Approach to Difficult and Failed

Airway
Mohd Zakaria
19th August 2010
 Outline
 Definitions.

 Evaluations of Difficult Airway

 Equipments:

 Algorithm:
-ACEP
 Definition

 Difficult Airway: Clinical situation in which a

conventionally trained anesthesiologist
experiences difficulty with face mask
ventilation of the upper airway, difficulty with
tracheal intubation, or both.

Practice Guidelines for Management of the Difficult Airway.An Updated

Report by the American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Anesthesiology, V 98, No 5, May
2003
 Definition
 Difficult face mask ventilation:
It is not possible for the anesthesiologist to provide
adequate face mask ventilation due to one or more of
the following problems: inadequate mask seal,
excessive gas leak, or excessive resistance to the
ingress or egress of gas.

Practice Guidelines for Management of the Difficult Airway.An Updated

Report by the American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Anesthesiology, V 98, No 5, May 2003
 Definition
 Difficult laryngoscopy: (a) It is not possible to visualize any
portion of the vocal cords after multiple attempts at conventional
laryngoscopy

 Difficult tracheal intubation: (a) Tracheal intubation requires

multiple attempts, in the presence or absence of tracheal
pathology.

 Failed intubation: (a) Placement of the endotracheal tube fails

after multiple intubation attempts.

Practice Guidelines for Management of the Difficult Airway.An Updated

Report by the American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Anesthesiology, V 98, No 5, May 2003
 Definition

 A “failed airway” exists when one or both of the following

scenarios occur:
1. Inability to ventilate or intubate the patients
2. Three intubation attempts by the same operator, even when
O2 saturation able to be maintain

Practice Guidelines for Management of the Difficult Airway.An Updated

Report by the American Society of Anesthesiologists Task Force on
Management of the Difficult Airway. Anesthesiology, V 98, No 5, May
2003
Evaluations for Difficult BVM Ventilation
 MOANS:
MOANS Assesses the Potential for Difficult Bag-
Valve-Mask Ventilation

 Mask seal -Inadequate mask seal?

 Obesity/Obstruction ->26 kg/m2
 Age ->55 years
 No teeth -Impair BVM effectiveness
 Stiff ventilation -Asthma, COPD, ARDS, term
pregnancy
Walls RM and Murphy MF: Manual of Emergency Airway Management, 3rd edition, Philadelphia,
Lippincott, Williams, and Wilkins 2008.
 Evaluations for Difficult Laryngoscopy
LEMON:
LEMON Assesses the Potential for Difficult Laryngoscopy

 Look -Injury, large incisors, large tongue, beard

 Evaluate “3-3-2” -finger-breadth measurement*
 Mallampati Score -≥3
 Obstruction -Any condition causing obstruction
 Neck -Limited neck mobility
*3= inter-incision; 3=floor of mandible; 2=thyroid to hyoid

Reed MJ. Can an airway assessment score predict difficulty at intubation in the emergency department?
Emergency Medicine Journal 2005; 22:99-102.
 Evaluations for Difficult Laryngoscopy
This study assessed the ability of the LEMON score to predict
difficult airways. 156 ED patients had a LEMON score performed
and correlated with the Cormack-Lehane score during
laryngoscopy. 73% of patients were classified as “easy
intubations,” and 27% were “difficult intubations.” Patients with
large incisors [p <0.001], a reduced inter-incisor distance [p
<0.05], or a reduced thyroid to mandible distance [p <0.05] were
more likely to have a poor laryngoscopic view and a potentially
more difficult intubation.

 The “Big teeth, small mouth, short neck” all predict a potentially
difficult airway. Citing this paper, the LEMON law was recently
recommended in the updated 8th edition of the ATLS Guidelines.
 Evaluations for Difficult Cricothyrotomy
 SHORT:
SHORT Assesses the Potential for Difficult Cricothyrotomy

 Surgery -Prior neck surgery

 Hematoma -Significant midline neck hematoma
 Obesity ->26 kg/m2
 Radiation -Prior neck radiotherapy
 Tumor -History of head and neck cancer

Walls RM and Murphy MF: Manual of Emergency Airway Management, 3rd edition, Philadelphia,
Lippincott, Williams, and Wilkins 2008.
 Epidemiology

 Bair AE. The failed intubation attempt in the emergency

department: analysis of prevalence, techniques, and personnel.
Journal of Emergency Medicine 2002; 23:131.
 Prospective, observational study of ED airway management in 30 hospitals
in the U.S., Canada, and Singapore participating in the National
Emergency Airway Registry [NEAR].Jan 1998-Feb 2001.
 Patients were enrolled if the first technique was unsuccessful and a rescue
was required.
 7,712 emergency intubation with 207(2.7%) meets inclusion criteria.

