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Emerg Med Clin N Am 21 (2003) 259289

Management of the dicult airway: alternative airway techniques and adjuncts

Kenneth H. Butler, DO, FACEPa,*, Brian Clyne, MDb

Emergency Medicine Residency Program, Division of Emergency Medicine, Department of Surgery, University of Maryland School of Medicine, 419 West Redwood Street, Suite 280, Baltimore, MD 21201, USA b Division of Emergency Medicine, Brown University School of Medicine, 593 Eddy Street, Samuels 2, Providence, RI 02903, USA

Management and stabilization of the airway is the single most important procedure in emergency medicine and truly denes the specialty. No other organ system can be resuscitated successfully without its securement. Emergency physicians are frequently called on to provide expeditious airway interventions for patients in extremis, many of whom have acute respiratory deterioration and airway compromise under the most dicult circumstances. Failure to secure a patients airway can lead to permanent neurologic damage or death in a matter of minutes. Often, little time is available to obtain an adequate patient history or to prepare the patient as in conventional airway management. Accordingly, the few seconds or minutes spent in evaluation, planning, and preparation for such scenarios can make the dierence between life and death. To provide optimal care under these circumstances, the emergency physician must be skilled in a variety of methods in airway management and have the proper equipment and devices available at all times. As the specialty of emergency medicine matures, physicians are becoming increasingly procient in airway management and are relying less frequently on assistance from other medical specialties [1]. Despite this trend, a national survey of emergency medicine residency training programs showed that only half of these programs provided any experience with an alternative device and little training in nonsurgical approaches to the dicult airway [2]. Many emergency physicians thus graduate from residency programs with inadequate training in the management of a dicult airway. Residency

* Corresponding author. E-mail address: (K.H. Butler). 0733-8627/03/$ - see front matter 2003, Elsevier Inc. All rights reserved. doi:10.1016/S0733-8627(03)00007-5


K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289

workshops on airway management tend to focus on standard laryngoscopic procedures and seldom cover alternative methods for managing a dicult airway. As a result, most graduating physicians are more competent in establishing a surgical airway than in applying alternative nonsurgical airway skills, even though new Advanced Cardiac Life Support (ACLS) guidelines include the laryngeal mask airway (LMA) and esophageal-tracheal Combitube (ETC) as better alternatives to facemask ventilation and as acceptable alternatives to tracheal intubation [3]. Despite technologic advances and the development of new devices for airway management, rapid-sequence intubation (RSI) remains the standard of care in the practice of emergency medicine. Direct laryngoscopy remains almost exclusively the manner in which all emergency airways are secured. Numerous emergency department (ED) case series and multicenter studies have shown intubation success rates at or greater than 98% using RSI and direct laryngoscopy. Standard laryngoscopic intubation, however, may not provide a denitive airway in every patient with a dicult airway. Instead of repeating the standard approach and increasing complications, the clinician should consider an alternative device or method of securing the airway. Furthermore, clinical pathways for controlled situations, such as the awake intubation arm of the American Society of Anesthesiologists dicult airway algorithm (Fig. 1) [4,5], are not applicable to the acuity of the ED patient who is agitated, hypoxic, and traumatized, with bloody secretions and vomitus. As these patients tend to be our dicult airways, reliance on preparation, prediction, evaluation, and familiarity with an alternative airway management device will increase our rate of successful intubation. The incidence of dicult intubations in the ED cannot be extrapolated from the anesthesiology literature. It seems reasonable to expect that dicult airways will be more frequent in EDs than in operating rooms, given the urgent need for the procedure and the lack of preparation of the patient [6]. When assessing a patient in need of airway support, the emergency physician rst should attempt to identify clinical clues that suggest the presence of a dicult airway and, when appropriate, select an alternative device. This strategy can prevent a patients deterioration or demise caused by multiple attempts using standard methods. Alternative devices and techniques include the laryngeal mask airway, dual-lumen devices, tracheal introducers, transillumination intubation, exible beroptic scopes, and semi-rigid stylets.
c Fig. 1. Dicult airway algorithm. *Nonsurgical tracheal intubation choices consist of laryngoscopy with a rigid laryngoscope blade (many types), blind orotracheal or nasotracheal technique, beroptic/stylet technique, retrograde technique, illuminating stylet, rigid bronchoscope, and percutaneous dilational tracheal entry. Always consider calling for help (eg, technical, medical, surgical) when diculty with mask ventilation or tracheal intubation is encountered. ++Consider the need to preserve spontaneous ventilation. From Benumof J. The laryngeal mask airway and the ASA dicult airway algorithm. Anesthesiology 1996;84:68699; with permission.

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K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289

The American Society of Anesthesiologists Task Force on Management of the Dicult Airway denes a dicult airway as a clinical situation in which a conventionally trained anesthesiologist experiences diculty with mask ventilation, diculty with tracheal intubation, or both [7]. The task force denes dicult mask ventilation as occurring when it is not possible to maintain the PO2 [ 90% using 100% oxygen and positive pressure mask ventilation, and dicult intubations as occurring when more than three attempts are required using conventional laryngoscopy. Despite careful preprocedure evaluation, airway management diculties may not be predicted in some cases; therefore, strategies for managing the unanticipated difcult airway should be formulated and practiced. The A in the ABCs also can represent an alternative device in airway management.

