(+)Michael A.

Gibbs, MD, FACEP

Chief, Department of Emergency
Medicine, Maine Medical Center,
Portland, Maine; Associate Professor,
University of Vermont School of
Medicine, Burlington, Vermont

The Unexpected Difficult Airway: How to

Avoid It and How to Manage It
Nothing is more stressful for the emergency physician than a
“cannot intubate, cannot ventilate” airway scenario. Airway
assessment can be misleading, and if and when an
unexpected difficult airway is encountered, emergency
physicians must have a “Plan B” ready to institute. The
presenter will address initial airway assessment and the
necessary goal of first-pass success with each intubation, as
well as suggest a sequenced plan when an unanticipated and
difficult intubation is encountered. (This course is a
prerequisite to the "Advanced Airway Lab".)
• Discuss airway assessment and its limitations.
• Emphasize the need for ease and simplicity when faced
with an unanticipated difficult airway.
• Explain the necessity of first-pass success for all
intubations.
• Suggest an algorithm when faced with an unanticipated
difficult airway.

MO-40
Monday, October 5, 2009
1:30 PM - 2:20 PM
Boston Convention & Exhibition Center

(+)No significant financial relationships to disclose

Scientific Assembly 2009: Advanced Airway Techniques 

What Is Your Rescue Airway Plan: Advanced Airway Techniques

Michael A. Gibbs, MD, FACEP
Chair, Department of Emergency Medicine
Maine Medical Center
Professor of Emergency Medicine
Tufts University School of Medicine

Questions For The Emergency Physician:

1. Can I predict the difficult airway?

2. How often can I expect to be faced with a difficult airway?
3. What tools do I have to manage the difficult airway?
4. What is the best strategy for managing the difficult airway?

Question #1: Can I Predict The Difficult Airway?

Airway management is a skill that defines Emergency Medicine. We are expected to

manage the most challenging airways in the hospital with little time, little information,
and no margin for error, complication, or failure.

Success will require three unique skill sets:

1. Ability to immediately predict the difficult airway,

2. Sophisticated proficiency with conventional laryngoscopy and a growing number
of airway management devices,
3. A well thought-out approach for dealing with the difficult and failed airway.

It is important to understand two definitions:

The “difficult airway” has three components that may or may not co-exist:
1. Difficult bag-valve mask ventilation
2. Difficult laryngoscopy
3. Difficult surgical airway

ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277.

Scientific Assembly 2009: Advanced Airway Techniques 

A “failed airway” exists when one or both of the following scenarios occur:
1. Inability to ventilate or intubate the paralyzed patients
2. Three intubation attempts by the same operator

ASA Difficult Airway Task Force. Anesthesiology 2003; 93:1269-1277.

It is logical that predicting the difficult airway would be desirable, and a number of
different parameters have been proposed:

ƒ Long upper incisors and/or a prominent overbite

ƒ Inter-incisor distance <3 finger breaths
ƒ Mandibular floor distance <3 finger breaths
ƒ Thyromental distance <2 finger breaths
ƒ Mallampati score >2
ƒ High arched palate
ƒ Large, thick tongue
ƒ Short, thick neck
ƒ Patient unable to touch the chin to the chest

In 2003, the ASA Difficult Airway Task force completed an evidence-based review of the
available literature and concluded that there was insufficient evidence to definitively
recommend any specific predictive tool, although data suggested that some of these
markers were “associated” with difficult airways.

Levitan RM. Limitations of difficult airway predictors in patients intubated in the

emergency department. Annals of Emergency Medicine 2004; 44:307-313.

This study evaluated whether parameters used to identify potentially difficult airways
[Mallampati score, thyromental distance, and neck mobility] could be practically
assessed in a population of ED patients undergoing intubation. Mallampati scoring was
deemed unobtainable if patients could not follow simple commands. Neck mobility and
thyromental assessment were deemed unobtainable with cervical spine precautions.
838 patients undergoing RSI were included. 452 [53%] patients could not follow simple
commands and cervical immobilization was present in 370 [44%]. The authors pointed
out that these measures could only be obtained in about one third of patients.

