Questions For The Emergency Physician: 1. Can I predict the
difficult airway? 2. How often can I expect to be faced with a
difficult airway? 3. What tools do I have to manage the difficult
airway? 4. What is the best strategy for managing the difficult
airway?
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1-Can I Predict The Difficult Airway? Airway management is a
skill that defines Emergency Medicine. We are expected to manage
the most challenging airways in the hospital with little time,
little information, and no margin for error, complication, or
failure
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Success will require three unique skill sets: 1. Ability to
immediately predict the difficult airway, 2. Sophisticated
proficiency with conventional laryngoscopy and a growing number of
airway management devices, 3. A well thought-out approach for
dealing with the difficult and failed airway.
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It is important to understand two definitions 1-The difficult
airway has three components that may or may not co-exist: 1.
Difficult bag-valve mask ventilation 2. Difficult laryngoscopy 3.
Difficult surgical airway ASA Difficult Airway Task Force.
Anesthesiology 2003; 93:1269-1277.
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2-A failed airway exists when one or both of the following
scenarios occur: 1. Inability to ventilate or intubate the
paralyzed patients 2. Three intubation attempts by the same
operator ASA Difficult Airway Task Force. Anesthesiology 2003;
93:1269-1277
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In 2003, the ASA Difficult Airway Task force completed an
evidence-based review of the available literature and concluded
that there was insufficient evidence to definitively recommend any
specific predictive tool, although data suggested that some of
these markers were associated with difficult airways
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2-How Often Can I Expect To Be Faced With A Difficult
Airway?
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3- What Tools Do I Have To Deal With The Difficult Airway? 1)
Blind insertion supra-glottic airway devices a) Double-lumen
laryngeal devices i) Combitube ii) King-LT b) Laryngeal mask
airways i) Standard LMA ii) Intubating LMA [Fastrack] c) Intubating
stylets i) Gum-elastic bougie ii) Lighted stylet [Trachlight]
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2 ) Direct vision supra-glottic airway devices a) Hand-held
fiberoptic intubating stylets i) Levitan Scope ii) Shikani Optical
Stylet iii) RIFL b) Hand-held fiberoptic laryngoscopes i) McGraf
Scope ii) Glidescope iii) Storz Videolaryngoscope iv) Pentax Airway
Scope c) Traditional flexible fiberoscopes d) Prism/mirror assisted
scopes [Airtraq]
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3 ) Infra-glottic airway devices a) Retrograde intubation b)
Transtracheal jet ventilation c) Surgical cricothyrotomy i) Open
ii) Percutaneous
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4-What Is The Best Strategy For Managing The Difficult
Airway?
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Case Example 1: Consider a morbidly obese patient who presents
to the ED after an overdose. He has stable vital signs, but is
obtunded and not protecting his airway. Airway dimensions and
anatomy are normal. Oxygen saturations are >95% on supplemental
oxygen. Following sedation and paralysis the glottis can not be
visualized despite three attempts with re-positioning. Oxygenation
can be maintained with BVM ventilation
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Case Example 2: Now consider the same overdose patient who you
have paralyzed and sedated. Aspiration is evident after the first
attempt at laryngoscopy and you are having difficulty oxygenating
the patient even with adequate positioning and an oral airway.
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Case Example 3: Consider a patient with Ludwigs Angina in the
setting of a severe dental infection. The patient has stable vital
signs and oxygen saturations in the high 90s. On physical exam this
is significant trismus and a large submandibular hematoma. Because
of progressive swelling you decide to intubate the patient prior to
transfer to a tertiary center
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Case Example 4: Consider a patient with a gunshot wound to the
mouth. The mandible is blown apart and blood is pouring into the
airway. Oxygen saturations are dropping and the patient is
impossible to bag.
