Case Review

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Case Review 20THE DIFFICULT AIRWAY

• Jim Pointer, MD, FACEP
• Medical Director
• Alameda County EMS

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INTRODUCTION

• Field intubation success rates
• Oral 80-95
• Nasal 60-85
• RSI not universally available
• Recognition of difficult airway is important
• At least one backup, rescue airway technique is
  essential

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DEFINITION

• Difficult airway ANYTHING that interferes with
  ventilation or intubation
• Anatomic
• Traumatic
• Infectious
• Allergic
• Behavioral

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CLUES TO LOOK FOR
CL

• Prominent incisors
• Limited jaw / mouth opening
• Short neck
• Big tongue
• Small mandible
• Limited cervical mobility
• Facial trauma
• Burns

• Neck injury
• Obesity
• Foreign bodies
• Children
• Infections
• Allergic edema
• Neoplasm / irradiation
• Inhalation injuries
• Facial hair

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FOUR Ds

• Distortion
• Disproportion
• Dysmobility
• Dentition

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MNEUMONIC BONES

• Beard
• Obese
• No teeth
• Elderly
• Snoring (sleep apnea)

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MALLAMPATI CLASSIFICATION
Class I Class II Class III Class IV
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ANATOMY
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60-SECOND EXAM LEMON

• Look for external difficulty
• Evaluate using 332 rule

• 3 fingers fit in mouth
• 3 fingers fit from mentum
• to hyoid cartilage
• 2 fingers fit from mandible
• to top of thyroid cartilage

• Mallampati rule (class I II)
• Obstruction
• Neck mobility

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10-SECOND QUICK EXAM

• Can you see the uvula?
• Can you fit 3 fingers from mentum to hyoid?
• Can the patient extend head back on neck?

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PREPARATION

• Prepare equipment ahead of time
• Check and recheck
• Gather all airway devices
• in one bag or area
• Pre-oxygenate with 100 O2

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SNIFFING POSITION

• Flex neck on chest 35
• Extend head on neck 80
• Use pillow or other
• object under occiput

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BURP, OELM, ELM

• External
• Laryngeal
• Manipulation

• Backward
• Upward
• Rightward
• Pressure on thyroid cartilage

• Optimal
• External
• Laryngeal
• Manipulation

Intubator uses BURP to establish position
assistant holds in place
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Helpful device for intubation that is practical

• GUM ELASTIC BOUGIE (GEB)
• Used in England
• Cheap
• Good in patients in whom
• only epiglottis is visualized

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Rotate ET tube until bevel faces posteriorly
GEB in trachea
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Helpful devices for intubationthat are NOT
practical in the field

• Light wands
• Fiberoptics
• Tracheostomy lights
• Blind techniques

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Adjuncts to Nasotracheal Intubation

• Endotrol
• Afrin and lidocaine on nasal trumpet
• BAAM whistle
• Positioning
• straight back, not upward

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Endotrol
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BAAM Whistle
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RESCUE AIRWAYS
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Laryngeal Mask Airway (LMA ) and Intubating LMA
(ILMA)

• Used in surgery
• Risk of aspiration
• Rescue technique
• Tube must be used
• with curve reversed

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LMA and ILMA (cont.)

• Intubating LMA
• Accepts larger tube
• (8.0)
• Can be used for rescue
• Is expensive
• LMA ILMA not
• used in California EMS

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COMBITUBE

• Most commonly used rescue airway in EMS

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Needle or Surgical Cricothyrotomy

• Needle must be used with high powered O2 in
  adults
• Surgical techniques forbidden in California EMS

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Preferred Surgical Cricothyrotomy

• Seldinger technique
• Catheter-over-needle
• Wire-through-needle

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Confirmation of Intubation Techniques

• Auscultation
• Both lung fields and epigastrum
• Persistent oxygenation on pulse oximetry
• Chest wall motion
• Tube fogging
• Chest x-ray
• End-tidal CO2
• Esophageal detector device (EDD)

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Confirmation of Intubation Techniques (cont.)

• ALL techniques may be unreliable!
• End-tidal CO2 and EDD are MOST reliable.
• Both are mandatory in Alameda County policy 10102

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End-tidal CO2

• Colorimetric
• Capnography
• Capnometry
• Drawback
• Cardiac arrest state

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(No Transcript)
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Esophageal Detector Device

• Drawbacks
• Air in stomach causes false positives
• Poorer performance in obese patients
• Cold can impact bulb type
• MUST be used correctly

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SUMMARY

• Be prepared mentally logistically
• Know how to assess a potential difficult airway
• Use proper techniques
• Utilize assistive devices to facilitate intubation

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SUMMARY (cont.)

• Know when to use rescue techniques
• Confirm your intubation using multiple techniques
• End-tidal CO2 and EDD are mandatory!
• Monitor patient using pulse oximetry and
  end-tidal CO2