Difficult Airway Flashcards
Define 2022 difficult airway
“For these practice guidelines, a difficult airway includes the
clinical situation in which anticipated or unanticipated difficulty or
failure is experienced,
including but not limited to one or more of the following:
facemask ventilation, laryngoscopy, ventilation using a supraglottic
airway, tracheal intubation, extubation, or invasive airway.”
Scariest thing about difficult airway algorithm
Not being able to oxygenate
Main modifications to 2022 algorithm by ASA
Extensive choice between awake/asleep
Limit attempts
Consider awakening
Best mark twain quote as related to intubation
“It’s easier to stay out of trouble than get out of trouble”
Factors in deciding the airway strategy/technique
Experience
Available equipment
Availability and competency of help
Context
What should we be optimizing throughout our intubation attempts?
Oxygenation
Don’t put a patient to sleep unless:
You believe you can perform supraglottic ventilation
What’s a recipe for disaster in difficult airway management?
Using videolaryngoscopy as a crutch
What are our alternatives?
Alternative awake non-invasive technique
Awake elective invasive
Regional or local
List invasive airway techniques
-Retrograde wire-aided intubation
● Surgical cricothyrotomy
● Surgical tracheostomy
● TTJV
● Rigid bronchoscopy
● ECMO
-Usually need preinserted cannula
First step after a failed airway
Call for help
How many DL attempts are acceptable?
3
If you can ventilate and have failed intubation what do you do?
Wake them up numb nuts
While advancing ett over fiber optic it meets resistance at 16cm, what do you do and what is the cause?
Caught on the arytenoid
Pullback, rotate 90 degrees and read Vance
Ett gets stuck on fiber optic at 16cm, what do you do?
Caught on the arytenoid
Pullback, rotate 90 degrees and read Vance
Stridor
Harsh monotone airway sound produced from partial airway obstruction
Occurs in supraglottic region and the large intrathoracic conducting airways
AIRWAY EMERGENCY
Stertor
Snoring, partial upper airway obstruction
High pitched inspiratory Stridor
Supraglottic
Expiratory Stridor
Intrathoracic large conducting airways
Low pitched
Medium pitched biphasic Stridor
Mid-tracheal
What is Heliox?
mixture of He and O2 [70/30; 60/40] that generates less resistance
than oxygen or air and thereby temporarily improves airway obstruction
and decreases work of breathing
● Drawback: decreased maximum FiO2
Temporizing respiratory distress
Sit upright
Humidified oxygen
Racemic epi- if tissue swelling
Steroids
Heliox
With neck hematomas and airway compromise, why doesn’t opening
the hematoma always relieve the airway obstruction?
Airway compromise in this setting is due to (1) direct mass effect from
the hematoma and (2) pressure from the hematoma impeding venous
and lymphatic drainage causing tissue edema. Only mechanism #1 is
relieved by hematoma evacuation
When is infraglottic your first approach?
Potentially with severe Stridor and difficult airway
-do NOT obliterate spontaneous ventilation
Obesity hypoventilation sydrome
Failure to achieve adequate rate or volume results in a rise in PaCO2 and is associated with pulmonary TN
Steps for FO intubation
Patient sitting upright, monitor, Metoclopramide, and glyco
-organize supplies-orient yourself correctly
-Oral FO guide
-check light source
-defog
-7.0 ett loaded ,lubed and deflated
Barrys FO cocktail
4% aerosolized lido X 15 min
-don’t skimp on time and hold the neb upright, no talking!!
-gargle viscous lido 5cc 2-3 times and suction
Don’t let them swallow….
Medication for Fiberoptic intubation
1-2 versed
25mcg fentanyl-titrate RR <6?
Best friend for awake intubation and extubation for cough suppression
Narcotic
Implications of RA in airway management
Acute atlanto-axial subluxation during direct laryngoscopy due to RA
involvement can result in spinal cord compression.
● 50% of RA
● Cricoarytenoid involvement with RA can result in stridor and TVC
dysfunction, especially if subluxation of this joint occurs during
intubation
Why do we see difficult airways in morbidly obese patients?
● Mobile adipose tissue deposits in lateral pharyngeal walls
● Obstructs visualization of glottic opening
● Short necks
● Limited head extension due to posterior neck fat pads
