Management of Difficult Intubation

The following plans (A-D) provide a stepwise strategy to handle difficult or failed intubation scenarios.

 

Quick Reference Table

Plan	Goal	Actions
A	Secure airway via tracheal intubation	Optimized intubation attempts (max 3), use adjuncts, change techniques or equipment
B	Establish ventilation with supraglottic device	Insert SAD (LMA, i-gel), confirm placement, ventilate, consider intubation through SAD if necessary
C	Re-establish face mask ventilation	Optimize mask ventilation techniques, use airway adjuncts, two-person technique, reposition patient
D	Emergency oxygenation via front of neck access	Perform cricothyrotomy using scalpel-bougie technique, confirm placement, secure airway

 

 

Plan A: Initial Intubation Attempts

Goal: Secure the airway via tracheal intubation using optimized techniques.

 

Preparation

• Optimal Positioning:
  • Use the sniffing position or ramping (especially in obese patients) to align airway axes.

 

• Preoxygenation:
  • Administer 100% oxygen to maximize oxygen reserves.

 

• Equipment Check:
  • Ensure all necessary equipment is ready and functioning:
    • Laryngoscope (direct or video)
    • Endotracheal tubes of various sizes
    • Stylets and bougies
    • Suction devices

 

• Team Briefing:
  • Assign roles and communicate the airway plan to all team members.

 

• Airway Assessment:
  • Reassess for any predictors of a difficult airway using the LEMON mnemonic.

 

Intubation Attempts

• Limit Attempts:
  • Maximum of 3 attempts, ideally by the most experienced clinician available.

 

• Optimize Each Attempt:
  • First Attempt:
    • Use the best technique and equipment based on airway assessment.
    • Consider using a video laryngoscope if available.
  • Subsequent Attempts:
    • Change one or more variables:
      • Different blade size or type.
      • Use of a bougie or stylet.
      • External laryngeal manipulation (bimanual laryngoscopy).
      • Adjust patient positioning.

 

Failure to Intubate

• If unable to intubate after optimized attempts, move to Plan B.

 

 

Plan B: Supraglottic Airway Device (SAD) Placement

Goal: Establish oxygenation and ventilation using a supraglottic airway device.

 

Actions

• Insert a Supraglottic Airway Device:
  • Examples include:
    • Laryngeal Mask Airway (LMA)
    • i-gel
    • Laryngeal Tube Airway
• Confirm Placement:
  • Use capnography to detect end-tidal CO2.
  • Observe chest rise and auscultate breath sounds.
• Ventilation:
  • Provide gentle positive pressure ventilation.

 

Considerations

• Limit Attempts:
  • Limit to two attempts at SAD placement.
• Size Selection:
  • Choose the appropriate size based on patient weight and device guidelines.
• Secure the Device:
  • Ensure the SAD is secured to prevent displacement.

 

If Ventilation is Adequate

• Options:
  • Proceed with Surgery or Procedure if appropriate.
  • Consider Intubation Through the SAD:
    • Use a fiberoptic bronchoscope to guide an endotracheal tube through the SAD.

 

If Ventilation is Inadequate

• Move to Plan C if unable to ventilate adequately with the SAD.

 

 

Plan C: Face Mask Ventilation

Goal: Re-establish effective face mask ventilation to oxygenate the patient.

 

Actions

• Attempt Face Mask Ventilation:
  • Use optimal mask fitting and seal techniques.
• Use Airway Adjuncts:
  • Oropharyngeal Airway (OPA)
  • Nasopharyngeal Airway (NPA)
• Two-Person Technique:
  • One provider maintains mask seal and airway maneuvers while the other provides ventilation.
• Apply Positive End-Expiratory Pressure (PEEP):
  • Use a PEEP valve to improve oxygenation if available.

 

Optimizing Ventilation

• Head and Neck Positioning:
  • Reposition to improve airway patency.
• Jaw Thrust and Chin Lift:
  • Relieve obstruction caused by soft tissue collapse.

 

If Ventilation is Adequate

• Options:
  • Wake the Patient:
    • Allow spontaneous breathing and postpone the procedure if possible.
  • Seek Expert Help:
    • Consult anesthesiology or an airway specialist.
  • Reassess Airway Plan:
    • Consider alternative techniques or equipment.

 

If Ventilation is Inadequate

• Move to Plan D immediately.

 

 

Plan D: Front of Neck Access (FONA)

Goal: Establish emergency oxygenation via surgical airway access.

 

Actions

• Perform Emergency Cricothyrotomy:
  • Scalpel-Bougie Technique is preferred in adults.
• Equipment Needed:
  • Scalpel (size 10 blade)
  • Bougie (gum elastic bougie)
  • Size 6.0 mm cuffed endotracheal tube or tracheostomy tube
• Declare an Airway Emergency:
  • Communicate clearly to the team.
  • Assign roles for efficient execution.

 

Scalpel-Bougie Cricothyrotomy Steps

1. Identify the Cricothyroid Membrane:
   • Palpate between the thyroid cartilage and cricoid cartilage.
2. Stabilize the Larynx:
   • Use the non-dominant hand to hold the thyroid cartilage firmly.
3. Make a Horizontal Incision:
   • Use the scalpel to make a transverse incision through the skin and cricothyroid membrane.
4. Insert the Bougie:
   • Slide the bougie through the incision into the trachea.
   • Feel for tracheal rings or hold-up to confirm placement.
5. Railroad the Tube:
   • Thread the endotracheal tube over the bougie into the trachea.
6. Inflate the Cuff and Confirm Placement:
   • Inflate the cuff with air.
   • Confirm placement with capnography, chest rise, and auscultation.
7. Secure the Tube:
   • Secure the tube to prevent dislodgement.

 

Alternative Techniques

• Needle Cricothyrotomy with Jet Ventilation:
  • Use in children under 12 years old.
  • Less preferred in adults due to insufficient ventilation.

 

Post-Procedural Care

• Ventilate Appropriately:
  • Adjust ventilation settings as needed.
• Prepare for Definitive Airway Management:
  • Arrange for surgical tracheostomy if necessary.

 

 

Summary

Plan A: Attempt tracheal intubation with optimal techniques and limited attempts.

Plan B: Use a supraglottic airway device if intubation fails.

Plan C: Attempt face mask ventilation if SAD placement fails.

Plan D: Perform emergency front of neck access (cricothyrotomy) if unable to oxygenate.