Prediction of the dicult airway One single preprocedural indicator specically for determining a diculty in ventilation, laryngoscopy, or intubation has not been found. The grading tools used by anesthesiologists provide accuracy in the preoperative assessment of stable patients. In contrast, emergency patients are dicult to assess. They are acutely decompensating, have a low margin for safety, hypoxemia, hypertension, hypotension, and other stressors, and require rapid intubation under suboptimal conditions. Often they are in extremis, agitated, and combative, have facial or laryngeal trauma, full stomachs, and cervical immobilization, and are unable to speak, making any assessment extremely dicult. Some predictors have proven consistently useful; combinations of predictors are the most sensitive. The most used predictive scheme for airway assessment in anesthesiology is the Mallampati classication. This system assigns three gradations based on increasing diculty in visualizing the posterior pharyngeal structures to predict dicult laryngeal exposure (Box 1) [8]. Samsoon and Young modied the Mallampati scoring system

Box 1. Mallampati airway classication system Class I Soft palate, fauces, uvula, anterior and posterior tonsillar pillars are visible Class II Soft palate, fauces, uvula are visible Class III Soft palate, base of uvula are visible Class IV Soft palate not visible at all
Reproduced with permission from Deem S, Bishop MJ: Evaluation and management of the dicult airway. Crit Care Clin 1995; 11:127 (citing Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict dicult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32:42934.)

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into four classes; increasing class number suggests greater diculty in glottic exposure (Fig. 2) [9]. This predictive score evaluates the size of the tongue in relation to the oropharynx, which indicates the ease or diculty of achieving optimal visualization. Airway assessment scoring systems have been based on variables such as the evaluation of mouth opening, jaw size, thyromental distance, and cervical range of motion, each individually having limited sensitivity and specicity. Combining scoring systems provides better prediction. The Rule of Threes oers the simplest predictor at the bedside. If the examiner can place three nger breaths (approximately 67 cm) between the upper and lower teeth, between the mandible and the hyoid bone, and between the thyroid cartilage and the sternal notch, direct laryngoscopy is usually successful [10]. Signicant diculty with two or more of these components justies a more detailed assessment, because the probability of diculty increases threefold. Predictors of dicult bag-valvemask (BVM) ventilation (ie, high body mass index, advancing age, presence of a beard, lack of teeth) also should be factored into a prediction, because recent evidence suggests the incidence of failure with this technique may be higher than previously believed [11]. In the presence of predictors of airway diculty, the use of an alternative device should be anticipated.

Preparation The frequency of failed intubations in the emergency department is approximately 1 in 500 [12]. The single most important factor in dictating the success or failure of airway management remains the skill level of the airway manager. The intubating physician must be familiar with various types of airway equipment and must select and apply the appropriate device

Fig. 2. Samsoon and Young modication of Mallampati classication, evaluating relative size of oropharyngeal structures to predict diculty in laryngeal exposure during direct laryngoscopy. Higher class number suggests greater diculty in glottic exposure. From Samsoon GLT, Young JRB. Dicult tracheal intubation. Anaesthesia 1987;42:48790; with permission.


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or technique for every airway resuscitation. Knowledge of and skill maintenance for plan B strategies prepares the intubator for dicult cases and facilitates establishment of a stable airway if initial intubation attempts fail. The airway manager must check all airway equipment personally before each emergency department shift. Equipment should be arranged in an easily accessible order at the head of the bed.

Prehospital intervention The dicult airway may rst declare itself in the eld when emergency medical services (EMS) personnel report that multiple attempts using standard laryngoscopic techniques failed, that the patient remained agitated and combative because of hypoxia, or that intravenous (IV) access could not be established. Although paramedics are well trained in airway management and frequently respond to patients in respiratory distress, one fourth of endotracheal tubes (ETTs) inserted by prehospital personnel in urban EMS systems are misplaced [13]. All patients intubated in the eld must have their airway reassessed in the ED. Direct laryngoscopic conrmation of ETT placement and use of a colorimetric or end-tidal carbon dioxide (ETCO2) detector should be rst priorities on arrival. Pediatric patients may not benet from endotracheal intubation if BVM ventilation can be performed properly by EMS personnel. The addition of out-of-hospital endotracheal intubation (ETI) to a paramedic scope of practice that already included BVM ventilation did not improve survival or neurologic outcome of pediatric patients in an urban EMS system [14]. A detailed mental picture of the patients condition and stability of the airway conveyed by radio transmission should help ED personnel prepare the resuscitation room before the patients arrival. The risk for intubation failure increases if the resuscitation room equipment is not inventoried properly and checked routinely for proper function. The simple mnemonic S-O-A-P-ME [15] should be used in the anticipatory phase and facilitates a clean intubation: S suction, O oxygen, A airway equipment, P pharmacologic agent, ME monitoring equipment. In this phase, the intubator checks the suctioning device and connection, selects the appropriate BVM and attachment to a wall oxygen source, veries illumination of the laryngoscope blade, ensures accessibility of sedation and paralytic drugs, and prepares all mechanical monitoring equipment.

Initial evaluation On arrival at the ED, all patient moorings should be checked, secured, and transferred to a permanent source. A second IV line should be established, as many placed in the eld have been inltrated or lost as a result

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of physical movement. Patients should be rehydrated, as their insensible water loss has been increased by tachypnea. Adults should receive a liter of normal saline before intubation if their cardiopulmonary status permits. Fluid administration may decrease the incidence of postintubation hypotension caused by the change from negative intrathoracic pressure to the positive intrathoracic pressure of mechanical ventilation. The decrease in venous return associated with an increase in intrathoracic pressure leads to a decrease in cardiac output and a subsequent decrease in blood pressure [16]. The patients anatomic airway should be evaluated in tandem with physiologic monitoring. In 1993, the American Society of Anesthesiologists published an algorithm for management of dicult intubations in the operating room [4]. An update published in 1996 (Fig. 1) incorporates the laryngeal mask airway. As in preprocedure assessments, this algorithm for stable patients may not be applicable to the practice of emergency medicine. In the ED, intubation is conducted to secure the airway and prevent the underlying condition from causing rapid deterioration. Obstruction, trauma, altered level of consciousness, respiratory and pulmonary failure, or underlying shock does not allow the option of bringing the patient out of anesthesia to resume spontaneous ventilation or awakening the patient if diculty is encountered, as recommended in the algorithm. In addition, the ASA suggestion to cancel the case and regroup may not be realistic for emergency medicine physicians, especially those in community hospitals. Emergency physicians must optimize their rst attempt at intubation. If failure is inevitable, they must provide proper BVM ventilation and be skilled in at least one alternative device for securement of the airway.

