emergency medicine some tools for managing the difficult airway joe lex, md, faaem temple university...

Emergency MedicineEmergency Medicine

Some Tools for Some Tools for Managing the Difficult Managing the Difficult

AirwayAirway

Some Tools for Some Tools for Managing the Difficult Managing the Difficult

AirwayAirway

Joe Lex, MD, FAAEMJoe Lex, MD, FAAEM

Temple UniversityTemple University

Philadelphia, PAPhiladelphia, PA

Airway management is really easy…Airway management is really easy…Airway management is really easy…Airway management is really easy…

……except when it isn’t… except when it isn’t…


Our Options Are DifferentOur Options Are DifferentOur Options Are DifferentOur Options Are Different

AnesthesiologyAnesthesiology

• Plan in advancePlan in advance

Can’t get airway...Can’t get airway...

……awaken patientawaken patient

……regroupregroup

……go for coffeego for coffee

EmergencyEmergency

• What will be, will What will be, will bebe

Can’t get airway…Can’t get airway…

……wipe browwipe brow

……change shortschange shorts

……call attorneycall attorney

……call coronercall coroner


It can be difficult to…It can be difficult to…It can be difficult to…It can be difficult to…

……oxygenateoxygenate

……ventilateventilate

……intubateintubate

……perform cricothyrotomyperform cricothyrotomy


To Maximize Success…To Maximize Success…To Maximize Success…To Maximize Success…

……recognize and predict difficult recognize and predict difficult airwayairway

……choose appropriate technique choose appropriate technique and equipmentand equipment

……possess technical skills, drugs, possess technical skills, drugs, and devicesand devices


Predicting the Predicting the Difficult AirwayDifficult Airway

…if you have time…if you have time

Predicting the Predicting the Difficult AirwayDifficult Airway

…if you have time…if you have time


LEMON LawLEMON LawLEMON LawLEMON LawLLook at anatomyook at anatomy

EExamine the airwayxamine the airway

MMallampatiallampati

OObstructionsbstructions

NNeck mobilityeck mobility


LookLook at Anatomy at AnatomyLookLook at Anatomy at Anatomy

• ObesityObesity: rapid desaturation, difficult : rapid desaturation, difficult intubation, ventilationintubation, ventilation

• Facial hairFacial hair: hides small chin, can : hides small chin, can make bagging difficult / impossiblemake bagging difficult / impossible

• Large teethLarge teeth: hide airway, obscure : hide airway, obscure tube passagetube passage

• Jagged teethJagged teeth: lacerate balloon: lacerate balloon



• Narrow face, high-arched palateNarrow face, high-arched palate: : decreased side-to-side diameterdecreased side-to-side diameter

• Large tongueLarge tongue: hides airway: hides airway

• False teethFalse teeth: help bagging, remove : help bagging, remove for intubationfor intubation


ExamineExamine Airway AirwayExamineExamine Airway Airway



The 3 – 3 – 2 ruleThe 3 – 3 – 2 rule

• Mouth open: 3 fingersMouth open: 3 fingers

• Mentum to hyoid: 3 fingersMentum to hyoid: 3 fingers

• Floor of mouth to thyroid Floor of mouth to thyroid cartilage: 2 fingerscartilage: 2 fingers



• Mouth openMouth open: 3 fingers: 3 fingers Allows insertion of tube, Allows insertion of tube,

laryngoscopelaryngoscope

• Mentum to hyoidMentum to hyoid: 3 fingers: 3 fingers Predicts ability to lift tongue Predicts ability to lift tongue

into mandibleinto mandible



• Floor of mouth to thyroid Floor of mouth to thyroid cartilagecartilage: 2 fingers: 2 fingers If high larynx, airway tucked If high larynx, airway tucked

under base of tongue, hard to under base of tongue, hard to visualizevisualize


MallampatiMallampati Score ScoreMallampatiMallampati Score Score

• With patient seated: extend With patient seated: extend neck neck open mouth open mouth stick stick out tongueout tongue

• Visualize base of tongue, Visualize base of tongue, faucial pillars, uvula, pharynxfaucial pillars, uvula, pharynx

MallampatiMallampati Score ScoreMallampatiMallampati Score Score

DifficultyDifficultyNoneNone NoneNone ModerateModerate SevereSevere


Airway Airway ObstructionsObstructionsAirway Airway ObstructionsObstructions


Airway Airway ObstructionsObstructionsAirway Airway ObstructionsObstructions

• Angioedema?Angioedema?

• Hematoma?Hematoma? Look under shirt collarLook under shirt collar

• Dentures?Dentures?

• Epiglottis?Epiglottis?


