How to successfully manage any patient with a difficult airway.

1. by DR. BERNARD FIIFI BRAKATU

2.  INTRODUCTION
 RELEVANT ANATOMY
 ASSESSMENT OF THE AIRWAY
 MANAGEMENT

3.  Clinical situation in which a conventionally trained
anesthesiologist experiences difficulty with face mask
ventilation of the upper airway, difficulty with tracheal
intubation, or both.
 (Practice Guidelines for Management of the
Difficult Airway; Anesthesiology 2003; 98: 1269)
 It represents a complex interaction between patient
factors, the clinical setting and the skills of the
practitioner

4.  Explicit descriptions that can be categorized or expressed
as numerical values are encouraged and includes(but not
limited to):
1. Difficult face mask ventilation –
 a)inadequate mask seal, excessive gas leak or excessive
resistance to the ingress or egress of gas
 b) Signs of inadequate face mask ventilation – absent or
poor chest movement, absent or inadequate breath
sounds, auscultatory signs or severe
obstruction, cyanosis, gastric air entry or
dilatation, decreasing or inadequate SpO2, absent or
inadequate exhaled CO2, absent or inadequate spirometric
measures of exhaled gas flow, hemodynamic changes
associated with hypoxemia or hypercarbia(e.g.
hypertension, tachycardia, arrhythmia).

5.  2. Difficult laryngoscopy – inability to visualize any
portion of the vocal cords after multiple attempts at
conventional laryngoscopy
 3. Difficult/failed tracheal intubation – requiring
multiple attempts, in the presence or absence of
tracheal pathology

6.  Death!!
 Brain injury
 Cardiopulmonary arrest
 Unnecessary tracheostomy
 Airway trauma
 Damage to teeth

7. March 147

10.  Large tongue short neck(esp neonate)
 Larynx is cephalad
 Narrower cricoid cartilage
 Epiglottis is U-shaped and stiff
 Glottic opening is anterior in a neonate
 Results in difficulty in aligning the oral, pharyngeal
and glottic axes and elevation of epiglottis for full
exposure of glottic opening thus resistance to passage
of tubes through the glottic opening.

11.  Comprehensive history and physical exam
 HISTORY
 - identify risk group and risk factors for the patient
 - PMH and past surgical hx
 Check records on previous anesthesia if available
 PHYSICAL EXAMINATION
 -General exam- note hoarseness, stridor or prev
tracheostomy scar suggests possible tracheal stenosis
-Systemic examination

12.  Inspect from both ant and lat views – facial features for bony and soft
tissue abnormalities, receding chin, mandibular and maxillary
fractures
 MOUTH OPENING – Score acc to Mallampati’s classification
 Check for:
 TMJ mobility –space btn mandibular condyle and tragus shd admit one
finger
 Aperture btn incisors shd admit 2 fingers
 -intra-oral tumors
 -dentition- loose teeth, prostheses, dental abnormalities
 Can patient protrude the tongue maximally?
 NECK
 -Inspect for neck swellings, tracheal deviation and scarring
 -Check for full flexion, extension, rotation and the thyromental
distance on full extension(difficulty if <6.5cm or 3fingerbreadths)

13.  Recent Imaging studies eg CT or MRI scans may help
define difficult anatomy and guide mngt
 **Occipito-atlanto-axial disease(R/O in RA or
ankylosing spondylitis) is more predictive of difficult
laryngoscopy than disease below C2
 **Plain Lateral X-rays may show flexion/extension
deformities and subluxation

14.  Anatomical anomalies eg. Micrognathia(Pierre-Robbin’s),
Macroglossia(Down’s, acromegaly, congenital
hypothyrodism, amyloidosis), Burns and contractures
involving head and neck
 Obese patients – shorter neck and reduced motion at C-
spine
 Pregnant patients – ecclampsia(laryngeal edema)
 Upper airway obstruction- tumors, infections, maxillofacial
trauma, large goiter
 C-spine pathologies-fracture, subluxation/dislocation,
Rheumatoid arthritis, ankylosing spondylitis
 PMH of difficult intubation during prev anaesthesia

15.  MALLAMPATI’S CLASSIFICATION
 CORMACK AND LEHANE CLASSIFICATION

16.  Done during pre-op assessment
 Predicts difficulty of intubation
 Patient sits up with Anesthetist at eye level, opens
mouth as wide as possible and protrudes the tongue
 Pharyngeal structures are identical w/o the pt
phonating
 Results influenced by ability to open the mouth, sizee
and mobility of tongue and other intra-oral structures