Aids to ventilation The laryngeal mask airway The laryngeal mask airway (LMA) (North America, Inc., San Diego, CA) is an innovative airway management device intended as an alternative to facemask use. For ventilation, the LMA is more eective than a BVM alone in anesthetized patients, because BVM ventilation often requires two hands to maintain a good seal [17]. The LMA provides an eective emergency airway in a variety of crisis situations. For anesthesiologists and anesthetists, the LMA is likely the most familiar rst option in the algorithm for managing a dicult airway (Fig. 3) [5]. The LMA consists of a semirigid tube attachment and an inatable mask that is placed into the hypopharynx and advanced over the larynx. When inated, the mask cu provides a seal around the glottic aperture (Fig. 4) [18]. The LMA is available as a reusable latex-free device and as a disposable one. Sizes range from those appropriate for neonates to large adults. If endotracheal intubation has failed, the LMA may be successful [4].


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Fig. 4. The components of the laryngeal mask airway. From LMA North America, Inc., San Diego, CA; with permission.

Insertion technique The LMA lies in a supraglottic position in the hypopharynx, and its ease of insertion is usually independent of anatomic and pathologic factors associated with the dicult airway (Box 2). Placement of the LMA is unrelated to the Mallampati [23], Cormack, and Lehane scores, and is unaected by manual inline stabilization or the presence of a rigid cervical collar [24]. Once the LMA is inserted, its aperture is lined up anatomically with the glottis, which makes it useful as an aid to intubation while giving oxygen and monitoring ventilation by way of capnography (Fig. 5). Hypoxic damage resulting from persistent conventional attempts to intubate a cyanotic patient may be avoided. Cricoid pressure can be maintained with the LMA in situ [25]. Once hypoxia is resolved, an alternative technique can be considered if the need for endotracheal intubation remains (eg, use of a exible beroptic scope). Indications and advantages When a surgical airway is being considered, an attempt to ventilate with the LMA may be benecial simply because it usually can be inserted within
b Fig. 3. The laryngeal mask airway (LMA) ts into the ASA algorithm on the management of the dicult airway in ve places, as an airway (ventilatory device) or a conduit for a berscope. From Benumof J. The laryngeal mask airway and the ASA dicult airway algorithm. Anesthesiology 1996;84:68699; with permission.


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Box 2. Primary advantages of the laryngeal mask airway in management of the difcult airway Reliance on direct visualization of the cords for successful airway control is obviated [19,20]. Neuromuscular blockade is not required for insertion and function (but obtunded airway reexes are required) [20]. The LMA usually can be inserted readily despite abnormal supraglottic anatomy. [19,21] It is not recommended for patients with acute epiglottitis. Intraglottic problems may impede LMA effectiveness after placement. The LMA can be used alone or as an aid to endotracheal intubation [20,22].
Adapted from Pollack CV Jr. The laryngeal mask airway: a comprehensive review for the emergency physician. J Emerg Med 2001;20(1):5366.

Fig. 5. Dorsal view of the laryngeal mask airway, showing position in relation to pharyngeal anatomy. From LMA North America, Inc., San Diego, CA; with permission.

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a few seconds and the rst-pass success rate is high [26]. In cardiopulmonary resuscitation, the LMA has been used successfully by physicians, nurses, and paramedics [2729]. Its insertion is independent of anatomic features used to predict or score dicult intubation and is not impeded by manual inline cervical immobilization or a rigid collar [30]. It can even be inserted in prone patients and those with otherwise inaccessible airways [31,32]. The LMA has demonstrated usefulness for dicult airway management in children and adults. The Pediatric Emergency Medicine Committee of the American College of Emergency Physicians advocates the LMA as the optimum alternative when RSI is unsuccessful [33]. The success rate of the application of the LMA depends on the operators familiarity with the device. The standard LMA may be used as a conduit for passing an ETT by way of a gum elastic bougie, exible beroptic scope, or lighted stylet, but its use as an adjunct for these procedures is expected to decline now that the intubating LMA is available [3436]. The LMA also may be a conduit for the administration of resuscitation medication. Epinephrine and aerosolized albuterol have been delivered successfully by way of the LMA [37,38]. Contraindications and disadvantages The most important issue mitigating use of the LMA in the ED is the risk for aspiration of gastric contents. Unlike an ETT with an inated cu, the ventilating device does not physically separate the respiratory and alimentary tracts [39]. Another contraindication to the use of the LMA for ventilation is the need for high pulmonary ination pressures because of increased airway resistance or very low lung compliance. Inadequate ventilation because of air leakage and gastric distention are the predictable adverse eects of attempting positive-pressure ventilation in tight asthmatics. The primary limitation of the LMA is the concern over incomplete protection of the airway. This should not be considered an absolute contraindication to its use because a living patient with aspiration pneumonitis is preferable to a patient dead for lack of an airway. The primary concerns about use of the LMA are (1) the risk for gastric insuation, (2) the potential for inadequate ventilation because of suboptimal positioning, and (3) the inability to generate high ination pressures in bronchospastic patients. Table 1 compares the LMA with other means of ventilation in patients with dicult airways. The intubating LMA The intubating LMA (ILMA) (LMA-Fastrach, Gensia Automedics, San Diego, CA) was designed specically for blind tracheal intubation. The ILMA functions as an airway in the same fashion as the LMA. Its shorter, wider ventilating conduit makes the ILMA easy to pass or withdraw over a translaryngeal tube.


