DIFFICULT AIRWAY

MANAGEMENT

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First Case of the Day

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 ASA Definition
The Difficult Airway-
is defined as the clinical situation in which a
conventionally trained Anesthesiologist experiences
difficulty with facemask ventilation of the upper
airway, difficulty with tracheal intubation, or both
Difficult to Ventilate-
is when signs of inadequate ventilation could not be
reversed by mask ventilation or oxygen saturation
could not be maintained above 90%
Difficult to Intubate-
is when a trained Anesthetist using conventional
laryngoscope takes more than 3 attempts
DISCUSSION

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Degrees of Airway Difficulty

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Overlap

Difficult
Mask
Ventilation

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 Overlap

Difficult Mask Difficult

Ventilation
SGA

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 Triple Failure

Difficult Difficult
Mask
SGA
Ventilation

Difficult
Intubatio DANGER
ZONE
n

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An Emergent Surgical Airway is
Not Always Assured

Difficult
Mask Difficult
Ventilation surgical
airway

Difficult
Danger Zone
Intubation

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 4th National Audit Project
Sept 2008-Sept NAP4
2009 estimated
2,900,000 GA
performed in the UK
Data collected on
114,904 GAs from
309 hospitals over a
2 week period
184 serious airway
complications,
including:
-Death (14)
-Brain Damage
-Emergent Surgical
Airway 10
NAP4 Lessons Learned

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 NAP4 Lessons Learned
Poor Airway Assessment & Poor
Planning contributed to Poor
Outcomes
1.Failure to match strategy to
assessment (technique)
2.Failure to have prepared
strategy (plan B and C)

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 NAP4 Lessons Learned

Emergency
Percutaneous
Cricothyrotom
y failed 60%
of the time

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 NAP4 Lessons Learned
A common theme was failure to plan
for failure
In some cases when airway
management was unexpectedly difficult
the response was unstructured. In
these cases outcomes were generally
poor.
The project identified numerous cases
where awake fiber-optic intubation was
indicated but not used
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 NAP4 Lessons Learned
Aspiration was the single most
common cause of death in anesthesia
events
Importantly most aspirations occur due
to failure to recognize risk factors and
failure to adjust the anesthetic
technique accordingly
Aspiration remains the most frequent
cause of airway related deaths during
anesthesia.
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 NAP4 Lessons Learned
One third of the events occurred during
emergence or in recovery. Obstruction
was the common cause in these events
Recommendations:
Nasal Trumpets
Oral Airway
Airway exchange catheter
SGA prior to removal of ETT (Bailey
Maneuver)
Awaken patient with SGA in place
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 Predictors of Difficult Mask
Ventilation
Beard

OSA

Obesity

Male Gender

Mallampati class III or IV

Neck Circumference
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 Predictors of Difficult
Intubation
Inadequate Preoperative
Assessment.
History of difficult intubation
Inadequate equipment
Experience not enough.
Poor technique.
Increased Age
Mallampati III or IV
 Anatomical Factors Affecting
Laryngoscopy
Neck Circumference (Single Major Predictor in Obese)
Short Neck.
Protruding incisor teeth.
Long high arched palate.
Increase in either anterior depth or Posterior depth of
the mandible decrease in Atlanto Occipital distance
Limited cervical range of motion
Small mouth opening
Temporomandibular joint pathology
Basic Airway Evaluation in
All Patients
Previous anesthetic problems
General appearance of the neck, face,
maxilla and mandible
Jaw movements
Head extension and movements
The teeth and oropharynx
The soft tissues of the neck
Recent chest and cervical spine x-rays
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Think L-E-M-O-N When Assessing
a Difficult Airway

Look externally.
Evaluate the 3-3-2 rule.
Mallampati.
Obstruction?
Neck mobility.
 L: Look Externally
Obesity or very small.
Short Muscular neck
Large breasts
Prominent Upper Incisors (Buck Teeth)
Receding Jaw (Dentures)
Burns
Facial Trauma
Stridor
Macroglossia (Lg Tongue)
E-Evaluate the 3-3-2 Rule
3 fingers fit in mouth
3 fingers fit from mentum
to hyoid cartilage

2 fingers fit from the floor

of the mouth to the top of
the thyroid cartilage

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 E-Evaluate the 3-3-2 Rule

02/22/17 24
 M- Mallampati classification
Class-I Class-II

soft palate, fauces; the soft palate, fauces

Uvula, pillars. and uvula

Class-III Class-IV

soft palate and base of uvula Only hard palate

Mallampati ?

