Basic Emergency

Airway

Objectives
Differentiate the Emergency Airway from elective
intubation in the OR
Assessment of airway compromise
Indications for airway intervention
Recognition of the difficult airway
Bag-Mask Techniques
Laryngoscopy

Emergency Airway Management :

Unique Considerations
Full stomach - high aspiration risk
Altered level of consciousness
Deteriorating cardiorespiratory
physiology - (hypotension, hypoxia)
Abnormal or distorted upper airway
anatomy
No time for pre-op assessment

Airway Assessment
Assessment for airway compromise
or threats and need for interventions
Examination for the potentially
difficult airway

The Three Pillars of Airway Management:

( Assessment of Compromises or Threats )

1 Patency of Upper Airway

( airflow integrity )

2 Protection against aspiration

3 Assurance of oxygenation and
ventilation

Indications for Active Airway

Intervention: including intubation

Failure to maintain patency

Protection from aspiration
Hypoxic/ hypercapnic respiratory failure
Airway access for pulmonary toilet, drug
delivery,therapeutic hyperventilation
Intractable Shock
Anticipated clinical deterioration

Indications for Intubation

Is there failure of airway maintenance ?
Is there failure of airway protection ?
Is there failure of oxygenation or
ventilation?
What is the anticipated clinical course ?
(i.e., expected deterioration, long
transport, long time in radiology, etc.)

Clinical Signs of Airway Compromise :

Threatened Patency

Inspiratory stridor
Snoring ( pharyngeal obstruction )
Gurgling ( blood/ secretions )
Drooling ( epiglottitis )
Hoarseness ( laryngeal edema/ vocal cord paralysis)
Paradoxical chest wall movement
Tracheal tug
Mass - abscess, hematoma, angioedema

Clinical Signs of Airway Compromise:

Inadequate Protection

Blood in upper airway

Pus in upper airway
Persistent vomiting
Loss of protective airway reflexes
swallowing reflex is superior to gag reflex

Clinical Signs of Airway Compromise:

Oxygenation and Ventilation

Central cyanosis
Obtundation and diaphoresis
Rapid shallow respirations
Accessory muscle use
Retractions
Abdominal paradox

Clinical Signs of Airway Compromise:

Oxygenation and Ventilation
The assessment of oxygenation and
ventilation is a clinical one.
Arterial blood gases should not be
relied upon to assess whether
intubation is necessary.

Techniques for the

Compromised Airway

Head Positioning
Jaw Thrust, Chin lift
Orophryngeal/ Nasopharyngeal airways
Bag-Valve-Mask Ventilation
Endotracheal Intubation
Advanced techniques
Cric, LMA, Combitube, Retrograde, Fibreoptic,
Light wand, Bouge

The Difficult Airway

Difficult Laryngoscopy
poor visualization of cords

Difficult bag-mask ventilation

unable to oxygenate or ventilate

Lower airway difficulty

severe bronchospasm

Golden Rules of Bagging

Anybody ( almost ) can be oxygenated
and ventilated with a bag and a mask
The art of bagging should be mastered
before the art of intubation
Manual ventilation skill with proper
equipment is a fundamental premise of
advanced airway Rx

BVM Ventilation
The most important airway skill
Always the first response to inadequate
oxygenation and ventilation
The first bail-out maneuver to a failed
intubation attempt
Attenuates the urgency to intubate
Do not abandon bagging unless it is impossible
with two people and both an OP and NP airway

BVM Ventilation
Requires practice to master
One hand to
maintain face seal
position head
maintain patency

Other hand ventilates

BVM Ventilation: Technique

Insert oropharyngeal/nasopharyngeal
Sniffingposition if C-spine OK
Thumb + index to maintain face seal
Middle finger under mandibular
symphysis
Ring/little finger under angle of mandible
Maintain jaw thrust/mouth open

Predictors of a Difficult Airway :

BVM

Upper airway obstruction

Lack of dentures
Beard
Midfacial smash
Facial burns, dressings, scarring
Poor lung mechanics
resistance or compliance

Difficult Airway : BVM

degree of difficulty from zero to infinite

Zero = no external effort or internal device required
one person jaw thrust/ face seal
oropharyngeal or nasopharyngeal AW
two person jaw thrust / face seal
both internal airway devices
Infinite = no patency despite maximal external
effort and full use of OP/NP

Algorithm for Difficulty

Bagging
Remove Foreign Bodies - Magill forceps
Triple maneuver if c-spine clear
Head tilt, jaw lift, mouth opening
Nasal or oropharyngeal airways
Two-person, four-hand technique

BVM Ventilation:
Mask Seal Tips and Pearls
Easier to get seals with masks too large
than too small
Inflate mask collar correctly
Apply lubricant to beards to mat down
hair
If edentulous insert gauze sponges into
cheeks

Prediction of the Difficult

Airway: Laryngoscopy
History of past airway problems
check previous OR anesthesia records if time
permits
cricothyroidotomy scar

Careful physical assessment

mouth opening
tongue to pharyngeal size
hyo-mental distance
Neck flexion, Head extension

Technique of Laryngoscopy
Sniffing position to align oral-pharyngeallaryngeal axis
Flex neck by placing pillow beneath occiput
( raise 10 cm )
Extend head maximally
With laryngoscope
open mouth fully
push tongue to left out of view
pull upward at 45 degrees

Adducted vocal cords

Predictors of Difficult
Laryngoscopy

Short thick neck

Receding mandible
Buck teeth
Poor mandibular mobility/ limited jaw
opening
Limited head and neck movement
( including trauma )

Difficult Airway : Laryngoscopy

Tumor, abscess or hematoma

Burns
Angioneurotic edema
Blunt or penetrating trauma
Rheumatoid arthritis, ankylosing spondylitis
Congenital syndromes
Neck surgery or radiation

Predictors of Difficult
Laryngoscopy

3 fingerbreadths mentum to hyoid

3 fb chin to thyroid notch
3 fb upper to lower incisors
Head extension and neck flexion
Mallimpadi classification
Previous history of difficult intubation

Mallimpadi Classification
(Tongue to Pharyngeal Size)
I - soft palate, uvula, tonsillar pillars
visible
99 % have grade I laryngoscopic view

II - soft palate, uvula visible

III - soft palate, base of uvula
IV - soft palate not visible
100% grade III or grade IV views

The 4 Ds of Difficult Intubation

Distortion
( edema, blood, vomitus, tumor, infection)

Dysmobility of joints
( TMJ, alanto-occipital, C-spine)

Disproportion
thyomental, Mallimpadi, etc

Dentition
prominent upper teeth

Unsuccessful Intubation

Bag the patient

Maximize neck flex/ head ex
Move tongue out of line of site
Maximize mouth opening
ID landmarks and adjust blade
BURP maneuver
Increasing lifting force
Consider Miller blade
Bag the patient

(Backwards Upwards Rightwards Pressure on Thyroid Cart.)

BURP
The Efficacy of the "BURP" Maneuver
During a Difficult Laryngoscopy. Takahata
O Anesth Analg - 1997 Feb; 84(2): 419-21

[The difficult intubation. The value of BURP and 3 predictive tests of difficult intubation] Ulrich B - Anaesthesist - 1998 Jan; 47(1): 45-50

LEMON Mallampati score

Mallampati score
Grade 1: entire post. Pharynx,
visualized to tonsillar pillars
No difficulty

Grade 2: hard palate, soft

palate and top of uvula only
No difficulty

Grade 3: hard and soft palate

only
Moderate difficulty

Grade 4: no visualization post

pharynx or uvula (hard palate
only
Severe difficulty

Basic Airway Management

Positioning