The document provides guidelines for managing difficult airways in ICU settings, defining difficult intubation and causes related to both anesthetists and patients. It outlines a systematic approach for evaluation and planning, including the importance of preoperative assessment, equipment availability, and communication with colleagues. Key techniques for airway management, such as various intubation methods and backup plans, are discussed to ensure effective handling of anticipated challenges.

1. Difficult intubation guidelines
in ICU
BY
ANN SNEHA VINCENT

2. Definition of difficult airway
• A difficult airway includes the clinical situation in which anticipated or
unanticipated difficulty or failure is experienced by a physician trained
in anesthesia care
• Facemask ventilation,larynogoscopy, ventilation using a supraglottic
airway, tracheal intubation, extubation, or invasive airway

3. DEFINITION
Difficult to ventilate: when sign of inadequate ventilation could not be
resersved by mask ventilation or oxygen saturation could not be
maintained above 90%
Difficult to intubate: if a trained anaesthetist using conventional
laryngoscope take’s more than 3 attempts
Or
More than 10 minute are required to complete tracheal
intubation

4. CAUSES OF DIFFICULT INTUBATION
Anaesthetist
1. Inadequate preoperation assessment
2. Experience not enough
3. Poor technique
4. Inexperience assistance
5. Inadequate equipment
6. Malfunctioning of equipment
Patient
7. Congenital causes
8. Acquired causes

5. ANATOMICAL FACTORS AFFECTING
LARYNGOSCOPY
• Neck
• Disturbing incisor teeth
• Long high arched palate
• Poor mobility
• Increase in either anterior depth or posterior depth of the mandilble
decrease in atlanto occipital distance

6. Basic airway evaluation in all patients
• Previous anaesthetic problems
• General appearance of the neck, face, maxilla and mandibute
• Jaw movements
• Head extention and movements
• The teeth and oro-pharyngx
• The soft tissues of the neck
• Recent chest and cervical spine x-rays

7. FOUR TECHNICAL OPERATIONS OF THE
DIFFICULT AIRWAY
• Difficult bag valve mask ventilation
MOANS/BONES
• Difficult laryngoscopy and intubation
LEMON
• Difficult supra-giottic device
RODS
• Difficult cricothyrotomy
SHORT

8. DIFFICULT BAG-MASK
VENTILATION: MOANS
• Mask seal
BONES
• Obstruction/obesity Beard
obese
• Age>55 No teeth
Bdeny
• No teeth deep apnea
• Stiff lungs

9. DIFFICULT LARYNGOSCOPY AND INTUBATION:
LEMON
• Look externally
• Evaluate 3-3-2
• Mallampati score
• Obstruction /obesity
• Neck mobility

10. L: LOOK EXTERNALLY
• Obesity or very small
• Short muscular neck
• Prominent upper incisors (BUCK TEETH)
• Large breasts
• Receding (dentures)
• Burns
• Facial trauma
• Stridor
• macroglossia

11. DIFFICULT LARYNGOSCOPY AND INTUBATION:
LEMON
• Evaluate 3-3-2 rule:
relates the mouth opening to size of the mandible to the
position of the larynx in the terms of likehood of the successful
visualization of the glottis bt direct laryngoscopy

12. E- EVALUATE THE 3-3-2
• 3 finger fit in mouth
• 3 finger fit from mentum to hyoid cartilage
• 2 fingers fit from the floor of the mouth to the top of the thyroid cartilage

13. DIFFICULT LARYNGOSCOPY AND INTUBATION:
LEMON
• First “3”
• Assesses for mouth opening
• 3 fingers between the upper and lower incisors

14. DIFFICULT LARYNGOSCOPY AND INTUBATION:
LEMON
• Second “3”
• length of the mandibular space
• Menturn to hyoid

15. DIFFICULT LARYNGOSCOPY AND INTUBATION:
LEMON
• “2”
• Position of the glottis in relation to the base of the tongue
• Space from chin-neck junction (hyoid) to and thyroid notch

