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The Difficult AirwayThe Difficult Airway

Robert J. Vissers, MD FACEPDepartment of Emergency Medicine

Legacy, Emanuel Hospital

Robert J. Vissers, MD FACEPRobert J. Vissers, MD FACEPDepartment of Emergency Medicine Department of Emergency Medicine

Legacy, Emanuel HospitalLegacy, Emanuel Hospital

The Difficult AirwayThe Difficult Airway

Defining the problemDefining the difficult airwayIdentifying the difficult airwayManaging the difficult airway

DefDefiinniing the problemng the problemDefDefiinniing the dng the diiffffiicult acult aiirwayrwayIdIdententiifyfyiing the dng the diiffffiicult acult aiirwayrwayManagManagiing the dng the diiffffiicult acult aiirwayrway

Difficult Airway Algorithms: ASADifficult Airway Algorithms: ASAFig 1ASA DIFFICULT AIRWAY ALGORITHM

Anesthesiology 1996;84:686A

Fig 1ASA DIFFICULT AIRWAY ALGORITHM

Anesthesiology 1996;84:686A

Cancel Case

Awaken

Ectopic AnesthesiaEctopic Anesthesia

Problem:UrgencyCost of failure Formula for error

Problem:Problem:UrgencyUrgencyCost of failure Cost of failure Formula for errorFormula for error

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Emergency Airway Management

Emergency Airway Management

Solution:PreparationAnticipate difficulties Simple, consistent, reproducible approach

Solution:Solution:PreparationPreparationAnticipate difficulties Anticipate difficulties Simple, consistent, reproducible Simple, consistent, reproducible approachapproach

Difficult Airway AlgorithmsDifficult Airway Algorithms

Common principles Assessment of ventilation difficultyAssessment of intubation difficultyAwake vs. induction and paralysisCalling for helpSurgical airway is a potential endpoint

Common principles Common principles Assessment of ventilation difficultyAssessment of ventilation difficultyAssessment of intubation difficultyAssessment of intubation difficultyAwake vs. induction and paralysisAwake vs. induction and paralysisCalling for helpCalling for helpSurgical airway is a potential endpointSurgical airway is a potential endpoint

Decision to intubate

Near death?Unresponsive?

Difficult Airway?

Rapid Sequence Intubation

Failed AirwayDifficult

Airway Techniques

Crash Airway

Adapted from: Walls RM, Ed. The Manual of Emergency Airway Management Philadelphia, Lippincott, 2000.

Approach to the Emergency Airway Decision to IntubateDecision to Intubate

Airway maintenanceOxygenationVentilationFacilitate therapyExpected course

Airway maintenanceAirway maintenanceOxygenationOxygenationVentilationVentilationFacilitate therapyFacilitate therapyExpected courseExpected course

Decision to intubate

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Decision to Intubate: ModifiersDecision to Intubate: Modifiers

Operator experienceSetting Potential for a difficult airway

Never take away what you cannot replace

Operator experienceOperator experienceSetting Setting Potential for a difficult airwayPotential for a difficult airway

Never take away what you cannot replaceNever take away what you cannot replace

National Emergency Airway Registry (NEAR)

National Emergency Airway Registry (NEAR)

Prospective airway registry n = 12,000<1% fail rate with RSICricothyrotomy rate 0.6% No cases of “cannot intubate, cannot ventilate” with death

Prospective airway registry n = 12,000Prospective airway registry n = 12,000<1% fail rate with RSI<1% fail rate with RSICricothyrotomy rate 0.6% Cricothyrotomy rate 0.6% No cases of No cases of ““cannot intubate, cannot cannot intubate, cannot ventilateventilate”” with deathwith death

The Difficult AirwayThe Difficult Airway

DIFFICULT BAGAND MASK VENTILATION

DIFFICULT LARYNGOSCOPYAND INTUBATION

DIFFICULTDIFFICULTCRICOTHYROTOMYCRICOTHYROTOMY

“SAKLES’ TRIANGLE”

