Some Tools for

Managing the Difficult

Airway
Joe Lex, MD, FAAEM
Temple University
Philadelphia, PA
Emergency Medicine
Airway management is really easy…
…except when it isn’t…
 Our Options Are Different
Anesthesiology Emergency
• Plan in advance • What will be, will
be
Can’t get airway... Can’t get airway…
…awaken patient …wipe brow
…regroup …change shorts
…go for coffee …call attorney
…call coroner
Emergency Medicine
 It can be difficult to…

…oxygenate
…ventilate
…intubate
…perform cricothyrotomy

Emergency Medicine
 To Maximize Success…
…recognize and predict difficult
airway
…choose appropriate technique
and equipment
…possess technical skills, drugs,
and devices

Emergency Medicine
 Predicting the
Difficult Airway

…if you have time

Emergency Medicine
 LEMON Law
Look at anatomy
Examine the airway
Mallampati
Obstructions
Neck mobility
Emergency Medicine
 Look at Anatomy
• Obesity: rapid desaturation, difficult
intubation, ventilation
• Facial hair: hides small chin, can
make bagging difficult / impossible
• Large teeth: hide airway, obscure
tube passage
• Jagged teeth: lacerate balloon

Emergency Medicine
Look at Anatomy

Emergency Medicine
 Look at Anatomy
• Narrow face, high-arched palate:
decreased side-to-side diameter
• Large tongue: hides airway
• False teeth: help bagging, remove
for intubation

Emergency Medicine
Examine Airway

Emergency Medicine
 Examine Airway
The 3 – 3 – 2 rule
• Mouth open: 3 fingers
• Mentum to hyoid: 3 fingers
• Floor of mouth to thyroid
cartilage: 2 fingers

Emergency Medicine
 Examine Airway
• Mouth open: 3 fingers
 Allows insertion of tube,
laryngoscope
• Mentum to hyoid: 3 fingers
 Predicts ability to lift tongue
into mandible

Emergency Medicine
 Examine Airway
• Floor of mouth to thyroid
cartilage: 2 fingers
 If high larynx, airway tucked
under base of tongue, hard to
visualize

Emergency Medicine
 Mallampati Score
• With patient seated: extend
neck  open mouth  stick
out tongue
• Visualize base of tongue,
faucial pillars, uvula, pharynx

Emergency Medicine
 Mallampati Score
Difficulty
None None Moderate Severe
Airway Obstructions

Emergency Medicine
 Airway Obstructions
• Angioedema?
• Hematoma?
 Look under shirt collar
• Dentures?
• Epiglottis?

Emergency Medicine
 Neck Mobility
Prior condition
• Surgery
• Rheumatoid
arthritis
• Osteoarthritis
• Others

Emergency Medicine
Neck Mobility

Emergency Medicine
 Neck Mobility
• Cervical spine rigidity:
reduces ability to align
anatomic axes
• Inability to mobilize neck can
make intubation difficult or
impossible

Emergency Medicine
Moving Beyond Laryngoscopy
Some Equipment, Old & New
 Difficult Airway Cart
• Bag valve mask • Lightwand
• Combitube™ • Bougie
• LMA • Transtracheal jet
• Intubation LMA • Retrograde
• Fiberoptic: rigid, • Digital
flexible • Cricothyrotomy

Emergency Medicine
1. Bag Valve Mask
 1. Bag Valve Mask (BVM)
• Practice: skills essential
• Use appropriate size oral airway or
nasal trumpet
• Leave dentures
• Use water-soluble lubricant to get
good seal, especially if lots of facial
hair

Emergency Medicine
2. Combitube®
 2. Combitube®
• Double lumen tube functions as
esophageal obturator airway plus
standard cuffed endotracheal tube
• Insert blindly  90% esophageal
• Inflate proximal balloon: 100 mL
• Inflate distal balloon: 5 –15mL

Emergency Medicine
 2. Combitube®
• Seals oropharyngeal and
nasopharyngeal cavities
• Ventilate through blue port
 Good breath sounds and no air in
stomach  continue ventilating
 No breath sounds and air in stomach
 use white tube

Emergency Medicine
2. Combitube®

Emergency Medicine
3. Laryngeal Mask Airway
 Indications
• Routine / emergency procedures
• Known / unknown difficult airway
• During resuscitation in profoundly
unconscious patient with no
glossopharyngeal or laryngeal
reflexes when tracheal intubation
not possible

Emergency Medicine
 Contraindications
In elective patient who…
…has not fasted
…may have gastric contents
…has fixed  lung compliance
…is not profoundly unconscious
…resists LMA airway insertion

