Difficult Airway

DIFFICULT AIRWAY MANAGEMENT

Brooke Army Medical Center

07/17/09

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DIFFICULT AIRWAY MANAGEMENT • Principle elements of airway management – – – – – 07/17/09

Assessment Anticipation Preparedness Resources Skill 2

DIFFICULT AIRWAY MANAGEMENT •

Assessment – Large beard can make exam hard, ventilation impossible and intubation difficult. – Neck trauma, cervical collars – Ear and hand anomalies suggest difficult airway – Mandible to hyoid should be at least 2 fingerbreaths – Receding or hypoplastic mandible =anterior larynx – Expect difficulty with short thick neck and/or obese pt

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DIFFICULT AIRWAY MANAGEMENT • Assessment – Edentulous pts are seldom difficult – Proturberant upper incisors make laryngoscopy difficult – Large tongue make intubation difficult – If uvula cannot be seen watch out 07/17/09

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DIFFICULT AIRWAY MANAGEMENT • Mask ventilation – Fingers on the bone, not the soft tissue – Downward displace the mask with thumb and 1st finger – Up displacement of mandible with other three fingers 07/17/09

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DIFFICULT AIRWAY MANAGEMENT • Two handed mask – Obesity, tumors, infections or inflammatory disorders – Helpful in edentulous patient if you leave in dentures

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DIFFICULT AIRWAY MANAGEMENT • Airway adjuncts – Used when airway cannot be maintained – Helps displace the tongue and soft tissue forward, allowing unobstructed air passage

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DIFFICULT AIRWAY MANAGEMENT • Oral Airway – Avoid in conscious pts – Be careful of teeth – Avoid use in prone pts with neck flexion

• Nasal airway – Semi conscious pts – Relative contraindicated in coagulopathy, basilar skull fractures, nasal infections and deformities 07/17/09

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DIFFICULT AIRWAY MANAGEMENT • Laryngeal Mask Airway – Maintain seal around larygngeal inlet – Allows spontaneous ventilation – Allows controlled ventilation up to 15 cm H2O positive pressure

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DIFFICULT AIRWAY MANAGEMENT: Laryngeal Mask Airway • Unsuitable for conscious patient • Elective use in pt with increased risk of aspiration is contraindicated • However, may be inserted as emergency airway if mask vent or intubation difficult 07/17/09

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DIFFICULT AIRWAY MANAGEMENT: Combitube • Useful as emergency airway • Two lumens allow function whether place in esophagus or trachea • Esophageal balloon minimizes aspiration • Contraindicated in folks < 5 ft, intact gag, esophageal disease, or caustic ingestion 07/17/09

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DIFFICULT AIRWAY MANAGEMENT: Endotracheal Intubation •

Unless contraindicated the head should be placed in a sniffing position

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DIFFICULT AIRWAY MANAGEMENT: Endotracheal Intubation • Difficulties in visualization may be due – Head position – Blade too far advanced or not far enough – Anterior cricoid can be improved by downward pressure 07/17/09

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DIFFICULT AIRWAY MANAGEMENT: Endotracheal Intubation

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DIFFICULT AIRWAY MANAGEMENT: Can’t Intubate • Okay for use in ventilate but can’t intubate • Ideal for ET placement in unstable cervical spine • Difficult to use if blood in oropharynx • Not quick unless skilled

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DIFFICULT AIRWAY MANAGEMENT: Can’t Intubate • Place LMA first, then intubate • Useful in emergency only if LMA allows adequate ventilation and oxygenation

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DIFFICULT AIRWAY MANAGEMENT: Needle cricothyroidectomy •

Percutaneous catheter placement – Short term trans trach oxygenation – Ineffective ambu ventilation – Jet ventilation – retrograde endotracheal intubation – Buys time for surgical airway – Saved a life on Commercial Airliner

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DIFFICULT AIRWAY MANAGEMENT: Can’t Intubate • Retrograde Intubation

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DIFFICULT AIRWAY MANAGEMENT: Can’t Intubate, can’t ventilate • Surgical Airway – Tracheostomy too slow – Cricothyroidotomy quick and allows placement of 6.0 OET

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DIFFICULT AIRWAY MANAGEMENT: Verify • ETCO2 detector

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?’s 07/17/09

Don Daniels, M.D.

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