Difficult Airway Toolkit
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Some Tools for Managing the Difficult Airway Joe Lex, MD, FAAEM Temple University Philadelphia, PA Emergency Medicine
Airway management is really easy… …except when it isn’t…
Our Options Are Different •
Anesthesiology Plan in advance
Can’t get airway... …awaken patient …regroup …go for coffee
Emergency • What will be, will be Can’t get airway… …wipe brow …change shorts …call attorney …call coroner Emergency Medicine
It can be difficult to… …oxygenate …ventilate …intubate …perform cricothyrotomy Emergency Medicine
To Maximize Success… …recognize and predict difficult airway …choose appropriate technique and equipment …possess technical skills, drugs, and devices Emergency Medicine
Predicting the Difficult Airway …if you have time Emergency Medicine
LEMON Law Look at anatomy Examine the airway Mallampati Obstructions Neck mobility Emergency Medicine
Look at Anatomy • • • •
Obesity: rapid desaturation, difficult intubation, ventilation Facial hair: hides small chin, can make bagging difficult / impossible Large teeth: hide airway, obscure tube passage Jagged teeth: lacerate balloon Emergency Medicine
Look at Anatomy
Emergency Medicine
Look at Anatomy • • •
Narrow face, high-arched palate: decreased side-to-side diameter Large tongue: hides airway False teeth: help bagging, remove for intubation
Emergency Medicine
Examine Airway
Emergency Medicine
Examine Airway
• • •
The 3 – 3 – 2 rule Mouth open: 3 fingers Mentum to hyoid: 3 fingers Floor of mouth to thyroid cartilage: 2 fingers Emergency Medicine
Examine Airway
• Mouth open: 3 fingers Allows insertion of tube, laryngoscope
• Mentum to hyoid: 3 fingers Predicts ability to lift tongue into mandible Emergency Medicine
Examine Airway
• Floor of mouth to thyroid
cartilage: 2 fingers If high larynx, airway tucked under base of tongue, hard to visualize
Emergency Medicine
Mallampati Score
• •
With patient seated: extend neck open mouth stick out tongue Visualize base of tongue, faucial pillars, uvula, pharynx
Emergency Medicine
Mallampati Score Difficulty None
None
Moderate
Severe
Airway Obstructions
Emergency Medicine
Airway Obstructions
• •
Angioedema? Hematoma?
Look under shirt collar
• •
Dentures? Epiglottis? Emergency Medicine
Neck Mobility Prior condition • Surgery • Rheumatoid arthritis • Osteoarthritis • Others
Emergency Medicine
Neck Mobility
Emergency Medicine
Neck Mobility
• •
Cervical spine rigidity: reduces ability to align anatomic axes Inability to mobilize neck can make intubation difficult or impossible Emergency Medicine
Moving Beyond Laryngoscopy
Some Equipment, Old & New
Difficult Airway Cart
• • • • •
Bag valve mask Combitube™ LMA Intubation LMA Fiberoptic: rigid, flexible
• • • • • •
Lightwand Bougie Transtracheal jet Retrograde Digital Cricothyrotomy Emergency Medicine
1. Bag Valve Mask
1. Bag Valve Mask (BVM)
• • • •
Practice: skills essential Use appropriate size oral airway or nasal trumpet Leave dentures Use water-soluble lubricant to get good seal, especially if lots of facial hair Emergency Medicine
2. Combitube®
2. Combitube®
• • • •
Double lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tube Insert blindly 90% esophageal Inflate proximal balloon: 100 mL Inflate distal balloon: 5 –15mL
Emergency Medicine
2. Combitube®
• •
Seals oropharyngeal and nasopharyngeal cavities Ventilate through blue port
Good breath sounds and no air in stomach continue ventilating No breath sounds and air in stomach use white tube
Emergency Medicine
2. Combitube®
Emergency Medicine
3. Laryngeal Mask Airway
Indications
• • •
Routine / emergency procedures Known / unknown difficult airway During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible Emergency Medicine
Contraindications In elective patient who… …has not fasted …may have gastric contents …has fixed lung compliance …is not profoundly unconscious …resists LMA airway insertion Emergency Medicine
Usage
Emergency Medicine
Usage
Emergency Medicine
Usage
Emergency Medicine
Usage
Emergency Medicine
Usage
Emergency Medicine
4. Intubating LMA
Emergency Medicine