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Usage

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Usage

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Usage

Emergency Medicine
Usage

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Usage

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4. Intubating LMA
Emergency Medicine
 LMA Take-Home Points
• Test cuff before use
• Don’t lubricate anterior mask
• Insert only in comatose patient
• Keep cuff inflated until patient
awake
• Don’t throw out!! Used 40 – 50
times

Emergency Medicine
5. Flexible Fiberoptic Scope
 5. Flexible Fiberoptic Scope
Advantages
• Allows direct airway visualization
• Causes little hemodynamic stress
• Nasotracheal or orotracheal route
• Can be done in all age groups
• Requires minimal neck movement

Emergency Medicine
 5. Flexible Fiberoptic Scope
Disadvantages
• Expensive
• Expertise requires practice
• Delicate equipment needs careful
maintenance
• Visual field easily impaired by blood
and secretions

Emergency Medicine
6. Rigid Fiberoptic Scope
6. Rigid Fiberoptic Scope
Bullard Wu Scope

Emergency Medicine
6. Rigid Fiberoptic Scope
Upsher GlideScope

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6. Rigid Fiberoptic Scope
Levitan Scope

Emergency Medicine
 6. Rigid Fiberoptic Scope
Advantages
• Direct airway visualization
• Minimal neck movement
• May overcome difficult view
• Useful in disrupted airway
• Durable, sturdy instruments

Emergency Medicine
 6. Rigid Fiberoptic Scope
Disadvantages
• Expensive
• Expertise requires practice
• Visual field easily impaired by blood
and secretions
• Not readily available

Emergency Medicine
7. Lightwand (Trachlight)
7. Lightwand (Trachlight)
 7. Lightwand (Trachlight)
Advantages
• Minimal neck movement
• Useful adjunct to laryngoscopy
• Portable and inexpensive
• Usable in bloody airway
• Provides definitive airway

Emergency Medicine
 7. Lightwand (Trachlight)
Disadvantages
• Blind technique
• May damage airway
• Usually requires darkened room
• Expertise requires practice

Emergency Medicine
8. Intubating Stylet (Bougie)
 8. Intubating Stylet (Bougie)
• Gum elastic – use as guidewire
Advantages
• Gives definitive airway
• Easy to learn
• Inexpensive
• Can be used blindly

Emergency Medicine
 8. Intubating Stylet (Bougie)
• Gum elastic – use as guidewire
Disadvantages
• Expertise requires practice
• Not recommended in “can’t intubate
/ can’t ventilate” scenario

Emergency Medicine
9. Transtracheal Jet Ventilation
 9. Transtracheal Jet Ventilation
Advantages
• Surgical airway of choice if 8 years
or younger
• Effective
• Can serve as temporary airway
before permanent airway
• Relatively simple procedure
Emergency Medicine
 9. Transtracheal Jet Ventilation
Disadvantages
• Significant complications if
misplaced
• Need proper equipment
• Need high-pressure oxygen
• Does not protect against aspiration

Emergency Medicine
10. Retrograde Intubation
 10. Retrograde Intubation
• Puncture cricothyroid membrane
• Thread wire through vocal cords
• Exit nose or mouth
• Guide endotracheal tube through
vocal cords over wire

Emergency Medicine
 10. Retrograde Intubation
Advantages
• Definitive airway
• Minimal neck movement
• Does not require full mouth open

Emergency Medicine
 10. Retrograde Intubation
Disadvantages
• Takes time
• Requires skill
• Not recommended in cannot
intubate / cannot ventilate

Emergency Medicine
11. Digital Intubation
 11. Digital Intubation
• You need long fingers
• Make sure patient is really
unconscious
• Not commonly used, but can be life-
saver

Emergency Medicine
 11. Digital Intubation
Indications
• Poor lighting, difficult patient
position, disrupted airway, potential
cervical spine injury
• Can’t see larynx due to blood
• Equipment failure
• Intubation failure

Emergency Medicine
12. Cricothyrotomy
 12. Cricothyrotomy
• Life-saving technique
• Surgical vs. needle / Seldinger vs.
percutaneous kit
• You must know this procedure
before starting rapid sequence

Emergency Medicine
 12. Cricothyrotomy
• Final common pathways for all
cannot intubate / cannot ventilate
scenarios
• “The hardest part of doing a
cricothyrotomy is picking up the
knife.” – Peter Rosen

Emergency Medicine
 And finally…
BURP your patient – grab the larynx
and give…
…Backward
…Upward
…Rightward
…Pressure

Emergency Medicine
 Conclusions
• Recognize the difficult airway
 How much time do you have?
 Who else is around?
 What is your backup procedure
• Know both old and new methods
• Choose backups based on skills

Emergency Medicine
Dziękuję bardzo

joe@joelex.net
joe@joelex.net
Emergency Medicine