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14 OR Nurse2009 September www.ORNurseJournal.com

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2.1ANCC CONTACT HOURS

By Linda Heltemes, CRNA, MS

While airway management is routinely performedin the surgical setting, it’s never taken lightly. Forpatients with a difficult airway, the end result can becatastrophic. The difficult airway is a commonlydocumented cause of adverse outcomes in anesthe-sia, including hypoxic brain injury and death.1

In most cases, the anesthesia provider initially ven-tilates an apneic patient using a face mask, and theninserts an airway device—often times, either a trachealtube (TT) or a laryngeal mask airway (LMA). In thebroadest sense, a difficult airway is clinically identifiedby two undesirable scenarios—difficulty administeringventilation via face mask and a difficult tracheal intu-bation.1 These scenarios may be present alone or incombination.

Even with airways that aren’t by definition “diffi-cult,” there’s always the potential for a challenge. Avariety of factors can impact the effectiveness of air-way management. (See Factors that promote effective

airway management.) In particular, the skill level andexperience of the practitioner managing the airwaygreatly impacts the outcome.1 Another major factoris the availability of skilled assistance from otherteam members.1 Every instance of patient care thatrequires establishment of an airway is a critical eventand warrants the attention and focus of the health-care team. While airway management is a complextopic, this article is intended to provide a general dis-cussion of some primary elements to consider dur-ing management of the difficult airway in the surgicalsetting.

An unexpected outcomeThe OR nurse should be familiar with and know thelocation of the emergency airway equipment and beprepared to assist the anesthesia provider during themanagement of a patient with a difficult airway.Consider the following scenario in the OR: You’re

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www.ORNurseJournal.com September OR Nurse2009 15

the circulating nurse and your patient, a 35-year-oldman with no prior surgical history, is undergoing anonemergent cholecystectomy. His medical historyincludes only hypertension. You’re beside the patientduring induction of general anesthesia. After preoxy-genation, the certified registered nurse anesthetist(CRNA) administers I.V. fentanyl and propofol.As the patient’s eyelids begin to close, you watchhis chest rise and fall. When he becomes apneic,the CRNA effectively seals the patient’s face maskand squeezes the oxygen reservoir bag, deliveringtwo breaths. She administers an I.V. dose of suc-cinylcholine to paralyze the patient and facilitateintubation. You hear the familiar beep of the pulseoximeter in the background.

When the oximetry tone changes, though, youglance at the patient monitor and notice his oxygensaturation level has decreased from 99% to 92%.The CRNA repositions the patient’s chin and jaw,

as well as the face mask, but she’s unable to ventilate.The tone of the pulse oximeter rises sharply as thepatient’s oxygen saturation level continues to drop.The CRNA inserts an oral airway, but is still unableto effectively ventilate the patient. On the anesthesiacart, you see an 8.0 endotracheal tube and a laryn-goscope handle with #3 Macintosh blade attached.As the CRNA reaches for the laryngoscope, younote the patient has produced a moderateamount of oral secretions. You have an oral cannu-la and tubing readily available and attached to a suc-tion device; you turn on the suction. The patient’soxygen saturation has dropped to 82%. After oral-ly suctioning the patient, the CRNA inserts thelaryngoscope blade into his mouth. “I can’t see any-thing,” she says. With her right hand, she externallymanipulates the larynx. “I can see the cords now,”she says. “Will you hold this position?” You take overexternal laryngeal manipulation and the CRNA


inserts the TT. Your patient’s oxygen saturation is75% and he’s cyanotic. The CRNA inflates the TTcuff and auscultates breath sounds. An end-tidalCO2 waveform appears on the patient monitor.“Breath sounds are equal bilaterally,” the CRNAsays. “You can release pressure now. Thank you forall the help.” The CRNA secures the TT with tape.With continued ventilation, the patient’s oxygen sat-uration level quickly climbs to 98% and his colorreturns to normal.

