1. Difficult tracheal intubation
Dr Tuan Pham Duc
06/2010

2. Plan Preintubation checklist. Intubation kit .
RSI ( Rapid sequence intubation )
Predicting difficult tracheal intubation
Bougie ( Eschmann stylet ) .
Laryngeal mask airway-Fastrach ( Intubating LMA)
Cricothyroidotomy
Alternatives intubation techniques
Confirmation of ETT placement .
Miscellaneous
Summary

3. Preintubation checklist

4. Intubation kit Laryngoscope ET Stylet Syringe 10ml Suction catheter
Carbon dioxide detector
Oral & nasal airways
Ambu bag & mask attached to oxygen source

5. Rapid sequence intubation
Endotracheal intubation using RSI is the cornerstone of emergency airway management .
RSI: the administration of a potent induction agent followed immediately
by a rapidly neuromuscular blocking agent to induce unconsciousness & motor paralysis for tracheal intubation

6. RSI 3 phases: pretreatment-induction-paralysis.
Pretreatment : LOAD Lidocaine Opiod analgesics Atropine Defasciculating agents

7. Pretreatment medications

8. Induction medications

9. Paralytic medications

10. Predicting difficult tracheal intubation
LEMON rule
Look externally
E Evaluate the rule
Mallampati scale
Obstruction present ?
Neck mobility

11. Difficult airway assessement
Look externally : physical features such as a small mandible , large tongue , short bull neck & obesity , facial or mandibular fracture are all red flags for a difficult airway

13. Difficult airway assessement
Mallampati classification

14. Difficult airway assessement
Obstruction : 3 signs of upper airway obstruction are stridor , muffled voice,difficulty swallowing secretions.
Neck mobility:cervical spine immobilization in trauma , medical condition such as ankylosing spondylitis or RA.

15. McCormack & Lehane grade

16. Bougie ( Eschmann stylet )

17. Bougie ( Eschmann stylet )
It can be beneficial in the following situations :
Grade 3 view
Poor grade 2 view
As a general intubation aid

18. A bougie can be used on the 1st attempt intubation when DL has failed to yield an adequate view

19. LMA
A laryngeal mask airway

21. LMA

22. Fastrach( Intubating LMA)

23. Intubating LMA sizes 1 (<5kg) 1,5 (10-20kg ) 2,4 ( 20-50kg )

24. Cricothyroidotomy
Insertion of a tracheal tube through an incision in the cricothyroid membrane .

25. Alternatives intubation techniques
Glottiscope ( Airtraq..)
Special laryngoscopes
Lighted stylet intubation
Fiberoptic techniques.
Esophageal-tracheal Combitube
Retrograde intubation

26. Airtraq

27. Combitube

28. Confirmation of ETT placement
Chest auscultation: bilateral breath sounds
Detection of CO2 exhaled.
Chest Xray :

29. A- Capnography B-C CO2 color change indicator

30. Miscellanous Cricoid pressure:Sellick’s maneuver
External Laryngeal Manipulation or BURP Backward Upward Right Pressure maneuver
ELM improved the laryngoscopic view by one whole grade in most pts initially rated 2 or 3
All pts presenting grade 3 view were converted to grade 1 or 2 with ELM

31. Summary Always be prepared for a difficult airway.
No single airway assessment tool is sufficiently sensitive nor specific to reliably predict or rule out a difficult airway.
In many cases features of the patient’s morphology & pathology enable prediction of a difficult airway