 Conclusion …Failed airways are rare and therefore, clinician experience

with any specific rescue device is typically very limited.
Equipments for Difficult & Failed Airways
 1) Blind insertion supra-glottic airway devices
a) Double-lumen laryngeal devices
i) Combitube®
b) Laryngeal mask airways
i) Standard LMA®
ii) Intubating LMA [Fastrach®]
c) Intubating stylets
i) Gum-elastic bougie
ii) Lighted stylet [Trachlight®]
Equipments for Difficult & Failed Airways
 2) Direct vision supra-glottic airway devices
a) Hand-held fiberoptic intubating stylets
i) Levitan Scope®
ii) Shikani Optical Stylet®
iii) RIFL®
b) Hand-held fiberoptic laryngoscopes
i) McGraf Scope®
ii) Glidescope®
iii) Storz Videolaryngoscope®
iv) Pentax Airway Scope®
c) Traditional flexible fiberoscopes
d) Prism/mirror assisted scopes [Airtraq®]
Equipments for Difficult & Failed Airways
 3) Infra-glottic airway devices
a) Retrograde intubation
b) Transtracheal jet ventilation
c) Surgical cricothyrotomy
i) Open
ii) Percutaneous
Equipments for Difficult & Failed Airways
 Before we discuss these devices, remember... always
consider the “easy stuff first.”
 Effective patient positioning, use of the BURP
technique and bimanual laryngoscopy may avert the
need to reach for a fancy device

 Levitan R. Laryngeal view during laryngoscopy: A randomized trial

comparing cricoid pressure, backward-upwardsrightwards pressure
and bimanual laryngoscopy. Annals of Emergency Medicine 2006;
46:548.
 BID:Supra-Glottic Airway
 Accurate placement without direct vision
 Recommended for anatomically intact airways.
 Avoids potential iatrogenic injury or misplacement

a)Double Lumen Laryngeal Devices

 BID:Supra-Glottic Airway

Combitube®
Advantages Disadvantages
Inexpensive Blind-insertion approach
Easy to teach and learn Not a definitive airway

Ventilation superior to a Rare reports of airway

standard BVM injury

Can intubate with the May cause cervical motion

device in place in fracture

May be difficult to insert

with neck in-line

 BID:Supra-Glottic Airway
b)Laryngeal Mask Airways
 The LMA® and Intubating-LMA [Fastrach®] both rely on
seating of the device in the esophagus.
 The Fastrach™ allows for intubation of the trachea with a
cuffed tube.
 BID:Supra-Glottic Airway
LMA ..con’t
Sizes: 2: 10-20kg
3: 30-50kg
4: normal adults
50-70kg
5: large adults
70-100kg
6.>100kg
 BID:Supra-Glottic Airway
Fastrach™
 Single Use, but may be used up to 40 times

 Ideal for areas of the hospital where use will be frequent,

especially teaching situations
 Comes with specially-designed ETT which may be used up to

10 times
 Blind intubation success rate as high as 96.4% in difficult to

intubate patients after 3 attempts*

Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A: Use of the
intubating LMA Fastrach™ in 254 patients with difficult-to-manage airways.
Anesthesiology 2001; 95:1175-81
 BID:Supra-Glottic Airway
Standard Laryngeal Mask Airway®
Advantages Disadvantages
Relatively inexpensive Blind-insertion approach
Ventilation superior to a standard Not a definitive airway

BVM Requires careful sizing to fit in the

airway

Intubating Laryngeal Mask Airway [Fastrach®]

Advantages Disadvantages
Ventilation superior to a standard Expensive
BVM Requires careful sizing to fit in the
Provides a definitive airway airway
 BID:Supra-Glottic Airway
c)Intubating Stylets
 There are a number of intubating stylets on the
market. The classic gum-elastic bougie is inserted
under direct vision or blindly “by feel” into the
airway.

 The Trachlight® relies on trans-illumination of the

larynx during blind insertion.
 BID:Supra-Glottic Airway
Gum Elastic Bougie
Advantages Disadvantages
Inexpensive  Blind technique difficult
Provides a definite airway

Can use as an adjunct to

laryngoscopy
Can insert visually or blindly

Lighted Stylet [Trachlight®]

