Difficult Airway Management

Airway management is really easy….

Except when it isn’t

DEFFINATIONDifficult Intubation is:Failure to intubate with conventional laryngoscopy after

an optimal/best attempt with:• Reasonable experienced laryngoscopist• No significant resistive muscle tone• Use of optimal sniffing position• Use of external laryngeal manipulation• Change of laryngoscope balde type a single time, and• Change of laryngoscope balde length a single time

PREVALENCEFailed tracheal intubation 0.05 – 0.35 %

Failed tracheal intubation with inadequate mask ventilation 0.01 – 0.03 %

This is in OR when:• Plan in advance• Can’t get airway .. awaken patient .. Regroup

• go for coffee

If only they looked this good…

But our options are different

More Difficult Situation:

What makes it difficult in emergency situation

Training/requirements Non-controlled settings Limited pre-procedural evaluation Hypoxia, hypotension, agitation, dynamic

medical conditions Numerous logistical & implementation issues

MOST OF OUR PATIENTS ARE ALREADY “DIFFICULT AIRWAYS” BY “OR” STANDARDS.

The American Society of Anesthesiology (ASA) has noted:

“there is strong agreement among consultants that preparatory efforts enhance success and minimize risk”

And “The literature provides strong evidence that specific strategies facilitate the management of the difficult airway”

Thus identifying a potentially difficult airway is essential to preparation and developing a strategy.

How to identify a difficult airway?

We will not talk about

• The basic anatomy of the Airway

• BLS airway maneuvers and Endotracheal Intubation by Oral and Nasal means

• The concept and procedure of RSI

Airway EvaluationPast Medical History

Decreased cervical mobility

Anatomic upper airway abnormalities

History of Previous Problems in surgery

Predictors of difficult mask ventilation “BONES”:(two or more)

Beard

Obesity with BMI > 26

No teeth

Elderly > 55

Snorers

Airway Evaluation

Dr. Binnions LEMON Law: An easy way to remember multiple tests

• Look externally

• Evaluate 3-3-2 rule

• Mallampati

• Obstructions

• Neck mobility

Airway Evaluation

LEMON Law - Look externally Obesity or very small. Short Muscular neck Large breasts Prominent Upper Incisors (Buck

Teeth) Receding Jaw (Dentures) Burns Facial Trauma S/S of Anaphylaxis Stridor

Airway Evaluation

LEMON Law - Evaluate 3-3-2 rule Mouth opening ≥ 3 fingers Tip of the chin to the hyoid bone ≥ 3 fingers Hyoid bone to the top of the thyroid cartilage ≥ 2

fingers

Airway Evaluation

Airway EvaluationLEMON Law – Mallampati

(difficult direct laryngoscopy Cormack & Lehane grading)

Airway EvaluationLEMON Law - Obstructions

Blood Vomitus Teeth Tumers Epiglotitis

LEMON Law - Neck mobility

Prior condition Surgery Rheumatoid arthritis Osteoarthritis Others

Airway Evaluation

What alternative tools do we have?

Airway Rescue Tools

Airway Rescue Tools

• Bag valve mask• Combitube• LMA• Intubation LMA• Fiberoptic: rigid,

flexible

• Lightwand• Bougie• Transtracheal jet• Retrograde• Cricothyrotomy• Tracheostomy

Nasopharyngeal &Oropharyngeal Airways

COPA – Cuffed Oral-pharynageal Airway

Laryngoscopes

Flexible Tip Laryngoscope

Flexiblade

CL (Corazelli-London) Flexible Tip

Laryngoscope

BURPbackwardsupwardsright pressure

Cricoid pressure vs External Laryngeal Manipulation

Bougie or Eschmann Stylette

Lighted Stylette

Lighted Stylette

Combitube Airway

Combitube Airway

Pharyngeal-Tracheal Lumen Airway (PTL)

Laryngeal Mask Airway (LMA)

Laryngeal Mask Airway (LMA)

Laryngeal Mask Airway (LMA)

Laryngeal Mask Airway (LMA)

Laryngeal Mask Airway (LMA)

Laryngeal-Tracheal Airway

Intubating LMA (iLMA)

Intubating LMA (iLMA)

Intubating LMA (iLMA)

Intubating LMA (iLMA)

Intubating LMA (iLMA)

Retrograde Tracheal Intubation

Retrograde Tracheal Intubation

Flexible Fiberoptic Scope

Flexible Fiberoptic Scope

Rigid Fiberoptic Scope

Rigid Fiberoptic Scope

Bullard Wu Scope

Rigid Fiberoptic Scope

Upsher Levitan Scope

Video Laryngoscope

Glidescoe McGrath

VIDEO

Video LaryngoscopeGlidescope

Video Laryngoscope

LMA C-Trach

Video Laryngoscope

Surgical Airway: Cricothyroidotomy

Surgical Airway: Cricothyroidotomy

Surgical Airway: Cricothyroidotomy

Quicktrach Emergency Cricothyrotomy

Tran-Tracheal Jet Ventilation (TTJV)

TTJV

Awake Intubation

Expired CO2 Confirmation

YELLOW = CO2 PURPLE = NO CO2

Difficult AirwaySpecific strategies:• Appreciate the importance of developing

a primary and secondary approach• Identify fundemental prenciples, as

adapted from ASA Difficult Airway Algorithm

• Know when to consider an airway “failed” and what takes priority when an airway is failed

Difficult Airway Before intubation

• Do we have to intubate?

• CPAP ?• PPV with BVM or Demand Valve?• Nasal ETT?

Difficult AirwayManagement

• Prearranged Emergency airway trolley available?

• Most senior staff• Emergency airway algorithm• Discussion with colleagues in advance.• Deliver supplemental O2

Difficult AirwayUunexpected Difficult Airway Proble

• Unexpected difficult airway is mostly gone worse because mainly GA is already given including (NMB)

• Equipment may not be in hand.

• Senior and back up plan not available.

Difficult Airwaywhat are we going to do if we don’t

get the tube? Plans “A”, “B” and “C” Know this answer before you tube.

Plan A: Alternate

• Different Length of blade• Different Type of Blade• Different Position• BURP

Plan B: Blind Techniques BVM Bougi Videolaryngoscope LMA, iLMA Combitube Retrograde intubation? TTJV?

Plan C: Can’t intubate, Can’t ventilate

• Cricthyrotomy (needle or surgical)• Tracheostomy

1alternative

2alternative

3alternative

4 alternative

1Manipulation of airway different blade, bugie

2LMA, ILMA, CombitubeBougi, videolaryngoscope

3Trantracheal Jet Ventilation?Retrograde intubation?

4Cricothireotomy, Tracheostomy

Difficult Airway

Airway Rescue

Pearls of Airway Management• Be familiar with all airway rescue tools and

techniques• Recognize the difficult airway• If you can’t intubate – Bag!• If at first you don’t succeed, change

something• Don’t turn difficult airways into failed airways• Plan ahead, and communicate that plan• Get help early, often

Mandibular Aplasia

Thank you!