This is a power point presentation on Airway Management given by our deputy director in Emergency Medicine Training at the Wollongong Hospital, Paul Labana (consultant Emergency Physician) that presents a case illustrating difficulties in airway management and gives an overview of airway management in the emergency department. (Nb another video to do with airway management, and "airway exchange" can be found on this link http://youtu.be/6vaWNknIDQg) - thanks to Paul for sharing his educational material in the name of free open access meducation (#FOAMed)

1. Airway Management
Dr. Paul Labana
Emergency Medicine Consultant
12th February 2014

2. Overview
 Case presentation
 Assessment
 Clinical features
 Decision making algorithms
 Equipment used

3.  35 yr male is t/f to TWH with 5% PT burns to face, neck,
anterior chest after methylated spirits explodes from fire
 PMHx – Type I DM, hypercholesterolaemia, hypertension,
smoker, occasional EtOH
 Coversyl +, Amlodipine, Atorvastatin, Protophane, Actrapid
 Allergic to penicillin
 On examination: A, B, C currently stable pain under control,
covered in dressings with only nose showing, blisters/swelling
around lips/oropharynx
 Starts to complain of SOB – vitals OK on high flow oxygen

4. What would you do next?

5.  O/E facial swelling (but not in mouth), blisters on lips, nasal
hair singed
 Decision for definitive airway
 Pre-ox, cricoid pressure, propofol, suxamethonium
 Initially grade 2 view with McCoy blade + stylet
 ETT dislodged on removing stylet (paraffin all over
face/gloves making jaw thrust impossible)
 Bag & Mask ventilation
 Sux. wearing off, biting through guedel, desat 55% at lowest
 Further propofol, sux – Fastrach inserted #5 but big leak
 Replaced with classic – good ventilation
 Pt. became bradycardic – atropine 300 mcg
 Further attempts at ETT with swollen tongue, eventually
intubated as confirmed by ETCO2

6. Progress
 Continued to improve over next 5 days
 Successfully extubated with nil stridor and good ABG’s
 D/C to burns unit
 Later d/c and was well

7. General Principles of Airway Management

8. Airway Management
 Aims of management
 Maintain oxygenation, prevent hypercarbia
 Minimise airway trauma (i.e. minimal
instrumentation)
 3 main scenarios
 Anticipated difficult airway e.g. burns
 Unanticipated difficult airway
 Facial/neck trauma

9. Methods of assessment
 Anaesthetic history (if at all available)
 History
 Previous difficult intubation/ventilation
 Congenital syndromes
 Down’s syndrome, large tongue, Atlanto-axial
instability
 Nasal polyps, neck and TMJ problems, loose teeth
 Examination
 Facial hair
 Teeth: protruding or long upper incisors, prominent
overbite
 Mouth opening (need at least 3-4 cm between incisors)
 High arched, narrow palate
 Mandibular protrusion (upper lip bite)
 Neck mobility and masses
 Thyromental distance (>6cm normal)

10. Examination
 General Habitus
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 Ethnic differences: anterior larynx, small jaw, protruberant teeth
 Pregnant: Large breasts, mucosal hypervascularity, reduced oxygen reservoir with risk
of desaturation
 Congenital syndromes: Downs’ syndrome, Goldenhaar, Pierre-Robin, Achondroplasia
 Orofacial trauma - (patient in C-spine collar?)
Nose
 Nasal polyps, deviated septum, hypervascularity in pregnancy
Mouth
 Small or restricted mouth opening, restricting laryngoscope passage
Teeth
 Protruberant incisors, loose teeth (potential airway obstruction if knocked out)
Tongue
 Macroglossia (Down’s Syndrome, Acromegaly)
Jaw (incl. TMJ)
 Small or recessive jaw, previous TMJ surgery causing restriction may impede
laryngoscopic view
Neck
 Bullneck, previous surgery/tracheostomy
 Reduced ROM: Ankylosing Spondylitis, previous fusion, rheumatoid instability
Environment
 Lack of equipment, skilled assistant

11. Relative Tongue/Pharyngeal size

Modified Mallampati classification gives variable
prediction of airway difficulty (rarely possible in
emergency setting)
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I: Soft Palate, Fauces, Uvula, Ant + Post pillars
II: Soft palate, Fauces, Uvula
III: Soft palate, base of uvula
IV: Hard palate only
Performed with patient seated, head in neutral position,
mouth open to widest extent and tongue maximally
protruded without phonation
Correlation with Cormack-Lehane grading:
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Class I: Grade I view 99-100% of the time
Class IV: Grade III or IV view 100% of the time
Class II and III are poor predictors

12. The Mallampati classification is a simple scoring system that relates the amount of
mouth opening to the size of the tongue, and provides an estimate of space
available for oral intubation by direct laryngoscopy. According to the Mallampati
scale, class one is present when the soft palate, uvula, and pillars are visible, class
two when the soft palate and uvula are visible, class three when the soft palate and
only the base of the uvula are visible, and class four when only the hard palate is
visible.

