Advanced Airway ManagementPart 4

The Difficult AirwayThe Difficult Airway

By Steve Cole, CCEMT-PBy Steve Cole, CCEMT-P

…So I said “Hey Ya’ll…watch this”…………

Goals

Predict a difficult airway based on clinical criteriaPredict a difficult airway based on clinical criteria Plan for appropriate action in the difficult airwayPlan for appropriate action in the difficult airway Initiate appropriate plans of attack with confidence Initiate appropriate plans of attack with confidence

in the “Can’t Ventilate/Can't Intubate” (CVCI) in the “Can’t Ventilate/Can't Intubate” (CVCI) situationsituation

Become informed about some new (and not so Become informed about some new (and not so new) airway options out there.new) airway options out there.

What this class assumes :

You already understand the basic anatomy of the You already understand the basic anatomy of the AirwayAirway

You already have a basic understanding of both BLS You already have a basic understanding of both BLS airway maneuvers and Endotracheal Intubation by airway maneuvers and Endotracheal Intubation by Oral and Nasal meansOral and Nasal means

That the concept and procedure of RSI is well That the concept and procedure of RSI is well understoodunderstood

You are familiar with needle and traditional surgical You are familiar with needle and traditional surgical airway procedures. airway procedures.

You are an experienced operator in the field of EMS.You are an experienced operator in the field of EMS.

As Such:

I have skipped over some of the basics to fit I have skipped over some of the basics to fit new stuff in the time allottednew stuff in the time allotted

I have tried to entice your interest with I have tried to entice your interest with some of the “Hot Topics” in airway some of the “Hot Topics” in airway management.management.

Because:Because:

“A mind once stretched by new Ideas never regains it original dimensions…”

Why do we Intubate?

Inability to protect and maintain patent Inability to protect and maintain patent airway.airway.

Failure of oxygenation or ventilation.Failure of oxygenation or ventilation. Anticipated need based on clinical courseAnticipated need based on clinical course

Ideal conditions for intubation

Ideal Lighting, positioning, etc.Ideal Lighting, positioning, etc. Plenty of assistancePlenty of assistance Time to prepare, plan, discussTime to prepare, plan, discuss Option to AbortOption to Abort Empty StomachEmpty Stomach Back up available.Back up available.

Ideal Pt. for intubation

Intact, clear airwayIntact, clear airway Wide open mouthWide open mouth Pre-OxygenatedPre-Oxygenated Intact respiratory driveIntact respiratory drive Normal dentition/good oral hygieneNormal dentition/good oral hygiene Clearly identifiable and intact Neck and FaceClearly identifiable and intact Neck and Face Big open NostrilsBig open Nostrils Good Neck MobilityGood Neck Mobility Greater than 90 KG, Less than 110 kg.Greater than 90 KG, Less than 110 kg.

If only they looked this good…

Ped and Adult Normal Trachea

How many of our Pt’s are like That?

In Reality Our patients are:

ImmobilizedImmobilized TraumatizedTraumatized CompromisedCompromised PrioritizedPrioritized Beer-n-Pizza-izedBeer-n-Pizza-ized

They Tend to look like This:

And This:

And This (after failed ETT attempt)

Most of our Patients are already “difficult airways” by “OR” Standards. Why should EMS personnel try to further identify a difficult airway?

The American Society of Anesthesiology (AMA)has noted: “… “… there is strong agreement among consultants there is strong agreement among consultants

that preparatory efforts enhance success and that preparatory efforts enhance success and minimize risk.”minimize risk.”

And “…The literature provides strong evidence And “…The literature provides strong evidence that specific strategies facilitate the management that specific strategies facilitate the management of the difficult airway “of the difficult airway “

Thus Identifying a potentially difficult airway is Thus Identifying a potentially difficult airway is essential to preparation and developing a strategy.essential to preparation and developing a strategy.

What does this mean to us?

Well, many Anesthesiologist have the option to Well, many Anesthesiologist have the option to “Abort” induction, or to work through a problem “Abort” induction, or to work through a problem with as much assistance as needed.with as much assistance as needed.

In the REAL WORLD of EMS that is seldom the In the REAL WORLD of EMS that is seldom the case for Paramedics. case for Paramedics.

However many of the BASIC principles are valid However many of the BASIC principles are valid in the clinical evaluation of Patients, and thus in the clinical evaluation of Patients, and thus valuable in our education as medics. valuable in our education as medics.

Knowing these principles will improve our Knowing these principles will improve our decision making process and Patient Care;.decision making process and Patient Care;.

How can we further identify a difficult airway? PMHxPMHx Basic Physical ExamBasic Physical Exam Thyromental DistanceThyromental Distance Dr. Binnions “Lemon” LawDr. Binnions “Lemon” Law Mallampati ClassificationMallampati Classification

Past Medical History Rheumatoid ArthritisRheumatoid Arthritis Ankylosing Spondylitis: Painful Stiffening of the Ankylosing Spondylitis: Painful Stiffening of the

JointJoint Cervical Fixation DevicesCervical Fixation Devices Klippel-Fiel Syndrome: Klippel-Fiel Syndrome: Short wide neck, reduction in Short wide neck, reduction in

number of cervical vertebrae, and possible fusion of vertebrae.number of cervical vertebrae, and possible fusion of vertebrae. Thyroid or major neck surgeriesThyroid or major neck surgeries Pierre Robin Syndrome: Pierre Robin Syndrome: Small Jaw, cleft Pallet, No Gag Small Jaw, cleft Pallet, No Gag

reflex, downward displacement of tonguereflex, downward displacement of tongue Acromegaly: Thickening of Jaw, Soft tissue structures Acromegaly: Thickening of Jaw, Soft tissue structures

of the face, associated with middle ageof the face, associated with middle age

Past Medical History (Continued)

Reduced Jaw MobilityReduced Jaw Mobility EpiglottitisEpiglottitis Tumors, Known Abnormal StructuresTumors, Known Abnormal Structures Previous Problems in surgeryPrevious Problems in surgery

Basic Physical Exam

Anything that would limit movement of the Anything that would limit movement of the neckneck

Scars that indicate neck surgeriesScars that indicate neck surgeries KyphosisKyphosis BurnsBurns Trauma, especialy instability of the facial Trauma, especialy instability of the facial

and neck structures.and neck structures.

