Difficult intubation

Last Updated on January 21, 2022 by frcemuser

Markers for difficult bag-mask ventilation

Poor mask seal	Solution
Blood and vomit creating a slippery surface	Clear the airway with suction; use a towel to dry the patient’s face
Edentulous patient	Replace the dentures or pack the cheeks with gauze if dentures missing
Unstable facial fractures	Use a two-person technique Consider early intubation
Beard	Apply gel to improve the seal
Facial asymmetry	Use a two-person technique??

Difficult ventilation	Solution
History of snoring	Attention to correct head/neck positioning +/-adjuncts +/- two-person technique
Abdominal distension including obesity, third trimester and ascites	Consider elevating the head end in non-traumatic patients
Stiff or immobilised neck	No options available. Do not force elderly patients necks
COPD/asthma	Aggressive medical therapy
??Big tongue	Consider oropharyngeal airway

Remember O HELP following a failed initial attempt at intubation:

Oxygenation
Head elevation
External laryngeal manipulation
Laryngoscope blade change
Pal – call for assistance
Ensure full muscle relaxation has occurred before attempting intubation.
Continuous SpO2 monitoring is essential.
Cease intubation attempts and reoxygenate the patient’s lungs using bag-mask ventilation before the SpO2 reaches the steep part of the oxyhaemoglobin dissociation curve: this point is 92%.
A maximum of three attempts at intubation is recommended.

During intubation, if the laryngeal inlet and vocal cords cannot be seen immediately, the following interventions may improve the grade of view:

Clear secretions, blood or debris rapidly with a wide-bore suction device
Ensure optimal positioning of the patient – ensure the head is fully extended at the atlanto-occipital joint and the neck is flexed
External back, upward and rightward pressure (BURP) maneuver on the larynx by an assistant (different to cricoid pressure)
Use an alternative laryngoscope – this may be a variant of a standard blade e.g. McCoy blade or a video laryngoscope that is not reliant on an unobstructed straight-line view from the mouth to the larynx to see the cords
Change practitioner
An intubating bougie will frequently be used to assist intubation with the reduced view.

Failed Intubation Plan

Airway attempt unsuccessful, unable to ventilate
- supraglottic airway- unsuccessful then
- final attempt with face mask ventilation- unsuccessful then
- surgical airway

If oxygenation continues to deteriorate and the above methods are unsuccessful