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

Pre-Intubation

See:

• Predicting the difficult airway
• Apneic oxygenation

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 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
Percutaneous transtracheal 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

• Surgical cricothyrotomy
• Needle cricothyrotomy
• Pediatric jet ventilation

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)