4. Failure to maintain or protect airway
Comatose (prevents aspiration)
Airway trauma
Failure of ventilation or oxygenation
Ventilation failure not reversible
Deteriorating oxygenation even with supplemental O2
Cardiac arrest

5. In emergencies there is about a 1 - 2% failure to intubate
Therefore:
Need to identify the difficult airway:
So that you can make plans for the event of possible failure to intubate
Neuromuscular paralysis should be used with extreme caution

6. Assessment 1. External markers of difficulty 2. Neck mobility
of bag-mask ventilation
of intubation
2. Neck mobility
3. Mouth opening
4. Oral access (Mallampati)
5. Estimate difficulty for direct laryngoscopy
6. Laryngoscopic view (Cormack and Lehane)

7. 1. External markers No teeth Obesity History of snoring Beard
Difficult bag-mask ventilation
No teeth
Obesity
History of snoring
Beard
Age > 55years
Anatomically abnormal facies
Facial or neck trauma
Obstructive airways disease
Third trimester pregnancy

8. 1. External markers Difficult intubation Anatomically abnormal facies
Neck trauma
Prominent incisors or passion gap
Receding mandible
Short thick neck
Obesity
Neck immobilisation

9. 2. Neck mobility 3. Mouth opening
Flex and extend through full range of motion
3. Mouth opening
Open mouth as wide as possible
Should insert 3 fingers between upper and lower incisors

10. 4. Oral access = Mallampati scale (sitting up, not saying “Ah”)
Class 1: Full visibility of tonsils,
uvula and soft palate
Class 2 : Visibility of hard and
soft palate, upper portion of
tonsils and uvula
Class 3 : Soft and hard palate and
base of the uvula are visible
Class 4 : Only hard palate visible

11. 5. Estimate difficulty for direct laryngoscopy
Distance - Chin to hyoid
Estimates size of mandible
3 fingers
Distance - Thyroid cartilage to mandible
Estimates position of larynx in neck
2 fingers

12. Laryngoscopic view = Cormack and Lehane
Grade I : Most of glottis is seen
Grade II : Only posterior portion
of glottis can be seen
Grade III : Only epiglottis may be
seen (none of glottis
seen)
Grade IV : Neither epiglottis nor
glottis can be seen

13. The mneumonic “LEMON”
L = Look externally (facial trauma, large incisors, beard or moustache, and large tongue)
E = Evaluate the rule (incisor distance < 3 fingers hyoid / chin distance < 3 fingers thyroid-to-mandible distance < 2 fingers)
M = Mallampati (Mallampati score 3 or more)
O = Obstruction (presence of any condition that could cause an obstructed airway)
N = Neck mobility (limited neck mobility)

14. Bag-mask ventilation Oxygen source
We use a self inflating resuscitator (e.g. Ambu®-, Laerdal®- bag)
Reservoir bag
O2 at 15 L min-1 straight from
regulator not through
humidifier
Oxygen source

15. Suction
Yankauers
Magills forceps

16. Laryngoscope Types Consists of blade varying sizes (000 - 0 - 4)
Handle
Types
MacIntosh (curved blade)
Miller (straight blade)

17. Endotracheal tubes (ETT)
Different types
Cuffed vs. uncuffed
Average size of ETT’s for
Adult male = 8
Adult female = 7,5
Child = (Age / 4) + 4
Maintain sterility
Syringe to inflate cuff

18. Secondary confirmation devices
Introducer / bougie
KY jelly
Stethoscope
Tie / tape to secure ETT
Secondary confirmation devices
Oesophageal detector device (ODD)
Capnography

19. If unconscious then easy If awake / semi-conscious then need a RSI
RSI = Rapid Sequence Intubation
Rapid placement of ETT into trachea
Pre-oxygenation
After administering a sedative / induction agent
Apply cricoid pressure (Sellick’s manoeuvre)
Followed by the muscle relaxant, suxamethonium ('scoline')
Prevents regurgitation and aspiration

20. Pre-oxygenate for 5 min or 6 vital capacity breaths
Prepare equipment
Pre-oxygenate for 5 min or 6 vital capacity breaths
FIO2 = 0,8 - 1,0
Paralysis with induction
Induction agent
Cricoid pressure
Paralysing agent - Suxamethonium
Pass ETT once fasciculated or 60 sec (whichever is first)
Confirm position and then release cricoid pressure
Post-intubation care

21. Head positioning Sniffing morning air
Allows a straight line of vision from mouth to vocal cords
Neck extension, head flexion

22. Laryngoscope introduced into right side of mouth (held in left hand)
Tongue swept to left
Tip of blade advanced until epiglottis seen

23. Tip of blade into the vallecula
Entire laryngoscope lifted in direction of the handle. (Do not pivot or lever on the teeth!)

24. Tip of ETT advanced through the cords under direct vision Depth:
Black line at cords /
cuff just through cords
Approx. ETT size x 3
Note marking at lip
Confirm with ODD
Then inflate balloon
Check placement
Secure ETT

25. 'Major signs' of endotracheal placement (Reliable)
Direct visualisation of ETT through cords
End-tidal CO2
Oesophageal detector device
'Minor signs' of endotracheal placement (False positives)
Absent sounds on auscultation over the epigastrium, with breath sounds in axillae and bases (i.e. 5 point auscultation)
Fogging / misting of tube
Equal rise and fall of chest
Pulse oximetry (Late sign! esp. with pre-oxygenation)
Exclude endobronchial placement
Clear and equal bilateral breath sounds in axillae and bases NB. Auscultation is not a reliable sign of correct endotracheal placement

26. Squeeze, attach to ETT and release, then allow to re-expand
If in the oesophagus, it will not re-expand as the oesophagus will collapse round the ODD
Done before any bagging
False positive May falsely re-expand if stomach is filled with air due to ventilation
False negatives May falsely not re-expand
if a small child (<20kg)
or obese

27. Want to look at end-tidal CO2 to assess if in trachea
Qualitative = Capnodisc Yellow = yes
pH sensitive filter paper
Turns yellow if >2 - 5 kPa PETCO2
Only qualitative
Quantitative = Capnography
Infrared detection
Waveform analysis

28. Problems with qualitative:
False positives
Gassy cooldrinks
Gastric distension from mouth-to-mouth ventilation
False negatives
Cardiac arrest
Massive pulmonary embolus
Massive obesity

29. Pulse oximeter detects haemoglobin oxygen saturation peripherally
Is a delayed response
Especially if pre-oxygenated
Remember to be careful if:
Nail polish
High ambient light
Carbon monoxide poisoning
No pulse in patient
Hypotensive
Hypothermic

30. Laryngospasm / bronchospasm Oesophageal intubation
Trauma
Lips
Teeth
Airway
Vocal cords
Infection
Laryngospasm / bronchospasm
Oesophageal intubation
Right main bronchus intubation
Tension pneumothorax

31. DOPES check
D = Displacement of ETT (right bronchus/oesophagus)
O = Obstruction of ETT / circuit
P = Pneumothorax
E = Equipment failure
S = Stomach full of air (especially children)

32. Go back to basics and bag-mask ventilate
If cannot intubate, but can ventilate then
Ventilate
Stay calm, call for help
Try to intubate later
If still cannot then rescue device:
LMA
Combitube
If cannot intubate, cannot ventilate
Rescue device
Last resort → Surgical airway (cricothyroidotomy)