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Table 1 Comparison of laryngeal mask airway (LMA) with other approaches for dicult or failed airways ET intubation 0 + + LMA/ intubating LMA BVM + + + + + + + + Lighted Fiber- Surgical Combitube stylet scope airway + + + + + + + + + + + + + + + +

Characteristic Avoidance of laryngoscopy Avoidance of esophageal intubation Ease of placement Allows ventilation without intubation Patient tolerance Cardiovascular/ sympathetic response Aspiration risk PPV requirement Security of airway Use with distorted facial anatomy Pediatric use Anesthetic depth Learning curve

+ + + + + + + + + + + + +

+ + 0 + + +

+ + + + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + +

+ + NA + + +

+ 0

+ NA

+ + + + + + + + +

+ + + + + + + + + + + +

+ + + + + + + + + + + +

+ + + + + + + + + + + + + + + +

+ + + + + + + + + 0 + + + + + + + +

+ + NA NA + 0 + + + + +

+ + NA NA + + + + + +

+ + + + + + + + + + + + + + NA +

+ + + + + + + + + + + + + + + + + +

Abbreviations: BVM, bag, valve, mask; NA, not applicable; PPV, positive pressure ventilation. From Pollack CV Jr. The laryngeal mask airway: a comprehensive review for the emergency physician. J Emerg Med 2001;20:5366.

Insertion technique A redesigned, tapered tracheal tube is passed blindly through the ventilating airway (Fig. 6). The orotracheal tube can be as large as 8 mm. The ILMA has a at metal handle that projects posteriorly. This allows the intubator to stand above the head of a supine patient and reposition the ILMA for blind attempts to pass the tracheal tube. Indications and advantages The ILMA is indicated in anticipated or unexpected dicult airway situations and for use as a guide for intubation of the trachea. Similar to the LMA, the ILMA does not reliably protect the airway from regurgitation and aspiration, but in the emergency pathway of cannot intubate, cannot ventilate, the risk for aspiration must be weighed against the potential for establishing an airway. Burgoyne and Cyna compared the ILMA and LMA for ease of insertion and successful ventilation when used by inexperienced resuscitators (nonanesthetic personnel). There were no clinically relevant dierences in the mean time to airway insertion (within 2 minutes), successful ventilation, or expired tidal volume [40]. Emergency physicians using the

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Fig. 6. Insertion technique for intubating laryngeal mask airway (LMA-Fastrach). If no resistance is felt, continue to advance the ETT while holding the LMA-Fastrach steady until intubation has been accomplished. From Gensia Automedics, Inc., San Diego, CA; with permission.

ILMA for the rst time achieved ventilation in less than 15 seconds and tracheal intubation in less than 1 minute [41]. In a large study involving 245 patients with dicult airways (ie, patients with Cormack-Lehane grade 4 views, immobilized cervical spines, airways distorted by tumors, surgery, or radiation therapy, or wearing sterotactic frames), insertion of the ILMA was accomplished in three attempts or fewer. The overall success rates for blind and beroptically-guided intubation through the ILMA were 96.5% and 100%, respectively, suggesting the device is useful in the emergent treatment of patients for whom intubation with standard rigid laryngoscopic failed [41,42]. The ILMA also has been compared with beroptic intubation for management of the dicult airway and proved to have a high success rate and a comparable time to achieve tracheal intubation [43]. The ILMA also may be used in children who weigh more than 30 kg (Table 2). Most investigators agree that prociency in use of the ILMA requires practice in a controlled setting before it can be used successfully under emergent circumstances. Fiberoptic intubation Flexible beroptic intubating scopes have become more advanced and geared to use in the emergency setting. Scopes have become smaller in diameter, compared with those used by pulmonologists, and completely


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Table 2 Larynegeal mask airway (LMA) and intubating LMA sizes and maximum cu ination volumes Mask Patient size description 1 1.5 2 2.5 3 4 5 6 Infants up to 5 kg Infants 510 kg Infants and children 1020 kg Children 2030 kg Children 3050 kg Adults 5070 kg Adults 70100 kg Large adults > 100 kg Available in Available in Available in LMA-Unique LMA-Fastrach Max. cu LMA-ClassicRM (disposable) (intubating LMA) volume (cc) X X X X X X X X 4 7 10 14 20 30 40 50



From Pollack CV Jr. The laryngeal mask airway: a comprehensive review for the emergency physician. J Emerg Med 2001;20:5366.

portable. Their built-in battery light source eliminates the time-consuming setup and connection to a bulky power source. Fiberoptic intubation, like all alternatives to RSI, has a place in airway management for selected patients. Awake intubation benets patients with marked laryngeal or cervical pathology, for whom paralysis and suppression of the respiratory drive or insertion of a laryngoscope blade may be detrimental. A study of more than 13,000 intubations demonstrated that a simple algorithm for endotracheal intubation conned to only two methods (conventional or beroptic intubation) is reliable, successful (failure rate, 0.045%), and easy to learn [44]. Insertion technique The nasotracheal approach to the airway with a exible beroptic scope is often simpler than the oral approach because the instrument is aimed directly at the glottis as it emerges from the nasopharynx into the hypopharynx. Intubation over a beroptic scope can be performed successfully through an LMA and around the ETC. Indications and advantages There are many advantages to the use of this technique, including application to all age groups, excellent airway visualization, ability to insuate oxygen during the procedure, high success rate, and immediate conrmation of ETT placement [45]. Contraindications and disadvantages There may be diculty in the use of a beroptic scope in the emergency setting. The presence of uncontrolled secretions, mucus, or active bleeding markedly impairs visualization. Suction through these instruments is

