Airway Management in Emergencies

AIRWAY MANAGEMENT
IN EMERGENCIES
䉴 NOTICE
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required. The authors and the publisher
of this work have checked with sources believed to be reliable in their efforts to provide infor-
mation that is complete and generally in accord with the standards accepted at the time of pub-
lication. However, in view of the possibility of human error and changes in medical sciences,
neither the editors nor the publisher nor any other party who has been involved in the prepara-
tion or publication of this work warrants that the information contained herein is in every respect
accurate or complete, and they disclaim all responsibility for any errors or omissions or for the
results obtained from use of the information contained in this work. Readers are encouraged to
confirm the information contained herein with other sources. For example and in particular, readers
are advised to check the product information sheet included in the package of each drug they
plan to administer to be certain that the information contained in this work is accurate and that
changes have not been made in the recommended dose or in the contraindications for adminis-
tration. This recommendation is of particular importance in connection with new or infrequently
used drugs.
AIRWAY MANAGEMENT
IN EMERGENCIES
GEORGE KOVACS, MD
Professor
Department of Emergency Medicine
Dalhousie University
Nova Scotia, Halifax, Canada
and
J. ADAM LAW, MD
Professor
Departments of Anesthesiology and Surgery
Nova Scotia, Halifax, Canada
New York Chicago San Francisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore Sydney Toronto
Copyright © 2008 by The McGraw-Hill Companies, Inc. All rights reserved. Manufactured in the United States of America. Except
as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form
or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.
0-07-159348-9
The material in this eBook also appears in the print version of this title: 0-07-147005-0.
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trademarked
name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention of infringement of the
trademark. Where such designations appear in this book, they have been printed with initial caps.
McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for use in corporate
training programs. For more information, please contact George Hoare, Special Sales, at [email protected] or (212)
904-4069.
TERMS OF USE
This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGraw-Hill”) and its licensors reserve all rights in and to the
work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve
one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon,
transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may
use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work
may be terminated if you fail to comply with these terms.
THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES OR WARRANTIES
AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED FROM USING THE
WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA HYPERLINK OR
OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED
TO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its
licensors do not warrant or guarantee that the functions contained in the work will meet your requirements or that its operation will be
uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else for any inaccuracy, error or
omission, regardless of cause, in the work or for any damages resulting therefrom. McGraw-Hill has no responsibility for the content
of any information accessed through the work. Under no circumstances shall McGraw-Hill and/or its licensors be liable for any
indirect, incidental, special, punitive, consequential or similar damages that result from the use of or inability to use the work, even if
any of them has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause
whatsoever whether such claim or cause arises in contract, tort or otherwise.
DOI: 10.1036/0071470050
Professional
Want to learn more?

We hope you enjoy this
McGraw-Hill eBook! If
you’d like more information about this book,
its author, or related books and websites,
please click here.
From GK. To my partner in life, Sandra Kovacs, and my four children,
Hannah, Maya, Ben, and Aaron: thank you for your love, tolerance,
and support.
From JAL. For Trevor, Simon, and Julia—may your love of life and learning
always be with you—and my wife Kate, for her support and loyalty.
Thanks must also go to my parents, for laying the foundation,
and to fellow AIME contributors and instructors, for making a
difference.
This page intentionally left blank
For more information about this title, click here
Contents
Editors and Lead Authors/Contributing Authors ix

Illustrations/Photography x
Foreword xi
Preface xii
Acknowledgments xiii
1. Introduction 1
2. Definitive Airway Management: When Is It Time? 5
03. Airway Physiology and Anatomy 13
04. Oxygen Delivery Devices and Bag-Mask Ventilation 33
15. Tracheal Intubation by Direct Laryngoscopy 53
06. Alternative Intubation Techniques 93
07. Rescue Oxygenation 127
8. How to do Awake Tracheal Intubations—Oral and Nasal 151
9. Rapid Sequence Intubation—Why and How to do it 169
10. Postintubation Management 179
11. Approach to Tracheal Intubation 187
12. Response to an Encountered Difficult Airway 199
13. Airway Pharmacology 211
14. Central Nervous System Emergencies 237
15. Cardiovascular Emergencies 245
16. Respiratory Emergencies 251
17. The Critically Ill Patient 259
vii
viii CONTENTS
18. The Very Young and the Very Old Patient 265
19. Prehospital Airway Management Considerations 275
20. Human Factors in Airway Management 283
Index 291
Editors and Lead Authors
GEORGE KOVACS, MD, MHPE, FRCPC J. ADAM LAW, MD, FRCPC

Professor, Department of Emergency Medicine Professor, Departments of Anesthesiology and Surgery
Dalhousie University Dalhousie University
Halifax, Nova Scotia, Canada Halifax, Nova Scotia, Canada
Contributing Authors
GRAHAM BULLOCK, MD, FRCPC DAVID A PETRIE, MD, FRCPC

Associate Professor, Department of Emergency Medicine Associate Professor, Department of Emergency Medicine
Dalhousie University Dalhousie University
Halifax, Nova Scotia, Canada Director, Division of Emergency Medical Services
Halifax, Nova Scotia, Canada
SAM CAMPBELL, MB BCH, CCFP(EM)
Associate Professor, Department of Emergency Medicine JOHN A ROSS, MD, FRCPC
Dalhousie University Professor, Departments of Emergency Medicine and
Halifax, Nova Scotia, Canada Anesthesiology
Head, Department of Emergency Medicine
T.J. COONAN, MD, FRCPC Dalhousie University
Chief, Department of Emergency Medicine, Queen
Professor, Departments of Anesthesiology and Surgery
Elizabeth II Health Sciences Centre
Halifax, NS Canada
PAT CROSKERRY, PHD, MD, CCFP(EM) CHRISTIAN M. SODER, MD, FRCPC

Associate Professor, Departments of Anesthesiology
Professor, Department of Emergency Medicine
and Pediatrics
Chief, Department of Pediatric Critical Care, IWK Health
Centre
KIRK MACQUARRIE, MD, FRCPC Halifax, Nova Scotia, Canada
Assistant Professor, Departments of Anesthesiology
and Surgery JOHN M TALLON, MD, FRCPC
Associate Professor, Departments of Emergency Medicine
and Surgery
WILLIAM A MCCAULEY, MD, MHPE, FRCPC Medical Director, Nova Scotia Trauma Program and
Associate Professor, Division of Emergency Medicine Queen Elizabeth II Health Sciences Centre Trauma
University of Western Ontario Program
London, Ontario, Canada Halifax, Nova Scotia, Canada
ix
Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use.
Illustrations
TIM FEDAK, BSC, PHD JANET DAVISON, BFA

Halifax, Nova Scotia, Canada Chamonix, France
JIRI J. DUBEC, MD, CCFP (EM)
Surrey, British Columbia, Canada
Photography
JOSEPH O’LEARY
Foreword
George Kovacs and Adam Law have created a apparent. The imaging and line art assembled
text that covers the physiology, anatomy, tech- within these pages comes from years of acad-
niques, and devices of emergency airway man- emic focus and a real passion for the topic.
agement in a readable, concise, and practical I especially appreciate the juxtaposition of
manner. The well thought out outlines, inter- beautifully prepared drawings with fluo-
esting clinical cases, and recommended ap- roscopy images and direct laryngoscopy
proaches have evolved from real world prac- imaging. Overall, this text is a great addition to
tice. This teaching method is clearly a result of the educational resources available to emer-
the authors’ extensive clinical expertise, but also gency airway providers.
comes from their vast experience running train-
ing courses and supervising physicians in train-
ing. The rare combination of both an emergency Richard M. Levitan, MD
medicine and anesthesia perspective is also
xi
Preface
Acute-care clinicians are well aware of the al- hospital, a general surgeon, internist, intensivist,
phabetical “ABC” (airway, breathing, circulation) paramedic, nurse, physician assistant, or respi-
directive of resuscitation. This term has been ratory therapist, the airway belongs to the most
widely disseminated through programs such as skilled clinician available at the bedside when
Advanced Trauma Life Support (ATLS) and Ad- time and urgency mandate immediate action.
vanced Cardiac Life Support (ACLS). In fact, Declaring “ownership” of the airway should not
both courses have contributed significantly to be based on departmental borders, but rather, on
improving awareness of resuscitation priorities whether the clinician has the required knowledge
required in managing patients rendered criti- and skills to safely manage the patient.
cally ill from trauma or cardiac events. Indeed, It has become apparent that the “A” needs
many hospital administrators require active cer- to come out of the “ABCs” to stand alone as an
tification in these programs (and others) for clin- educational focus. The perceived deficit in clin-
icians working in environments such as the ician confidence in acute airway management
emergency department (ED). However, from a has led to the development of several focused
real-world perspective, it is the “A” of the ABCs educational programs to address these needs.
that often poses the greatest challenge, or pro- This text is based in part on the manual used in
duces significant anxiety in the clinician. one such program (AIME—Airway Interventions
As a relatively new specialty, Emergency and Management in Emergencies). In delivering
Medicine has appropriately taken on responsi- this course and similar educational content to
bility for airway management in the ED. The thousands of clinicians over the years, the lead
first described use of pharmacologic aids, in- authors of this text have gained significant in-
cluding neuromuscular blockers, to facilitate sight into the issues surrounding improving
intubation outside the operating room precipi- airway management knowledge and skills.
tated turf battles, out of concerns for safety. A team of emergency physicians and anes-
However, the need for nonanesthesiologists to thesiologists has written this text. The goal is to
gain expertise in acute airway management support the educational needs of all medical
could not be disputed for long. Over time, ap- and allied health clinicians involved in the care
peased by observed good clinical practice, and of acutely ill patients requiring airway manage-
supported by the literature, the opposition has ment in an emergency setting.
appropriately waned.
Clearly the term “acute-care clinician” is not
defined by emergency medicine alone. Be it George Kovacs, MD
a general practitioner in a small community J. Adam Law, MD
xii
Acknowledgments
This book has roots as the informal manual to We also wish to thank the Department of Emer-
accompany a one-day airway course (AIME— gency Medicine at Dalhousie University, and in
Airway Interventions and Management in Emer- particular Ms. Corrine Burke for administrative
gencies) for delivery to Canadian emergency assistance. For peer review, we are indebted to
physicians. The Canadian Association of Emer- Drs. T.J. Coonan, Ian Morris, Michael Murphy,
gency Physicians (CAEP), and in particular Ms. Hugh Devitt, Orlando Hung and Ron Stewart,
Vera Klein and Dr. Tim Allen were instrumental as well as Mr. Paul Brousseau. Finally, many
in supporting the development of this educa- thanks to Mr. Derek Leblanc, the Atlantic Health
tional program, for delivery in communities in Training and Simulation Centre, and Emergency
need. The entire founding course faculty has Health Services (EHS) Nova Scotia for the op-
contributed to this book: all continue to teach portunity to test and develop our educational
the course across Canada and must be ac- material.—GK and JAL.
knowledged for their enthusiasm and dedication.
xiii
Chapter 1
Introduction
䉴 INTRODUCTION TO AIRWAY prepared with the cognitive, psychomotor, and

