The High-Risk Airway

Robert J. Vissers, MD
 Difficult Airway Algorithms

Common principles
Š Assessment of ventilation difficulty
Š Assessment of intubation difficulty
Š Awake vs. induction and paralysis
Š Calling for help
Š Surgical airway is a potential endpoint
 Difficult Airway Algorithms

Important principles

;
Š Make a Plan
Š Use a Checklist
Š Share with the Team
 Approach to the
Decision to
intubate Emergency Airway

Near death? Crash

Unresponsive? Airway

Failed
Difficult Difficult Airway
Airway? Airway
Techniques

Rapid
Sequence
Intubation
Adapted from: Walls RM, Ed. The Manual of Emergency Airway Management Philadelphia, Lippincott, 2000.
 AIRWAY Approach to the
High Risk Airway
Decision to
intubate

TIME
Crash Airway?
Cricothyrotomy?
ANATOMY
Difficult
Airway?

RSI PHYSIOLOGY
Adapted from: Walls RM, Ed. The
Manual of Emergency Airway
Management Philadelphia,
Lippincott, 2000.
 The Difficult Airway

DIFFICULT BAG DIFFICULT LARYNGOSCOPY

MOANS
AND MASK VENTILATION LEMON
AND INTUBATION

DIFFICULT
RODS
DIFFICULT RESCUE SHORT
CRICOTHYROTOMY

“The 4 Elements of Difficulty”

* The Difficult Airway Course: Emergency
Walls RM, Murphy MF, editors. Manual of emergency airway management,
3rd edition. Philadelphia: Lippincott Williams & Wilkins; 2008.
 The Difficult Airway

DIFFICULT BAG DIFFICULT LARYNGOSCOPY

AND MASK VENTILATION AND INTUBATION

MOANS*
DIFFICULT
DIFFICULT RESCUE
CRICOTHYROTOMY

“The 4 Elements of Difficulty”

* The Difficult Airway Course: Emergency
Walls RM, Murphy MF, editors. Manual of emergency airway management,
3rd edition. Philadelphia: Lippincott Williams & Wilkins; 2008.
 Assessment of Difficult BVM:
MOANS
M ask seal
O besity/obstruction
A ge > 55
N o teeth
S tiff lungs
* The Difficult Airway Course: Emergency
Walls RM, Murphy MF, editors. Manual of emergency airway management,
3rd edition. Philadelphia: Lippincott Williams & Wilkins; 2008.
 The Difficult Airway

DIFFICULT BAG DIFFICULT LARYNGOSCOPY

AND MASK VENTILATION AND INTUBATION

LEMON
DIFFICULT
DIFFICULT RESCUE
CRICOTHYROTOMY

“The 4 Elements of Difficulty”

* The Difficult Airway Course: Emergency
Walls RM, Murphy MF, editors. Manual of emergency airway management,
3rd edition. Philadelphia: Lippincott Williams & Wilkins; 2008.
 “LEMON” Law

L ook externally
E xamine (3 -3-2)
(3-3-2)
M allampati grade
O bstruction
N eck mobility
Adapted from: Walls RM, Ed. The Manual of Emergency Airway Management
Philadelphia, Lippincott, 2000.

Cognitive forcing strategies in clinical decisionmaking. P Croskerry. Ann Emerg Med Jan, 2003.
 LEMON: Look

Simple visual inspection often reveals

obvious potential difficulties
LEMON: Examine 3-3-2
Assess oral opening - 3 fingers
Measure the mandible - 3 fingers
Position of larynx - 2 fingers
 LEMON: Examine 3-3-2

Assess oral
opening –
should be able
to
accommodate
3 fingers
 LEMON: Examine 3-3-2

Measure the
mandible - should
be able to fit 3
fingers between
the mentum and
the hyoid bone
 LEMON: Examine 3-3-2

Assess position of
larynx – should
get 2 fingers
between the
thyroid cartilage
and the mandible
 LEMON: Mallampati

Class I Class II

Class III Class IV

LEMON: Obstruction?

1) Location?
2) Fixed or mobile?
3) Speed of progression?
 LEMON: Neck Mobility

Š Can the patient flex and extend the

neck?
Š Actively assess in the non -trauma
non-trauma
obtunded patient.
Š Cervical spine immobilization - remove
anterior collar while cc-spine
-spine is
immobilized.
“LEMON” Law

L ook externally
E xamine (3 -3-2)
(3-3-2)
M allampati grade
O bstruction
N eck mobility
 LEMON: Predictive?
Š 156 ED patients requiring intubation
Š Scored using LEMON
Š Simple point system used (0 to 10)
Š Compared to laryngoscopic view (Cormack
–Lehane)
–Lehane)
Š Felt to be predictive, P<0.05

Reed MJ et al. Can an airway assessment score predict difficulty at

intubation in the emergency department? Emerg Med J 2005 Feb;
22:99-102.
 LEMON: Predictive?