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The Difficult AirwayThe Difficult Airway

DIFFICULT BAGAND MASK VENTILATION

DIFFICULT LARYNGOSCOPYAND INTUBATION

DIFFICULTCRICOTHYROTOMY

“SAKLES’ TRIANGLE”

Assessment of Difficult BVMAssessment of Difficult BVM

Assessment of Difficult BVMAssessment of Difficult BVM

Consider potential difficulty of BVM ventilation before RSIBeware the full stomachEquipment out and readyFive predictors of difficult BVM: facial hair, obesity, adentulous, elderly, snoring *

Consider potential difficulty of BVM Consider potential difficulty of BVM ventilation ventilation beforebefore RSIRSIBeware the full stomachBeware the full stomachEquipment out and readyEquipment out and readyFive predictors of difficult BVM: facial Five predictors of difficult BVM: facial hair, obesity, hair, obesity, adentulousadentulous, elderly, , elderly, snoringsnoring **

*Langeron O, et al. Anesthesiology, 2000.

Assessment of Difficult BVM: Bones

Assessment of Difficult BVM: Bones

M ask sealO besity/obstructionA ge > 55N o teethS tiff lungs

MM ask sealask sealOO besitybesity/obstruction/obstructionAA gege > 55> 55NN o teetho teethSS tiff lungstiff lungs

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The Difficult AirwayThe Difficult Airway

DIFFICULT BAGAND MASK VENTILATION

DIFFICULT LARYNGOSCOPYAND INTUBATION

DIFFICULTCRICOTHYROTOMY

“SAKLES’ TRIANGLE”

Assessment of Difficult Intubation

Assessment of Difficult Intubation

Laryngoscopic view (Cormack-Lehane) – too lateSystems too complex, impracticalNeed simple, fast approach

LaryngoscopicLaryngoscopic view (Cormackview (Cormack--LehaneLehane) ) –– too latetoo lateSystems too complex, impracticalSystems too complex, impracticalNeed simple, fast approachNeed simple, fast approach

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Difficult Airway…? “LEMON” Law“LEMON” Law

L ook externallyE xamine (3-3-2)M allampati gradeO bstructionN eck mobility

LL ookook externallyexternallyEE xaminexamine (3(3--33--2)2)MM allampatiallampati gradegradeOO bstructionbstructionNN eckeck mobilitymobility

Cognitive forcing strategies in clinical decisionmaking. P Croskerry. Ann Emerg Med Jan, 2003.

Adapted from: Walls RM, Ed. The Manual of Emergency Airway ManagementPhiladelphia, Lippincott, 2000.

LEMON: LookLEMON: Look

Simple visual inspection often reveals obvious potential difficulties

Simple visual inspection often reveals Simple visual inspection often reveals obvious potential difficultiesobvious potential difficulties

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LEMON: Examine 3-3-2LEMON: Examine 3-3-2Assess oral opening - 3 fingers

Measure the mandible - 3 fingers Position of larynx - 2 fingers

Assess oral opening Assess oral opening -- 3 fingers3 fingersMeasure the mandible Measure the mandible -- 3 fingers 3 fingers

Position of larynx Position of larynx -- 2 fingers 2 fingers

LEMON: Examine 3-3-2LEMON: Examine 3-3-2

Assess oral opening –should be able to accommodate 3 fingers

Assess oral Assess oral opening opening ––should be able should be able to to accommodate accommodate 3 fingers3 fingers

LEMON: Examine 3-3-2LEMON: Examine 3-3-2

Measure the mandible - should be able to fit 3 fingers between the mentum and the hyoid bone

Measure the Measure the mandible mandible -- should should be able to fit 3 be able to fit 3 fingers between fingers between the the mentummentum and and the hyoid bonethe hyoid bone

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LEMON: Examine 3-3-2LEMON: Examine 3-3-2

Assess position of larynx – should get 2 fingers between the thyroid cartilage and the mandible

Assess position of Assess position of larynx larynx –– should should get 2 fingers get 2 fingers between the between the thyroid cartilage thyroid cartilage and the mandibleand the mandible

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Class I

Class IV

Class II

Class III

LEMON: MallampatiLEMON: Mallampati

LEMON: Obstruction?LEMON: Obstruction?