MANAGEMENT IN EMERGENCIES affective skills required to competently man-
age patients such as the one presented above.
These core competencies in airway management
are summarized in Table 1–1.
䉴 Case 1.1 Clinical competence is best viewed as a
You are in the emergency department (ED) continuum, varying from being considered sim-
at 3 a.m. when you get a “heads up” from ply safe, to being an expert. Ideally, clinicians
the nurse that paramedics are 3 minutes out with acute-care responsibilities should strive to
with a 20-year-old posthanging victim. The attain an expert skill level in airway manage-
paramedics were unable to intubate the ment. It may not be realistic to expect exper-
patient at the scene. On arrival in the ED, tise “out of the gate” from any training pro-
the patient, a large (100 kg), bearded male, gram; however, with appropriate learning
is immobilized on a backboard and is pos- experiences, clinicians can acquire and main-
turing. He has noisy upper airway sounds tain the knowledge and skills needed to safely
and is producing pink, frothy pulmonary manage the vast majority of airway emergen-
edema. His oxygen saturation (SaO2) is 82% cies. A novice making the statement that he
with assisted bag-mask ventilation. has “never intubated the esophagus” may be
viewed as skilled by a second novice. How-
ever, to the veteran clinician, the statement is
simply a sign of inexperience. In other words,
The emergency care of this patient illustrates if you haven’t experienced difficulty, you will
several layers of complexity in airway manage- remain inexperienced!
ment decision making. Acute-care clinicians Procedural skill competence is dependent
must consider two often competing issues— on sound decision making, but is also predi-
prevalence and acuity—in their diagnosis and cated upon practice in an observed setting, with
management of a patient.1 More simply, they timely feedback.2 This practice should ideally
must be prepared to manage “what is common begin with simulation (e.g., using airway train-
and what can kill.” Even in high volume clinical ing mannequins) and then move to a controlled
settings, high-acuity scenarios involving airway setting such as the operating room. How much
management and resuscitations make up only a experience is required to learn and maintain
small fraction of presenting cases. However, in competency in various airway skills? Investiga-
spite of the small numbers, clinicians must be tors examining the learning curve for direct
2 CHAPTER 1
䉴 TABLE 1–1 AIRWAY MANAGEMENT CORE COMPETENCIES
Cognitive Psychomotor Affective
• Indications for advanced airway • Bag mask ventilation • Crisis Resource

management (including response to Management skills:
• Relevant airway anatomy and physiology difficulty) • Anticipation and
• Predictors of the difficult airway • Direct laryngoscopy and planning
• Approach to the difficult airway—whether intubation (including • Leadership and
predicted or not response to difficulty) communications
• Indications and contraindications for • Alternative intubation • Situation awareness
rapid sequence intubation and awake techniques • Team dynamics
intubation • Rescue oxygenation
• Airway pharmacology techniques, including
extraglottic devices and
cricothyrotomy
laryngoscopy and intubation have estimated than cognitive and psychomotor skill.9 Excite-
that up to 50 intubations are required before a ment, fear, and/or anxiety are all very real “gut”
predetermined level of proficiency is reached.3–6 emotions that even experienced clinicians will
Although a prerequisite minimum number of feel on hearing the heads-up about this patient.
intubations alone will never guarantee compe- Professional athletes and actors acknowledge a
tence or ensure safety, the message that volume certain performance-enhancing effect associ-
matters and practice improves skills cannot be ated with the stress of high-stakes events in their
disputed. respective areas of expertise. Unprepared, how-
Skills transfer from simulation to the live set- ever, in times of extreme stress or near disas-
ting is not perfect, and depends in part on the ter, it has been said that 10% of individuals will
degree of similarity between the two settings.7,8 naturally lead, 10% will be incapacitated, and
Although the airway equipment used in both the remainder will neither lead nor flounder,
simulation and “live” airway management is but are able to follow. 10 Successful resusci-
identical, the physical tissue interface used in tative airway management requires effective
most simulators is still relatively immature com- anticipation, communication, and leadership
pared to the human patient. Imperfect as the skills in a team setting.
simulation setting may be, it does provide the The major challenge in teaching and learn-
opportunity to attain the psychomotor skills ing airway management for emergencies is to
needed for many tools and techniques. In addi- create an integrated cognitive, psychomotor, and
tion, instructors can manipulate the clinical con- affective network that promotes easy retrieval
text to provide the learner with an opportunity and a rapid appropriate response to change.
to address various cognitive and human factors Medical administrators, educators, and learners
issues related to airway management. all seem to have a natural affinity for line dia-
Prior to this patient’s arrival (and during the grams and algorithms. Rare is the medical text
resuscitation) it is likely that the clinician will that does not include such figures, and this book
have to acknowledge and deal with immediate is no exception (e.g., Fig. 11–3, and Fig. 12–1).
psychological (affective) issues. The ability to effec- These algorithms support the three major
tively manage the patient in extremis requires more questions that must be addressed to manage
INTRODUCTION 3
the airway, reinforced by experience, knowl- REFERENCES

edge, and skill:
1. Kovacs G, Croskerry P. Clinical decision making:
an emergency medicine perspective. Acad Emerg
A. Is the procedure indicated? Med. 1999;6(9):947–952.
B. What is the safest and most efficacious way 2. Kovacs G, Bullock G, Ackroyd-Stolarz S, et al.
to proceed when difficulty is anticipated A randomized controlled trial on the effect of
(see Fig. 11–3)? educational interventions in promoting airway
C. How will you respond to difficulty once management skill maintenance. Ann Emerg Med.
encountered (see Fig. 12–1)? 2000;36(4):301.
3. Charuluxananan S, Kyokong O, Somboonviboon
Efforts to simplify airway management deci- W, et al. Learning manual skills in spinal anesthe-
sia and orotracheal intubation: is there any recom-
sion making have become somewhat clouded
mended number of cases for anesthesia residency
in recent years by attempts to produce the
training program? J Med Assoc Thai. 2001;84 Suppl
“Holy Grail” of airway tools. Such tools are 1:S251–S5.
often marketed as requiring minimal skills and 4. de Oliveira Filho GR. The construction of learning
possessing the potential to render the term curves for basic skills in anesthetic procedures: an
“difficult airway” obsolete. To this exploding application for the cumulative sum method. Anesth
equipment industry can be added a growing Analg. 2002;95(2):411–416.
body of literature on managing the difficult air- 5. Konrad C, Schupfer G, Wietlisbach M, et al. Learning
way. Is this devotion appropriate, or overkill? manual skills in anesthesiology: Is there a recom-
In actual fact, we have not arrived at the point mended number of cases for anesthetic procedures?
where airway management decisions are black Anesth Analg. 1998;86(3):635–639.
6. Mulcaster JT, Mills J, Hung OR, et al. Laryngoscopic
and white, or our tools foolproof. Claims that
intubation: learning and performance. Anesthesiol-
standard skills such as direct laryngoscopy are
ogy. 2003;98(1):23–27.
soon to become procedures of the past are 7. Issenberg SB, McGaghie WC, Hart IR, et al. Simu-
likely premature. In addition, this direction car- lation technology for health care professional
ries a significant risk of compromising the skills training and assessment. JAMA. 1999;282(9):
acquisition and maintenance of competence in 861–866.
needed core skills. 8. Hall RE, Plant JR, Bands CJ, et al. Human patient
Successful airway management of the previ- simulation is effective for teaching paramedic stu-
ously described case should not be defined sim- dents endotracheal intubation. Acad Emerg Med.
ply by the correct placement of an endotracheal 2005;12(9):850–855.
tube. At the end of the day, success must be 9. Schull MJ, Ferris LE, Tu JV, et al. Problems for clin-
ical judgement: 3. Thinking clearly in an emer-
measured by positive patient outcomes. To
gency. CMAJ. 2001;164(8):1170–1175.
improve these outcomes, the clinician must
10. Leach J. Why people ‘freeze’ in an emergency:
work at enhancing the knowledge and skills temporal and cognitive constraints on survival
needed for successful airway management in responses. Aviat Space Environ Med. 2004;75(6):
emergencies. 539–542.
Chapter 2
Definitive Airway Management:
When Is It Time?
䉴 KEY POINTS 䉴 CASE PRESENTATIONS
• The basic goals of airway management Consider the following patient presentations:
are oxygenation and ventilation. Initially,
this may require simple airway opening 䉴 Case 2.1
maneuvers and bag-mask ventilation (BMV)
support. A 20-year-old male with a fracture/dislocation
• The indications for intubation are to of his ankle has had it reduced under “proce-
(a) obtain and maintain the airway, dural sedation”. Some time later, the spouse of
(b) correct abnormalities of gas exchange the patient in the adjoining bay comes to get
(c) protect the airway, and (d) secure the help. She reports that the 20-year old is blue
airway early in the face of predicted clin- and does not appear to be breathing. The blood
ical deterioration. pressure (BP) is 170/90, heart rate (HR) is 100,
respiratory rate (RR) 4, and the oxygen satu-
ration (SaO2) is 65% on room air.
䉴 INTRODUCTION
䉴 Case 2.2
Successful airway management requires com-
petent decision-making and good procedural A 45-year-old female presents to the emergency
skills. The decision of whether a patient requires department (ED). Shortly before, while at home,
definitive airway management must be made she had complained of a sudden-onset severe
early in the clinical assessment. In the sponta- headache, then collapsed. She was transported
neously breathing patient, there is often a sig- by ambulance. On arrival, she is receiving oxy-
nificant delay in making this decision. This gen, but is unresponsive and has snoring respi-
chapter reviews the presentation of patients rations. The BP is 180/100, HR 55, RR 25, SaO2
requiring basic airway support, as well as the 92% with nonrebreathing face mask (NRFM),
indications for endotracheal intubation. and the Glasgow Coma Scale (GCS) is 7.
6 CHAPTER 2
view endotracheal intubation as the definitive

