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==LEMON Mnemonic==
==LEMON Mnemonic==
===LOOK===
===LOOK===
*Look at the patient externally for characteristics that are known to cause difficult laryngoscopy,
*Look at the patient externally for characteristics that are known to cause difficult laryngoscopy, intubation or ventilation<ref> Rennie LM, Dunn MJG, et al. Is the ‘LEMON’ method an easily applied emergency airway assessment tool? European Journal of Emergency Medicine 2004;11:154–7</ref>
intubation or ventilation<ref> Rennie LM, Dunn MJG, et al. Is the ‘LEMON’ method an easily applied emergency airway assessment tool? European Journal of Emergency Medicine 2004;11:154–7</ref>


#Trauma
*Trauma
#Short neck
*Short neck
#Micrognathia
*Micrognathia
#Prior surgery
*Prior surgery
#May also be difficult to bag
*May also be difficult to bag
##Body mass index
**Body mass index
##Advanced age
**Advanced age
##Beard
**Beard
##No teeth
**No teeth
##Snoring
**Snoring
**Dentures


===Evaluate 3-3-2-1 ===
===Evaluate 3-3-2-1 ===
*Ideally the distance between the patient's incisor teeth should be at least 3 finger breadths (3), distance between the hyoid bone and the chin should be at least 3 finger breadths (3), distance between the thyroid notch and the floor of the mouth should be at least 2 finger breadths (2). Lower jaw should not sublux more than 1cm (1).
* 3 - Ideally the distance between the patient's incisor teeth should be at least 3 finger breadths
* 3 - Distance between the hyoid bone and the chin should be at least 3 finger breadths
* 2 - Distance between the thyroid notch and the floor of the mouth should be at least 2 finger breadths  
* 1 - Lower jaw should not sublux more than 1cm
 
===Mallampati===
===Mallampati===
*The patient sits upright, opens mouth and protrudes tongue
*The patient sits upright, opens mouth and protrudes tongue
*Grades are based on visibility of the uvula, posterior pharynx, hard, and soft palate
*Grades are based on visibility of the uvula, posterior pharynx, hard, and soft palate
===Obstruction===
===Obstruction===
*Assess for conditions leading to airway obstruction such as peritonsillar abscesses, trauma, or epiglottitis.
*Assess for conditions leading to airway obstruction such as [[Peritonsillar Abscess (PTA)]], trauma, or [[Epiglottitis]].
 
===Neck Mobility===
===Neck Mobility===
*Patient places chin down onto their chest and extend their neck. Remove the hard collar and provide manual stabilization in trauma patients. Poor neck mobility impacts ability to have airway access alignment.
*Patient places chin down onto their chest and extend their neck.
*Remove the hard collar and provide manual stabilization in trauma patients.
*Poor neck mobility impacts ability to have airway access alignment.


[[File:Mallampati Score.png|thumb|Mallampati Score]]
[[File:Mallampati Score.png|thumb|Mallampati Score]]
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==ASA DIFF AIRWAY ALGORITHM==
==ASA Difficult Airway Algorithm==
*Does not necessary apply to the Emergency Department since the patient can always be awakened and case cancelled
*Does not necessary apply to the ED since the patient can always be awakened and case cancelled
#[[Cricothyrotomy]] should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate
**[[Cricothyrotomy]] should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate
#Straight blade- Miller- may offer better manipulation of a large epiglottis in children or for micrognathia or "buck teeth"
**Straight blade- Miller- may offer better manipulation of a large epiglottis in children or for micrognathia or "buck teeth"


==Airway Adjuncts==
==Airway Adjuncts==
===Gum Bougie===
===Gum Bougie===
Blind orotracheal intubation
*Blind orotracheal intubation


===Blind Naso Trach Intubation===
===Blind Naso Trach Intubation===
#Not as successful but still an option
*Not as successful but still an option
#Higher complication rate- bleeding, emesis, and airway trauma
*Higher complication rate - bleeding, emesis, and airway trauma
'''Do not attempt in patients with posterior pharyngeal swelling such as in angioedema'''
**'''Do not attempt in patients with posterior pharyngeal swelling such as in [[Angioedema (Upper Airway)]]'''