1) Location? 2) Fixed or mobile?

3) Speed of progression?

1) Location? 1) Location? 2) Fixed or mobile?2) Fixed or mobile?

3) Speed of progression?3) Speed of progression?

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LEMON: Neck MobilityLEMON: Neck Mobility

Can the patient flex and extend the neck?Actively assess in the non-trauma obtunded patient.Cervical spine immobilization - remove anterior collar while c-spine is immobilized.

Can the patient flex and extend the Can the patient flex and extend the neck?neck?Actively assess in the nonActively assess in the non--trauma trauma obtunded patient.obtunded patient.Cervical spine immobilization Cervical spine immobilization -- remove remove anterior collar while canterior collar while c--spine is spine is immobilized.immobilized.

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“LEMON” Law“LEMON” Law

L ook externallyE xamine (3-3-2)M allampati gradeO bstructionN eck mobility

LL ookook externallyexternallyEE xaminexamine (3(3--33--2)2)MM allampatiallampati gradegradeOO bstructionbstructionNN eckeck mobilitymobility

LEMON: Predictive?LEMON: Predictive?

156 ED patients requiring intubationScored using LEMONSimple point system used (0 to 10)Compared to laryngoscopic view (Cormack –Lehane)Felt to be predictive, P<0.05

156 ED patients requiring intubation156 ED patients requiring intubationScored using LEMONScored using LEMONSimple point system used (0 to 10)Simple point system used (0 to 10)Compared to Compared to laryngoscopiclaryngoscopic view (Cormack view (Cormack ––LehaneLehane))Felt to be predictive, P<0.05Felt to be predictive, P<0.05

Reed MJ et al. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J 2005 Feb; 22:99-102.

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LEMON: Predictive?LEMON: Predictive?

Reed MJ et al. Can an airway assessment score predict difficulty at intubation in the emergency department? EmergMed J 2005 Feb; 22:99-102.

Reed MJ et al. Can an airway assessment score predict Reed MJ et al. Can an airway assessment score predict difficulty at intubation in the emergency department? difficulty at intubation in the emergency department? EmergEmergMed JMed J 2005 Feb; 22:992005 Feb; 22:99--102. 102.

Airway alternatives

Airway alternatives

BVMIntubating LMA®LightwandGlidescopeFiberopticsBougieCombitubeKing-LT

TTJVCricothyrotomy

Zone of Increasing Sphincter Tone

Supraglottic:

Infraglottic:

ZIST

Nasal

BNTIFiberoptics

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Rescue DevicesRescue Devices

Most require oral accessMost are designed to deal with high anterior cords

I-LMA, King-LT, CombitubeIntubating stylet (bougie, frova, etc.)Video - glidescope

Most require oral accessMost require oral accessMost are designed to deal with high Most are designed to deal with high anterior cordsanterior cords

II--LMA, KingLMA, King--LT, LT, CombitubeCombitubeIntubatingIntubating styletstylet ((bougiebougie, , frovafrova, etc.), etc.)Video Video -- glidescopeglidescope

CombitubeCombitube

King-LTKing-LT I-LMA I-LMA

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Video LaryngoscopyVideo Laryngoscopy LMA CTrachLMA CTrach

GlidescopeGlidescope

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Pediatric AsthmaticPediatric Asthmatic

Beginning to fatigueSats droppingNeeds to be intubated

Beginning to fatigueBeginning to fatigueSatsSats droppingdroppingNeeds to be Needs to be intubatedintubated

Preoxygenation: DesaturationPreoxygenation: Desaturation

From: Benumof JL: Anesthesiology 87:979-982, 1997.