ThyroMental Distance Measure from upper edge of thyroid cartilage to chin Measure from upper edge of thyroid cartilage to chin

with the head fully extended. with the head fully extended. A short thyromental distance equates with an anterior A short thyromental distance equates with an anterior

larynx that is at a more acute angle and also results in larynx that is at a more acute angle and also results in less space for the tongue to be compressed into by the less space for the tongue to be compressed into by the laryngoscope blade. laryngoscope blade.

Greater than 7 cm is usually a sign of an easy intubationGreater than 7 cm is usually a sign of an easy intubation Less than 6 cm is an indicator of a difficult airwayLess than 6 cm is an indicator of a difficult airway Relatively unreliable test unless combined with other Relatively unreliable test unless combined with other

tests.tests.

Dr. Binnions Lemon Law: An easy way to remember multiple tests…

LLook externally.ook externally. EEvaluate the 3-3-2 rule.valuate the 3-3-2 rule. MMallampati.allampati. OObstruction?bstruction? NNeck mobility.eck mobility.

L: Look Externally

Obesity or very small.Obesity or very small. Short Muscular neckShort Muscular neck Large breastsLarge breasts Prominent Upper Incisors (Buck Teeth)Prominent Upper Incisors (Buck Teeth) Receding Jaw (Dentures)Receding Jaw (Dentures) BurnsBurns Facial TraumaFacial Trauma S/S of AnaphylaxisS/S of Anaphylaxis StridorStridor FBAOFBAO

E: Evaluate the 3-3-2 rule

Greater than three fingers from Jaw to NeckGreater than three fingers from Jaw to Neck Jaw is Greater than 3 fingers wideJaw is Greater than 3 fingers wide You can open the mouth greater than two You can open the mouth greater than two

fingers fingers

M: Mellampati classification

A Method used by Anesthesiologist, A Method used by Anesthesiologist, reliable to predict difficult direct reliable to predict difficult direct Laryngoscopy (Cormack & Lehane Laryngoscopy (Cormack & Lehane grading)grading)

A Class I view is a Grade I Intubation 99% A Class I view is a Grade I Intubation 99% of the timeof the time

A Class IV view is a Grade III or IV A Class IV view is a Grade III or IV intubation 99% of the timeintubation 99% of the time

Mellampati Classification

Cormack & Lehane Grading

O: Obstruction?

BloodBlood VomitusVomitus Teeth (“chicklets”)Teeth (“chicklets”) EpiglotisEpiglotis DenturesDentures TumorsTumors Impaled ObjectsImpaled Objects

N: Neck Mobility

Spinal PrecautionsSpinal Precautions Impaled ObjectsImpaled Objects Lack of accessLack of access See PMHx for others.See PMHx for others.

What do we do when we have a difficult airway?

The ASA calls a Failed/Difficult Laryngeoscopy a: Any airway that takes more than 3 attemptsAny airway that takes more than 3 attempts Any airway that takes more than 10 minutes Any airway that takes more than 10 minutes

to secure an airwayto secure an airway No wonder they say they have a 90 % No wonder they say they have a 90 %

success ratesuccess rate If we had those standards our Pt’s would be If we had those standards our Pt’s would be

dead.dead.

So what do we do?

A little pre-planning goes a long way…

Before intubation

Is there another means of getting our desired Is there another means of getting our desired results BEFORE we attempt Direct Oral ETT? results BEFORE we attempt Direct Oral ETT? (Especially if we RSI)(Especially if we RSI)

CPAP ?CPAP ? PPV with BVM or Demand Valve?PPV with BVM or Demand Valve? Nasal ETT?Nasal ETT? Do we have all the help we need, all Airway Do we have all the help we need, all Airway

equipment with us? (Suction?)equipment with us? (Suction?)

What are we going to do if we don’t get the Tube? Plans “A”, “B” and “C”Plans “A”, “B” and “C” Know this answer before you tube.Know this answer before you tube.

Plan “A”: (ALTERNATE)

Different Length of bladeDifferent Length of blade Different Type of BladeDifferent Type of Blade Different PositionDifferent Position

Plan “B”: (BVM and BLIND INTUBATION Techniques ) Cam you Ventilate with a BVM? (Consider Cam you Ventilate with a BVM? (Consider

two NPA’s and a OPA, gentile Ventilation)two NPA’s and a OPA, gentile Ventilation) Combi-Tube? PTLA (No Longer produced)Combi-Tube? PTLA (No Longer produced) EOA, EGTA?EOA, EGTA? LMA an Option? LMA an Option? Retrograde Intubation?Retrograde Intubation?

What do we do when faced with a Can’t Intubate Can’t Ventilate situation?

Plan “C”: (CRIC) Needle, Surgical, Plan “C”: (CRIC) Needle, Surgical,

Do YOU feel ready to enact Plans A, B, C at a drop of a hat? Feel familiar with all those tools and Feel familiar with all those tools and

techniques?techniques? As Paramedics we should, After all we will As Paramedics we should, After all we will

provide the only definitive care in these provide the only definitive care in these patients.patients.

ACEMS ED will be trying to increase ACEMS ED will be trying to increase training in these areas.training in these areas.

OK , Here You Go!

Mandibular AplasiaMandibular Aplasia