DIFFICULT AIRWAY

MANAGEMENT

First Case of the Day

ASA Definition
The Difficult Airwayis defined as the clinical situation in which a
conventionally trained Anesthesiologist experiences
difficulty with facemask ventilation of the upper
airway, difficulty with tracheal intubation, or both

Difficult to Ventilateis when signs of inadequate ventilation could not be

reversed by mask ventilation or oxygen saturation
could not be maintained above 90%

Difficult to Intubateis when a trained Anesthetist using conventional

laryngoscope takes more than 3 attempts

DISCUSSION

Degrees of Airway Difficulty

Overlap
Difficult
Mask
Ventilation

Overlap
Difficult Mask
Ventilation

Difficult
SGA

Triple Failure
Difficult
Mask
Ventilation

Difficult
Intubatio
n

Difficult
SGA

DANGER
ZONE

An Emergent Surgical Airway is

Not Always Assured
Difficult
Mask
Ventilation

Difficult
surgical
airway

Difficult
Intubation

Danger Zone

4th National Audit Project

Sept 2008-Sept NAP4

2009 estimated
2,900,000 GA
performed in the UK
Data collected on
114,904 GAs from
309 hospitals over a
2 week period
184 serious airway
complications,
including:
-Death (14)
-Brain Damage
-Emergent Surgical
Airway

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NAP4 Lessons Learned

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NAP4 Lessons Learned

Poor Airway Assessment & Poor
Planning contributed to Poor
Outcomes
1.Failure to match strategy to

assessment (technique)

2.Failure to have prepared

strategy (plan B and C)

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NAP4 Lessons Learned

Emergency
Percutaneous
Cricothyrotom
y failed 60%
of the time

13

NAP4 Lessons Learned

A common theme was failure to plan
for failure
In some cases when airway

management was unexpectedly difficult

the response was unstructured. In
these cases outcomes were generally
poor.
The project identified numerous cases

where awake fiber-optic intubation was

indicated but not used
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NAP4 Lessons Learned

Aspiration was the single most

common cause of death in anesthesia

events
Importantly most aspirations occur due

to failure to recognize risk factors and

failure to adjust the anesthetic
technique accordingly
Aspiration remains the most frequent

cause of airway related deaths during

anesthesia.
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NAP4 Lessons Learned

One third of the events occurred during
emergence or in recovery. Obstruction
was the common cause in these events
Recommendations:
Nasal Trumpets
Oral Airway
Airway exchange catheter
SGA prior to removal of ETT (Bailey

Maneuver)

Awaken patient with SGA in place

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Predictors of Difficult Mask

Ventilation
Beard
OSA
Obesity
Male Gender
Mallampati class III or IV
Neck Circumference
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Predictors of Difficult
Intubation

Inadequate Preoperative
Assessment.
History of difficult intubation
Inadequate equipment
Experience not enough.
Poor technique.
Increased Age
Mallampati III or IV

Anatomical Factors Affecting

Laryngoscopy

Neck Circumference (Single Major Predictor in Obese)

Short Neck.

Protruding incisor teeth.

Long high arched palate.

Increase in either anterior depth or Posterior depth of

the mandible decrease in Atlanto Occipital distance

Limited cervical range of motion

Small mouth opening

Temporomandibular joint pathology

Basic Airway Evaluation in

All Patients
Previous anesthetic problems
General appearance of the neck, face,

maxilla and mandible

Jaw movements
Head extension and movements
The teeth and oropharynx
The soft tissues of the neck
Recent chest and cervical spine x-rays
20

Think L-E-M-O-N When Assessing

a Difficult Airway
Look externally.
Evaluate the 3-3-2 rule.
Mallampati.
Obstruction?
Neck mobility.

L: Look Externally
Obesity or very small.
Short Muscular neck
Large breasts
Prominent Upper Incisors (Buck Teeth)
Receding Jaw (Dentures)
Burns
Facial Trauma
Stridor
Macroglossia (Lg Tongue)

E-Evaluate the 3-3-2 Rule

3 fingers fit in mouth

fingers fit from mentum

to hyoid cartilage

2 fingers fit from the floor

of the mouth to the top of
the thyroid cartilage

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E-Evaluate the 3-3-2 Rule

12/28/15

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M- Mallampati classification
Class-I

soft palate, fauces;

Uvula, pillars.