Defining the difficult airwayBy definition, a difficult airway isapparent in a patient by the CRNA’sinability to effectively provide ventila-tion by way of face mask, performtracheal intubation, or both.2

Difficult mask ventilation (DMV) ischaracterized by the inability of anunassisted anesthesia provider tomaintain a patient’s oxygen satura-tion level at greater than 92%; or bythe inability to prevent or reversesigns of inadequate ventilation whileproviding positive-pressure ventilationduring general anesthesia.1 In onestudy of 1,502 patients, 5% (75) werefound to demonstrate DMV. Twolater studies found the rate of DMVto be approximately 8% and 2%.1

Difficult tracheal intubation (DTI)involves scenarios in which multipleattempts at intubation occur in eitherthe presence or absence of trachealpathology.1 The incidence of DTI is

estimated to range between 1.5% to 8.5% of patients.1

Predicting the difficult airwayIn general, a history of previous airway manage-ment difficulty is an important predictor of futuredifficulty in this area, unless the challenges to airwaymanagement were related to temporary factors.1

Certain preexisting factors may contribute toincreased DMV or DTI. Among other etiologies,these factors can be related to pathologic condi-tions of the pharynx, neck, or mediastinum.1 (SeePreexisting temporary factors associated with challengesto airway management.)

Predicting the potential for either DMV or DTIinvolves the consideration of multiple factors. (SeePredicting the difficult airway: DMV and DTI.) It’s worthnoting that some research suggests that commonlyused forms of assessment, such as the Mallampatitest, as well as some generally accepted physical indi-cators, lack the sensitivity to predict DTI.1 For exam-ple, while decreased neck mobility may be presentin a patient who’s difficult to intubate, this attributeisn’t valuable for use in preoperative prediction ofDTI. Likewise, a history of obstructive sleep apnea isalso not a sensitive predictor of DTI.1 (See Ineffectivesole indicators of DTI.)


Managing the difficult airway

Factors that promote effective airway management1

Skill and experience Neck mobility. The need to avoid level of practitioner manipulating a potentially unstableproviding airway cervical spine increases the difficulty ofmanagement airway management. Likewise, Halo fix-

ation without elective tracheostomy isassociated with a high risk for emergent/semi-emergent intubation, as well as mor -tality related to airway complications.

Availability of skilled Effective preoxygenation. Inadequate assistance or ineffective preoxygenation increases

the risk for hypoxia if there’s a delay insecuring the airway.

Patient positioning Proper choice of equipment. This inclu -des correct size of laryngoscope bladeand correct size of endotracheal tube.

Properly functioning Immediate availability of airway equipment (for exam-, adjuncts. These include oral and ple laryngoscopes, nasal airways.laryngoscope blades)

Preexisting temporary factorsassociated with challenges to airway management1

• Airway swelling

• Pharyngeal abscess

• Limited mouth opening due to modifiablepathology (for example, recent jaw injury)

• Difficulty swallowing (dysphagia)

• Voice abnormality, such as hoarseness (dysphonia)

• Dyspnea

• Stridor



Though potentially useful, pre-operative evaluation isn’t alwaysa guaranteed predictor of difficul-ty with airway management. Inone review of anesthesia litera-ture, researchers found that 1in 10,000 patients will have anunpredicted difficult airway.3 Withall patients, the practice of thor-ough airway evaluation can helpsharpen the focus on potentialstrategies for airway managementshould problems arise.1

Patient careFor patients in whom a difficultairway is known or suspected,the American Society of Anes -thesiologists (ASA) recommendsthat the anesthesia provider takecertain preparatory steps toensure the best possible patient outcome. (See ASArecommendations for patients with known or suspecteddifficult airway.) Included among the preparatorysteps is preoxygenation, which involves the admin-istration of 100% oxygen via face mask to the spon-taneously breathing patient before sedation or anes-thetic induction.2

At the cellular level, preoxygenation allows fordenitrogenation, or the replacement of the lung’snitrogen volume with oxygen.4 During induction ofgeneral anesthesia, standard care includes inducingunconsciousness, as well as the administration of amuscle relaxant for paralysis, if necessary. Onceanesthetized and apneic, the patient requires artificialventilation. In a patient who’s difficult to ventilate,the oxygen saturation level can fall rapidly. Pre -oxygenation takes into consideration a potentialdelay in securing the patient’s airway, and reducesthe risk of oxygen desaturation during the apneicperiod.

