen
 Grade II– partial view of the vocal cords (posterior)
 Grade III– epiglottis only
 Grade IV– no view.
Difficult airway assessment cont …

 By themselves these examinations are very poor in

prediction of difficult airways. They should be used in
combination
 Difficult airway assessment cont …
In a study of 10,500 patients who were assessed
prospectively prior to anesthesia, and who were then
graded according to the difficulty of intubation or
ventilation, el Ganzouri et al (Anesth Analg 1996 Jun;
82(6): 1197-204) identified the following seven criteria
as independent risk factors for difficulty with
laryngoscopy
1= mouth opening, 2=oropharyngeal classification
(Mallampati), 3=neck movement 4=thyromental
distance,5= ability to prognath, 6=body weight and
7=history of difficult tracheal intubation.
 Difficult air way risks factors
1. Teeth (mouth opening)- inter incisor distance
(<3.5cm)
2. Mouth and pharynx – Mallampati classification
• based on the fact that the base of the tongue is the source
of airway obstruction in the anaesthetized patient
• is also based on close proximity to the Laryngeal inlet. A
massive tongue not only over shadows the larynx but also
masks the Visibility of the pharyngeal space and other
structures.
• see picture below
 
Difficult air way 2 : Mouth and pharynx
 Difficult air way 2 : Mallampati classification

Class I : Soft palate, fauces, entire uvula, tonsillar pillars

Class II : Soft palate, fauces, uvula
Class III : Soft palate, base of uvula
Class IV : Soft palate only
 Difficult air way risks factors cont…
 3. Neck extension:
 4. The thyro-mental distance :
 5. The sterno-mental distance
 6. Anterior protrusion of the mandibular teeth
relative to the maxillary teeth.
 7. The Wilson risk sum
 is calculated on the basis of five risk factors. They are,
1=weight, 2=head and neck movement 3=jaw
movement, 4=mandibular recession and 5= the
presence or absence of protruding teeth.
 Risk factor 7: The Wilson risk sum
Risk factor Level score Score
Weight <90 kg 0
90-100kg 1

>100kg 2

Head and neck movement Above 90 degrees 0

About 90 degrees 1

Below 90 degrees 2

Jaw movement IIG >5 cm or sLux >0 0

IIG <5 cm and sLux =0 1

IIG <5 cm and sLux <0 2

Each of these is given a score from 0 to 2 and a score above 2 is
considered
Receding mandiblea predictor ofNormal
difficult intubation 0
 Alternate airway devices
There are increasing numbers of alternative airway
devices including variants of

• Supraglottic devices
• Intubation devices
.
• These various airway adjuncts have certain advantages
and disadvantages.
• Factors to be considered include ease of use, cost and
maintenance.
•  
 Alternate airway devices cont ..

• A) SUPRAGLOTTIC AIRWAYS

• Laryngeal mask or intubating laryngeal mask

• The Esophageal Tracheal Combitube (Combitube) was developed by Dr.
Michael Frass, a critical care physician in Vienna, Austria, in 1986
• The Combitube (CBT) is a twin lumen device designed for use in emergency
situations and difficult airways.
 

 
 Alternate airway devices cont ..

Laryngeal Tube LT oropharyngeal airway

Oesophageal Tracheal nasal air way

Combitube
 Alternate airway devices cont ..
  B) Intubation devices
An ideal intubating device should be
 easy to use, quickly learnt, portable
 allow rapid intubation without the risk of aspiration
and minimal haemodynamic disturbance or airway
trauma and cervical manipulation.
 It should be suitable for awake and general anaesthesia,
nasal and oral intubation in both adults and peadiatrics
 allow for ventilation during intubation
 Intubation techniques can be classified as:- 
 Direct laryngoscopy
 Indirect laryngoscopy
 Direct laryngoscopy
Laryngoscopy simply tries to obtain a direct line of sight
from the anaesthetist to the larynx
LARYNGOSCOPE BLADES
 Indirect laryngoscopy devices
Flexible fibreoptic bronchoscope
Rigid fibreoptic laryngoscopes (e.g. Bullard)
Video laryngoscopes (e.g. Glidescope)
Optical laryngoscopes (e.g. airtraq)
Optical Sylets (e.g. Bonfils)
Inferred intubation
Light guided stylet (eg. Light wand)
Hearing feeling air movement
Digital intubation
Blind techniques
 Indirect laryngoscopy technique cont ...