13. The Cormack-Lehane system for grading
laryngoscopic view at intubation

14. Difficult ventilation
Pregnant
 Increased breast tissue with reduced chest
compliance
 Obese
 As above, plus increased pharyngeal tissue with
increased upper airway resistance
 OSA / Snorers
 Beard
 Difficult to achieve seal with mask
 Edentulous
 Difficult to achieve seal with mask


15. Neck mobility and correct positioning
1. Bad : neutral position
2. Better : C6/C7 flexion
3. Best : Flexion at C6/C7
Extension at C1/C2 (~ 35º)
“Sniffing the morning air…”

16. Complications of difficult airway access
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Hypoxaemia
Soft tissue injury of the airway
Increased gastric aspiration/regurgitation
risk
Haemodynamic stress of repeated
laryngoscopic stress attempts
Unnecessary tracheostomy
Tooth damage

17. Facial/Neck Trauma & Burns
 Ensure senior anaesthetic/surgical help present
 Early consideration of intubation/surgical airway essential
 Childhood infections causing partial obstruction generally approached
via gentle inhalational induction therefore call anaesthetics a.s.a.p.
 Can return to spontaneous breathing if laryngoscopic view poor, or
offer option of FOB (bearing in mind it may occlude already narrow
lumen)
 In cases of marked deformed anatomy, tracheostomy is generally the
definitive management
 Open vs percutaneous dilational: No major difference in outcome,
PDT associated with reduced risk of pneumomediastinum/bleeding
 May be performed under local anaesthetic (ketamine has also been
described)

18. LEMON
 L ook (facies, anatomy, obesity etc.)
 E valuate 3-3-2 (see below)
 M allampati
 O bstruction (mass, infection, SOL)
 N eck mobility (“sniffing morning air”)

19. Preparation for intubation
P repare patient & drugs & P ositioning
E nd-tidal CO2
M ask (& bag connected to O2 AND ON)
A djuncts (LMA/Guedel/Nasopharyngeal)
I ntroducer
L aryngoscope
S uction (turned on at head of bed)

21. Failed Intubation

22. Laryngoscopes
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Macintosh (standard used on airway trolleys)
McCoy
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Kessel
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Modified Macintosh blade with increased handle-blade angle (110˚): easier
insertion in large-breasted (pregnant) women
Miller
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Levered mobile tip allowing elevation of epiglottis
Potentially reduces C-L grade by one
Useful in cervical collar patients, anterior larynx
Straight blade with curved tip for elevating epiglottis
Thinner profile: easier insertion in small-mouth opening pts
Huffman

Macintosh blade with 30 or 80˚ refractive prism towards larynx: allows
indirect laryngoscopy

23. Intubation Aides

Gum elastic bougie (Eschmann tracheal tube introducer)
 60cm, 15F (adults)/10F (children), Coude tip. Introduced in the 1970’s
 Portex reusable bougies most common. Disposable available but
reported to have reduced success with intubation (?due to less
malleable texture)
 Used in conjunction with laryngoscope to facilitate ETT passage where
laryngeal inlet is incompletely visualised (or can be inserted blindly)
 Advantages are
 Longer compared with stylets

Malleable, angled tip - ideally at 60˚ to capture tracheal
“clicks”
Flexible yet firm enough to have ETT railroaded over it
Signs that bougie is endotracheal (therefore safe to railroad ETT)
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“Clicks” from tracheal rings
Hold-up/Resistance at ~40cm (within bronchial tree)
Coughing

24. Intubation Aides 2
 Airway exchange catheters
 Functions as bougie, but with central lumen allowing
ongoing oxygenation between intubation attempts
 Internal diameter varies between 3.7mm (Cook exchange
catheters) to 4.7mm (Aintree airway catheters)
 NICE paper demonstrating use in conjunction with
LMA and fibreoptic bronchoscope:

Low-skill fibreoptic intubation: use of the Aintree catheter with the classic LMA.
Anaesthesia 2005; 60: 915-920
Stylet

Malleable, single use stylets used to shape ETT, allowing for easier
passage into anterior larynxes
BURP/2 person intubation

25. Laryngeal Mask Airway
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Most are disposable
Once inserted, the mask is bounded by:
 Tip at level of inferior constrictor
 Sides abutting piriform fossae
 Top against base of tongue
Provides airway support rather than definitive airway
 Valuable tool in rescue “can’t intubate, can’t mask ventilate” situations
Serves as a conduit for endotracheal intubation
 Theoretically #4 can fit a 5.5 ETT, but clumsy fit at best
 Narrowest point is at LMA connector - ETT cuff may be torn here
 Length of LMA tube may lead to improper depth of ETT placement
 Very difficult to remove LMA once ETT is placed
 Gum-elastic bougie/Fibreoptic bronchoscope may be fed down lumen to
facilitate endotracheal intubation and confirm position
Bronchoscopic port connector allows simultaneous ventilation & FOB

26. Cook Kit (Seldinger technique)
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Seldinger technique safer than blind
approach
Aspirate air with the needle and syringe to
check placement, cut with scalpel
Remove syringe, insert wire into
needle, remove needle
Thread dilator with airway already loaded
onto wire
Remove wire

28. Needle cricothyroidotomy
 Oxygenation NOT ventilation
 Use 14 g cannula with syringe attached, once
aspirating air, insert sheath and remove needle
 Connect a 3 way valve to sheath and to oxygen
tubing
 15 L/min oxygen for 1 sec followed by 4 secs
expiration phase
 Approximately 45 mins to get definitive
airway

29. 
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Cricothyroid membrane between thyroid and
cricoid cartilage
Locate hyoid with thumb & index finger and
middle finger will fall on correct area (1-1.5 cm
below)

30. Standard Surgical Airway
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Equipment always available BUT need
most senior help available
Vertical incision in skin of neck
Transverse incision of cricothyroid
membrane
Artery forceps/finger to open airway
Insert cuffed ETT 6.0 into trachea

31. Surgical Airway

33. Questions ???