Difficult(Airway(Management(

Suleiman(Herwis,(MD(

Consultant(Anesthesiologist(

King%Faisal%Specialist%Hospital%and%Research%Center%
 Adverse(Respiratory(Events((
(
• The(single(largest(category(
of(anestheticArelated(injury(
is(respiratory(events(

• The(three(main(causes(
– (Inadequate(ventilation((

– Esophageal(intubation((

– Difficult(tracheal(intubation.((
 Difficult(Airway(
“The(clinical(situation(in(which(a(conventionally(
trained(anesthesiologist(experiences:(

• Difficulty(with(face(mask(ventilation,(

• Difficulty(with(tracheal(intubation,(

• Both(
6Suggested%definition%from%ASA%Practice%Guidelines%%
 Ventilation(
Will(ventilation(by(face(mask(
be(difficult?(
• Will(I(be(able(to(ventilate?((
– I%think%so,%but%maybe%not..%!!!%

• Golden%rule!%
“It(is%never%a%sin%if%you%are%
unable%to%intubate,%but%it%is%
criminal%if%you%do%not%
ventilate%and%oxygenate.”%(
 OPTIMAL VENTILATION!

1. POSITION

2. OPTIMAL JAW THRUST + MASK SEAL

3. OROPHARYNGEAL AIRWAY

4. NASOPHARYNGEAL AIRWAYS
Positioning(
 Mask(Ventilation(
Pediatric Difficult Airway Algorithm
Mask Ventilation Difficult

Check patients position

Check&patients&position&
Then:
Then:&Oropharyngeal airway
Nasopharyngeal airway
• Oropharyngeal(airway(
Laryngeal mask airway
• Nasopharyngeal(airway((
If this fails
• Laryngeal(mask(airway(
Awaken!
 Mask(VentilationA(Airway(Maneuvers(
Pediatric Difficult Airway Algorithm
Mask Ventilation Difficult

1.Head4tilt&chin4lift&
Check patients position

2.(Jaw4thrust&((
Then:
Oropharyngeal airway
( Nasopharyngeal airway
( Laryngeal mask airway
If this fails
Awaken!
Mask(VentilationA(Airway(Maneuvers(
Mask(VentilationA(Airway(Maneuvers(
Airway(Adjuncts(
Airway(Adjuncts(
Airway(Adjuncts(

Oropharyngeal(
airway(in(place(
LMA(
LMA(insertion(
 DEFINITION OF !
OPTIMAL INTUBATION ATTEMPT !

1. REASONABLY EXPERIENCED ENDOSCOPIST

2. NO SIGNIFICANT MUSCLE TONE
3. OPTIMAL SNIFF POSITION
4. OPTIMAL EXTERNAL LARNYGEAL PRESSURE
5. CHANGE LENGTH OF BLADE X1
6. CHANGE TYPE OF BLADE X1
(
Lehane&and&Cormack&Classification&&
 Direct(Laryngoscopy
FourAgrade(scheme(for(view(of(laryngeal(inlets(
((obtained(at(laryngoscopy)(:(
• ((((grade(1:(all(or(most(of(glottis(
• ((((grade(2:(only(posterior(portion(of(glottis(
• ((((grade(3:(only(epiglottis(
• ((((grade(4:(can’t(see(glottis(or(epiglottis(at(all(
 Mallampati&Classification&
&

((

((

(
The&Mallampati&Test&&
 Difficult(Airway(AApproach(

• Anticipation((

• Planning(

• Preparation(
Features&Suggesting&the&Presence&of&a&Difficult&Airway&&

1. Relatively long upper incisors

2. Prominent overbite
3. Interincisor distance less than 3 cm
4. Mallampati class greater than 2
5. Highly arched or narrow palate
6. Stiff or indurated mandibular space
7. Thyromental distance less than three finger breadths
8. Short neck, Thick neck
9. Limited range of motion of head and neck
 Difficult(Airway(AApproach(

• Anticipation((

• Planning(

• Preparation(
Difficult&Airway&Management&Techniques(

• Direct(laryngoscopy(
• Fiberoptic(intubation(
• Videoscopes(
• Intubating(LMA(
• Rigid(bronchoscopy(
• Lighted(stylet(
• Surgical(airway(
 Tracheal Intubation Tools:
Airway(Tools(
2010

A%tool%is%not%a%plan!%
 American&Society&Of&Anesthesiologists&
&
PRACTICE GUIDELINES FOR MANAGEMENT
OF THE DIFFICULT AIRWAY
(Approved by House of Delegates on October 21,
1992,
and last amended October 16, 2002)
Updated Februry 2013

&
 Purpose of the Guidelines for Difficult
Airway Management

“To facilitate the management of the difficult

airway and to reduce the likelihood of
adverse outcomes..”

