DIFFICULT AIRWAY MANAGEMENT

03
LEARNING OBJECTIVES
y Getting familiar with an evidence-based, structured approach to managing a difficult airway

SIGNS AND SYMPTOMS

y Failure to ventilate or intubate a patient
y Airway edema and trauma from repeated intubation attempts
y Desaturation and subsequent hypoxia
y Absent or minimal end-tidal CO2
y Insufficient tidal volumes
y Cyanosis
y Cardiac arrest

RISK FACTORS
Difficult intubation Difficult laryngeal mask Difficult front-neck access
airway

History of difficult intubation Anatomical variations Obesity

Distorted airway anatomy Obesity Anatomical abnormalities
Airway bleeding or hematoma Beard Presence of goiter or thyroid enlargement
Tumor Poor dentition Limited neck extension
Foreign body History of radiation to the neck Prior surgery or radiation
Snoring Airway abnormalities Infection or inflammation
Obstructive sleep apnea
Diabetes mellitus
Increasing Mallampati and modified
Mallampati scores
Thyromental distance < 6 cm
Sternomental distance < 12.5 cm
Interincisor distance < 4 cm
Large neck circumference
Reduced neck mobility
Acquired or congenital disease:
- Ankylosing spondylitis
- Degenerative osteoarthritis
- Treacher-collins
- Klippel-Feil syndrome
- Down syndrome

22 Difficult airway management

DIFFICULT INTUBATION GUIDELINES
Plan A SUCCEED
Facemask ventilation and (Video)laryngoscopy Tracheal intuation
tracheal intubation

DECLARE FAILED INTUBATION STOP AND THINK

Options (consider risks and benifits)
Plan B SUCCEED 1. Wake the patient up
Maintain oxygenation: Supraglottic Airway
Device (SAD) 2.Intubate trachea via the SAD
SAD insertion
3.Proceed without intubating the trachea
FAILED SAD VENTILATION
4.Tracheostomy or cricothyrodotomy

Plan C Final attempt at face SUCCEED

Wake the patient up
Facemask ventilation mask ventilation

CICO

Plan D
Emergency front of neck Cricothyroidotomy
access

SAD, Supraglottic airway device; CICO, can’t intubate, can’t oxygenate

MANAGEMENT OF UNANTICIPATED DIFFICULT TRACHEAL

INTUBATION IN ADULTS

Plan A: Facemask ventilation and tracheal intubation

Optimise head and neck position
Preoxygenate IF IN DIFFICULTY CALL FOR HELP
Adequate neuromuscular blockade
SUCCEED
Direct/Video Laryngoscopy (maximum 3+1 attempts) Confirm tracheal intubation with capnography
External laryngeal manipulation
Bougie
Remove cricoid pressure
Mantain oxygenation and anaesthesia
DECLARE FAILED INTUBATION STOP AND THINK
+ CALL FOR HELP Options (consider risks and benefits):
Plan B: Maintaining oxygenation: SAD insertion 1. Wake the patient up
2nd generation SAD recommended SUCCEED 2. Intubate trachea via the SAD
Change device or size (maximum 3 attempts) 3. Proceed wihout intubating the trachea
Oxygenate and ventilate 4. Tracheostomy or cricothyroidotomy

DECLARE FAILED INTUBATION

Plan C: Facemask ventilation
If facemask ventilation impossible, paralyse SUCCEED
Wake the patient up
Final attempt at facemask ventilation
Use 2 person technique and adjuncts
DECLARE CICO

Plan D: Emergency front of neck access

Post- operative care and follow up
• Formulate immediate airway management plan
Scalpel cricothyroidotomy • Monitor for complications
• Complete airway alert form
• Explain to the patient in person and in writting
• Send written report to GP and local database

SAD, Supraglottic airway device; CICO, can’t intubate, can’t oxygenate

Difficult airway management 23

FAILED INTUBATION, FAILED OXYGENATION IN THE PARALYZED,
ANESTHETIZED PATIENT

CALL FOR HELP

Continue 100% O2
Declare CICO

Plan D: Emergency front of neck access

Continue to give oxygen via upper airway

Ensure neuromuscular blockade
Position patient to extend neck

Scalpel cricothyroidotomy
Equipment: 1. Scalpel (number 10 blade)
2. Bougie
3. Tube (cuffed 6.0 mm ID)
Laryngeal handshake to identify cricothyroid membrane
Palpable cricothyroid membrane
Transverse stab incision through cricothyroid membrane
Turn blade through 90⁰ (sharp edge caudally)
Slide coude tip of bougie along blade into trachea
Railroad lubricated 6.0 mm cuffed tracheal tube into trachea
Ventilate, inflate cuff and confirm position with capnography
Secure tube
Impalpable cricothyroid membrane
Make an 8-10 cm vertical skin incision, caudad to cephalad
Use blunt dissection with fingers of both hands to separate tissues
Identify and stabilize the larynx
Proceed with technique for palpable cricothyroid membrane as above

Post-operative care and follow up

• Postpone surgery unless immediately life treatening
• Urgent surgical review of cricothyroidotomy site
• Document and follow up as in main flow chart

