Incidence of inauspicious airway intubation can attain as excessive as 8.5% in commonplace apply and as excessive as 14% in emergency division settings.1 Reaching a profitable, safe airway for these sufferers depends on the talents and data of emergency drugs and important care suppliers.
By Invoice Pruitt, MBA, RRT, CPFT, FAARC
Establishing a safe, protected airway is important look after a affected person who has stopped respiratory. Circumstances necessitating a synthetic airway could embody cardiac arrest, trauma, neurological points, drug overdose, impending cardiac or respiratory failure, and so on. Intubation could also be wanted for an emergency, or could also be an elective process comparable to in a deliberate surgical procedure or invasive process. Short-term help could be completed by bag/masks air flow, however BMV can’t be carried out for extended durations as it will probably trigger issues with gastric distention, insufficient air flow/oxygenation, hyperventilation, and elevated threat of aspiration.
A brief-term airway can also be completed utilizing units comparable to a laryngeal masks airway, however a safe, long-term, and protecting airway is established utilizing an endotracheal tube (or a tracheostomy tube). Having the talents and data to intubate a affected person is a essential responsibility for emergency drugs and important care suppliers. This text will discover the chance components for tough airway intubation in adults and talk about among the methods that may assist obtain a profitable, safe airway.
Danger Components
There are various threat components that may result in tough intubation. Most of those relate to the anatomy of the face and higher airway (See Desk 1: Danger components for tough intubation.) 2-3
Different threat components that will come into play embody insufficient preparation (not having all tools wanted, or a wanted piece of kit will not be functioning), insufficient evaluation of the affected person’s anatomy, not understanding the affected person has a historical past of inauspicious intubation, or lack of ability within the individual making an attempt the intubation. There isn’t any good approach to predict that an intubation will probably be tough however systematic analysis of the airway utilizing the mnemonic “LEMON” may also help uncover the opportunity of a tough intubation.4
Desk 1. Danger Components for Troublesome Intubation (“LEMON”)
| L | Look for anatomic options that will make | • Brief neck • Receding mandible • Giant tongue • Protruding maxillary incisors • Slim mouth with excessive arch palate • Giant breasts • Weight problems |
| E | Consider the 3-3-2 rule (profitable laryngoscopy relies on regular anatomy) | • Mouth opening (3 finger breadths) • Hyoid – chin distance (3 finger breadths) • Thyroid cartilage – ground of mouth distance (2 finger breadths) |
| M | Mallampati rating | Mallampati class >3 is indicative of a tough intubation.4 The Mallampati classification entails examination of the oropharynx with the mouth opened facet and tongue extruded to assign a quantity from 1 to 4. • Class I: taste bud, uvula, pillars seen • Class II: taste bud, uvula seen • Class III: taste bud, base of uvula seen • Class IV: onerous palate seen |
| O | Obstruction | Obstruction or weight problems that will limit visualizing the vocal cords |
| N | Neck mobility | Neck mobility is restricted and should contribute to tough passage of the endotracheal tube into the trachea |
^Tailored from references 2. (Traylor B, McCutchan A.) and three. (Joffe AM, Aziz MF, et al)
Airway Methods to Think about
Oral Tracheal Intubation
Oral intubation is usually completed by two approaches: both by direct visualization of the larynx, vocal cords, and the glottis utilizing a Miller (straight) blade or McIntosh (curved) blade connected to a laryngoscope the place the intubator (the individual performing the intubation) straight sees the trail into the trachea, or by video laryngoscope the place the intubator makes use of a digicam and observes the trail on a video display screen (with the identical two decisions for blade configuration). Each of those approaches allow placement for oral intubation.4 An alternative choice entails putting the endotracheal tube over a fiberoptic bronchoscope (FOB), then visualizing and intubating the trachea utilizing the bronchoscope to see the trail to the decrease airway as a substitute of utilizing a laryngoscope or video laryngoscope and blade. Utilizing the FOB to intubate permits for both oral or nasal intubation.4 (See nasotracheal intubation beneath.)