Advantages Disadvantages
Provides a definitive airway  Technique requires expertise
Can use as an adjunct to

laryngoscopy
Minimal neck movement
 DVD:Supra-Glottic Airway
 The hand-held fiberoptic stylets and laryngoscopes have
revolutionized emergency airway management.
 These devices offer the advantage of direct visualization of the
airway without the technical complexity and cost of more
traditional flexible fiberoptic scopes.
 Each of these has a different design and it is difficult to
strongly recommend one over the other.
 Furthermore, in videolaryngoscopy is an excellent teaching
tool that should rapidly become the standard at Emergency
Medicine training programs.
 DVD:Supra-Glottic Airway

a)Hand-Held Fiberoptic Laryngoscopes

 The Glidescope® employs similar technology but a different
approach, whereby the device is inserted blindly and guided
into the airway by watching a monitor.
 DVD:Supra-Glottic Airway
Hand-Held Fiberoptic Laryngoscopes
Advantages Disadvantages
 Less expensive than Relatively expensive
traditional fiberscope Different psychomotor skill

Easier to use than a flexible Tip can be obscured by fog,

fiberscope secretions
Direct vision of the airway

Definitive airway

Allows for “supervised”

airway visualization
 Infra-Glottic Airway Devices
b)Transtracheal Jet Ventilation
 TTJV relies on placement of a rigid catheter through the
cricothyroid membrane into the airway. Ventilation is
delivered in intermittent “jets” using a regulator system
attached to a standard medical gas oxygen port.
 Infra-Glottic Airway Devices
Transtracheal Jet Ventilation
Advantages Disadvantages
Less invasive than a surgical Not a definite airway
airway Contraindicated in airway

Less complex than a surgical obstruction

airway May cause barotrauma

Provided a “bridge” to other

techniques

If I am that far down the algorithm, i.e.: about to move to an infra-glottic technique… I
would choose a formal cricothyrotomy over TTJV. The notable exception is in children
<8, where open cricothyrotomy is contraindicated.
 Infra-Glottic Airway Devices
c)Retrograde Intubation
 Infra-Glottic Airway Devices
 Retrograde intubation employs a Seldinger guide-wire system
advanced through the cricothyroid membrane and then
retrograde into the posterior pharynx. The wire is retrieved
through the mouth, a rigid introducer is placed over the wire, a
standard endotracheal tube is advanced over the introducer and
advanced through the glottis, and the wire removed.

 Given the number of steps required and the growing number

of less complicated alternatives, I would not recommend
retrograde intubation for ED airway rescue during which
there is always little time, tenuous physiology, and a full
stomach.
 Infra-Glottic Airway Devices
d)Cricothyrotomy
 Surgical cricothyrotomy;
either open or percutaneous,
remain the “last box” on
every airway algorithm ever
published.
 Infra-Glottic Airway Devices

Cadaver studies by Chan TM, et al [Journal of Emergency

Medicine 1999] and Schaumann N, et al [Anesthesiology
2004] have demonstrated that:

 The time to completion is similar for both techniques

 Success rates [85% to 95%] are similar
 Misplacement is more common with the percutaneous
technique
 Tissue injury is more common with the open technique
 Surgical Cricothyroidotomy
 Equipment: Scalpel - short and rounded(no. 20 or Minitrach
scalpel).Small (e.g. 6 or 7 mm) cuffed tracheal or tracheostomy
tube
 4-step Technique:
1. Identify cricothyroid membrane
2. Stab incision through skin and membrane
Enlarge incision with blunt dissection
(e.g. scalpel handle, forceps or dilator)
3. Caudal traction on cricoid cartilage with tracheal hook
4. Insert tube and inflate cuff
Ventilate with low-pressure source
Verify tube position and pulmonary ventilation
 Difficult Airway

Normal Anatomy Abnormal Anatomy

Adequate Oxygenation Adequate Oxygenation

Normal Anatomy Abnormal Anatomy

Inadequate Oxygenation Inadequate Oxygenation

Michael A. Gibbs, What Is Your Rescue Airway Plan: Advanced Airway

Techniques. American College of Emergency Physicians Scientific Assembly
2008: Advanced Airway Techniques; October 28, 2008.
Difficult Airway
Difficult Airway
Emergency Airway Algorithm
Crash airway algorithm
Difficult airway algorithm
Failed airway algorithm
 References:
 Difficult Airway Course: Emergency™
 Walls RM and Murphy MF: Manual of Emergency Airway
Management, 3rd edition, Philadelphia, Lippincott, Williams,
and Wilkins 2008.
 Practice Guidelines for Management of the Difficult Airway.An
Updated Report by the American Society of Anesthesiologists
Task Force on Management of the Difficult Airway.
Anesthesiology, V 98, No 5, May 2003
 Michael A. Gibbs, What Is Your Rescue Airway Plan:
Advanced Airway Techniques. American College of
Emergency Physicians Scientific Assembly 2008: Advanced
Airway Techniques; October 28, 2008.
 Morbid Obesity

 “Stacking”
maneuver
• Draw a line to join
external auditory
meatus to
suprasternal notch
 Place blankets/
towel rolls beneath
shoulder and neck
until the line
become horizontal