DIFFICULT AIRWAY ALGORITHM

Dr. Shikha Shah

• The ASA defines the difficult airway as the
situation in which the “conventionally trained
anesthesiologist experiences difficulty with
intubation, mask ventilation or both.
 Airway assessment
• Assessment include:
1. Mouth opening: an incisor distance of 3cm or
greater is desirable in an adult.
2. Upper lip bite test: the lower teeth are brought
in front of the upper teeth. The degree to which
this can be done estimates the range of motion
of the temperomandibular joints.
3. Mallampati classification: it examines the size of
the tongue in relation to the oral cavity
 Mallampati classification

Class 1: the entire palatal arch, including the

bilateral faucial pillars, are visible down to their
bases.
Class 2: the upper part of the faucial pillars and
most of the uvula are visible.
Class 3: only the soft and hard palates are
visible.
Class 4: only the hard palate is visible.
4.Thyromental distance: a distance greater
than 3 finger breadths is desirable.

5.Neck circumference : greater than 27inch is

suggestive of difficulties in visualization of the
glottic opening.
 LARYNGOSCOPIC VIEW
Cormack lehane
• CLASS LARYNGOSCOPIC VIEW
• 1 Entire glottic
• 2 Posterior commisure
• 3 Tip of epiglottis
• 4 No glottic structure.
Causes of difficult intubation
 AIRWAY EXAMINATION WHICH SUGGEST
DIFFICULTY WITH INTUBATION
1. Long upper incisors
2. A prominent overbite
3. The patient cannot protrude the mandibular incisors anterior to
maxillary incisors
4. Interincisor distance is less than 3cm when mouth is fully opened.
5. Uvula is not visible when tongue is protruded with patient in
sitting position
6. Shape of palate is highly arched or very narrow
7. Mandibular space is noncompliant
8. Thyromental distance is less than three finger breadths
9. Neck is short or thick
10. Patient lacks normal range of motion of head and neck.
 Assessment and Predictability of
Difficult Mask Ventilation
Criteria for difficult mask ventilation
1. Inability for one anesthesiologist to maintain
oxygen saturation >92%
2. Significant gas leak around face mask
3. Need for ≥4 Litres per minute gas flow (or use
of fresh gas flow button more than twice)
4. No chest movement
5. Two-handed mask ventilation needed
6. Change of operator required
 Awake Airway Management