Each time an intubation is required, there must be a main plan and backup plans in place in case one thing goes incorrect. Whether it is anticipated that this will probably be a tough intubation, a video laryngoscope is commonly used on the onset. A 2004 publication in Anesthesia describes an algorithm that describes main plans for the first plan and the beneficial backup steps to comply with if the first plan will not be profitable.6 Previous to beginning the process, it is strongly recommended to pre-oxygenate and try to take care of enough oxygenation all through the process.
Major plan: Awake
Make the most of efficient BVM air flow with supplemental oxygen adopted by profitable intubation. If not profitable, resume BVM air flow and make the most of any/the entire following: reposition the affected person’s head and/or neck, administer a paralytic remedy, apply cricoid stress, incorporate use of a bougie to facilitate entry into the glottic opening. (A bougie is a protracted, smaller diameter tube that may move simpler by the glottic opening. The endotracheal tube is handed over the bougie as soon as it has been positioned into the glottis/trachea). If utilizing direct laryngoscopy, change to a video laryngoscope. If the first plan with added steps is unsuccessful, transfer to Plan B.
Plan B
Insert a supraglottic airway (ie laryngeal masks airway) to oxygenate/ventilate and analyze the state of affairs for choices. Choices embody aborting the process (whether it is elective) or use the supraglottic airway and proceed with the process or use the supraglottic airway as a conduit to intubate. If these will not be viable choices and/or intubation will not be profitable, transfer to Plan C.
Plan C
Reattempt BVM air flow with paralysis and guarantee enough oxygenation- try to intubate utilizing any/the entire non-compulsory steps within the main plan. If unable to oxygenate, or intubation is unsuccessful transfer to Plan D. If this stage within the process is reached, it’s also known as, “Can’t intubate, can’t oxygenate.” (Known as CICO.)
Plan D
Emergency entrance of neck entry: carry out a cricothyroidotomy. For a surgical process, the cricothyroid membrane is positioned and a scalpel is used to make an incision by this membrane. As soon as the opening has been made by the scalpel, the index finger is inserted instantly to take care of the opening and a bougie is inserted into the opening. A 6.0 mm cuffed endotracheal tube (ETT) or a No.4 cuffed Shiley trаϲhеоѕtomy tube is handed over the bougie, by the incision and into the trachea (the 6.0 mm ETT could be lower to cut back the size of tubing that extends exterior of the neck). The cricothyroidotomy can also be accomplished percutaneously.
As soon as an airway has been inserted the ballon is inflated to supply a seal and permit for constructive stress air flow by the airway. There are kits out there that include the mandatory tools to carry out this process (eg, the Cook dinner Melker package) or a prefabricated percutaneous system (eg, Quicktrach II). Commonplace precautions must be used to guard towards blood and physique fluid publicity—together with gloves, face masks, protecting eye defend, robe, and shoe covers. This process ought to solely be carried out by a talented clinician who has obtained formal coaching.7
Speedy Sequence Intubation (RSI)
In an emergency, airways are sometimes established utilizing fast sequence intubation (RSI) to facilitate the process. This method makes use of administration of a mix of sedative and paralytic drugs which have a fast onset and quick period and are administered inside a short while body (ie, inside 30 seconds). The RSI method has been proven to extend the success of intubation on the primary try and cut back the chance of aspiration. Because the affected person is paralyzed and sedated, air flow/oxygenation is vital and good BVM approach should be utilized to keep away from hypoxia.4
Nasotracheal Intubation
An alternative choice in instances of inauspicious intubation is to make use of a nasotracheal method. The nasotracheal method could also be most helpful in instances the place the affected person has a restricted mouth opening (ie, temporomandibular joint ankylosis or maxillofacial surgical procedure), broken enamel, extreme bleeding, harm within the higher airways, or the place different supportive tools will not be out there (ie, no entry to video laryngoscope, fiberoptic bronchoscope, and so on.).8 This method is ceaselessly used when intubating away from a hospital setting comparable to with paramedics working within the discipline.