Difficult airway algorithmIn 2003, the ASA updated The Difficult AirwayAlgorithm, which is intended to facilitate manage-ment of the difficult airway, as well as to reduce thelikelihood of adverse outcomes.2 These guidelinesprovide a step-by-step approach to airway manage-ment in a flowchart format (see The difficult airwayalgorithm).

The ASA difficult airway algorithm begins withassessing the likelihood of encountering a difficultairway, as well as evaluating the impact of difficultywith airway management.2 Once a patient is apneic,even before attempting to secure the airway, itmay be difficult to ventilate the patient via facemask. In those cases, establishing a secure airwaybecomes even more urgent.

Predicting the difficult airway: DMV and DTI1,3

Predictors of DMV Predictors of DTI

Over age 55 Disease processes of the larynx orpharynx (neoplasm)

Body mass index over 26 kg/m2

Thyroid mass

Edentulousness (absenceof natural teeth)

Acromegaly (chronic metabolic condi-tion characterized by elongation andenlargement of the bones of the face,jaw, and extremities)

History of snoring Large or poorly compliant tongue

Presence of a beard (caninterfere with sealing themask against the face)

Decreased compliance of submental(situated under the chin) tissue

Limited protrusion of thelower jaw

Limited protrusion of the lower jaw

Ineffective sole indicators of DTI1,4

• The Mallampati Test is used to grade the patientbased on structures visible upon examinationof the oropharynx with maximal opening ofthe patient’s mouth. This assessment notesthe degree to which the base of the tongueobscures the pharyngeal structures. Findingsrange from Mallampati I (entire uvula fully visi-ble) to Mallampati IV (only hard palate visible).Research suggests this test alone is insufficientfor predicting DTI.

• Male sex• Increased age

• History of obstructive sleep apnea

• Temporomandibular joint pathology

• Abnormal upper teeth

• Short thyromental distance (distance from thethyroid notch to the tip of the chin)


The ASA advises creating at least one portable stor-age unit containing equipment for use in managementof the difficult airway.2 (See ASA recommended contentsof portable unit for use in difficult airway management.) In

addition to the items listed, oral suction equipmentshould be readily available.

Included among the variety of approaches to air-way management are emergency invasive airwayaccess devices. (See Overview of emergency airwayaccess devices.) While it’s important to be familiar withall modalities of airway management, this article willfocus on the basics of three primary approaches: tra-cheal intubation of the anesthetized patient, trachealintubation of the conscious patient, and LMA inser-tion. Following the ASA algorithm, in cases whereattempts at tracheal intubation fail and face maskventilation is inadequate, insertion of an LMA maybe considered.2

Approaches to airway managementTracheal intubation of the anesthetized patientMost often, oral tracheal intubation is accomplishedusing direct visualization of the vocal cords (SeeStructures seen during direct laryngoscopy). With this

approach, a lighted laryngoscopeblade is inserted into the rightside of the mouth, and thetongue is displaced to the left.Generally, one of two types oflaryngoscope blades is usedduring oral tracheal intubation:the Macintosh (aka “Mac”) or theMiller. The tip of the Macintosh(curved) blade is advanced intothe vallecula, which is a groovedspace just anterior to the epiglot-tis. The tip of the Miller (straight)blade is positioned directlybeneath the epiglottis. In anuncomplicated intubation, whenthe vocal cords are visualized,the TT is advanced past thecords at a depth of at least 2cm.4 The cuff on the distal endof the TT is then inflated, whichcreates a seal in the trachea andreduces the risk of aspiration ofgastric contents into the lungs.

In the patient with an unantici-pated difficult airway, hypoxemia,hypercarbia, and hemodynamicinstability can rapidly ensue. Inall cases, adequate preparation



ASA recommendations for patientswith known or suspected difficultairway2

• Inform the patient (or person legally responsiblefor the patient) of associated risks and proceduresrelated to management of the difficult airway.

• Identify at least one individual who’s readily andimmediately available to assist the anesthesiaprovider with the airway management process.

• Whenever possible, preoxygenate the patient viaface mask before initiating airway management.

• Utilize opportunities to administer supplemen-tal oxygen during management of the difficultairway.