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ineective. Attaching an oxygen source to the suction channel may increase the eld of view by blowing away oending secretions or debris. Advancement of the ETT over the beroptic scope may be dicult, as the bevel of the tube may catch on the arytenoids, cartilages, or aryepiglottic folds. Withdrawing and rotating the ETT 90 and readvancing or changing to a smaller tube usually solves this problem. In a study of 60 consecutive intubations using a exible beroptic nasotracheal technique, the failure rate was 13% and bleeding occurred in 22%, demonstrating its limitations [46]. Other emergency department studies have shown that immediate airway control is often dicult with beroptic-aided endotracheal intubation; therefore, the technique should be used only in selected patients [47]. In a study of ED practices at U.S. teaching hospitals, Levitan found that beroptic intubation was seldom used as a means of managing the dicult airway [2]. Barriers to the selection of exible beroptic intubation include the following: (1) it is not standard equipment in most emergency departments, (2) an initial training period is required, (3) the learning curve is steep, and (4) skills decay because the procedure is used so infrequently. Combitube The esophageal-tracheal Combitube (ETC) (Combitube, KendallSheridan Catheter Corp, Argyle, NY) is a blindly inserted, double-lumen tube designed to facilitate ventilation during cardiopulmonary resuscitation (CPR) [12]. Its predecessor, the esophageal obturator airway (EOA), led to complications such as esophageal rupture and tracheal obstruction, prompting an improved design [48]. The ETC combines the concept of the EOA with that of the ETT. The device consists of two lumens: a pharyngeal lumen and a tracheal lumen separated by a partition wall. One lumen has an open distal end, similar to an ETT, and the other is closed at the distal end, with multiple ventilating eyes proximal to its inatable cu. A second larger oropharyngeal balloon inates to secure the ETC in position. Because ventilation is possible through either lumen, the Combitube can be used after esophageal or tracheal insertion (Figs. 7, 8). The device comes in two sizes: a 41 Fr for adult males and a 37 Fr (Combitube SA) for women and small adults. Insertion technique The ETC was designed to be inserted blindly; however, some investigators recommend use of a laryngoscope to limit trauma and facilitate insertion [48,49]. While grasping the patients tongue and jaw between the thumb and forenger, the clinician inserts the device to a depth at which the two black ring markers are between the front teeth or alveolar ridges. With blind insertion, there is a high probability the distal tip will enter the esophagus [48]. The oropharyngeal balloon is then inated with 100 mL of air using the large


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Fig. 7. The Combitube in the esophageal position. Reproduced with permission from Combitube and Combitube SA (Small Adult) dual-lumen airways; Kendall, a unit of Tyco Healthcare Group, LP, Manseld, MA.

prepackaged syringe. This seals the tube in the posterior pharynx, limiting aspiration of oral contents and minimizing movement. Next the esophageal cu is inated with 15 mL of air, sealing the esophagus. Ventilation should be attempted rst through the pharyngeal lumen and the chest auscultated for breath sounds. If breath sounds are absent or end-tidal CO2 is not present, the distal tip was blindly inserted into the trachea and the patient should be ventilated through the tracheal lumen and the chest again auscultated for breath sounds. Tube placement can be conrmed by conventional means such as auscultation, end-tidal CO2, and self-inating bulb [50,51].

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Fig. 8. The Combitube in the tracheal position. Reproduced with permission from Combitube and Combitube SA (Small Adult) dual-lumen airways; Kendall, a unit of Tyco Healthcare Group, LP, Manseld, MA.

Indications and advantages The Combitube is indicated as an alternative to endotracheal intubation (ETI) for medical personnel unskilled in airway management. As such, it is best suited for the prehospital setting, where patient positioning and environmental conditions may preclude laryngoscopy. For those skilled in airway management, the main indication for the Combitube is as a rescue device for the failed airway or the cannot intubate, cannot ventilate scenario in which cricothyrotomy is contraindicated, unsuccessful, or not immediately available. The main advantage of the Combitube for the emergency physician is that it may obviate the need for cricothyrotomy in patients with failed airways and those with maxillofacial or neck trauma [52]. The insertion technique is easily learned, allowing medical personnel without training in laryngoscopy to establish airway support in emergency situations. Studies of untrained providers indicate that use of the Combitube is safe, eective, and easily learned [5355]. The ETC has been used successfully in the prehospital


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environment and was preferred in one study over the LMA by emergency medical personnel [56]. Oxygenation and ventilation using the Combitube are comparable to, if not better than, those achieved with standard ETI, and the Combitube may be used for prolonged ventilation [12,57]. It has been suggested that the ETC may oer an advantage over ETI in patients with cervical spine injuries because it is inserted with the head and neck in the neutral position, but this claim is not supported consistently by the literature [58,59]. The Combitube oers adequate protection of the airway from aspiration [60]. Contraindications and disadvantages The Combitube is contraindicated in patients with intact laryngeal or pharyngeal reexes, known esophageal pathology, or corrosive ingestions. It is also contraindicated in patients with upper airway obstruction caused by a foreign body or pathologic conditions. The Combitube SA, designed for small adults, should not be used in patients under 4 feet tall. It is not available in pediatric sizes. As with other blind techniques, the ETC presents the potential for esophageal or pharyngeal trauma. There are case reports of subcutaneous emphysema resulting from piriform sinus perforation or esophageal laceration, apparently caused by direct esophageal trauma during ETC insertion [6163]. Pneumomediastinum and pneumoperitoneum also have been reported with its use [63]. Unlike an ETT, suction of tracheal secretions is not possible with the Combitube. The literature supports use of the ETC as an eective alternative to endotracheal intubation. It is a noninvasive, easily acquired skill, and the device functions when inserted into either the esophagus or the trachea. Although its primary role is in prehospital care, emergency physicians should be familiar with the device and consider it for dicult and failed airway situations. Whenever conventional intubation cannot be performed readily, the Combitube may be a useful alternative. Lighted stylet Light-guided intubation evolved from the observation that a bright light transilluminates the soft tissues of the anterior neck when placed in the trachea [64]. Using this principle, several lighted stylets or light wand devices have been developed for blind oral or nasal endotracheal intubation. Among the more popular is the Trachlight (Laerdal Medical, Armonk, NY), a light wand device with three parts: (1) a reusable handle containing a battery pack and light source, (2) a exible tube with a light bulb at the distal tip, and (3) and a retractable stylet within the light wand to provide stability. Insertion technique The lighted stylet should be lubricated and positioned within a standard ETT so the light bulb is just at the distal end of the tube. The tube is then