Comment
It is useful to remember that not every airway assessment tool can be obtained in every
patient. On the other hand, I would argue that “some information is better than no
information.” The Emergency Physician must adapt his/her assessment to a wide array
of patient care scenarios in the ED.
Scientific Assembly 2009: Advanced Airway Techniques 

The Difficult Airway Course™ has developed a series of tools to predict the potentially
difficult airway.* These are intuitive, practical, and supported by prospective evaluation.

MOANS: Assesses the Potential for Difficult Bag-Valve-Mask Ventilation

Mask seal Inadequate mask seal?
Obesity >26 kg/m2
Aged >55 years
No teeth No teeth impair BVM effectiveness
Stiff ventilation Asthma, COPD, ARDS, term pregnancy

LEMON: Assesses the Potential for Difficult Laryngoscopy

Look Injury, large incisors, large tongue, beard
Evaluate “3-3-2” finger-breadth measurement†
Mallampati Score ≥3
Obstruction Any condition causing obstruction
Neck Limited neck mobility
†
3= inter-incision; 3=floor of mandible; 2=thyroid to mandible

SHORT: Assesses the Potential for Difficult Cricothyrotomy

Surgery Prior neck surgery
Hematoma Significant midline neck hematoma
Obesity >26 kg/m2
Radiation Prior neck radiotherapy
Tumor History of head and neck cancer

*Adapted with permission from The Difficult Airway Course: Emergency™ and from Walls RM and
Murphy MF: Manual of Emergency Airway Management, 3rd edition, Philadelphia, Lippincott, Williams,
and Wilkins© 2008.

Reed MJ. Can an airway assessment score predict difficulty at intubation in the
emergency department? Emergency Medicine Journal 2005; 22:99-102.

This study assessed the ability of the LEMON score to predict difficult airways. 156 ED
patients had a LEMON score performed and correlated with the Cormack-Lehane score
during laryngoscopy. 73% of patients were classified as “easy intubations,” and 27%
were “difficult intubations.” Patients with large incisors [p <0.001], a reduced inter-incisor
distance [p <0.05], or a reduced thyroid to mandible distance [p <0.05] were more likely
to have a poor laryngoscopic view and a potentially more difficult intubation.

Comment:
The “LEMON Law” [or at least portions of it] can be rapidly performed in ED setting. “Big
teeth, small mouth, short neck” all predict a potentially difficult airway. Citing this paper,
the LEMON law was recently recommended in the updated 8th edition of the ATLS
Guidelines [see: Kortbeck JB. Journal of Trauma 2008 64:1638].
Scientific Assembly 2009: Advanced Airway Techniques 

Question #2: How Often Can I Expect To Be Faced With A Difficult Airway?

Bair AE. The failed intubation attempt in the emergency department: analysis of
prevalence, techniques, and personnel. Journal of Emergency Medicine 2002; 23:131.

Prospective, observational study of ED airway management in 30 hospitals in the U.S.,

Canada, and Singapore participating in the National Emergency Airway Registry [NEAR].
Patients were enrolled if the first technique was unsuccessful and a rescue was required.

Results & Comment:

7,712 Patients

207 [2.7%] Failed

Rescue RSI 102 [49%]  Surgical 43 [21%] Other 59 [28%]

OTI w/o Drugs 37  RSI 26

OTI with Sedation 29  Other 17

Nasotracheal 36 

Rescue Techniques Used:

Non-RSI RSI Total

Surgical 17 26 43 [0.5%]
Fiberoptic 4 7 11 [0.14%]
Endotrol™ 7 0 7 [0.09%]
LMA™ 2 0 2 [0.025%]
Retrograde 2 0 2 [0.025%]

This study reminds us that failed airways are rare and therefore, clinician experience
with any specific rescue device is typically very limited.
Scientific Assembly 2009: Advanced Airway Techniques 

Question #2: How Often Can I Expect To Be Faced With A Difficult Airway?

Peterson GN. Management of the difficult airway: A closed claims analysis.

Anesthesiology 2005; 103:33.