The difficult airway algorithmBelow is the ASA recommendations for management of the difficultairway. The anesthesia provider will (1) assess the patient anddetermine the likelihood and clinical impact of airway managementproblems, (2) initiate attempts to deliver supplemental oxygenthroughout the process of managing the difficult airway, and (3)develop primary strategies and consider alternative basic airwaymanagement strategies.

Source: Barash PG, Cullen BF, Stoelting RK. Handbook of Clinical Anesthesia. 5th Ed. Philadelphia, LippincottWilliams & Wilkins, 2006: 1034.

Box A Box B

AWAKE INTUBATION INTUBATION ATTEMPTS AFTERINDUCTION OF ANESTHESIA

Initial intubationattempts successful

Initial intubationattempts unsuccessful

Face mask ventilation not adequate

Consider/attempt LMA

LMA adequate LMA not adequateor feasible

Emergency pathway

Call for help

Emergency noninvasive airway ventilation

Invasiveairway

Awakenpatient

Otheroptions

Invasiveairway

FAIL, aftermultiple attempts

Successfulintubation

Alternative approachesto intubation

Nonemergency pathway

Face mask ventilation adequate

FROM THIS POINTONWARD CONSIDER1. Calling for help2. Returning to spontaneous ventilation3. Awakening the patient

Airway approached bynoninvasive intubation

Invasiveairway access

FAILSucceed

Consider feasibilityof other options

Cancelcase

Invasiveairway access



of the patient, staff, and equipment are criticalto provide effective airway management.1 Unlikethe LMA, tracheal intubation requires advancedskill level.

When visualization of the vocal cords is difficult,another member of the OR team may be asked toapply pressure to the cricoid cartilage, which canimprove the view of the vocal cords. Applying pres-sure to the cricoid cartilage also compresses theesophagus, which can prevent passive regurgitation,but isn’t intended to prevent complications due toactive vomiting. For the purposes of improving visual-ization of the vocal cords, current studies suggestapplication of cricoid pressure may not be the mosteffective strategy.1

Likewise, the application of backward, upward, andrightward pressure, or BURP maneuver, on the cricoidcartilage by a team member may help to improvevisualization of the vocal cords.1 However, researchhas shown that cricoid pressure and the BURPmaneuver may impair visualization of the vocalcords as often as 30% of the time when performed

ASA recommended contents ofportable unit for use in difficultairway management2

• Laryngoscope blades of varying sizes and styles;may include rigid fiberoptic laryngoscope

• Tracheal tubes of assorted sizes

• Tracheal tube guides, including stylets, trachealtube changers, light wands, and Magill’s forceps(used to manipulate the distal tip of the trachealtube)

• LMAs of various sizes and styles (may include“intubating LMAs”)

• Equipment used for flexible fiberoptic intubation

• Emergency invasive airway equipment(cricothyrotomy supplies)

• Emergency noninvasive airway equipment(esophageal tracheal Combitube, hollow jet ven-tilation stylet, transtracheal jet ventilator)

• Retrograde intubation equipment• Exhaled CO2 detector

Overview of emergency airway access devices2,4,5

Esophageal- Usually inserted blindly (without visualization of the vocal cords), this device consists of tracheal two fused tubes. The longer blue-colored tube has an occluded distal tip, as well as side Combitube perforations that allow gas to exit. The shorter, clear tube has an open tip, and no perfo-

rations. Inserted blindly, the distal lumen of the Combitube will lie in the esophagus in95% of cases. In this position, ventilation through the blue tube will force gas throughthe side perforations, and into the lungs. The shorter, clear tube can then be used forgastric decompression. Alternatively, if the distal portion of the Combitube enters thetrachea, ventilation via the clear tube will force gas into the trachea.

Flexible FOB FOB may be especially useful when direct visualization of the vocal cords is undesir-able or impossible. Such situations include poor range of motion of the temporo-mandibular joint, unstable cervical spine, and certain congenital or acquired airwayanomalies. The FOB contains two main bundles of fibers, each consisting of 10,000 to15,000 individual fibers. One bundle transmits light from a light source, while the otherbundle provides a high-resolution image. The FOB allows for indirect visualization ofthe vocal cords, especially in the unique situations described above, as well as withawake intubation.

