The difficult airway

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

Non-Traditional Intubation Types

• Awake intubation

Nasal intubation

• Not as successful but still an option
• Higher complication rate - bleeding, emesis, and airway trauma
  • Do not attempt in patients with posterior pharyngeal swelling such as in Angioedema (Upper Airway)

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 Airways

• Surgical cricothyrotomy
• Needle cricothyrotomy
• 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 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

1. Empty the stomach
   • Place an NG and suction out blood
     • Varices are not a contraindication
   • Metoclopramide 10mg IV
     • Increases LES tone
2. Intubate with HOB at 45°
3. Preoxygenate!
   • Want to avoid bagging if possible
4. Intubation meds
   • Use sedative that is BP stable (etomidate, ketamine)
   • Use paralytics (actually increases LES tone)
5. If need to bag:
   • Bag gently and slowly (10BPM)
   • Consider placing LMA
6. If patient vomits
   • Place in Trendelenberg
   • Place LMA
   • Use meconium aspirator
7. If patient aspirates anticipate a sepsis-like syndrome
   • May need pressors, additional fluid (not antibiotic!)

See Also

Airway Pages

• Pre-intubation
  • Predicting the difficult airway
  • Bag valve mask ventilation
    • Oropharyngeal airway
    • Supraglottic airway
  • Apneic oxygenation
    • EBQ:ED Preoxygenation
• Induction
  • Critical care quick reference
  • Rapid sequence intubation
  • Delayed sequence intubation
• Intubation
  • Intubation (peds)
  • Direct laryngoscopy
  • Video Laryngoscopy
  • Bougie
  • The difficult airway
  • Advanced airway adjuncts
    • Supraglottic airway
  • Non-traditional intubation
    • Awake intubation
    • Nasal intubation
    • Blind digital intubation
• Surgical airways
  • Surgical cricothyrotomy
  • Needle cricothyrotomy
  • Pediatric jet ventilation
• Post-intubation
  • Mechanical ventilation (main)
  • Deterioration after intubation (DOPE)

Mechanical Ventilation Pages

• Noninvasive ventilation
• Intubation
  • Intubation (peds)
• Mechanical ventilation (main)
  • Ventilation modes
  • Initial mechanical ventilation settings
    • Initial mechanical ventilation settings (peds)
  • Adjusting mechanical ventilation settings
    • Deterioration after intubation
    • Lung recruitment maneuver
    • Ventilator high pressures
    • Ventilator associated lung injury
  • Weaning mechanical ventilation
    • Extubation
• Miscellaneous
  • ARDS and EBQ:ARDSnet
  • Airway pressure release ventilation
  • Ideal Body Weight Estimation

Video

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