This study reviews a series of closed claims from difficult airway management
associated with either death or neurological disability. The authors attempted to
correlate “improvement” in litigation activities with the introduction of the ASA Difficult
Airway Algorithm.

Comment:
While it is difficult to definitively correlate the introduction of the algorithm with a clear
reduction in claim frequency or severity, the investigators made several critical
observations:

First:
Emergency procedures were associated with more severe outcomes than elective
procedures. No surprise and welcome to Emergency Medicine! This underscores the
difficulty of managing challenging airways in our world, i.e.: no data, no time,
compromised physiology, full stomachs.

Second:
Difficult mask ventilation increased the risk of an airway emergency and death. As
stated above, meticulous attention to the airway assessment will help minimize this.

Third:
The highest predictor of bad outcome around the time of airway management involved
persistent attempts at intubation before attempting another method. In this situation,
outcomes were poor even if a surgical airway was attempted and ultimately secured.
This seems obvious, but it remains a critical pitfall in both the operating room and the
emergency department. Developing a well thought out approach to the difficult and
failed airway is absolutely essential.

Fourth:
A variety of rescue techniques were employed, including LMA®, Combitube®, retrograde
intubation, and jet ventilation. Limited familiarity with the rescue technique employed
increased the likelihood of complications. It is important for the Emergency Physician to
have more than one option for airway rescue.
Scientific Assembly 2009: Advanced Airway Techniques 

Question #3: What Tools Do I Have To Deal With The Difficult Airway?

The number of airway devices on the market continues to grow at a dizzying pace. The
discussion below will outline the strengths and weaknesses of three general categories
of airway adjuncts:

1) Blind insertion supra-glottic airway devices

a) Double-lumen laryngeal devices
i) Combitube®
ii) King-LT®
b) Laryngeal mask airways
i) Standard LMA®
ii) Intubating LMA [Fastrack®]
c) Intubating stylets
i) Gum-elastic bougie
ii) Lighted stylet [Trachlight®]

2) Direct vision supra-glottic airway devices

a) Hand-held fiberoptic intubating stylets
i) Levitan Scope®
ii) Shikani Optical Stylet®
iii) RIFL®
b) Hand-held fiberoptic laryngoscopes
i) McGraf Scope®
ii) Glidescope®
iii) Storz Videolaryngoscope®
iv) Pentax Airway Scope®
c) Traditional flexible fiberoscopes
d) Prism/mirror assisted scopes [Airtraq®]

3) Infra-glottic airway devices

a) Retrograde intubation
b) Transtracheal jet ventilation
c) Surgical cricothyrotomy
i) Open
ii) Percutaneous

Before we discuss these devices, remember... always consider the “easy stuff first.”
Effective patient positioning, use of the BURP technique, and bimanual laryngoscopy
may avert the need to reach for a fancy device [see: Levitan R. Laryngeal view during
laryngoscopy: A randomized trial comparing cricoid pressure, backward-upwards-
rightwards pressure and bimanual laryngoscopy. Annals of Emergency Medicine
2006; 46:548.].
Scientific Assembly 2009: Advanced Airway Techniques 

Blind Insertion Supra-Glottic Airway Devices

By definition, the “blind-insertion” devices rely on accurate placement without the benefit
of directly vision. As such, use is generally recommended in patients with anatomically
intact airways. This approach avoids the potential for iatrogenic injury or misplacement.

Double Lumen Laryngeal Devices

The Combitube® and King-LT® are inserted through the mouth, with the device almost
always seated in the esophagus. The trachea is ventilated through side ports.

Combitube®
Advantages Disadvantages
Inexpensive Blind-insertion approach
Easy to teach and learn Not a definitive airway
Ventilation superior to a standard BVM Rare reports of airway injury
Can intubate with the device in place May cause cervical motion in fracture
May be difficult to insert with neck in-line

King-LT®
Advantages Disadvantages
Inexpensive Blind-insertion approach
Easy to teach and learn Not a definitive airway
Ventilation superior to a standard BVM Can not intubate with the device in place
Single balloon inflation

Laryngeal Mask Airways

The LMA® and Intubating-LMA [Fastrack®] both rely on seating of the device in the
esophagus. The Fastrack™ allows for intubation of the trachea with a cuffed tube.

