Difficult AirwayDifficult Airway

Dr. Sara LaryDr. Sara Lary

International EM FellowInternational EM Fellow

Loma Linda Medical CenterLoma Linda Medical Center

Loma Linda University Medical Loma Linda University Medical CenterCenter

DefinitionDefinition

Difficult Intubation:Difficult Intubation:– Multiple attempts requiredMultiple attempts required– Multiple operatorsMultiple operators– Multiple devicesMultiple devices– Excessive lifting forceExcessive lifting force– External laryngeal manipulationExternal laryngeal manipulation– Inadequate glottic viewInadequate glottic view

IntubationIntubation

Bag Valve Mask Bag Valve Mask Direct Direct

Laryngoscopy Laryngoscopy Crash Intubation Crash Intubation Difficult Airway Difficult Airway Surgical AirwaySurgical Airway Extraglottic AirwayExtraglottic Airway

Airway QuestionsAirway Questions

Is pt unconscious/unreactive/near death – Y ->Is pt unconscious/unreactive/near death – Y ->

Crash AirwayCrash Airway

Is pt difficult airway – N -> Is pt difficult airway – N ->

RSIRSI

If difficult airway, crash airway or RSI fails -> If difficult airway, crash airway or RSI fails ->

Alternative or Surgical airwayAlternative or Surgical airway

Difficult Airway AssessmentDifficult Airway AssessmentLEMONLEMON

LLOOK at the patient’s anatomyOOK at the patient’s anatomysmall mandible small mandible large tonguelarge tongueshort bull neckshort bull neckobeseobeseabnormal facial/neck anatomyabnormal facial/neck anatomy

EEVALUATE – 3,3,2 finger widths betweenVALUATE – 3,3,2 finger widths betweenteethteethhyoid and mentumhyoid and mentumhyoid and thyroidhyoid and thyroid

MMALLAMPATIALLAMPATIOOBSTRUCITIONBSTRUCITION

secretions, stridor, muffled voice, mass, fbsecretions, stridor, muffled voice, mass, fbNNECK MOBILITYECK MOBILITY

c-spine immobilization, RA, Ankylosing Spondylitisc-spine immobilization, RA, Ankylosing Spondylitis

Difficult Airway AlgorithimDifficult Airway Algorithim

Help/Setup EARLY! Assume difficulty SpO2 >90% Supplemental O2 SpO2 maintained? RSI? – can I BMV RSI? – can I

intubate

Awake intubation? Alternatives LMA Fiberoptic Cricothyroidotomy Lighted stylet Blind Nasotracheal

Difficult BMV VentilationDifficult BMV VentilationMOANSMOANS

MMask seal – facial hair, facial ask seal – facial hair, facial anatomy, secretions, ability to anatomy, secretions, ability to apply pressure to faceapply pressure to face

OObesity/late pregnancy – chest besity/late pregnancy – chest wall and abdominal resistance wall and abdominal resistance impede airflow, reverse impede airflow, reverse Trendelenburg can helpTrendelenburg can help

AAge>55 – loss of tissue elasticityge>55 – loss of tissue elasticity NNo teetho teeth SStiffness – asthma, COPD, tiffness – asthma, COPD,

pulmonary edema, ARDSpulmonary edema, ARDS

Grades of Difficult Laryngoscopy

McCormack and LehaneGrade I: most of glottis is seen Grade II: only posterior portion of glottis can be seen Grade III: only epiglottis may be seen (none of glottis seen)Grade IV: neither epiglottis nor glottis can be seen

Extraglottic AirwayExtraglottic Airway

SUPRAGLOTICSUPRAGLOTIC– LMA laryngeal LMA laryngeal

airwayairway– LTS laryngeal tube LTS laryngeal tube

suctionsuction– PLA perilaryngeal PLA perilaryngeal

airwayairway– PLMA proseal PLMA proseal

laryngeal mask laryngeal mask airwayairway

RETROGLOTICRETROGLOTIC– Combitube, King LTCombitube, King LT

Difficult CricothyrodotomyDifficult CricothyrodotomySHORTSHORT

SSurgery/disrupted airwayurgery/disrupted airway HHematoma/Infectionematoma/Infection OObesebese RRadiationadiation TTumorumor

Surgical Airway: Surgical Airway: CrycothyroidotomyCrycothyroidotomy Assemble equipmentAssemble equipment

Identify anatomical Identify anatomical landmarkslandmarks

Stabilize thyroid cartilageStabilize thyroid cartilage Make 2-3cm vertical incision Make 2-3cm vertical incision

through crycothyroid through crycothyroid membrane membrane

Place hemostat or blade at 90 Place hemostat or blade at 90 degree angle to open incisiondegree angle to open incision

Insert endotracheal tube or Insert endotracheal tube or tracheostomy tube into the tracheostomy tube into the airway, directed towards the airway, directed towards the chest. The best size ET tube chest. The best size ET tube for an adult for an adult cricothyroidotomy is a size cricothyroidotomy is a size 6.0. 6.0.

Monitor oxygen saturationMonitor oxygen saturation

Summary – A, B, CSummary – A, B, C

Assume difficulty, prepareAssume difficulty, prepare Assess – the Assess – the SHORT LEMON MOANSSHORT LEMON MOANS Assemble personnel, equipment, airway Assemble personnel, equipment, airway

devicesdevices Be proactiveBe proactive BVM is your friendBVM is your friend Create an alternative airwayCreate an alternative airway Cry later, keep CalmCry later, keep Calm

ReferencesReferencesChallenges and Advances in Intubation: Airway Evaluation and Controversies with Intubation.

Emergency Medicine Clinics of North America - Volume 26, Issue 4 (November 2008) www.mdconsult.com/das/journal/view/0/N/216354...

A Comparison of the Laryngeal Mask Airway ProSeal™ and the Laryngeal Tube Airway in Paralyzed Anesthetized Adult Patients Undergoing Pressure-Controlled Ventilation . www.anesthesia-analgesia.org/.../95/3/770.full

Gens, David. “Surgical Airway Management”. Chapter 20, Tintanelli 119-123The Influence of Head and Neck Position on the Oropharyngeal Leak Pressure and Cuff

Position of Three Supraglottic Airway Devices. www.anesthesia-analgesia.org/.../108/1/112.full

“Practice Guidelines for Management of the Difficult Airway”. An Updated Report by the American Society of Anesthesiologist Task Force on Management of the Difficult Airway. Anesthiology 2003; 98:1269-77

Roman, Michael. “Noninvasive Airway Management: Chapter 18, Tinatnelli 102-107A. Vasudevan & A. S. Badhe : Predictors of difficult intubation – a simple approach. The

Internet Journal of Anesthesiology. 2009 Volume 20 Number 2: www.ispub.com/journal/the_internet_journal_of_anesthesiology/volume_20_number_2/article_printable/predictors-of-difficult-intubation-a-simple-approach.html

Vissers, Robert. “Tracheal Intubation and Mechanical Ventilation”.Chapter 19, Tintanelli 108 – 119

Walls, R. and Murphy, M. The difficult airway in adults. UpToDate. www.uptodate.com/online

ImagesImagesfocosi.altervista.org/Cormack_Lehane_1.jpgwww.carestream.com/?page_id=66 ether.stanford.edu/difficult_airway.htmlwww.anesthesia-analgesia.org/.../95/3/770.fullwww.uptodate.com/online