Last Updated on February 13, 2019 by FRCEM Intermediate

Identifying Patients

Conscious patients

• Patient with airway compromise typically sit upright intuitively
• Look for the swollen tongue in angioedema cases
• inflammation and sooty sputum following thermal injury
• Neck hematoma following blunt or penetrating injury
• Listen for stridor or wheeze
• Gently feel for unstable facial fractures and the crepitus and surgical emphysema of laryngeal injury
• Increased work of breathing seen in severe asthma

Unconscious patients

• look for abnormal chest and abdominal wall movement
• lack of fogging of the oxygen mask
• Listen for the snoring noise of partial airway obstruction

Airway Management

Simple Manoeuvres

• Suction
• Chin-Lift Manoeuvre
• The Jaw Thrust

Simple Airway Adjuncts

• The Oropharyngeal Airway -The correct size oropharyngeal airway should reach from the patient’s incisors to the angle of the jaw
• The Nasopharyngeal Airway – Sized by measuring from the tip of the patient’s nose to the earlobe

Ventilation

Having secured a patent airway, ask yourself whether the patient needs:

• Ventilation
• Assisted ventilation
• An oxygen masks

How would you confirm poor ventilation?

• Recognition of a poor mask seal
• Limited chest wall movement
• Limited breath sounds on auscultation
• More resistance in the bag than you might anticipate
• Cyanosis
• Low pO2 and high pCO2 on blood gas analysis

Adequate ventilation can be confirmed by looking for

• chest wall rises and fall, and
• improvement in oxygen saturation

Ventilation – Persistent Difficulty in Ventilation

• Call for senior help, if you haven’t already
• Check you have achieved optimum patient positioning
• Try two nasopharyngeal airways and an oropharyngeal airway
• If there is still no improvement, try a laryngeal mask airway
• If there is still no improvement allow some head and neck repositioning in trauma patients, since lack of airway patency overrides cervical spine considerations

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

 

Failed intubation

Failed attempt at intubation

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.

Improving the laryngeal view

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.

Can’t intubate, can’t oxygenate’ (CICO) situation

Rescue technique of choice

• Supraglottic airway device (SAD)

If oxygenation continues to deteriorate and the above methods are unsuccessful

• Needle cricothyroidotomy
• Surgical cricothyroidotomy
• Tracheostomy

What makes EMERGENCY INTUBATION DIFFICULT?

• A dynamically deteriorating clinical situation, i.e., there is a real “need for speed”
• Non-cooperative patient
• Respiratory and ventilatory compromise
• Impaired oxygenation
• Full stomach (increased risk of regurgitation, vomiting, aspiration)
• Extremely short safe apnea times
• Secretions, blood, vomitus, and distorted anatomy

 

 

 

 

 

 

 

 

 

 

 

STRAYER AIRWAY ALGORITHM

• RSI vs. Awake – latter preferred if:
  • Less urgent intubation
  • More difficult airway features
  • Low risk of vomiting
• Prepare for failure of intubation and failure of ventilation
  • Discuss plan A, B, C, D with team
  • Equipment for plan A, B, C, D at bedside
• Airway attempt successful
  • post-intubation management
• Airway attempt unsuccessful, able to ventilate
  -> Plan B/C/D
  • change patient postion
  • change blade
  • change modality (e.g. direct vs video laryngoscopy)
  • change proceduralist
• Airway attempt unsuccessful, unable to ventilate
  • supraglottic airway- unsuccessful then
  • final attempt with face mask ventilation- unsuccessful then
  • surgical airway

Refer:

Difficult Airway Management