Management of the Difficult Airway

Question 1

What is the single most important factor leading to a failed airway?

Answer 1

According to the ASA Closed Claims Database failure to evaluate the airway and predict difficulty is the single most important factor leading to a failed airway.

Question 2

What are predictors of difficult bag-valve-mask ventilation?

Answer 2

1. Lack of teeth
2. Age > 55 years
3. Beard
4. Limited mandible protrusion test
5. Hx of OSA/snoring
6. decreased pulmonary compliance
7. Increased body mass index (>26 kg/m^2)
8. h/o neck radiation
9. male sex
10. airway tumors, hematoma, foreign bodies

Question 3

What are predictors of difficult laryngoscopy and intubation?

Answer 3

1. History of difficult intubation
2. Mallampati class III or IV
3. High-arched palate, large tongue, prominent incisors, reeding mandible short/thick neck
4. Mouth opening < 2 to 3 cm
5. Thyromental distance < 6cm
6. Acromegaly, diabetes, rheumatoid arthritis
7. Limited cervical spine movement

Question 4

What is the management of the difficult airway?

Answer 4

1. Assess difficulty of BMV and DL
2. If difficulty anticipated, consider awake intubation
3. If anesthesiologist is skilled in an alternative technique to DL, reasonable to proceed to GA assuming no anticipated difficulty with BMV or LMA

Question 5

What is the approach to the unexpected difficult airway as per the Difficult Airway Society?

Answer 5

Plan A: DL (initial intubation plan)
Plan B: ILMA or LMA (2ndary intubation plan)
Plan C: BMV (maintenance of ventilation plan, postpone surgery and wake up)
Plan D: LMA (awaken patient)
Plan E: surgical airway (cricothyrotomy)