The Difficult Airway

The clinical scenario when safe

oxygenation and ventilation cannot be
achieved in the desired way with the
use of an individual’s usual practice
Difficult Mask Ventilation

Difficult Intubation
 Difficult Mask Ventilation

Difficult Supraglottic Airway

Difficult Intubation
 Incidence in general population
Difficult
Mask 1:20

Supraglottic 1:25

Intubation 1:50
 Incidence in general population
Difficult Failed
Mask 1:20 1:600

Supraglottic 1:25 1:300

Intubation 1:50 1:2000

 Incidence in general population
Difficult Failed
Mask 1:20 1:600

Supraglottic 1:25 1:300

Intubation 1:50 1:2000

Pre-Hospital 1:6 1:50

Timmermann et al., 2006 Resuscitation 70:179-85 (1106 patients)

 Trauma patients had highest
incidence of difficult and failed
intubation
Difficult Mask Ventilation
(DMV)
 Degrees of Difficulty
1 Single person BVM with chin lift+/-jaw thrust

2 Above + OP or NP airway or both

3 Above plus assistant to squeeze bag or provide

jaw thrust/face mask seal

4 Anaesthetist plus 2 assistants; one to squeeze

bag and other to provide jaw thrust/face mask
seal
Obese (BMI>26)
Bearded
Elderly (>55)
Snorers
Endentulous

Male
‘n’eck
Mallampati (grade 3 or 4)
Difficult Supraglottic Airway
Inability to open mouth more than 2.5cm
(impossible if <2.0cm)

Intraoral/pharyngeal masses
Difficult Intubation
Look externally
Evaluate 3-3-2
Mallampati
Obstruction
Neck mobility
Look externally - trauma, limited mouth opening
Look externally

Evaluate 3-3-2
3 fingers between the teeth
3 fingers between the tip
of the jaw and start of neck
2 fingers between the thyroid notch
and floor of mandible
Look externally

Evaluate 3-3-2

Mallampati assessment
Class 1 - soft palate, fauces, uvula, & both anterior and
posterior pillars
Class 2 - soft palate, fauces, and uvula
Class 3 - soft palate and the base of the uvula
Class 4 - soft palate is not visible
1 2

3 4
Look externally

Evaluate 3-3-2

Mallampati assessment

Obstruction - epiglottitis, peritonsillar abscess, trauma

Look externally

Evaluate 3-3-2

Mallampati assessment

Obstruction

Neck mobility - limited movement, cervical collar

Is LEMON useful?
Look externally Large incisors

Evaluate 3-3-2 Reduced mouth opening & reduced

thyroid to floor of mouth distance

Mallampati assessment
Obstruction
Neck mobility
114 grade 1 29 grade 2
11 grade 3 2 grade 4
Reed et al., 2005 EMJ 22:99-102
2509 patients
Upper front teeth
Previous Hx of difficult intubation
Mallampati >1
Mouth opening <4cm

Diff intub (%) 0 2 4 8 17

Risk factors 0 1 2 3 4

Eberhart et al., EJA March 2010

But does it all really matter?
When do we intubate?
Are all of our intubations ‘difficult’?
Blood/vomitus in airway

Limited mouth opening

Facial/neck trauma

C-Spine precautions
Preoxygenation
Preoxygenation with Non-Invasive
Ventilation in critically ill patients is
better than BVM preoxygenation

Baillard et al., 2006 Am J Respir Crit Care Med 174:171-7

NIV - pressure support to obtain an expired tidal
volume of 7–10 ml/kg with a PEEP of 5 cm H2O for 3
minutes

Control – BVM with 15 L/min oxygen. Patients were

allowed to breath spontaneously with occasional
assistance
Baillard et al., 2006 Am J Respir Crit Care Med 174:171-7
Preoxygenation of morbidly obese
patients at 25° head up is better
than supine

Dixon et al., 2005 Anesthesiology 102:1110-5

Time to reach an SpO2 of 92%
in morbidly obese patients

Head up 25° = 201 ± 56 s

Supine = 155 ± 70 s (p=0.02)

Dixon et al., 2005 Anesthesiology 102:1110-5
Better gas exchange by
reducing atelectasis
reducing V/Q mismatch
less reduced FRC

Dixon et al., 2005 Anesthesiology 102:1110-5

You have a look and can’t see
anything
 30 second drills

Change operator position

Change patient position (small pad under head with
neck in neutral position)

Release cricoid and use bi-manual laryngoscopy

Use better suction where secretions or blood block
view

Laryngoscope can be inserted deeply and slowly
withdrawn until identifiable anatomy is seen

Consider changing laryngoscope blade size or type

Consider changing operator
 Six variables to correct

Experienced practitioner

No significant muscle tone

Optimal position

Blade length

Blade type

Use of laryngeal manipulation

Benumof 1994 Canadian Journal of Anaesthesia 41:361-5

Posture
The novices tended to crouch,
head closer to the mouth, elbow
more flexed and forearm further
from the horizontal.