NeckNeck Mobility MobilityNeckNeck Mobility Mobility

Prior conditionPrior condition

• SurgerySurgery

• Rheumatoid Rheumatoid arthritisarthritis

• OsteoarthritisOsteoarthritis

• OthersOthers



• Cervical spine rigidity: Cervical spine rigidity: reduces ability to align reduces ability to align anatomic axesanatomic axes

• Inability to mobilize neck can Inability to mobilize neck can make intubation difficult or make intubation difficult or impossibleimpossible

Moving Beyond LaryngoscopyMoving Beyond LaryngoscopyMoving Beyond LaryngoscopyMoving Beyond Laryngoscopy

Some Equipment, Old & NewSome Equipment, Old & NewSome Equipment, Old & NewSome Equipment, Old & New


Difficult Airway CartDifficult Airway CartDifficult Airway CartDifficult Airway Cart

• Bag valve maskBag valve mask

• Combitube™Combitube™

• LMALMA

• Intubation LMAIntubation LMA

• Fiberoptic: rigid, Fiberoptic: rigid, flexibleflexible

• LightwandLightwand

• BougieBougie

• Transtracheal jetTranstracheal jet

• RetrogradeRetrograde

• Digital Digital

• CricothyrotomyCricothyrotomy

1. Bag Valve Mask1. Bag Valve Mask1. Bag Valve Mask1. Bag Valve Mask


1. Bag Valve Mask (BVM)1. Bag Valve Mask (BVM)1. Bag Valve Mask (BVM)1. Bag Valve Mask (BVM)

• Practice: skills essentialPractice: skills essential

• Use appropriate size oral airway or Use appropriate size oral airway or nasal trumpetnasal trumpet

• Leave denturesLeave dentures

• Use water-soluble lubricant to get Use water-soluble lubricant to get good seal, especially if lots of facial good seal, especially if lots of facial hairhair

2. Combitube®2. Combitube®2. Combitube®2. Combitube®



• Double lumen tube functions as Double lumen tube functions as esophageal obturator airway plus esophageal obturator airway plus standard cuffed endotracheal tubestandard cuffed endotracheal tube

• Insert blindly Insert blindly 90% esophageal 90% esophageal

• Inflate proximal balloon: 100 mLInflate proximal balloon: 100 mL

• Inflate distal balloon: 5 –15mLInflate distal balloon: 5 –15mL



• Seals oropharyngeal and Seals oropharyngeal and nasopharyngeal cavitiesnasopharyngeal cavities

• Ventilate through blue portVentilate through blue port Good breath sounds and no air in Good breath sounds and no air in

stomach stomach continue ventilating continue ventilating No breath sounds and air in stomach No breath sounds and air in stomach

use white tube use white tube

3. Laryngeal Mask Airway3. Laryngeal Mask Airway3. Laryngeal Mask Airway3. Laryngeal Mask Airway


IndicationsIndicationsIndicationsIndications

• Routine / emergency procedures Routine / emergency procedures

• Known / unknown difficult airway Known / unknown difficult airway

• During resuscitation in profoundly During resuscitation in profoundly unconscious patient with no unconscious patient with no glossopharyngeal or laryngeal glossopharyngeal or laryngeal reflexes when tracheal intubation reflexes when tracheal intubation not possiblenot possible


ContraindicationsContraindicationsContraindicationsContraindications

In In electiveelective patient who… patient who…

……has not fastedhas not fasted

……may have gastric contentsmay have gastric contents

……has fixed has fixed lung compliance lung compliance

……is not profoundly unconsciousis not profoundly unconscious

……resists LMA airway insertionresists LMA airway insertion


UsageUsageUsageUsage

4. Intubating LMA4. Intubating LMA4. Intubating LMA4. Intubating LMA


LMA Take-Home PointsLMA Take-Home PointsLMA Take-Home PointsLMA Take-Home Points

• Test cuff before useTest cuff before use

• Don’t lubricate anterior maskDon’t lubricate anterior mask

• Insert only in comatose patientInsert only in comatose patient

• Keep cuff inflated until patient Keep cuff inflated until patient awakeawake

• Don’t throw out!! Used 40 – 50 Don’t throw out!! Used 40 – 50 timestimes

5. Flexible Fiberoptic Scope5. Flexible Fiberoptic Scope5. Flexible Fiberoptic Scope5. Flexible Fiberoptic Scope



AdvantagesAdvantages• Allows direct airway visualizationAllows direct airway visualization

• Causes little hemodynamic stressCauses little hemodynamic stress

• Nasotracheal or orotracheal routeNasotracheal or orotracheal route

• Can be done in all age groupsCan be done in all age groups

• Requires minimal neck movementRequires minimal neck movement



DisadvantagesDisadvantages• ExpensiveExpensive

• Expertise requires practice Expertise requires practice

• Delicate equipment needs careful Delicate equipment needs careful maintenancemaintenance

• Visual field easily impaired by blood Visual field easily impaired by blood and secretionsand secretions

6. Rigid Fiberoptic Scope6. Rigid Fiberoptic Scope6. Rigid Fiberoptic Scope6. Rigid Fiberoptic Scope



Bullard Bullard Wu ScopeWu Scope



Upsher Upsher GlideScopeGlideScope


Levitan ScopeLevitan Scope




AdvantagesAdvantages• Direct airway visualizationDirect airway visualization

• Minimal neck movementMinimal neck movement

• May overcome difficult viewMay overcome difficult view

• Useful in disrupted airwayUseful in disrupted airway

• Durable, sturdy instruments Durable, sturdy instruments



DisadvantagesDisadvantages• ExpensiveExpensive

• Expertise requires practiceExpertise requires practice

• Visual field easily impaired by blood Visual field easily impaired by blood and secretionsand secretions