Class-III

soft palate and base of uvula

Class-II

the soft palate, fauces

and uvula

Class-IV

Only hard palate

Mallampati ?

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Cormack & Lehane Grading

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O-Obstruction
Blood
Vomit
Teeth
Dentures
Epiglottis
Tumors
Foreign Body (piercings)
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N-Neck mobility -Measurement of

Atlanto-Occipital Angle

Atlanto-Occipital Angle
Estimates the angle
traversed by the
occluded surface of
the upper teeth
Grade
Grade
Grade
Grade

I --- > 35
II - 22-34
III 12-21
IV -- < 12
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Thyromental Distance
Measure from upper edge of thyroid
cartilage to chin with the head fully
extended.
A short thyromental distance equates
with an anterior larynx
Greater than 7 cm is usually a sign of an
easy intubation
Less than 6 cm is an indicator of a
difficult airway
Relatively unreliable test unless
combined with other tests
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Thyromental Distance

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MANAGEMENT PLAN OF
ANTICEPATED DIFFICULT AIRWAY
1.

Discussion with colleagues in advance

2.

Equipment tested before

3.

Senior help backup

4.

Definite initial plan (A) for ventilation and

intubation

5.

Definite plan (B) than option of awake

intubation

6.

Ideal situation surgery team standby

Preoxygenation
Two Techniques Common in Use:
1.

Tidal volume breathing (TVB) of 100%

oxygen via a tight-fitting face mask for 5
minutes (Preferred Method)

2.

Deep breaths/Vital Capacity 4 times within

0.5 min (Time to desaturation is consistently
shorter then preferred method)

Why Preoxygenate?

O2 Consumption Vo2=250ml/min and 2500ml O2

in FRC (after preO2) = 10 minutes to use this O2

Airway Management A-B-C

Start with Plan A
If plan A fails-

Go to plan B
If plan B fails-

Go to plan C

Plan A: (ALTERNATE)
Different Length of blade
Different Type of Blade
Different Position
Different Equipment

Plan B: (BVM and BLIND

INTUBATION Techniques )
Mask Ventilation
Bougie
Combi-Tube?
LMA an Option?
Fiberoptic?

Plan-C Cant Intubate.. Cant

Ventilate
Needle Cricothyrotomy
Transtracheal Jet Ventilation
Retrograde Wire Intubation

Failure.. Why does it happen

No critical discussion with colleagues

about proposed management plan

No request for experienced help

Exaggerated idea of personal ability
Ill-conceived plan A and/or plan B
Poorly executed plan A and/or plan B
Persisting with plan A too long,

starting the rescue plan too late

Not involving, and preparing,

surgical colleagues

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GALLERY
OF
TOOLS
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Rigid Laryngoscope Blades Of

Alternate Design And Size
Macintosh

Mc Coy

Magill

Miller
Polio

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Video Laryngoscopy

Airtraq
McGrath
C-Mac
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Video Laryngoscopy
VL Calls on a
Alternative Skill
Set
In Critical
Situations
Unpracticed
Techniques may
not be Helpful

43

Video Laryngoscopy
Use a stylet and
shape it to match
your VL Blade
Watch the patient
not the monitor
when
inserting the VL
Blade
Trouble passing tube
-Withdraw

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Video Laryngoscopy Versus

Direct Laryngoscopy
Improved Glottic
View
Experienced vs
Inexperienced
Cost
Standard of the
future?
Picture Confirmation?

45

Bullard Rigid Fiberoptic

Laryngoscope

Time
Experience
Limited Maneuverability
46

Stylet Devices
Optical Stylet

No Nasal Intubation
No Suction
Limited to above Cords

Lighted Stylet

47

GUM ELASTIC BOUGIE (GEB)

First used in England
Cheap
Good in patients in whom
only epiglottis is visualized

48

Supraglottic Airways SGA

Combitube

LMA

49

The EsophagealTracheal Combitube

Useful as emergency
airway
Two lumens allow
function whether
place in esophagus or
trachea
Esophageal balloon
minimizes aspiration
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Laryngeal Mask Airway

