Basic Emergency

Airway
Management

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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,
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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
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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
• “Sniffing”position 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 ordhsradiation
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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 D’s 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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