Advanced Airway

1. See Also
   1. Rapid Sequence Intubation
   2. Endotracheal Intubation
   3. Endotracheal Tube
   4. Rapid Sequence Intubation
   5. Advanced Airway
2. Indications
   1. Airway Protection
      1. Unconscious patient (Glasgow Coma Scale <=8)
      2. Severe maxillofacial trauma
      3. Aspiration risk
         1. Bleeding into upper airway
         2. Vomiting
         3. Unable to speak or swallow
      4. Airway obstruction risk
         1. Neck hematoma
         2. Tracheal injury
         3. Stridor
         4. Inhalation burn or other inhalation injury (with cord edema)
         5. Prolonged Seizure
      5. Multiple trauma, Head Injury and abnormal mental status
   2. Ventilation and Oxygenation
      1. Respiratory arrest
      2. Respiratory failure
         1. Hypoventilation/Hypercarbia
            1. paCO2 >55 mmHg
         2. Arterial Hypoxemia refractory to oxygen
            1. paO2 <55 RA, <70 on 100% face mask
         3. Respiratory Acidosis
      3. Need for prolonged Ventilatory support
      4. Class III or IV hemorrhage with poor perfusion
      5. Severe chest injury (e.g. Flail Chest or Pulmonary Contusion)
      6. Severe Closed Head Injury (GCS<8)
3. Assessment (from the Difficult Airway Course)
   1. Anticipate difficult Direct Laryngoscopy (Mnemonic: LEMON)
      1. Look externally (gestalt)
         1. Long or short Mandible
         2. High arched Palate
         3. Short neck
      2. Evaluate the 3-3-2 rule
         1. Three fingers of mouth opening
         2. Three fingers between mentum and hyoid
         3. Two fingers between hyoid and Thyroid cartilage
      3. Mallampati Score
         1. Score of 3-4 suggests higher risk
      4. Obstruction ("hot potato voice", inability to swallow secretions, Stridor)
      5. Neck mobility reduced (e.g. cervical spine immobilization, Rheumatoid Arthritis)
   2. Anticipate difficult mask ventilation (Mnemonic: MOANS)
      1. Mask seal (e.g. beard)
      2. Obstruction
      3. Older Age
      4. No teeth (replace dentures for Bag Valve Mask ventilation)
      5. Stiff lungs requiring increased Ventilatory pressures (Asthma, COPD, ARDS, term pregnancy)
   3. Anticipate difficult cricothyrotomy (Mnemonic: SHORT)
      1. Surgery distorting the airway and tracheal access
      2. Hematoma, infection or mass in the path of the cricothryotomy
      3. Obesity or fixed flexion deformity of the neck
      4. Radiation to the neck
      5. Tumors involving the airway or in vicinity
   4. Anticipate difficult extraglottic device (Mnemonic: RODS)
      1. Restricted mouth opening
      2. Obstruction of the upper airway or Larynx
      3. Distorted or disrupted airway
      4. Stiff lungs requiring increased Ventilatory pressures (Asthma, COPD, ARDS, term pregnancy)
   5. Resources
      1. Difficult Airway Course
         1. http://www.theairwaysite.com
4. Precautions: Children
   1. Consider consulting anesthesia for semi-elective intubations in children
   2. Large Tongue and small jaw can make intubating children more challenging
   3. Congenital syndromes with head and neck anatomic abnormalities can make intubation more difficult
      1. Down Syndrome
      2. Pierre Robin Syndrome
   4. Consider alternatives to Endotracheal Intubation if difficult airway is anticipated
      1. Laryngeal mask airway (LMA) as rescue airway in children
         1. Failure rate: 5-10% (due to large epiglottis)
         2. Pediatric LMAs are available
      2. Needle Cricothyrotomy
         1. Can be used to temporize in children under age 10 years
         2. Surgical cricothyrotomy is contraindicated in under age 10 years due to very small cricothyroid membrane
5. Protocol: Overview
   1. Advanced Airway is indicated (based on above indications)
      1. Endotracheal Intubation
      2. Laryngeal mask airway (LMA)
   2. Consider which of 3 scenarios are required
      1. Crash Airway (patient comatose or in cardiopulmonary arrest)
         1. Able to ventilate
            1. Attempt intubation
            2. If initial attempt fails, give Succinylcholine 2 mg/kg IV
            3. Make up to 3 additional attempts at intubation
         2. Unable to ventilate or oxygenate
            1. Go below to failed airway
      2. Difficult airway expected
         1. Call for help
         2. Unable to oxygenate or ventilate with Bag Valve Mask prior to any intervention attempt
            1. Go below to failed airway
         3. Able to ventilate (with Bag Valve Mask)?
            1. Yes: May precede below with Rapid Sequence Intubation
            2. No: Anticipate inability to effectively Bag Valve Mask (PPV)
               1. Use awake patient measures
                  1. Direct Laryngoscopy
                  2. Video intubation
                  3. Fiberoptic intubation
               2. Use refractory measures
                  1. Intubating laryngeal mask
                  2. Blind Nasotracheal Intubation
      3. Rapid Sequence Intubation (routine intubation allows time for premedication)
         1. See Rapid Sequence Intubation
   3. Failed airway options
      1. Failed intubation or cervical immobilization?
         1. Nasotracheal Intubation (if no maxillofacial trauma, basil skull Fracture)
      2. Failed Nasotracheal Intubation
         1. Cricothyroidotomy
6. References
   1. Majoewsky (2012) EM: RAP-C3 2(5): 3-4
   2. Walls (2012) Emergency Airway Management, 3rd Ed, Lippincott, Philadelphia, p. 9-22, 82-93