Basic Emergency Airway ManagementPat Melanson,MD

- the most essential skill in EM- establishing or protecting on airway is frequently the essential maneuver for saving a persons life- conversely, failure to do so is the fastest way to assure a patients demise- assessment and management of the airway have been appropriately assigned the A in the well known ABCs of resuscitation for scientific reasons as well as alphabetic

ObjectivesDifferentiate the Emergency Airway from elective intubation in the ORAssessment of airway compromiseIndications for airway interventionRecognition of the difficult airwayBag-Mask TechniquesLaryngoscopy

Emergency Airway Management : Unique ConsiderationsFull stomach - high aspiration riskAltered level of consciousnessDeteriorating cardiorespiratory physiology - (hypotension, hypoxia)Abnormal or distorted upper airway anatomyNo time for pre-op assessment

Airway AssessmentAssessment for airway compromise or threats and need for interventions

Examination for the potentially difficult airway

The Three Pillars of Airway Management: ( Assessment of Compromises or Threats )Patency of Upper Airway ( airflow integrity )

Protection against aspirationAssurance of oxygenation and ventilation

Indications for Active Airway Intervention: including intubationFailure to maintain patency Protection from aspirationHypoxic/ hypercapnic respiratory failureAirway access for pulmonary toilet, drug delivery,therapeutic hyperventilationIntractable ShockAnticipated clinical deterioration

Indications for IntubationIs there failure of airway maintenance ?Is there failure of airway protection ?Is there failure of oxygenation or ventilation?What is the anticipated clinical course ? (i.e., expected deterioration, long transport, long time in radiology, etc.)

Clinical Signs of Airway Compromise : Threatened PatencyInspiratory stridorSnoring ( pharyngeal obstruction )Gurgling ( blood/ secretions )Drooling ( epiglottitis )Hoarseness ( laryngeal edema/ vocal cord paralysis)Paradoxical chest wall movementTracheal tugMass - abscess, hematoma, angioedema

Clinical Signs of Airway Compromise: Inadequate Protection

Blood in upper airwayPus in upper airwayPersistent vomitingLoss of protective airway reflexesswallowing reflex is superior to gag reflex

Clinical Signs of Airway Compromise:Oxygenation and VentilationCentral cyanosisObtundation and diaphoresisRapid shallow respirationsAccessory muscle useRetractionsAbdominal paradox

Clinical Signs of Airway Compromise:Oxygenation and VentilationThe assessment of oxygenation and ventilation is a clinical one.

Arterial blood gases should not be relied upon to assess whether intubation is necessary.

Techniques for the Compromised AirwayHead PositioningJaw Thrust, Chin liftOrophryngeal/ Nasopharyngeal airwaysBag-Valve-Mask VentilationEndotracheal IntubationAdvanced techniquesCric, LMA, Combitube, Retrograde, Fibreoptic, Light wand, Bouge

The Difficult AirwayDifficult Laryngoscopy poor visualization of cords

Difficult bag-mask ventilationunable to oxygenate or ventilate

Lower airway difficulty severe bronchospasm

Golden Rules of Bagging Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask The art of bagging should be mastered before the art of intubationManual ventilation skill with proper equipment is a fundamental premise of advanced airway Rx

BVM VentilationThe most important airway skillAlways the first response to inadequate oxygenation and ventilationThe first bail-out maneuver to a failed intubation attemptAttenuates the urgency to intubateDo not abandon bagging unless it is impossible with two people and both an OP and NP airway

BVM Ventilation Requires practice to masterOne hand tomaintain face sealposition headmaintain patencyOther hand ventilates

BVM Ventilation: TechniqueInsert oropharyngeal/nasopharyngealSniffingposition if C-spine OKThumb + index to maintain face sealMiddle finger under mandibular symphysisRing/little finger under angle of mandibleMaintain jaw thrust/mouth open

