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| [[Predicting the difficult airway]]
| | ==Background== |
| | *ASA Difficult Airway Algorithm does not necessary apply to the ED since the patient can always be awakened and case cancelled |
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| ==ASA Difficult Airway Algorithm== | | ==Pre-Intubation== |
| *Does not necessary apply to the ED since the patient can always be awakened and case cancelled
| | See: |
| **[[Cricothyrotomy]] should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate
| | *[[Predicting the difficult airway]] |
| **Straight blade- Miller- may offer better manipulation of a large epiglottis in children or for micrognathia or "buck teeth"
| | *[[Apneic oxygenation]] |
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| ==Improving Passive Oxygenation==
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| *Use in overweight, poor O2 reserve, hypoxia at baseline, concerns for rapid progression to hypoxia once apnea
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| *Pre-oxygenate while sitting upright, only lay back once [[RSI]] drugs pushed.
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| *30 degrees reverse trendelenburg position for intubation
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| *Nasal O2 while pre oxygenating and DURING intubation (after induction increase to 15L)
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| ==Airway Adjuncts==
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| ===Endotracheal tube introducer (ETI)/Gum Elastic Bougie===
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| *Higher first pass success when used with direct laryngscope vs. styletted ET tube regardless of whether difficult airway was expected or not <ref>Driver, B. E., Prekker, M. E., Klein, L. R., Reardon, R. F., Miner, J. R., Fagerstrom, E. T., … Cole, J. B. (2018). Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(21), 2179–2189.</ref>
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| *Blind orotracheal intubation | |
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| ===[[Nasal intubation]]===
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| *Not as successful but still an option
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| *Higher complication rate - bleeding, emesis, and airway trauma
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| **'''Do not attempt in patients with posterior pharyngeal swelling such as in [[Angioedema (Upper Airway)]]'''
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| ===Lighted Optical Stylets===
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| *High success rate - especially good for trauma, c-spine precautions | |
| *Use for both reg and nasotrach
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| *Lower complication rate
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| *Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience
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| ===[[LMA]]===
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| *Can use without muscle relaxants
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| *Better than face mask
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| *Can be used as bridge to fiberoptic intubation
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| *Limited by unreliable seal at peak insp pressure
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| *Aspiration risk
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| *Mucosal trauma
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| *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>
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| *Intubating LMA (LMA-Fastrach) provides the opportunity to convert to a definitive airway after rescue with the supraglottic device
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| ===Combitube- esoph obturator=== | | ==Difficult Intubation== |
| *Good for nurses and paramedics with limited intubation skill
| | {{Advanced Airway Adjuncts Chart}} |
| *Indicated if difficult airway predicted: cannot see glottis with laryngoscope
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| *Reduced risk for aspiration compared to face mask or LMA
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| *Can maintain spinal immobilization
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| *Large size predisposes to esophogeal dilatation and laceration as a complication
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| ===[[Percutaneous transtracheal ventilation]]=== | | ===Intubation Options=== |
| *PTV
| | {| {{table}} |
| *Prefered over crithyrotomy in children up to age 10-12
| | | align="center" style="background:#f0f0f0;"|'''Intubation Type''' |
| *Needle, 16-18ga through cricoid membrane, connected to 50 psi 02<ref>Beck, E., Kharasch, M., Casey, J., Ochoa, P., Menon, S., Calabrese, N. and Wang, E. (2011) ‘Percutaneous Transtracheal jet ventilation’, Academic Emergency Medicine, 18(5), pp. e38–e38.</ref>
| | | align="center" style="background:#f0f0f0;"|'''Pros''' |
| **Oxygenates well
| | | align="center" style="background:#f0f0f0;"|'''Cons''' |
| **Ventilate through glottis and upper airway - can retain CO2
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| *Need adequate oxygen pressure
| | | Traditional|||| |
| *1 sec insp and 2- 3 sec exp to avoid breath stacking
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| *Can use for 30-45 min
| | | [[Awake intubation]]|||| |
| *May cause pneumothorax or barotrauma
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| *Contraindications | | | [[Nasal intubation]]|||| |
| **Distorted anatomy | | *Lower success rate |
| **Bleeding diathesis | | *Higher complication rate (e.g. bleeding, emesis, and airway trauma) |
| **Complete airway obstruction
| | *'''Do not attempt in patients with posterior pharyngeal swelling such as in [[angioedema]]''' |
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| ===Retrograde Intubation===
| | | Retrograde intubation|||| |
| *Percutaneous guide wire through cricoid and retrograde intubation over wire
| | *Need time to set up |
| *Use guide catheter over wire and then ett
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| *Need time to set up | |
| *Risk hematoma, pneumothorax | | *Risk hematoma, pneumothorax |
| *Contraindicated
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| **Bleeding
| | | Fiberoptic bronchoscopic intubation|||| |
| **Distorted anatomy
| | *Takes time to set up |
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| ===Fiberoptic Bronchoscopic Intubation===
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| *Takes time to set up | |
| *Good for c-spine injury or awake patient with diff airway
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| *Go through nose
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| *Use for all ages, can give 02 during procedure thru fiberscope, immediate confirmation of position
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| *Limited by secretions, bleeding, poor suction, | | *Limited by secretions, bleeding, poor suction, |
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| | | [[Blind digital intubation|Digital intubation]]|||| |
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| ===Rigid Fiberoptic Laryngoscopes=== | | ==Surgical Airways== |
| *Use for diff airway or spinal immobolization
| | ''A surgical airway should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate'' |
| *Not as good and longer time to intubate than flex scope
| | *[[Surgical cricothyrotomy]] |
| | | *[[Needle cricothyrotomy]] |
| ==[[Surgical cricothyrotomy]]==
| | *[[Pediatric jet ventilation]] |
| *Can get subglottic stenosis | |
| *Rapid 4 step procedure faster but higher complication rate - cric cart fx | |
| *Can also do wire guided
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| *Long term morbid, mortality similar to tracheostomy
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| ==See Also== | | ==See Also== |
| *[[Predicting the difficult airway]]
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| {{Related Difficult Airway Pages}} | | {{Related Difficult Airway Pages}} |
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| ==Video==
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| {{#widget:YouTube|id=8y8QN1j_m4g}}
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| ==References== | | ==References== |
