This document summarizes guidelines for managing the unanticipated difficult airway. It outlines a 4-plan approach: Plan A is the initial intubation attempt. Plan B is secondary intubation methods if Plan A fails, such as video laryngoscopy or supraglottic airway devices. Plan C focuses on oxygenation and ventilation if intubation still cannot be achieved. Plan D describes rescue techniques for "can't intubate, can't ventilate" situations. It recommends cannula cricothyroidotomy as first-line over surgical cricothyroidotomy, as studies show anaesthetists have lower success rates with scalpel techniques than surgeons. Proper training and familiar equipment are

1. Airway assessment and management
of difficult airway; Optimization of
visualization of larynx
Dr.Ranjeet Bihari
MD ANESTHESIA

2. Airway assessment
• This comprises the anatomical assessment of
the upper airway

9. Airway assessment indices
1. Individual indices.
3. Group indices - Wilson’s score
- Benumof’s analysis
- Saghei & safavi test
- Lemon assesment
3. Radiological indices

23. Upper lip Bite Test

25. • Distance from the upper border of the
manubrium to the tip of mentum, neck
fully extended, mouth closed
• Minimal acceptable value – 12.5 cm
• Single best predictor of difficult
laryngoscopy and
intubation ( Has high sensitivity &
specificity).
STERNO-MENTALDISTANCE (SA
VV
ATEST)

28. X-Ray neck (lateral view)
1. Occiput - C1 spinous process
distance< 5mm.
2. Increase in posterior
mandible depth > 2.5cm.
3. Ratio of effective mandibular
length to its posterior depth
<3.6.
4. Tracheal compression
CT Scan:
1. Tumors of floor of
mouth, pharynx, larynx
2. Cervical spine
trauma, inflammation
3. Mediastinal mass
Helical CT (3D-reconstruction):
• Exact location and degree of airway
compression
Bed side Ultrasound
Trachea, Soft tissues
Radiological assessment

33. Optimization
of
visualization of larynx

38. Sniffing position
• The end point of the position should be verified
by checking the horizontal alignment of the
external auditory meatus with the sternum notch
• The mode value of neck flexion angle was 35° and
that of plane of the face extension was 15° to the
horizontal
• Other factor; include the a)type and size of the
blade, b)laryngoscope lifting force, c)operator
experience,and d) most importantly, the patient’s
airway anatomy

39. How to get optimal sniffing position;
anesthesia and analgesia

40. • The components of best performance of
laryngoscopy consist of
-------- optimal sniff position,
---------good complete muscle relaxation,
---------experienced laryngoscopist,
---------firm forward traction on the laryngoscope
-----------external laryngeal manipulation.

42. RAMP position for short neck and
morbid obese patients

43. “BURP” & “External
Laryngeal
Manipulation”
• Backward, Upward, Rightward
Pressure: manipulation of the
trachea
• 90% of the time the best view
will be obtained by pressing
over the thyroid cartilage

44. Bimanual Laryngoscopy

45. Even after all the single and multiple
parameters

48. Management
of
Difficult airway

49. Difficult airway Constitute two parts
• Anatomical difficult airway
• Physiological difficult airway

54. Definition of difficult larygoscopy

56. Difficult mask ventilation
• Inability to keep spo2 more than 90 percent
• Inability to reverse sigh of inadequate
ventilation
• Incidence 0.09 to 5.0%

60. Two Types of Anatomical difficult
intubation
• Anticipated
• unanticipated

62. Difficult airway

63. Physiological difficult airway
• The physiologically difficult airway can be
defined as one in which severe physiological
derangement place the patients at increased
risk of cardiovascular collapse and death
during tracheal intubation and transition to
positive pressure ventilation

64. Normal steps of intubation

66. Complication of the critically ill condition meta
analysis;Myatra et al IJA dec 2016

67. Pre oxygenation

68. Benumoff curve ;desaturation after giving
the muscle relaxant

70. Airway assessment; MACOCHA SCORE; AJRCCM
2013

72. Team preparation and positioning
itensive care medicine 2010
chest 2018
• Presence of two operator(at least one should
be skilled in the airway management)
• Use of check least
• Clear communication among the team
members about the airway concerns, air way
plan, back up plan role and responsibility of
the team members before proceeding for
tracheal intubation

