Basic Emergency Airway Management

Basic Emergency Airway

ManagementPat Melanson,MD

Basic Emergency Airway

ManagementPat Melanson,MD

Objectives• Differentiate the Emergency Airway from

elective intubation in the OR

• Assessment of airway compromise

• Indications for airway intervention

• Recognition of the difficult airway

• Bag-Mask Techniques

• Laryngoscopy

Emergency Airway Management : Unique Considerations

• Full stomach - high aspiration risk

• Altered level of consciousness

• Deteriorating cardiorespiratory physiology - (hypotension, hypoxia)

• Abnormal or distorted upper airway anatomy

• No time for “pre-op” assessment

Airway Assessment

• Assessment for airway compromise or threats and need for interventions

• Examination for the potentially difficult airway

The Three Pillars of Airway Management: ( Assessment of Compromises or Threats )

1 Patency of Upper Airway – ( airflow integrity )

2 Protection against aspiration

3 Assurance of oxygenation and ventilation

Indications for Active Airway Intervention: including intubation

• Failure to maintain patency

• Protection from aspiration

• Hypoxic/ hypercapnic respiratory failure

• Airway access for pulmonary toilet, drug delivery,therapeutic hyperventilation

• Intractable Shock

• Anticipated clinical deterioration

Indications for Intubation

• Is there failure of airway maintenance ?

• Is there failure of airway protection ?

• Is there failure of oxygenation or ventilation?

• What is the anticipated clinical course ? (i.e., expected deterioration, long transport, long time in radiology, etc.)

Clinical Signs of Airway Compromise : Threatened Patency

• Inspiratory stridor• Snoring ( pharyngeal obstruction )• Gurgling ( blood/ secretions )• Drooling ( epiglottitis )• Hoarseness ( laryngeal edema/ vocal cord

paralysis)• Paradoxical chest wall movement• Tracheal tug• Mass - abscess, hematoma, angioedema

Clinical Signs of Airway Compromise: Inadequate Protection

• Blood in upper airway

• Pus in upper airway

• Persistent vomiting

• Loss of protective airway reflexes– swallowing reflex is superior to gag reflex

Clinical Signs of Airway Compromise:Oxygenation and Ventilation

• Central cyanosis

• Obtundation and diaphoresis

• Rapid shallow respirations

• Accessory muscle use

• Retractions

• Abdominal paradox

Clinical Signs of Airway Compromise:Oxygenation and Ventilation

• The assessment of oxygenation and ventilation is a clinical one.

• Arterial blood gases should not be relied upon to assess whether intubation is necessary.

Techniques for the Compromised Airway

• Head Positioning

• Jaw Thrust, Chin lift

• Orophryngeal/ Nasopharyngeal airways

• Bag-Valve-Mask Ventilation

• Endotracheal Intubation

• Advanced techniques– Cric, LMA, Combitube, Retrograde, Fibreoptic,

Light wand, Bouge

The Difficult Airway

• Difficult Laryngoscopy – poor visualization of cords

• Difficult bag-mask ventilation– unable to oxygenate or ventilate

• Lower airway difficulty – severe bronchospasm

Golden Rules of Bagging

• “ Anybody ( almost ) can be oxygenated and ventilated with a bag and a mask “

• The art of bagging should be mastered before the art of intubation

• Manual ventilation skill with proper equipment is a fundamental premise of advanced airway Rx

BVM Ventilation

• The most important airway skill

• Always the first response to inadequate oxygenation and ventilation

• The first “bail-out” maneuver to a failed intubation attempt

• Attenuates the urgency to intubate

• Do not abandon bagging unless it is impossible with two people and both an OP and NP airway

BVM Ventilation

• Requires practice to master

• One hand to– maintain face seal– position head– maintain patency

• Other hand ventilates

BVM Ventilation: Technique

• Insert oropharyngeal/nasopharyngeal

• “Sniffing”position if C-spine OK

• Thumb + index to maintain face seal

• Middle finger under mandibular symphysis

• Ring/little finger under angle of mandible

• Maintain jaw thrust/mouth open

Predictors of a Difficult Airway : BVM

• Upper airway obstruction

• Lack of dentures

• Beard

• Midfacial smash

• Facial burns, dressings, scarring

• Poor lung mechanics– resistance or compliance

Difficult Airway : BVM• degree of difficulty from zero to infinite• Zero = no external effort or internal device

required• one person jaw thrust/ face seal• oropharyngeal or nasopharyngeal AW• two person jaw thrust / face seal– both internal airway devices

• Infinite = no patency despite maximal external effort and full use of OP/NP

Algorithm for Difficulty “Bagging”

• Remove Foreign Bodies - Magill forceps

• Triple maneuver if c-spine clear

– Head tilt, jaw lift, mouth opening

• Nasal or oropharyngeal airways

• Two-person, four-hand technique

BVM Ventilation: Mask Seal Tips and Pearls

• Easier to get seals with masks too large than too small

• Inflate mask collar correctly

• Apply lubricant to beards to “mat down” hair

• If edentulous insert gauze sponges into cheeks

Prediction of the Difficult Airway: Laryngoscopy

• History of past airway problems – check previous OR anesthesia records if time

permits– cricothyroidotomy scar

• Careful physical assessment– mouth opening

– tongue to pharyngeal size

– hyo-mental distance

– Neck flexion, Head extension

Technique of Laryngoscopy

• “Sniffing” position to align oral-pharyngeal-laryngeal axis

• Flex neck by placing pillow beneath occiput ( raise 10 cm )

• Extend head maximally

• With laryngoscope– open mouth fully– push tongue to left out of view– pull upward at 45 degrees

Adducted vocal cords

Predictors of Difficult Laryngoscopy

• Short thick neck

• Receding mandible

• Buck teeth

• Poor mandibular mobility/ limited jaw opening

• Limited head and neck movement – ( including trauma )

Difficult Airway : Laryngoscopy

• Tumor, abscess or hematoma

• Burns

• Angioneurotic edema

• Blunt or penetrating trauma

• Rheumatoid arthritis, ankylosing spondylitis

• Congenital syndromes

• Neck surgery or radiation

Predictors of Difficult Laryngoscopy

• 3 fingerbreadths mentum to hyoid

• 3 fb chin to thyroid notch

• 3 fb upper to lower incisors

• Head extension and neck flexion

• Mallimpadi classification

• Previous history of difficult intubation

Mallimpadi Classification (Tongue to Pharyngeal Size)

• I - soft palate, uvula, tonsillar pillars visible– 99 % have grade I laryngoscopic view

• II - soft palate, uvula visible

• III - soft palate, base of uvula

• IV - soft palate not visible– 100% grade III or grade IV views

The 4 D’s of Difficult Intubation

• Distortion – ( edema, blood, vomitus, tumor, infection)

• Dysmobility of joints – ( TMJ, alanto-occipital, C-spine)

• Disproportion– thyomental, Mallimpadi, etc

• Dentition– prominent upper teeth

Unsuccessful Intubation• Bag the patient

• Maximize neck flex/ head ex

• Move tongue out of line of site

• Maximize mouth opening

• ID landmarks and adjust blade• BURP maneuver (Backwards Upwards Rightwards Pressure on Thyroid Cart.)

• Increasing lifting force

• Consider Miller blade

• Bag the patient