䉴 Case 2.3 intervention of airway management, other maneu-
vers, often perceived as basic, are all potentially
A 35-year-old female, 8 months pregnant, life saving. Recognition of the obstructed airway,
was involved in a motor vehicle collision airway opening maneuvers, the administration
(MVC). At the scene she was complaining of of high flow oxygen, and bag-mask ventilation
right-sided chest discomfort and pain in what (BMV) are all crucial airway management skills.
appeared to be a broken right arm. She was In most cases it would be inappropriate to pro-
transported by ambulance to the ED “back- ceed with intubation before any of these basic
boarded and collared.” She is now uncon- life support (BLS) interventions had first been
scious, and has snoring respirations. Only attempted.
her systolic BP is obtainable at 50/, HR 140, Despite the importance of BLS maneuvers as
RR 35; SaO2 is unobtainable on a 40% sim- initial steps in correcting or maintaining oxy-
ple facemask, and her GCS is 7. genation, many patients will go on to require
endotracheal intubation. A cuffed endotracheal
tube (ETT) placed below the cords provides both
airway protection and an efficient means of pro-
䉴 Case 2.4 viding gas exchange. Although extraglottic devices
such as the Laryngeal Mask Airway (LMA) or
A 55-year-old male was in a house fire. Although
Esophageal-Tracheal Combitube (ETC) are also
his burns seemed limited, 6 hours after the
very effective at providing gas exchange, place-
injury he started complaining of shortness
ment of an ETT remains a gold standard for airway
of breath, and subsequently developed stri-
management in emergencies.
dor on inspiration. His BP is 160/90, HR 90,
RR 30, SaO2 92% with NRFM, and his GCS
is 15. 䉴 INDICATIONS FOR
ENDOTRACHEAL INTUBATION
There are four broad categories of indication for

䉴 Case 2.5 endotracheal intubation in emergencies:
A 35-year-old female, well known in the A. To obtain and maintain a patent airway
intensive care unit, has been receiving maxi- (e.g., in the face of an obstructed airway
mal medical therapy for an acute exacerbation from any cause).
of asthma. She remains “tight” and is moving B. To correct deficient gas exchange (i.e.,
very little air. Although her SaO2 is 91% with hypoxia and/or hypercarbia).
oxygen, she is visibly tired and getting drowsy. C. To protect the airway (e.g., against aspira-
Her BP is 170/100, HR 120, RR 30, SaO2 91% tion of gastric contents or blood).
with NRFM, and her GCS is 14. D. To preempt predicted clinical deteriora-
tion (to one of the above three situations).
The patients described in the above cases all Obtain and Maintain
require urgent airway management. The ulti-
mate goal of resuscitation efforts and airway Airway obstruction can occur from functional,
management is gas exchange, with oxygen pathologic, or mechanical causes. Functional
delivery the priority. Although many clinicians obstruction can occur in the patient with a
DEFINITIVE AIRWAY MANAGEMENT: WHEN IS IT TIME? 7
depressed level of consciousness, as loss of mus- Respiratory failure is a clinical term describing
cular tone results in posterior relaxation of the inadequate pulmonary gas exchange. Inade-
soft palate, tongue, and epiglottis toward the quate oxygenation (hypoxemia) can be quanti-
posterior pharyngeal wall. Functional obstruc- fied through the measurement of arterial blood
tion will most often be alleviated by BLS gases (ABGs) or estimated noninvasively using
maneuvers such as head tilt or chin lift (unless pulse oximetry. Early clinical effects of hypox-
contraindicated by C-spine precautions in the emia are not always readily apparent. Cyanosis
trauma patient), or, more effectively, a jaw is a late clinical sign of hypoxemia and may be
thrust. If respiratory effort is still present, ade- absent in profoundly anemic patients or in those
quate gas exchange can then resume, although with dark skin. Ventilation refers to the mechan-
intubation may still be indicated to maintain ics of effective gas exchange, and is commonly
ongoing airway patency. In the apneic patient, quantified using arterial Pco2. An acutely elevated
initial BLS maneuvers are still indicated to assess PCO2 is often clinically apparent as CO2 narco-
and establish airway patency, but positive pres- sis with a diminished level of consciousness,
sure ventilation with BMV will be the next step frequently combined with an inadequate respira-
to reoxygenate the patient. Here again, unless tory effort.
the cause of the apnea can be rapidly corrected, Despite the fact that respiratory failure can
intubation will be indicated to maintain a patent be determined by ABGs (i.e., Po2 less than
airway. 60 mm Hg/Pco2 greater than 60 mm Hg), the
Pathologic airway obstruction may result decision to intervene with airway and venti-
from an intrinsic process such as edema, latory support should be a clinical one, and
hematoma, infection, or tumor, while mechanical in most situations, precede ABG testing.
obstruction can occur from extrinsic processes Although failure of oxygenation and ventila-
such as excessive application of cricoid pressure tion usually occur together, this is not always
or foreign body. Pathologic airway obstruction the case. Critically ill asthmatics may be able to
is rarely quickly corrected and often requires maintain an SaO2 above 90% with supplemen-
intubation to obtain and maintain a patent air- tal oxygen, but still require ventilatory support
way while the underlying cause of obstruction as they fatigue. Furthermore, a patient in circu-
is addressed. latory shock may have no ventilatory abnormal-
Regardless of the nature of obstruction, it is ities but may still require intubation to optimize
crucial that the signs and symptoms of obstruc- oxygen delivery.
tion (discussed in more detail in Chap. 4) be Included in this category is the need for “pul-
recognized early and addressed promptly to monary toilet,” that is, the suctioning of secre-
safely secure the airway. tions from the lower airway of patients who
cannot adequately cough.
Correction of Gas Exchange

Protection
Cellular metabolism and function depends on
the delivery and uptake of oxygen. Oxygen The awake patient with intact airway reflexes is
delivery in turn depends on adequate lung func- able to respond to secretions or other material
tion, sufficient hemoglobin levels, and an effec- threatening the airway by swallowing and/or
tive cardiac output. In return, carbon dioxide coughing. Although the gag reflex is commonly
(CO2) produced as a byproduct of cellular assessed as a measure of airway protection, its
metabolism must be delivered to the lungs for utility has been questioned following findings
removal by ventilation. that up to a third of the general population
8 CHAPTER 2
has an attenuated or absent gag reflex.1,2 Fur- [CT] scan) or transportation to another institu-
thermore, testing for the gag reflex can itself be tion. In this population, intubation may be desir-
hazardous, with the risk of provoking vomiting. able in anticipation of the patient’s risk of dete-
As with any reflex, intact and coordinated riorating, which would require intubation in a
sensory and motor pathways must exist through less favorable environment (where adequately
a central connection.3 Protective airway reflexes trained personnel or appropriate equipment may
become diminished as the patient’s level of con- be lacking), or at a time when intubating may be
sciousness decreases. Rigid suction should always significantly more difficult, for example, due to
be available during airway interventions and progressive airway edema.
the clinician should be prepared to rapidly suction It must be appreciated that active airway
and safely reposition the patient. interventions such as intubation are not without
The patient’s ability to swallow and cough complications. Intubation for the indications of
may be thought of as confirming intact protec- obtaining and maintaining a patent airway and
tive reflexes. However, the effectiveness of these correction of gas exchange may be mandated
reflexes in managing significant vomitus or urgently as part of the “ABCs” (airway, breath-
blood in a patient with a depressed level of con- ing, circulation) of resuscitation. On the other
sciousness is always uncertain. The presence of hand, intubation for the sole indication of air-
pooled secretions or fluid in the posterior phar- way protection or predicted clinical deteriora-
ynx is strongly suggestive of impaired airway tion is somewhat different, especially in a patient
protective reflexes, as is the ability to tolerate an who is currently maintaining a patent airway
oropharyngeal airway. with adequate gas exchange. In this latter situ-
The Glasgow Coma Scale (GCS) is often used ation, risk/benefit analysis may point to defer-
as a gross marker of a patient’s ability to protect ring the procedure until better conditions and
the airway.4 The Advanced Trauma Life Support expert personnel are available.
(ATLS) program recommends that patients with a
GCS below 8 should be intubated, unless a rapid
improvement in level of consciousness occurs or 䉴 CASE REVIEW
is anticipated.5 Unfortunately, clinical application
of the GCS is fraught with difficulties as a prospec- The five cases presented earlier will be reviewed
tive decision tool.6–8 Rather than rigidly using a here, with reference to the four categories of
certain GCS cutoff, the patient’s clinical ability to indication for intubation discussed above.
handle secretions should be assessed in conjunc-
tion with level of consciousness (as measured by
GCS or otherwise).
䉴 Case 2.1
䉴 Predicted Clinical Deterioration A 20-year-old male with a fracture/dislocation
of his ankle has had it reduced under “proce-
The foregoing discussion refers to assessing the dural sedation”. Some time later, the spouse of
patient’s immediate need for intubation. How- the patient in the adjoining bay comes to get
ever, the clinician should always be thinking of help. She reports that the 20-year old is blue
the patient’s expected clinical course. This and doesn’t appear to be breathing. The blood
includes consideration of the patient’s present- pressure (BP) is 170/90, heart rate (HR) is
ing condition, potential for deterioration, and 100, respiratory rate (RR) 4, and the oxygen
other factors such as the need to facilitate emer- saturation (SaO2) is 65% on room air.
gent investigations (e.g., computed tomography
With the relief of pain following reduction In assessing the ABCs in this patient, snor-
of his fracture, the patient became bradyp- ing is likely to be indicative of functional airway
neic, as he had lost much of the stimulus that obstruction, due to the patient’s obtunded state.
was competing with the respiratory depres- Other signs of functional obstruction may be
sive effect of the sedative/analgesic combina- present, such as supra- and intercostal indraw-
tion. Visible cyanosis is a late sign of oxygen ing, and a “rocking” pattern of respiration,
desaturation. The patient should be briefly whereby the chest falls and the abdomen rises
assessed for airway patency and respiratory with attempted inspiration. The airway should
effort. His airway should be opened with head be opened with head tilt/jaw thrust. An oral air-
tilt/chin lift/jaw thrust, and if spontaneous way can be inserted. If the airway is now patent,
respirations do not resume, positive pressure oxygen by nonrebreathing face mask should be
BMV with oxygen should be rapidly insti- administered. The patient will require intuba-
tuted. Naloxone administration (with or with- tion for a number of reasons: airway mainte-
out the benzodiazepine antagonist Flumaze- nance, airway protection, and predicted clinical
nil) will probably result in a rapid return of course. The condition of this patient is too ten-
spontaneous respirations and consciousness, uous for her to be sent to the diagnostic imaging
and intubation will most likely not be needed. department without having an airway secured by
Other clinical states which may be reversible intubation.
before intubation is required, include the fol-
lowing:
• Ventricular arrhythmias—may respond to 䉴 Case 2.3

