Difficult Airway Management

Hesham Alkharabsheh, MD
Assistant Consultant Cardiac Anesthesia
King Faisal Specialist Hospital and Research Center
 Adverse Respiratory Events

• The single largest category

of anesthetic-related injury
is respiratory events
• The three main causes
– Inadequate ventilation

– Esophageal intubation

– Difficult tracheal intubation.

 Difficult Airway
“The clinical situation in which a conventionally
trained anesthesiologist experiences:
• Difficulty with face mask ventilation,
• Difficulty with tracheal intubation,
• Both
-Suggested definition from ASA Practice Guidelines
 OPTIMAL VENTILATION

1. POSITION
2. AIRWAY MANEURVERS
1. Head-tilt chin-lift
2. Jaw-thrust
3. GOOD MASK SEAL ( C&E)
4. AIRWAY ADJUNCTS:
1. OROPHARYNGEAL AIRWAY
2. NASOPHARYNGEAL AIRWAYS
Positioning
 Airway Maneuvers

1.Head-tilt chin-lift
1. Intact Cervical Spine

2. Jaw-thrust
1. Cervical Spine Injury
Mask Ventilation- Airway Maneuvers
Mask Ventilation- Airway Maneuvers
 Airway Adjuncts
Oropharyngeal airway:
• Sized from the angle of
the mouth to the
earlobe.
• Not in patients with
intact gag reflex.
 Airway Adjuncts
Nasopharyngeal airway:
• Sized from the nose tip to
the earlobe.
• In patients with intact
gag reflex.
Airway Adjuncts

Oropharyngeal
airway in place
 Advanced Airways

• Laryngeal mask airway (LMA).

• Endotracheal tube.
LMA
LMA insertion
Endotracheal Tube
 DEFINITION OF
OPTIMAL INTUBATION ATTEMPT

1. REASONABLY EXPERIENCED ENDOSCOPIST

2. NO SIGNIFICANT MUSCLE TONE
3. OPTIMAL SNIFF POSITION
4. OPTIMAL EXTERNAL LARNYGEAL PRESSURE
5. CHANGE LENGTH OF BLADE X1
6. CHANGE TYPE OF BLADE X1
Lehane and Cormack Classification
 Direct Laryngoscopy
Four-grade scheme for view of laryngeal inlets
( obtained at laryngoscopy) :
• grade 1: all or most of glottis
• grade 2: only posterior portion of glottis
• grade 3: only epiglottis
• grade 4: can’t see glottis or epiglottis at all
Airway Examination

Mallampati Classification
Mallampati Classification
The Mallampati Test & direct laryngoscopy
 Difficult Airway -Approach

• Anticipation
• Planning
• Preparation
Features Suggesting the Presence of a Difficult Airway

1. Relatively long upper incisors

2. Prominent “overbite”
3. Interincisor distance less than 3 cm
4. Mallampati class greater than 2
5. Highly arched or narrow palate
6. Stiff or indurated mandibular space
7. Thyromental distance less than three finger breadths
8. Short neck, Thick neck
9. Limited range of motion of head and neck
Difficult Airway Management Techniques

• Direct laryngoscopy

• Fiberoptic intubation

• Videoscopes

• Intubating LMA

• Rigid bronchoscopy

• Lighted stylet

• Surgical airway
 Flexible Bronchoscope

• The “Gold Standard” tool for

difficult airway management
• The most versatile
instrument
• Mandatory tool and skill
for every practitioner
• • Improved image quality
with new scopes
 Glidescope Cobalt

• Reusable video baton that

slides into disposable plastic
blades/handles
• • Similar to Macintosh blade
design
• Warming at lens limits fogging
• Relatively portable
• Simple to setup
• Intuitive use
Laryngeal Masks as Intubation Conduits
 Airway Tools

A tool is not a plan!

 Difficult Airway Algorithm

3. Consider the relative merits and feasibility

of basic management choices:

Intubation Attempts After

A. Awake Intubation Vs. Induction of General
Anesthesia

Non-Invasive Technique Invasive Technique

B. for Initial Approach to for Initial Approach to
Vs.
Intubation Intubation

C. Preservation of Ablation of Spontaneous

Spontaneous Ventilation Vs. Ventilation
 Management of the Difficult Airway – Summary
• Anticipation is often key to success, and it is preferable to err on the
side of conservatism
• Develop Plans A, B , and C
• Goals: protect the airway, adequately ventilate, and adequately
oxygenate
• Get good assistance
• Do not continue to do the same thing and expect a different result
– It’s Not Okay to Continue with Failed Techniques
• Do not be afraid to wake up or proceed with a surgical airway if
necessary