The Difficult and Failed Airway

The Difficult and Failed Airway
Principles of Rapid Sequence
Jason Carter, B.S., L.P.
I. The Difficult Airway
A. Defined
Difficult to oxygenate and ventilate
Difficult to intubate
Difficult to perform a cricothyroidotomy
B. Predicting the Difficult
Look externally
Evaluate the 3-3-2 rule
Mallampati classification
Obstruction ?
Neck Mobility
1. Look externally
• Beard or Moustache
that hinders seal of
• Abnormal Facial
• Extreme cachexia
• Endentulous mouth
with sunken cheeks
• Disruption of the
lower face due to
• Large central incisors
• High-arching palate
• Receding mandible
• Short bull neck
• Morbid obesity
2. Evaluate the 3-3-2 Rule
• Three finger mouth opening
• Three finger mentum-to-hyoid
• Two finger floor-of-mouth-to-thyroid
3. Mallampati classification
• Spaciousness of
• Done sitting with
head in sniffing
position, mouth wide
open and tongue
sticking out
4. Obstruction
Foreign object – Magill forceps
Laryngeal tumor
Known or suspected epiglottitis
Known or suspected peritonsillar abscess
Direct airway trauma
Extrinsic airway hematoma with
5. Neck mobility
• Spinal motion restriction automatically
makes the RSI difficult
• Non-trauma patients should be able to
bring their head into the sniffing position
II. Clinical Approach to the
Difficult Airway
• First complication is mechanics
• Worst is esophageal intubation
• Factors in failure vs. success
A. Clinical Techniques
Re-position the head – non-traumatic
Jaw Lift in trauma patients
Miller blade for epiglottis
BURP technique
Leave inadvertent esophageal tube in place
1 – 1.5 size smaller ETT
III. The Failed Airway
A. Failed airway defined
• failure of single attempt at oral intubation
followed by inability to maintain SpO2 
90% with BVM
• Three failed attempts made by an
experienced airway manager
B. Management of the Failed
• “Can’t intubate, can
oxygenate” has time
CombiTube Placement
Digital Intubation
Smaller tube
• “Can’t intubate, cannot
oxygenate” immediate
– Needle or Surgical
IV. Conclusion
• General Rule—prepare for the worst and
hope for the best
• Before RSI, determine difficulty of
intubation using LEMON law
• All Spinal Motion Restriction patients are
automatically difficult
• Keep up intubation skills
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