Table 1. Challenges encountered during non-Operating Room intubation and solutions.

Challenge Solution
Situationally Difficult Airway (common)
Human factors
Unclear roles Clear role allocation
Poor assessment Clear assessment of patient, team, situation
Poor planning / prioritization Hospital-wide algorithm
Poor decision making Shared mental model
Fixation error
Perseverance with intubation attempts despite patient Auditory cues, saturation stop-point, empowering observers,
desaturation prioritization
Perseverance with same intubation technique despite Pre-planning initial and subsequent attempts, change between
failure of that technique attempts, algorithm
Perseverance with orotracheal intubation despite Alternate methods of oxygenation, maximum # attempts, pathway
multiple failed attempts for escalation
Unfamiliar equipment Standardized equipment
Unfamiliar location of equipment Standardized location / set-up
Physiologically Difficult Airway (common)
Hypoxemia pre-intubation Position 20o reverse trendelenberg
Gaseous gastric decompression
Positive end-expiratory pressure during pre-oxygenation

Hypotension pre-intubation
Anatomically difficult airway (uncommon)
Cervical-spine immobilization / airway injury / airway
illness / pre-morbid anatomical difficulty
Unfasted patient
Positive airway pressure ventilation during apneic phase
Nasal cannula oxygen during laryngoscopy
Clear saturation stop-point for aborting attempt
Fluid bolus
Inotrope infusion
Dose titration of induction agent
Rescue (bolus)-dose inotrope / vasopressor
Difficult mask oxygenation: depth of anesthesia / paralysis,
position, airway opening manovers, OPA/NPA, 2-person
technique, gaseous gastric decompression
Consider SGA rescue
Difficult tracheal intubation: position, change of equipment /
operator, bougie / frova intubating catheterTM, video-assisted direct
laryngoscopy, indirect laryngoscopy, fiber-optic intubation
Can’t intubate can oxygenate: tracheostomy (if can’t wake)
Can’t intubate, can’t oxygenate: declare emergency, front-of-neck
access (needle and / or scalpel-based technique)
Modified RSI
Pre-medication for situational control only
PEEP during pre-oxygenation
Avoidance of sympatholytic induction agents
 Dose titration of induction agent
Use of long-acting non-depolarizing paralytic
Non-use of cricoid force
Continued oxygen delivery during apneic phase / laryngoscopy
End-tidal CO2 monitoring to confirm correct ETT placement
No option to wake patient and defer intubation Pre-planning options for can’t intubate situation
Infrequency Simulation-based skill training
Simulation-based human factors training
Operating room-based skills training
Audit and review of cases

Abbreviations: OPA=oropharyngeal airway, NPA=nasopharyngeal airway, SGA=supraglottic airway, RSI=rapid sequence intubation,
PEEP=positive end-expiratory pressure, ETT=endotracheal tube
Team and equipment location for non-operating room emergency airway management.
Emergency Intubation
usE iN CoNJuNCTioN WiTH Basic LiFE SUPPoRT GUiDELiNES. sEE RCH aiRWay MaNaGEMENT CLiNicaL PRacTicE GUiDELiNES.

Anaesthesia, PICU, NICU, and Emergency

DIRECT LARYNGOSCOPYANY PROBLEM AT ANY TIMECALL FOR HELP

Assess Check Help Plan Optimise Anaesthetis ext

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Operating Theatre52000
ext
• Airway • Equipment • Who? •Discuss Plans Optimise position 52001
Preparation • Severity
of
• Monitors
• Drugs for
• Availability?
• Inform
(A, B, C and
D) with your
of the head
and neck
PICUext 52327
condition team NICUext 52211
anaesthesia consultant
• Your skills • Resuscitation
•Nominate EDext 52169
a METext 777
• Get help successive attempts at intubation must have different personnel,
REMEMBER:
timekeeper
if
position, or equipment.
difficulty •Can this
MAINTAIN: oxygenation, sedation and paralysis between each attempt.
anticipated patient be

