The difficult airway

LEMON mnemonic

Look- as in Diff to BVM

Evaluate 3-2-2

Mallampati

Obstruction

Neck Mobility

Look

- trauma

- short neck

- micrognathia

- prior surgery

- may also be difficult to bag

- body mass index

- advanced age

- beard

- no teeth

- snoring

Evaluate

- 3 finger-breadths mouth opening

- 3 fingers from chin to hyoid

- 2 from thryroid to sternum

ASA DIFF AIRWAY ALGORITHM

- in OR, can always let pt wake up and cancel case

- if can't do BVM after failed intubation- do cric or transtracheal jet since will desat otherwise

- straight blade- Miller- better for deep glottis, buck teeth

Gum Bougie

- blind orotracheal intubation

Blind Naso Trach Intub

- not as successful but still an option

- higher complication rate- bleeding, emesis

Lighted Optical Stylets

- high success rate- esp good for trauma, cspine

- use for both reg and nasotrach

- low complication rate

- limited by fogging, secretion, recognition of anatomy, cost

LMA

- can use without muscle relaxants

- better than face mask

- can be used as bridge to fiberoptic intubation

- limited by unreliable seal at peak insp pressure

- asp risk

- mucosal trauma

- LMA better than ett for paramedics

- intubating LMA (ILMA) better for ventilating ED pts but intubating through ILMA more difficult for neophyte

Combitube- esoph obturator

- good for nurses and paramedics

- indicated if diff airway predicted, can't see glottis with laryngoscope,

- reduced risk for aspiration compared to face mask or LMA

- can maintain spinal immobilization

- large size predisposes to esoph dilatation, laceration

Trans Trach Jet Vent

- TTJV

- needle through cric mem, connected to 50 psi 02- can ventilate and oxygenate ok

- need adequate 02 pressure

- 1 sec insp and 2- 3 sec exp to avoid breath stacking

- may get ptx or barotrauma

- contraindications- distorted anatomy, bleeding diathesis, complete airway obstr

Retrograde Intubation

- perc guide wire through cric and retrograde intubation over wire

- use guide catheter over wire and then ett

- need time to set up

- risk hematoma, ptx

- contra- bleeding, distorted anatomy

Fiberoptic Bronchoscopic Intubation

- takes time to set up

- good for c-spine injury or awake pt with diff airway

- go through nose

- use for all ages, can give 02 during procedure thru fiberscope, immediate confirmation of position

- limited by secretions, bleeding, poor suction,

Rigid Fiberoptic Laryngoscopes

- use for diff airway or spinal immob

- not as good and longer time to intubate than flex scope

Surgical Airway

- can get subglottic stenosis

- rapid 4 step procedure faster but higher compl rate- cric cart fx

- can also do wire guided

- long term morbid, mortality similar to tracheostomy

Source

7/06 MISTRY