Matthews et al., 1998 Anaesthesia 53:331-4

The novices tended to crouch,
head closer to the mouth, elbow
more flexed and forearm further
from the horizontal.

The trained subjects tended to

stand back, elbow less flexed and
forearm close to or even below the
horizontal.
Matthews et al., 1998 Anaesthesia 53:331-4
 The more
experienced group
levered less,with
signifcantly lower
laryngoscope
handle angles (C)
Eye-to-
laryngoscope
distances (D) were
greater in the more
experienced group

Walker 2002 Br J Anaesth 89:772-4

Tesler et al., 2003 Resuscitation 56:83-9
Tesler et al., 2003 Resuscitation 56:83-9
Tesler et al., 2003 Resuscitation 56:83-9
Robinson et al., 2004 Air Med Journal 23:40-3
Position
Brodsky et al., 2003 Anesthesia and Analgesia 96:1841-2
Manual In-Line Stabilisation
 MILS

Does not limit cervical movement with
jaw thrust and laryngoscopy

Worsens laryngeal view which prolongs
intubation attempt1

Increases pressures applied by the
laryngoscope blade during
laryngoscopy2

1 Thiboutot et al., 2009 Can J Anaesth 56:412-8

2 Santoni et al., 2009 Anesthesiology 110:6-7
 It is prudent for clinicians to
use manual in-line stabilization
when it does not hinder
intubation attempts

Manoach and Paladino 2007 Ann Emerg Medicine 50:236-45

Cricoid Pressure
 An Essay on the Recovery of the
Apparently Drowned
"the restoring of the action of the lungs to
be of the very first importance in all our
attempts to recover the apparently dead."
In addition, a description of pressure on
the front of the neck as follows to
"prevent the air passing into the stomach
instead of entering the lungs."

Royal Humane Society, London: Silver Medal Winner (1788)

Charles Kite of Gravesend
Sellick 1961 The Lancet 278 7199:404-6
 Cricoid Pressure

Fails to prevent aspiration

Reduces lower oesophageal sphincter pressure

May prevent gastric insufflation during mask
ventilation

Makes ventilation more difficult

Causes lateral displacement and/or incomplete
obstruction of oesophagus

Makes LMA insertion and ventilation more difficult

May worsen laryngeal view

May cause significant movements of cervical spine

Is often applied incorrectly
Cricoid pressure entered medical practice
on a limited evidence base but with
common sense supporting its use.

Ellis et al., 2007 Annals Emerg Med 50:653-5

Given that the risks of cricoid pressure
worsening laryngeal view and reducing
airway patency have been well described,
we recommend that the removal of cricoid
pressure be an immediate consideration if
there is any difficulty either intubating or
ventilating the ED patient.

Ellis et al., 2007 Annals Emerg Med 50:653-5

Given that the risks of cricoid pressure
worsening laryngeal view and reducing
airway patency have been well described,
we recommend that the removal of cricoid
pressure be an immediate consideration if
there is any difficulty either intubating or
ventilating the ED patient.

Ellis et al., 2007 Annals Emerg Med 50:653-5

BURP?
Anaes Analgesia 1997:84:419-21
OELM or Bimanual Laryngoscopy
 Percentage of
cases with
improved view

Cricoid 52%
BURP 54%
Bimanual 89%

Annals Emerg Med 2006:47;548-55

Prospective observational study
Effects of cricoid pressure and laryngeal manipulation on
laryngeal view in London HEMS

402 patients
98.8% patients intubated on the first or second attempt.
In 61 intubations the larynx required manipulation.

Cricoid pressure removed in 22 - view improved in 50%.

Bimanual manipulation used in 25 – view improved in 60%.
BURP used in 14 - view improved in 64%.

Two patients regurgitated when cricoid pressure was

released.

Harris et al., Resuscitation epub 2010

Cook 2000 Anaesthesia 55:274-9
 Bougie
Fibreoptic

Cook 2000 Anaesthesia 55:274-9

Levitan et al., 1998 Acad Emerg Med 5:919-23
Bougie or stylet?
The gum elastic bougie is superior to the
stylet for a simulated difficult intubation

Gataure et al, Anaesthesia 1996 51:935-8

Gataure et al, Anaesthesia 1996 51:935-8
Stylet - intubation was difficult and
needed more time, especially
when glottic opening was not
visible

Bougie - duration and ease of

intubation was not influenced by
laryngeal view
Noguchi et al., 2003 Can J Anaesth 50:712-7
When is a bougie not a bougie?
When it’s a tracheal tube introducer
BMJ 1949; 1:28
How do I know the bougie is in the
trachea?
 Clicks

Distal hold-up

Coughing
 Clicks
Tip of bougie touches the tracheal
cartilages

Distal hold-up
Tip is touching the carina (approx 40cm)