(
 Flexible(Bronchoscope((
• The(“Gold(Standard”(tool(
for(difficult(airway(
(
management((
• The(most(versatile(
instrument(
•(Mandatory(tool(and(skill(
for(every((practitioner((
• •(Improved(image(quality(
with(new(scopes((
(
(
 Video/Optical(Laryngoscopy((
Skill(set(overlaps(with(direct(laryngoscopy((

• Intuitive(use((

• Does(not(require(neck(extension((

• Portable((

• Neonates(–(Adults((

(
 Glidescope(Cobalt((
• Reusable(video(baton(that(slides(
(
into(disposable(plastic(blades/
handles((
• •(Similar(to(Macintosh(blade(
design((
• Warming(at(lens(limits(fogging((
• Relatively(portable((
• Simple(to(setup((
• Intuitive(use((
 Laryngeal(Masks(as(Intubation(Conduits((
track for Kids

ith LMA
( the LMA
Intubation through
aine
sizes 3,

Sedate/Topicalize/ (Paralyze)
the airway according to the
algorithm
Insert the LMA
Mount ETT onto bronchoscope
Pass bronchoscope to the
carina
Remove LMA
Advance tube over the
bronchoscope
Equipment(preparation(:Ensure'that'all'
Preoperative Preparation for the
equipment'is'at'hand'and'checked(
Anticipated Difficult Airway

Tracheal Intubation Tools:

2010
 Difficult&Airway&Algorithm&

3.&Consider&the&relative&merits&and&feasibility&&
of&basic&management&choices:&

Intubation(Attempts(After(
A.( Awake(Intubation( Vs.(( Induction(of(General(
Anesthesia(

NonAInvasive(Technique(( Invasive(Technique((
B.( for(Initial(Approach(to(( for(Initial(Approach(to((
Vs.((
Intubation( Intubation(

C.( Preservation(of(( Ablation(of(Spontaneous((

Spontaneous(Ventilation( Vs.(( Ventilation(
 Difficult&Airway&Algorithm&

B.(Intubation(Attempts(After(Induction(of(General(Anesthesia(

Initial(Intubation(Attempts( Initial(Intubation(Attempts(
Successful( UNSUCCESSFUL&

From%this%point%%
onwards%consider%

1. Calling for Help

2. Returning to Spontaneous Ventilation
3. Awakening the Patient
 Difficult&Airway&Algorithm&

Initial(Intubation(Attempts(UNSUCCESSFUL&

Face(Mask(Ventilation( Face(Mask(Ventilation(
Adequate( Not(Adequate(

NONAEMERGENCY(
PATHWAY(
(Ventilation(adequate(but((
intubation(unsuccessful)(

Failure(

EMERGENCY&PATHWAY!&
 Management&of&the&Difficult&Airway&–&Summary(
• Anticipation(is(often(key(to(success,(and(it(is(preferable(to(err(on(the(
side(of(conservatism(
&
&
• (Develop(Plans(A,(B(,(and(C((
&
&• Goals:(protect(the(airway,(adequately(ventilate,(and(adequately(
oxygenate(

• Get'good'assistance'

• Do'not'continue'to'do'the'same'thing'and'expect'a'different'result''

– It s'Not'Okay'to'Continue'with'Failed'Techniques'

• Do'not'be'afraid'to'wake'up'or'proceed'with'a'surgical'airway'if'
necessary''
Difficult(Airway(Management(
Suleiman(Herwis,(MD(

Consultant(Anesthesiologist(

King%Faisal%Specialist%Hospital%and%Research%Center%

September(26,(2018(