Difficult Airway Management
Airway management is really easy….
Except when it isn’t
DEFFINATION
Difficult Intubation is:
Failure to intubate with conventional laryngoscopy after
an optimal/best attempt with:
• Reasonable experienced laryngoscopist
• No significant resistive muscle tone
• Use of optimal sniffing position
• Use of external laryngeal manipulation
• Change of laryngoscope balde type a single time, and
• Change of laryngoscope balde length a single time
PREVALENCE
Failed tracheal intubation
0.05 – 0.35 %
Failed tracheal intubation with inadequate mask
ventilation
0.01 – 0.03 %
This is in OR when:
• Plan in advance
• Can’t get airway .. awaken patient .. Regroup
• go for coffee
If only they looked this good…
But our options are different
More Difficult Situation:
What makes it difficult in
emergency situation




Training/requirements
Non-controlled settings
Limited pre-procedural evaluation
Hypoxia, hypotension, agitation, dynamic
medical conditions
 Numerous logistical & implementation issues
MOST OF OUR PATIENTS ARE ALREADY
“DIFFICULT AIRWAYS” BY “OR”
STANDARDS.
The American Society of
Anesthesiology (ASA) has noted:



“there is strong agreement among consultants that
preparatory efforts enhance success and minimize
risk”
And “The literature provides strong evidence that
specific strategies facilitate the management of the
difficult airway”
Thus identifying a potentially difficult airway is
essential to preparation and developing a strategy.
How to identify a difficult
airway?
We will not talk about
•
The basic anatomy of the Airway
•
BLS airway maneuvers and Endotracheal
Intubation by Oral and Nasal means
•
The concept and procedure of RSI
Airway Evaluation
Past Medical History

Decreased cervical mobility

Anatomic upper airway abnormalities

History of Previous Problems in surgery
Airway Evaluation
Predictors of difficult mask ventilation “BONES”:
(two or more)
 Beard
 Obesity with BMI > 26
 No teeth
 Elderly > 55
 Snorers
Airway Evaluation
Dr. Binnions LEMON Law: An easy way to
remember multiple tests
• Look externally
• Evaluate 3-3-2 rule
• Mallampati
• Obstructions
• Neck mobility
Airway Evaluation
LEMON Law - Look externally
 Obesity or very small.
 Short Muscular neck
 Large breasts
 Prominent Upper Incisors (Buck
Teeth)
 Receding Jaw (Dentures)
 Burns
 Facial Trauma
 S/S of Anaphylaxis
 Stridor
Airway Evaluation
LEMON Law - Evaluate 3-3-2 rule
 Mouth opening ≥ 3 fingers
 Tip of the chin to the hyoid bone ≥ 3 fingers
 Hyoid bone to the top of the thyroid cartilage ≥ 2
fingers
Airway Evaluation
LEMON Law – Mallampati
(difficult direct laryngoscopy Cormack & Lehane grading)
Airway Evaluation
LEMON Law - Obstructions
 Blood
 Vomitus
 Teeth
 Tumers
 Epiglotitis
Airway Evaluation
LEMON Law - Neck mobility





Prior condition
Surgery
Rheumatoid arthritis
Osteoarthritis
Others
What alternative tools do
we have?
Airway Rescue Tools
Airway Rescue Tools
• Bag valve mask
• Combitube
• LMA
• Intubation LMA
• Fiberoptic: rigid,
flexible
• Lightwand
• Bougie
• Transtracheal jet
• Retrograde
• Cricothyrotomy
• Tracheostomy
Nasopharyngeal
& Oropharyngeal
Airways
COPA – Cuffed Oral-pharynageal Airway
Laryngoscopes
CL (Corazelli-London)
Flexible Tip
Laryngoscope
Flexible Tip
Laryngoscope
Flexiblade
Cricoid pressure vs External
Laryngeal Manipulation
BURP
backwards
upwards
right pressure
Bougie or Eschmann Stylette
Lighted Stylette
Lighted Stylette
Combitube Airway
Combitube Airway
Pharyngeal-Tracheal Lumen Airway
(PTL)
Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA)
Laryngeal Mask Airway (LMA)
Laryngeal-Tracheal Airway
Intubating LMA (iLMA)
Intubating LMA (iLMA)
Intubating LMA (iLMA)
Intubating LMA (iLMA)
Intubating LMA (iLMA)
Retrograde Tracheal Intubation
Retrograde Tracheal Intubation
Flexible Fiberoptic Scope
Flexible Fiberoptic Scope
Rigid Fiberoptic Scope
Rigid Fiberoptic Scope
Bullard
Wu Scope
Rigid Fiberoptic Scope
Upsher
Levitan Scope
Video Laryngoscope
Glidescoe
McGrath
Video Laryngoscope
Glidescope
VIDEO
Video Laryngoscope
Video Laryngoscope
LMA C-Trach
Surgical Airway:
Cricothyroidotomy
Surgical Airway:
Cricothyroidotomy
Surgical Airway:
Cricothyroidotomy
Quicktrach Emergency
Cricothyrotomy
Tran-Tracheal Jet Ventilation
(TTJV)
TTJV
Awake Intubation
Expired CO2 Confirmation
YELLOW = CO2
PURPLE = NO CO2
Difficult Airway
Specific strategies:
• Appreciate the importance of developing
a primary and secondary approach
• Identify fundemental prenciples, as
adapted from ASA Difficult Airway
Algorithm
• Know when to consider an airway “failed”
and what takes priority when an airway is
failed
Difficult Airway
Before intubation
• Do we have to intubate?
• CPAP?
• PPV with BVM or Demand Valve?
• Nasal ETT?
Difficult Airway
Management
• Prearranged Emergency airway trolley
available?
• Most senior staff
• Emergency airway algorithm
• Discussion with colleagues in advance.
• Deliver supplemental O2
Difficult Airway
Uunexpected Difficult Airway Proble
• Unexpected difficult airway is mostly gone
worse because mainly GA is already given
including (NMB)
• Equipment may not be in hand.
• Senior and back up plan not available.
Difficult Airway
what are we going to do if we don’t
get the tube?
Plans “A”, “B” and “C”
 Know this answer before you tube.

Plan A: Alternate
•
•
•
•
Different Length of blade
Different Type of Blade
Different Position
BURP
Plan B: Blind Techniques
BVM
 Bougi
 Videolaryngoscope
 LMA, iLMA
 Combitube
 Retrograde intubation?
 TTJV?

Plan C: Can’t intubate, Can’t
ventilate
• Cricthyrotomy (needle or surgical)
• Tracheostomy
Difficult Airway
1
Manipulation of airway
different blade, bugie
1
alternative
2
alternative
3
alternative
2
LMA, ILMA, Combitube
Bougi, videolaryngoscope
3
Trantracheal Jet Ventilation?
Retrograde intubation?
4
alternative
4
Cricothireotomy, Tracheostomy
Airway Rescue
Pearls of Airway Management
• Be familiar with all airway rescue tools and
techniques
• Recognize the difficult airway
• If you can’t intubate – Bag!
• If at first you don’t succeed, change
something
• Don’t turn difficult airways into failed airways
• Plan ahead, and communicate that plan
• Get help early, often
Mandibular Aplasia
Thank you!