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bent to a sharp 90 angle just proximal to the endotracheal cu to facilitate insertion around the tongue and maximize light intensity at the anterior neck. The intubator can approach the patient from the head or the side. The tongue and jaw are gently pulled forward from the side of the mouth with the nondominant hand and the ETT is inserted blindly into the back of the mouth at the midline. The tip of the ETT then is moved gently anteriorly until a bright, well dened glow illuminates the thyroid prominence (Fig. 9). The stylet then is retracted 510 cm to allow exibility at the tip and the tube is advanced until the light disappears just below the sternal notch. At this point, the tip of the ETT is reliably positioned between the cords and the carina. The stylet then is removed, followed by standard conrmation of tube placement. Indications and advantages Most emergency physicians have limited experience with lighted stylets and continue to use direct laryngoscopy as the primary method of securing the airway. In dicult airway situations, however, the lighted stylet is an appropriate backup choice. Indications for the lighted stylet include dicult airways caused by anatomic considerations, temporomandibular immobility, large overbites, restricted mouth opening, or poor dentition [26,65]. It has been used as a nasotracheal or orotracheal adjunct for severe facial trauma [66,67]. Lighted stylet intubation requires training, but prociency is acquired quickly and emergency physicians have used these devices with success [68]. Studies comparing lighted stylet intubation with direct laryngoscopy have shown faster times to intubation, fewer intubation attempts, less trauma, and fewer adverse hemodynamic eects with the stylet [6871]. Also, in patients with limited neck mobility or cervical spine injury, the lighted stylet is able to negotiate oropharyngeal angles better than laryngoscopy, with little or no head or neck manipulation [72]. In dicult airways, the light wand can be used as intended or as a standard stylet to aid in direct visualization of the cords. Contraindications and disadvantages There are no absolute contraindications to lighted stylets, but limitations may be encountered in patients with known inammatory laryngeal disorders such as epiglottitis, retropharyngeal abscess, and tracheal stenosis. They are relatively contraindicated in patients known to have laryngeal tumors, polyps, foreign bodies, or an unknown cause of upper airway compromise [73]. Factors such as copious oropharyngeal blood, dark skin, obesity, or bright ambient lighting may limit the degree of transillumination achieved with the lighted stylet. Conversely, in thin, fair-skinned patients, transillumination may be present with esophageal placement [68]. It should be


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Fig. 9. Light-guided intubation with Trachlight is based on the principle of transillumination of the soft tissues in the neck. This technique takes advantage of the anterior location of the trachea relative to the esophagus. A well dened, circumscribed glow can be seen in the anterior neck when the endotracheal tube and light enter the glottic opening. If the tip of the tube is placed in the esophagus, the light glow is diuse and is not seen easily. Trachlight illustration courtesy of Laerdal Medical Corporation.

stressed that lighted stylet intubation is a blind technique and tracheal placement should be conrmed by standard means. Trauma to the upper airway using the lighted stylet is generally minor (bleeding, dysphagia, sore throat) and less common than with direct laryngoscopy. For the emergency physician, lighted stylet intubation can be a valuable tool in dicult airway situations. It is an easily learned technique that is

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quick and reliable and has minimal complications. In the ED, it is best used as a backup technique for the patient who cannot be intubated by traditional laryngoscopy but who can be ventilated. For patients with unstable cervical spine injuries or patients who cannot be intubated orally, it may be a faster, more accessible rst choice over beroptic intubation. As with any airway device, preparation and frequent practice are essential to maintain skills. Gum elastic bougie The gum elastic bougie or Eschmann stylet is an endotracheal tube introducer originally described by Macintosh in 1949 as an aid to intubation [74]. The standard bougie is a semirigid malleable device, 60 cm long, made of woven polyester with a resin coating. It has a diameter of 15 Fr (5 mm), allowing easier passage through the vocal cords, and has a 40 angle 3.5 cm from its distal tip to facilitate tracheal placement [75]. A plastic, less expensive version of the bougie is available in the United States as the FlexGuide endotracheal tube introducer (ETTI) (GreenField Medical Sourcing, Inc., Northborough, MA) [76]. The bougie is commonly used in Europe for dicult intubations and has reduced the incidence of failed intubation and cricothyrotomy [7678]. Insertion technique When visualization of the vocal cords is poor or impossible, the lubricated bougie is passed posterior to the epiglottis with the distal tip angled anteriorly. If it enters the trachea, palpable clicks are felt as the tip of the stylet passes over the tracheal cartilage rings. This washboard eect and the fact the stylet cannot be passed beyond 40 cm (as the tip reaches the small bronchi) are reliable signs of tracheal placement [79]. With esophageal placement, clicks are not felt and the device can be advanced unobstructed beyond 45 cm. With the bougie stabilized in place by an assistant and the laryngoscope maintaining anterior displacement of the oropharyngeal structures, an ETT is passed over the bougie into the trachea (Fig. 10). Passage of the ETT is made easier by rotating the tube 90 counterclockwise, keeping the bevel of the tube posterior [80]. Indications and advantages The bougie is indicated whenever anatomic, traumatic, or pathologic factors prevent a good view of the vocal cords by direct laryngoscopy. It has proven particularly useful in patients with airway edema, neck trauma, and cervical spine immobilization [8183]. It is reasonable to attempt one bougie-assisted intubation before performing a cricothyrotomy in certain failed airway situations. It should be stressed that the bougie is no substitute for proper technique and should be used only after other attempts to optimize the laryngoscopic view have failed.


