1. Special Airway Devices and Techniques for the Difficult or Failed Airway
Pat Melanson,MD

2. Difficult Airway Kit: ASA Recommendations
Multiple blades and ETTs
ETT guides (stylets, bougé, light wand)
Emergency nonsurgical ventilation ( LMA, Combitube, TTJV )
Emergency surgical airway access ( Cricothyrotomy kit, cricotomes )
ETT placement verification
Fiberoptic and retrograde intubation

3. ETT Placement Methods Direct vision Indirect indicator
laryngoscope
Bronchoscope
Indirect indicator
transillumination with light wand
listening for air ( BNTI)
Blind tactile digital intubation
Blindly without indicator

4. ETT Guides : Gum Elastic Bougie (ETT Introducer)
Long, thin, flexible guide
60 cm long, 15 Fr, distal 3 cm has 40 degree bend
small diameter allows easier passage through cords than ETT
Useful with Grade III views (epiglottis only)
direct tip underneath epiglottis and “walk up’ dorsum of epiglottis to anteriorly to cords
feel for “clicks” of tracheal cartilages or resistance at carina
advance ETT over bougie into trachea
Useful when neck movement contraindicated

5. ETT Guides : Light Wand
uses transillumination of neck soft tissues to guide tube
technique is easier to teach, skill easier to maintain than conventional laryngoscopy
produces less airway trauma
less physiologic disturbance

6. ETT Guides : Light Wand Indications Contraindications
Impossible Laryngoscopy with adequate Bag-Mask-Ventilation
TMJ ankylosis
limited C-spine mobility
facial trauma
Contraindications
Upper airway masses or lesions (blind technique)

7. Light Wand : Technique Load and lubricate ETT on wand
Bend ETT just proximal to balloon cuff to near right angle
Place head and neck in neutral position
Grasp and lift upward the lower alveolar ridge and mentum with non-dominant hand
Advance light wand in midline
Lift jaw to aid passage under epiglottis
Position light wand for maximum well circumscribed glow at anterior neck just below laryngeal prominence
Retract rigid stylet and advance ETT

8. Emergency Non-surgical Ventilation: Laryngeal Mask Airway
Designed to be placed in the supraglottic area, seal the larynx, and direct gas into trachea
Oval inflatable cuff seals larynx
Easy to use
Does not provide definitive management
does not prevent aspiration
temporizing measure after failed intubation

9. Laryngeal Mask Airway : Technique
Lubricate both sides
Open airway with head tilt, sniffing position
Insert LMA with laryngeal surface down
Press device onto hard palate
Advance using index finger
Use curve to advance over base of tongue
pushed as far as possible into hypopharynx
Stop when resistance felt(upper esophag. sphincter)
Inflate collar and start bag ventilation

10. LMA and the Difficult Airway
Consider use early in a can’t intubate, can’t ventilate situation while also getting prepared for a surgical airway or TTJV
A temporizing measure but can be used as a conduit for endotracheal intubation
the “Intubating Laryngeal Mask”
The LMA is a supraglottic device
Not suitable if the airway difficulty is due to laryngeal problems i.e., (laryngospasm) or local pharyngeal abnormalities ( abscess, hematoma, edema)

11. Emergency Non-surgical Ventilation : Combitube
Dual-lumen, dual-cuffed rescue airway device
The two lumens allow ventilation whether placed in trachea or esophagus
If in trachea position, functions like an ETT
If in esophageal position, the two balloons seal hypopharynx proximally and esophagus distally and perforations in esophageal lumen between the cuffs allow for ventilation
Placed blindly

12. Emergency Non-surgical Ventilation: Transtracheal Jet Ventilation
Puncture cricothyroid membrane with large-bore (12 or 14 Gauge) kink-resistant catheter connected to 3-way stopcock or to a suction catheter with control vent
50 psi wall oxygen source
High pressure tubing
Ventilate for 2 seconds (or until chest rise)
Release valve for 4 to 5 seconds (exhalation)

13. Emergency Surgical Access : Cricothyrotomy

14. Emergency Surgical Access: Cricotomes
Commercially available kits
Seldinger technique
Cricothyroid membrane punctured with needle
Guidewire advanced into trachea through needle
Cannula loaded on dilator is advanced over guidewire into trachea

15. Fiberoptic Intubation
Indications
Predicted Difficult Airway with adequate oxygenation/ventilation(time required)
Distorted upper airway anatomy or
C-spine injury
Contraindications
Excessive blood and secretions
Inadequate oxygenation

16. Bullard Laryngoscope
Indirect fiberoptic laryngoscope with anatomically shaped blade
Not necessary to align oral-pharyngeal-laryngeal axis
Useful for C-spine immobility
Does not require significant mouth opening

17. Digital Intubation tactile technique
operator uses fingers to blindly direct ETT
not an easy technique
requires large hands

18. Retrograde Intubation
Indications
C-spine motion to be avoided and difficulty anticipated with conventional techniques
Failed intubation with adequate bag/mask ventilation and time is not limited
Contraindications
infected skin over puncture site
infectious or neoplastic laryngeal lesions

19. Confirmation of ETT Placement: Clinical Evaluation
Observation of ETT pacing through cords
Clear, equal breath sounds bilaterally
Absence of breath sounds over epigastrium
Symmetrical rising of chest
Condensation or “fogging” of ETT
Chest X-ray
ALL SUBJECT TO FAILURE
Pulse oximetry is LATE indicator

20. Confirmation of ETT Placement
Placement of ETT in the esophagus is an accepted complication of intubation
However, failure to recognize and correct esophageal intubation immediately IS NOT ACCEPTABLE
Either ETCO2 detection or an aspiration technique should be used on every emergency intubation

21. Confirmation of ETT Placement: End-tidal CO2 Detection
Colorimetric
Small, disposable
Useful in pre-hospital care
Changes from purple to yellow if CO2
100 % specific if bright yellow
Indeterminate ( brown ) can indicate esophagus with carbonated beverage, or low output state

22. Confirmation of ETT Placement: End-tidal CO2 Detection
Quantitative End-Tidal CO2 Detection
indicates successful tube placement
early indicator of inadvertent extubation
adequacy of ventilation ( CO2 level )
prognosis in cardiac arrest
monitoring/ therapy guide in arrest
ETCO2 detectors can be falsely negative during cardiac arrest (inadequate perfusion for CO2 delivery to lungs)

23. Confirmation of ETT Placement: Esophageal Detection Devices
Bulb or Syringe Aspiration Devices
Aspiration of a large volume of air rapidly through an ETT to determine whether the tube is in the esophagus or trachea
Esophagus is soft and will collapse if negative pressure applied
Less than free and immediate ( < 2 sec) aspiration of air should be considered to be esophageal until proven otherwise
Useful in cardiac arrests

24. Confirmation of ETT Placement: Esophageal Detection Devices
False positive results
massive gastric insufflation
incompetent lower esophageal sphincter (pregnancy, hiatal hernia)