Airway Strategy to manage accordingly

1. Difficult Airway

2. The Difficult Airway
 The key is to maintain:
1. Oxygenation
2. Ventilation

3. The Difficult Airway
 A difficult airway can be defined as a clinical situation in which a conventionally
trained ALS provider experiences difficulty with mask ventilation, difficulty with
tracheal intubation or both

4. The Difficult Airway
 Definition: Difficult to oxygenate and ventilate
 Difficult to intubate

5. Complexity
 The difficult airway represents a complex interaction between patient factors, the
prehospital/clinical setting, and the skills of the EMS provider

6. Difficult Mask Ventilation
 Not possible for the EMS provider to maintain the SPO2 > 90% using 100% oxygen
and positive pressure mask ventilation
 It is not possible for the EMS provider to prevent or reverse signs of inadequate
ventilation during PPV

7. The Difficult Airway
 Difficult to oxygenate and ventilate (BMV)
 Beard
 Obese
 No teeth (Edentulous)
 Elderly
 Snores (OSA)

8. The Difficult Airway
 Difficult to intubate;
 Look at head & neck
 Evaluate ability to open mouth /access oropharynx
 Mallampati or Cormack scales
 Obstruction
 Neck mobility

9. Look at Head & Neck
 Anatomical features
 Recessed chin
 Buck teeth
 Short neck or “no neck”
 Signs of previous surgery

10. Difficult Endotracheal Intubation
 Proper insertion of the tracheal tube with conventional laryngoscopy requires more than
03 attempts
 Proper insertion of the tracheal tube with conventional laryngoscopy requires more than
10 minutes

11. Intubation Difficulty May Be Due To;
 Incorrect position of the patient
 Inadequate or improper equipment
 Unusual or abnormal anatomy
 Pathologic causes

12. Evaluate Access to Oral Cavity
 Opening of mouth < 20mm predisposes to difficult airway

13. Evaluate Access to Oral Cavity
 Rule of thumb;
 An opening of at least 3 fingers breadths between upper and lower incisors in adult is
desirable

14. Mallampati Scale

15. Assessing Oral Cavity

16. Cormack & Lehane Scale

17. Difficult Laryngoscopy
 It is not possible to visualize any portion of the vocal cords with conventional
laryngoscopy

18. Factors Contributing to Difficulty Laryngoscopy
The following factors may be contributors to difficult airway;
 Obstruction
 Infections
 Trauma
 Rheumatoid Arthritis
 Congenital problems
 Pregnancy

19. Obstruction
 Foreign body airway obstruction is a common cause of failed airways.
 Direct laryngoscopy must be used with caution as it may result in further advancement
of Foreign Body in the airway

20. Obstruction
 Obstruction of the airway can also be anatomical or pathological, causing narrowing or
complete blockage of the airway

21. Infections
 Infectious processes such as abscess, croup, bronchitis, and pneumonia can distort
normal anatomy

22. Trauma
 Maxillofacial or head trauma may distort normal airway resulting in clenched teeth and
edema

23. Obesity
 Obesity results in airway and respiratory problems secondary to altered respiratory
pathophysiology and distorted upper airway anatomy

24. Rheumatoid Arthritis
 Patient with rheumatoid arthritis and other connective tissue diseases often limit Range
Of Motion (ROM) of the cervical spine

25. Tumors
 Tumors of the neck and airway can distort anatomy, limiting the space for
instrumentation

26. Congenital Disorders
 Congenital disorders may be associated with airway difficulty due to mandibular
hypoplasia, cervical abnormalities, large tongue or cleft palate

27. Pregnancy
 Pregnancy is associated with a difficult upper airway, an increased risk of aspiration
and limited tolerance of apnea

28. The Most Difficult Airway

29. Summary
 The difficult airway is a significant problem to the patient and EMS provider in terms
of mortality, morbidity and cost
 It is imperative to be aware of the factors that contribute to a difficult airway so that;
a. EMS providers may improve their ability to be prepared
b. The morbidity and mortality of difficult airway patients can be minimised
c. Patient outcome can be improved upon

30. Thanks