LMA Take-Home Points
• • • • •
Test cuff before use Don’t lubricate anterior mask Insert only in comatose patient Keep cuff inflated until patient awake Don’t throw out!! Used 40 – 50 times Emergency Medicine
5. Flexible Fiberoptic Scope
5. Flexible Fiberoptic Scope Advantages
• • • • •
Allows direct airway visualization Causes little hemodynamic stress Nasotracheal or orotracheal route Can be done in all age groups Requires minimal neck movement Emergency Medicine
5. Flexible Fiberoptic Scope Disadvantages
• • • •
Expensive Expertise requires practice Delicate equipment needs careful maintenance Visual field easily impaired by blood and secretions Emergency Medicine
6. Rigid Fiberoptic Scope
6. Rigid Fiberoptic Scope Bullard
Wu Scope
Emergency Medicine
6. Rigid Fiberoptic Scope Upsher
GlideScope
Emergency Medicine
6. Rigid Fiberoptic Scope Levitan Scope
Emergency Medicine
6. Rigid Fiberoptic Scope Advantages
• • • • •
Direct airway visualization Minimal neck movement May overcome difficult view Useful in disrupted airway Durable, sturdy instruments Emergency Medicine
6. Rigid Fiberoptic Scope Disadvantages
• • • •
Expensive Expertise requires practice Visual field easily impaired by blood and secretions Not readily available Emergency Medicine
7. Lightwand (Trachlight)
7. Lightwand (Trachlight)
7. Lightwand (Trachlight) Advantages
• • • • •
Minimal neck movement Useful adjunct to laryngoscopy Portable and inexpensive Usable in bloody airway Provides definitive airway Emergency Medicine
7. Lightwand (Trachlight) Disadvantages
• • • •
Blind technique May damage airway Usually requires darkened room Expertise requires practice
Emergency Medicine
8. Intubating Stylet (Bougie)
8. Intubating Stylet (Bougie)
•
Gum elastic – use as guidewire
Advantages
• • • •
Gives definitive airway Easy to learn Inexpensive Can be used blindly Emergency Medicine
8. Intubating Stylet (Bougie)
•
Gum elastic – use as guidewire
Disadvantages
• •
Expertise requires practice Not recommended in “can’t intubate / can’t ventilate” scenario
Emergency Medicine
9. Transtracheal Jet Ventilation
9. Transtracheal Jet Ventilation Advantages • Surgical airway of choice if 8 years or younger • Effective • Can serve as temporary airway before permanent airway • Relatively simple procedure Emergency Medicine
9. Transtracheal Jet Ventilation Disadvantages • Significant complications if misplaced • Need proper equipment • Need high-pressure oxygen • Does not protect against aspiration
Emergency Medicine
10. Retrograde Intubation
10. Retrograde Intubation
• • • •
Puncture cricothyroid membrane Thread wire through vocal cords Exit nose or mouth Guide endotracheal tube through vocal cords over wire
Emergency Medicine
10. Retrograde Intubation Advantages
• • •
Definitive airway Minimal neck movement Does not require full mouth open
Emergency Medicine
10. Retrograde Intubation Disadvantages
• • •
Takes time Requires skill Not recommended in cannot intubate / cannot ventilate
Emergency Medicine
11. Digital Intubation
11. Digital Intubation
• • •
You need long fingers Make sure patient is really unconscious Not commonly used, but can be lifesaver
Emergency Medicine
11. Digital Intubation Indications
• • • •
Poor lighting, difficult patient position, disrupted airway, potential cervical spine injury Can’t see larynx due to blood Equipment failure Intubation failure Emergency Medicine
12. Cricothyrotomy
12. Cricothyrotomy
• • •
Life-saving technique Surgical vs. needle / Seldinger vs. percutaneous kit You must know this procedure before starting rapid sequence
Emergency Medicine
12. Cricothyrotomy
• •
Final common pathways for all cannot intubate / cannot ventilate scenarios “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen
Emergency Medicine
And finally… BURP your patient – grab the larynx and give…
…Backward …Upward …Rightward …Pressure Emergency Medicine
Conclusions
•
Recognize the difficult airway
• •
How much time do you have? Who else is around? What is your backup procedure
Know both old and new methods Choose backups based on skills
Emergency Medicine
