The difficult airway

LEMON Mnemonic

• Look- as in Diff to BVM
• Evaluate 3-2-2
• Mallampati
• Obstruction
• Neck Mobility

Look

• trauma
• short neck
• micrognathia
• prior surgery
• may also be difficult to bag
• body mass index
• advanced age
• beard
• no teeth
• snoring

Evaluate

• 3 finger-breadths mouth opening
• 3 fingers from chin to hyoid
• 2 from thryroid to sternum

ASA DIFF AIRWAY ALGORITHM

• in OR, can always let pt wake up and cancel case
• if can't do BVM after failed intubation- do cric or transtracheal jet since will desat otherwise
• straight blade- Miller- better for deep glottis, buck teeth

Gum Bougie

• blind orotracheal intubation

Blind Naso Trach Intub

• not as successful but still an option
• higher complication rate- bleeding, emesis

Lighted Optical Stylets

• high success rate- esp good for trauma, cspine
• use for both reg and nasotrach
• low complication rate
• limited by fogging, secretion, recognition of anatomy, cost

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
• asp risk
• mucosal trauma
• LMA better than ett for paramedics
• intubating LMA (ILMA) better for ventilating ED pts but intubating through ILMA more difficult for neophyte

Combitube- esoph obturator

• good for nurses and paramedics
• indicated if diff 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 esoph dilatation, laceration

Trans Trach Jet Vent

• TTJV
• needle through cric mem, connected to 50 psi 02- can ventilate and oxygenate ok
• need adequate 02 pressure
• 1 sec insp and 2- 3 sec exp to avoid breath stacking
• may get ptx or barotrauma
• contraindications- distorted anatomy, bleeding diathesis, complete airway obstr

Retrograde Intubation

• perc guide wire through cric and retrograde intubation over wire
• use guide catheter over wire and then ett
• need time to set up
• risk hematoma, ptx
• contra- 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 immob
• not as good and longer time to intubate than flex scope

Surgical Airway

• can get subglottic stenosis
• rapid 4 step procedure faster but higher compl rate- cric cart fx
• can also do wire guided
• long term morbid, mortality similar to tracheostomy

Source

7/06 MISTRY