Airway Emergencies - expected difficult airway - 1
How to manage the Expected Difficult Airway
Common Causes
- Anatomical problems
- Pathological obstruction of periglottic area
- Facio-Maxillary trauma
- Laryngeal trauma
Anatomical problems - (resulting in grade III or IV view at laryngoscopy)
Awake FOB (fibreoptic bronchoscopy)
- Use a drying agent and a vasoconstrictor to nasal mucosa
- Unrushed LA by method of your choice
- Nasal FOB easier than Oral route
- Sedatives + / - midazolam / remifentanil 0.05 ug / kg /min
General anaesthesia
- Don’t consider if difficult mask ventilation likely
- Don’t give muscle relaxant until confirmed adequate mask ventilation
- Confirm view with laryngoscope and choose an appropriate intubation method
- Consider non intubation
Intubation choices
- Right-angled intubaton devices: ILM, Bullard, Upsure. Useful when
the reason for a poor view of the larynx is that the airway axes are not aligned
- FOB. NB 2 person technique, with one person using a laryngoscope to position the FOB behind the epiglottis
- LMA and FOB. LM opens up the posterior pharyngeal space and keeps FOB midline. Railroad a size 6 reinforced ETT
over the FOB
- ILM ± FOB. Need to choose correct size or inlet will not lie over the larynx.
- Light wand -requires expertise
- Straight blade - useful in patients with a large tongue, epiglottis or prominent
incisors
- Macintosh blade - useful in patients with a small oropharynx
- Tubular scopes - useful where there is pharyngeal oedema or tumour, as they
push the tissues apart
- McCoy blade - moves fulcrum from teeth to hyoepiglottic ligament, decreasing dental damage
St. Vincent's Hospital Melbourne. Department of Anaesthesia. ©2003