16. DIFFICULT LARYNGODCOPY AND INTUBATION:
LEMON
• Mallampati
sitting up
head in sniffing position
open mouth, protrude tongue without phanation
• Class I-IV
• Class I & II = low intubation failure rate
• Class III & IV = intubation failure may be > 10%

17. M- Mallampati classification (LEMON)

18. DIFFICULT LARYNGOSCOPY AND INTUBATION:
LEMON
• Obstruction/obesity
• Four cardinal signs of upper airway obstruction:
- muffied voice
-difficulty swallowing secretions
-stridor
-sensation of dyspnea

19. DIFFICULT LARYNGOSCOPY AND INTUBATION:
LEMON
• Neck mobility
- C spine immobilization may compound the effects of other
difficult airway markers
• Trauma,ra, ankylosing spondylitis
• May require video laryngoscopy

20. DIFFICULT SUPRAGLOTIC DEVICE: RODS
• Restricted mouth opening
• Obstruction
• Disrupted or distorted airway
• Stiff lungs or cervical spine

21. DIFFICULT SUPRALOTTIC DEVICE: RODS
• Restricted mouth opening
- allowing for oral access to insert device

22. DIFFICULT SUPRAGLOTTIC DEVICE: RODS
• Disrupted or distorted airway
- seal/ seal compromised of the device

23. DIFFICULT SUPRAGLOTTIC DEVICE: RODS
• Stiff lungs or cervical spine
- Increased airway resistance
-severe asthma
- Decreased pulmonary compliance
-pulmonary ederna
- Decreased cervical movement

24. DIFFICULT CRICOTHYROTOMY: SHORT
• Surgery or disrupted any way
• Hematoma (infection/abscess)
• Obesity
• Radiation
• Tumor

25. DIFFICULT CRICOTHYROTOMY: SHORT
• Tumor
-extrinsic
- intrinsic

26. PREPARATION FOR DIFFICULT AIRWAY
MANAGEMENT
1. The availability of equipment for airway management
2. Informing the patient; / senior colleague/ expert help / assistance
3. Preoxygenation;
4. Patient positioning ;
5. Sedative administration ;
6. Local anesthesia;
7. Supplemental oxygen;
8. Patient monitoring; and
9. Human factors.##

27. MANAGEMENT PLAN OF ANTICEPATED
DIFFICULT AIRWAY
1. Discussion with colleagues in advance
2. Equipment tested before
3. Senior help backup
4. Definite initial plan (A) for ventilation and intubation.
5. Definite plan (B) than option of awake intrubation
6. Ideal situation surgery team standby

28. PRE-OXYGENATION: HO MUCH IS ENOUGH?
Two techniques common in use:
1. Tidal volume breathing (TVB) of oxygen for 3-5 min
2. Deep breath (DB) 4 times within 30sec
Both are equally effective in increasing arterial oxygen
tension (pao2)

29. CONSIDER THE MERITS AND
FEASIBILITY
Awake intubation vs intubation after induction of GA
Non-invasive technique vs invasive technique for initial approach
For initial approach
Preservation of spontaneous vs abiation of spontan ventilation
Ventilation

30. WHAT WE ARE GOING TO DO IF WE
DON’T GET THE TUBE
• Plan “A” “B” and “C”
• Know this answer before you tube

31. PLAN “A”: ( ALERNATE)
• Different length of blade
• Different type of blade
• Different type position

32. PLAN B: ( BYM AND BLIND
INTUBATION TECHNIQUES)
1. Can you ventilate with a BVM ? (consider two person mask
ventilation)
2. Combi-tube?
3. LMA an Option?

33. WHAT DO WE DO WHEN FACED WITH A CAN’T
INTUBATE CAN’T VENTILATE SITUATION?
• Plan “c” : (CRIC) needle, surgical.

35. THANK YOU
BY
ANN SNEHA VINCET