Management of a Difficult Airway

Question 1

If unable to see vocal cords or pass ETT during first DL:

Answer 1

1. Consider External Laryngeal Manipulation, BURP (Backwards Upwards
   Rightwards Pressure).
2. Consider placing Bougie introducer.
3. Limit total number of DL attempts to 2.
4. Recommend Video-Assisted Laryngoscopy.
5. Before repeating DL, consider mask ventilation with oral/nasal airways.
6. Consider optimizing patient position and/or blade selection.

Question 2

If you cannot intubate then:

Answer 2

1. attempt face mask ventilation

2. call for difficult airway cart

Question 3

If you CAN ventilate:

Answer 3

If ventilation remains adequate,
CONSIDER:
1. Awakening patient.
2. Complete case with LMA or
face mask.
3. Video-assisted Laryngoscopy.
4. Asleep fiberoptic bronchoscopy.
5. LMA as conduit for intubation or intubating LMA.
6. Retrograde wire intubation.

Question 4

If you can NOT ventilate:

Answer 4

1. CALL FOR HELP
2. Place oral, nasal airway and
   switch to two-handed mask ventilation.
3. Place LMA if feasible.

Question 5

If you STILL can NOT ventilate & becoming an EMERGENCY:

Answer 5

1. Call for Surgical Help.
2. Perform Cricothyrotomy.
3. Confirm successful placement with ETCO2 and bilateral breath sounds

Question 6

Options for known difficult airways:

Answer 6

(1) awake intubation
(2) video-assisted laryngoscopy,
(3) intubating stylets or tube-changers,
(4) LMA, laryngeal tube
(5 ) fiberoptic-guided intubation

-consider regional anesthesia

Question 7

When to Cric?

Answer 7

If the patient cannot be awakened, emergency airway access must be attempted in a life-threatening situation in which the patient cannot be ventilated or intubated.

Question 8

Exam component and nonreassuring findings:

Answer 8

1. Length of upper incisors = Relatively long
2. Relationship of maxillary and mandibular incisors
   during normal jaw closure
   = Prominent “overbite” (maxillary incisors anterior to mandibular incisors)
3. Relationship of maxillary and mandibular incisors
   during voluntary protrusion of mandible = Patient cannot bring mandibular incisors anterior to (in front of) maxillary incisors
4. Interincisor distance = Less than 3 cm
5. Visibility of uvula = Not visible when tongue is protruded with patient in sitting position (e.g., Mallampati class >2)
6. Shape of palate = Highly arched or very narrow
7. Compliance of mandibular space = Stiff, indurated, occupied by mass, or nonresilient
8. Thyromental distance = Less than three ordinary finger breadths
9. Length of neck = Short
10. Thickness of neck = Thick
11. Range of motion of head and neck = Patient cannot touch tip of chin to chest or cannot extend neck

Question 9

Patients that will not tolerate an apneic period?

Answer 9

patients who are obese, are pregnant, or have pulmonary disease, peds

Question 10

Alterations to induction to consider for difficult airways

Answer 10

• IV induction or Inhalation induction

- Choice of NMBA (duration, reversal)

Question 11

You have induced general anesthesia, given a paralytic and attempted direct laryngoscopy and found a grade 4 view. You attempt to mask ventilate and do not get chest rise or ETCO2. What are your next immediate actions?

Answer 11

Attempt to place a supraglottic airway

Call for help

Question 12

Other significant airway-related complications include?

Answer 12

-aspiration of gastric contents, laryngospasm, bronchospasm

Question 13

Reasons why anesthetist is unable to provide adequate ventilation?

Answer 13

-inadequate mask or LMA seal, excessive gas leak, excessive resistance to the inward/outward movement of gas.

Question 14

S/S of inadequate ventilation

Answer 14

-absent chest movement or breath sounds, cyanosis, decreasing Spo2, absent or inadequate ETco2, hemodynamic changes associated with hypoxia or hypercarbia (HTN, hypotension, tachycardia, arrhythmia)

Question 15

Difficult laryngoscopy:

Answer 15

-it is not possible to visualize any portion of the vocal cords after multiple attempts at DL

Question 16

Difficult intubation:

Answer 16

-tracheal intubation requires multiple attempts in the presence or absence of tracheal pathology

Question 17

Failed intubation:

Answer 17

placement of the ETT fails after multiple attempts

Question 18

strategies for difficult airways

Answer 18

• awake intubation
• video-assisted
• fiber-optic intubation
• use of stylets or tube-changers
• SGAs for ventilation

Question 19

Difficult mask ventilation

Answer 19

Inability of an unassisted anesthesia clinician to maintain alveolar
oxygen delivery or reverse signs of inadequate ventilation

Question 20

inappropriate airway management often cited in malpractice

Answer 20

• inadequate evaluation
• failure to plan for difficult intubation
• failure to use a supraglottic airway for rescue
• delay in calling for help
• perseveration on failed techniques

Question 21

good questions to direct airway management:

Answer 21

• Is airway control required?
• Could laryngoscopy be difficult?
• Could supraglottic ventilation be used?
• Is there risk of aspiration?
• Will the patient tolerate a period of apnea?