73. Pre oxygenation

75. Billard et al .AJRCCM 2006

76. FLORALI 2 study

77. Result of FLORALI 2 Trail

78. OPTINIV trail

79. Drugs for intubation in ICU
Lancet 2009

80. Use of Ketamine vs Etomidate for RSI
ann emergency medicine ;2017

81. Use of pre intubation 500ML fluid vs
no fluid in critically ill patients

82. DELAYED SEQUANCE INTUBATION

83. DELAYED SEQUACE INTUBATION

84. RSI VS RSI WITH MUSCLE RELAXANT

89. TOOL
&
INSTRUMENT

96. Use of capnography for the
confirmation of tube

97. BJA 2011

98. No of Attempts of the intubation
&
limitation of attempt

100. What guidelines are there and what can we
learn from them?
Plan A:
Initial tracheal
intubation plan
Plan B:
Secondary tracheal
intubation plan
Plan C:
Maintenance of
oxygenation, ventilation,
postponement of
surgery and awakening
Plan D:
Rescue techniques
for "can't intubate,
can't ventilate" situation
Direct laryngoscopy
failed intubation
succeed
succeed
Tracheal intubation
failed oxygenation
Revert to face mask
Oxygenate & ventilate
failed oxygenation
LMATM
increasing hypoxaemia
or
fail
Cannula
cricothyroidotomy
Surgical
cricothyroidotomy
improved
oxygenation
Awaken patient
Confirm - then
succeed fibreoptic tracheal
ILMATM or LMATM
intubation through
ILMATM or LMATM
Postpone surgery
Awaken patient
failed intubation
ASA
Italian
DAS
UK & I
Canadian

101. Guideline of endotracheal intubation at ICU
AIDAA 2016

105. • Optimising success on first
attempt at Laryngoscopy
• Position, pre-oxygenation, muscle relaxant
• Video laryngoscope included
• There may be need of more than one tool
• Maximum 3 attempts

106. Patel at al 2015
• in extending apnoea time in pts with
difficult airways undergoing GA. There were
no saturations below 90%, despite an
average apnoea time of 17 minTHRIVE
beneficial
• Rate of rise of carbon dioxide levels was
between 0.35 and 0.45 kPa/min in
previous studies. With THRIVE, the rate of
carbon dioxide increase was 0.15 kPa/min

108. • It’s about oxygenation
• 2nd generation SADs
• Maximum 3 attempts
Plan B

110. What if PLAN B fails?

111. Plan C

112. What if PLAN C fails?

113. CICO
Difficult Airway Society 2004

114. The Great Airway Debate
PRO- SURGICAL
• EVIDENCE
• SIMPLICITY
• STANDARDISATION

115. The Great Airway Debate
Is the Scalpel mightier than the
Cannula?

116. NAP4 Data CICO
• 2.9 million GAs/ yr
• 133 serious airway
complications 58 attempts at
cricothyroidotomyOf 58 invasive
airway attempts:33 by surgeon
(surgical) Majority successful
• 25 by anaesthetist Only 9 of these
successful

117. 100%
success

118. Mabry RL.
An analysis of battlefield cricothyrotomy in Iraq
and Afghanistan.
76 surgical crics with 85%
success by army doctors.
Journal of Special Operations Medicine.
2012;12(1):17-23.

119. • London Air Ambulance Service
• Largest single reported series on scalpel
bougie technique
• Done by anaesthetists and EM docs

120. • Doctor-paramedic team attended 28,939
patients
• Advanced airway management required by 7,265
(25%)
• 98 scalpel bougie procedures with 100%
success

121. Required equipment
for Surgical Cricothyroidotomy

122. Anaesthetists are not good at
using scapels under stress??

123. CONCLUDE---------Small bore
needles should be first choice

124. • Properly trained
• Dedicated & familiar
equipment
• EXPERT at Ventilation using
high pressure oxygen through
a narrow bore cannula.
• NO need for a cuffed
Tube in place
Cannula techniques ONLY if

126. Observers View
1-Stab 2-Twist
3-Bougie 4-Tube

127. Impalpable CT Membrane

130. Better education &training as
Scalpel FONA better technique

131. SUMMARY
Guidelines for the
Unanticipated Difficult Airway

133. Thanks