Standard Laryngeal Mask Airway®

Advantages Disadvantages
Relatively inexpensive Blind-insertion approach
Ventilation superior to a standard BVM Not a definitive airway
Requires careful sizing to fit in the airway

Intubating Laryngeal Mask Airway [Fastrack®]

Advantages Disadvantages
Ventilation superior to a standard BVM Expensive
Provides a definitive airway Requires careful sizing to fit in the airway
Scientific Assembly 2009: Advanced Airway Techniques 

Blind Insertion Supra-Glottic Airway Devices [continued]

Intubating Stylets
There are a number of intubating stylets on the market. The classic gum-elastic bougie
is inserted under direct vision or blindly “by feel” into the airway. The Trachlight® relies
on trans-illumination of the larynx during blind insertion.

Gum Elastic Bougie

Advantages Disadvantages
Inexpensive Blind technique difficult
Provides a definite airway
Can use as an adjunct to laryngoscopy
Can insert visually or blindly

Lighted Stylet [Trachlight®]

Advantages Disadvantages
Provides a definitive airway Technique requires expertise
Can use as an adjunct to laryngoscopy
Minimal neck movement

Direct Vision Supra-Glottic Airway Devices

The hand-held fiberoptic stylets and laryngoscopes have revolutionized emergency

airway management. These devices offer the advantage of direct visualization of the
airway without the technical complexity and cost of more traditional flexible fiberoptic
scopes. Each of these has a different design and it is difficult to strongly recommend
one over the other. I believe every emergency department should have at least one of
these devices in the difficult airway cart. Furthermore, in videolaryngoscopy is an
excellent teaching tool that should rapidly become the standard at Emergency Medicine
training programs.

The disposable Airtraq Scope®, that uses a prism/mirror system, offers a cheap
alternative to direct airway visualization and a guide port for insertion of the ETT.

Hand-Held Fiberoptic Intubating Stylets

The Levitan Scope®, Shikani Optical Stylet®, and RIFL® use similar technology; with a
fiberoptic bundle in a rigid or semi-flexible metal stylet. The RIFL® incorporates a trigger
mechanism that elevates the distal tip of the stylet. With each a standard endotracheal
tube is loaded over the stylet and advanced into the airway under direct vision through
an eyepiece. While each has a unique design the principles of insertion, advantages,
and disadvantages are similar.
Scientific Assembly 2009: Advanced Airway Techniques 

Direct Vision Supra-Glottic Airway Devices [Continued]

Hand-Held Fiberoptic Laryngoscopes

The McGrath Scope®, Storz Scope®, and Pentax Airway Scope® use similar technology;
with a fiberoptic “eye” at the tip of a modified laryngoscope blade. These devices are
advanced into the mouth like a standard laryngoscope and the airway is then visualized
on either a small video screen on the handle of the device [McGrath, Pentax Airway
Scope® ] or a monitor attached to the device via a cable [Storz®]. The Glidescope®
employs similar technology but a different approach, whereby the device is inserted
blindly and guided into the airway by watching a monitor.

Hand-Held Fiberoptic Stylets And Hand-Held Fiberoptic Laryngoscopes

Advantages Disadvantages
Less expensive than traditional fiberscope Relatively expensive
Easier to use than a flexible fiberscope Different psychomotor skill
Direct vision of the airway Tip can be obscured by fog, secretions
Definitive airway
Allows for “supervised” airway visualization

Infra-Glottic Airway Devices

Transtracheal Jet Ventilation

TTJV relies on placement of a rigid catheter through the cricothyroid membrane into the
airway. Ventilation is delivered in intermittent “jets” using a regulator system attached to
a standard medical gas oxygen port.

