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Some Tools for Managing the Difficult Airway

• Joe Lex, MD, FAAEM
• Temple University
• Philadelphia, PA

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Airway management is really easy

• except when it isnt

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(No Transcript)
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Our Options Are Different

• Anesthesiology
• Plan in advance
• Cant get airway...
• awaken patient
• regroup
• go for coffee

• Emergency
• What will be, will be
• Cant get airway
• wipe brow
• change shorts
• call attorney
• call coroner

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It can be difficult to

• oxygenate
• ventilate
• intubate
• perform cricothyrotomy

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To Maximize Success

• recognize and predict difficult airway
• choose appropriate technique and equipment
• possess technical skills, drugs, and devices

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Predicting the Difficult Airwayif you have time
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LEMON Law

• Look at anatomy
• Examine the airway
• Mallampati
• Obstructions
• Neck mobility

LEMON
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Look at Anatomy

• Obesity rapid desaturation, difficult
  intubation, ventilation
• Facial hair hides small chin, can make bagging
  difficult / impossible
• Large teeth hide airway, obscure tube passage
• Jagged teeth lacerate balloon

LEMON
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Look at Anatomy
LEMON
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Look at Anatomy

• Narrow face, high-arched palate decreased
  side-to-side diameter
• Large tongue hides airway
• False teeth help bagging, remove for intubation

LEMON
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Examine Airway
LEMON
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Examine Airway

• The 3 3 2 rule
• Mouth open 3 fingers
• Mentum to hyoid 3 fingers
• Floor of mouth to thyroid cartilage 2 fingers

LEMON
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Examine Airway

• Mouth open 3 fingers
• Allows insertion of tube, laryngoscope
• Mentum to hyoid 3 fingers
• Predicts ability to lift tongue into mandible

LEMON
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Examine Airway

• Floor of mouth to thyroid cartilage 2 fingers
• If high larynx, airway tucked under base of
  tongue, hard to visualize

LEMON
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Mallampati Score

• With patient seated extend neck ? open mouth ?
  stick out tongue
• Visualize base of tongue, faucial pillars, uvula,
  pharynx

LEMON
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Mallampati Score
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Airway Obstructions
LEMON
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Airway Obstructions

• Angioedema?
• Hematoma?
• Look under shirt collar
• Dentures?
• Epiglottis?

LEMON
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Neck Mobility

• Prior condition
• Surgery
• Rheumatoid arthritis
• Osteoarthritis
• Others

LEMON
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Neck Mobility
LEMON
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Neck Mobility

• Cervical spine rigidity reduces ability to align
  anatomic axes
• Inability to mobilize neck can make intubation
  difficult or impossible

LEMON
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Moving Beyond Laryngoscopy
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Some Equipment, Old New
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Difficult Airway Cart

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

• Lightwand
• Bougie
• Transtracheal jet
• Retrograde
• Digital
• Cricothyrotomy

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1. Bag Valve Mask
B V M
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1. Bag Valve Mask (BVM)

• Practice skills essential
• Use appropriate size oral airway or nasal trumpet
• Leave dentures
• Use water-soluble lubricant to get good seal,
  especially if lots of facial hair

B V M
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2. Combitube
Combitube
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2. Combitube

• Double lumen tube functions as esophageal
  obturator airway plus standard cuffed
  endotracheal tube
• Insert blindly ? 90 esophageal
• Inflate proximal balloon 100 mL
• Inflate distal balloon 5 15mL

Combitube
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2. Combitube

• Seals oropharyngeal and nasopharyngeal cavities
• Ventilate through blue port
• Good breath sounds and no air in stomach ?
  continue ventilating
• No breath sounds and air in stomach ? use white
  tube

Combitube
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2. Combitube
Combitube
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3. Laryngeal Mask Airway
L M A
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Indications

• Routine / emergency procedures
• Known / unknown difficult airway
• During resuscitation in profoundly unconscious
  patient with no glossopharyngeal or laryngeal
  reflexes when tracheal intubation not possible

L M A
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Contraindications

• In elective patient who
• has not fasted
• may have gastric contents
• has fixed ? lung compliance
• is not profoundly unconscious
• resists LMA airway insertion

L M A
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Usage
L M A
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Usage
L M A
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Usage
L M A
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Usage
L M A
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Usage
L M A
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4. Intubating LMA
L M A
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L M A
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LMA Take-Home Points

• Test cuff before use
• Dont lubricate anterior mask
• Insert only in comatose patient
• Keep cuff inflated until patient awake
• Dont throw out!! Used 40 50 times