defibrillation.
• Hypoglycemia—may respond to glucose. A 35-year-old female, 8 months pregnant,
• Anaphylaxis—may respond to epinephrine. was involved in a motor vehicle collision
(MVC). At the scene she was complaining of
Concomitant basic airway management may right-sided chest discomfort and pain in what
well still be indicated in these scenarios, and appeared to be a broken right arm. She was
depending on the response to treatment, intu- transported by ambulance to the ED “back-
bation may also be required. boarded and collared.” She is now uncon-
scious, and has snoring respirations. Only
her systolic BP is obtainable at 50/, HR 140,
RR 35; SaO2 is unobtainable on a 40% sim-
ple facemask, and her GCS is 7.
䉴 Case 2.2
A 45-year-old female presents to the emer-
gency department (ED). Shortly before, while This patient also has an airway which is func-
at home, she had complained of a sudden- tionally obstructed at initial presentation. As a
onset severe headache, then collapsed. She trauma victim with a depressed level of con-
was transported by ambulance. On arrival, sciousness, C-spine precautions are in effect.
she is receiving oxygen, but is unresponsive However, the front of the cervical collar should
and has snoring respirations. The BP is be removed and replaced with manual in-line
180/100, HR 55, RR 25, SaO2 92% with non- stabilization. A jaw thrust may be performed to
rebreathing face mask (NRFM), and the Glas- open the airway, but head tilt and chin lift
gow Coma Scale (GCS) is 7. should be omitted. 100% oxygen should be
administered. Concomitantly, the patient must
10 CHAPTER 2
be removed from the supine position, as a

supine hypotension syndrome due to the 䉴 Case 2.5
gravid uterus causing aorto-caval compression
may be causing or contributing to the hypoten- A 35-year-old female, well known in the inten-
sion. A wedge should be placed under the right sive care unit, has been receiving maximal
side of the spine board. Fluid resuscitation medical therapy for an acute exacerbation of
should be initiated, and vital signs reevaluated. asthma. She remains “tight” and is moving
In this case, relief of caval compression helped very little air. Although her SaO2 is 91% with
restore preload, and BP rapidly reached 100/70. oxygen, she is visibly tiring and getting drowsy.
The patient regained consciousness, and now Her BP is 170/100, HR 120, RR 30, SaO2 91%
maintaining her own airway, did not acutely with NRFM, and her GCS is 14.
require intubation.
therapy and her condition will worsen as she

䉴 Case 2.4 tires. Hypoxia will ensue and as her CO2 nar-
cosis progresses, she may also be unable to pro-
A 55-year-old male was in a house fire. Although tect her airway.
his burns seemed limited, 6 hours after the
injury he started complaining of shortness
of breath, and subsequently developed
䉴 SUMMARY
stridor on inspiration. His BP is 160/90, HR
In the foregoing cases, some patients required
90, RR 30, SaO2 92% with NRFM, and his
immediate attention with basic airway opening
GCS is 15.
maneuvers and only temporary airway support,
while others went on to require intubation.
Either way, an initial assessment of airway patency
The patient with an inhalational thermal injury and effectiveness of gas exchange should always
can develop progressive airway edema which be made. Noninvasive maneuvers to main-
may eventually threaten airway patency. Critical tain oxygenation and ventilation should be
narrowing at the laryngeal inlet is often heralded undertaken as needed, while a determina-
by inspiratory stridor. Stridor should generally be tion is made about the subsequent need for
regarded as a sign of impending complete air- intubation. Intubation may be needed to obtain
way obstruction. Intubation is indicated in this and maintain an airway, correct gas exchange,
patient to obtain and maintain a patent airway protect the airway, or for an anticipated adverse
and for predicted clinical deterioration. While predicted clinical course.
making preparations for intubation, elevation of
the head of the bed and the administration of a REFERENCES
helium-oxygen mixture (if immediately available)
1. Bleach NR. The gag reflex and aspiration: a ret-
may help temporize the situation.9
rospective analysis of 120 patients assessed by
The patient described in Case 2.5 is main-
videofluoroscopy. Clin Otolaryngol Allied Sci.
taining her airway at present, and requires no 1993;18(4):303–307.
basic airway intervention other than oxygen 2. Davies AE, Kidd D, Stone SP, et al. Pharyngeal sen-
administration. However, intubation is indicated sation and gag reflex in healthy subjects. Lancet.
for impaired gas exchange (her Pco2 is steadily 25, 1995;345(8948):487–488.
climbing), and predicted clinical deterioration. 3. Altschuler SM. Laryngeal and respiratory protective
The patient has received maximal medical reflexes. Am J Med. 3, 2001;111 (Suppl 8A):90S–94S.
4. Mackay LE, Morgan AS, Bernstein BA. Swallowing 8. Al-Salamah MA, McDowell I, Stiell IG, et al. Initial
disorders in severe brain injury: risk factors affect- emergency department trauma scores from the
ing return to oral intake. Arch Phys Med Rehabil. OPALS study: the case for the motor score in blunt
1999;80(4):365–371. trauma. Acad Emerg Med. 2004;11(8):834–842.
5. Advanced Trauma Life Support for Doctors. 9. Ho AM, Dion PW, Karmakar MK, et al. Use of heliox
American College of Surgeons; 2004; No. 46. in critical upper airway obstruction. Physical and
6. Gill M, Windemuth R, Steele R, et al. A comparison physiologic considerations in choosing the optimal
of the Glasgow Coma Scale score to simplified helium:oxygen mix. Resuscitation. 2002;52(3):
alternative scores for the prediction of traumatic 297–300.
brain injury outcomes. Ann Emerg Med. 2005;45(1):
37–42.
7. Gill MR, Reiley DG, Green SM. Interrater reliabil-
ity of Glasgow Coma Scale scores in the emergency
department. Ann Emerg Med. 2004;43(2):215–223.
Chapter 3
Airway Physiology and
Anatomy
䉴 KEY POINTS • When managing a child’s airway, it is impor-

tant to appreciate that there are more
• Oxygen delivery depends on having an anatomical and physiologic similarities to
adequate pump (cardiac output), carrier adults than differences. The Broselow tape
(hemoglobin), and oxygen saturation. can significantly assist the practitioner in
• Time to desaturation is extended by metic- assembling equipment for the critically ill
ulous attention to preoxygenation, and child.
shortened by factors that adversely affect
oxygen storage (the functional residual 䉴 AIRWAY PHYSIOLOGY:
capacity, FRC) and consumption (VO2). INTRODUCTION
• Pulse oximetry may be inaccurate in low-
flow clinical conditions. Hypoxia is a common terminal event in the crit-
• The epiglottis is an important landmark in ically ill patient. Human cells require oxygen for
airway management, and should be a vital metabolic processes. Although cells in some
source of reassurance, not anxiety. organs can survive without oxygen for short
• Attempts to lift the tongue prematurely periods of time via less efficient anaerobic metab-
during direct laryngoscopy, before the olism, cells in vital organs such as heart and brain
hyoepiglottic ligament is engaged at the function only by aerobic metabolism. As oxygen
base of the vallecula, will often result in stores are limited in the human body, these
an inadequate view of the glottic inlet. organs require a continual supply of oxygen mol-
• The maximal outer diameter of a tube or can- ecules to function and survive: death follows
nula placed through the cricothyroid mem- quickly in the absence of oxygen delivery.
brane should be no greater than 8.5 mm.
• The Cormack-Lehane (C-L) classification 䉴 THE OXYGEN ECONOMY
and percentage of glottic opening (POGO)
score both provide a means of describing As in most economies, cells operate on a supply
glottic visualization. A modified version of and demand system. The currency is oxygen.
the C-L classification may help the clini- Cellular survival depends on an appropriate
cian decide how best to proceed with match between oxygen delivery (DO2) and
endotracheal intubation. consumption (VO2).
13
14 CHAPTER 3
Alveolar Ventilation into the pulmonary venous blood will always

