Basic Emergency Airway Management

Pat Melanson,MD

Objectives
Differentiate the Emergency Airway from elective intubation in the OR Assessment of airway compromise Indications for airway intervention Recognition of the difficult airway Bag-Mask Techniques Laryngoscopy

Emergency Airway Management : Unique Considerations

Full stomach - high aspiration risk Altered level of consciousness Deteriorating cardiorespiratory physiology - (hypotension, hypoxia) Abnormal or distorted upper airway anatomy No time for pre-op assessment

Airway Assessment
Assessment for airway compromise or threats and need for interventions Examination for the potentially difficult airway

The Three Pillars of Airway Management: ( Assessment of Compromises or Threats )

1 Patency of Upper Airway

( airflow integrity )

2 Protection against aspiration 3 Assurance of oxygenation and ventilation

Indications for Active Airway Intervention: including intubation

Failure to maintain patency Protection from aspiration Hypoxic/ hypercapnic respiratory failure Airway access for pulmonary toilet, drug delivery,therapeutic hyperventilation Intractable Shock Anticipated clinical deterioration

Indications for Intubation

Is there failure of airway maintenance ? Is there failure of airway protection ? Is there failure of oxygenation or ventilation? What is the anticipated clinical course ? (i.e., expected deterioration, long transport, long time in radiology, etc.)

Clinical Signs of Airway Compromise :

Threatened Patency
Inspiratory stridor Snoring ( pharyngeal obstruction ) Gurgling ( blood/ secretions ) Drooling ( epiglottitis ) Hoarseness ( laryngeal edema/ vocal cord paralysis) Paradoxical chest wall movement Tracheal tug Mass - abscess, hematoma, angioedema

Clinical Signs of Airway Compromise:

Inadequate Protection
Blood in upper airway Pus in upper airway Persistent vomiting Loss of protective airway reflexes
swallowing reflex is superior to gag reflex

Clinical Signs of Airway Compromise: Oxygenation and Ventilation

Central cyanosis Obtundation and diaphoresis Rapid shallow respirations Accessory muscle use Retractions Abdominal paradox

Clinical Signs of Airway Compromise: Oxygenation and Ventilation

The assessment of oxygenation and ventilation is a clinical one. Arterial blood gases should not be relied upon to assess whether intubation is necessary.

Techniques for the Compromised Airway

Head Positioning Jaw Thrust, Chin lift Orophryngeal/ Nasopharyngeal airways Bag-Valve-Mask Ventilation Endotracheal Intubation Advanced techniques
Cric, LMA, Combitube, Retrograde, Fibreoptic, Light wand, Bouge

The Difficult Airway

Difficult Laryngoscopy
poor visualization of cords

Difficult bag-mask ventilation

unable to oxygenate or ventilate

Lower airway difficulty

severe bronchospasm

Golden Rules of Bagging

Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask The art of bagging should be mastered before the art of intubation Manual ventilation skill with proper equipment is a fundamental premise of advanced airway Rx

BVM Ventilation
The most important airway skill Always the first response to inadequate oxygenation and ventilation The first bail-out maneuver to a failed intubation attempt Attenuates the urgency to intubate Do not abandon bagging unless it is impossible with two people and both an OP and NP airway

BVM Ventilation
Requires practice to master One hand to
maintain face seal position head maintain patency

Other hand ventilates

BVM Ventilation: Technique

Insert oropharyngeal/nasopharyngeal Sniffingposition if C-spine OK Thumb + index to maintain face seal Middle finger under mandibular symphysis Ring/little finger under angle of mandible Maintain jaw thrust/mouth open

Predictors of a Difficult Airway : BVM

Upper airway obstruction Lack of dentures Beard Midfacial smash Facial burns, dressings, scarring Poor lung mechanics
resistance or compliance

Difficult Airway : BVM

degree of difficulty from zero to infinite Zero = no external effort or internal device required one person jaw thrust/ face seal oropharyngeal or nasopharyngeal AW two person jaw thrust / face seal both internal airway devices Infinite = no patency despite maximal external effort and full use of OP/NP

Algorithm for Difficulty Bagging

Remove Foreign Bodies - Magill forceps Triple maneuver if c-spine clear Head tilt, jaw lift, mouth opening Nasal or oropharyngeal airways Two-person, four-hand technique

BVM Ventilation: Mask Seal Tips and Pearls

Easier to get seals with masks too large than too small Inflate mask collar correctly Apply lubricant to beards to mat down hair If edentulous insert gauze sponges into cheeks

Prediction of the Difficult Airway: Laryngoscopy

History of past airway problems
check previous OR anesthesia records if time permits cricothyroidotomy scar

Careful physical assessment

mouth opening tongue to pharyngeal size hyo-mental distance Neck flexion, Head extension

Technique of Laryngoscopy
Sniffing position to align oralpharyngeal-laryngeal axis Flex neck by placing pillow beneath occiput ( raise 10 cm ) Extend head maximally With laryngoscope
open mouth fully push tongue to left out of view pull upward at 45 degrees

Adducted vocal cords

Predictors of Difficult Laryngoscopy

Short thick neck Receding mandible Buck teeth Poor mandibular mobility/ limited jaw opening Limited head and neck movement
( including trauma )

Difficult Airway : Laryngoscopy

Tumor, abscess or hematoma Burns Angioneurotic edema Blunt or penetrating trauma Rheumatoid arthritis, ankylosing spondylitis Congenital syndromes Neck surgery or radiation

Predictors of Difficult Laryngoscopy

3 fingerbreadths mentum to hyoid 3 fb chin to thyroid notch 3 fb upper to lower incisors Head extension and neck flexion Mallimpadi classification Previous history of difficult intubation

Mallimpadi Classification (Tongue to Pharyngeal Size)

I - soft palate, uvula, tonsillar pillars visible
99 % have grade I laryngoscopic view

II - soft palate, uvula visible III - soft palate, base of uvula IV - soft palate not visible
100% grade III or grade IV views

The 4 Ds of Difficult Intubation

Distortion
( edema, blood, vomitus, tumor, infection)

Dysmobility of joints
( TMJ, alanto-occipital, C-spine)

Disproportion
thyomental, Mallimpadi, etc

Dentition
prominent upper teeth

Unsuccessful Intubation
Bag the patient Maximize neck flex/ head ex Move tongue out of line of site Maximize mouth opening ID landmarks and adjust blade BURP maneuver Increasing lifting force Consider Miller blade Bag the patient

(Backwards Upwards Rightwards Pressure on Thyroid Cart.)