The nasotracheal path is ready by administering mucosal vasoconstrictors and native anesthetic brokers. With the pinnacle and neck within the sniffing place, a lubricated ETT is superior into the nostril and down the nasopharynx. In a respiratory affected person, because the ETT approaches the epiglottis and glottis, breath sounds could be heard by ETT and enhance in power. Throughout inspiration, the tube is advance by the glottis and into the trachea.8
This success of this process could be enhanced through the use of a easy system, the Beck Airway Airflow Monitor (BAAM) whistle (Life Medical Provider USA). This can be a small pink cap that matches over the distal finish of the ETT and creates a whistle with every breath that will increase with depth because the ETT approaches the glottis.9 Magill forceps can be used throughout a nasotracheal intubation to extend success. There’s a tendency throughout nasotracheal intubation for the ETT to maneuver into the esophagus posteriorly and never enter the glottis. The Magill forceps is inserted into the open mouth and is used to seize the tip of the ETT because it passes by the again of the oropharynx, then information the tube extra anteriorly and into the glottis because the tube is superior.
Confirming Right Airway Placement
With any of the approaches for intubation, appropriate placement of the ETT should be confirmed. After inserting the ETT by the vocal cords into the trachea and inflating the cuff, a number of strategies must be used to test correct placement. These embody checking for bilateral breath sounds, commentary of chest rise and fall throughout BVM air flow, absence of gastric sounds when ventilating, affirmation of end-tidal CO2 detection, improved oxygenation (by SpO2 rise, enhancing pores and skin shade) and chest radiographic proof for correct placement and correct depth.
As soon as confirmed, the ETT must be secured. The truth that this was a tough intubation (together with the the explanation why) and the strategies confirming placement must be documented within the medical document.
Conclusion
When intubating any affected person, the healthcare group must take steps to be prepared if the intubation seems to be a tough case. Consciousness of the chance components for tough intubation could present hints to the group to be vigilant and ready. Having the appropriate tools/units is crucial and the individual(s) who’s intubating must have the talents and data wanted to handle a number of choices to acquire a safe, functioning airway. Affirmation of correct placement, securing the tube, and documenting the process are the ultimate steps within the course of.
RT
Invoice Pruitt, MBA, RRT, CPFT, FAARC, is a author, lecturer, and marketing consultant. He has over 40 years of expertise in respiratory care and has over 20 years instructing on the College of South Alabama within the division of Cardiorespiratory Care. After retiring from instructing, he continues to supply visitor lectures and write professionally. For extra info, contact [email protected].
References
- Waheed S, et al. Analysis Waheed, S., Razzak, J.A., Khan, N. et al. Derivation of the Troublesome Airway Physiological Rating (DAPS) in adults present process endotracheal intubation within the emergency division. BMC Emerg Med 24, 40 (2024).
- Traylor B, McCutchan A. Unanticipated Troublesome Intubation in an Grownup Affected person. Stat Pearls. Up to date Jan 2023.
- Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB. Administration of Troublesome Tracheal Intubation: A Closed Claims Evaluation. Anesthesiology. 2019 Oct;131(4):818-829
- Alvarado A, Panakos P. Endotracheal Tube Intubation Strategies. Stat Pearls. Up to date July, 2023.
- Summer time J, Wright H. Mallampati Rating and Predicting Sleep Apnea. Sleep Basis. Up to date October 16, 2023.
- Henderson JJ, Popat MT, Latto IP, Pearce AC. Troublesome Airway Society pointers for administration of the unanticipated tough intubation. Anaesthesia. 2004 Jul;59(7):675-94.
- Sakles J. Emergency cricothyrotomy (cricothyroidotomy). UpToDate. Up to date April 2024. Accessed Jan 2025.
- Yoo H, Choi JM, Jo JY, Lee S, Jeong SM. Blind nasal intubation as a substitute for tough intubation approaches. Journal of dental anesthesia and ache drugs. 2015 Sep 1;15(3):181-4.
- Zhang J, Lamb A, Hung O, Hung C, Hung D. Blind nasal intubation: instructing a dying artwork. Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2014 Nov;61:1055-6.
Troublesome Airway Intubation