Tracheotomy Accomplished by making an incision into the trachea through the neck, below the levelof the vocal cords. Sometimes utilized to gain airway access in cases of tumor, edema ofthe glottis, or when foreign body obstruction is present.

Cricothyrotomy Insertion of a large-bore I.V. catheter or commercially available cannula through thecricothyroid membrane and into the trachea. Once the needle is removed, ventilation isachieved by forcing gas through the remaining cannula. Devices used for ventilationinclude transtracheal jet ventilators, as this equipment provides a driving force highenough to generate sufficient gas flow. Cricothyrotomy is generally contraindicated inchildren under age 10.


by an assistant. 1 For improvingvisualization of the vocal cords,bimanual laryngoscopy (exter-nal lar yngeal manipulation) hasbeen found to be superior toboth cricoid pressure and theBURP maneuver.1

Bimanual laryngoscopyrequires the practitioner per-forming intubation to externallymanipulate the larynx by placingthe right hand on the patient’sneck while maneuvering thelaryngoscope blade using the lefthand. Once optimal visualiza-tion is achieved, another mem-ber of the team takes over theexternal laryngeal manipulationand maintains pressure at thatlocation, allowing the practition-

er performing the intubation to insert the TT with theright hand (See Bimanual laryngoscopy).1

Verification of TT placement includes confirmationof end-tidal CO2, as well as auscultation of bilateralbreath sounds. Once placement is confirmed, theTT is secured with tape or a device specificallydesigned for this purpose.

Tracheal intubation of the conscious patientAwake intubation is indicated when thorough airwayassessment or known patient history suggests theinability to safely control ventilation and oxygenationwithout the risk of pulmonary aspiration.4 One ofthe most undesirable airway-related scenariosinvolves patients who are both difficult to ventilatevia face mask and difficult to intubate. For thesepatients, awake intubation may also be an appropri-ate option.2 As noted, when attempts at trachealintubation are unsuccessful, insertion of an LMA maybe appropriate.2 However, because the LMA doesn’tdefinitively protect the airway from aspiration of gas-tric contents, tracheal intubation may be preferableover LMA insertion.1

In order to effectively accomplish awake intubation,the patient should be advised of the rationale for theprocedure, as well as the steps involved. Wheneverpossible, medications should be administered toreduce patient anxiety. Additionally, medication suchas glycopyrrolate (Robinul) may be administered to



Structures seen during direct laryngoscopy

Locating anatomic structures with a laryngoscope is key to successfulintubation. This illustration shows the anatomic structures of the larynx.

Source: Mastering ACLS, 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2006:23.

TongueValleculaEpiglottis

Vocal cord

Glottic opening

Arytenoid cartilage

Bimanual laryngoscopy

Source: http://www.airwaycam.com/bimanual.aspx. Used with permission.

Direction on neck is opposite direction of lift onthe laryngoscope.

An assistant then maintains pressure at thislocation, freeing the laryngoscopist’s righthand to place the tracheal tube.



reduce oral secretions.4 Local anesthetics are used todecrease airway sensitivity to the procedure. Methodsof local anesthetic administration include topical (witha cotton-tipped applicator or aerosol spray) andtranstracheal injection (for a nerve block).4

Following local anesthesia, a fiberoptic broncho-scope (FOB) is inserted through a TT, and thenpassed through either the mouth or nose. For oralintubation, a hollow bite block is inserted into themouth, and the FOB is passed through the biteblock. If the TT is passed nasally, vasoconstrictivemedication is instilled into each nostril to reducebleeding from potential trauma.5 Using the FOB forindirect visualization, the TT is advanced through thevocal cords. The cuff on the distal end of the TT isthen inflated, creating a seal in the trachea and reduc-ing the risk of pulmonary aspiration of gastric con-tents. Correct placement of the TT is verified byway of confirmation of end-tidal CO2, as wellas through auscultation of bilateral breath sounds.The TT is then secured with tape or a device specif-ically designed for this purpose. Once the airway issecured, the patient can be safely anesthetized.

