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
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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.
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Pregnancy
Inflammatory Disease
Small mouths
Infections
Endocrine
Congenital
Trauma
Foreign Body
Tumours
Examination
LEMON
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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
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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
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LMA/Laryngeal Tube
Transtracheal Jet Ventilation
Fibreoptic Intubation
Retrograde Intubation
Lightwand
Combitube
Surgical Airway
Laryngeal Mask
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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
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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:
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Bleeding
Infection
Vocal cord damage
Tracheal stenosis
– C/I
• <12yrs
• Laryngotracheal Disruption
• Coagulopathy
The End