Dziękuję bardzo [email protected] [email protected] Emergency Medicine
Airway management is really easy… …except when it isn’t…
Our Options Are Different •
Anesthesiology Plan in advance
Can’t get airway... …awaken patient …regroup …go for coffee
Emergency • What will be, will be Can’t get airway… …wipe brow …change shorts …call attorney …call coroner Emergency Medicine
It can be difficult to… …oxygenate …ventilate …intubate …perform cricothyrotomy Emergency Medicine
To Maximize Success… …recognize and predict difficult airway …choose appropriate technique and equipment …possess technical skills, drugs, and devices Emergency Medicine
Predicting the Difficult Airway …if you have time Emergency Medicine
LEMON Law Look at anatomy Examine the airway Mallampati Obstructions Neck mobility Emergency Medicine
Look at Anatomy • • • •
Obesity: rapid desaturation, difficult intubation, ventilation Facial hair: hides small chin, can make bagging difficult / impossible Large teeth: hide airway, obscure tube passage Jagged teeth: lacerate balloon Emergency Medicine
Look at Anatomy
Emergency Medicine
Look at Anatomy • • •
Narrow face, high-arched palate: decreased side-to-side diameter Large tongue: hides airway False teeth: help bagging, remove for intubation
Emergency Medicine
Examine Airway
Emergency Medicine
Examine Airway
• • •
The 3 – 3 – 2 rule Mouth open: 3 fingers Mentum to hyoid: 3 fingers Floor of mouth to thyroid cartilage: 2 fingers Emergency Medicine
Examine Airway
• Mouth open: 3 fingers Allows insertion of tube, laryngoscope
• Mentum to hyoid: 3 fingers Predicts ability to lift tongue into mandible Emergency Medicine
Examine Airway
• Floor of mouth to thyroid
cartilage: 2 fingers If high larynx, airway tucked under base of tongue, hard to visualize
Emergency Medicine
Mallampati Score
• •
With patient seated: extend neck open mouth stick out tongue Visualize base of tongue, faucial pillars, uvula, pharynx
Emergency Medicine
Mallampati Score Difficulty None
None
Moderate
Severe
Airway Obstructions
Emergency Medicine
Airway Obstructions
• •
Angioedema? Hematoma?
Look under shirt collar
• •
Dentures? Epiglottis? Emergency Medicine
Neck Mobility Prior condition • Surgery • Rheumatoid arthritis • Osteoarthritis • Others
Emergency Medicine
Neck Mobility
Emergency Medicine
Neck Mobility
• •
Cervical spine rigidity: reduces ability to align anatomic axes Inability to mobilize neck can make intubation difficult or impossible Emergency Medicine
Moving Beyond Laryngoscopy
Some Equipment, Old & New
Difficult Airway Cart
• • • • •
Bag valve mask Combitube™ LMA Intubation LMA Fiberoptic: rigid, flexible
• • • • • •
Lightwand Bougie Transtracheal jet Retrograde Digital Cricothyrotomy Emergency Medicine
1. Bag Valve Mask
1. Bag Valve Mask (BVM)
• • • •
Practice: skills essential Use appropriate size oral airway or nasal trumpet Leave dentures Use water-soluble lubricant to get good seal, especially if lots of facial hair Emergency Medicine
2. Combitube®
2. Combitube®
• • • •
Double lumen tube functions as esophageal obturator airway plus standard cuffed endotracheal tube Insert blindly 90% esophageal Inflate proximal balloon: 100 mL Inflate distal balloon: 5 –15mL
Emergency Medicine
2. Combitube®
• •
Seals oropharyngeal and nasopharyngeal cavities Ventilate through blue port
Good breath sounds and no air in stomach continue ventilating No breath sounds and air in stomach use white tube
Emergency Medicine
2. Combitube®
Emergency Medicine
3. Laryngeal Mask Airway
Indications
• • •
Routine / emergency procedures Known / unknown difficult airway During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible Emergency Medicine
Contraindications In elective patient who… …has not fasted …may have gastric contents …has fixed lung compliance …is not profoundly unconscious …resists LMA airway insertion Emergency Medicine
Usage
Emergency Medicine
Usage
Emergency Medicine
Usage
Emergency Medicine
Usage
Emergency Medicine
Usage
Emergency Medicine
4. Intubating LMA
Emergency Medicine
LMA Take-Home Points
• • • • •
