What equipment should be
in your Difficult Airway
Cart ?
Margaret Healy
CNM 2 Anaesthesia
University College Hospital
Galway
What is a “Difficult
Airway”?
The difficult airway is defined as the
clinical situation in which a
conventionally trained anaesthetist
experiences difficulty with mask
ventilation, difficulty with tracheal
intubation, or both
Difficult Airway Society
recommendations
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Practitioners should be competent in a number
of core airway skills.
Work in an appropriate environment (trained
assistance, with access to a range of airway devices
and techniques, appropriate monitoring during surgery
and facilities for the appropriate level of post op care)
That equipment is stocked in dedicated trolleys.
These should be regularly checked and stocked.
The exact number and location of each trolley
should be determined locally
All anaesthetists and anaesthetic assistants should be
familiar with the contents and location of the trolley
Training should be provided in the use of equipment
selected by each department
There should be a Consultant Airway Coordinator in
each department, a training room and dedicated lists
for airway training
CORE SKILLS
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LMA for ventilation
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FOI through LMA, Aintree
or other airway
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ILMA
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Indirect laryngoscopes
Glidescope, Airtraq etc
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Emergency cricothyrotomy
Difficult Airway Trolley
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A shelf and 5 Drawers
that follow sequence of
Difficult Airway
Algorithm
Mobile
Robust
Clearly labelled
Easily cleaned
Attach DAS algorithms
Restocking list
Recommended equipment for
management of unanticipated
difficult intubation
 DAS guidelines algorithm flowcharts
 Equipment list for restocking
 At least one alternative blade(e.g. straight,
McCoy)
 Intubating LMA (Size 3,4,5 with dedicated tubes
and pushers)
 Flexible fibreoptic laryngoscope (with
portable/battery light source)
 Aintree Intubation Catheter
 Proseal LMA / Supreme LMA
 Cricothyroid cannulae with High pressure jet
ventilation system (Manujet) OR
 Large bore cricothyroid cannulae (e.g. Cuffed
Melker) OR
 Surgical Cricothyroidotomy kit
Miller Blades (Straight)
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The Miller blades are commonly used for infants. It
is easier to visualize the glottis using these blades
than the Macintosh blade in infants, due to the
larger size of the epiglottis relative to that of the
glottis.
Levering Laryngoscope
(McCoy)
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Hinged tip which facilitates elevation of the
epiglottis
Less force required to intubate
Improves view at laryngoscopy
Useful in patients wearing cervical hard collars
Inexpensive
Steep learning curve
Supraglottic Devices
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Supraglottic devices are the suitable
alternative to endotracheal intubation,
Useful when endotracheal intubation has
failed
Suitable for use by those with limited
experience with endotracheal intubation
Should be immediately available for every
difficult airway situation
Various types available
Fastrach (Intubating
LMA)
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Advanced version of the
standard LMA, which allows
a specifically designed ETT
to be passed blindly into the
trachea
Useful in “can’t intubate,
can’t ventilate” scenarios
Allows fast insertion into
correct position without
moving patients head or
neck
Can be used alone or as a
guide to intubation
Facilitates ventilation
between ILMA insertion and
ETT insertion
Available in 3 sizes, 3, 4 & 5
with dedicated ETTs
available in 6 / 6.5 / 7 / 7.5 &
8mm
LMA Pro-Seal
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Not necessarily a Difficult
Airway Device, but is useful
in situation where patient
has not been fasting
May be useful in failed
obstetric intubation
This has an extra tube
which provides excess
access to stomach contents
Protects against aspiration
by providing an escape for
unexpected regurgitation
Drain tube prevents against
gastric insufflation
LMA Supreme™
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Quite new to the market,
combines all the best features
of all previous LMA except you
can’t intubate through it
The SLMA is easily and rapidly
inserted, providing a reliable
airway and a good airway seal
Rates of failure, manipulations
required and complications
are very low.