create a small degree of shunt, other causes
Oxygen in the atmosphere∗ moves along a pres- include atelectasis, lung consolidation
sure gradient, through the respiratory tract and with fluid-filled alveoli, or small airway
alveoli, via arterial blood and capillaries to tis- closure.
sues and cells. In the alveoli, the partial pres- • Diffusion abnormalities: Generally, diffu-
sure of oxygen (PAO2) drops from 150 mm Hg sion of oxygen from alveolus to capillary
to around 100 mm Hg, due to the balance of along the pressure gradient is complete by
oxygen uptake by the pulmonary capillaries and the time blood has traveled only one-third of
its supply by ventilation. The partial pressure of the way along the capillary. Diffusion is gen-
deoxygenated blood in the pulmonary capillaries, erally completed even if cardiac output is
returned to the lungs via the pulmonary arteries, increased (e.g., in exercise). Thus, the con-
is about 40 mm Hg. Oxygen thus diffuses from tribution of any impairment in diffusion to
the alveoli to the pulmonary capillaries along a an alveolar/arterial PO2 difference will be
pressure gradient. minimal in the absence of significant pul-
In a perfect lung, blood leaving the pulmonary disease.
monary capillaries via the pulmonary veins
would be fully oxygenated, that is, with no
alveolar/arterial PO2 difference. In practice, Oxygen Transport in the Blood
this does not happen because of a number of
factors: Following its entry by diffusion into blood, oxygen
is carried in two ways:
• Ventilation-perfusion mismatch: Ideally
all alveoli would receive an equal share of
• In combination with hemoglobin:
alveolar ventilation and all pulmonary capil-
Each gram of hemoglobin can chemically
laries would receive an equal share of car-
combine with a maximum of 1.31 mL of
diac output. In reality, some alveoli are rela-
oxygen: this is termed the oxygen capacity.
tively overventilated, while some are relatively
Thus, with a blood hemoglobin concen-
overperfused.
tration of 15 g/dL (150 g/L), each liter of
• Shunt occurs when alveoli are perfused
blood can carry (150 g/L × 1.31 mL/g) =
but receive no ventilation (an extreme
197 mL of oxygen. The term oxygen sat-
form of ventilation-perfusion [VQ] mis-
uration (SaO 2 ) describes the percentage
match). Deoxygenated blood has no chance
of hemoglobin which is combined with
to become oxygenated and returns to the
oxygen.
pulmonary veins still in a deoxygenated
• Dissolved in plasma and intracellular
state. While physiologic drainage of intrin-
fluid: At atmospheric pressure, 0.3 mL/dL
sic cardiac (thebesian) and bronchial veins
(or 3 mL/L) of oxygen are carried in phys-
ical solution. Although a very small pro-
portion, this amount increases to 20 mL/L
*Air is composed of 21% oxygen, 78% nitrogen, and 1% other by breathing 100% oxygen, and can be
gases, at a pressure of 760 mm Hg at sea level. The partial raised even further under hyperbaric
pressure of oxygen when first inspired is therefore (760)
(.21) = 159 mm Hg. Inspired air is humidified in the upper conditions.
airway, and as the total pressure exerted by a mixture of
gases is equal to the partial pressure of each of the compo- The arterial oxygen content thus reflects
nent gases, the partial pressure of water vapor (47 mm Hg)
drops the partial pressure of inspired oxygen, thus: (760–47) the hemoglobin concentration, its percent satura-
(.21) = 150 mm Hg. tion with oxygen, and the amount of dissolved
AIRWAY PHYSIOLOGY AND ANATOMY 15
oxygen. In a patient with a hemoglobin of 15 delivery (DO 2 ), and equals the cardiac out-
g/dL and an SaO2 of 95%, the arterial oxygen put × arterial oxygen content. With a typical
content will be (.95 × 150 g/L × 1.31 mL/g) + cardiac output of 5 L/min, DO2 is 5 L/min × 190
3 mL/L dissolved O2 = 190 mL/L. mL/L = approximately 1000 mL O2/min. In the
The relationship between the arterial partial healthy, resting patient, VO 2 is 250 mL/min,
pressure of oxygen (PaO2) and SaO2 is that is, 25% of available oxygen is consumed.
described by the oxyhemoglobin dissociation Thus, the hemoglobin in mixed venous
curve (Fig. 3–1). The flat upper portion of the blood is 95% – 25% = 70% saturated. This
curve indicates that with an initial fall in PaO2, 70% oxygen saturation of venous blood rep-
the SaO2 falls little, and the arterial oxygen con- resents an important reserve from which
tent is little changed. However, as the PaO2 tissues can extract extra oxygen when com-
continues to fall below 60 mm Hg, the slope of pensating for decreased DO2. Below a critical
the curve becomes steeper. While this steeper value of DO 2 , however, compensation no
part of the slope reflects easier offloading of longer occurs and evidence of tissue hypoxia
oxygen to the tissues, it also implies that once occurs.
oxygen desaturation begins, its progression is The foregoing discussion on DO2 is clini-
quick. The linear portion of this curve can be cally relevant, as it points to areas which can
estimated by the 90–60, 60–30 rule of thumb, result in inadequate tissue oxygenation (i.e.,
whereby an SaO2 of 90% corresponds roughly to tissue hypoxia):
a PaO2 of 60 and an SaO2 of 60% corresponds
to a PaO2 of 30. A. Low cardiac output (stagnant or circula-
The total quantity of oxygen available to tory hypoxia). Even with a normal arterial
the tissues in one minute is termed oxygen oxygen content, circulatory failure can result
100
Poor O2 delivery to tissue
90
pH Left shift pH
Temp Temp
Right shift
PaCO2 PaCO2
60 Good O2 delivery to tissue

SaO2 (%)
50
0
27 30 50 60 90 100
PaO2 (mm Hg)
Figure 3–1. The oxyhemoglobin dissociation curve.

16 CHAPTER 3
in failure of tissue oxygenation, due to lack This in turn can affect the efficacy of pharma-
of delivery of oxygen to the tissues. This cologic and other therapy.
can happen globally, or regionally, with
inadequate blood flow to a particular organ. Oxygen Stores
Initially, tissues will compensate by increasing
oxygen extraction, but as perfusion wors- Oxygen stores in the body are sufficiently lim-
ens, this becomes insufficient and tissue ited that life cannot be sustained for more than
hypoxia develops. a few minutes once breathing stops. Oxygen is
B. Low arterial oxygen saturation (hypoxic stored mainly in the blood and lungs, with small
hypoxia). This is defined as an inadequate amounts bound or dissolved in tissues. Blood
arterial PO2. This may result from many stores depend on the blood volume and hemo-
causes, including decreased inspired par- globin concentration. Lung stores of oxygen
tial pressure of oxygen (e.g., at altitude); depend on the alveolar PO2 and the lung volume
hypoventilation from central (e.g., due to at end expiration (the functional residual
sedative medications) or peripheral (e.g., capacity [FRC], about 35 cc/kg or 2.5 L). This
functional airway obstruction) causes; or volume of 2.5 L contains a reservoir of 2500 mL
from inadequate alveolar-capillary transfer x .21 (the FiO2) = 500 mL of oxygen. With threat-
(e.g., from V-Q mismatch, shunt, or diffusion ened hypoxemia, only part of the oxygen stored
abnormalities). in the blood (mainly bound to hemoglobin), is
C. Low hemoglobin concentration (anemic released before a critical decrease in blood
hypoxia). With profound anemia, oxygen PaO2 has occurred (Fig. 3–1). The better reser-
content will fall in proportion to the hemo- voir for oxygen is the FRC of the lungs, partic-
globin concentration, even with a normal ularly if preoxygenation has been undertaken
PaO2. A compensatory increase in cardiac prior to apnea: this can increase the FRC
output may occur, but if or when this can no oxygen stores from 500 mL to 2500 mL (the
longer be sustained, tissue hypoxia occurs. FRC of 2500 mL x 1.0 [the FiO2]), 80% of which
Alternatively, if hemoglobin is rendered inca- can be used before the PaO2 falls below nor-
pable of carrying oxygen, for example, by mal. Preoxygenation of a patient using 100%
carbon monoxide poisoning, a similar reduc- oxygen, applied via a tightly fitting face mask,
tion in DO2 can occur. prolongs the time to desaturation after onset of
D. Histotoxic hypoxia. In spite of normal apnea by many minutes, compared to a patient
delivery of oxygen to the tissues, cellular breathing room air.1 This is shown in Fig. 3–2,
metabolic processes utilizing oxygen can be using data derived from healthy elective surgi-
impaired, an example of which is cyanide cal patients. Shown in the same graph is the
poisoning. markedly shortened apnea time available in the
patient with an FRC decreased by obesity. Other
In the critically ill patient, VO2 is often conditions that may lessen the effectiveness
increased, a factor over which we have little of preoxygenation by limiting FRC include
control in the short term. Thus, in the early advanced pregnancy and any process that limits
phase of resuscitation, attention must be the patient’s ability to take a deep breath (e.g.,
directed to maximizing DO2, by avoiding oxygen rib fractures, pneumothorax, pulmonary con-
desaturation, as well as by maintaining or restor- tusion). The critically ill patient has also been
ing cardiac output and hemoglobin concentra- shown to benefit less from preoxygenation,2
tion. If tissue oxygenation demands are not as fever, trauma, and other physiological stres-
met, anaerobic metabolism occurs, leading to sors increase metabolic demands and the rate
lactic acid production and metabolic acidosis. of VO2.
Time to Hemoglobin Desaturation with Initial The clinician should recognize that other factors
FAO2 = 0.87 may contribute to the appearance of cyanosis.
100 Normal Decreased tissue blood flow can cause so-called
70-kg peripheral cyanosis, whereby apparent cyanosis
adult
occurs even with a normal arterial oxygen con-
Moderately ill
90 70-kg tent. This can be observed in patients with
adult hypothermia, decreased cardiac output, or in
Normal some, simply when placed in the supine or Tren-
SaO2 %
10-kg delenburg position. Ambient lighting differences

80 child
Obese can affect how easily cyanosis is detected, and
127-kg certain drugs (e.g., benzocaine) can cause the
adult appearance of cyanosis, also with a normal arte-
70 rial oxygen content.
Arterial Blood Gases