Predictors of a Difficult Airway : BVMUpper airway obstructionLack of denturesBeardMidfacial smashFacial burns, dressings, scarringPoor lung mechanics resistance or compliance

Difficult Airway : BVMdegree of difficulty from zero to infiniteZero = no external effort or internal device requiredone person jaw thrust/ face sealoropharyngeal or nasopharyngeal AWtwo person jaw thrust / face sealboth internal airway devicesInfinite = no patency despite maximal external effort and full use of OP/NP

Algorithm for Difficulty BaggingRemove Foreign Bodies - Magill forcepsTriple maneuver if c-spine clear Head tilt, jaw lift, mouth opening Nasal or oropharyngeal airwaysTwo-person, four-hand technique

BVM Ventilation: Mask Seal Tips and PearlsEasier to get seals with masks too large than too smallInflate mask collar correctlyApply lubricant to beards to mat down hairIf edentulous insert gauze sponges into cheeks

Prediction of the Difficult Airway: Laryngoscopy History of past airway problems check previous OR anesthesia records if time permitscricothyroidotomy scarCareful physical assessmentmouth openingtongue to pharyngeal sizehyo-mental distanceNeck flexion, Head extension

Technique of LaryngoscopySniffing position to align oral-pharyngeal-laryngeal axisFlex neck by placing pillow beneath occiput ( raise 10 cm )Extend head maximallyWith laryngoscopeopen mouth fullypush tongue to left out of viewpull upward at 45 degrees

Adducted vocal cords

Predictors of Difficult LaryngoscopyShort thick neckReceding mandibleBuck teethPoor mandibular mobility/ limited jaw openingLimited head and neck movement ( including trauma )

Difficult Airway : LaryngoscopyTumor, abscess or hematomaBurnsAngioneurotic edemaBlunt or penetrating traumaRheumatoid arthritis, ankylosing spondylitisCongenital syndromesNeck surgery or radiation

Predictors of Difficult Laryngoscopy3 fingerbreadths mentum to hyoid3 fb chin to thyroid notch3 fb upper to lower incisorsHead extension and neck flexionMallimpadi classificationPrevious history of difficult intubation

Mallimpadi Classification (Tongue to Pharyngeal Size)I - soft palate, uvula, tonsillar pillars visible99 % have grade I laryngoscopic viewII - soft palate, uvula visibleIII - soft palate, base of uvulaIV - soft palate not visible100% grade III or grade IV views

The 4 Ds of Difficult IntubationDistortion ( edema, blood, vomitus, tumor, infection)Dysmobility of joints ( TMJ, alanto-occipital, C-spine)Disproportionthyomental, Mallimpadi, etcDentitionprominent upper teeth

Unsuccessful IntubationBag the patientMaximize neck flex/ head exMove tongue out of line of siteMaximize mouth openingID landmarks and adjust bladeBURP maneuver (Backwards Upwards Rightwards Pressure on Thyroid Cart.)Increasing lifting forceConsider Miller bladeBag the patient

BURPThe Efficacy of the "BURP" Maneuver During a Difficult Laryngoscopy. Takahata O Anesth Analg - 1997 Feb; 84(2): 419-21

[The difficult intubation. The value of BURP and 3 predictive tests of difficult intubation] Ulrich B - Anaesthesist - 1998 Jan; 47(1): 45-50

LEMON Mallampati scoreMallampati scoreGrade 1: entire post. Pharynx, visualized to tonsillar pillarsNo difficultyGrade 2: hard palate, soft palate and top of uvula onlyNo difficultyGrade 3: hard and soft palate onlyModerate difficultyGrade 4: no visualization post pharynx or uvula (hard palate onlySevere difficulty

Basic Airway ManagementPositioning

- the most essential skill in EM- establishing or protecting on airway is frequently the essential maneuver for saving a persons life- conversely, failure to do so is the fastest way to assure a patients demise- assessment and management of the airway have been appropriately assigned the A in the well known ABCs of resuscitation for scientific reasons as well as alphabetic