• Not readily availableNot readily available

7. Lightwand (Trachlight)7. Lightwand (Trachlight)7. Lightwand (Trachlight)7. Lightwand (Trachlight)



AdvantagesAdvantages• Minimal neck movementMinimal neck movement

• Useful adjunct to laryngoscopyUseful adjunct to laryngoscopy

• Portable and inexpensivePortable and inexpensive

• Usable in bloody airwayUsable in bloody airway

• Provides definitive airwayProvides definitive airway



DisadvantagesDisadvantages• Blind techniqueBlind technique

• May damage airwayMay damage airway

• Usually requires darkened roomUsually requires darkened room

• Expertise requires practiceExpertise requires practice

8. Intubating Stylet (Bougie)8. Intubating Stylet (Bougie)8. Intubating Stylet (Bougie)8. Intubating Stylet (Bougie)



• Gum elastic – use as guidewireGum elastic – use as guidewire

AdvantagesAdvantages• Gives definitive airwayGives definitive airway

• Easy to learnEasy to learn

• InexpensiveInexpensive

• Can be used blindlyCan be used blindly



• Gum elastic – use as guidewireGum elastic – use as guidewire

DisadvantagesDisadvantages• Expertise requires practiceExpertise requires practice

• Not recommended in “can’t intubate Not recommended in “can’t intubate / can’t ventilate” scenario/ can’t ventilate” scenario

9. Transtracheal Jet Ventilation9. Transtracheal Jet Ventilation9. Transtracheal Jet Ventilation9. Transtracheal Jet Ventilation

http://www.chestjournal.org/content/vol116/issue6/images/large/cb1092477001.jpeg



AdvantagesAdvantages

• Surgical airway of choice if 8 years Surgical airway of choice if 8 years or youngeror younger

• EffectiveEffective

• Can serve as temporary airway Can serve as temporary airway before permanent airway before permanent airway

• Relatively simple procedureRelatively simple procedure



DisadvantagesDisadvantages

• Significant complications if Significant complications if misplacedmisplaced

• Need proper equipmentNeed proper equipment

• Need high-pressure oxygenNeed high-pressure oxygen

• Does not protect against aspirationDoes not protect against aspiration

10. Retrograde Intubation10. Retrograde Intubation10. Retrograde Intubation10. Retrograde Intubation



• Puncture cricothyroid membranePuncture cricothyroid membrane

• Thread wire through vocal cordsThread wire through vocal cords

• Exit nose or mouthExit nose or mouth

• Guide endotracheal tube through Guide endotracheal tube through vocal cords over wirevocal cords over wire



AdvantagesAdvantages• Definitive airwayDefinitive airway

• Minimal neck movementMinimal neck movement

• Does not require full mouth openDoes not require full mouth open



DisadvantagesDisadvantages• Takes timeTakes time

• Requires skillRequires skill

• Not recommended in cannot Not recommended in cannot intubate / cannot ventilateintubate / cannot ventilate

11. Digital Intubation11. Digital Intubation11. Digital Intubation11. Digital Intubation



• You need long fingersYou need long fingers

• Make sure patient is really Make sure patient is really unconsciousunconscious

• Not commonly used, but can be life-Not commonly used, but can be life-saversaver



IndicationsIndications• Poor lighting, difficult patient Poor lighting, difficult patient

position, disrupted airway, potential position, disrupted airway, potential cervical spine injurycervical spine injury

• Can’t see larynx due to bloodCan’t see larynx due to blood

• Equipment failureEquipment failure

• Intubation failureIntubation failure

12. Cricothyrotomy12. Cricothyrotomy12. Cricothyrotomy12. Cricothyrotomy



• Life-saving techniqueLife-saving technique

• Surgical vs. needle / Seldinger vs. Surgical vs. needle / Seldinger vs. percutaneous kitpercutaneous kit

• You must know this procedure You must know this procedure before starting rapid sequencebefore starting rapid sequence



• Final common pathways for all Final common pathways for all cannot intubate / cannot ventilate cannot intubate / cannot ventilate scenariosscenarios

• ““The hardest part of doing a The hardest part of doing a cricothyrotomy is picking up the cricothyrotomy is picking up the knife.” – Peter Rosenknife.” – Peter Rosen


And finally…And finally…And finally…And finally…

BURP your patient – grab the larynx BURP your patient – grab the larynx and give…and give…

……BackwardBackward

……UpwardUpward

……RightwardRightward

……PressurePressure


ConclusionsConclusionsConclusionsConclusions

• Recognize the difficult airwayRecognize the difficult airway How much time do you have?How much time do you have? Who else is around?Who else is around? What is your backup procedureWhat is your backup procedure

• Know both old and new methodsKnow both old and new methods

• Choose backups based on skillsChoose backups based on skills


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emergency medicine some tools for managing the difficult airway joe lex, md, faaem temple university...

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