Difficult intubation

Last Updated on 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


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.

Failed Intubation Plan

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

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

If oxygenation continues to deteriorate and the above methods are unsuccessful

  • Needle cricothyroidotomy
  • Surgical cricothyroidotomy
  • Tracheostomy












Was this article helpful?

Related Articles

Leave A Comment?

This site uses Akismet to reduce spam. Learn how your comment data is processed.