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Cormack & Lehane Grading

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 O-Obstruction
Blood
Vomit
Teeth
Dentures
Epiglottis
Tumors
Foreign Body (piercings)
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N-Neck mobility -Measurement of

Atlanto-Occipital Angle
 Atlanto-Occipital Angle
Estimates the angle
traversed by the
occluded surface of
the upper teeth

Grade I --- > 35

Grade II - 22-34
Grade III 12-21
Grade IV -- < 12

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 Thyromental Distance
Measure from upper edge of thyroid
cartilage to chin with the head fully
extended.
A short thyromental distance equates
with an anterior larynx
Greater than 7 cm is usually a sign of an
easy intubation
Less than 6 cm is an indicator of a
difficult airway
Relatively unreliable test unless
combined with other tests
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Thyromental Distance

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 MANAGEMENT PLAN OF
ANTICEPATED DIFFICULT AIRWAY
1. Discussion with colleagues in advance

2. Equipment tested before

3. Senior help backup

4. Definite initial plan (A) for ventilation and

intubation

5. Definite plan (B) than option of awake

intubation

6. Ideal situation surgery team standby

 Preoxygenation
Two Techniques Common in Use:
1. Tidal volume breathing (TVB) of 100%
oxygen via a tight-fitting face mask for 5
minutes (Preferred Method)
2. Deep breaths/Vital Capacity 4 times within
0.5 min (Time to desaturation is consistently
shorter then preferred method)
Why Preoxygenate?
O2 Consumption Vo2=250ml/min and 2500ml O2
in FRC (after preO2) = 10 minutes to use this O2
 Airway Management A-B-C

Start with Plan A

If plan A fails-

Go to plan B
If plan B fails-

Go to plan C
 Plan A: (ALTERNATE)

Different Length of blade

Different Type of Blade

Different Position

Different Equipment
Plan B: (BVM and BLIND
INTUBATION Techniques )
Mask Ventilation
Bougie
Combi-Tube?
LMA an Option?
Fiberoptic?
 Plan-C Cant Intubate.. Cant
Ventilate
Needle Cricothyrotomy

Transtracheal Jet Ventilation

Retrograde Wire Intubation

Failure.. Why does it happen
No critical discussion with colleagues
about proposed management plan
No request for experienced help
Exaggerated idea of personal ability
Ill-conceived plan A and/or plan B
Poorly executed plan A and/or plan B
Persisting with plan A too long,
starting the rescue plan too late
Not involving, and preparing,
surgical colleagues
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GALLERY
OF
TOOLS
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Rigid Laryngoscope Blades Of
Alternate Design And Size
Mc Coy
Macintosh

Magill

Miller

Polio

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Video Laryngoscopy

Airtraq
McGrath
C-Mac
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 Video Laryngoscopy
VL Calls on a
Alternative Skill
Set

In Critical
Situations
Unpracticed
Techniques may
not be Helpful

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 Video Laryngoscopy

Use a stylet and

shape it to match
your VL Blade

Watch the patient

not the monitor
when

inserting the VL
Blade

Trouble passing tube

-Withdraw 44
 Video Laryngoscopy Versus
Direct Laryngoscopy
Improved Glottic
View
Experienced vs
Inexperienced
Cost
Standard of the
future?
Picture Confirmation?

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 Bullard Rigid Fiberoptic
Laryngoscope

Time
Experience
Limited Maneuverability
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 Stylet Devices
Optical Stylet Lighted Stylet

No Nasal Intubation
No Suction
Limited to above Cords 47
GUM ELASTIC BOUGIE (GEB)
First used in England
Cheap
Good in patients in whom
only epiglottis is visualized

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Supraglottic Airways SGA
Combitube LMA

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 The Esophageal-
Tracheal Combitube
Useful as emergency
airway

Two lumens allow

function whether
place in esophagus or
trachea

Esophageal balloon
minimizes aspiration

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Laryngeal Mask Airway
 VARIATIONS OF LMA

