Special Airway Devices and Techniques for the Difficult or Failed Airway

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Special Airway Devices and Techniques for the
Difficult or Failed Airway

• Pat Melanson,MD

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Difficult Airway Kit ASA Recommendations

• Multiple blades and ETTs
• ETT guides (stylets, bougé, light wand)
• Emergency nonsurgical ventilation
  ( LMA, Combitube, TTJV )
• Emergency surgical airway access (
  Cricothyrotomy kit, cricotomes )
• ETT placement verification
• Fiberoptic and retrograde intubation

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ETT Placement Methods

• Direct vision
• laryngoscope
• Bronchoscope
• Indirect indicator
• transillumination with light wand
• listening for air ( BNTI)
• Blind tactile digital intubation
• Blindly without indicator

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ETT Guides Gum Elastic Bougie (ETT Introducer)

• Long, thin, flexible guide
• 60 cm long, 15 Fr, distal 3 cm has 40 degree bend
• small diameter allows easier passage through
  cords than ETT
• Useful with Grade III views (epiglottis only)
• direct tip underneath epiglottis and walk up
  dorsum of epiglottis to anteriorly to cords
• feel for clicks of tracheal cartilages or
  resistance at carina
• advance ETT over bougie into trachea
• Useful when neck movement contraindicated

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ETT Guides Light Wand

• uses transillumination of neck soft tissues to
  guide tube
• technique is easier to teach, skill easier to
  maintain than conventional laryngoscopy
• produces less airway trauma
• less physiologic disturbance

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ETT Guides Light Wand

• Indications
• Impossible Laryngoscopy with adequate
  Bag-Mask-Ventilation
• TMJ ankylosis
• limited C-spine mobility
• facial trauma
• Contraindications
• Upper airway masses or lesions (blind technique)

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Light Wand Technique

• Load and lubricate ETT on wand
• Bend ETT just proximal to balloon cuff to near
  right angle
• Place head and neck in neutral position
• Grasp and lift upward the lower alveolar ridge
  and mentum with non-dominant hand
• Advance light wand in midline
• Lift jaw to aid passage under epiglottis
• Position light wand for maximum well
  circumscribed glow at anterior neck just below
  laryngeal prominence
• Retract rigid stylet and advance ETT

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Emergency Non-surgical Ventilation Laryngeal
Mask Airway

• Designed to be placed in the supraglottic area,
  seal the larynx, and direct gas into trachea
• Oval inflatable cuff seals larynx
• Easy to use
• Does not provide definitive management
• does not prevent aspiration
• temporizing measure after failed intubation

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Laryngeal Mask Airway Technique

• Lubricate both sides
• Open airway with head tilt, sniffing position
• Insert LMA with laryngeal surface down
• Press device onto hard palate
• Advance using index finger
• Use curve to advance over base of tongue
• pushed as far as possible into hypopharynx
• Stop when resistance felt(upper esophag.
  sphincter)
• Inflate collar and start bag ventilation

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LMA and the Difficult Airway

• Consider use early in a cant intubate, cant
  ventilate situation while also getting prepared
  for a surgical airway or TTJV
• A temporizing measure but can be used as a
  conduit for endotracheal intubation
• the Intubating Laryngeal Mask
• The LMA is a supraglottic device
• Not suitable if the airway difficulty is due to
  laryngeal problems i.e., (laryngospasm) or local
  pharyngeal abnormalities ( abscess, hematoma,
  edema)

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Emergency Non-surgical Ventilation Combitube

• Dual-lumen, dual-cuffed rescue airway device
• The two lumens allow ventilation whether placed
  in trachea or esophagus
• If in trachea position, functions like an ETT
• If in esophageal position, the two balloons seal
  hypopharynx proximally and esophagus distally and
  perforations in esophageal lumen between the
  cuffs allow for ventilation
• Placed blindly

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Emergency Non-surgical Ventilation Transtracheal
Jet Ventilation

• Puncture cricothyroid membrane with large-bore
  (12 or 14 Gauge) kink-resistant catheter
  connected to 3-way stopcock or to a suction
  catheter with control vent
• 50 psi wall oxygen source
• High pressure tubing
• Ventilate for 2 seconds (or until chest rise)
• Release valve for 4 to 5 seconds (exhalation)

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Emergency Surgical Access Cricothyrotomy
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Emergency Surgical Access Cricotomes

• Commercially available kits
• Seldinger technique
• Cricothyroid membrane punctured with needle
• Guidewire advanced into trachea through needle
• Cannula loaded on dilator is advanced over
  guidewire into trachea

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Fiberoptic Intubation

• Indications
• Predicted Difficult Airway with adequate
  oxygenation/ventilation(time required)
• Distorted upper airway anatomy or
• C-spine injury
• Contraindications
• Excessive blood and secretions
• Inadequate oxygenation

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Bullard Laryngoscope

• Indirect fiberoptic laryngoscope with
  anatomically shaped blade
• Not necessary to align oral-pharyngeal-laryngeal
  axis
• Useful for C-spine immobility
• Does not require significant mouth opening

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Digital Intubation

• tactile technique
• operator uses fingers to blindly direct ETT
• not an easy technique
• requires large hands

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Retrograde Intubation

• Indications
• C-spine motion to be avoided and difficulty
  anticipated with conventional techniques
• Failed intubation with adequate bag/mask
  ventilation and time is not limited
• Contraindications
• infected skin over puncture site
• infectious or neoplastic laryngeal lesions

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Confirmation of ETT PlacementClinical Evaluation

• Observation of ETT pacing through cords
• Clear, equal breath sounds bilaterally
• Absence of breath sounds over epigastrium
• Symmetrical rising of chest
• Condensation or fogging of ETT
• Chest X-ray
• ALL SUBJECT TO FAILURE
• Pulse oximetry is LATE indicator

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Confirmation of ETT Placement

• Placement of ETT in the esophagus is an accepted
  complication of intubation
• However, failure to recognize and correct
  esophageal intubation immediately IS NOT
  ACCEPTABLE
• Either ETCO2 detection or an aspiration technique
  should be used on every emergency intubation

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Confirmation of ETT PlacementEnd-tidal CO2
Detection

• Colorimetric
• Small, disposable
• Useful in pre-hospital care
• Changes from purple to yellow if CO2
• 100 specific if bright yellow
• Indeterminate ( brown ) can indicate esophagus
  with carbonated beverage, or low output state

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Confirmation of ETT PlacementEnd-tidal CO2
Detection

• Quantitative End-Tidal CO2 Detection
• indicates successful tube placement
• early indicator of inadvertent extubation
• adequacy of ventilation ( CO2 level )
• prognosis in cardiac arrest
• monitoring/ therapy guide in arrest
• ETCO2 detectors can be falsely negative during
  cardiac arrest (inadequate perfusion for CO2
  delivery to lungs)

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Confirmation of ETT Placement Esophageal
Detection Devices

• Bulb or Syringe Aspiration Devices
• Aspiration of a large volume of air rapidly
  through an ETT to determine whether the tube is
  in the esophagus or trachea
• Esophagus is soft and will collapse if negative
  pressure applied
• Less than free and immediate ( lt 2 sec)
  aspiration of air should be considered to be
  esophageal until proven otherwise
• Useful in cardiac arrests

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Confirmation of ETT Placement Esophageal
Detection Devices

• False positive results
• massive gastric insufflation
• incompetent lower esophageal sphincter
  (pregnancy, hiatal hernia)