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Key Points
■ The difficult airway must be considered to involve at least one of the following: difficult
laryngoscopy and difficult mask ventilation and/or difficult tracheal intubation.
■ It is important to realize that identification of the difficult airway before manipulation is the first
step in preparing for optimal patient care and a safe outcome.
■ The otolaryngologist with training and expertise in endoscopic techniques—such as rigid and
flexible laryngoscopy, bronchoscopy, and the ability to provide open surgical access to the airway—
is an essential member of the difficult-airway response team.
■ Techniques commonly used in management of the difficult airway include awake fiberoptic
laryngoscopy, intubation through a laryngeal mask airway with or without fiberoptic laryngoscopy,
intubation by direct laryngoscopy with an anterior commissure laryngoscope, and the surgical airway.
■ Awake fiberoptic intubation should be considered in the obese patient with obstructive sleep
apnea, in conditions that result in supraglottic obstruction (e.g., edema, supraglottic tumor), and in
patients with a history of difficult intubation by other techniques.
■ Lack of training and experience in fiberoptic bronchoscopy is a common cause of failure in awake
fiberoptic intubation.
■ Once the “cannot intubate/cannot ventilate” situation has been identified, immediate consideration
should be given to surgical airway access.
F ailure to maintain a patent airway can result in catastrophic difficult laryngoscopy to be reliable, and for the preceding
events for the patient, including brain damage or death. In laryngoscopic grading system to be helpful, the reported grades
1990, more than 85% of all respiratory event–related closed must describe the best view that was obtained, which in turn
malpractice claims involved an anoxic brain injury or death.1 depends on the best performance of laryngoscopy.4 The techni-
Difficulties with intubation and emergent airway issues remain cal components that optimize laryngoscopy include optimal
the leading causes of serious intraoperative complications.2 As position, complete muscle relaxation, firm forward and upward
many as 30% of deaths attributable to anesthesia involve failure traction on the laryngoscope, and, if necessary, firm external
to manage the difficult airway.3 In any given patient, the risk of laryngeal manipulation with cricoid pressure. External laryn-
anoxic injury or death increases in direct proportion to the geal pressure, for example, may reduce the incidence of a
degree of difficulty in maintaining a patent airway.4 Any scien- grade III view from 9% to 1.3%.8 Theoretically, if the preceding
tific or clinical description of the difficult airway must include technical components of laryngoscopy are used, and the pitfalls
clearly defined terminology. are avoided, all laryngoscopists, both novice and expert, should
This chapter considers the difficult airway as involving three have close to the same laryngoscopic view. Difficult laryngos-
distinct but often clinically related scenarios. The first of these copy is synonymous with difficult intubation in most patients.
is difficult tracheal intubation, which exists when multiple attempts A grade II or III laryngoscopic view that requires multiple
are needed in the presence or absence of tracheal disease. An attempts with different blades is relatively common and occurs
infinitely difficult intubation means the trachea cannot be intu- in 100 to 1800 of 10,000 patients.9 The incidence of a higher
bated under direct vision, despite full paralysis, optimal head grade III laryngoscopic view ranges from 100 to 400 per 10,000
and neck positioning, cricoid pressure, forceful anterior eleva- patients.10,11
tion of the laryngoscope blade, and attempts by multiple opera- The third difficult airway scenario is difficult mask ventilation
tors with a variety of laryngoscope blades.4 The incidence of (DMV), a condition in which it is not possible to provide ade-
failed endotracheal intubation ranges from 5 to 35 per 10,000 quate facemask ventilation as a result of inadequate mask seal
patients.5,6 or excessive resistance because of inadequate patency of the
The second difficult airway scenario is the difficult laryngos- airway.4 Langeron and colleagues12 compiled a list of predictors
copy, described as inability to visualize any portion of the larynx, of DMV based on a survey of anesthesiologists, asking them to
vocal folds, or glottic aperture after multiple attempts at con- rate the difficulty of facemask ventilation; this difficulty rating
ventional laryngoscopy. Many investigators include grades III was based on whether it was clinically relevant and could have
and IV or grade IV alone, according to the Cormack-Lehane7 led to potential problems if mask ventilation had to be main-
original grading of the rigid laryngoscopic view. For studies of tained for a longer time. Six reasons for DMV were identified:
86
6 | SURGICAL MANAGEMENT OF THE DIFFICULT ADULT AIRWAY 87
INDICATIONS
When the airway is compromised or a difficult airway is antici-
pated, awake fiberoptic intubation (FOI) with or without seda-
tion should be considered (Box 6-2). Awake FOI is an ideal
procedure for patients with morbid obesity, supraglottic mass,
or edema with the ability to visualize the glottic aperture; when
there is a risk of aspiration, a history of known DMV or prior
difficulty with transoral intubation using other techniques; and
in patients with limited mandible excursion or trismus. Contra-
indications to awake FOI include fixed stenotic lesions at all
levels that will not allow passage of an ETT without dilation,
active bleeding that obscures visualization, an acute obstructing
supraglottitis, and in patients unable to cooperate during the
examination. In general, many patients who might be denied
general anesthesia or who might receive a tracheostomy can be
safely intubated using the FOB. To intubate patients safely and FIGURE 6-2. Cart for anesthesia for the difficult airway demonstrates orga-
quickly, certain preparatory steps should be taken. nization of ancillary items used for fiberoptic intubation.
