DIFFICULT AIRWAY SOCIETY GUIDELINES PPT

1. DIFFICULT
AIRWAY
SOCIETY
GUIDELINES
Dr KUSUMA JAGARAPU

3. BONES
B-BEARDED INDIVIDUALS
O-OBESE
N-NO TEETH
E-ELDERLY
S-SNORERS
Difficult Facemask Ventilation

4. RODS
• R-RESTRICTED MOUTH OPENING
• O-OBSTRUCTED MOUTH OPENING
• D-DISRUPTED UPPER AIRWAY
FOLLOWING TRAUMA AND BURNS
• S-STIFF LUNGS(POOR LUNG OR
THORACIC COMPLAINCE)
Difficult Supraglottic Airway Ventilation

5. Difficult Laryngoscopy
It is not possible to visualize any portion of the vocal cords
after multiple attempts at laryngoscopy Difficult or Failed
Tracheal Intubation
Tracheal intubation requires multiple attempts or tracheal
intubation fails after multiple attempts

6. The loss of airway patency and
adequate ventilation after removal of a
tracheal tube or supraglottic airway
from a patient with a known or
suspected difficult airway.
Difficult or Failed Tracheal Extubation

7. Difficult surgical airway

8. Inadequate Ventilation
Indicators: absent or inadequate-
• exhaled carbon dioxide,
• chest movement,
• breath sounds,
• auscultatory signs of severe obstruction, cyanosis,
• gastric air entry or dilatation,
• decreasing or inadequate oxygen saturation,
• exhaled gas flow as measured by spirometry,
• anatomic lung abnormalities as detected by lung
ultrasound, and hemodynamic changes
associated with hypoxemia or hypercarbia (e.g.,
hypertension, tachycardia, bradycardia,
arrhythmia).

10. WHAT IS COMMON TO ALL THESE
ALGORITHMS
•A guide to decision making during airway
emergencies
• Importance of prior assessment of airway and
previous anesthetic records
• Formulation of a prior airway management
strategy
• Significance of oxygenation
• Establishment of adequate neuromuscular
blockade prior to declaring failed BMV
• Call for help early
• Formulation of strategy for extubation

14. The laryngeal handshake. (a) Palpation of the greater cornu of the hyoid bone with the
index finger and thumb. (b) Roll the larynx from side to side. (c) The fingers and
thumb slide down over the thyroid lamina. (d) Keep the middle finger and thumb on
the cricoid cartilage and move the index finger down to palpate the cricothyroid
membrane

37. ASA GUIDELINES
FOR DIFFICULT
AIRWAY

38. Purposes of the Guidelines
To guide the management of patients with difficult airways,
optimize first attempt success of airway management,
improve patient safety during airway management,
minimize/avoid adverse events.

40. (3) Issues addressed in these guidelines
include:
(a) measurement of facial and jaw features,
(b) anatomical measurements and
landmarks,
(c) imaging with ultrasound or virtual
laryngoscopy/bronchoscopy,
(d) three-dimensional printing,
(e) bedside endoscopy.
This Photo by Unknown Author is licensed under CC BY

41. • ASA GUIDELINES 2013

42. ASA GUIDELINES
2022

43. Note these major changes from 2013 to 2022:
1.TO PERFORM AWAKE INTUBATION. There are minimal airway risks when a
patient is awake, and the benefit of placing the endotracheal tube in a difficult
airway patient while the patient is awake is immense. Inducing general anesthesia
prior to intubation in these patients can lead to a “Can’t intubate-can’t
oxygenate” emergency, which can lead to a cardiac arrest and possible anoxic
brain damage.
2.“OPTIMIZE OXYGENATION THROUGHOUT,”- Low- or high-flow nasal cannula,
head elevated position throughout procedure. Keep oxygen flowing via nasal
cannula throughout airway management attempts to minimize hypoxia, and to
keep the head elevated to maximize the functional residual capacity (FRC).

44. 3.“LIMIT ATTEMPTS, Consider calling for help” FAILED INTUBATION ATTEMPT AFTER
GENERAL ANESTHESIA’. (an effort to prevent repetitive unsuccessful intubation
attempts).
4.“LIMIT ATTEMPTS AND CONSIDER AWAKENING THE PATIENT” when “Ventilation
adequate/intubation unsuccessful.
5.“LIMIT ATTEMPTS AND BE AWARE OF THE PASSAGE OF TIME, CALL FOR HELP/FOR
INVASIVE ACCESS” when MASK VENTILATION NOT ADEQUATE, SUPRAGLOTTIC
AIRWAY NOT ADEQUATE.

45. AIDAA GUIDELINES
FOR DIFFICULT AIRWAY

47. • Optimum pre-oxygenation and nasal insufflation of 15 L/min oxygen
during apnoea.
• Transnasal humidified rapid insufflations of oxygen at 70 L/min
(THRIVE) should be used when available.
• Application of continuous positive airway pressure (CPAP) of 5–10 cm
H2O during pre-oxygenation.
• No more than three attempts at tracheal intubation and two attempts at
supraglottic airway device (SAD) insertion.
• Intubation through SAD should only be performed under vision, using a
flexible fibre-optic bronchoscope only
RECOMMENDATIONS OF AIDAA ( that are different from ASA and DAS)

48. • A pre-shaped stylet or gum-elastic bougie may be used to facilitate tracheal
intubation in Cook's modification of Cormack and Lehane Grade 2b and 3a
laryngeal view.
• Failure to intubate the trachea as well as an inability to ventilate the lungs by
face mask and SAD constitutes ‘complete ventilation failure’.
• Patient counselling, documentation and standard reporting of the airway
difficulty using a ‘difficult airway alert form’.

50. SUMMARY
BY THE LISTENERS

51. • All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal
intubation in adultsSheila Nainan Myatra, Amit Shah,1 Pankaj Kundra,2 Apeksh Patwa,1 Venkateswaran
Ramkumar,3 Jigeeshu Vasishtha Divatia, Ubaradka S Raveendra,4 Sumalatha Radhakrishna Shetty,4 Syed Moied
Ahmed,5 Jeson Rajan Doctor, Dilip K Pawar,6 Singaravelu Ramesh,7 Sabyasachi Das,8 and Rakesh Garg9Author
information Copyright and License information PMC Disclaimer
• Association of Anaesthetists of Great Britain and Ireland. Checking Anaesthetic Equipment
2012. Anaesthesia 2012; 67: 660-68.
• Cook TM, Woodall N, Frerk C, eds. The NAP4 report: Major complications of airway management in the
UK. Royal College of Anaesthetists. London; 2011. http://www.rcoa.ac.uk/index.asp?PageID=1089 Accessed
20th March 2014
• Greenland KB, Irwin MG. Airway management – ‘spinning silk from cocoons’. British Journal of
Anaesthesia 2014; 69: 296-300
• Difficult Airway
Trolley http://www.airwaytraining.co.uk/index.php?option=com_content&view=article&id=55:difficult-airway-
trolley&catid=5:resources&Itemid=20
REFERENCES:

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