Transtracheal Jet Ventilation

Advantages Disadvantages
Less invasive than a surgical airway Not a definite airway
Less complex than a surgical airway Contraindicated in airway obstruction
Provided a “bridge” to other techniques May cause barotrauma

If I am that far down the algorithm, i.e.: about to move to an infra-glottic technique… I
would choose a formal cricothyrotomy over TTJV. The notable exception is in children
<8, where cricothyrotomy is contraindicated.
Scientific Assembly 2009: Advanced Airway Techniques 

Infra-Glottic Airway Devices [Continued]

Retrograde Intubation
Retrograde intubation employs a Seldinger guide-wire system advanced through the
cricothyroid membrane and then retrograde into the posterior pharynx. The wire is
retrieved through the mouth, a rigid introducer is placed over the wire, a standard
endotracheal tube is advanced over the introducer and advanced through the glottis,
and the wire removed.

Given the number of steps required and the growing number of less complicated
alternatives, I would not recommend retrograde intubation for ED airway rescue during
which there is always little time, tenuous physiology, and a full stomach.

Cricothyrotomy
Surgical cricothyrotomy; either open or percutaneous, remain the “last box” on every
airway algorithm ever published. All clinicians responsible for emergency airway
management must master one of these techniques, and preferable both. Because most
emergency physicians are seldom, if ever called upon to perform this life-saving
procedure, periodic cadaver, animal, or simulator training is essential.

Cadaver studies by Chan TM, et al [Journal of Emergency Medicine 1999] and

Schaumann N, et al [Anesthesiology 2004] have demonstrated that:

ƒ The time to completion is similar for both techniques

ƒ Success rates [85% to 95%] are similar
ƒ Misplacement is more common with the percutaneous technique
ƒ Tissue injury is more common with the open technique

The decision to perform one technique versus the other boils down to one vital issue:
airway landmarks. In patients with a readily identifiable/palpable cricothyroid membrane;
either technique is likely to be effective and the rationale for selecting a less invasive
method [i.e.: percutaneous] is logical. Conversely, if the airway landmarks are difficult to
identify, I would strongly recommend the open technique, that allows the operator to cut
down to the larynx and reliably access the airway.
Scientific Assembly 2009: Advanced Airway Techniques 

Question #4: What Is The Best Strategy For Managing The Difficult Airway?

A number of algorithms have been proposed addressing this vexing problem. The
American Society of Anesthesiology difficult airway algorithm [Anesthesiology 2003] is
difficult to apply in the ED setting. The Difficult Airway Course – Emergency™ has a
series of airway algorithms that are more germane to our environment [see Appendix I].
These provide a logical framework for dealing with both the difficult and the failed
airway.

A few years ago I put together a “Difficult Airway Grid” reliant on the answer to two very
simple questions:

First: Is airway anatomy “normal” or “abnormal?”

Second: Is oxygenation adequate [i.e.: O2 saturations >90%]

In the context of this grid, an “abnormal anatomy” implies disrupted or altered anatomy
and not just an anticpated difficulty in visualizing the glottis. Examples of a difficult
airway with “abnormal anatomy” include trauma, burn, hematoma, cancer, abscess,
foreign body and angioedema. Examples of a difficult airway with “normal anatomy”
include obesity, a small mouth, and a high anterior larynx.

Normal Anatomy Abnormal Anatomy

Adequate Oxygenation Adequate Oxygenation

Normal Anatomy Abnormal Anatomy

Inadequate Oxygenation Inadequate Oxygenation

“Locating yourself” in one of these four boxes allows you to risk-stratify the patient and
choose quickly from a menu of airway rescue devices to appropriate for the case at
hand.

It is worth noting that this Grid was developed prior to the introduction of the hand-held
fiberoptic devices and video laryngoscopy. The “solutions” for each of the four boxes
have been updated accordingly.
Scientific Assembly 2009: Advanced Airway Techniques 

Principles and solutions for each box on the grid are listed below. It is important to
recognize that while these principles are generalizeable, the solutions will vary based on
skill level and equipment availability.