===Lighted Optical Stylets===
===Lighted Optical Stylets===
#High success rate- esp good for trauma, cspine
*High success rate - esp good for trauma, c-spine precautions
#Use for both reg and nasotrach
*Use for both reg and nasotrach
#Low complication rate
*Lower complication rate
#Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience
*Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience


===[[LMA]]===
===[[LMA]]===
#Can use without muscle relaxants
*Can use without muscle relaxants
#Better than face mask
*Better than face mask
#Can be used as bridge to fiberoptic intubation
*Can be used as bridge to fiberoptic intubation
#Limited by unreliable seal at peak insp pressure
*Limited by unreliable seal at peak insp pressure
#Aspiration risk
*Aspiration risk
#Mucosal trauma
*Mucosal trauma
#LMA better than endotracheal for paramedics, especially in pediatric patients<ref>Zhu X-Y, Lin B-C, Zhang Q-S, Ye H-M, Yu R-J. A prospective evaluation of the efficacy of the laryngeal mask airway during neonatal resuscitation. Resuscitation. 2011;82(11):1405–1409. doi:10.1016/j.resuscitation.2011.06.010</ref><ref>Calkins MD, Robinson TD. Combat trauma airway management: endotracheal intubation versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance combat corpsmen. J Trauma. 1999;46(5):927–932</ref>
*LMA better than endotracheal for paramedics, especially in pediatric patients<ref>Zhu X-Y, Lin B-C, Zhang Q-S, Ye H-M, Yu R-J. A prospective evaluation of the efficacy of the laryngeal mask airway during neonatal resuscitation. Resuscitation. 2011;82(11):1405–1409. doi:10.1016/j.resuscitation.2011.06.010</ref><ref>Calkins MD, Robinson TD. Combat trauma airway management: endotracheal intubation versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance combat corpsmen. J Trauma. 1999;46(5):927–932</ref>


#Itubating LMA (LMA-Fastrach) provides the opportunity to convert to a definitive airway after rescue with the supraglottic device
*Intubating LMA (LMA-Fastrach) provides the opportunity to convert to a definitive airway after rescue with the supraglottic device


===Combitube- esoph obturator===
===Combitube- esoph obturator===
#Good for nurses and paramedics with limited intubation skill
*Good for nurses and paramedics with limited intubation skill
#Indicated if diff airway predicted, can't see glottis with laryngoscope,
*Indicated if difficult airway predicted: can't see glottis with laryngoscope
#Reduced risk for aspiration compared to  face mask or LMA
*Reduced risk for aspiration compared to  face mask or LMA
#Can maintain spinal immobilization
*Can maintain spinal immobilization
#Large size predisposes to esoph dilatation and laceration as a complication
*Large size predisposes to esophogeal dilatation and laceration as a complication


===Trans Trach Jet Vent===
===Trans Tracheal Jet Vent===
#TTJV
*TTJV
#Needle through cric mem, connected to 50 psi 02- can ventilate and oxygenate ok
*Needle through cricoid membrane, connected to 50 psi 02- can ventilate and oxygenate ok
#Need adequate oxygen pressure
*Need adequate oxygen pressure
#1 sec insp and 2- 3 sec exp to avoid breath stacking
*1 sec insp and 2- 3 sec exp to avoid breath stacking
#May get ptx or barotrauma
*May cause pneumothorax or barotrauma
#Contraindications- distorted anatomy, bleeding diathesis,  complete airway obstruction
*Contraindications
**Distorted anatomy
**Bleeding diathesis
**Complete airway obstruction


===Retrograde Intubation===
===Retrograde Intubation===
#Perc guide wire through cric and retrograde intubation over wire
*Percutaneous guide wire through cricoid and retrograde intubation over wire
#Use guide catheter over wire and then ett
*Use guide catheter over wire and then ett
#Need time to set up
*Need time to set up
#Risk hematoma, ptx
*Risk hematoma, pneumothorax
#Contra- bleeding, distorted anatomy
*Contraindicated
**Bleeding
**Distorted anatomy


