THE DIFFICULT AIRWAY

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THE DIFFICULT AIRWAY
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THE DIFFICULT AIRWAY

• The Key is to maintain
• Oxygenation
• Ventilation

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The Difficult Airway

• A difficult airway can be defined as a clinical
  situation in which a conventionally trained ALS
  provider experiences difficulty with mask
  ventilation, difficulty with tracheal intubation
  or both.

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THE DIFFICULT AIRWAY

• Definition
• Difficult to oxygenate and ventilate
• Difficult to intubate

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Complexity

• The difficult airway represents a complex
  interaction between patient factors, the
  prehospital/clinical setting, and the skills of
  the EMS provider.

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Difficult Mask Ventilation

• Not possible for the EMS provider to maintain the
  SpO2 gt90 using 100 oxygen and positive pressure
  mask ventilation.
• It is not possible for the EMS provider to
  prevent or reverse signs of inadequate
  ventilation during PPV.

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THE DIFFICULT AIRWAY

• Difficult to oxygenate and ventilate (BMV)
• Beard
• Obese
• No Teeth
• Elderly
• Snores

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The Difficult Airway

• Difficult to intubate
• Look at head and neck
• Evaluate ability to open mouth/access oropharynx
• Mallampati or Cormack Scales
• Obstruction
• Neck Mobility

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Look at head and neck

• Anatomical Features
• Recessed Chin
• Buck teeth
• Short neck or no neck
• Signs of previous surgery

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Difficult Endotracheal Intubation

• Proper insertion of the tracheal tube with
  conventional laryngoscopy requires more than
  three attempts
• Proper insertion of the tracheal tube with
  conventional laryngoscopy requires more than 10
  minutes.

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Intubation Difficulty May Be Due To

• Incorrect position of the patient
• Inadequate or improper equipment
• Unusual or abnormal anatomy
• Pathologic causes

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Evaluate Access to Oral Cavity

• Opening of mouth lt20 mm predisposes to difficult
  airway

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Evaluate Access to Oral Cavity

• Rule of thumb an opening of at least two large
  finger breadths between upper and lower incisors
  in the adult is desirable

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Mallampati Scale
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Assessing the Oral Cavity
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Cormack Scale
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Difficult Laryngoscopy

• It is not possible to visualize any portion of
  the vocal cords with conventional laryngoscopy.

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Factors Contributing to Difficult Laryngoscopy

• The following factors may be contributors to a
  difficult airway
• Obstruction
• Infections
• Trauma
• Rheumatoid Arthritis
• Congenital Problems
• Pregnancy

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Obstruction

• Foreign body airway obstruction is a common cause
  of failed airways.
• Direct laryngoscopy must be used with caution as
  it may result in further advancement of the
  foreign body into the airway

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Obstruction

• Obstruction of the airway can also be anatomical
  or pathological, causing narrowing or complete
  blockage of the airway.

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Infections

• Infectious processes such as abscesses, croup,
  bronchitis, and pneumonia can distort normal
  anatomy.

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Trauma

• Maxillofacial or head trauma may distort normal
  airway anatomy, resulting in clenched teeth and
  edema.

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Obesity

• Obesity results in airway and respiratory
  problems secondary to altered respiratory
  pathophysiology and distorted upper airway
  anatomy.

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Rheumatoid Arthritis

• Patients with rheumatoid arthritis and other
  connective tissue diseases often limit ROM of the
  cervical spine.

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Tumors

• Tumors of the neck and airway can distort
  anatomy, limiting the space for instrumentation.

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Congenital Disorders

• Congenital disorders may be associated with
  airway difficulty due to mandibular hypoplasia,
  cervical abnormalities, large tongue or a cleft
  palate.

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Pregnancy

• Pregnancy is associated with a difficult upper
  airway, an increased risk of aspiration and
  limited tolerance to apnea.

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The Most Difficult Airway

• The one the EMT or Paramedic insists that he can
  get it
• Almost a guarantee the patient will die

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Summary

• The difficult airway is a significant problem to
  the patient and EMS provider in terms of
  mortality, morbidity and cost.

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Summary

• It is imperative to be aware of the factors that
  contribute to a difficult airway so that
• EMS providers may improve their ability to be
  prepared
• The morbidity and mortality of difficult airway
  patients can be minimized
• Patient outcome can be improved upon

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Questions?
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THE DIFFICULT AIRWAY

• BIBLIOGRAPHY
• Walker LA Using Rapid Sequence to Facilitate
  Tracheal Intubation. Emergency Med Reports
  14125-132, 1993.
• Chari R Drugs for Conscious Sedation and
  Neuromuscular Paralysis. Emergency Med Reports
  199-20, 1998
• McAllister JD, Gnauck KA Rapid Sequence
  Intubation of the Pediatric Patient. Ped Clin NA
  461249-1276, 1999.
• Pousman RM Rapid Sequence Induction for
  Prehospital Providers. Www.ispub.com/journals/IJE
  ICM/Vo14N1/rapid.htm.