Emergency Medicine Some Tools for Managing the Difficult Airway Joe Lex, MD, FAAEM Temple University Philadelphia, PA

Airway management is really easy… …except when it isn’t…

Emergency Medicine Our Options Are Different Anesthesiology Plan in advance Plan in advance Can’t get airway... …awaken patient …regroup …go for coffee Emergency What will be, will be What will be, will be Can’t get airway… …wipe brow …change shorts …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 L ook at anatomy E xamine the airway M allampati O bstructions N eck mobility

Emergency Medicine Look at Anatomy Obesity: rapid desaturation, difficult intubation, ventilation Obesity: rapid desaturation, difficult intubation, ventilation Facial hair: hides small chin, can make bagging difficult / impossible Facial hair: hides small chin, can make bagging difficult / impossible Large teeth: hide airway, obscure tube passage Large teeth: hide airway, obscure tube passage Jagged teeth: lacerate balloon Jagged teeth: lacerate balloon

Emergency Medicine Look at Anatomy

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

Emergency Medicine Examine Airway

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

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

Emergency Medicine Examine Airway Floor of mouth to thyroid cartilage : 2 fingers 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 With patient seated: extend neck  open mouth  stick out tongue Visualize base of tongue, faucial pillars, uvula, pharynx Visualize base of tongue, faucial pillars, uvula, pharynx

Mallampati Score DifficultyNoneNoneModerateSevere

Emergency Medicine Airway Obstructions

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

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

Emergency Medicine Neck Mobility

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

Moving Beyond Laryngoscopy

Some Equipment, Old & New

Emergency Medicine Difficult Airway Cart Bag valve mask Bag valve mask Combitube™ Combitube™ LMA LMA Intubation LMA Intubation LMA Fiberoptic: rigid, flexible Fiberoptic: rigid, flexible Lightwand Lightwand Bougie Bougie Transtracheal jet Transtracheal jet Retrograde Retrograde Digital Digital Cricothyrotomy Cricothyrotomy

1. Bag Valve Mask

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

2. Combitube®

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

Emergency Medicine 2. Combitube® Seals oropharyngeal and nasopharyngeal cavities Seals oropharyngeal and nasopharyngeal cavities Ventilate through blue port 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®

3. Laryngeal Mask Airway

Emergency Medicine IndicationsIndications Routine / emergency procedures Routine / emergency procedures Known / unknown difficult airway Known / unknown difficult airway During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible During resuscitation in profoundly unconscious patient with no glossopharyngeal or laryngeal reflexes when tracheal intubation not possible

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

Emergency Medicine UsageUsage

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4. Intubating LMA

Emergency Medicine

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

5. Flexible Fiberoptic Scope

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

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

6. Rigid Fiberoptic Scope

Emergency Medicine 6. Rigid Fiberoptic Scope Bullard Wu Scope

Emergency Medicine 6. Rigid Fiberoptic Scope Upsher GlideScope

Emergency Medicine Levitan Scope 6. Rigid Fiberoptic Scope

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

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

7. Lightwand (Trachlight)

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

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

8. Intubating Stylet (Bougie)

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

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

9. Transtracheal Jet Ventilation

Emergency Medicine 9. Transtracheal Jet Ventilation Advantages Surgical airway of choice if 8 years or younger Surgical airway of choice if 8 years or younger Effective Effective Can serve as temporary airway before permanent airway Can serve as temporary airway before permanent airway Relatively simple procedure Relatively simple procedure

Emergency Medicine 9. Transtracheal Jet Ventilation Disadvantages Significant complications if misplaced Significant complications if misplaced Need proper equipment Need proper equipment Need high-pressure oxygen Need high-pressure oxygen Does not protect against aspiration Does not protect against aspiration

10. Retrograde Intubation

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

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

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

11. Digital Intubation

Emergency Medicine 11. Digital Intubation You need long fingers You need long fingers Make sure patient is really unconscious Make sure patient is really unconscious Not commonly used, but can be life- saver 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 Poor lighting, difficult patient position, disrupted airway, potential cervical spine injury Can’t see larynx due to blood Can’t see larynx due to blood Equipment failure Equipment failure Intubation failure Intubation failure

12. Cricothyrotomy

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

Emergency Medicine 12. Cricothyrotomy Final common pathways for all cannot intubate / cannot ventilate scenarios Final common pathways for all cannot intubate / cannot ventilate scenarios “The hardest part of doing a cricothyrotomy is picking up the knife.” – Peter Rosen “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 ConclusionsConclusions Recognize the difficult airway 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 Know both old and new methods Choose backups based on skills Choose backups based on skills

Emergency Medicine