===Fiberoptic Bronchoscopic Intubation===
===Fiberoptic Bronchoscopic Intubation===
#Takes time to set up
*Takes time to set up
#Good for c-spine injury or awake pt with diff airway
*Good for c-spine injury or awake pt with diff airway
#Go through nose
*Go through nose
#Use for all ages, can give 02 during procedure thru fiberscope, immediate confirmation of position
*Use for all ages, can give 02 during procedure thru fiberscope, immediate confirmation of position
#Limited by secretions, bleeding, poor suction,
*Limited by secretions, bleeding, poor suction,


===Rigid Fiberoptic Laryngoscopes===
===Rigid Fiberoptic Laryngoscopes===
#Use for diff airway or spinal immob
*Use for diff airway or spinal immobolization
#Not as good and longer time to intubate than flex scope
*Not as good and longer time to intubate than flex scope
 


==Improving Passive Oxygenation==
==Improving Passive Oxygenation==
#Use in overweight, poor O2 reserve, hypoxia at baseline, concerns for rapid progression to hypoxia once apnea  
*Use in overweight, poor O2 reserve, hypoxia at baseline, concerns for rapid progression to hypoxia once apnea  
#Pre oxygenate while sitting upright, only lay back once RSI drugs pushed.  
*Pre-oxygenate while sitting upright, only lay back once RSI drugs pushed.  
#30 degrees reverse trendelenburg position for intubation
*30 degrees reverse trendelenburg position for intubation
#Nasal O2 while pre oxygenating and DURING intubation (after induction increase to 15L)  
*Nasal O2 while pre oxygenating and DURING intubation (after induction increase to 15L)  
 


==Surgical Airway==
==Surgical Airway==
#can get subglottic stenosis
*Can get subglottic stenosis
#rapid 4 step procedure faster but higher compl rate- cric cart fx
*Rapid 4 step procedure faster but higher complication rate - cric cart fx
#can also do wire guided
*Can also do wire guided
#long term morbid, mortality similar to tracheostomy  
*Long term morbid, mortality similar to tracheostomy  


==See Also==
==See Also==
{{Related Difficult Airway Pages}}
{{Related Difficult Airway Pages}}
[[Needle Cricothyrotomy]]


==Source==
==References==
<references/>
<references/>


[[Category:Airway/Resus]]
[[Category:Airway/Resus]]
[[Category:Critical Care]]
[[Category:Critical Care]]

Revision as of 22:52, 8 April 2015

LEMON Mnemonic

LOOK

  • Look at the patient externally for characteristics that are known to cause difficult laryngoscopy, intubation or ventilation[1]
  • Trauma
  • Short neck
  • Micrognathia
  • Prior surgery
  • May also be difficult to bag
    • Body mass index
    • Advanced age
    • Beard
    • No teeth
    • Snoring
    • Dentures

Evaluate 3-3-2-1

  • 3 - Ideally the distance between the patient's incisor teeth should be at least 3 finger breadths
  • 3 - Distance between the hyoid bone and the chin should be at least 3 finger breadths
  • 2 - Distance between the thyroid notch and the floor of the mouth should be at least 2 finger breadths
  • 1 - Lower jaw should not sublux more than 1cm

Mallampati

  • The patient sits upright, opens mouth and protrudes tongue
  • Grades are based on visibility of the uvula, posterior pharynx, hard, and soft palate

Obstruction

Neck Mobility

  • Patient places chin down onto their chest and extend their neck.
  • Remove the hard collar and provide manual stabilization in trauma patients.
  • Poor neck mobility impacts ability to have airway access alignment.
Mallampati Score
3-3-2 ruleDistance between patient's incisor teeth of 3 finger breadths and distance between the thyroid notch and the floor of the mouth should be at least 2 finger widths