Can be used when tracheal
intubation fails in non-fasted
patients
Can be used in CPR
Useful in “failed intubation”
and the “can’t intubate-can’t
ventilate” situation
Fibreoptic Bronchoscope
Fiberoptic Intubation
(FBI)
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The use of a flexible bronchoscope to intubate
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The endotracheal tube is passed directly over the bronchoscope into the trachea
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Uses: - Patients with difficult airways
- Pre-operative assessment
- Extubation assessment
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Advantages:
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This technique allows direct visualization of the airway
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Direct confirmation of ETT placement
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Can be done awake
Disadvantages:
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Expensive, difficult, requires care and skill
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View may be hampered by blood or secretions
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Requires detailed decontamination / traceability
Berman Airway
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Berman, an American anaesthetist ,
designed airways to aid blind intubation
Useful to aid oral fibreoptic intubation
Also useful as a bite block
Aintree Intubation
Catheter
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Hollow bougie which fits over a standard intubating fibrescope
Aids intubation through a dedicated airway such as a
laryngeal mask
Place LMA, load Aintree onto fibrescope, pass fibrescope to
the carina and slide off the aintree. Remove the fibrescope
and LMA and intubate over the Aintree
Possible to ventilate via this catheter if necessary, throughout
the intubation procedure
Surgical Techniques
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A cricothyrotomy is only indicated when all
other devices and techniques have failed or
are not available
Final step for CICV in all airway algorithms
Quicker than a tracheotomy
Life saving
Convert to definitive airway asap
Must be provided on all carts
Surgical Airway
Technique
3 different techniques
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Needle Cricothyrotomy +TTJV
(Manujet)
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Large Cannulae Cricothyrotomy (Melker /
Quicktrach)
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Surgical Cricothyrotomy
1.Needle Cricothyrotomy
(Manujet III with Jet Ventilation
Catheter)
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Useful for elective or emergency TTJV
Perc puncture of cricothyroid ligament
It consists of an injector with pressure gauge and
adjustable driving pressure (0-4 BAR)
Catheters available in 3 sizes Adult 13g, Child 14g
and Baby 16g
1.Transtracheal Jet
Ventilation (TTJV)
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Jet ventilation using either specialized ventilator or high
pressure driven valve circuit via a catheter passed through the
cricothyroid membrane
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Similar technique to previous
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Disadvantages
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Requires high pressure gas source
– May cause subcutaneous emphysema, pneumomediastinum, pneumothorax or other types of barotrauma
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Uses:
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Emergency ventilation in the can’t intubate can’t ventilate
scenario
2. Cricothyrotomy Catheter
(Melker cuffed/ Quicktrach)
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Syringe
18g Introducer
Needles (5cm &
7cm)
Guidewire
Curved Dilator
Airway Catheter
2. Large Cannulae
Cricothyrotomy
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Used for emergency airway access when
conventional ETT intubation cannot be
performed
Percutaneous entry ( Seldinger ) technique
via cricothyroid membrane
Dilate the tract and tracheal entrance site to
permit passage of the emergency airway
Cuffed catheter to protect and control
airway
3.Surgical Cricothyrotomy
Requirements:
 No 11 blade
 Size 6 Shiley tracheostomy
( OR small ETT size 5.0-6.0)
 Small artery forceps
Technique:
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Head fully extended
longitudinal incision is made through
the skin and subcutaneous fat over the
thyroid and cricoid cartilages
Tissue bluntly dissected
Cricothyroid ligament is transversely
incised
Tracheal tube inserted
Accessories
Fibreoptic Bronchoscopy accessories – suction
adaptor, irrigation valve, camera head, light cable,
Leak tester,
mouth guard,
 Berman airway
 Endoscopy masks
 Airway anaesthesia – nebuliser, atomiser,
 Xylocaine Spray , Xylocaine 4% topical,
Co-Phenylcaine
 Battery Light Source
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Documentation
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D.A.S. guidelines
Set up instructions
Decontamination
Instructions
Checking /
Restocking List
Conclusion
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Lack of clear instructions
Technology is changing quickly
Core skills are vital
Difficult Airway devices should be used
in routine cases to ensure familiarity
?? Standard Difficult Airway Cart
nationally