Coughing
Muscle relaxation is incomplete
 Clicks – 90%

Distal hold-up – 100%

Kidd et al., 1988 Anaesthesia 43:437-8

Hodzovic et al., Anaesthesia 2004 59:811-6
Hodzovic et al.,
Anaesthesia 2004 59:811-6
Pre-hospital use of bougie
1442 pre-hospital intubations over 30 months

41 patients (3%) required a bougie

Bougie successful in 33 cases (78%)

8 patients required a second technique

Jabre et al., 2005 Am J Emerg Med 23:552-5

Laryngoscope Blades
 Best results for intubation were
obtained with the Macintosh and
the McCoy

A good laryngeal view does not

equate with ease of intubation

Arino et al., 2003 Can J Anaesth 50:501-6

 Size 4 English Macintosh
performed the best at all insertion
depths

Yardeni et al., 2002 Acta Anaes Scand 46:1003-9

Other tricks
Left Molar Approach
Yamamoto et al., 2000 Anesthesiology 92:70-4
 The left molar approach reduces the
distance from the patient's teeth to larynx
and prevents intrusion of maxillary
structures into the line of view.

Although it may offer advantages in terms

of laryngoscopic view, there can be
difficulty in the insertion of the tracheal
tube.

Cuvas et al., 2009 J Anesth 23:36-40

 Failed intubation

 3-4 attempts with some of the manoeuvres

described
 Declare a failed intubation
 Maintain cricoid
 Insert oral airway and ventilate with 100% O2
 If ventilation difficult, try LMA; if still no ventilation,
and if laryngospasm excluded use crico-thyroid
puncture
 insanity (n) [in-san-i-tee] :
doing the same thing over and
over again and expecting
different results
Albert Einstein, (attributed)
US (German-born) physicist (1879 - 1955)
LMA and Cricoid Pressure
The LMA is indicated in the known
or difficult airway situation

The clinical record of the LMA in

the CICV situation is excellent
Prehospital use of the ProSeal
LMA
Successful use in 3 cases of failed
intubation

Polytrauma
Burns
Maxillofacial Trauma

Grier at al., 2009 Resuscitation 80:138-41

 Insertion technique

Bougie inserted under direct

vision into oesophagus

ProSeal railroaded over bougie

Howarth et al., 2002 Anaes Int Care 30:624-7

Intubating LMA (Fastrach) also
been used successfully in
prehospital difficult-to-manage
airways

Timmermann 2007 BJA 99:286-91

Pre-hospital resuscitation using the
iGEL.

Thomas M, Benger J.

Resuscitation. 2009 80(12) 1437

 Rapid sequence airway (RSA)
with a LMA Supreme is quicker to
‘secure’ the airway (with less
hypoxia) compared to a RSI in a
simulated difficult trauma airway.

Southard et al., 2010 Resuscitation 81(5) 576-8

 Confirmation of correct tube
placement
 Direct visualisation
 Auscultation for breath sounds
 Chest movement
 Feel of reservoir bag

CO2 detectors
 Oesophageal detectors: withdraw air freely from
trachea but the oesophagus will collapse
 False negative

 Equipment failure
 Disconnection
 Kinked gas sampling tube
 Kinked tracheal tube
 Severe airway obstruction
 Poor pulmonary perfusion
 False positive

 Tube in oesophagus after exhaled gases

forced into stomach

 Tube in oesophagus after fizzy drinks

 Distal end of tube in pharynx

Gadgets
Video Laryngoscopes
(VLEs)
Van Zundert et al., 2009 Anesthesia and Analgesia109: 825-31
Van Zundert et al., 2009 Anesthesia and Analgesia109: 825-31
Van Zundert et al., 2009 Anesthesia and Analgesia109: 825-31
Although VLSs offer several
advantages........a good laryngeal view
does not guarantee easy or successful
tracheal tube insertion.

We recommend that the geometry of

VLSs, including blade design, should be
studied in more detail.

Van Zundert et al., 2009 Anesthesia and Analgesia109: 825-31

Indirect Laryngoscopes with
tracheal tube conduit
 Airtraq
2006 – 4
2007 – 19
2008 – 18
2009 – 22
2010 – 20+
Airway Scope
2006 – 1
2007 – 20
2008 – 22
2009 – 18
2010 – 13+
54 paramedics used each device
(Macintosh laryngoscope, Airtraq
and Airway Scope) in a random
order on three manikins
standard airway - no manipulation of the
manikin’s airway

difficult airway - set to simulate grade 3

laryngoscopy view

sitting manikin - no manipulation of the

airway
 In the difficult airway manikin.....
Tracheal intubation with the AWS was
more successful and faster than the Airtraq
and Macintosh laryngoscopes
Dogma is the established belief or
doctrine held by a religion,
ideology or any kind of
organization: it is authoritative and
not to be disputed, doubted or
diverged from