0
0 1 2 3 4 5 6 7 8 9 10
Apnea time (minutes) Arterial blood gas monitoring is the gold standard
for monitoring blood oxygen tension. Although
Figure 3–2. Times to oxygen desaturation
following onset of apnea in preoxygenated invasive, it has the advantage of also giving infor-
elective surgical patients (From Benumof J,1 mation about carbon dioxide and acid-base
with permission). status: many contemporary point-of-care blood-
gas analyzers can also deliver other blood chem-
istry results. However, it is important to recognize
䉴 MONITORING OXYGENATION that even with a normal PaO2 (and SaO2), tissue
hypoxia can occur from low cardiac-output states,
Signs and symptoms of hypoxemia include anemia, or failure of the tissues to utilize oxygen.
tachycardia, dysrhythmias, tachypnea, dyspnea, In addition, regional hypoxia in a vital organ (e.g.,
cyanosis, and mental status changes. All are non- brain or heart) can cause morbidity or death in a
specific and of little value in reliably detecting normally oxygenated patient..3
hypoxemia. The clinician should be well-versed
in the advantages and limitations of methods
Pulse Oximetry
available for monitoring the oxygenation status
of the critically ill patient.
Pulse oximeters noninvasively measure the
percentage of hemoglobin that is saturated
Cyanosis with oxygen. A transcutaneous probe (usually
applied to a digit) emits light at two different
Cyanosis is a bluish discoloration of skin and wavelengths. One wavelength is absorbed by
mucus membranes which occurs with oxygen oxyhemoglobin in the tissues, and one by deoxy-
desaturation. The presence of cyanosis should hemoglobin. The relative absorption of each
be used as an indication to more objectively wavelength enables the processor to calculate
monitor and manage who is most likely a the proportion of hemoglobin which is saturated.
hypoxemic patient. Cyanosis will appear at an The technique is enhanced by signal processing
SaO2 of 85%–90%, although variation exists. It to separate the pulsatile (oxygenated arterial
will be less apparent in the anemic patient, and blood) and nonpulsatile (venous capillary) signal.
more readily visible in the polycythemic patient. In this way, the pulse oximeter can estimate
18 CHAPTER 3
arterial SaO2 with a high degree of accuracy. facilitates the appropriate performance of
Pulse oximeters measure SaO2, and not the more airway opening skills and BMV. These skills
familiar PaO2. A drop in the SaO2 with the asso- depend on an understanding of functional
ciated warning drop in pulse oximeter tone is airway anatomy and how the tissues behave
familiar to most clinicians. with the patient in either the awake or
Pulse oximetry is not always accurate. At obtunded state.
oxygen saturations less than 75%, many (espe- C. Landmark recognition A sound three-
cially older) instruments become increasingly dimensional appreciation of the laryngeal
inaccurate. In burns and smoke inhalation inlet and its surroundings is critical for
injury, the presence of carboxyhemoglobin may optimal laryngoscopy. Anatomic structures
cause a pulse oximeter to read falsely high adjacent to the glottic opening, such as the
because of the similar light absorption spectra epiglottis and paired posterior cartilages
of oxyhemoglobin and carboxyhemoglobin. help provide a “roadmap” to the cords. In
However, the most common problem with addition, anatomic or pathologic variations
oximetry occurs with a reduction in pulsatile in airway anatomy must be understood and
signal brought about by peripheral vasocon- anticipated.
striction caused by hypothermia, low cardiac D. Spatial orientation Particularly when
output, or hypovolemia. This may lead to com- using blind or indirect visual intubation
plete loss of oximeter readings. Finally, move- techniques, a clear mental image of the
ment of the probe can confuse microprocessor anatomy through which the instrument is
algorithms, making pulse oximetry difficult in traveling is required. Problem solving
patients with tremors, seizure, or other repeti- through intubation with a lightwand or intu-
tive movement disorders. bating laryngeal mask airway is much
easier with a solid appreciation of potential
䉴 AIRWAY ANATOMY: ITS anatomical barriers.
IMPORTANCE
䉴 FUNCTIONAL AIRWAY ANATOMY
A clear mental picture or “gestalt” of upper airway
anatomy is an essential cognitive underpinning The Upper Airway
to emergency airway management skills. This
knowledge is important for the following The immediate goal of airway management
reasons: during resuscitation is to obtain a patent upper
airway and ensure adequate oxygenation. The
A. Making decisions Assessment of a patient’s upper airway may be defined as the space
airway anatomy is the foundation upon which extending from the nose and mouth down to
the airway plan is built. Can the patient be the cricoid cartilage, while the lower airway
ventilated with bag-mask ventilation (BMV)? refers to the tracheobronchial tree.
Can the patient be intubated by direct laryn-
goscopy? If difficulty is encountered, can The Nasal Cavity
rescue oxygenation occur via an extraglottic
device or cricothyrotomy? Based on this assess- During normal breathing in the awake state,
ment, the clinician can decide how to proceed: inspired air travels through, and is humidified
with a rapid-sequence intubation (RSI), an by, the nasal cavity. The nasal cavity is bounded
awake intubation, or primary surgical airway. laterally by a bony framework which includes
B. Structure and function Knowledge of the three turbinates (conchae) (Fig. 3–3) and
airway anatomy and its dynamic changes medially by the nasal septum. Septal deviation
located cribriform plate. The nasal cavity is well

vascularized, particularly at the anterior infe-
rior aspect of the nasal septum. Many author-
ities espouse directing an endotracheal tube’s
bevel toward the septum to minimize the
potential for bleeding caused by traumatizing
the vascular Kiesselbach plexus. However,
published case series suggest that significant
A
bleeding with nasal intubations is less frequent
than commonly feared, occurring in under 15%
B
of cases.5,6
C
The Naso- and Oropharynx,
and the Mandible
D
The nasal cavity terminates posteriorly at the
level of the end of the nasal septum (the nasal
choanae). The space from here to the tip of the
soft palate is referred to as the nasopharynx.4
E
The oropharynx extends backward from the
F
palatoglossal fold (arching from the lateral
aspect of the soft palate to the junction of the
G anterior two-thirds with the posterior one-third
of the tongue4), down to the epiglottis. The oro-
H and nasopharynx are common sites of narrowing
or complete airway obstruction in the obtunded
Figure 3–3. Upper airway anatomy: A. Inferior patient, as the loss of tone in muscles responsi-
turbinate, B. Major nasal airway, C. Vallecula, ble for maintenance of airway patency allows
D. Epiglottis, E. Hyoid bone, F. Hyoepiglottic for posterior movement of soft palate, tongue, and
ligament, G. Thyroid (laryngeal) cartilage, epiglottis. Although classic teaching has been
H. Cricoid cartilage.
that it is collapse of the tongue against the pos-
terior pharyngeal wall which causes functional
airway obstruction in the obtunded patient, in
fact, significant airway narrowing or obstruc-
occurs commonly, and can impede passage of tion can occur in one or all of three locations7–9
a nasal endotracheal tube, as can a hypertro- (Fig. 3–4 A and B):
phied inferior turbinate. The space between the
inferior turbinate and the floor of the nasal cav- • In the nasopharynx, as the soft palate
ity, termed the major nasal airway,4 is ori- meets the posterior pharyngeal wall.
ented slightly downward. During an attempted • In the oropharynx, as the tongue moves
nasal intubation, the tube should therefore be posteriorly to lie against or near the soft
directed straight back and slightly inferiorly. This palate and posterior pharyngeal wall.
will help traverse the widest aspect of the nasal • In the laryngopharynx, as the epiglottis
airway, beneath the inferior turbinate, while moves posteriorly toward the posterior pha-
avoiding the thin bone of the more superiorly ryngeal wall.
20 CHAPTER 3
Figure 3–4 A, B. Sites of airway obstruction in the obtunded patient. A. Patent airway in the
awake state. B. In the obtunded state, functional airway obstruction occurs as the soft palate,
tongue and epiglottis fall back toward the posterior pharyngeal wall.
The mandible figures prominently in allevi- posterior pharyngeal wall, helping to attain a
ating functional airway obstruction. The horse- clear airway in the obtunded patient.
shoe- shaped mandible extends superiorly via • During laryngoscopy, the laryngoscope
two rami to end in the coronoid process and blade moves the mandible forward, helping
condylar head.4 The condylar head in turn artic- to displace the tongue anteriorly and away
ulates with the temporal bone at the temporo- from obstructing the line-of-sight view of
mandibular joint (TMJ), and allows for mouth the laryngeal inlet.
opening by rotation. In addition, anterior trans-
lation of the condyle at the TMJ permits forward In addition to forward movement of the
movement of the mandible. The latter is crucial mandible and tongue, a laryngoscope blade also
for two reasons: seeks to compress or displace the tongue into
the bony framework of the mandible: this is
• As the inferior aspect of the tongue is why individuals with small mandibles (so-called
attached to the mandible, anterior translation receding chins) can present difficulty with laryn-
of the jaw elevates the tongue away from the goscopy.
The Laryngopharynx attached by the thyrohyoid membrane to the