Normal Anatomy + Adequate Oxygenation

Principles
You have time
No need for a surgical airway
Blind-insertion devices [BID] appropriate
Hand-held fiberoptics ideal
Cuffed tube the goal
Solutions
Hand-held fiberoptics available
Any of these should work
Hand-held fiberoptics not available
1st choice I-LMA™, 2nd choice Bougie

Case Example 1:
Consider a morbidly obese patient who presents to the ED after an overdose. He has
stable vital signs, but is obtunded and not protecting his airway. Airway dimensions and
anatomy are “normal.” Oxygen saturations are >95% on supplemental oxygen.
Following sedation and paralysis the glottis can not be visualized despite three attempts
with re-positioning. Oxygenation can be maintained with BVM ventilation.

This case illustrates two key features: First, because oxygenation can be maintained
you have some time. Second, there is nothing “wrong” with the airway, you just can’t
see it. Blind insertion devices are therefore safe and would be a reasonable choice.
Hand-held fiberoptic devices that provide a direct view of the glottis are an even better
choice.

Normal Anatomy + Inadequate Oxygenation

Principles
No time
Multiple BID attempts inappropriate
Use what you know best
Surgical airway if 1st rescue plan fails
Solutions
Hand-held fiberoptics available
Limited attempts with these, then surgical
Hand-held fiberoptics not available
Limited attempts with I-LMA, then surgical

Case Example 2:
Now consider the same overdose patient who you have paralyzed and sedated.
Aspiration is evident after the first attempt at laryngoscopy and you are having difficulty
oxygenating the patient even with adequate positioning and an oral airway.

The key difference this scenario and Case 1 is that you no longer have time. Your
“device menu” is essentially the same, but multiple attempts with any of these are
neither possible nor appropriate. In this situation, limited attempts [1-2 at most] using
the rescue device with which you have the most experience, and therefore the highest
likelihood of success, should be your first move. If this is unsuccessful, a surgical airway
is your next step.
Scientific Assembly 2009: Advanced Airway Techniques 

Abnormal Anatomy + Adequate Oxygenation

Principles
Blind insertion device risky
Direct airway visualization preferred
Fiberoptic OK if not obscured by blood
Surgical airway back-up
Solutions
Hand-held fiberoptic available
Limited attempts with fiberoptic
Surgical airway if unsuccessful
Hand-held fiberoptic not available
Surgical airway

Case Example 3:
Consider a patient with Ludwig’s Angina in the setting of a severe dental infection. The
patient has stable vital signs and oxygen saturations in the high 90’s. On physical exam
this is significant trismus and a large submandibular hematoma. Because of progressive
swelling you decide to intubate the patient prior to transfer to a tertiary center.

This case illustrates several important concepts: First, you have some time, but not
much. Second, blind insertion devices are not recommended in the setting of
significantly altered airway anatomy as these are unlikely to be successful and may
cause additional injury during insertion attempts. Third, a direct view of the glottis using
a fiberoptic device [traditional or hand-held] is preferred. Fourth, if fiberoptic devices are
to work, the airway must be relatively clear of blood and secretions.

Abnormal Airway + Inadequate Oxygenation

Principles
No time
Blind insertion devices contraindicated
Fiberoptic OK if not obscured by blood
st
Surgical often the best 1 choice
Solutions
Hand-held fiberoptic available
1 attempt with fiberoptic if feasible
Surgical airway if unsuccessful
Hand-held fiberoptic not available
Surgical airway

Case Example 4:
Consider a patient with a gunshot wound to the mouth. The mandible is blown apart and
blood is pouring into the airway. Oxygen saturations are dropping and the patient is
impossible to bag.

The key message here is don’t outsmart yourself. Because the likelihood of failure with
most techniques is so high, it can be easily argued that an immediate surgical airway is
the only answer to this case.
Scientific Assembly 2009: Advanced Airway Techniques 

Appendix I: Difficult Airway Course™ – Emergency Algorithms*

*Adapted with permission from The Difficult Airway Course: Emergency™ and from Walls RM and
Murphy MF: Manual of Emergency Airway Management, 3rd edition, Philadelphia, Lippincott, Williams,
and Wilkins© 2008.