Because the patient is awake and spontaneouslybreathing, It’s not necessary to rush when perform-ing this procedure.5 If ventilation or oxygenationbecomes inadequate, the FOB is removed, and thepatient is ventilated via face mask.5

Successful awake intubation requires advancedskill. This procedure also carries additional risks for

injuring the patient. The FOB should only be advancedwhen a lumen is visible.5 If only the wall of the TT ora mucus membrane is visible, blindly advancing theFOB may result in tissue injury or perforation.

Insertion of the laryngeal mask airwaySince it was introduced in 1988, the LMA hasbecome commonly used in the anesthesia setting.Several types of LMAs are now available for use;however, the classic design involves a small, mask-like device mounted on a hollow tube. The LMA isplaced by blindly inserting the mask-like portioninto the lower pharynx so that it’s seated over thelaryngeal inlet.1 Inflation of the mask-like portionwith air may be necessary to create a seal within thehypopharynx and allow for adequate ventilation (SeeLaryngeal mask airway and endotracheal intubation).

LMA insertion can be effectively accomplishedby personnel with limited advanced airway skills.1

Studies evaluating usage of the LMA in cardiacarrest scenarios suggest this device is superior to bagmask ventilation.1 It’s estimated that 1 in 10,000patients can’t be ventilated by face mask and arealso unable to be intubated by traditional means. Incomparison, approximately 1 in 800,000 patientscan’t be successfully managed using an LMA.4

One significant disadvantage of the LMA involvesthe risk for pulmonary aspiration of gastric contents;however, some researchers suggest this risk may be

Laryngeal mask airway and endotracheal intubation

The illustrations below show the laryngeal mask airway in place and intranasal and oral endotrachealintubation.

Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins;2008:511.

Esophagus

Trachea

Epiglottis

A. Laryngeal mask airway B. Intranasal intubation C. Oral intubation

Esophagus

Trachea

EpiglottisEsophagus

Trachea

Epiglottis

Laryngealmask


overestimated.1 Certain styles of LMA allow for theinsertion of a gastric tube to evacuate stomach con-tents. Another potential concern involves inadequateventilation, which may occur due to ineffective seal-ing of the device in the hypopharynx. Ventilationwith pressures of greater than 30 cm H2O canincrease gas leakage from around the device, as wellas the portion of gas entering the esophagus.1 Inturn, gastric inflation can increase the risk of refluxand subsequent pulmonary aspiration.

Postoperative considerationsDuring patient follow-up, the anesthesia providerassesses for potential complications related to difficultairway management, including aspiration, trachealand esophageal perforation, pneumothorax, edema,and bleeding.2

The patient should be advised of signs and symp-toms that may precede potentially life-threateningcomplications (for example, pain or swelling of theface and neck, sore throat, subcutaneous emphysema,chest pain, and difficulty swallowing).2 In addition, theanesthesia provider should thoroughly document the

presence and nature of the airway difficulty encoun-tered. Documentation should differentiate between allmodalities of airway management used (for example,face-mask ventilation, LMA insertion, and trachealintubation). Likewise, documentation should describethe degree to which each intervention was beneficialor detrimental to the process of difficult airway man-agement. Thorough documentation can be useful infacilitating and guiding future patient care.2 OR

REFERENCES

1. Lavery GG, McCloskey BV. The difficult airway in adult critical care.Crit Care Med. 2008;36(7):2163-2173.

2. American Society of Anesthesiologists. Special article: practice guide-lines for management of the difficult airway. Anesthesiology. 2003;98(5):1269-1277.

3. Birnbaumer DM, Pollack Jr. CV. Troubleshooting and managing thedifficult airway. Semin Respir Crit Care Med. 2002;23(1):3-9.

4. Barash PG, Cullen BF, Stoelting RK. Handbook of clinical anesthesia.5th ed. Lippincott Williams & Wilkins: Philadelphia, Pa.; 2006:341-356.

5. Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed.McGraw-Hill: New York; 2006:91-116.

Linda Heltemes is a CRNA at Valley Anesthesia Associates, and presidentof Summit Communications, LLC, Fargo, N.D.

The author has disclosed that she has no significant relationship with orfinancial interest in any commercial companies that pertain to this educa-tional activity.



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