hyoid bone above, and articulates inferiorly with
The laryngopharynx extends from the epiglottis the cricoid cartilage. The cricoid cartilage is a cir-
down to the inferior border of the cricoid carti- cular, signet-ring-shaped cartilage which marks
lage. The laryngopharynx can be looked upon as the lower border of the laryngeal structure. The
a “tube within a tube,” with the circular structure hyoid bone and thyroid and cricoid cartilages are
of the larynx located anteriorly within the larger all palpable in the anterior neck. The vocal cords
pharyngeal tube. On either side of the larynx, in attach anteriorly to the inner aspect of the thy-
the pharynx, are the piriform recesses, while the roid cartilage, and posteriorly to the arytenoid
esophagus is located posteriorly (Fig. 3–5). The cartilages, which in turn also articulate with
larynx, which sits at the entrance to the trachea the cricoid cartilage. The cricoid cartilage is sig-
opposite the fourth, fifth, and sixth cervical ver- nificant in airway management for a number of
tebrae, is a complex box-like structure consisting reasons:
of multiple articulating cartilages, ligaments,
and muscles. The major cartilages involved are A. Because of its rigid nature, application of
the cricoid, thyroid, and epiglottis, together with posterior pressure on the cricoid cartilage
the smaller paired arytenoid, corniculate, and can occlude the underlying esophagus,
cuneiform cartilages. Located anteriorly in the helping to prevent passive regurgitation of
midline, the shield-shaped thyroid cartilage is gastric contents.
I C
E
G
Figure 3–5. Laryngeal inlet anatomy: structures seen at laryngoscopy. A. Median and lateral
glossoepiglottic folds, B. Vocal folds (true cords), C. Vestibular folds (false cords), D. Aryepiglottic
folds, E. Posterior cartilages, F. Interarytenoid notch, G. Esophagus, H. Piriform recess, I. Vallecula.
J. Epiglottis.
22 CHAPTER 3
B. It is the narrowest point of the airway in the advanced into the vallecula until it engages the
pediatric patient (the glottic opening is nar- underlying hyoepiglottic ligament. Pressure on
rowest in the adult patient), and can be an this ligament with the blade tip helps evert
area of potential obstruction due to swelling (“flips up”) the epiglottis to achieve a line-of-
(producing the clinical syndrome pediatri- sight view into the larynx. Attempts to lift the
cians call croup), or congenital or acquired tongue prematurely, before the hyoepiglottic
subglottic stenosis. Such narrowing of the ligament is engaged at the base of the vallec-
subglottic space may block passage of even ula, will often result in an inadequate view of
a normally sized endotracheal tube (ETT). the glottic inlet. Clinicians preferring straight
C. The cricoid cartilage, together with the thy- blade direct laryngoscopy usually elect to place
roid cartilage, is a landmark for locating the the blade beneath the epiglottis and directly lift
cricothyroid membrane, an area of critical it. Either way, the epiglottis is an important
importance in performing an emergency landmark in airway management, and should
surgical airway. be a source of reassurance, not anxiety. Indeed,
it should be actively sought by the laryngoscopist
The Laryngeal Inlet as a guide to the underlying glottic opening.
Originating laterally from each side of the
The clinician should be very familiar with the epiglottis toward its base, the aryepiglottic folds
component parts of the laryngeal inlet which form the lateral aspect of the laryngeal inlet
are visually presented at laryngoscopy. The by sweeping posteriorly to incorporate the
paired vocal cords are the “target” for the laryn- cuneiform and corniculate cartilages. The cor-
goscopist, and are identified by their whitish niculate cartilages overlie the corresponding
color and triangular orientation. Surrounding arytenoid cartilages, and appear as the charac-
the vocal cords, the laryngeal inlet is bordered teristic “bumps” (tubercles) posterior to the
anteriorly by the epiglottis, laterally by the vocal cords. In practice, many clinicians refer to
aryepiglottic folds, and inferiorly by the these prominences as the arytenoids. Confusion
cuneiform and corniculate tubercles (carti- can be avoided by referring to these tubercles
lages), and the interarytenoid notch (Fig. 3–5). collectively simply as the posterior cartilages.
The epiglottis projects upward and backward, The underlying arytenoids are anatomic hinges
behind the hyoid bone and base of tongue, used by laryngeal muscles to open and close
and overhangs the laryngeal inlet.10 The base the cords. Between and slightly inferior to the
of the superior surface of the epiglottis is paired posterior cartilages lies the interarytenoid
attached to the hyoid bone by the hyoepiglottic notch (Fig. 3–6). With the cords in the abducted
ligament (Fig. 3–3), while the inferior surface position, this notch widens to a ledge of
attaches to the thyroid cartilage via the thy- mucosa stretching between the posterior carti-
roepiglottic ligament. The overlying mucosa lages, but with the cords in a more adducted
on the upper surface of the epiglottis sweeps position, the interarytenoid notch narrows
forward to join the base of the tongue, with simply to a small vertical line. This notch lies
prominences forming the median and paired slightly inferior to the posterior cartilages and
lateral glossoepiglottic folds. The paired valleys is important during laryngoscopy because in a
between these folds are called the vallecul- restricted view situation, it may be the only
lae, although both vallecullae are com- landmark identifying the entrance to the glottic
monly referred to together as the vallecula opening above.11
(Fig. 3–3 and 3–5). Posterior to the laryngeal inlet lies the esoph-
To expose the vocal cords, the tip of a curved agus. It should be noted that the entrance to the
(e.g., Macintosh) laryngoscope blade can be upper esophagus is not held open by any rigid
of the oral and pharyngeal/tracheal axes then

occurs with extension at the atlantooccipital
junction and upper few cervical vertebrae
(Fig. 3–7 A, B). Final visualization by line-
of-sight is then achieved using the laryngo-
scope blade to anteriorly lift the mandible and
displace the tongue (Fig. 3–8). This alignment
of axes by proper positioning before laryn-
goscopy reduces the need for tongue dis-
placement required during laryngoscopy,
which may in turn reduce the amount of force
A
required to expose the cords. Where not con-
traindicated by C-spine precautions, the airway
B
axes can be aligned before laryngoscopy by
C
placing folded blankets under the extended
head to produce the “sniffing position.”
The Lower Airway
The trachea extends from the inferior border

Figure 3–6. Laryngeal inlet anatomy: A. of the cricoid cartilage to the level of the sixth
Aryepiglottic fold, B. Posterior cartilages, C. thoracic vertebra, where it splits into the left
Interarytenoid notch.
and right mainstem bronchus. The trachea is
12 to 15 cm long in the average adult and is
composed of C-shaped cartilages joined verti-
structures, and at laryngoscopy is often not cally by fibroelastic tissue and completed pos-
seen at all. Conversely, when the esophageal teriorly by the vertical trachealis muscle.10 The
entrance is seen, it can look like a dark, (and anterior tracheal cartilaginous rings are respon-
sometimes inviting) opening. This highlights the sible for the “clicking” sensation transmitted to
importance to the laryngoscopist of knowing a clinician’s fingers following successful
the expected landmarks of the laryngeal inlet: introduction and advancement of a tracheal
the posterior cartilages, aryepiglottic folds and tube introducer (bougie). The right mainstem
overlying epiglottis flank the glottic opening, bronchus is shorter and more vertical than the
and not the esophagus! left, making it a common location for the tip of
an endotracheal tube that has been advanced
too far. Avoiding a right mainstem intubation
Airway Axes will be aided by situating the ETT no more than
23 cm at the teeth in males and 21 cm in females,
In the standard anatomic (military) position, reflecting the average teeth-to-carina distance of
the axis of the oral cavity sits at close to right 27 and 23 cm in the average male and female,
angles to the axes of the pharynx and trachea. respectively.
To obtain direct visualization during laryn-
goscopy, this angle needs to be increased to Surgical Airway Anatomy
180°. The pharyngeal and tracheal axes can be
aligned by flexion of the lower cervical spine One-third of the trachea lies external to the
at the cervicothoracic junction, while alignment thorax: the first 3–4 tracheal rings lie between
24 CHAPTER 3
Figure 3–7 A, B. Alignment of oral and pharyngeal/tracheal axes (A) before and (B) after plac-
ing the patient in the “sniff” position.
the cricoid and the sternal notch. These rings are and thyroid cartilages, the membrane is 22–30 mm
the common location for elective tracheotomies. wide and 9–10 mm high, in the average adult.
Urgent percutaneous access to the trachea is This means that the maximal outer diameter of a
more commonly achieved through the relatively tube or cannula placed through the cricothyroid
avascular and easily palpable cricothyroid mem- membrane, as part of an emergent surgical
brane (Fig. 3–9). Located between the cricoid airway, should be no greater than 8.5 mm (the
Figure 3–8. Final alignment of the airway axes is achieved through tongue displacement and
anterior lift of the mandible using a laryngoscope.
outside diameter [OD] of a #4 tracheostomy cricoid cartilage initially lies immediately

tube is 8 mm; the OD of a #6 tracheostomy beneath the thyroid cartilage. For this reason,
tube is 10 mm; and a 6.0 ID ETT has an OD of in the younger pediatric patient (i.e., up to age
8.2 mm). The average distance between the mid- 8), there is no well-defined cricothyroid mem-
point of the cricothyroid membrane and the brane allowing easy access to the airway.
vocal cords above is only 13 mm. The lower
third of the membrane is usually less vascular
than the upper third. 䉴 AIRWAY INNERVATION
Emergency cricothyrotomies are performed
after failure to intubate, in conjunction with Knowledge of the innervation of the airway is
a failure to oxygenate by BMV or extraglottic important to the airway manager contemplating
device. Rarely, airway pathology may mandate application of airway anesthesia to facilitate
a primary cricothyrotomy or tracheotomy. It an “awake” intubation. The posterior third of
should be noted that developmentally, the the tongue is innervated primarily by the
26 CHAPTER 3
D
E
A
F
Figure 3–9. Anterior neck landmarks.

A. Hyoid bone, B. Laryngeal prominence
(“Adam’s apple”), C. Thyroid (laryngeal) carti- C
lage, D. Cricothyroid membrane, E. Cricoid
cartilage, F. Thyroid gland.
Figure 3–10. Airway innervation. Distribu-