The Difficult Airway Algorithm

Difficult airway
Call for assistance
predicted

yes
Failure to Maintain Failed
Oxygenation? airway

no

BMV or EGD yes yes

predicted to be Intubation predicted
to be successful? RSI
successful?
no
no

yes
Awake DL, FO or Post-intubation
VL successful? management
or RSI
no

ILMA
FO or VL Go to main
algorithm
Cricothyrotomy
BNTI
Lighted stylet

© 2008 The Difficult Airway Course: Emergency™

Scientific Assembly 2009: Advanced Airway Techniques 

Appendix I: Difficult Airway Course™ – Emergency Algorithms*

*Adapted with permission from The Difficult Airway Course: Emergency™ and from Walls RM and
Murphy MF: Manual of Emergency Airway Management, 3rd edition, Philadelphia, Lippincott, Williams,
and Wilkins© 2008.

The Failed Airway Algorithm

Failed airway Call for assistance

criteria
EGD may
be attempted

Failure to maintain yes

Oxygenation? Cricothyrotomy

no If contraindicated

Choose one of:

Fiberoptic method
Video laryngoscope
EGD
Lighted Stylet
Cricothyrotomy

yes
Post-intubation
Cuffed ETT placed? management

no

Arrange for
definitive airway
management

© 2008 The Difficult Airway Course: Emergency™

Scientific Assembly 2009: Advanced Airway Techniques 

Appendix II: Annotated Bibliography of Recent Airway Management Literature

Airtraq Laryngoscope

Hirabayashi Y. A comparison of cervical spine movement during laryngoscopy using the

Airtraq® or Macintosh laryngoscopes. Anaesthesia 2008; 63:635.

Maharaj CH. Endotracheal intubation in patients with cervical spine immobilization: A

comparison of Macintosh and Airtraq® laryngoscopes. Anesthesiology 2007; 107:53.

Maharaj CH. Evaluation of the Airtraq® and Macintosh laryngoscopes in patients at

increased risk for difficult tracheal intubation. Anaesthesia 2008; 63:182.

Airway Assessment

ASA Difficult Airway Taskforce. Practice guidelines for management of the difficult
airway. Anesthesiology 2003; 98:1269.

Gonzalez H. The importance of increased neck circumference to intubation difficulties in

obese patients. Anesthesia Analogues 2008; 106:1132.

Kheterpal S. Incidence and predictors of difficult and impossible mask ventilation.

Anesthesiology 2006; 105:885.

Krobbuaban B. The predictive value of the height ratio and thyromental distance: Four
predictive tests for difficult laryngoscopy. Anesthesia Analogues 2005; 101:1542.

Lee A. A systematic review [meta-analysis] of the accuracy of the Mallampati tests to

predict the difficult airway. Anesthesia Analogues 2006; 102:1867.

Levitan RM. Limitations of difficult airway predictors in patients intubated in the

emergency department. Annals of Emergency Medicine 2004; 44:307.

Peterson GN. Management of the difficult airway: A closed claims analysis.

Anesthesiology 2005; 103:33.

Reed MJ. Can an airway assessment score predict difficulty at intubation in the
emergency department? Emergency Medicine Journal 2005; 22:99.

Tripathi M. Short thryomental distance: A predictor of difficult intubation or an indicator

for small blade selection? Anesthesiology 2006; 104:1131.
Scientific Assembly 2009: Advanced Airway Techniques 

Combitube
Davis DP. The Combitube as a salvage airway device for paramedic rapid sequence
intubation. Annals of Emergency Medicine 2003; 42:697.

Lefrancois DP. Use of the esophageal tracheal combitube by basic emergency medical
technicians. Resuscitation 2002; 52:77.

Mercer MH. Insertion of the Combitube airway with the cervical spine immobilised in a
rigid cervical collar. Anaesthesia 1998; 53:971-4.

Mort TC. Laryngeal mask airway and bougie intubation failures: The Combitube as a
secondary rescue device for in-hospital emergency airway management. Anesthesia
Analogues 2006 103:1264.

Vezina MC. Complications associated with the Esophageal-Tracheal Combitube® in the

prehosptial setting. Canadian Journal of Anesthesiology 2007; 54:124.