VARIATIONS OF LMA
LMA Classic (standard)
LMA Flexible (reinforced)
LMA Unique (disposable LMA)
LMA Fastrach (intubating LMA)
LMA C-Trach
(Visualization/Intubation)
LMA Proseal (gastric LMA)
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LMA Fastrach (Intubating LMA)

Rigid, anatomically curved,

airway tube that is wide enough
to accept an 8.0 mm cuffed ETT
and is short enough to ensure
passage of the ETT cuff beyond
the vocal cords

Rigid handle to facilitate onehanded insertion, removal

Epiglottic elevating bar in the

mask aperture which elevates
the epiglottis as the ETT is
passed through

Available in three sizes, one size

for children, two sizes for adults

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LMA C-Trach
Ventilation
Visualization
Intubation
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LMA-Proseal
High seal pressure - up to

30 cm H20 - Providing a
tighter seal against the
glottic opening with no
increase in mucosal
pressure
Provides more airway
security
Enables use of PPV in those
cases where it may be
required
A built-in drain tube
designed to channel fluid
away and permit gastric
access for patients with
GERD
55

LMA-Proseal

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Fiberoptic Aided Intubation

Most Versatile Tool
Available for Difficult
Intubation
Optical Elements are
Small
Visualization Below
the
Cords
Awake Intubation
Unique Skillset
Lens Contamination
Cost
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Cant Ventilate/Cant
Intubate

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Cricothyrotomy
Airway established
through the
Cricothyroid
Membrane
Not a Tracheostomy
Large Bore Catheter
Expected skill of the
Anesthetist
Contraindicated in
Neonates and
Children under age
6
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Transtracheal Jet Ventilation

Maxillofacial,
Pharyngeal, or
Laryngeal Trauma,
Pathology or Deformity
16-Gauge or Larger
(16g- tidal volume 400700)
15-30 psi with
Insufflation 1-1.5 sec.
Specialized systems
capable of using Lowpressure O2
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Retrograde Intubation
Local Anesthesia of the airway, skin wheel at

puncture site.
Cricothyrotomy performed with air aspiration
Retrograde wire is advanced until it emerges

from the mouth. (Magill Forceps)

Wire is Clamped/Secured at the entry site
ETT advanced over the wire (Many

Techniques)
Wire removed leaving ETT in place
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Retrograde Intubation

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Extubation of the Difficult

Airway

63

Airway Exchange Catheter

Extubation in a
controlled manner with
a AEC
Well tolerated
Airway can be
reintubated
Can deliver Oxygen
Provides an avenue for
suction
64

Airway Exchange Catheter

Localize the airway through existing

ETT
Mark AEC at required depth (tube

depth +3 CM)

Insert AEC and remove ETT

Tape AEC in place
Assess for removal of AEC
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Bailey Maneuver
Exchange of ETT for
a LMA
Decreased Severity
of
Cough
Maximum
change SBP
Maximum
change HR
Sore throat

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Bailey Maneuver
Patient is Deep
Oral-pharyngeal
suction
Deflated LMA
placed behind ETT
LMA cuff inflated
ETT cuff deflated
and removed
LMA used for
ventilation
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What's New in the ASA Difficult

Airway Algorithm
2003

2013

68

What's New in the ASA Difficult Airway Algorithm

Assess Likelihood and Impact section.

Added:
Difficult Supraglottic airway placement
Separated: Intubation and Laryngoscopy

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What's New in the ASA Difficult Airway Algorithm

2003

2013

Basic Management Choices:

Video-assisted Laryngoscopy as
initial approach to Intubation

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What's New in the ASA Difficult Airway Algorithm

2003

2013

LMA changed to SGA

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What's New in the ASA Difficult Airway Algorithm

2003

2013

Video-Assisted Laryngoscopy: Listed first

under Alternative Difficult Intubation
Approach
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What's New in the ASA Difficult Airway Algorithm

2003

2013

Under Invasive Airway

Access: Percutaneous airway
techniques and jet ventilation
remain but are
de-emphasized

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Two For The Road

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Two For The Road

Be familiar with alternative

intubating techniques and use

them on a regular basis in your
day to day practice.

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Two For The Road

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Questions?

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Questions?

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