ASA Difficult Airway Algorithm

  • Does not necessary apply to the ED since the patient can always be awakened and case cancelled
    • Cricothyrotomy should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate
    • Straight blade- Miller- may offer better manipulation of a large epiglottis in children or for micrognathia or "buck teeth"

Airway Adjuncts

Gum Bougie

  • Blind orotracheal intubation

Blind Naso Trach Intubation

  • Not as successful but still an option
  • Higher complication rate - bleeding, emesis, and airway trauma

Lighted Optical Stylets

  • High success rate - esp good for trauma, c-spine precautions
  • Use for both reg and nasotrach
  • Lower complication rate
  • Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience

LMA

  • Can use without muscle relaxants
  • Better than face mask
  • Can be used as bridge to fiberoptic intubation
  • Limited by unreliable seal at peak insp pressure
  • Aspiration risk
  • Mucosal trauma
  • LMA better than endotracheal for paramedics, especially in pediatric patients[2][3]
  • Intubating LMA (LMA-Fastrach) provides the opportunity to convert to a definitive airway after rescue with the supraglottic device

Combitube- esoph obturator

  • Good for nurses and paramedics with limited intubation skill
  • Indicated if difficult airway predicted: can't see glottis with laryngoscope
  • Reduced risk for aspiration compared to face mask or LMA
  • Can maintain spinal immobilization
  • Large size predisposes to esophogeal dilatation and laceration as a complication

Trans Tracheal Jet Vent

  • TTJV
  • Needle through cricoid membrane, connected to 50 psi 02- can ventilate and oxygenate ok
  • Need adequate oxygen pressure
  • 1 sec insp and 2- 3 sec exp to avoid breath stacking
  • May cause pneumothorax or barotrauma
  • Contraindications
    • Distorted anatomy
    • Bleeding diathesis
    • Complete airway obstruction

Retrograde Intubation

  • Percutaneous guide wire through cricoid and retrograde intubation over wire
  • Use guide catheter over wire and then ett
  • Need time to set up
  • Risk hematoma, pneumothorax
  • Contraindicated
    • Bleeding
    • Distorted anatomy

Fiberoptic Bronchoscopic Intubation

  • Takes time to set up
  • Good for c-spine injury or awake pt with diff airway
  • Go through nose
  • Use for all ages, can give 02 during procedure thru fiberscope, immediate confirmation of position
  • Limited by secretions, bleeding, poor suction,

Rigid Fiberoptic Laryngoscopes

  • Use for diff airway or spinal immobolization
  • Not as good and longer time to intubate than flex scope

Improving Passive Oxygenation

  • Use in overweight, poor O2 reserve, hypoxia at baseline, concerns for rapid progression to hypoxia once apnea
  • Pre-oxygenate while sitting upright, only lay back once RSI drugs pushed.
  • 30 degrees reverse trendelenburg position for intubation
  • Nasal O2 while pre oxygenating and DURING intubation (after induction increase to 15L)

Surgical Airway

  • Can get subglottic stenosis
  • Rapid 4 step procedure faster but higher complication rate - cric cart fx
  • Can also do wire guided
  • Long term morbid, mortality similar to tracheostomy

See Also

Airway Pages

Needle Cricothyrotomy

References

  1. ↑ Rennie LM, Dunn MJG, et al. Is the ‘LEMON’ method an easily applied emergency airway assessment tool? European Journal of Emergency Medicine 2004;11:154–7
  2. ↑ Zhu X-Y, Lin B-C, Zhang Q-S, Ye H-M, Yu R-J. A prospective evaluation of the efficacy of the laryngeal mask airway during neonatal resuscitation. Resuscitation. 2011;82(11):1405–1409. doi:10.1016/j.resuscitation.2011.06.010
  3. ↑ Calkins MD, Robinson TD. Combat trauma airway management: endotracheal intubation versus laryngeal mask airway versus combitube use by Navy SEAL and Reconnaissance combat corpsmen. J Trauma. 1999;46(5):927–932
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