The difficult airway: Difference between revisions
 
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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


==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]]


==Improving Passive Oxygenation==
==Difficult Intubation==
See [[Apneic oxygenation]]
{{Advanced Airway Adjuncts Chart}}


==[[Advanced airway adjuncts]]==
===Intubation Options===
 
{| {{table}}
==Intubation Options==
| align="center" style="background:#f0f0f0;"|'''Intubation Type'''
*Traditional intubation
| align="center" style="background:#f0f0f0;"|'''Pros'''
*[[Awake intubation]]
| align="center" style="background:#f0f0f0;"|'''Cons'''
 
|-
===[[Nasal intubation]]===
| Traditional||||
*Not as successful but still an option
|-
*Higher complication rate - bleeding, emesis, and airway trauma
| [[Awake intubation]]||||
**'''Do not attempt in patients with posterior pharyngeal swelling such as in [[Angioedema (Upper Airway)]]'''
|-
 
| [[Nasal intubation]]||||
===Retrograde Intubation===
*Lower success rate
*Percutaneous guide wire through cricoid and retrograde intubation over wire
*Higher complication rate (e.g. bleeding, emesis, and airway trauma)
*Use guide catheter over wire and then ett
*'''Do not attempt in patients with posterior pharyngeal swelling such as in [[angioedema]]'''
*Need time to set up
|-
| Retrograde intubation||||
*Need time to set up  
*Risk hematoma, pneumothorax
*Risk hematoma, pneumothorax
*Contraindicated
|-
**Bleeding
| Fiberoptic bronchoscopic intubation||||
**Distorted anatomy
*Takes time to set up  
 
===Fiberoptic Bronchoscopic Intubation===
*Takes time to set up
*Good for c-spine injury or awake patient 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,
*Limited by secretions, bleeding, poor suction,
 
|-
===Rigid Fiberoptic Laryngoscopes===
| [[Blind digital intubation|Digital intubation]]||||
*Use for diff airway or spinal immobolization
|}
*Not as good and longer time to intubate than flex scope


==Surgical Airways==
==Surgical Airways==
''A surgical airway should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate''
*[[Surgical cricothyrotomy]]
*[[Surgical cricothyrotomy]]
*[[Needle cricothyrotomy]]
*[[Needle cricothyrotomy]]
*[[Pediatric jet ventilation]]
*[[Pediatric jet ventilation]]
==Special Situations==
===Severe [[Metabolic Acidosis]]===
''Further drop in pH during intubation can be catastrophic''
*NIV (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
**SIMV on ventilator, not NIV machine
**"Pseudo-SIMV" mode
*Attach end-tidal CO2 and observe value
*Push [[Rapid Sequence Intubation (RSI)|RSI]] medications
*Turn the respiratory rate to 12
*Perform jaw thrust
*Wait 45sec
*[[Intubate]]
*Re-attach the ventilator
*Immediately increase rate to 30
*Change Vt to 8cc/kg
*Change flow rate to 60 LPM (normal setting)
*Make sure end-tidal CO2 is at least as low as before
===Active [[GI Bleed]]===
#Empty the stomach
#*Place an NG and suction out blood
#**Varices are not a contraindication
#*Metoclopramide 10mg IV
#**Increases LES tone
#Intubate with HOB at 45°
#Preoxygenate!
#*Want to avoid bagging if possible
#Intubation meds
#*Use sedative that is BP stable (etomidate, ketamine)
#*Use paralytics (actually increases LES tone)
#If need to bag:
#*Bag gently and slowly (10BPM)
#*Consider placing LMA
#If patient vomits
#*Place in Trendelenberg
#*Place LMA
#*Use meconium aspirator
#If patient aspirates anticipate a sepsis-like syndrome
#*May need [[pressors]], additional fluid (not antibiotic!)


==See Also==
==See Also==
{{Related Difficult Airway Pages}}
{{Related Difficult Airway Pages}}
{{Mechanical ventilation pages}}
==Video==
{{#widget:YouTube|id=8y8QN1j_m4g}}


==References==
==References==

Latest revision as of 22:45, 27 March 2024

Background

  • ASA Difficult Airway Algorithm does not necessary apply to the ED since the patient can always be awakened and case cancelled

Pre-Intubation

See:

Difficult Intubation

Advanced Airway Adjuncts Chart

Airway Adjunct Examples Pros Cons
Endotracheal tube introducer Gum elastic bougie
  • Higher first pass success when used with direct laryngscope vs. styletted ET tube regardless of whether difficult airway was expected or not[1]
  • Can pass blind and confirm tracheal placement with tracheal clicks and hold-up sign
  • Success rates likely depend on operator familiarity with device
Lighted optical stylets
  • High success rate - especially 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
Supraglottic airway LMA
  • Easy to place
  • Can be placed quickly
  • Does not protect against aspiration
Esophogeal obturator Combitube
  • Good for nurses and paramedics with limited intubation skill
  • Indicated if difficult airway predicted: cannot 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
Pediatric jet ventilation
  • Prefered over cricothyrotomy in children up to age 10-12
  • Oxygenates well
  • Can use for 30-45 min
  • Can retain CO2
  • May cause pneumothorax or barotrauma

Intubation Options

Intubation Type Pros Cons
Traditional
Awake intubation
Nasal intubation
  • Lower success rate
  • Higher complication rate (e.g. bleeding, emesis, and airway trauma)
  • Do not attempt in patients with posterior pharyngeal swelling such as in angioedema
Retrograde intubation
  • Need time to set up
  • Risk hematoma, pneumothorax
Fiberoptic bronchoscopic intubation
  • Takes time to set up
  • Limited by secretions, bleeding, poor suction,
Digital intubation

Surgical Airways

A surgical airway should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate

See Also

Airway Pages

References

  1. ↑ 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.
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