• Awake airway management remains mainstay of

the ASA's difficult airway algorithm
• Its advantages are
1. maintenance of spontaneous ventilation in the
event that the airway cannot be secured rapidly,
2. increased size and patency of the pharynx,
3. relative forward placement of the base of the
tongue,
4. posterior placement of the larynx, and
5. patency of the retropalatal space.
• Awake state confers some maintenance of
upper and lower esophageal sphincter tone,
thus reducing the risk of reflux.
• In the event that reflux occurs, the patient
can close the glottis and/or expel aspirated
foreign bodies by cough.
• Contraindications to elective awake intubation
include patient refusal or inability to cooperate
(e.g., child, profound mental retardation,
dementia, intoxication) or allergy to local
anesthetics
• appropriate explanation, medication can also be
used to allay anxiety.
• Small doses of benzodiazepines (diazepam,
midazolam, lorazepam) are commonly used to
alleviate anxiety without producing significant
respiratory depression.
• Opioid receptor agonists (e.g., fentanyl,
alfentanil, remifentanil) can also be used in
small, titrated doses for their sedative and
antitussive effects, although caution must be
taken. A specific antagonist (e.g., naloxone)
should always be immediately available.
• Ketamine, droperidol, and dexmedetomidine
have also been popular .
• Dexmedetomidine, a highly selective centrally
acting α2-adrenergic agonist, has been used for
sedation and analgesia without respiratory
depression in patients who underwent awake
fiberoptic intubation, cervical spine problems,
and inability to cooperate with awake intubation.
• Dexmedetomidine may cause hypotension, which
can be corrected by phenylephrine or ephedrine.
• Administration of antisialagogues is also
important.
• The commonly used drugs atropine (0.5 to 1 mg
intramuscularly or intravenously) and
glycopyrrolate (0.2 to 0.4 mg intramuscularly or
intravenously).
• Vasoconstriction of the nasal passages is required
if there is to be instrumentation of this part of the
airway. Oxymetazoline is a potent and long-
lasting vasoconstrictor.
• Local anesthetics are a cornerstone of awake
airway control techniques
• Cocaine is a popular topical agent. It is a highly
effective local anesthetic, and also it is a
potent vasoconstrictor. It is commonly
available in a 4% solution.
• Lidocaine, an amide local anesthetic. Topically
applied, peak onset is within 15 minutes.
• Tetracaine has a longer duration of action than
either cocaine or lidocaine.
• Benzocaine is popular because of its very rapid
onset (<1 minute) and short duration
(approximately 10 minutes).
• It has been combined with tetracaine to
prolong the duration of action.
• There are three anatomic areas to which the
clinician directs local anesthetic therapy:
1. the nasal cavity/nasopharynx,
2. the pharynx/base of tongue, and
3. the hypopharynx/larynx/trachea
• Nerve supply:The oropharynx is innervated by
branches of the vagus, facial, and
glossopharyngeal nerves.
• The glossopharyngeal nerve has three branches
supplying sensory innervation to the posterior third
of the tongue, the vallecula, the anterior surface of
the epiglottis (lingual branch), the walls of the
pharynx (pharyngeal branch), and the tonsils
(tonsillar branch).
• To block this nerve, a spinal needle is inserted at the
base of the anterior tonsillar pillar , just lateral to the
base of the tongue.
• The internal branch of the superior laryngeal nerve,
which is a branch of the vagus nerve, provides
sensory innervation to the base of the tongue,
epiglottis, aryepiglottic folds, and arytenoids.
• The external branch, supplies motor innervation to
the cricothyroid muscle.
• The recurrent laryngeal nerves supply all of the
intrinsic muscles of the larynx (with the exception of
cricothyroid).
• To block superior laryngeal nerve 3 landmarks
are used : superior cornu of hyoid , superior
cornu of the thyroid cartilage and superior
notch of thyroid cartilage.
• Translaryngeal or transtracheal block provides
anesthesia of the trachea and vocal cords.
• This is useful in situations where a neurologic
examination is needed after intubation.
• It makes the presence of the ETT in the
trachea more comfortable.
 Alternative approaches to intubation
• It includes video assisted laryngoscopy,
• Alternative laryngoscope blades,
• SGA
• Fiberoptic intubation
• Intubating stylet or tube changer
• Light wand
• Blind oral or nasal intubation.
 Invasive airway access
• It includes
• Surgical or percutaneous airway,
• Jet ventilation
• And retrograde intubation
 Other options
• Face mask or supraglottic airway
• Local anesthesia infiltration,
• Regional nerve blockade.
 Awaken the patient: consider re preparation
of the patient for awake intubation or
cancelling the surgery.
 Fiberoptic bronchoscope
• A flexible bronchoscope allows indirect
visualization of the larynx in situation in which
awake intubation is planned.
• The insertion tube contains two bundles of
fibers. One bundle transmits light from the
light source, whereas the other provides a
high-resolution image.
 Esophageal Tracheal Combitube:
• The Combitube is inserted “blindly.
• Advantages of the Combitube include
1. rapid airway control,
2. airway protection from regurgitation,
3. ease of use by the inexperienced operator,
4. no requirement to visualize the larynx,
5. and the ability to maintain the neck in a
neutral position.
 Supraglottic airways
• It include devices that are blindly inserted into
the pharynx to provide a patent conduit for
ventilation, oxygenation without the need for
tracheal intubation.
• it is well tolerated by the patient.
• It is a blind technique not hindered by blood,
secretions, debris, and edema from previous
attempts at laryngoscopy.
 LMA
• It is helpful in patients with difficult airway
because of its ease of insertion and relatively high
success rate (95–99%)
• An LMA consists of a wide-bore tube whose
proximal end connects to a breathing circuit , and
whose distal end is attached to an elliptical cuff
that can be inflated through a pilot tube. The
deflated cuff is lubricated and inserted blindly
into the hypopharynx , and it is inflated to form a
low-pressure seal around the entrance to the
larynx.
 Video laryngoscopes
• Video or optically based laryngoscopes have
either a video chip or a lens/mirror at the tip
of the intubation blade to transmit a view of
the glottis to the operator.
• They generally improve visualization of
laryngeal structures.
 Retrograde intubation
• The retrograde technique of intubation consists of
percutaneously passing a narrow flexible guide into
the trachea from a site below the vocal cords and
advancing this guide through the larynx and out the
mouth or nose.
• In the basic technique, the tracheal tube is then
passed over the guide into the upper part of the
trachea, the guide is removed, and the tube is
advanced into the trachea.
 Other Devices

 Lighted Stylets: These devices rely on

transillumination of the airway.
• A light source introduced into the trachea will
produce a well-circumscribed glow of the
tissues over the larynx and trachea.
• The same light placed in the esophagus will
produce no light or a diffuse light.
 Airway Bougie: Airway bougies encompass a series of
solid or hollow, semimalleable stylets that maybe be
blindly manipulated in to the trachea.
• An ETT is then “threaded” over the bougie and into
the trachea
 Percutaneous airways
It includes
• transtracheal jet ventilation,
• cricothyrothomy,
• and tracheostomy.
 Transtracheal jet ventilation
• It is an invasive technique.
• Inspiration during TTJV is achieved by insufflation of
pressurized oxygen through a cannula placed by
cricothyrotomy.
• It should not be performed in patients with sustained
direct damage to the cricoid cartilage or larynx or in
patients with complete upper airway obstruction.
 Cricothyroidotomy
• It is emergent invasive technique for establishing
an air passage through the cricothyroid
membrane.
• The cricothyroid membrane is a fibroelastic
membrane, lying over the tracheal mucosa. It is
attached to the inferior border of the thyroid
cartilage and superior edge of the cricoid
cartilage.
• Cricothyrotomy is contraindicated in neonates
and children younger than 6 years of age, and in
patients with laryngeal fractures.
• The two most common techniques for performing a
cricothyrotomy are the percutaneous dilational
cricothyrotomy and surgical cricothyrotomy .
• The most preferred technique is percutaneous
technique.
• The patient neck is extended, and the cricothyroid
groove is identified.
• An 18 gauge needle catheter attached to a fluid filled
syringe is passed through the incision at a 45 degree
angle in caudal direction with continous aspiration.
• Aspiration of free air confirms passage through the
cricothyroid membrane.
• The catheter is advanced over the needle into the
trachea.
• The needle is removed, and the catheter is left in
place.
• The guidewire is inserted caudally to a depth of
approximately 2 to 3 cm.
• The catheter is removed, and the curved dilator with
the airway cannula is threaded over the guidewire.
• The dilator and cannula unit is advanced while
maintaining control of the guidewire.
• The dialator and guidewire are removed
together while cannula remains in place.
• The cuff is inflated, and ventilation is
attempted.
• Proper placement is confirmed by
capnography, and the airway cannula is
secured in place.
THANK YOU