Test cuff before use Don’t lubricate anterior mask Insert only in comatose patient Keep cuff inflated until patient awake Don’t throw out!! Used 40 – 50 times Emergency Medicine
5. Flexible Fiberoptic Scope
5. Flexible Fiberoptic Scope Advantages
• • • • •
Allows direct airway visualization Causes little hemodynamic stress Nasotracheal or orotracheal route Can be done in all age groups Requires minimal neck movement Emergency Medicine
5. Flexible Fiberoptic Scope Disadvantages
• • • •
Expensive Expertise requires practice Delicate equipment needs careful maintenance Visual field easily impaired by blood and secretions Emergency Medicine
6. Rigid Fiberoptic Scope
6. Rigid Fiberoptic Scope Bullard
Wu Scope
Emergency Medicine
6. Rigid Fiberoptic Scope Upsher
GlideScope
Emergency Medicine
6. Rigid Fiberoptic Scope Levitan Scope
Emergency Medicine
6. Rigid Fiberoptic Scope Advantages
• • • • •
Direct airway visualization Minimal neck movement May overcome difficult view Useful in disrupted airway Durable, sturdy instruments Emergency Medicine
6. Rigid Fiberoptic Scope Disadvantages
• • • •
Expensive Expertise requires practice Visual field easily impaired by blood and secretions Not readily available Emergency Medicine
7. Lightwand (Trachlight)
7. Lightwand (Trachlight)
7. Lightwand (Trachlight) Advantages
• • • • •
Minimal neck movement Useful adjunct to laryngoscopy Portable and inexpensive Usable in bloody airway Provides definitive airway Emergency Medicine
7. Lightwand (Trachlight) Disadvantages
• • • •
Blind technique May damage airway Usually requires darkened room Expertise requires practice
Emergency Medicine
8. Intubating Stylet (Bougie)
8. Intubating Stylet (Bougie)
•
Gum elastic – use as guidewire
Advantages
• • • •
Gives definitive airway Easy to learn Inexpensive Can be used blindly Emergency Medicine
8. Intubating Stylet (Bougie)
•
Gum elastic – use as guidewire
Disadvantages
• •
Expertise requires practice Not recommended in “can’t intubate / can’t ventilate” scenario
Emergency Medicine
9. Transtracheal Jet Ventilation
9. Transtracheal Jet Ventilation Advantages • Surgical airway of choice if 8 years or younger • Effective • Can serve as temporary airway before permanent airway • Relatively simple procedure Emergency Medicine
9. Transtracheal Jet Ventilation Disadvantages • Significant complications if misplaced • Need proper equipment • Need high-pressure oxygen • Does not protect against aspiration
Emergency Medicine
10. Retrograde Intubation
10. Retrograde Intubation
• • • •
Puncture cricothyroid membrane Thread wire through vocal cords Exit nose or mouth Guide endotracheal tube through vocal cords over wire
Emergency Medicine
10. Retrograde Intubation Advantages
• • •
Definitive airway Minimal neck movement Does not require full mouth open
Emergency Medicine
10. Retrograde Intubation Disadvantages
• • •
Takes time Requires skill Not recommended in cannot intubate / cannot ventilate
Emergency Medicine
11. Digital Intubation
11. Digital Intubation
• • •
You need long fingers Make sure patient is really unconscious Not commonly used, but can be lifesaver
Emergency Medicine
11. Digital Intubation Indications
• • • •
Poor lighting, difficult patient position, disrupted airway, potential cervical spine injury Can’t see larynx due to blood Equipment failure Intubation failure Emergency Medicine
12. Cricothyrotomy
12. Cricothyrotomy
• • •
Life-saving technique Surgical vs. needle / Seldinger vs. percutaneous kit You must know this procedure before starting rapid sequence
Emergency Medicine
12. Cricothyrotomy
• •
Final common pathways for all cannot intubate / cannot ventilate scenarios “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen
Emergency Medicine
And finally… BURP your patient – grab the larynx and give…
…Backward …Upward …Rightward …Pressure Emergency Medicine
Conclusions
•
Recognize the difficult airway
• •
How much time do you have? Who else is around? What is your backup procedure
Know both old and new methods Choose backups based on skills
Emergency Medicine
Dziękuję bardzo [email protected] [email protected] Emergency Medicine
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