1. THE DIFFICULT AIRWAY

2. THE DIFFICULT AIRWAY
The Key is to maintain:
Oxygenation
Ventilation

3. The Difficult Airway
A difficult airway can be defined as a clinical situation in which a conventionally trained ALS provider experiences difficulty with mask ventilation, difficulty with tracheal intubation or both.

4. THE DIFFICULT AIRWAY Definition: Difficult to oxygenate and ventilate
Difficult to intubate

5. Complexity
The difficult airway represents a complex interaction between patient factors, the prehospital/clinical setting, and the skills of the EMS provider.

6. 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.

7. THE DIFFICULT AIRWAY Difficult to oxygenate and ventilate (BMV) Beard
Obese
No Teeth
Elderly
Snores

8. 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

10. Look at head and neck: Anatomical Features Recessed Chin Buck teeth
Short neck or “no neck”
Signs of previous surgery

13. 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.

14. Intubation Difficulty May Be Due To:
Incorrect position of the patient
Inadequate or improper equipment
Unusual or abnormal anatomy
Pathologic causes

15. Evaluate Access to Oral Cavity
Opening of mouth <20 mm predisposes to difficult airway

16. 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

17. Mallampati Scale

18. Assessing the Oral Cavity

19. Cormack Scale

20. Difficult Laryngoscopy
It is not possible to visualize any portion of the vocal cords with conventional laryngoscopy.

21. Factors Contributing to Difficult Laryngoscopy
The following factors may be contributors to a difficult airway:
Obstruction
Infections
Trauma
Rheumatoid Arthritis
Congenital Problems
Pregnancy

22. 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

23. Obstruction
Obstruction of the airway can also be anatomical or pathological, causing narrowing or complete blockage of the airway.

24. Infections
Infectious processes such as abscesses, croup, bronchitis, and pneumonia can distort normal anatomy.

25. Trauma
Maxillofacial or head trauma may distort normal airway anatomy, resulting in clenched teeth and edema.

26. Obesity
Obesity results in airway and respiratory problems secondary to altered respiratory pathophysiology and distorted upper airway anatomy.

27. Rheumatoid Arthritis
Patients with rheumatoid arthritis and other connective tissue diseases often limit ROM of the cervical spine.

28. Tumors
Tumors of the neck and airway can distort anatomy, limiting the space for instrumentation.

29. Congenital Disorders
Congenital disorders may be associated with airway difficulty due to mandibular hypoplasia, cervical abnormalities, large tongue or a cleft palate.

30. Pregnancy
Pregnancy is associated with a difficult upper airway, an increased risk of aspiration and limited tolerance to apnea.

31. The Most Difficult Airway
The one the EMT or Paramedic insists that he can “get it”
Almost a guarantee the patient will die

32. Summary
The difficult airway is a significant problem to the patient and EMS provider in terms of mortality, morbidity and cost.

33. 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

34. Questions?

35. THE DIFFICULT AIRWAY BIBLIOGRAPHY
Walker LA: Using Rapid Sequence to Facilitate Tracheal Intubation. Emergency Med Reports 14: , 1993.
Chari R: Drugs for Conscious Sedation and Neuromuscular Paralysis. Emergency Med Reports 19:9-20, 1998
McAllister JD, Gnauck KA: Rapid Sequence Intubation of the Pediatric Patient. Ped Clin NA 46: , 1999.
Pousman RM: Rapid Sequence Induction for Prehospital Providers.