Cricothyrotomy

Benkhadra M. A comparison of two emergency cricothyroidotomy kits in human

cadavers. Anesthesia Analogues 2008; 106:182.

Chan TC. Comparison of wire-guided cricothyrotomy versus standard surgical

cricothyrotomy technique. Journal of Emergency Medicine 1999; 17:957.

Schaumann N. Evaluation of Seldinger technique emergency cricothyroidotomy versus

standard cricothyroidotomy in 200 cadavers. Anesthesiology 2005; 102:7.

Difficult Airway

Bair AE. The failed intubation attempt in the emergency department: analysis of
prevalence, techniques, and personnel. Journal of Emergency Medicine 2002; 23:13.

Brimacombe J. Cervical spine motion during airway management: a cinefluoroscopic

study of the posteriorly destabilized third cervical vertebrae in human cadavers.
Anesthesia & Analgesia 2000; 91:1274.

Combes X. Unanticipated difficult airway in anesthetized patients: Prospective validation

of a management algorithm. Anesthesiology 2004; 100:1146.

Laryngeal view during laryngoscopy: A randomized trial comparing cricoid pressure,

backward-upwards-rightwards pressure and bimanual laryngoscopy. Annals of
Emergency Medicine 2006; 46:548.
Scientific Assembly 2009: Advanced Airway Techniques 

Gum Elastic Bougie

Noguchi T. The gum elastic bougie eases tracheal intubation while apply cricoids
pressure compared to a stylet. Canadian Journal of Anaesthesia 2003; 50:712.

Laryngeal Mask Airway

Combes X. Intubating laryngeal mask airway in morbidly obese and lean patients: A
comparative study. Anesthesiology 2005; 102:1106.

Frapper J. Airway management using the intubating laryngeal mask airway for the
morbidly obese patient. Anesthesia Analogues 2003; 96:1510.

Kihara S. Intubating laryngeal mask airway size selection: A randomized triple

crossover study in paralyzed anesthetized male and female patients. Anesthesia
Analogues 2002; 94:1023.

Langeron O. Comparison of the intubating laryngeal mask airway with the fiberoptic
intubation in anticipated difficult airway management. Anesthesiology 2001; 94:968.

Timmermann A. Novices ventilate and intubate quicker and safer via intubating
laryngeal mask than by conventional bag-mask ventilation and laryngoscopy.
Anesthesiology 107:570.

Liu EH. Success of tracheal intubation with intubating laryngeal mask airways: A
randomized trial of the LMA Fastrach™ and LMA CTrach™. Anesthesiology 2008;
108:621.

Video Laryngoscopy

Cooper RM. Early clinical experience with a new videolaryngoscope [Glidescope®] in

728 patients. Canadian Journal of Anesthesiology 2005; 52:191.

Greenland KB. Comparison of the Levitan FPS Scope and the single-use bougie for
simulated difficult intubation in anaesthetized patients. Anaesthesia 2007; 62:509.

Hirabayashi Y. Cervical spine movement during laryngoscopy using the Airway Scope
compared with the Macintosh laryngoscope. Anaesthesia 2007; 62:1050.

Low D. The use of the BERCI DCI® video laryngoscope for teaching novices direct
laryngoscopy and tracheal intubation. Anaesthesia 2008; 63:195.

Robitalille A. Cervical spine motion during intubation with manual in-line stabilization:
Direct laryngoscopy versus Glidescope® videolaryngoscopy. Anesthesia Analogues
2008; 106:935.
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Suzuki A. The Pentax-AWS® rigid indirect video laryngoscope: Clinical assessment of

performance in 320 cases. Anaesthesia 2008; 63:641.

Tremblay MH, Poor visualization during direct laryngoscopy and high upper lip bite
score are predictors of difficult intubation with the Glidescope videolaryngoscopy.
Anesthesia Analogues 2008; 106:1498.

Turkstra TP. Cervical spine motion: A fluoroscopic comparison of Shikani Optical Stylet
versus Macintosh laryngoscopy. Canadian Journal of Anesthesia 2007; 54:441.