THE DIFFICULT AIRWAYTHE DIFFICULT AIRWAY

P. AndrewsP. Andrews

F08F08

Stages Of Respiratory Stages Of Respiratory CompromiseCompromise

Respiratory DistressRespiratory Distress

Respiratory FailureRespiratory Failure

Respiratory ArrestRespiratory Arrest

THE DIFFICULT AIRWAYTHE DIFFICULT AIRWAY

The Key is to maintain:The Key is to maintain: OxygenationOxygenation VentilationVentilation

The Difficult AirwayThe Difficult Airway

A difficult airway can be defined as A difficult airway can be defined as a clinical situation in which a a clinical situation in which a conventionally trained ALS conventionally trained ALS provider experiences difficulty provider experiences difficulty with:with:

• Bag mask ventilationBag mask ventilation

• Difficulty with tracheal intubationDifficulty with tracheal intubation

• Or both.Or both.

ComplexityComplexity

The difficult airway represents a The difficult airway represents a complex interaction between complex interaction between

patient factors, the patient factors, the prehospital/clinical setting, and the prehospital/clinical setting, and the

skills of the EMS provider.skills of the EMS provider.

Difficult Mask VentilationDifficult Mask Ventilation

Not possible for the EMS provider Not possible for the EMS provider to maintain the SpO2 >90% using to maintain the SpO2 >90% using 100% oxygen and positive 100% oxygen and positive pressure mask ventilation.pressure mask ventilation.

It is not possible for the EMS It is not possible for the EMS provider to prevent or reverse provider to prevent or reverse signs of inadequate ventilation signs of inadequate ventilation during PPV.during PPV.

THE DIFFICULT AIRWAYTHE DIFFICULT AIRWAY

Difficult to oxygenate and ventilate Difficult to oxygenate and ventilate (BVM)(BVM)

BBeardeard OObesebese NNo Teetho Teeth EElderlylderly SSnoresnores

The Difficult AirwayThe Difficult Airway

Difficult to intubateDifficult to intubate LLook at head and neckook at head and neck

EEvaluate ability to open mouth & valuate ability to open mouth &

access oropharynxaccess oropharynx

MMallampati or Cormack Scalesallampati or Cormack Scales

OObstructionbstruction

NNeck Mobilityeck Mobility

Look at head and neck:Look at head and neck:

Anatomical FeaturesAnatomical Features Recessed ChinRecessed Chin Buck teethBuck teeth Short neck or “no neck”Short neck or “no neck” Signs of previous surgerySigns of previous surgery

Difficult Endotracheal Difficult Endotracheal IntubationIntubation

Proper insertion of the tracheal tube Proper insertion of the tracheal tube with conventional laryngoscopy with conventional laryngoscopy requires more than requires more than three three attemptsattempts

Proper insertion of the tracheal tube Proper insertion of the tracheal tube with conventional laryngoscopy with conventional laryngoscopy requires requires more than 10 minutes.more than 10 minutes.

Intubation Difficulty May Intubation Difficulty May Be Due To:Be Due To:

Incorrect position of the patientIncorrect position of the patient

Inadequate or improper equipmentInadequate or improper equipment

Unusual or abnormal anatomyUnusual or abnormal anatomy

Pathologic causesPathologic causes

Evaluate Access to Oral Evaluate Access to Oral CavityCavity

Opening of mouth <20 mm Opening of mouth <20 mm predisposes to difficult airwaypredisposes to difficult airway

Rule of thumb: an opening of at Rule of thumb: an opening of at least two large finger breadths least two large finger breadths between upper and lower incisors between upper and lower incisors in the adult is desirable in the adult is desirable

Evaluate Access to Oral Evaluate Access to Oral CavityCavity

Mallampati ScaleMallampati Scale

Assessing the Oral CavityAssessing the Oral Cavity

Cormack ScaleCormack Scale

Difficult LaryngoscopyDifficult Laryngoscopy

It is not possible to visualize any It is not possible to visualize any portion of the vocal cords with portion of the vocal cords with conventional laryngoscopy.conventional laryngoscopy.

