The first step in managing a difficult airway is to realize the potential for it to occur so one can prepare. Calling for assistance from a colleague, even a different specialty or service, is appropriate and indicated in difficult cases. In high-risk cases, such as in the examples below, involvement of Anesthesia should be considered:
a. A patient requires intubation and has what appears
to be a “difficult airway”
b.
A patient who in the course of attempted
intubation is deemed to have a “difficult airway”.
Anesthesia support is best acquired by calling
323-5631 (Chandler OR front desk) and providing a clear message, “I have a
difficult airway in X location and need Anesthesia STAT”.
Anesthesia will involve the Trauma Surgery service
for the establishment of, or provide a notice of the possibility of, an
emergency surgical airway. Certainly, the primary clinical service can
call the Trauma/Acute Care Surgery (TACS) Service if needed. The TACS
Service is in-house 24/7, including an attending surgeon (859-330-0211), and is
the most reliable service to provide this support to our patients.
The need for a surgical airway should not be
considered a failure.
When a specialty service has
been consulted for a difficult airway, it’s appropriate to defer to that
service’s technical approach, including location of choice for the airway
maneuvers (ie, moving the patient to the OR where more/different material
and/or human resources may available).
High Risk Diagnoses that
May Indicate a Difficult Airway
1.
Limited neck mobility
(e.g., cervical fusion, halo or cervical traction)
2.
Neck mass with tracheal compression or deviation (e.g., hematoma, significant thyromegaly)
3.
Anterior mediastinal mass with tracheal compression (It may be impossible to ventilate the patient
following intubation.)
Physical Factors that May Indicate a Difficult Airway
4.
Large weight
(>90kg)
5.
Higher Mallampati
score (with the modification described by Samsoon and Young):
o
Class 1: soft
palate, fauces, uvula, and pillars visible
o
Class 2: soft
palate, fauces, and uvula visible
o
Class 3: soft
palate and base of uvula visible
o
Class 4: none of
the soft palate visible
6.
Inter-incisor gap
with the mouth fully open < 5cm (or large incisors)
7.
Receding mandible
8.
Limited neck
extension
9.
Large neck
circumference
10. History of previous difficulty with laryngoscopy or
intubation
11. Disease associated with difficulties in laryngoscopy or
intubation, such as acromegaly and cervical spondylosis with limitation of neck
movements
12. Obstructive sleep apnea
13. Craniofacial disorders
