The document addresses difficult airway management, outlining clinical situations where face mask ventilation and intubation are challenging. It covers the assessment methods, including Cormack and Lehane classifications, Mallampati scores, and the importance of having emergency airway equipment readily available. Various management techniques, including alternative airway methods and surgical interventions, are discussed, emphasizing preparation and senior staff involvement in emergencies.

1. Difficult Airway Management
2009
Adrian Sieberhagen

2. • Clinical situation in which there is difficulty
in Face Mask Ventilation and inability to
intubate

3. What makes it difficult in ED’s
• Training/requirements
• Non-controlled setting
• Limited pre-procedural evaluation
• Hypoxia, hypotension, agitation, dynamic
medical conditions
• Numerous logistical & implementation
issues

4. Predicting the Difficult Airway
• History
• Physical Examination

5. History

6. Cormack and Lehane
• Class I: the vocal
cords are visible
• Class II the vocals
cords are only partly
visible
• Class III only the
epiglottis is seen
• Class IV the epiglottis
cannot be seen.

7. • Pregnancy
• Inflammatory Disease
• Small mouths
• Infections
• Endocrine
• Congenital
• Trauma
• Foreign Body
• Tumours

8. Examination

9. LEMON
• Look for external deformities
• Evaluate 3-3-2 rule
• Mallampati
• Obstruction
• Neck Mobility

10. Mallampati Score
• Class I
– visualization of the soft palate,
fauces, uvula, and both anterior
and posterior pillars
• Class II
– visualization of the soft palate,
fauces, and uvula
• Class III
– visualization of the soft palate
and the base of the uvula
• Class IV
– soft palate is not visible at all

11. • Thyromental Distance
• 6.5cm normal
• Sternomental Distance
• >12.5cm normal
• Protrusion of Mandible

12. Management
• Prearranged Emergency airway trolley
available
• Most senior staff

13. Emergency Airway Trolley
• Rigid laryngoscope blades
• Tracheal tubes
• Tracheal tube guides
• Laryngeal Mask Airways
• Fibreoptic intubation equipment
• Non-invasive/minimally invasive airways
• Surgical Airway
• CO2 detectors

14. Management
• Prearranged Emergency airway trolley
available
• Most senior staff
• Emergency airway algorithm
• Deliver supplemental O2

17. Alternative Airway Techniques
• LMA/Laryngeal Tube
• Transtracheal Jet Ventilation
• Fibreoptic Intubation
• Retrograde Intubation
• Lightwand
• Combitube
• Surgical Airway

18. Laryngeal Mask
• Lubricated LMA inserted into hypopharynx
• Tip in upper oesophogeal sphincter
• Inflate Cuff
• Muscle relaxants not necessary
• C/I:
– Need for high Peak Pressures
– Risk of Aspiration
– Pts with low lung compliance

19. Laryngeal Tube

20. Transtracheal Jet Insuflation

21. Fibreoptic Intubation

22. Retrograde Intubation
• Place guidewire through cricothyroid
membrane
• Guidewire passes cephalad through
pharynx and out mouth/nose
• Railroad ET tube

23. Lightwand
• Flexible
• Inserted through ET tube
• Insert into larynx
• Light dims if entering oesophagus
• Limitations: Dark room

24. Combitube
• Double lumen tube
• Placed into hypopharynx blindly
• C/I
– Oesophageal pathology

25. Surgical Airway
• Cricothyroidotomy
– Complications:
• Bleeding
• Infection
• Vocal cord damage
• Tracheal stenosis
– C/I
• <12yrs
• Laryngotracheal Disruption
• Coagulopathy

26. The End