Factors Contributing to Factors Contributing to Difficult LaryngoscopyDifficult Laryngoscopy

The following factors may be The following factors may be contributors to a difficult airway:contributors to a difficult airway:– ObstructionObstruction– InfectionsInfections– TraumaTrauma– Rheumatoid ArthritisRheumatoid Arthritis– Congenital ProblemsCongenital Problems– PregnancyPregnancy

ObstructionObstruction Foreign body Foreign body

airway obstruction airway obstruction is a common cause is a common cause of failed airways.of failed airways.

Direct Direct laryngoscopy must laryngoscopy must be used with be used with caution as it may caution as it may result in further result in further advancement of advancement of the foreign body the foreign body into the airwayinto the airway

ObstructionObstruction

Obstruction of the Obstruction of the airway can also airway can also be anatomical or be anatomical or pathological, pathological, causing narrowing causing narrowing or complete or complete blockage of the blockage of the airway.airway.

InfectionsInfections

Infectious Infectious

processes such processes such

as abscesses, as abscesses,

croup, bronchitis, croup, bronchitis,

and pneumonia and pneumonia

can distort can distort

normal anatomy.normal anatomy.

TraumaTrauma

Maxillofacial or Maxillofacial or

head trauma may head trauma may

distort normal distort normal

airway anatomy, airway anatomy,

resulting in resulting in

clenched teeth clenched teeth

and edema.and edema.

ObesityObesity

Obesity results in Obesity results in airway and airway and respiratory respiratory problems problems secondary to secondary to altered respiratory altered respiratory pathophysiology pathophysiology and distorted upper and distorted upper airway anatomy.airway anatomy.

Rheumatoid ArthritisRheumatoid Arthritis

Patients with Patients with rheumatoid rheumatoid arthritis and other arthritis and other connective tissue connective tissue diseases often diseases often limit ROM of the limit ROM of the cervical spine.cervical spine.

TumorsTumors

Tumors of the neck and airway can Tumors of the neck and airway can

distort anatomy, limiting the space distort anatomy, limiting the space

for instrumentation.for instrumentation.

Congenital DisordersCongenital Disorders

Congenital Congenital disorders may be disorders may be associated with associated with airway difficulty airway difficulty due to mandibular due to mandibular hypoplasia, hypoplasia, cervical cervical abnormalities, abnormalities, large tongue or a large tongue or a cleft palate.cleft palate.

PregnancyPregnancy

Pregnancy is Pregnancy is associated with associated with a difficult upper a difficult upper airway, an airway, an increased risk of increased risk of aspiration and aspiration and limited tolerance limited tolerance to apnea.to apnea.

The Most Difficult AirwayThe Most Difficult Airway

When the EMT or When the EMT or Paramedic Paramedic insistsinsists that that

he can “get it”he can “get it”

Almost a guarantee the Almost a guarantee the patient will diepatient will die

What to do?What to do? Be preparedBe prepared

– Equipment in good working conditionEquipment in good working condition

Alternative equipmentAlternative equipment

Different personal positioningDifferent personal positioning

Different positioning of the patientDifferent positioning of the patient

– On the floorOn the floor

– To open airwayTo open airway

The Rule!The Rule!

Experienced providers – two Experienced providers – two attempts at intubationattempts at intubation

New providers – one attemptNew providers – one attempt Use a King airway or Combi-tubeUse a King airway or Combi-tube THE PRIORITY IS TO CONTROL THE THE PRIORITY IS TO CONTROL THE

AIRWAYAIRWAY

SummarySummary

The difficult airway is a significant The difficult airway is a significant problem to the patient and EMS problem to the patient and EMS provider in terms of mortality, provider in terms of mortality, morbidity and cost.morbidity and cost.

SummarySummary

It is imperative to be aware of the It is imperative to be aware of the factors that contribute to a factors that contribute to a difficult airway so that:difficult airway so that:

EMS providers may improve their EMS providers may improve their ability to be preparedability to be prepared

The morbidity and mortality of difficult The morbidity and mortality of difficult airway patients can be minimizedairway patients can be minimized

Patient outcome can be improved uponPatient outcome can be improved upon

Questions?Questions?