1. CAP – Module 4 DIFFICULT AIRWAY MANAGEMENT
GHEMS_V

2. Objectives Review Anatomy and Physiology
Review the approach to the difficult airway
Review the protocols associated with difficult and failed airway management
Review the difficult and failed airway algorithms

3. A&P Review Upper airway Nasopharynx Oropharynx Laryngopharynx Larynx
OBJ: anatomy review: depth should be tailored to needs of least experienced operator

4. A&P Review Glottic structures Glottic opening Vocal cords
Cuneiform cartilage
Corniculate cartilage
Together make up the
Arytenoid Cartilage

5. A&P Review Laryngeal landmarks Thyroid cartilage Cricothyroid membrane
Cricoid membrane
Thyroid gland
OBJ: important to correlate laryngeal anatomy with surface anatomy landmarks

6. Airway Management – Difficult Airway
Indications: All Prehospital airways should be considered difficult to some degree. The provider must have preexisting criteria for predicting possible difficult airway situations and a set algorithm based on agency resources and County protocols for managing the difficult airway.
Critically ill patients will de-saturate quickly, possibly resulting in a failed airway situation.
OBJ: major points: predicting the difficult airway, having a plan (algorithm)

7. Airway Management Approaching the Difficult Airway Predicting
Use the LEMON pneumonic
L - Look Externally
E - Evaluate with rule
M - Mallampati score
O - Obstruction
N - Neck mobility
Look Externally: beard, dentition, obesity, etc.

8. Look Externally
For every patient who may require intubation, the paramedic should always look for readily apparent, even cosmetic, characteristics that may predict a potentially difficult airway. These include among others; obesity, micrognathia, evidence of previous head and neck surgery or irradiation, presence of facial hair, dental abnormalities (poor dentition, dentures, large teeth), a narrow face, a high and arched palate, a short or thick neck, and facial or neck trauma.

9. External look

10. 3-3-2 Rule

11. Mallampati Score Mallampati, Cormack and Lehane scores
OBJ: Mallampati may be obtainable on initial patient evaluation, with patient sitting in sniffing position; this slide attempts correlation with the laryngoscopic view of the Cormick Lehane system, which is basically a predictor of ET placement success

12. Obstruction Foreign body Trauma Swelling Esophageal spasms Growth
Infection

13. Obstruction list discussion
Foreign body – remove by direct laryngoscopy and Magill forceps
Trauma – Follow protocols and airway algorithms
Swelling – Follow protocols and airway algorithms
Esophageal spasms – Use of Succinylcholine
Growth – Follow protocols and airway algorithms
Infection – Follow protocols and airway algorithms

14. Neck Mobility Arthritis Spinal immobilization Location of patient
Entrapment – discuss possibilities

15. Decision Making Question One Is Ventilation Adequate or Inadequate?
Question Two
Is the Airway Normal or Disrupted?
Another approach to determining the difficult airway, answering these two questions and applying them to the grid below

16. Decision Making: Ventilation
Adequate
Inadequate
SaO2 > 90%
Also note respiratory rate, effort
EtCO2 spot reading may be unhelpful (e.g. CO2 retainers)
SaO2 < 90%
Note baseline may be below 90%
Also note respiratory rate, effort
Note: SaO2 is the key part of the definition. SaO2 below 90% may be baseline for a patient, but does not mean physiologically that patient will have a correspondingly lower set point to rapid desaturation; it is hemaglobin-dependent. These patients should be considered essentially in the failed airway protocol from the start.

17. Decision Making: Airway
Normal Airway
Disrupted Airway
Still identified as technically difficult
Anatomy intact
Examples:
Obesity
Anterior glottis
Small mouth
Still identified as technically difficult
Abnormal anatomy
Examples:
Trauma/burn
Infection
Hematoma
Cancer
Foreign body
Note here that Normal Airway dose not equate with non-Difficult Airway

18. Decision Making: Resources
Supraglottic
Infraglottic
Combitube
PROC 120
Eschmann catheter (“bougie”)
PROC 100
Percutaneous cricothyrotomy (Rusch quicktrach)
PROC 290
Surgical cricothyrotomy
Retrograde is so operator-dependant it should be discouraged as a resource for those not practiced with it.
Resources will not be available in all agencies.
Fiberoptic is not readily available as of early 2008, but many products are on the horizon and should be expected to penetrate the prehospital environment in the near future.

22. Airway Management – Difficult Airway
Approaching the Difficult Airway
Call for additional assistance
Maximize your chances
Position, medications, dentures out if needed
Have a PLAN
BVM/airway adjuncts
RSI
Partner tries or second try with different blade
ET introducer “Eschmann catheter”
Multi-Lumen Airway “combitube”
OBJ: reemphasize the need to have a plan/algorithm

23. Difficult Airway Algorithm
Call for additional assistance
Move to failed airway algorithm No
Able to BVM Pt w/adjuncts
Yes
Follow post intubation protocol
Yes
RSI completed No
Try with a different blade/partner tries
RSI completed
Yes No
Yes
Use Eschmann Catheter
RSI Completed No
Move to failed airway algorithm

24. Airway Management – Failed Airway
Indications: provider is unable to secure a definitive airway.
Definition
Oxygen saturation is below 90% after one attempt at ETT OR
Three failed attempts at ETT
Management
Combitube: bridging airway until definitive airway is placed
Cricothyrotomy: surgical airway is definitive, non-surgical (e.g. “quicktrach”) is not

25. Failed Airway Algorithm
Call for assistance
Failed Airway criteria met
Cricothyrotomy No
Able to BVM patient?
Yes
Consider Combitube No
Time allows and successful?
Yes No
Able to maintain SpO2>90%
Yes
Arrange for definitive Airway Management

26. Airway Management
Questions?