The difficult airway: Difference between revisions
Line 10: Line 10:


==[[Advanced airway adjuncts]]==
==[[Advanced airway adjuncts]]==
===Endotracheal tube introducer (ETI)/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 <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>
*Blind orotracheal intubation


===[[Nasal intubation]]===
===[[Nasal intubation]]===
Line 18: Line 16:
*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 (Upper Airway)]]'''
**'''Do not attempt in patients with posterior pharyngeal swelling such as in [[Angioedema (Upper Airway)]]'''
===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
===[[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<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>
*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: 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
===[[Percutaneous transtracheal ventilation]]===
*PTV
*Prefered over crithyrotomy in children up to age 10-12
*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>
**Oxygenates well
**Ventilate through glottis and upper airway - can retain CO2
*Need adequate oxygen pressure
*1 sec insp and 2- 3 sec exp to avoid breath stacking
*Can use for 30-45 min
*May cause pneumothorax or barotrauma
*Contraindications
**Distorted anatomy
**Bleeding diathesis
**Complete airway obstruction


===Retrograde Intubation===
===Retrograde Intubation===

Revision as of 11:43, 2 February 2019

Predicting the difficult airway

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"

Improving Passive Oxygenation

See Apneic oxygenation

Advanced airway adjuncts

Nasal intubation

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

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 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,

Rigid Fiberoptic Laryngoscopes

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

Surgical cricothyrotomy

  • 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

Mechanical Ventilation Pages

Video

{{#widget:YouTube|id=8y8QN1j_m4g}}

References

Retrieved from "https://www.wikem.org/w/index.php?title=The_difficult_airway&oldid=205138"