Definition

Predicting a Difficult Airway
• Difficult bag-mask ventilation expected?
• Difficult laryngoscopy expected?
• Difficult endotracheal tube placement
expected?
• Difficult surgical airway management
predicted?

Predicting Difficulties with
Bag-Mask Ventilation
• Surgery
• Hematoma
• Obstruction
• Radiation
• Trauma or
• Tumors
• Bearded
• Obese
• Noo teeth
• Elderly
• Snorer

Predicting a Difficult Laryngoscopy
• Prominent mandibular or maxillary incisors
• Lack of jaw mobility
• Hard palate shape
• Neck length/thickness/mobility
• Compliance of submandibular space
• Visibility of the uvula and retropharyngeal
structures or Mallanpati score

Predicting a difficult ETT placement
or advancement
• Difficult laryngoscopy
• Unable to visualize or recognize vocal
cords
• Neck tumors or large hematomas
compressing the airway

Predicting a difficult surgical airway
• Difficult anatomy
• Lack of equipment
• Contraindications: infection, coagulopathy,
neck hardware
• Preparing for it after everything has failed

Preparing for a Difficult Airway
• Teamwork: respiratory therapist, nurses,
physicians, surgeons
• Formulate a plan: Know the difficult
airway algorithm
• Knowledge and availability of alternative
airway management techniques and
equipment

Preparing for a Difficult Airway
• Is this a crash airway?
• Patient preparation: Cooperation,
positioning, IV access, stabilization
• Aids during conventional laryngoscopy
• Alternative airway management
• ASK FOR HELP

Aides During Laryngoscopy
Positioning
Sedation, paralysis and topical
anesthesia
Bougie
Alternative laryngoscope blade
View Max, Truview, Flipper

Endotracheal Tube Introducer
(Bougie)
The top of bougie passes just beneath the
epiglottis.
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Vibrations, or clicks, can be palpated as the
soft tip of the bougie passes against the rigid
tracheal rings.

Truview

Rusch “View Max”
• Allows visualization of the vocal
cords in the most difficult cases
• Functions like a traditional laryngoscope
• Provides a patented lens system which
provides a more anterior view of the
larynx than a standard laryngoscope
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Max View

“Flipper” Laryngoscope blade
The Flipper® is a unique fiber
optic laryngoscope blade that can
give that extra bit of anterior
exposure sometimes needed
during difficult intubations.
Articulating tip design allows the
end of the blade to be raised by
squeezing a lever next to the
handle. One-handed operation
produces a more complete
exposure of the glottis, making
intubation easier.
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Alternatives to Laryngoscopy
• LMA (Fastrach) or Combitube
• Trachlight or Light wand
• Blind nasal intubation
• Fiber optic bronchoscopy
• Retrograde intubation
• Surgical airway:
• Cricothyrotomy – Needle or tube

Trachlight

“Based upon the principle of
transillumination of the soft
tissues of the neck, the
Trachlight device facilitates
intubation even in the most
challenging patients.”
Trachlight
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LMA
Sizes 4, 5, 6
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Combitube

Retrograde Intubation

Williams Airway
• An oralpharyngeal airway
• A means of intubating the
trachea
Sizes 9 & 10
• A guide for fiber optic
broncoscopy placement
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Aintree Intubation Catheter

Transtracheal Jet Ventilator /
Needle Trach
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Cricothyrotomy Kit

Emergency Cricothyrotomy Kit

Melker Cook “Quick
Trach”
Used for emergency
airway access when
endotracheal
intubation cannot be
performed. Airway
access is achieved
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CO2 Detector
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Extubation and ETT Exchange
• Avoid accidental and self extubations
• Use of Aintree or tube exchangers
• Ultimately may need a surgical airway

Cook Tube Exchanger
1
An AEC introducer (COOK) is
introduced through the lumen of
the existing tracheal tube after
airway evaluation
(laryngoscopy)
Dr AREZKI Farid
SERVICE D'ANESTHESIE REANIMATION
CH SARREGUEMINES. FRANCE
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Cook Tube Exchanger
2
The tracheal tube removed
Dr AREZKI Farid
SERVICE D'ANESTHESIE REANIMATION
CH SARREGUEMINES. FRANCE
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Cook Tube Exchanger
3
The new tracheostomy
tube is inserted over the
exchange catheter, with
the distal, supraglottic cuff
inflated (10 ml of air).
Dr AREZKI Farid
SERVICE D'ANESTHESIE REANIMATION
CH SARREGUEMINES. FRANCE
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Conclusions
• Difficult airways are uncommon but not
rare
• Frequently leads to serious adverse
outcomes
• Planning and preparation always improve
chances for better outcome

Conclusions
• Knowledge and frequent use of different
techniques and equipment are essential
You must learn to do your own tricks

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V1
Difficult Airway Algorithm. Anesthesiology, V 98, No 5, May 2003

Slide 64
V1 Victor, 10/24/2009

Difficult Airway Algorithm. Anesthesiology, V 98, No 5, May 2003

Parker directional Flex-it
stylet
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