Š Reed MJ et al. Can an airway assessment score predict

difficulty at intubation in the emergency department? Emerg
Med J 2005 Feb; 22:99-
22:99-102.
22:99-102.
 The Difficult Airway

DIFFICULT BAG DIFFICULT LARYNGOSCOPY

AND MASK VENTILATION AND INTUBATION

RODS
DIFFICULT
DIFFICULT RESCUE
CRICOTHYROTOMY

“The 4 Elements of Difficulty”

* The Difficult Airway Course: Emergency
Walls RM, Murphy MF, editors. Manual of emergency airway management,
3rd edition. Philadelphia: Lippincott Williams & Wilkins; 2008.
 Airway BNTI
Fiberoptics
alternatives
Nasal BVM
Intubating LMA®
Supraglottic:
Lightwand
Videolaryngoscope
Fiberoptics
Bougie
Combitube
King-LT

Infraglottic: TTJV
Cricothyrotomy
 Assessment of Difficult BVM:
RODS
R estricted oral opening
O bstruction
D isrupted or distorted
S tiff lungs

* The Difficult Airway Course: Emergency

Walls RM, Murphy MF, editors. Manual of emergency airway management,
3rd edition. Philadelphia: Lippincott Williams & Wilkins; 2008.
 Rescue Devices

Š Most require oral access

Š Most are designed to deal with high
anterior cords
Š II-LMA,
-LMA, King-LT, Combitube
King-LT,
Š Intubating stylet (bougie, frova, etc.)
Š Video – glidescope, C -mac, etc
C-mac,
 Agitated Burn Case

42 -year-old woman set herself on fire in

42-year-old
her car.
Uncooperative, yelling ““let
let me die ”.
die”.
70 -80% burns, mostly 3
70-80% °, to face, trunk,
3°,
anterior arms and thighs.
Unable to get a BP or O2 sat.
Intubating Stylet/Bougie
 Decision Making
#1::
Question #1
Is Oxygenation ““Adequate”
Adequate” Or ““Inadequate?”
Inadequate?”
[Are O2 saturations above or below 90%?
90%?]]

#2::
Question #2
Is The Airway ““Normal”
Normal” Or ““Disrupted?”
Disrupted?”
Combitube
King-LT
I-LMA
Video Laryngoscopy
Glidescope
 Awake look/scopes

Š Antisyalogogue – atropine or
glycopyrrolate
Š Anesthesia – lidocaine (2 -4%),
(2-4%),
benzocaine
Š Decongestant – oxymetazoline (afrin)
Š Nebulize, atomize (MADgic
(MADgic®),®), viscous
Š Sedation – ketamine, versed
 The Difficult Airway

DIFFICULT BAG DIFFICULT LARYNGOSCOPY

AND MASK VENTILATION AND INTUBATION

SHORT
DIFFICULT
DIFFICULT RESCUE
CRICOTHYROTOMY

“The 4 Elements of Difficulty”

* The Difficult Airway Course: Emergency
Walls RM, Murphy MF, editors. Manual of emergency airway management,
3rd edition. Philadelphia: Lippincott Williams & Wilkins; 2008.
Assessment of Difficult BVM:
SHORT
S urgery or disruption
H ematoma
O besity
R adiation
T umor
 No landmarks?

Š The tongue is your friend – find it and

follow it to the glottis
Š Suction
Suction,, suction, suction …
suction…
Š4 -finger rule for the cricothyroid
4-finger
membrane
Cricothyroid membrane
under the 4th finger
 Septic Shock
„
„24
24 yo woman
„
„Fever,
Fever, delerium
„
„Purpuric
Purpuric rash
„
„Hypotensive
Hypotensive 94/58
„
„TT 41°, P 152
41°,
„
„RR
RR 32, Pulse ox 100%
 RSI in Septic shock
„
„Primary
Primary goal: avoid exacerbation of
hypoperfusion
„
„Need
Need to differentiate shock state
„
„Consider
Consider before intubation:
„
„Assessment
Assessment of volume status
„
„IVFs
IVFs as pretreatment before intubation
„
„Vasopressor
Vasopressor before intubation
„
„AA vs C: hemodynamic compromise vs
hypoxia
 My Favorite Pretreatment
„
„Consider
Consider volume
status before
intubation
„
„Avoid
Avoid post
post--
intubation
hypotension
 RSI in Septic shock
„
„Acidosis
Acidosis associated with compensatory
respiratory alkalosis ((tachypnea,
tachypnea,
kussmaul ’s)
kussmaul’s)
„
„Post
Post intubation ventilate at high RR,
““normal
normal rate
rate”” may lead to transient
worsening of acidosis
More airway?
 Preparation
„
„Time-out
Time-out
„
„Run
Run the check -list
check-list
„
„Criticalpoints.net
Criticalpoints.net - course
 Summary

Š Organized, rapid, simple approach

Š Assess for difficult ventilation
MOANS
Š Assess for difficult intubation
LEMON
 Summary

Š Do I have TIME?
Š Does the ANATOMY predict rescue?
Š Anticipate PHYSIOLOGIC problems?
Š What ’s the PLAN?
What’s