Some Tools for Managing the Difficult Airway

1. Some Tools for Managing the Difficult Airway Joe Lex, MD, FAAEM Temple University Philadelphia, PA

2. Airway management is really easy… …except when it isn’t…

4. 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 Our Options Are Different

5. It can be difficult to… …oxygenate …ventilate …intubate …perform cricothyrotomy

6. To Maximize Success… …recognize and predict difficult airway …choose appropriate technique and equipment …possess technical skills, drugs, and devices

7. Predicting the Difficult Airway…if you have time

8. LEMON Law Look at anatomy Examine the airway Mallampati Obstructions Neck mobility LEMON

9. 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 LEMON

10. Look at Anatomy LEMON

11. Look at Anatomy • Narrow face, high-arched palate: decreased side-to-side diameter • Large tongue: hides airway • False teeth: help bagging, remove for intubation LEMON

12. Examine Airway LEMON

13. Examine Airway The 3 – 3 – 2 rule • Mouth open: 3 fingers • Mentum to hyoid: 3 fingers • Floor of mouth to thyroid cartilage: 2 fingers LEMON

14. Examine Airway • Mouth open: 3 fingers • Allows insertion of tube, laryngoscope • Mentum to hyoid: 3 fingers • Predicts ability to lift tongue into mandible LEMON

15. Examine Airway • Floor of mouth to thyroid cartilage: 2 fingers • If high larynx, airway tucked under base of tongue, hard to visualize LEMON

16. Mallampati Score • With patient seated:extend neck  open mouth  stick out tongue • Visualize base of tongue, faucial pillars, uvula, pharynx LEMON

17. Mallampati Score

18. Airway Obstructions LEMON

19. Airway Obstructions • Angioedema? • Hematoma? • Look under shirt collar • Dentures? • Epiglottis? LEMON

20. Neck Mobility Prior condition • Surgery • Rheumatoid arthritis • Osteoarthritis • Others LEMON

21. Neck Mobility LEMON

22. Neck Mobility • Cervical spine rigidity: reduces ability to align anatomic axes • Inability to mobilize neck can make intubation difficult or impossible LEMON

23. Moving Beyond Laryngoscopy

24. Some Equipment, Old & New

25. Bag valve mask Combitube™ LMA Intubation LMA Fiberoptic: rigid, flexible Lightwand Bougie Transtracheal jet Retrograde Digital Cricothyrotomy Difficult Airway Cart

26. 1. Bag Valve Mask B V M

27. 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 B V M

28. 2. Combitube® Combitube

29. 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 Combitube

30. 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 Combitube

31. 2. Combitube® Combitube

32. 3. Laryngeal Mask Airway L M A

33. 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 L M A

34. Contraindications In elective patient who… …has not fasted …may have gastric contents …has fixed  lung compliance …is not profoundly unconscious …resists LMA airway insertion L M A

35. Usage L M A

36. Usage L M A

37. Usage L M A

38. Usage L M A

39. Usage L M A

40. 4. Intubating LMA L M A

41. L M A

42. 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 L M A

43. 5. Flexible Fiberoptic Scope Fiberoptic

44. 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 Fiberoptic

45. 5. Flexible Fiberoptic Scope Disadvantages • Expensive • Expertise requires practice • Delicate equipment needs careful maintenance • Visual field easily impaired by blood and secretions Fiberoptic

46. 6. Rigid Fiberoptic Scope Fiberoptic

47. Bullard Wu Scope 6. Rigid Fiberoptic Scope Fiberoptic

48. Upsher GlideScope 6. Rigid Fiberoptic Scope Fiberoptic

49. Levitan Scope 6. Rigid Fiberoptic Scope Fiberoptic

50. 6. Rigid Fiberoptic Scope Advantages • Direct airway visualization • Minimal neck movement • May overcome difficult view • Useful in disrupted airway • Durable, sturdy instruments Fiberoptic