The Difficult Airway

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The Difficult Airway

• Dr. Richard Lee, MD, FRCPC
• Division of Emergency Medicine
• University of Alberta

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Objectives

• To be aware of the unique circumstances
  surrounding the emergency intubation.
• To be familiar with the indications for emergency
  intubation.
• To be able to asses and recognize potentially
  difficult airway situations.

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Objectives (cont.)

• To be familiar with certain rescue airway
  techniques.
• To develop an algorithm for the difficult airway.

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The Emergency Intubation

• Emergency Department
• Full stomach
• Unknown medical history
• Multisystem involvement
• Intubate or die

• Operating Room
• Empty stomach
• Cleared medically
• One system involved
• Can always cancel OR until your day off.

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The Emergency Intubation

• Emergency physicians are the experts in
  emergency intubations.
• 27 of 143 anesthesia programs in the US had a
  rotation dedicated to managing the difficult
  airway and most of this was lectures only (Koppel
  et al 1995)
• 91 successful intubation rate for EM residents
  vs. 66 for non-EM residents (Barton et al. 1998)
• Must be skilled, competent and knowledgeable
  about intubation and rescue techniques.

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Indications for Emergency Intubation

• Failure to maintain and protect the airway.
• Failure to ventilate.
• Failure to oxygenate.
• To provide supplemental therapy
• hyperventilation, pulmonary toilet etc.
• Anticipation of any of the above.

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Predictors of a Difficult Airway

• Mallampati and Cormack-Lehane scores used alone
  are unreliable.
• Use a combination of clinical features and
  clinical judgement.
• Anything that inhibits the alignment of the oral,
  pharyngeal and laryngeal axis will make
  intubation more dificult.

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Predictors of a Difficult Airway (cont.)

• Immobilized C-spine/ limited movement
• Combative patient
• Children
• Short bull neck (3 finger test)
• Prominent incisors/ bad teeth
• High arched palate with long narrow mouth

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Predictors of a Difficult Airway (cont.)

• Receding mandible
• Limited jaw opening (3 finger test)
• Upper airway obstruction
• Facial trauma
• Laryngeal trauma
• Obesity

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Successful intubation of the difficult airway

• Adequate preparation is the most important step
  of intubation.
• Be familiar with rescue equipment (use and
  location).
• Make sure your IV is secured.
• The physician most skilled in securing the airway
  should be the one securing it.

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Algorithm for the Difficult Airway

• If you cant intubate, ventilate.
• If you cant ventilate, oxygenate.
• If you cant oxygenate, cut the neck.

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Intubation Techniques

• RSI- the gold standard.
• Higher success rate (98.9 VS. 87.4)
• Lower complication rate (3.8 VS. 7.9)
• If you are unable to intubate after 3 attempts,
  you will be unable to intubate until conditions
  change.

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Alternatives to RSI

• Local anaesthetic awake intubation
• Blind nasal intubation
• Bronchoscopic assisted intubation
• Sedation without paralysis is not an option!

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The 6 Ps of the RSI

• Prepare (SOAP ME)
• Pre-oxygenate
• Pre-treat
• Paralysis (with induction)
• Pass the tube
• check Placement

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A Typical RSI Sequence

• T0 minus several minutes
• Prepare equipment.
• T0 minus 5 minutes
• 100 oxygen.
• T0 minus 2 minutes
• Fentanyl 3 ug/kg.

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A Typical RSI Sequence (cont.)

• T0
• Midazolam 0.1-0.3 mg/kg.
• T 0 5 seconds
• Succinocholine 1.5mg/kg.
• T0 30 seconds
• Sellick/ BURP maneuver.
• T0 60 seconds
• Pass tube, check placement.

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Variations of the RSI

• Prepare
• Have difficult airway cart available.
• Pre-oxygenate
• 4 deep conscious breaths.
• Pre-treat
• Lidocaine 1.5 mg/kg, and defasiculating/ priming
  dose for raised ICP.
• Atropine 0.01-0.02 mg/kg for children.

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Variations of the RSI (cont)

• Paralyse
• Consider rocuronium 0.6-1.2 mg/kg for raised ICP,
  children, renal failure, ocular injuries etc.
• Induction
• Ketamine 1-1.5 mg/kg for asthmatics, or
  hypotensive/ hypovolemic patients.
• Thiopental 3-5 mg/kg for raised ICP.
• Tube Placement
• consider ETCO2, EDD.

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Rescue Intubation Techniques

• All techniques must be perfected before they are
  needed.
• Retrograde intubation.
• Lighted wand stylet.
• Blind tactile intubation.
• Bullard laryngoscope

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Ventilation Techniques

• Bag-valve-mask the most important emergency
  medicine technique!
• Laryngeal mask.
• Combitube.
• Needle cricothyrotomy JET ventilation.

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Oxygenation Techniques

• Needle cricothyrotomy oxygenation.
• Oropharyngeal oxygenation.

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Surgical Airway Techniques

• Cricothyroidotomy.
• Tracheostomy.

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Summary

• To be aggressive is to be conservative.
• Emergency physicians must be competent in a
  variety of airway techniques.
• Be prepared for the difficult airway.
• When in doubt bag the patient.
• If you cant intubate, ventilate. If you cant
  ventilate, oxygenate. If you cant oxygenate, cut
  the neck.