The difficult airway

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Background

  • ASA Difficult Airway Algorithm does not necessary apply to the ED since the patient can always be awakened and case cancelled

Pre-Intubation

See:

Difficult Intubation

Advanced Airway Adjuncts Chart

Airway Adjunct Examples Pros Cons
Endotracheal tube introducer Gum elastic bougie
  • Higher first pass success when used with direct laryngscope vs. styletted ET tube regardless of whether difficult airway was expected or not[1]
  • Can pass blind and confirm tracheal placement with tracheal clicks and hold-up sign
  • Success rates likely depend on operator familiarity with device
Lighted optical stylets
  • High success rate - especially good for trauma, c-spine precautions
  • Use for both reg and nasotrach
  • Lower complication rate
  • Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience
Supraglottic airway LMA
  • Easy to place
  • Can be placed quickly
  • Does not protect against aspiration
Esophogeal obturator Combitube
  • Good for nurses and paramedics with limited intubation skill
  • Indicated if difficult airway predicted: cannot see glottis with laryngoscope
  • Reduced risk for aspiration compared to face mask or LMA *Can maintain spinal immobilization
  • Large size predisposes to esophogeal dilatation and laceration as a complication
Percutaneous transtracheal ventilation
  • Prefered over cricothyrotomy in children up to age 10-12
  • Oxygenates well
  • Can use for 30-45 min
  • Can retain CO2
  • May cause pneumothorax or barotrauma

Intubation Options

Intubation Type Pros Cons
Traditional
Awake intubation
Nasal intubation
  • Lower success rate
  • Higher complication rate (e.g. bleeding, emesis, and airway trauma)
  • Do not attempt in patients with posterior pharyngeal swelling such as in angioedema
Retrograde intubation
  • Need time to set up
  • Risk hematoma, pneumothorax
Fiberoptic bronchoscopic intubation
  • Takes time to set up
  • Limited by secretions, bleeding, poor suction,
Digital intubation

Surgical Airways

A surgical airway should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate

See Also

Airway Pages

Video

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References

  1. Driver, B. E., Prekker, M. E., Klein, L. R., Reardon, R. F., Miner, J. R., Fagerstrom, E. T., … Cole, J. B. (2018). Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(21), 2179–2189.