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Fig. 10. Gum elastic bougie directed into the trachea. The endotracheal tube is inserted over the bougie. From McCarroll SM, Lamont BJ, Buckland MR, Yates APB. The gum elastic bougie: old but still useful [letter]. Anesthesiology 1988;68:6434; with permission.

The bougie is an inexpensive, nonsurgical device that can be readily available for urgent use in the ED. Unlike other airway adjuncts, it requires little training time and no technical expertise beyond the skill of laryngoscopy. Its exibility allows the airway manager to customize the bougieto suit the patients anatomy and increase the likelihood of success. When inserted properly, the bougie is reliable in avoiding esophageal intubations. Contraindications and disadvantages The bougie is contraindicated when the epiglottis cannot be visualized under any circumstances. Unlike some airway adjuncts, it is not a blindly inserted device and should be guided under the epiglottis or through the vocal cords under direct vision. It is not indicated for patients who require nasotracheal intubation. The smallest ETT the standard bougie can accommodate is a 6.0 mm ETT, limiting use to adults. Minor complications associated with the bougie are uncommon and include local trauma to the

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airway, sore throat, and hoarseness [84]. Major complications such as pharyngeal perforation, pneumothorax, hemopneumothorax, and mediastinal emphysema have been reported only rarely [85,86]. The bougie is an inexpensive, easily used device and should be the rst backup device considered for the anticipated or known dicult airway. Routine or dicult, a bougie should be kept within arms reach during every intubation. Digital intubation Blind digital intubation or tactile intubation is an uncommon technique in which the intubator guides the ETT into the trachea with his or her ngers. The emergency physician has other devices and skills for management of the dicult airway, but digital intubation deserves mention as a valuable technique for some rarely encountered situations. Technique Using a stylet, the clinician forms an ETT into a U-shape. The intubator approaches with the nondominant hand closest to the patient and an assistant retracts the tongue. This pulls the epiglottis upward and facilitates palpation of the epiglottis and glottic opening. The index and middle ngers of the nondominant hand are inserted palm down toward the base of the tongue. The middle nger is used to identify the epiglottis and direct it anteriorly. The ETT with stylet is then passed between the index and middle ngers and advanced into the glottic opening, guided by the middle nger. The stylet is then withdrawn and placement is conrmed. Indications and advantages Digital intubation is indicated when poor lighting, patient positioning, copious airway secretions, or equipment failure render direct laryngoscopy dicult or impossible [87]. These situations are more likely to occur in the prehospital setting than in the emergency department. Other indications include cervical spine immobilization and disrupted airway anatomy. It should be considered a last resort before cricothyrotomy for the failed airway [88]. It can be performed as an adjunct to blind nasotracheal intubation [89]. Other than an ETT and a stylet (and gloves), digital intubation requires no technical equipment and can be performed rapidly in poorly lit environments with the patient in any position, making it particularly suitable to the prehospital setting. It has been used successfully in pediatric patients and is preferred by some for neonatal resuscitation [90]. Contraindications and disadvantages In the awake or semiconscious patient with intact oropharyngeal reexes, digital intubation is relatively contraindicated. Attempting this technique on responsive patients can lead to oropharyngeal trauma and biting injuries.


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Placing a bite block to prevent the patient from biting down reexively and double gloving may help minimize the risk for infectious disease transmission. Other relative contraindications include caustic ingestion, thermal burns, and upper airway foreign bodies. The length of the intubators ngers relative to the dimensions of the patients oropharynx is an important predictor of success. Factors such as limited mouth opening, large teeth, and distorted anatomy can further place the intubator at a disadvantage. Iatrogenic trauma to the upper airway is possible but can be avoided with gentle technique. Esophageal intubation is a concern with digital intubation; therefore, diligent conrmation of tracheal placement is required. Although rarely used, dicult to perform, and risky, digital intubation can be a life-saving skill and can prevent the need for creation of a surgical airway. It should be considered for select patients with dicult airways when alternative techniques are unavailable or inoperative. As with any airway technique, digital intubation requires preparation and practice. Retrograde intubation Retrograde intubation (RI) is an invasive technique that involves puncture through the cricothyroid membrane and passage of a guide wire retrograde into the oropharynx to facilitate ETT placement. Originally described in 1960, RI is simplistic in principle but requires time and practice to perform [91]. Technique Commercially available kits for RI contain a syringe, an 18-gauge introducer needle with catheter, a guide wire with a soft J-tip, and an introducer catheter. Although RI is used most commonly for patients with limited neck mobility, ideally the patients neck should be hyperextended. The cricothyroid membrane is identied and, time permitting, local anesthesia is inltrated after skin preparation. While the larynx is stabilized, an 18-gauge needle attached to a syringe partially lled with saline is used to puncture through the cricothyroid membrane in a cephalad direction. Aspiration of air conrms placement in the trachea. The guide wire is then threaded through the needle cephalad into the oropharynx and is retrieved under direct visualization using Magill forceps. The guide wire then can be placed directly into the lumen of an ETT or through the Murphy eye of the ETT. Passing the wire through the Murphy eye permits slightly more advancement of the ETT below the vocal cords [92]. Alternatively, a guide catheter can be placed over the guide wire to prevent lateral movement of the ETT and ease its passage through the vocal cords [93]. With the ETT advanced through the vocal cords and abutting the cricothyroid membrane, the guide wire is pulled out through the proximal end of the ETT and the ETT is advanced into its proper position. A common variation of this

