The Difficult and Failed Airway

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The Difficult and Failed Airway

• Principles of Rapid Sequence Intubation
• Jason Carter, B.S., L.P.

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I. The Difficult Airway

• Defined
• Difficult to oxygenate and ventilate
• Difficult to intubate
• Difficult to perform a cricothyroidotomy

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B. Predicting the Difficult Airway

• LEMON law
• Look externally
• Evaluate the 3-3-2 rule
• Mallampati classification
• Obstruction ?
• Neck Mobility

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1. Look externally

• Beard or Moustache that hinders seal of BVM
• Abnormal Facial Shape
• Extreme cachexia
• Endentulous mouth with sunken cheeks

• Disruption of the lower face due to trauma.
• Large central incisors
• High-arching palate
• Receding mandible
• Short bull neck
• Morbid obesity

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2. Evaluate the 3-3-2 Rule

• Three finger mouth opening
• Three finger mentum-to-hyoid
• Two finger floor-of-mouth-to-thyroid cartilage

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3. Mallampati classification

• Spaciousness of mouth
• Done sitting with head in sniffing position,
  mouth wide open and tongue sticking out

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4. Obstruction

• Foreign object Magill forceps
• Laryngeal tumor
• Known or suspected epiglottitis
• Known or suspected peritonsillar abscess
• Direct airway trauma
• Extrinsic airway hematoma with compression

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5. Neck mobility

• Spinal motion restriction automatically makes the
  RSI difficult
• Non-trauma patients should be able to bring their
  head into the sniffing position

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II. Clinical Approach to the Difficult Airway

• First complication is mechanics
• Worst is esophageal intubation
• Factors in failure vs. success

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A. Clinical Techniques

• Re-position the head non-traumatic
• Jaw Lift in trauma patients
• Miller blade for epiglottis
• BURP technique
• Leave inadvertent esophageal tube in place
• 1 1.5 size smaller ETT

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III. The Failed Airway

• Failed airway defined
• failure of single attempt at oral intubation
  followed by inability to maintain SpO2 ? 90 with
  BVM
• Three failed attempts made by an experienced
  airway manager

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B. Management of the Failed Airway

• Cant intubate, can oxygenate has time
• CombiTube Placement
• Digital Intubation
• Smaller tube
• BURP
• Cant intubate, cannot oxygenate immediate
  response
• Needle or Surgical Cricothyroidotomy

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Conclusion

• General Ruleprepare for the worst and hope for
  the best
• Before RSI, determine difficulty of intubation
  using LEMON law
• All Spinal Motion Restriction patients are
  automatically difficult
• Keep up intubation skills