MANAGEMENT OF DIFFICULT AIRWAY

1. Management
of the
Difficult Airway
Dr Bivash Halder
PGT,Dept. Of Anaesthesiology
Medical College & Hospital,Kolkata

2. “There is one skill above all else that
an anaesthetist is expected to exhibit
and that is to maintain the airway
impeccably”.
- M. Rosen and I. P. Latto 1984

3. Prevalence of Difficult Airway scenarios
•
Even with proper evaluation only 15 to 50 % of difficult
airway are picked up
•
Difficult face mask ventilation (DMV) in general is about 5 %
•
Difficult intubation in general surgery patients are around
1:2000, but in obstetrics is 1:300
Reference : Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology
2000, 92:1229-1236.

4. Prevalence of Difficult Airway scenarios…
contd
•
Face mask ventilation fails in about 1 in 1,500 cases.
•
Tracheal intubation fails in around 1 in 1–2,000 routine cases.
•
Laryngeal mask placement fails in around 1 in 50 cases.
•
‘Can’t Intubate Can’t Ventilate’ (CICV) is about 1 in 5,000 to
10,000 cases.
Reference : NAP4 Report and findings of the 4th National Audit Project of The Royal College of Anaesthetists

5. Definitive terms in difficult airway management:-
•
Difficult Airway is defined as “a clinical
situation in which a conventionally trained
anesthesiologists experiences difficulty with
tracheal intubation, mask ventilation, or
both”.
•
Difficult facemask or supraglottic airway
(SGA) ventilation(e.g., laryngeal mask
airway [LMA], intubatingLMA [ILMA],
laryngeal tube):

6. ..CONTD
•
Difficult laryngoscopy: It is not possible to visualize any portion of the vocal
cords after multiple attempts at conventional laryngoscopy.
•
Difficult tracheal intubation: Tracheal intubation requires multiple attempts,
in the presence or absence of tracheal pathology (requires > three attempts or
> ten minutes)
•
Failed intubation: Placement of the endotracheal tube fails after multiple
attempts.
-Anesthesiology 2013; 118:251–70

7. The Canadian Airway Focus Group defined
difficult intubation as-
An experienced laryngoscopist, using direct laryngoscopy,
requirs:
1. More than two attempts with same blade; or
2. A change in the blade or an adjunct to direct
laryngoscope(i.e. bougie); or
3. Use of an alternative device or technique following failed
intubation with direct laryngoscopy.

8. Suggested Contents of the Portable Storage
Unit for Difficult Airway Management
1)Rigid laryngoscope blades of alternate design
and size from those routinely used; this may
include a rigid fiberoptic laryngoscope.
2)Videolaryngoscope.
3)Tracheal tubes of assorted sizes.
4)Tracheal tube guides.

9. ..contd
5)Supraglottic airways (e.g., LMA or ILMA of assorted
sizes for noninvasive airway ventilation/intubation).
6)Flexible fiberoptic intubation equipment.
7)Equipment suitable for emergency invasive airway
access.
8)An exhaled carbon dioxide detector.

10. ..contd

11. Tracheal tubes and pharyngeal airways:

12. Laryngoscope commonly used:

13. Bullard Laryngoscope:

14. Wu scope:

15. Glide scope:

16. Truview scope:

17. Airtraq:

18. McGrath scope:

19. Tracheal tube guide:

20. 20
Supraglotic airway:
LMA LMA Proseal

21. Fastrach C Trach

22. Combitube I gel

23. Retrograde intubation set:

24. Percutaneous cricothyrotomy set:

25. Fibreoptic bronchoscope:

26. Percutaneous jet ventilation set:

27. Some emergency procedure

28. Fastrach(Intubating LMA)

29. Percutaneous cricothyrotomy:

30. 30
Percutaneous cricothyrotomy…condt

31. Combitube

32. Percutaneous jet ventilation

33. Algorithms For Management
Of Difficult Airway

35. If anticipated difficult airway; the following steps are
recommended:
* Inform the patient (or responsible person) of
the special
risks and procedures pertaining to
management of the
difficult airway.
* Ascertain that there is at least one additional
individual
who is immediately available to serve as an
assistant in

36. Six basic problems:
( 1) Difficulty with patient cooperation or consent,
(2) Difficult mask ventilation,
(3) Difficult SGA placement,
(4) Difficult laryngoscopy,
(5) Difficult intubation, and
(6) Difficult surgical airway access.

37. Basic management choices:
(1 ) Awake intubation versus intubation after
induction of general anesthesia,
(2) Noninvasive techniques versus invasive
techniques (i.e., surgical or percutaneous
airway) for the initial approach to
intubation,
(3) Video-assisted laryngoscopy as an initial
approach to intubation, and

40. Attempts UNSUCCESSFUL

47. Extubation strategy:
•
The relative merits of awake extubation versus
extubation before the return of consciousness.
•
General clinical factors that may produce an
adverse impact on ventilation after the patient
has been extubated.
•
Alternate airway management plan.
•
Short-term use of a device that can serve as a

48. Follow up care:
•
Document the presence and nature of the
airway difficulty in the medical record,
•
Inform the patient or responsible person of the
airway difficulty that was encountered,
•
Evaluate and follow-up with the patient for
potential complications of difficult airway
management.

49. Case Based Airway
Management

50. A patient with chronic burn contracture

51. A patient with neck swelling

52. An obese patient

53. A patient with facial trauma

54. A patient with cleft palet

55. A patient with mass in the floor of the mouth

56. A patient with hydrocephalas

57. Difficulty in airway during pregnancy

58. New points regarding assessment of airway:
•
Ultrasound imaging of airway.
-By Dr. Pankaj Kundra in National Airway
Conference.North Bengal.November2013
•
General Anesthesia Preceded by
Awake-Trial of LMA in a Child
with Freeman-Sheldon Syndrome.
-Ray, J Anesth Clin Res 2013, 4:1

59. TAKE HOME MESSAGE
•
The 1st
priority is always bag mask ventilation.
Don’t rush to intubate.
•
Call for early assistance.
•
If you can’t ventilate:intubate; If you can’t
intubate:ventilate.
•
If CVCI:open the neck.

60. References:
•
Practice Guidelines for Management of the Difficult Airway.
Anesthesiology 2013; 118:251-70
•
Practice Guidelines for Management of the Difficult Airway.
Anesthesiology 2003; 98:1269–77
•
Khan RM, Airway Management-4th
Edition 2011.Paras Medical
Publisers:New Delhi
•
NAP4 Report and findings of the 4th National Audit Project of The Royal
College of Anaesthetists
•
Butterworth JF, Morgan and Mekhail’s Clinical Anesthesiology-5th
Edition
2013. McGraw-Hill Education, LLCMcGraw-Hill Education, LLC

61. Thank you