Title/Cover Slide

Airway Management of Patients
with a Difficult Airway
Orlando Hung
Departments of Anesthesia and Surgery,
Dalhousie University, Halifax, Nova Scotia
This presenter does not have any financial
relationship with any device companies.
• Review basic principles of airway
• Context-sensitive Airway Management
• Device-Dependent Airway management
50 Ways to Intubate the Trachea
These algorithms will work if
there is:
Proper preparation
Principles of Airway Management
Case Presentation
• A 34 y.o. lady scheduled for laparotomy for a
pelvic mass
• 80 kg, 150 cm (BMI=35.6)
• No major medical problems
• Airway examination showed that she has a small
mouth opening (3.5 cm), Mallampati IV airway,
receding chin with a thyromental distance <4cm,
a short neck, but good neck mobility
What are your options to ventilate
and oxygenate this patient?
• Awake with spontaneous ventilation
(regional technique)
• Bag Mask Ventilation?
• Extraglottic device (LMA, Combitube,
• Tracheal intubation?
• Surgical Airway?
What alternative intubating techniques
can be considered?
• Direct laryngoscopy with a Macintosh laryngoscope
together with a “bougie”?
• The use of a video-laryngoscope?
• Flexible bronchoscope?
• Lightwand intubation?
• Intubation through the Fastrach (Intubating LMA)?
• Digital intubation?
• Blind nasal intubation?
• Retrograde intubation?
• Cricothyrotomy or tracheotomy?
A. General Anesthesia (GA), tracheal
intubation with a video-laryngoscope
B. Awake intubation using whatever
technique you are most comfortable with
C. Use of an extraglottic device (LMAProSeal, LMA-Classic, etc) if necessary
D. Cricothyrotomy if needed
What if she is 16 weeks pregnant?
Your plans are:
A. Regional anesthesia
B. Secure an airway by whatever means awake
if at all possible
What if she is 16 weeks pregnant with
bowel perforation, peritonitis and sepsis?
A. Regional anesthesia remains controversial
B. Secure the airway awake if at all possible
What if she is in septic shock with
severe hypotension and hypoxemia?
A. Secure the airway awake with a flexible
B. Rapid Sequence Induction and Intubation
(RSI) with a video-laryngoscope?
C. Awake tracheotomy?
What if this is not an emergency OB case, but she
is mentally challenged and unco-operative?
A. Secure the airway awake would be difficult even
with sedation
B. Secure the airway using a video-laryngoscope
under GA with mask induction and
spontaneous respiration
C. Secure the airway using a video-laryngoscope
under GA following iv induction
D. The use of extraglottic device
What if this mentally challenged patient needs an
emergency airway intervention in an MRI unit?
A. Can you bring a Macintosh laryngoscope into
the MRI unit?
B. What about a video-laryngoscope?
C. Can you use an extraglottic (iGel, LMA, etc.)?
D. What about a blind nasal intubation?
E. Digital intubation?
What if you are working in Haiti with
minimal resources?
• RSI with a Macintosh laryngoscope + an
Eschmann Tracheal Introducer (bougie)
• An Extraglottic device (LMA-Classic, or
• Lightwand intubation?
• BMV?
• Surgical AW?
Factors that influence how we
manage the airway of a patient:
• Can I ventilate the patient with a BMV, an extraglottic
device, or through a tracheal tube?
• Failing that, can I get a surgical airway easily?
• Emergency? Cyanotic? Do I have time?
• Pregnant?
• A child? Co-operative?
• Aspiration risk?
• Any assistance?
• Available resources?
• Skills with the airway devices
Difficult Laryngoscopic Intubation?
• When we identify a potentially difficult
laryngoscopic intubation, we must resist the
inclination to persist with direct laryngoscopy.
• With the currently available resources, airway
practitioners should be able to choose an
appropriate device or technique to effectively
manage a difficult laryngoscopy with
alternative plans depending on the situation
or environment as well as the skills of the
Strategy to manage patients with a
difficult airway:
Plan A
Plan B
Plan C
Plan D
These plans should be modified or changed
according to the environment or situations.
Principles of Airway Management
50 Ways to Intubate the Trachea
Device Dependent Airway Management
The Bad
The Bad
How are you going to manage this
patient’s airway?
How can I ventilate and
oxygenate this patient?
• Can I use the bag-mask-ventilation?
• Can I use an extraglottic device (LMA,
Combittube, etc.)?
• Can I place a tube in the trachea?
• What about a surgical airway?
• We should focus on ventilation and
oxygenation in airway management
• Plans to manage the airway of a patient
depend on many factors and situations and
all airway practitioners should modify their
approaches to meet these challenges.
• All airway practitioners should avoid relying
on a single airway device or technique.
Learning New Tricks?
Successful Airway Management
Requires A Team
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