Pre-oxygenate. Paralyse and sedate. Consider cricoid pressure

Plan A: Perform laryngoscopy and attempt intubation. If unable to see vocal cords:
Manipulate Remove cricoid Consider Remove
To optimise ventilation
• Correct mask size
Initial tracheal larynx pressure bougie cervical collar • Oral guedel airway
intubation If unable to ventilate, go to Plan B after a single intubation
attempt. Maximum 3 intubation attempts in 3 minutes.
• Two hands to hold mask

plan Faied Intubation Succeed

If still
ventilate,
unable
remove
to

guedel and insert

laryngeal mask
Plan B: Re-oxygenate. Check heart rate and blood pressure
Secondary Insert Get anaesthetist Prepare
laryngeal mask ext 52000 Glidescope
Revert to guedel if
unable to ventilate Verify tracheal intubation
tracheal If unable to ventilate go to Plan D immediately.
If the best possible attempt is unsuccessful, go to Plan
with capnography and visually
intubation C. Do not persist with further intubation attempts. if possible

plan If in doubt, take it out

 Verify tracheal
Failed Intubation Succeed
intubation with
capnography and visually
if possible
If in doubt, take it out
Failed intubation Failed Intubation and failed
with successful oxygenation with bradycardia
oxygenation (SpO2 <80%, or < 50% with
cyanotic heart disease)
Plan C: Maintain Ventilate via face mask with
oxygenation guedel, or laryngeal mask Plan D: Rescue Revert to face mask with oral
cricothyroidotomy/ and nasopharyngeal airway
Wake the patient if possible.
Call ENT for urgent tracheostomy Perform rescue
tracheostomy. cricothyroidotomy or
tracheostomy.

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www.rch.org.au
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Weight LMA size

(kg)
<5 1
5 ¬ 10 1.5
10 ¬ 20 2
20 ¬ 30 2.5
30 ¬ 50 3
50 ¬ 70 4
70 ¬ 100 5
Oropharyngeal
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Age ETT size ETT size Depth

(Microcuff) (Mallinckrodt) (Oral)
<8 months 3 8.5 cm
8 mo ¬ 2 yrs 3.5 11 cm
2 ¬ 4 yrs 4 12 cm
4 ¬ 6 yrs 4.5 14 cm
6 ¬ 8 yrs 5 15 cn
8 ¬ 10 yrs 5.5 16 cm
10 ¬ 12 yrs 6 17 cm
12 ¬ 14 yrs 6.5 18 cm
>14 yrs 7 19 cm
Emergency Intubation Checklist
For TEAM LEADER use prior to every EMERGENCY INTUBATION

Emergency Department

IV DRUGS
TEAM PATIENT MONITORS EQUIPMENT
1. Notify senior ED doctor 1. Optimise haemodynamics, 1. IV access functioning 1. T-piece/face mask checked for leak
2. Verbalise indication for intubation consider: 2. Intubation drugs/dose 2. Suction functioning
3. Allocate roles • Fluid bolus chosen and drawn up (yankauer and flexible)
4. Confirm intubation plan* • Inotrope/vasopressor 3. Cardiac monitoring 3. Airway
• Bolus dose 4. BP (2 minute cycle) equipment
A. Initial tracheal template complete
intubation attempts × 3 vasopressor drawn up 5. SpO2
2. Optimise pre-oxygenation, 4. Glidescope at bedside/turned on
B. Final tracheal 6. EtCO2
intubation attempt consider:
7. Post intubation sedation drawn up
C. Rescue plan to • 100% FiO2
maintain oxygenation • PEEP via t-piece
D.Rescue plan for • Apnoeic oxygenation
front of neck (NP) 2 L/kg/min
access (15L/min)
5. Assign lead for • Elevate head of bed
post-intubation debrief 3. Optimise position, consider:
• <1 year: towel/trauma Airway Group
mat under shoulders The Royal Children’s Hospital Melbourne
50 Flemington Road
• >8 years:
Parkville Victoria 3052 ER
towel/pillow under C
Australia EMaiL 16
head 00
* see Emergency Intubation Algorithm airway@rch.org.au 78
Fe
If any difficulties anticipated www.rch.org.au b
20

CALL FOR HELP 16