THE DIFFICULT AIRWAY P. Andrews F08 Stages Of Respiratory Compromise Respiratory Distress
Respiratory Failure Respiratory Arrest THE DIFFICULT AIRWAY The Key is to maintain: Oxygenation Ventilation
The Difficult Airway A difficult airway can be defined as a clinical situation in which a conventionally trained ALS provider experiences difficulty with: Bag mask ventilation
Difficulty with tracheal intubation Or both. Complexity The difficult airway represents a complex interaction between patient factors, the
prehospital/clinical setting, and the skills of the EMS provider. Difficult Mask Ventilation Not possible for the EMS provider to maintain the SpO2 >90% using 100% oxygen and positive pressure mask ventilation.
It is not possible for the EMS provider to prevent or reverse signs of inadequate ventilation during PPV. THE DIFFICULT AIRWAY Difficult to oxygenate and ventilate
(BVM) Beard Obese No Teeth Elderly
Snores The Difficult Airway Difficult to intubate Look at head and neck
Evaluate ability to open mouth & access oropharynx Mallampati or Cormack Scales Obstruction
Neck Mobility Look at head and neck:
Anatomical Features Recessed Chin Buck teeth Short neck or no neck Signs of previous surgery Difficult Endotracheal Intubation
Proper insertion of the tracheal tube with conventional laryngoscopy requires more than three attempts Proper insertion of the tracheal tube with conventional laryngoscopy requires more than 10 minutes. Intubation Difficulty May
Be Due To: Incorrect position of the patient Inadequate or improper equipment
Unusual or abnormal anatomy Pathologic causes Evaluate Access to Oral Cavity Opening of mouth <20 mm
predisposes to difficult airway Evaluate Access to Oral Cavity Rule of thumb: an opening of at least two large finger breadths between upper and lower incisors in the adult is desirable
Mallampati Scale Assessing the Oral Cavity Cormack Scale Difficult Laryngoscopy It is not possible to visualize any portion of the vocal cords with
conventional laryngoscopy. Factors Contributing to Difficult Laryngoscopy The following factors may be contributors to a difficult airway:
Obstruction Infections Trauma Rheumatoid Arthritis Congenital Problems Pregnancy
Obstruction Foreign body airway obstruction is a common cause of failed airways. Direct
laryngoscopy must be used with caution as it may result in further advancement of the foreign body into the airway Obstruction
Obstruction of the airway can also be anatomical or pathological, causing narrowing or complete blockage of the airway. Infections
Infectious processes such as abscesses, croup, bronchitis, and pneumonia can distort normal anatomy. Trauma
Maxillofacial or head trauma may distort normal airway anatomy, resulting in clenched teeth and edema. Obesity
Obesity results in airway and respiratory problems secondary to altered respiratory pathophysiology and distorted upper airway anatomy.
Rheumatoid Arthritis Patients with rheumatoid arthritis and other connective tissue diseases often limit ROM of the cervical spine.
Tumors Tumors of the neck and airway can distort anatomy, limiting the space for instrumentation. Congenital Disorders
Congenital disorders may be associated with airway difficulty due to mandibular hypoplasia, cervical abnormalities, large tongue or a cleft palate.
Pregnancy Pregnancy is associated with a difficult upper airway, an increased risk of aspiration and limited tolerance to apnea.
The Most Difficult Airway When the EMT or Paramedic insists that he can get it Almost a guarantee the patient will die What to do?
Be prepared Equipment in good working condition Alternative equipment Different personal positioning
Different positioning of the patient On the floor To open airway The Rule!
Experienced providers two attempts at intubation New providers one attempt Use a King airway or Combi-tube THE PRIORITY IS TO CONTROL THE AIRWAY Summary
The difficult airway is a significant problem to the patient and EMS provider in terms of mortality, morbidity and cost. Summary It is imperative to be aware of the
factors that contribute to a difficult airway so that: EMS providers may improve their ability to be prepared The morbidity and mortality of difficult airway patients can be minimized Patient outcome can be improved upon Questions?
