THE DIFFICULT AIRWAYTHE DIFFICULT AIRWAY

THE DIFFICULT AIRWAYTHE DIFFICULT AIRWAYThe Key is to maintain:The Key is to maintain: OxygenationOxygenation VentilationVentilation

The Difficult AirwayThe Difficult AirwayA difficult airway can be defined as A difficult airway can be defined as a clinical situation in which a a clinical situation in which a conventionally trained ALS conventionally trained ALS provider experiences difficulty with provider experiences difficulty with mask ventilation, difficulty with mask ventilation, difficulty with tracheal intubation or both.tracheal intubation or both.

THE DIFFICULT AIRWAYTHE DIFFICULT AIRWAYDefinition:Definition:

Difficult to oxygenate and ventilateDifficult to oxygenate and ventilate

Difficult to intubateDifficult to intubate

ComplexityComplexityThe difficult airway represents a The difficult airway represents a complex interaction between complex interaction between patient factors, the patient factors, the prehospital/clinical setting, and the prehospital/clinical setting, and the skills of the EMS provider.skills of the EMS provider.

Difficult Mask VentilationDifficult Mask Ventilation Not possible for the EMS provider to Not possible for the EMS provider to

maintain the SpO2 >90% using maintain the SpO2 >90% using 100% oxygen and positive pressure 100% oxygen and positive pressure mask ventilation.mask ventilation.

It is not possible for the EMS It is not possible for the EMS provider to prevent or reverse signs provider to prevent or reverse signs of inadequate ventilation during of inadequate ventilation during PPV.PPV.

THE DIFFICULT AIRWAYTHE DIFFICULT AIRWAY Difficult to oxygenate and ventilate Difficult to oxygenate and ventilate

(BMV)(BMV) BBeardeard OObesebese NNo Teetho Teeth EElderlylderly SSnoresnores

The Difficult AirwayThe Difficult Airway Difficult to intubateDifficult to intubate

LLook at head and neckook at head and neck EEvaluate ability to open mouth/access valuate ability to open mouth/access

oropharynxoropharynx MMallampati or Cormack Scalesallampati or Cormack Scales OObstructionbstruction NNeck Mobilityeck Mobility

Look at head and neck:Look at head and neck: Anatomical FeaturesAnatomical Features Recessed ChinRecessed Chin Buck teethBuck teeth Short neck or “no neck”Short neck or “no neck” Signs of previous surgerySigns of previous surgery

Difficult Endotracheal Difficult Endotracheal IntubationIntubation

Proper insertion of the tracheal tube Proper insertion of the tracheal tube with conventional laryngoscopy with conventional laryngoscopy requires more than requires more than three three attemptsattempts

Proper insertion of the tracheal tube Proper insertion of the tracheal tube with conventional laryngoscopy with conventional laryngoscopy requires requires more than 10 minutes.more than 10 minutes.

Intubation Difficulty May Intubation Difficulty May Be Due To:Be Due To:

Incorrect position of the patientIncorrect position of the patient

Inadequate or improper equipmentInadequate or improper equipment

Unusual or abnormal anatomyUnusual or abnormal anatomy

Pathologic causesPathologic causes

Evaluate Access to Oral Evaluate Access to Oral CavityCavity

Opening of mouth <20 mm Opening of mouth <20 mm predisposes to difficult airwaypredisposes to difficult airway

Rule of thumb: an opening of at Rule of thumb: an opening of at least two large finger breadths least two large finger breadths between upper and lower incisors between upper and lower incisors in the adult is desirable in the adult is desirable

Evaluate Access to Oral Evaluate Access to Oral CavityCavity

Mallampati ScaleMallampati Scale

Assessing the Oral CavityAssessing the Oral Cavity

Cormack ScaleCormack Scale

Difficult LaryngoscopyDifficult Laryngoscopy It is not possible to visualize any It is not possible to visualize any

portion of the vocal cords with portion of the vocal cords with conventional laryngoscopy.conventional laryngoscopy.

Factors Contributing to Factors Contributing to Difficult LaryngoscopyDifficult Laryngoscopy

The following factors may be The following factors may be contributors to a difficult airway:contributors to a difficult airway:– ObstructionObstruction– InfectionsInfections– TraumaTrauma– Rheumatoid ArthritisRheumatoid Arthritis– Congenital ProblemsCongenital Problems– PregnancyPregnancy

ObstructionObstruction Foreign body airway Foreign body airway

obstruction is a obstruction is a common cause of common cause of failed airways.failed airways.

Direct laryngoscopy Direct laryngoscopy must be used with must be used with caution as it may caution as it may result in further result in further advancement of the advancement of the foreign body into the foreign body into the airwayairway

ObstructionObstruction Obstruction of the Obstruction of the

airway can also airway can also be anatomical or be anatomical or pathological, pathological, causing narrowing causing narrowing or complete or complete blockage of the blockage of the airway.airway.

InfectionsInfections Infectious Infectious

processes such as processes such as abscesses, croup, abscesses, croup, bronchitis, and bronchitis, and pneumonia can pneumonia can distort normal distort normal anatomy.anatomy.

TraumaTrauma Maxillofacial or Maxillofacial or

head trauma may head trauma may distort normal distort normal airway anatomy, airway anatomy, resulting in resulting in clenched teeth clenched teeth and edema.and edema.

ObesityObesity Obesity results in Obesity results in

airway and airway and respiratory respiratory problems problems secondary to secondary to altered respiratory altered respiratory pathophysiology pathophysiology and distorted and distorted upper airway upper airway anatomy.anatomy.

Rheumatoid ArthritisRheumatoid Arthritis Patients with Patients with

rheumatoid rheumatoid arthritis and other arthritis and other connective tissue connective tissue diseases often diseases often limit ROM of the limit ROM of the cervical spine.cervical spine.

TumorsTumors Tumors of the neck and airway can Tumors of the neck and airway can

distort anatomy, limiting the space distort anatomy, limiting the space for instrumentation.for instrumentation.

Congenital DisordersCongenital Disorders Congenital Congenital

disorders may be disorders may be associated with associated with airway difficulty airway difficulty due to mandibular due to mandibular hypoplasia, hypoplasia, cervical cervical abnormalities, abnormalities, large tongue or a large tongue or a cleft palate.cleft palate.

PregnancyPregnancy Pregnancy is Pregnancy is

associated with associated with a difficult upper a difficult upper airway, an airway, an increased risk of increased risk of aspiration and aspiration and limited tolerance limited tolerance to apnea.to apnea.

The Most Difficult AirwayThe Most Difficult AirwayThe one the EMT or The one the EMT or

Paramedic Paramedic insistsinsists that that he can “get it”he can “get it”

Almost a guarantee the Almost a guarantee the patient will diepatient will die

SummarySummary The difficult airway is a significant The difficult airway is a significant

problem to the patient and EMS problem to the patient and EMS provider in terms of mortality, provider in terms of mortality, morbidity and cost.morbidity and cost.

SummarySummary It is imperative to be aware of the It is imperative to be aware of the

factors that contribute to a factors that contribute to a difficult airway so that:difficult airway so that:

EMS providers may improve their EMS providers may improve their ability to be preparedability to be prepared

The morbidity and mortality of difficult The morbidity and mortality of difficult airway patients can be minimizedairway patients can be minimized

Patient outcome can be improved uponPatient outcome can be improved upon

Questions?Questions?