Question 22

Difficult airway suspected on a patient whose stomach is not empty

Answer 22

-Patients predicted to be difficult to intubate who have not fasted or who are
otherwise at high risk for regurgitation and aspiration of gastric contents should be intubated awake and in control of their airway reflexes whenever possible

-consider spraying local anesthetic solution through the
flexible bronchoscope as it is advanced during the process of laryngoscopy and intubation

-The key to awake intubation in the patient with a full stomach is a smooth course, with avoidance of
gagging, coughing, and vomiting

-RSI (requires ability to intubate rapidly) may be inappropriate for patients who may be difficult to intubate

Question 23

Factors that complicate an awake intubation

Answer 23

• cognitive disability
• altered mental status
• extreme anxiety
• uncooperative

Question 24

Why is an awake intubation ideal in a known difficult airway?

Answer 24

-we preserve spontaneous ventilation, patient cooperation and airway reflexes

Question 25

Choice of induction technique when difficult airway management is predicted:

Answer 25

-IV induction is used when there is a high likelihood of successful ventilation by mask, SGA, or endotracheal intubation and the patient is not at significant risk of gastric contents aspiration or rapid desaturation -use short-acting drugs -careful consideration of the NMBA -When maintenance of spontaneous ventilation is preferred, an inhalation induction may be used, though IV access should be established prior to inhalation induction.

Question 26

Preferred airway device for a patient with a potentially difficult airway

Answer 26

ETT is considered by many to be the definitive method of airway control, however, not every patient requires endotracheal intubation, including the patient with a potentially difficult airway. Regardless of the technique chosen for airway management, ****a backup plan MUST be in place, with the necessary expertise and equipment immediately available***

Question 27

When to consider a SGA

Answer 27

Many patients who are predicted to be difficult to intubate and/or mask ventilate can be successfully ventilated with a SGA. **SGAs can be considered for use as the primary airway device when the risk of aspiration is relatively low and the need for higher airway pressures is not anticipated** A SGA specifically designed to allow intubation through the device may be a good choice for the patient who may be difficult to intubate

Question 28

When airway evaluation necessitates a surgical airway:

Answer 28

- if known, always have the surgical team consulted as part of the airway plan - if unknown, call for surgical help ASAP

Question 29

If a surgical airway fails or is impossible

Answer 29

-consider fem/fem cardiopulmonary bypass, ECMO

Question 30

Equipment preparation for a difficult airway

Answer 30

-have both routine and emergency airway equipment available -have an assortment of standard and alternative airway devices including facemasks, appropriate sizes and types of laryngoscopes (direct, indirect, flexible), oral and nasal airways, supraglottic airways (SGAs), bougies, and equipment for front-of-neck access -have the emergency airway cart nearby -always call for help earlier rather than later

Question 31

preparation for an awake intubation

Answer 31

- the administration of a drying agent (eg, glycopyrrolate 0.2 mg IV), nasal mucosal vasoconstrictors (if nasal intubation is a possibility), and anesthetic blocks (topical spray or invasive) of the upper airway.

Question 32

Timing of administration of NBMA

Answer 32

-mask ventilation should be established prior to the administration of NMBAs. In theory, this sequence allows the clinician to prove his or her ability to ventilate the patient before removing the patient's ability to ventilate on his or her own, while maintaining the option to awaken the patient should attempts at airway control fail. -but also consider that NMBAs may improve mask ventilation, especially when difficulty is the result of laryngospasm, opioid-induced rigidity, or light anesthesia.

Question 33

NMBA choice when difficult mask ventilation is predicted

Answer 33

when mask ventilation is predicted to be difficult, but laryngoscopy is predicted to be straightforward, a strategy that allows rapid intubation while minimizing the need for mask ventilation should be employed. Options include: Succinylcholine – a depolarizing NMBA. At a dose of 1 to 1.5 mg/kg IV, blockade is complete in approximately one minute, and recovery occurs in only six to nine minutes Rocuronium – a nondepolarizing NMBA. At a dose of 0.9 to 1.2 mg/kg IV, blockade is complete in less than two minutes, with a variable, long duration of action (38 to 150 minutes).... but Roc is reversible with sugammadex.....

Question 34

Inhalation induction for a difficult airway

Answer 34

- used to better maintain spontaneous ventilation until airway control (with facemask, SGA, or ETT) has been confirmed - may be preferred in patients predicted to have difficulty with intubation but NOT with mask ventilation. - IV access should be obtained in adults prior to inhalation induction - preoxygenate - Sevo is agent of choice - start low and gradually increase concentration

Question 35

Various maneuvers may improve the ability to mask ventilate

Answer 35

- place an oral or nasal airway - maneuvers to open upper airway (head tilt, chin lift, jaw thrust) - two-person mask technique

Question 36

awake intubation, instrument choice

Answer 36

- flexible scope intubation | - FSI through an endoscopy mask or an SGA permits ventilation during intubation.

Question 37

following an unsuccessful intubation attempt you should?

Answer 37

-attempt/resume mask ventilation

Question 38

limit attempts with any particular device

Answer 38

-Repeated instrumentation of the airway may lead to bleeding, edema, and further deterioration of the ability to ventilate

Question 39

if attempting a second time you should

Answer 39

-optimize conditions between attempts; for example, by improving head and neck position, changing laryngoscope blade, using a different device, or by having a more experienced clinician manage the airway.

Question 40

BURP stands for?

Answer 40

Thyroid cartilage pressure - backward, upwards, right pressure... attempting to improve laryngoscopic grade & bring cords into better view

Question 41

Cricoid pressure

Answer 41

decreases LES tone to prevent aspiration controversial contraindicated in unstable C-spine or active vomiting