Basic Emergency

Airway
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 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

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 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
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 Airway Assessment
Assessment for airway compromise
or threats and need for interventions

Examination for the potentially

difficult airway

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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

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 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
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 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.)

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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

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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

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Clinical Signs of Airway Compromise:
Oxygenation and Ventilation
Central cyanosis
Obtundation and diaphoresis
Rapid shallow respirations
Accessory muscle use
Retractions
Abdominal paradox

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 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.

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 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
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 The Difficult Airway
Difficult Laryngoscopy
poor visualization of cords

Difficult bag-mask ventilation

unable to oxygenate or ventilate

Lower airway difficulty

severe bronchospasm

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 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

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 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

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

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 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
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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
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 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

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 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

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 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

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 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

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 Technique of Laryngoscopy
Sniffing position to align oral-pharyngeal-
laryngeal 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

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Adducted vocal cords

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 Predictors of Difficult
Laryngoscopy

Short thick neck

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

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 Difficult Airway : Laryngoscopy
Tumor, abscess or hematoma
Burns
Angioneurotic edema
Blunt or penetrating trauma
Rheumatoid arthritis, ankylosing spondylitis
Congenital syndromes
Neck surgery or radiation

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 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
Mallampati/mallimpadi classification
Previous history of difficult intubation

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 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

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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
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 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 (Backwards Upwards Rightwards Pressure on Thyroid Cart.)

Increasing lifting force

Consider Miller blade
Bag the patient

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