1. Vanessa Fludder Worthing Anaesthetics Department
The Difficult Airway
Vanessa Fludder
Worthing Anaesthetics Department

2. Causes of a difficult airway
Small mouth opening
Large tongue
Dentition
Big sticky out upper teeth
Small lower jaw
Immobility of head/neck/jaw
Beard

3. The Difficult Airway - What exactly do we mean?
Difficult Mask Ventilation
Difficult Laryngoscopy
Difficult Intubation
All Three!

4. Causes of a difficult airway
Congenital
Infection
Trauma
Tumour
Endocrine
Body shape
Degenerative
Other (inhaled foreign body, anaphylaxis)

5. Congenital Down’s Syndrome Pierre Robin Treacher Collins Goldenhar’s
Hurler’s
Cleft Palate
Marfan’s
Klippel Feil

6. Down’s Syndrome Relatively large tongue Small mandible
Atlanto-axial instability (20%)
OSA is common
Difficult intubation
Smaller tube than predicted
Atlanto axial instability =
Poor muscle tone
Ligamentous laxity
Abnormal odontoid peg

7. Pierre Robin Severe micrognathia Posterior prolapse of tongue
(small mandible)
Posterior prolapse of tongue
Difficult intubation
Breathe better prone or on side
May need tracheostomy

8. Goldenhar’s
Facial Asymmetry
Difficult intubation

9. Hurler’s Difficult intubation Connective Tissue disorder
Mucopolysaccharidosis
Abnormal airway anatomy
Difficult intubation
Also have dwarfism, cardiac failure

10. Infection Epiglottitis Croup Tonsilitis Tonsilar/Peritonsilar abcesses
Dental abcess
Ludwig’s Angina
Tetanus
Distortion of anatomy
Narrowed airway
Lung soiling if ruptures

11. Epiglottitis Haemophilus influenzae type B
Adrenaline, heliox and steroids may help
Gas induction sevo in 100% oxygen

12. NB don’t do X-ray!

14. Ludwig’s Angina

15. Tracheostomy – Gold Standard?
Distorted anatomy, swollen tissue.
Inability of patient to lie flat.
Mediastinal spread of infection
Aspiration of pus
Recommended when retropharyngeal space is involved (CT scan)

16. Awake Fibre-optic Intubation
May be more difficult due to copious secretions which cannot be swallowed
Very important to avoid airway irritation and laryngeal spasm
Probably the safest overall technique

17. Tetanus

18. Trauma C-spine injury Facial trauma Facial Burns Inhalational injury
Post head/neck surgery/radiotherapy
Inhaled foreign body
Swelling, likely to get worse before better!
Distortion of normal anatomy
Hard collar
Vision obscured by blood
Post surgery or radiotherapy – scarring, immobility, relatively fixed.

19. C-spine injury Management Stable or Unstable? Elective
Most likely patient will be in a hard collar
Cannot move neck
Associated injuries
Management
Elective
Awake fibre-optic intubation
Emergency
RSI
Remove collar if need to
No evidence of damage to neck by intubation

21. Facial Burns Oedema worsens rapidly and may increase in 1st 24hrs
Consider intubation if
Soot in nostrils or in mouth
Burns to face
Do RSI, early rather than late, and don’t cut ETT

23. Inhalational Injury Airway oedema and obstruction Lung damage – ARDS
Consider intubation if
Voice changes
Carboxyhaemoglobin levels > 15%
CXR ranges
Deteriorating ABGs

24. Inhaled foreign body Tend to be young Object may not be radio-opaque
May push object further down by IPPV
Dex/Adren to reduce swelling
Inhalational induction
ENT surgeon
Ventilating rigid bronchoscope

25. Tumours

26. Airway tumours Pharyngeal Supraglottic Glottic Subglottic
Check nasendoscopy pictures
Look at CT scans
Discuss with surgeon
Change in voice
Difficulty breathing
Difficulty swallowing
Stridor

27. Airway Tumours Supra-glottic Sub-glottic Cricothyroid cannula
FOI asleep or awake
Sub-glottic
Laryngoscopy usually OK
Will need smaller ETT

28. Endocrine
Diabetes Mellitis
Acromegally
Thyroid Goitre

29. Diabetes Mellitis One third of IDDMs have a difficult airway!
? Due to glycosylation of tissue proteins
Limited joint mobility
Limited atlanto-occipital movement
(Prayer sign)

31. Acromegally
Enlarged facial features (Mask Ventilation can be difficult)
Overgrowth of soft tissue in airway
Enlarged tongue
Enlarged epiglottis
Smaller glottic aperture

32. Goitre

33. Degenerative/Autoimmune
Ankylosing Spondylitis
Rheumatoid Arthritis
Scleroderma

35. Ankylosing Spondylitis
Decreased mobility of whole spine
Fixed flexion deformity of head and neck
Some have limited mouth opening too due to flexed position of head
Consider
Type and length of operation
Risk of aspiration
Possibility of regional anaesthetic
May not have a problem with mask ventilation, or LMA
FOI asleep or awake

37. Rheumatoid Arthritis TMJ ankylosis Limited c-spine movement
Cricoarytenoid arthritis

38. What to do?
‘Keep in mind that the discomfort of an intubation or the deformity of a tracheostomy will be forgiven much more readily than an anoxic event that occurs during the chaos of an emergency airway crisis’ WW shockley

39. Body Shape Obesity Pregnancy Beards! Dentition
Obesity – increased soft tissue, obscuring view
More difficult to position
More difficult to ventilate, less overall compliance
Higher BMR, less Oxygen reserve Reduced FRC
OSAS

40. Pregnancy Increased risk of aspiration Increased airway tissue oedema
Friable mucous membranes – liable to bleed
Enlarged Breasts
Complicated by Increased BMR, and decreased FRC and oxygen reserve

41. Management of Pregnant Woman
Avoid GA!
Antacid and prokinetc (ranitidine + maxalon +/- Sodium citrate)
Optimum positioning
Good pre-oxygenation
RSI
Short handled blade
Don’t panic!

44. Avoiding Airway Problems
Correct Positioning
Proper equipment and preparation
Proper pre-op assessment
Plans A, B, C, D
Call for senior help 

45. Avoiding Airway Problems
Avoid GA!
Local infiltration
Local block
Regional block
Avoid traumatising the airway (BCMDI)
Glycopyrolate
Emergency Drugs
Pre-Oxygenate properly

46. Management Plan A If no risk of aspiration
If mask ventilation predicted not to be difficult
iv induction
Check mask ventilation
Direct laryngoscopy
Limited gentle attempts (ABCD)
Asleep FOI or LMA

47. Management Plan B Risk of aspiration deemed to be significant
Awake FOI
Glycopyrolate 200mcg 15 mins pre-op
Co-phenylcaine to nostrils
NIBP, ECG, SpO2
Oxygen (nasal cannula)
Epidural catheter in working channel, SAYGO
Prepare equipment and mount ETT B4 start

48. Awake cricothyroid cannula