Difficult Airway Management

2009

Adrian Sieberhagen

• Clinical situation in which there is difficulty in Face Mask Ventilation and inability to intubate

What makes it difficult in ED’s

• Training/requirements

• Non-controlled setting

• Limited pre-procedural evaluation

• Hypoxia, hypotension, agitation, dynamic medical conditions

• Numerous logistical & implementation issues

Predicting the Difficult Airway

• History

• Physical Examination

History

Cormack and Lehane

• Class I: the vocal cords are visible

• Class II the vocals cords are only partly visible

• Class III only the epiglottis is seen

• Class IV the epiglottis cannot be seen.

• Pregnancy• Inflammatory Disease• Small mouths• Infections• Endocrine• Congenital• Trauma• Foreign Body• Tumours

Examination

LEMON

• Look for external deformities

• Evaluate 3-3-2 rule

• Mallampati

• Obstruction

• Neck Mobility

Mallampati Score

• Class I– visualization of the soft palate,

fauces, uvula, and both anterior and posterior pillars

• Class II– visualization of the soft palate,

fauces, and uvula

• Class III– visualization of the soft palate

and the base of the uvula

• Class IV– soft palate is not visible at all

• Thyromental Distance• 6.5cm normal

• Sternomental Distance• >12.5cm normal

• Protrusion of Mandible

Management

• Prearranged Emergency airway trolley available

• Most senior staff

Emergency Airway Trolley

• Rigid laryngoscope blades• Tracheal tubes• Tracheal tube guides• Laryngeal Mask Airways• Fibreoptic intubation equipment• Non-invasive/minimally invasive airways• Surgical Airway• CO2 detectors

Management

• Prearranged Emergency airway trolley available

• Most senior staff

• Emergency airway algorithm

• Deliver supplemental O2

Alternative Airway Techniques

• LMA/Laryngeal Tube

• Transtracheal Jet Ventilation

• Fibreoptic Intubation

• Retrograde Intubation

• Lightwand

• Combitube

• Surgical Airway

Laryngeal Mask

• Lubricated LMA inserted into hypopharynx• Tip in upper oesophogeal sphincter• Inflate Cuff• Muscle relaxants not necessary• C/I:

– Need for high Peak Pressures– Risk of Aspiration– Pts with low lung compliance

Laryngeal Tube

Transtracheal Jet Insuflation

Fibreoptic Intubation

Retrograde Intubation

• Place guidewire through cricothyroid membrane

• Guidewire passes cephalad through pharynx and out mouth/nose

• Railroad ET tube

Lightwand

• Flexible

• Inserted through ET tube

• Insert into larynx

• Light dims if entering oesophagus

• Limitations: Dark room

Combitube

• Double lumen tube• Placed into hypopharynx blindly• C/I

– Oesophageal pathology

Surgical Airway

• Cricothyroidotomy– Complications:

• Bleeding• Infection• Vocal cord damage• Tracheal stenosis

– C/I• <12yrs• Laryngotracheal Disruption• Coagulopathy

The End