1. Difficult Airway Management 2009 Adrian Sieberhagen

2. Clinical situation in which there is difficulty in Face Mask Ventilation and inability to intubate

3. What makes it difficult in ED’s Training/requirements Non-controlled setting Limited pre-procedural evaluation Hypoxia, hypotension, agitation, dynamic medical conditions Numerous logistical & implementation issues

4. Predicting the Difficult Airway History Physical Examination

5. History

6. Cormack and Lehane Class I: the vocal cords are visible Class II the vocals cords are only partly visible Class III only the epiglottis is seen Class IV the epiglottis cannot be seen.

7. Pregnancy Inflammatory Disease Small mouths Infections Endocrine Congenital Trauma Foreign Body Tumours

8. Examination

9. LEMON Look for external deformities Evaluate 3-3-2 rule Mallampati Obstruction Neck Mobility

10. Mallampati Score Class I –visualization of the soft palate, fauces, uvula, and both anterior and posterior pillars Class II –visualization of the soft palate, fauces, and uvula Class III –visualization of the soft palate and the base of the uvula Class IV –soft palate is not visible at all

11. Thyromental Distance 6.5cm normal Sternomental Distance >12.5cm normal Protrusion of Mandible

12. Management Prearranged Emergency airway trolley available Most senior staff

13. Emergency Airway Trolley Rigid laryngoscope blades Tracheal tubes Tracheal tube guides Laryngeal Mask Airways Fibreoptic intubation equipment Non-invasive/minimally invasive airways Surgical Airway CO2 detectors

14. Management Prearranged Emergency airway trolley available Most senior staff Emergency airway algorithm Deliver supplemental O2

17. Alternative Airway Techniques LMA/Laryngeal Tube Transtracheal Jet Ventilation Fibreoptic Intubation Retrograde Intubation Lightwand Combitube Surgical Airway

18. Laryngeal Mask Lubricated LMA inserted into hypopharynx Tip in upper oesophogeal sphincter Inflate Cuff Muscle relaxants not necessary C/I: –Need for high Peak Pressures –Risk of Aspiration –Pts with low lung compliance

19. Laryngeal Tube

20. Transtracheal Jet Insuflation

21. Fibreoptic Intubation

22. Retrograde Intubation Place guidewire through cricothyroid membrane Guidewire passes cephalad through pharynx and out mouth/nose Railroad ET tube

23. Lightwand Flexible Inserted through ET tube Insert into larynx Light dims if entering oesophagus Limitations: Dark room

24. Combitube Double lumen tube Placed into hypopharynx blindly C/I –Oesophageal pathology

25. Surgical Airway Cricothyroidotomy –Complications: Bleeding Infection Vocal cord damage Tracheal stenosis –C/I <12yrs Laryngotracheal Disruption Coagulopathy

26. The End