6 | SURGICAL MANAGEMENT OF THE DIFFICULT ADULT AIRWAY 89
FIGURE 6-3. Nasal trumpet placed for dilation is lubricated with FIGURE 6-5. Optimal setup for fiberoptic intubation includes a patient with
lidocaine gel. the head elevated to minimize airway collapse, the operator facing patient,
and the entire team observing the procedure on the video monitor.
the vocal cords as it enters the oropharynx and is generally
better tolerated by the patient.31 Our preferred method is to
prepare the nose as described above while setting up the equip- no manipulation of the tip of the scope. In patients who are not
ment and supplies. The ETT is placed in warm saline to soften breathing spontaneously or who are older, the tongue and pha-
it. The cuff is tested by inflation, and to minimize resistance, ryngeal tissue may fall back and block the exposure of the larynx.
the cuff is retracted back when deflated so that it is flush with A few maneuvers help visualize the cords: these include extend-
the outer wall of the tube. The nasal passages are first dilated ing the head, applying jaw thrust, or gently pulling the tongue
to the appropriate diameter with increasingly larger nasal trum- forward. Once visualized, application of 3-mL aliquots of 2%
pets, which are generously lubricated with lidocaine gel and lidocaine instilled through the scope should be performed at
epinephrine solution (Fig. 6-3). The ETT is then placed into the level of the vocal folds before intubation, and time should
the nostril and directed downward, as it is advanced toward the be allowed for these to take effect. Patience is extremely helpful
nasopharynx. If the tube does not make the bend toward at this point, and continuous communication with the patient,
the oropharynx, it is pulled back and rotated 90 degrees to the letting him or her know that all is proceeding as planned, helps
right or left and then reintroduced. minimize anxiety. It is also helpful to have multiple syringes with
The FOB, which is connected to a videoendoscopy unit, is “slip-tips” preloaded with lidocaine, because repeated injections
then passed through the ETT and is used to visualize the airway may be necessary, until the patient no longer coughs in response
(Fig. 6-4). It is preferable to have the patient’s head elevated and, to stimulation. The scope is then advanced through the vocal
if possible, to be sitting near upright to minimize airway collapse; folds. Timing the entry of the scope with the breathing cycle is
the operator faces the patient and the video monitor (Fig. 6-5). a useful trick. Once adequate visualization is achieved, the scope
The video-assisted FOI provides feedback to those assisting with is then advanced into the cervical trachea, and additional lido-
the procedure and facilitates intubation. In 80% to 85% of caine in instilled. The scope is then advanced to a level just above
patients, the epiglottis and vocal folds are seen with minimal or the carina, and the ETT is passed over the scope into position.
If resistance is encountered during this maneuver, it is helpful
to rotate the ETT 90 degrees clockwise, changing the orientation
of the bevel.51
SURGICAL CRICOTHYROTOMY
Indications
The primary indication for cricothyrotomy is failure to intubate
by oral or nasal means in the presence of an immediate need
for definitive airway management and an inability to mask ven-
tilate the patient.
The ASA Difficult Airway Algorithm recommends a surgical
airway as the final end point for the unsuccessful arm of the
emergency pathway.64 Despite the introduction of numerous
rescue devices for failed airway, the most common errors in the CTM
management of the difficult airway result from repeated unsuc-
cessful attempts at intubation in these situations.65 Once the
cannot intubate/cannot ventilate situation has been identified, immedi-
ate consideration should be given to a surgical airway. Failure to
pursue this approach when unable to ventilate will most likely
result in a delay in achieving airway control, which places the FIGURE 6-6. With the superior cornu of the larynx firmly immobilized by
patient at risk for subsequent hypoxic brain injury and/or the thumb and long finger of the operator’s nondominant hand, the index
death. Often the main obstacle is lack of experience or timely finger is free to palpate and locate the cricothyroid membrane (CTM). (From
recognition of the need to perform this procedure. Adequate Walls RM, Murphy MF, Luten RC, et al. Manual of emergency airway management,
training in the laboratory, planning based on an algorithm and ed 2. Philadelphia: Lippincott Williams & Wilkins; 2004.)