L M A
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5. Flexible Fiberoptic Scope
Fiberoptic
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5. Flexible Fiberoptic Scope

• Advantages
• Allows direct airway visualization
• Causes little hemodynamic stress
• Nasotracheal or orotracheal route
• Can be done in all age groups
• Requires minimal neck movement

Fiberoptic
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5. Flexible Fiberoptic Scope

• Disadvantages
• Expensive
• Expertise requires practice
• Delicate equipment needs careful maintenance
• Visual field easily impaired by blood and
  secretions

Fiberoptic
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6. Rigid Fiberoptic Scope
Fiberoptic
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6. Rigid Fiberoptic Scope

• Bullard

• Wu Scope

Fiberoptic
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6. Rigid Fiberoptic Scope

• Upsher

• GlideScope

Fiberoptic
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6. Rigid Fiberoptic Scope

• Levitan Scope

Fiberoptic
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6. Rigid Fiberoptic Scope

• Advantages
• Direct airway visualization
• Minimal neck movement
• May overcome difficult view
• Useful in disrupted airway
• Durable, sturdy instruments

Fiberoptic
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6. Rigid Fiberoptic Scope

• Disadvantages
• Expensive
• Expertise requires practice
• Visual field easily impaired by blood and
  secretions
• Not readily available

Fiberoptic
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7. Lightwand (Trachlight)
Lightwand
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7. Lightwand (Trachlight)
Lightwand
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7. Lightwand (Trachlight)

• Advantages
• Minimal neck movement
• Useful adjunct to laryngoscopy
• Portable and inexpensive
• Usable in bloody airway
• Provides definitive airway

Lightwand
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7. Lightwand (Trachlight)

• Disadvantages
• Blind technique
• May damage airway
• Usually requires darkened room
• Expertise requires practice

Lightwand
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8. Intubating Stylet (Bougie)
Bougie
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8. Intubating Stylet (Bougie)

• Gum elastic use as guidewire
• Advantages
• Gives definitive airway
• Easy to learn
• Inexpensive
• Can be used blindly

Bougie
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8. Intubating Stylet (Bougie)

• Gum elastic use as guidewire
• Disadvantages
• Expertise requires practice
• Not recommended in cant intubate / cant
  ventilate scenario

Bougie
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9. Transtracheal Jet Ventilation
TTJV
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9. Transtracheal Jet Ventilation

• Advantages
• Surgical airway of choice if 8 years or younger
• Effective
• Can serve as temporary airway before permanent
  airway
• Relatively simple procedure

TTJV
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9. Transtracheal Jet Ventilation

• Disadvantages
• Significant complications if misplaced
• Need proper equipment
• Need high-pressure oxygen
• Does not protect against aspiration

TTJV
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10. Retrograde Intubation
Retrograde
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10. Retrograde Intubation

• Puncture cricothyroid membrane
• Thread wire through vocal cords
• Exit nose or mouth
• Guide endotracheal tube through vocal cords over
  wire

Retrograde
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10. Retrograde Intubation

• Advantages
• Definitive airway
• Minimal neck movement
• Does not require full mouth open

Retrograde
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10. Retrograde Intubation

• Disadvantages
• Takes time
• Requires skill
• Not recommended in cannot intubate / cannot
  ventilate

Retrograde
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11. Digital Intubation
Digital
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11. Digital Intubation

• You need long fingers
• Make sure patient is really unconscious
• Not commonly used, but can be life-saver

Digital
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11. Digital Intubation

• Indications
• Poor lighting, difficult patient position,
  disrupted airway, potential cervical spine injury
• Cant see larynx due to blood
• Equipment failure
• Intubation failure

Digital
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12. Cricothyrotomy
Cric
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12. Cricothyrotomy

• Life-saving technique
• Surgical vs. needle / Seldinger vs. percutaneous
  kit
• You must know this procedure before starting
  rapid sequence

Cric
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12. Cricothyrotomy

• Final common pathways for all cannot intubate /
  cannot ventilate scenarios
• The hardest part of doing a cricothyrotomy is
  picking up the knife. Peter Rosen

Cric
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And finally

• BURP your patient grab the larynx and give
• Backward
• Upward
• Rightward
• Pressure

BURP
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Conclusions

• Recognize the difficult airway
• How much time do you have?
• Who else is around?
• What is your backup procedure
• Know both old and new methods
• Choose backups based on skills

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Dziekuje bardzo
joe_at_joelex.net