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technique involves threading a beroptic bronchoscope over the guide wire, allowing direct visualization of the patients anatomy and the ability to deliver continuous oxygen [94]. Indications and advantages RI is indicated for the dicult airway resulting from cervical spine immobilization, anatomic abnormality, or trauma, particularly upper airway trauma that makes oral or nasal access dicult or impossible. It should be considered when intubation has failed but adequate oxygenation and ventilation can be maintained and when cricothyrotomy is impossible or unavailable. RI has been used successfully in the prehospital setting and the emergency department [95,96]. Contraindications and disadvantages Relative contraindications to RI include unfavorable upper airway anatomy such as exion deformity of the neck, pretracheal mass or infection, obesity, coagulopathy, and laryngeal injury [97]. Bleeding is a common but generally minor problem with RI. Other potential complications include subcutaneous emphysema, pneumomediastinum, infection, and injuries to the trachea and laryngeal structures. Data on RI for the pediatric population are limited, but the procedure seems to be useful and safe in experienced hands, particularly with the adjunct use of a beroptic bronchoscope [98]. Emergency physicians and anesthesiologists have used RI with success for dicult airway management. It should be considered when cervical spine immobilization, anatomic derangements, copious secretions, or blood prevents adequate laryngoscopy, and after failed intubation when time and patient status allow. Drawbacks to RI are that it is invasive, it can be time consuming, and the equipment may not be readily available. Jet ventilation Percutaneous transtracheal jet ventilation (TTJV) involves puncturing the cricothyroid membrane with a large-bore catheter for temporary ventilation in failed airway situations. It is a simple, quick, and eective technique associated with fewer complications than surgical cricothyrotomy. Although rarely performed, emergency physicians should be familiar with this lifesaving skill for desperate, cannot intubate, cannot ventilate scenarios when surgical cricothyroidotomy is unavailable or unsuccessful. It is considered the surgical airway of choice in children younger than 12 years of age as a bridge to securing a denitive airway. Technique If permissible, the patients neck should be hyperextended while the cricothyroid membrane is identied. With the larynx stabilized, a large-bore


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(12- to 16-gauge) catheter-over-needle attached to a 20-mL syringe partially lled with saline is directed caudally through the cricothyroid membrane. Large-bore wire-coiled transtracheal catheters that are less likely to kink are preferable to intravenous catheters. Tracheal puncture is marked by aspiration of air bubbles. The needle is then withdrawn slightly and the catheter is advanced over the needle and into the airway with the aid of a small skin incision. The catheter should be advanced to the hub, and placement in the trachea reconrmed by aspiration of air. Once in place, great care should be taken to stabilize the catheter and prevent subsequent air leak at the incision site. The hub of the catheter is then connected to the jet ventilation system. A variety of TTJV systems are available. The most commonly used is composed of high-pressure tubing in line with a regulator, a pressure gauge, and a jet ventilation toggle switch. The jet ventilation system is connected to a wall oxygen source of 50 pounds per square inch (psi). In children older than 5 years of age, the oxygen pressure should be down-regulated to 2030 psi to prevent barotrauma, and in children younger than 5 years of age, a bag should be used for ventilation. Ordinarily, less than 1 second of inspiration is required to provide an adequate tidal volume to the lung, whereas exhalation occurs passively because of the elastic recoil of the lung in 23 seconds. An inspiration to expiration ratio (I:E) of 1:3 therefore is recommended to allow adequate time for exhalation and avoid barotrauma. Maintaining upper airway patency by using a jaw thrust maneuver with oropharyngeal and nasopharyngeal airways helps maximize exhalation, preventing air trapping and high expiratory pressures. Indications and advantages In the emergency department, TTJV is rarely used. It is indicated for cannot intubate, cannot ventilate situations when a surgical airway is not possible and when the equipment or personnel for conventional airway management are unavailable. It is generally considered to be quicker and less prone to complications than surgical cricothyrotomy; however, familiarity with the jet ventilator assembly is critical for rapid execution of this technique [99]. It can be performed in all age groups and is the preferred surgical airway in children. Contraindications and disadvantages Airway obstruction below the vocal cords and complete upper airway obstruction render exhalation dicult or impossible and constitute relative contraindications to TTJV. In these situations, surgical cricothyrotomy is the best choice. Complications with TTJV are uncommon but include subcutaneous emphysema, esophageal puncture, bleeding, exhalation difculty, and barotrauma [100103]. The catheter used in TTJV can become kinked or obstructed and does not confer airway protection. TTJV should be viewed as a temporary rescue technique, primarily for children under 12 years of age, until a denitive airway can be established.

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Despite the infrequent need for TTJV in the ED, emergency physicians should be well versed in this technique for crisis situations. Summary Rapid-sequence intubation using conventional laryngoscopic technique remains the standard of airway management in emergency medicine and continues to have a success rate of approximately 98%. Preparation and proper intubation technique must be optimized at the initial attempt using direct laryngoscopy. Failure causes multiple repeated attempts, leading to a failed airway. Each repeated attempt increases the likelihood of bleeding, oral, pharyngeal, and laryngeal edema, and malposition, causing decreased visualization of the glottic opening, equipment failure, and hypoxia. Preparation must be an ongoing process. Faulty suction, no oxygen source, choice of the wrong laryngoscopic blade or ETT, poor light source, or misplaced equipment can domino into mechanical failure. Intubation equipment stations must be inventoried constantly, organized, and kept simple in their layout to decrease confusion during selection. Medication for sedation and paralysis should be readily available and not kept distant from the intubation station in a medication-dispensing unit that would require time for acquisition. Proper positioning of the patient remains paramount for alignment of the oral, pharyngeal, and laryngeal axis to provide optimal visualization of the vocal cords. Proper technique during insertion of the laryngoscope blade in the oral cavity for displacement of the tongue must be ensured. Without proper technique, even with proper positioning, the glottic opening cannot be visualized. Laryngeal pressure to maneuver the larynx into position should be exerted initially by the laryngoscopists right hand and, when in view, maintained by an assistant to free the laryngoscopists hand for ETT insertion. With preparation and proper technique, the rst attempt is the best attempt, and the vicious cycle of multiple attempts and complications will be averted. Acknowledgment The authors thank Linda J. Kesselring, MS, ELS, Division of Emergency Medicine, University of Maryland School of Medicine, for help with manuscript preparation. References
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