The difficult airway

Background

ASA Difficult Airway Algorithm does not necessary apply to the ED since the patient can always be awakened and case cancelled

See:

Airway Adjunct	Eamples	Pros	Cons
Endotracheal tube introducer	Gum elastic bougie	Higher first pass success when used with direct laryngscope vs. styletted ET tube regardless of whether difficult airway was expected or not[1]
Lighted optical stylets		High success rate - especially good for trauma, c-spine precautions Use for both reg and nasotrach Lower complication rate	Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience
Supraglottic airway	LMA
Esophogeal obturator	Combitube	Good for nurses and paramedics with limited intubation skill Indicated if difficult airway predicted: cannot see glottis with laryngoscope Reduced risk for aspiration compared to face mask or LMA *Can maintain spinal immobilization	Large size predisposes to esophogeal dilatation and laceration as a complication
Percutaneous transtracheal ventilation		Prefered over crithyrotomy in children up to age 10-12 Oxygenates well Can use for 30-45 min	Can retain CO2 May cause pneumothorax or barotrauma

Intubation Type	Pros	Cons
Traditional
Awake intubation
Nasal intubation		Lower success rate Higher complication rate (e.g. bleeding, emesis, and airway trauma) Do not attempt in patients with posterior pharyngeal swelling such as in angioedema
Retrograde intubation		Need time to set up Risk hematoma, pneumothorax
Fiberoptic bronchoscopic intubation		Takes time to set up Limited by secretions, bleeding, poor suction,

A surgical airway should always be the last step in patients with failure to oxygen and ventilate with BVM and inability to intubate

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Driver, B. E., Prekker, M. E., Klein, L. R., Reardon, R. F., Miner, J. R., Fagerstrom, E. T., … Cole, J. B. (2018). Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(21), 2179–2189.

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