17.  Class 1: Full visibility of tonsils, uvula, and soft palate
 Class 2 Visibility of hard and soft palate and, upper
portion of tonsils and uvula
 Class 3: Visibility of soft and hard palate and base of
the uvula
 Class 4: Visibility of only hard palate

18.  Grade 1 or 2 predicts an easier intubation
 Grade 3 or 4 predicts a more difficult intubation

19.  This system of grading is based on actual direct
laryngoscopic views
Grade 1-complete glottis visible
Grade 2- visualize only the posterior portion of laryngeal
aperture
Grade 3- visualize only the epiglottis
Grade 4- visualize only the soft palate

20.  ANTICIPATED DIFFICULT AIRWAY
 -Discuss with senior colleagues in advance
 -Test equipment before procedure
 -Senior help backup
 -Plan A for ventilation and intubation
 -Definite Plan B and option of awake intubation
 -Ideally, surgery team standby

22.  Positioning the patient- combines cervical flexion
and AO extension(sniffing position)
 Opening the patients mouth –scissors maneuver

23.  - Adv tip to base of the tongue by rotating tip around
tongue(shd follow natural curve of oropharynx and tongue
 -Insert blade to the rt of the tongue’s midline, moving
tongue to the lt
 -Once the tip of the blade lies at the base of the tongue(just
above the epiglottis), apply firm, steady upward and
forward traction to the laryngoscoe(45o from the
horizontal)
 Avoid rotating the laryngoscope, once it is at the base of
the tongue to avoid damage to the maxillary teeth
 **Stooping limits power in the arms, making it more
technically difficult

24.  In grade 3 or 4 larynx, epiglottis can be
used as landmark for guiding ETT
through the hidden vocal cords
 Pass tip of ETT underneath epiglottis
and anterior to esophagus whiles an
assistant applies cricoid pressure(moves
larynx posteriorly and helps bring vocal
cords into view)
 A malleable stylet(has a distal anterior J
curve) helps in guiding ETT through the
vocal cords

25.  Ford’s maneuver- Downwards pressure on ETT prior to
withdrawing of laryngoscope displaces glottis
posteriorly
 Note length of ETT at the lips; usually 21-24cm for
adult males and 18-22 in adult females(compare with
25cm in nasally intubated cases)
 Inflate ETT cuff with enough air to create a seal
around ETT during positive pressure ventilation
 Absolute confirmation is by observing capnograph
 Observe chest rise and fall with IPPV
 Listen to apex of each lung field for breath sounds

26.  Special trolley with range of euipment such as gum
elastic bougie, variety of laryngoscopes and tracheal
tubes and cricothyrotomy needles
Lighted stylette
bougie guided
intubation

27.  Nasopharyngeal
airway
 LMA
 Gum elastic bougies
 Laryngoscopes
 Magill’s forceps
 Fiberoptic scopes
 Lightwands, etc

28.  Manipulation of patient’s airway
 Use different blades of laryngoscope
 Use of LMA or combitube
 Cricothyrotomy/Tracheostomy

31. Indicated when intubation is deemed not possible or all
the above options are unsuitable
 Done under local anaesthesia ± iv sedation before
induction
 Give oxygen and monitor patient closely during
procedure

32.  Ensure that the patient is fully conscious prior to
extubation. Safer to leave the endotracheal tube in situ if
there is any doubt about airway patency post- extubation
 Closely observe in the recovery ward for signs of respiratory
distress and intervene
 Document clearly in the patients case history and
anaesthetic record stating the reasons for the difficult
intubation and methods used to overcome the problem
 Visit the patient post- op and explain about the difficulty in
intubation and instruct the patient to inform the next
anaesthetist if further anaesthesia is required

33.  Anaesthesia for Medical Students; Pat Sullivan M.D.
 1999 Edition; Chapter 6
 Difficult Airway Society guidelines for management of the unanticipated difficult
intubation; J. J. Henderson,1 M. T. Popat,2 I. P. Latto3 and A. C. Pearce4
 Mallampati SR, Gatt SP, Gugino LD, et al: A clinical sign to pre-
dictdifficulttrachealintubation: A prospective study. Can J Anaesth 32:429,1985.
 Medscape
 Practice Guidelines for Management of the Difficult Airway; 2003 American Society
of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc; Anesthesiology 2003;
98:1269 –77
 Samsoon GLT, Young JRB: Diffi- cult tracheal intubation: A retro-
 spective study. Anaesthesia 42:487,1987.
 http://www.airwaycam.com
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