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Difficult Airway Management
2009
Adrian Sieberhagen
• Clinical situation in which there is difficulty
in Face Mask Ventilation and inability to
intubate
What makes it difficult in ED’s
• Training/requirements
• Non-controlled setting
• Limited pre-procedural evaluation
• Hypoxia, hypotension, agitation, dynamic
medical conditions
• Numerous logistical & implementation
issues
Predicting the Difficult Airway
• History
• Physical Examination
History
Cormack and Lehane
• Class I: the vocal
cords are visible
• Class II the vocals
cords are only partly
visible
• Class III only the
epiglottis is seen
• Class IV the epiglottis
cannot be seen.
• Pregnancy
• Inflammatory Disease
• Small mouths
• Infections
• Endocrine
• Congenital
• Trauma
• Foreign Body
• Tumours
Examination
LEMON
• Look for external deformities
• Evaluate 3-3-2 rule
• Mallampati
• Obstruction
• Neck Mobility
Mallampati Score
• Class I
– visualization of the soft palate,
fauces, uvula, and both anterior
and posterior pillars
• Class II
– visualization of the soft palate,
fauces, and uvula
• Class III
– visualization of the soft palate
and the base of the uvula
• Class IV
– soft palate is not visible at all
• Thyromental Distance
• 6.5cm normal
• Sternomental Distance
• >12.5cm normal
• Protrusion of Mandible
Management
• Prearranged Emergency airway trolley
available
• Most senior staff
Emergency Airway Trolley
• Rigid laryngoscope blades
• Tracheal tubes
• Tracheal tube guides
• Laryngeal Mask Airways
• Fibreoptic intubation equipment
• Non-invasive/minimally invasive airways
• Surgical Airway
• CO2 detectors
Management
• Prearranged Emergency airway trolley
available
• Most senior staff
• Emergency airway algorithm
• Deliver supplemental O2
Difficult airway managemnt
Difficult airway managemnt
Alternative Airway Techniques
• LMA/Laryngeal Tube
• Transtracheal Jet Ventilation
• Fibreoptic Intubation
• Retrograde Intubation
• Lightwand
• Combitube
• Surgical Airway
Laryngeal Mask
• Lubricated LMA inserted into hypopharynx
• Tip in upper oesophogeal sphincter
• Inflate Cuff
• Muscle relaxants not necessary
• C/I:
– Need for high Peak Pressures
– Risk of Aspiration
– Pts with low lung compliance
Laryngeal Tube
Transtracheal Jet Insuflation
Fibreoptic Intubation
Retrograde Intubation
• Place guidewire through cricothyroid
membrane
• Guidewire passes cephalad through
pharynx and out mouth/nose
• Railroad ET tube
Lightwand
• Flexible
• Inserted through ET tube
• Insert into larynx
• Light dims if entering oesophagus
• Limitations: Dark room
Combitube
• Double lumen tube
• Placed into hypopharynx blindly
• C/I
– Oesophageal pathology
Surgical Airway
• Cricothyroidotomy
– Complications:
• Bleeding
• Infection
• Vocal cord damage
• Tracheal stenosis
– C/I
• <12yrs
• Laryngotracheal Disruption
• Coagulopathy
The End

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Difficult airway managemnt