availability of equipment, and trained personnel are the keys to
successful performance of the procedure. Availability of neces- of the thyroid cartilage (Fig. 6-11) to facilitate elevating and
sary equipment, preferably packaged as a preassembled kit, opening the airway. A small (5.0) endotracheal tube or a tra-
prevents wasting crucial minutes gathering supplies in an emer- cheostomy tube is then placed and secured in position (Fig.
gency situation (Box 6-5). 6-12). After stabilizing the patient, the cricothyrotomy should
Relative contraindications for cricothyrotomy include age be converted to a formal tracheostomy, preferably in the OR,
younger than 10 years, severe neck trauma with inability to if long-term intubation is anticipated. If early extubation is
palpate the landmarks, and expanding neck hematoma. Preex- anticipated, the cricothyrotomy may be used until extubation.
isting laryngeal disease with subglottic extension (e.g., malig- See Hsiao J & Pacheco-Fowler68 for the basic technique of
nancy) is another relative contraindication. A planned, urgent cricothyrotomy.
awake tracheostomy is preferred in this situation. Emergency
or “slash” tracheostomy is a procedure that carries a very high Rapid Five-Step Technique
risk of complications, up to five times that of an elective A rapid four-step technique has been described and is reported
procedure.66 to be simple to learn and faster in obtaining a surgical airway.69
This technique has many advantages that include 1) the need
Surgical Procedure for less equipment, 2) the need for only one operator without
Identification and palpation of the sternal notch; the thyroid assistance, and 3) the positioning is such that the operator
cartilage, especially the superior thyroid notch; and cricoid stands at the patient’s head.54 The authors prefer a slight modi-
cartilage, felt as an indentation below the thyroid cartilage, is fication and use a five-step rule:
the critical first step in a cricothyrotomy (Fig. 6-6). Stabilization 1. Identify landmarks and stabilize the airway.
of the upper airway with the operator’s nondominant hand 2. Make a vertical skin incision.
during the rest of the procedure is the single most important 3. Make a horizontal incision through the cricothyroid
factor in determining successful outcome.67 This technique membrane.
pins the larynx in the midline and facilitates dissection by 4. Insert a clamp to spread and elevate the airway.
maintaining anatomic positioning of the airway. 5. Insert a tracheostomy tube or small ETT.
A midline vertical skin incision over the cricoid cartilage
avoids the often engorged anterior jugular veins and minimizes
the risk of injury to the carotid arteries and jugular veins (Fig.
6-7). The membrane is palpated through the incision (Fig. 6-8)
and is entered with a horizontal incision at the lower edge of
the cricothyroid space (Fig. 6-9). This incision is then dilated
with a hemostat or Kelly clamp placed in the airway and is
opened horizontally while lifting upward to expose the opening
(Fig. 6-10). A cricoid hook may be placed at the inferior edge
FIGURE 6-10. The Trousseau dilator is used to enlarge the vertical dimen-
sion of the membrane, the aspect that provides the most resistance to
insertion of the tube. (From Hagberg CA, editor. Benumof’s airway management,
ed 2. Philadelphia: Elsevier; 2006.)
FIGURE 6-8. The index finger is used to directly palpate and relocate the
cricothyroid membrane. (From Walls RM, Murphy MF, Luten RC, et al. Manual
of emergency airway management, ed 2. Philadelphia: Lippincott Williams &
Wilkins; 2004.)
FIGURE 6-11. The tracheal hook exerts light traction on the inferior aspect
of the thyroid cartilage. (From Hagberg CA, editor. Benumof’s airway manage-
ment, ed 2. Philadelphia: Elsevier; 2006.)
CONCLUSION
It is my belief that difficult airway management is an emerging
subspecialty within otolaryngology–head and neck surgery. The
nature of these situations demands a multidisciplinary effort to
standardize institutional action plans and strategies for training
along with day-to-day management of these patients that capi-
talizes on the skills provided by experienced anesthesiologists,
otolaryngology–head and neck surgeons, general surgeons,
emergency department physicians, respiratory therapists, and
nursing staff.
ACKNOWLEDGMENT
I thank Dr. Kulsoom Laeeq, MD, for her help with editing the
manuscript for this chapter.
FIGURE 6-13. Cricoid cartilage shown split in the midline following emer-
gency cricothyrotomy. The site was repaired at the time of revision to formal For a complete list of references, see expertconsult.com.
tracheotomy.
SUGGESTED READINGS
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