 Flexible fibreoptic bronchoscope/laryngoscopy

 is an extremely versatile airway management technique
 has many benefits. Its primary indication is in the
nonemergency (time permitting) management of the
anticipated difficult airway.
 Indirect laryngoscopy technique cont ...
 The Bullard laryngoscope
 has three channels: a light, fibreoptic and working
channel
• The blade has a spatula shape & is only 6 mm thick
• Can be used with minimal mouth opening.
• The endotracheal tube can be passed freehand or
loaded onto an intubating stylet that is attached to the
Bullard laryngoscope.
 Alternative Difficult Airway
Management Techniques
• The anaesthetist must be prepared for unanticipated difficulty.
And Always need to have back up plans!
 The maintenance of oxygenation always takes priority
than all other issues!
 is highly dependent on the patient’s clinical state, available
resources & anaesthetic experience.
 Difficult laryngoscopy:- It is not possible to visualize any
portion of the vocal cords after multiple attempts at
conventional laryngoscopy
 Difficult intubation:- is defined as an inability to place an
endotracheal tube within 10 minutes or 3 attempts at direct
laryngoscopy.
 
 Difficult airway management cont..
 The challenge for the anaesthetist is
• to accurately predict all difficult airways,
• to immediately recognise airway failure and
• to reliably secure continuous gas exchange

 
 
 Difficult airway management technique s

• 1. Awake supraglottic airway

• 2. General anaesthesia supraglottic airway.
• 3. Awake laryngoscopy
Difficult airway management technique cont…
4. Intubation through a laryngeal mask/intubating
laryngeal mask 
 The standard laryngeal mask is an excellent primary
airway
 can also be used as a temporary airway in cases of
suspected difficult intubation
 as a rescue airway in failed intubation.
 In cases of suspected difficult intubation a laryngeal
mask may be inserted to awake or under
spontaneously breathing general anaesthesia.
 If the laryngeal mask provides a safe airway, the
anaesthetist can use it to pass an endotracheal tube.
Difficult airway management technique cont…
5. Digital intubation
 Digital intubation is an acceptable alternative to direct
laryngoscopy for tracheal intubation when the
standard technique is contraindicated, failed, or is not
possible because of an equipment problem.
 is easier in small adults and paediatric patients.
Difficult airway management technique cont…
• 6. Light wand Light-guided intubation using the
principle of transillumination has proven to be an
effective and simple technique.
• When the tip of the lightwand is placed inside the
glottis, a bright light glow can be seen easily in the
soft tissue of the anterior neck.
• In contrast, if the lightwand is placed in the
esophagus, no transillumination can be observed
Difficult airway management technique cont…
• 7. Blind nasal intubation
• is an option whenever oral access is difficult or even
impossible
• It is usually performed with the patient awake and the
airway anaesthetized by regional anaesthesia and
general anaesthesia.
• The best results are obtained by a combination of
regional block and sedation, which aims at decreasing
patient anxiety but allows patient cooperation and
always maintains a patent airway.
 