LMA Classic (standard)

LMA Flexible (reinforced)
LMA Unique (disposable LMA)
LMA Fastrach (intubating LMA)
LMA C-Trach
(Visualization/Intubation)
LMA Proseal (gastric LMA)

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LMA Fastrach (Intubating LMA)
Rigid, anatomically curved,
airway tube that is wide enough
to accept an 8.0 mm cuffed ETT
and is short enough to ensure
passage of the ETT cuff beyond
the vocal cords

Rigid handle to facilitate one-

handed insertion, removal

Epiglottic elevating bar in the

mask aperture which elevates
the epiglottis as the ETT is
passed through

Available in three sizes, one size

for children, two sizes for adults

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 LMA C-Trach

Ventilation

Visualization

Intubation

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 LMA-Proseal
High seal pressure - up to
30 cm H20 - Providing a
tighter seal against the
glottic opening with no
increase in mucosal
pressure
Provides more airway
security
Enables use of PPV in those
cases where it may be
required
A built-in drain tube
designed to channel fluid
away and permit gastric
access for patients with
GERD
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LMA-Proseal

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 Fiberoptic Aided Intubation
Most Versatile Tool
Available for Difficult
Intubation
Optical Elements are
Small
Visualization Below
the Cords
Awake Intubation
Unique Skillset
Lens Contamination
Cost

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Cant Ventilate/Cant
Intubate

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 Cricothyrotomy
Airway established
through the
Cricothyroid
Membrane
Not a Tracheostomy
Large Bore Catheter
Expected skill of the
Anesthetist
Contraindicated in
Neonates and
Children under age
6

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 Transtracheal Jet Ventilation
Maxillofacial,
Pharyngeal, or
Laryngeal Trauma,
Pathology or Deformity
16-Gauge or Larger
(16g- tidal volume 400-
700)
15-30 psi with
Insufflation 1-1.5 sec.
Specialized systems
capable of using Low-
pressure O2
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 Retrograde Intubation
Local Anesthesia of the airway, skin wheel at
puncture site.

Cricothyrotomy performed with air aspiration

Retrograde wire is advanced until it emerges

from the mouth. (Magill Forceps)

Wire is Clamped/Secured at the entry site

ETT advanced over the wire (Many

Techniques)

Wire removed leaving ETT in place

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Retrograde Intubation

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Extubation of the Difficult
Airway

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 Airway Exchange Catheter
Extubation in a
controlled manner with
a AEC

Well tolerated
Airway can be
reintubated
Can deliver Oxygen
Provides an avenue for
suction
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Airway Exchange Catheter

Localize the airway through existing

ETT
Mark AEC at required depth (tube
depth +3 CM)
Insert AEC and remove ETT
Tape AEC in place
Assess for removal of AEC

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 Bailey Maneuver
Exchange of ETT for
a LMA

Decreased Severity
of
Cough
Maximum
change SBP
Maximum
change HR
Sore throat 66
 Bailey Maneuver
Patient is Deep
Oral-pharyngeal
suction
Deflated LMA
placed behind ETT
LMA cuff inflated
ETT cuff deflated
and removed
LMA used for
ventilation
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 What's New in the ASA Difficult
Airway Algorithm
2003 2013

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What's New in the ASA Difficult Airway Algorithm

Assess Likelihood and Impact section.

Added:
Difficult Supraglottic airway placement
Separated: Intubation and Laryngoscopy

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 What's New in the ASA Difficult Airway Algorithm

2003 2013

Basic Management Choices:

Video-assisted Laryngoscopy as
initial approach to Intubation

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 What's New in the ASA Difficult Airway Algorithm

2003 2013

LMA changed to SGA

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 What's New in the ASA Difficult Airway Algorithm

2003 2013

Video-Assisted Laryngoscopy: Listed first

under Alternative Difficult Intubation
Approach
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 What's New in the ASA Difficult Airway Algorithm

2003 2013

Under Invasive Airway

Access: Percutaneous airway
techniques and jet ventilation
remain but are
de-emphasized

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Two For The Road

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 Two For The Road
Be familiar with alternative
intubating techniques and use
them on a regular basis in your
day to day practice.

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Two For The Road

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Questions?

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Questions?

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