24 Difficult airway management

MANAGEMENT

Difficult airway management

Awake airway Induction of

Pre-airway management
management anesthesia

YES

Suspected difficult laryngoscopy or Elective invasive

Awake technique Preoxygenation

Deliver oxygen / optimize oxygenation

intubation with direct or video airway
laryngoscopy?
YES YES

Call for help

Fail to establish Airway plan Continue as
Suspected difficult ventilation with tracheal successful

Deliver oxygen / optimize oxygenation

planned
facemask or supraglottic device? intubation
NO NO
NO
NO Is ventilation Emergency pathway
Significantly increased risk of Awake non-emergency pathway adequate? • Establish
aspiration? • Alternative awake technique
ventilation
• Awake elective invasive airway
NO YES • Face mask
• Alternative anesthetic techniques
• Tracheal tube
• If unstable or can’t be postponed,
Increased risk of rapid • Supraglottic
induction of anesthesia with Non-emergency
desaturation? airway
preparations for emergency invasive pathway
NO airway • Establish a secure
airway
• Use an alternative Ventilation remains
device inadequate
• Awake patient
Alternative devices: supraglottic airway, direct laryngoscope, video • Invasive airway
• Consider call for Emergency invasive
laryngoscope, flexible intubation scope help airway
Rigid bronchoscopy,
ECMO

HIGH-FLOW NASAL CANNULA OXYGEN

(HFNO) THERAPY
y High-flow nasal oxygen improves preoxygenation before intubation and maximizes
HFNO Contraindications
apnoea time before desaturation
y Maintains adequate oxygenation even in apnea and allows time for intubation or • Consciousness disorder if aspiration concern
alternative airway management • Agitated or uncooperative patient
y The major advantage of high-flow nasal oxygen is its ability to be administered • Facial injury (risk of airway soiling)
continuously during airway procedures, unlike oxygen delivered via a face mask, • High secretion load
which must be discontinued after the induction of general anesthesia • Patients at high risk of aspiration
y This method of preoxygenation may be especially advantageous for patients who • Base of skull fractures (risk of pneumocephalus)
have diminished functional residual capacity or an elevated oxygen demand due to • Complete or impending airway obstruction
conditions such as pregnancy, obesity, or sepsis

VORTEX APPROACH
y The Vortex Approach is a high-acuity tool designed to streamline complex decision-making and actions in emergency airway management situations
This approach rests on the foundation that there are three primary non-surgical ‘lifelines’ for establishing and verifying alveolar oxygen delivery:
à Face mask
à Supraglottic airway
à Endotracheal tube
y Failure to restore alveolar oxygen delivery after a ‘best effort’ with any of the lifelines necessitates a transition to the next available lifeline, as visualized
in the tool’s circular layout, which allows for any lifeline to be accessed first and followed by others in any sequence deemed suitable for the situation
y Should a ‘best effort’ with each of these lifelines fail, it indicates a ‘can’t intubate, can’t oxygenate’ (CICO) scenario, necessitating the initiation of
emergency front-of-neck access
y The tool includes a list of five optimization categories applicable to each lifeline, these categories are designed to enhance the chances of success
during the ‘best effort’ phase, guiding the options available to maximize effective airway management

Difficult airway management 25

 THE VORTEX FOR EACH LIFETIME COSIDER:
MANIPULATION
• HEAD & NECK
• LARYNX
• DEVICE

ADJUNCTS

SIZE / TYPE

SUCTION / 02 FLOW

MUSCLE TONE

Maximum three attempts at each lifeline (unless gamechanger) at least one attempt should be by most experienced
clinician priming status escalates with unsuccesful best effort at any lifetime

Figure adapted from vortexapproach.org.

KEEP IN MIND
y Always screen for a difficult airway
y When a difficult airway is suspected, consider an awake intubation
y Plan, anticipate, and communicate when a difficult airway is suspected
y Call for help early
y Know your team, your environment, and your tools and devices
y Allocate tasks to the team members
y Never neglect the basics: Positioning and pre-oxygenation
y Ensure adequate depth of anesthesia and muscle relaxation
y Keep track of time and oxygen saturation, oxygenation should be prioritized at all times
y Video laryngoscopy is an essential skill and should be promptly available
y A supraglottic airway and bag-mask ventilation are essential backup strategies, switch strategies when they prove unsuccessful
y When non-invasive strategies fail and a CICO (can’t intubate, can’t oxygenate) occurs, a scalpel cricothyroidotomy is the recommended rescue technique
y After a successful difficult intubation, reassess ABCD and make a plan for extubation
y Inform the patient about any airway difficulties encountered and ensure proper documentation for future anesthetic plans

SUGGESTED READING
y Ang KS, Green A, Ramaswamy KK, Frerk C. Preoxygenation using the Optiflow™ system. Br J Anaesth. 2017;118(3):463-464.
y Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology.
2022;136(1):31-81.
y Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth.
2015;115(6):827848.
y Lee MH, Kim HJ. Application of high-flow nasal oxygenation as a rescue therapy in difficult videolaryngoscopic intubation. SAGE Open Med Case Rep. 2021;9:2050313X211010015.
y Shallik N, Karmakar A. Is it time for high flow nasal oxygen to be included in the difficult airway algorithm?. Br J Anaesth. 2018;121(2):511-512.
y https://vortexapproach.org/

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