Difficult airway management technique cont…
• 8. Retrograde intubation
• used in awake, sedated and anaesthetized patients
• Can be used successfully in adult & pediatric patients
• is contraindicated in the presence of unfavorable
anatomy, laryngotracheal pathological conditions,
significant coagulopathy and infection.
• The two main problems are:-
 (1)The endotracheal tube is larger than the wire and may
catch on the epiglottis or laryngeal inlet. Using a guiding
catheter (or a small endotracheal tube) reduces the
difference in size between wire and endotracheal tube.
 (2). The endotracheal tube may inadvertently slip into the
oesophagus after withdrawal of the guide wire.
Difficult airway management technique cont…

9. Needle cricothyrotomy/surgical cricothyrotomy

• are essential airway skills.
• absolute contraindications
 1)endotracheal intubation can be achieved easily and
rapidly and no contraindications to endotracheal
intubation are present 
2)tracheal transection with retraction of the distal end
into the mediastinum
 3)fractured larynx or significant damage to the cricoid
cartilage or larynx.
 
Difficult airway management technique cont…
•  10. Tracheostomy
• Tracheostomy is a surgical procedure to create an
opening through the neck into the trachea a tube is
usually placed through this opening to provide an air
way and to remove secretions.

• An elective awake tracheostomy is the safest airway

choice in severe airway and minimal resources.
 Techniques of gas exchange

Generally :-There are four primary techniques for

ensuring gas exchange.
 1. Mask bag ventilation (BMV)
 2. Laryngoscopy and intubation
 3. Supraglottic airway devices (SGD)
 4. Surgical airway (SA)
 
 
 Techniques of gas exchange
1 =Ease of bag mask ventilation .
 Bag mask ventilation is the first rescue action for failed airways.
• All anesthetists must be proficient in bag mask ventilation.
 Techniques of gas exchange
 2= Ease of laryngoscopy/intubation
 Tracheal intubation by direct laryngoscopy is an
essential skill.
 It may be rendered more difficult or impossible due to
co-existing disease or abnormal physical features
 The anesthetist’s best attempt at laryngoscopy should
be their first attempt
 It has been estimated that a trainee requires about 50
intubations to ensure a 90% probability that
laryngoscopic intubation will be successful.
 Techniques of gas exchange
3=Ease of ventilation with a supraglottic airway. 
 Supraglottic devices such as the laryngeal mask airway
may be used as the primary Airway management plan for
anesthesia, a bridging airway or as a rescue device for
When intubation equipment or intubation skills are
unavailable or in the event of difficult Intubation.
4=Ease of surgical airway. 
 The surgical airway (needle cricothyrotomy/open
cricothyrotomy) is used mostly as a life saving technique.

 
 Emergency algorithm
Emergency airway management in the unprepared and
unfamiliar patient is often challenging.
 In emergencies all failure rates increase several-fold
 Complications of airway management increase in cases
of predicted difficulty and during emergency care
 Failed tracheal intubation in emergencies is reported
between 1 in 300 and 1 in 800.
 CICV in the emergency department may occur as often
as 1 in 200
 When failure occurs other complications become more
likely.
 Emergency algorithm cont …

 Inadequate ventilation, oesophageal intubation and

difficult intubation are the ‘big three’ accounting for
around up to 60% of all respiratory claims
 Approximately 5% be inter related to pulmonary
aspiration
 When major complications occurred many cases
progressed from intubation difficulty to CICV,
emphasising the importance of emergency surgical
airway as a rescue technique
 Emergency algorithm cont …
 A study examining complications of airway
management by Mort examined over 10,000
emergency tracheal intubations in one institution
over a period of 10 years.
 He found multiple attempts at laryngoscopy to be
highly associated with marked increases in rate of
complications. Compared to intubation which was
achieved on first or second laryngoscopy
 Put simply: if it’s not working, stop trying it and do
something different! The widely promulgated Difficult
Airway Society guidelines
 Endotracheal intubation is often called the ‘gold
standard’ for airway management in an emergency
.

