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Difficult Airway
Difficult Airway
Pat Melanson, MD
The Difficult Airway
• Must be able to assess or anticipate the
degree of difficulty
• Then select method most likely to succeed
• If properly assessed and felt to be intubatable
without significant difficulty
– 1-4 /1000 will be impossible intubations (O.R.)
– 1 / 280 obstetrical patients
– 1 /10,000 impossible to intubate or ventilate(O.R.)
– 1-2 % cricothyroidotomy rate in ED
Definitions
• Failed intubation
– inability to place an ETT
• Difficult intubation
– requires more than 3 attempts or 10 minutes
• Difficult laryngosopy
– Cormack and Lehane grade III (epiglottis only) or grade
IV view (soft palate only)
• Difficult mask ventilation
• Failed airway
– can’t intubate, can’t ventilate
The Difficult Airway:
Necessary Skills
• Clinical Airway Assessment
– ability to recognize/ predict Difficult Airway
• Facility with array of airway equipment
– knowledge of indications and advantages
– ability to choose most appropriate technique for
the particular situation
– manual skills
• Detailed knowledge of intubation medications
The Difficult Airway
• Not all airway management failures
are avoidable or predictable
• Attempt to minimize failures
• Have several definite back-up plans
ready for the “Failed Airway”
Prediction of the Difficult
Airway
• C-spine mobility
• External dimensions ( 3-3-2 rule)
– Mouth opening 3 fingers (TMJ)
– Mandible large enough to accommodate
tongue - 3 fingers from tip of chin to hyoid
– Length of neck/position of larynx - 2 fingers
between top of thyroid and floor of jaw
Prediction of the Difficult
Airway (con’t)
• Teeth
– large or protruding incisors obstruct vision
– jagged teeth can lacerate balloon
• Oral dimensions
– narrow facial features and high arched
palates (decreased lateral space)
– Mallimpadi classification
Mallimpadi Classification
(Tongue to Pharyngeal Size)
• Inability to oxygenate
The Failed Intubation
• If can’t intubate but can ventilate with
BVM have time to consider options
– Light guided technique (Lighted stylet)
– Combitube
– LMA
– Fiberoptic techniques
– Retrograde intubation
– Cricothyrotomy
The Failed Intubation