3.4 mL/kg/min6 mL/kg/min

Preoxygenation: DesaturationPreoxygenation: Desaturation

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Awake look/scopesAwake look/scopes

Antisyalogogue – atropine or glycopyrrolateAnesthesia – lidocaine (2-4%), benzocaineDecongestant – oxymetazoline (afrin)Nebulize, atomize (MADgic®), viscousSedation – ketamine, versed

AntisyalogogueAntisyalogogue –– atropine or atropine or glycopyrrolateglycopyrrolateAnesthesia Anesthesia –– lidocainelidocaine (2(2--4%), 4%), benzocainebenzocaineDecongestant Decongestant –– oxymetazolineoxymetazoline ((afrinafrin))NebulizeNebulize, atomize (, atomize (MADgicMADgic®®), viscous), viscousSedation Sedation –– ketamineketamine, versed, versed

Agitated Burn Case Agitated Burn Case

42-year-old woman set herself on fire in her car.

Uncooperative, yelling “let me die”. 70-80% burns, mostly 3°, to face, trunk,

anterior arms and thighs. Unable to get a BP or O2 sat.

4242--yearyear--old woman set herself on fire in old woman set herself on fire in her car. her car.

Uncooperative, yelling Uncooperative, yelling ““let me dielet me die””. . 7070--80% burns, mostly 380% burns, mostly 3°°, to face, trunk, , to face, trunk,

anterior arms and thighs. anterior arms and thighs. Unable to get a BP or O2 sat.Unable to get a BP or O2 sat.

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Intubating Stylet/BougieIntubating Stylet/Bougie

Clinical Issues: Agitated PatientClinical Issues: Agitated Patient

Assessment of the difficult airway –beware ego, fear, urgency The agitated or violent trauma patient

Haldol, Droperidol, Midazolam, Ketamine

Assessment of the difficult airway Assessment of the difficult airway ––beware ego, fear, urgency beware ego, fear, urgency The agitated or violent trauma patientThe agitated or violent trauma patient

HaldolHaldol, , DroperidolDroperidol, , MidazolamMidazolam, , KetamineKetamine

Oh, nuts…Oh, nuts…

5 yo girl, choked on peanuts last nightUnable to sleep, trouble breathingLooks tired, respdistress, tripod

5 5 yoyo girl, choked on girl, choked on peanuts last nightpeanuts last nightUnable to sleep, Unable to sleep, trouble breathingtrouble breathingLooks tired, Looks tired, resprespdistress, tripoddistress, tripod

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Airway alternatives

Airway alternatives

BVMIntubating LMA®LightwandGlidescopeFiberopticsBougieCombitubeKing-LT

TTJVCricothyrotomy

Zone of Increasing Sphincter Tone

Supraglottic:

Infraglottic:

ZIST

Nasal

BNTIFiberoptics

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No landmarks?No landmarks?

The tongue is your friend – find it and follow it to the glottisSuction, suction, suction…4-finger rule for the cricothyroid membrane

The The tonguetongue is your friend is your friend –– find it and find it and follow it to the glottisfollow it to the glottisSuctionSuction, suction, suction, suction, suction……44--finger rulefinger rule for the cricothyroid for the cricothyroid membranemembrane

Cricothyroid membrane under the 4th finger

Cricothyroid membrane under the 4th finger

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Consider surgical airway earlyConsider surgical airway early SummarySummary

Organized, rapid, simple approachAssess for difficult ventilationBONES

Assess for difficult intubationLEMON

Organized, rapid, simple approachOrganized, rapid, simple approachAssess for difficult ventilationAssess for difficult ventilationBONESBONES

Assess for difficult intubationAssess for difficult intubationLEMONLEMON

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Obese asthmaticObese asthmatic