Case
A 17-year-old girl presents for emergency
drainage of a submandibular abscess
Pridictors For Esophageal Intubation
•
 
All techniques can fail, unrecognized
esophageal intubation is fatal.
 1. Visualise the endotracheal tube passing
between the vocal cords. Error :- unable to
visualise or inadvertent tube movement
during patient position change. 
 2. Observation of chest wall movement- Error:
obesity, large breast, chest wall movement
can occur with oesophageal intubation
 3. Auscultation of chest wall breath sounds-
Error: can occur with oesophageal Intubation
Pridictors For Esophageal Intubation
Cont…
 4. Epigastric auscultation- Error: breath
sounds can be transmitted to the epigastric
area and vice versa.
 5. Assessment reservoir bag compliance and
inflation/deflation- Error: the reservoir bag can
inflate and deflate with ventilation of the
stomach. 
 6. Condensation of endotracheal tube- Error:
can occur with oesophageal intubation. 
 7. ETCO2- Error with cardiac arrest 30% false
negative ETCO2 monitoring may be by
 Strategy for Extubation of the
difficult Airway

 The recommended strategy for extubation of the

difficult airway includes consideration of:-
 The relative merits of awake extubation versus
extubation before the return of consciousness.
 General clinical factors that may produce an adverse
impact on ventilation after the patient has been
extubated.
 Strategy for Extubation of the
difficult Airway cont …

 An airway management plan that can be implemented

if the patient is not able to maintain adequate
ventilation after extubation.
 Short-term use of a device that can serve as a guide for
expedited re intubation. This type of device can be a
stylet (intubating bougie) or conduit. Stylets or
intubating bougies are usually inserted through the
lumen of the tracheal tube and into the trachea before
the tracheal tube is removed.
 Follow-up Care
The anesthetist should document the presence and nature of
the airway difficulty in the medical record
 Documentation guide & facilitate delivery of future care
 Documentation need to include :-
  Description of the airway difficulties encountered
 Description should distinguish between difficulties
encountered in facemask or supraglottic airway
ventilation and difficulties encountered in tracheal
intubation. 
 Description of airway management techniques used
 Description should indicate techniques served, beneficial
or harmful role in management of the difficult airway.
 
 Follow-up Care cont ..
• The anesthetist should inform the patient (or
responsible person) of the airway difficulty that was
encountered
• The information communicated may include
• reasons for difficulty
• how the intubation was accomplished, and
• implications for future care
• Notification systems might be
• Written report , letter to the patient, report in the medical
chart
• communication with the patient’s surgeon or primary
caregiver, or chart flags
•  
 Follow-up Care cont ..
Anesthetist should evaluate and follow-up the patient
for potential complications of difficult airway
management.
 Complications include : edema, bleeding, tracheal and
esophageal perforation, pneumothorax & aspiration
 Patient should be advised the potential clinical signs
and symptoms associated with life-threatening
complications of difficult airway management.
 These signs and symptoms include : sore throat, pain or
swelling of the face and neck, chest pain, subcutaneous
emphysema, and difficulty swallowing.
 
 Summary
Anesthetists experiences difficulty with facemask
ventilation of the upper airway, or difficulty with tracheal
intubation, or both
• DA is A complex interaction between patient factors, the
clinical setting, and the skills of the practitioner
• DA can be handled through different techniques & devices
Always question:-
 Is it necessary to intubate?
 Does the patient need to be unconscious?
 Do I have adequate resources and equipment?
 Do I have the experience and skill to manage the airway? If
not, get help before the crises occurs.
 Do I have an airway management plan?
 Summary cont …
 Bedside assessment of the airway will alert the anesthetist
to some cases of difficulties with intubation
 Difficult intubation, especially can’t intubate, can’t
ventilate, occurs rarely and can occur without warning.
 Patients don’t die of difficult laryngoscopy but they do die
from hypoxia.
 Saturations less than 60-70% lasting longer than 3
minutes will cause harm.
 Always have an airway management plan.
 The challenge for the anesthetist is to rapidly recognize
airway failure and to maintain oxygenation by following
their airway plan. Oxygenation and time are critical!!
Thank you