glossopharyngeal nerve (Fig. 3–10), as are the tions supplied by A. Glossopharyngeal nerve,
soft palate and palatoglossal folds. Pressure on B. Superior laryngeal nerve and C. Recurrent
these structures can evoke a “gag” response. The laryngeal branches of the vagus nerve.
glossopharyngeal nerve can be blocked with
small volumes of local anesthetic injected at the
base of the palatoglossal fold in the mouth, but 䉴 ABNORMAL AIRWAY ANATOMY
also responds well to topically applied anesthe-
sia. The internal branch of the superior laryngeal The challenge of airway management is increased
nerve supplies the laryngopharynx, including when the patient has airway anatomy that dif-
the inferior aspect of the epiglottis and the larynx fers from the norm. Variations from normal can
above the cords. It can be blocked topically by be classified in two ways:
holding pledgets soaked in local anesthetic solu-
tion (e.g., 4% xylocaine) in the piriform recesses. • Difficulties can be caused by normal anatomic
Alternatively, it can be blocked by injecting a variations such as a small chin, large tongue,
small volume of local anesthetic in the proximity high arched palate, or an obese neck.
of the nerves as they pierce the thyrohyoid mem- • Pathologic processes such as airway trauma,
brane, near the lateral aspects of the hyoid bone. inflammation, infection, tumor, or congenital
Below the cords, sensation is provided by the anomaly can create challenges in all aspects
recurrent laryngeal branch of the vagus nerve. of airway management.
Assessing the patient for anatomic variations principles of airway assessment and manage-
and pathologic conditions is an important step ment apply equally to both the pediatric and
that must occur during the preparation phase of adult airways. The differences of note between
airway management. adult and pediatric airways are most pronounced
in the first 2 years of life, with similarities out-
weighing differences thereafter (Fig. 3–14).
䉴 DESCRIBING THE VIEW
OBTAINED AT LARYNGOSCOPY
The view of the laryngeal inlet obtained at direct Pediatric Airway Anatomic
laryngoscopy is commonly recorded using a Differences
scale described by Cormack and Lehane12
(Table 3–1; Fig. 3–11). The Cormack-Lehane A summary of significant differences between
(C-L) scale is a widely accepted classification adults and children follows:
schema for glottic visualization, and will be
referred to throughout this book. Other authors A. The head-to-body size ratio is greater in
have further subdivided the Grade 2 and 3 infants and young children. Optimal airway
view13–15 (Table 3–1; Fig. 3–12). This is clinically angulation for laryngoscopy is achieved
relevant in that “easy” Grade 1 and 2A views are in infants by placing a towel under the
approached differently (direct laryngoscopy [DL] shoulders. Preschoolers are usually in good
alone +/– external laryngeal manipulation) than intubating position when lying flat on a
“restricted” Grade 2B and 3A views (DL plus stretcher; older children often require a
bougie). “Difficult” Grade 3B and Grade 4 views pillow under their heads to achieve the
are managed differently still (e.g., using alterna- sniffing position.
tive intubation techniques such as the LMA Fas- B. The infant tongue is large relative to the jaw,
trach, Trachlight, or indirect fiberoptic devices). and the larynx is more cephalad. In
Another classification is the POGO score, used infants, the larynx is at C 2–3 and migrates
to describe the Percentage Of Glottic Opening in the first 5 years to its adult location at
visualized during laryngoscopy (Fig. 3–13).16 C 4–5. This relatively high larynx creates an
Its use results in improved interrater reliability17 anatomic relationship sometimes called
in describing laryngeal views compared to the glossoptosis and is usually described by the
C-L classification. The POGO score is applicable laryngoscopist as an anterior larynx. This
to C-L Grades 1 and 2 situations only, and, requires more tongue displacement during
while useful to help record exactly how much laryngoscopy and explains the relative
of the laryngeal inlet was seen at laryngoscopy popularity among pediatric practitioners of
for charting or data collection purposes, it will straight laryngoscope blades for intubation.
not necessarily aid the clinician in making C. Preteen children may have large tonsils (so
prospective airway management decisions. large that they may meet in the midline). This
can interfere with laryngoscopy and may lead
to bleeding from laryngoscope trauma.
䉴 THE PEDIATRIC AIRWAY: D. Loose primary teeth may be dislodged and
PHYSIOLOGY AND ANATOMY aspirated.
E. From age 1 to 5, the epiglottis is growing
The differences between pediatric and adult faster than the rest of the larynx. It often
airway management are often overemphasized takes on an unusual appearance (like a
to the point of causing undue anxiety in the tulip), may be longer and more “U” shaped,
clinician. This need not be the case. Basic and is often soft and floppy. It is often
䉴 TABLE 3–1 CORMACK-LEHANE12 AND COOK MODIFICATION13 GRADING OF LARYNGEAL INLET STRUCTURES VISIBLE AT
LARYNGOSCOPY
Cormack-Lehane12 Cormack-Lehane Cook13 Modification Description of Cook Alternative Cook

Grade Description of Cormack Grade Modified Cormack Grades Nomenclature
Grade 1 All or most of the glottic Grade 1
aperture is visible
easy
Grade 2 Only the posterior extremity Grade 2A Posterior cords and
of the glottis is visible (i.e. cartilages visible
28
the posterior cartilages), Grade 2B Only posterior cartilages

visible visible
restricted
Grade 3 Only the epiglottis can be Grade 3A Epiglottis visible and
visualized: no part of the can be lifted
glottic aperture can be Grade 3 B Epiglottis adherent to
seen posterior pharynx
difficult
Grade 4 Not even the epiglottis can
be visualized
Grade I
Grade II
Grade III
Grade IV
Figure 3–11. The Cormack-Lehane (C-L) classification of glottic visualization.
difficult to evert by placing the blade tip in I. The short trachea often results in right main-
the vallecula. Pediatric laryngoscopists gen- stem ETT placement. ETT depth should be
erally position the laryngoscope blade age/2 + 12.
(curved or straight) posterior to the epiglottis J. Once an ETT is placed, moving the head
(i.e., picking it up directly) to expose the may cause the ETT to migrate up or down.
glottis. There is a significant risk of right main intu-
F. Cuffed ETTs are not essential below age 5 bation or inadvertent extubation after tube
because the cricoid ring, the narrowest part fixation. Radiographic recheck and confir-
of the pediatric airway, can form a reason- mation are frequently required.
ably tight fit and seal around the ETT. It is K. An ETT must be secured with particular care
important to demonstrate a small leak in children. Tonguing can be vigorous in
around the tube because an occlusive fit may children and small movements can lead to
lead to subglottic ischemic injury. kinking or extubation.
G. The glottic opening is tipped more inferiorly
(an adult’s is 90° to the line of sight, while a Pediatric Physiologic Differences
child’s is closer to 135°).
H. The small airway is prone to edema and Compared to adults, infants and children have
obstruction, especially at the subglottic level. a higher minute ventilation, basal O2 consumption
30 CHAPTER 3
Grade 3 A Grade 3 B
Figure 3–12. Cook’s modification of the Cormack-Lehane Grade 3 view: Grade 3A (epiglottis
obscures the view of any laryngeal structures, but is elevated) and 3B (epiglottis points poste-
riorly and/or lies on the posterior pharyngeal wall).
rate and cardiac output. Combined with a lower a profound drop in cardiac output, and hypoten-
FRC, this leads to more rapid desaturation dur- sion. Hypoxic bradycardia rarely progresses to
ing apnea. Infants respond rapidly to hypoxia true asystole unless hypoxia is prolonged. Although
by dropping the heart rate and raising pul- this rapid “death spiral” can be frightening, it
monary vascular resistance. This in turn leads to can be rapidly reversed with oxygenation and
100 %
Figure 3–13. Percentage of Glottic Opening (POGO) score.

Infant Adult
Figure 3–14. Pediatric airway anatomy differences are most apparent in the infant and
include a relatively large occiput, which places the neck into flexion; a relatively larger
tongue, and a more cephalad larynx. Other differences include a longer, “floppier”
epiglottis, more ‘angled’ glottis and a funnel shaped upper airway, narrowest at the
cricoid cartilage.
ventilation: atropine and epinephrine are rarely clinician must maintain a “mental image” of the
required. The best way to deal with this issue is airway anatomy through which they pass.
to prevent it: the pace of infant intubation
sequences must be much faster than that to
which most practitioners are accustomed in their
adult practice. REFERENCES
Medication dosing and equipment sizing 1. Benumof JL, Dagg R, Benumof R. Critical hemoglo-
for the pediatric patient can be addressed by bin desaturation will occur before return to
the use of the Broselow tape, with an accom- an unparalyzed state following 1 mg/kg intra-
panying dedicated pediatric airway and resus- venous succinylcholine. Anesthesiology. 1997;87(4):
citation cart. 979–982.
2. Mort TC. Preoxygenation in critically ill patients
requiring emergency tracheal intubation. Crit
Care Med. 2005;33(11):2672–2675.
䉴 SUMMARY 3. Bateman NT, Leach RM. ABC of oxygen. Acute oxy-
gen therapy. Bmj. 1998;317(7161):798–801.
A thorough knowledge of airway-related physi- 4. Morris IR. Functional anatomy of the upper airway.
ology and anatomy is vital for the acute-care Emerg Med Clin North Am. 1988;6(4):639–669.
clinician. Physiologic considerations dictate 5. Tintinalli JE, Claffey J. Complications of nasotra-
cheal intubation. Ann Emerg Med. 1981;10(3):
the need for preoxygenation and suggest when
142–144.
the patient will be less likely to tolerate diffi-
6. Latorre F, Otter W, Kleemann PP, Dick W,
culty, if encountered, with airway management. Jage J. Cocaine or phenylephrine/lignocaine for
Familiarity with airway anatomy is vital for suc- nasal fibreoptic intubation? Eur J Anaesthesiol.
cessful direct laryngoscopy, where landmark 1996;13(6):577–581.
recognition is instrumental in leading the clinician 7. Nandi PR, Charlesworth CH, Taylor SJ, Nunn JF,
to the laryngeal inlet. Equally, to be successful Dore CJ. Effect of general anaesthesia on the phar-
with the use of alternative intubation devices, the ynx. Br J Anaesth. 1991;66(2):157–162.
32 CHAPTER 3
8. Shorten GD, Opie NJ, Graziotti P, Morris I, Khangure 13. Cook TM, Nolan JP, Gabbott DA. Cricoid pressure—
M. Assessment of upper airway anatomy in awake, are two hands better than one? Anaesthesia.
sedated and anaesthetised patients using magnetic 1997;52(2):179–180.
resonance imaging. Anaesth Intensive Care. 14. Cook TM. A new practical classification of laryn-
1994;22(2):165–169. geal view. Anaesthesia. 2000;55(3):274–279.
9. Hillman DR, Platt PR, Eastwood PR. The upper 15. Yentis SM, Lee DJ. Evaluation of an improved scoring
airway during anaesthesia. Br J Anaesth. 2003;91(1): system for the grading of direct laryngoscopy.
31–39. Anaesthesia. 1998;53(11):1041–1044.
10. Ellis H, Feldman S. Anatomy for Anaesthetists. 16. Levitan RM, Ochroch EA, Kush S, Shofer FS, Hol-
6th ed. Oxford: Blackwell Scientific Publications; lander JE. Assessment of airway visualization:
1993. validation of the percentage of glottic opening
11. Levitan RM. The Airway Cam(TM) Guide to Intu- (POGO) scale. Acad Emerg Med. 1998;5(9):
bation and Practical Emergency Airway Manage- 919–923.
ment. Wayne, PA: Airway Cam Technologies, Inc. ; 17. O’Shea JK, Pinchalk ME, Wang HE. Reliability of
2004. paramedic ratings of laryngoscopic views during
12. Cormack RS, Lehane J. Difficult tracheal intubation in endotracheal intubation. Prehosp Emerg Care.
obstetrics. Anaesthesia. 1984;39(11):1105–1111. 2005;9(2):167–171.
Chapter 4
Oxygen Delivery Devices and
Bag-Mask Ventilation
䉴 KEY POINTS 䉴 INTRODUCTION
• It is important to avoid inappropriate fix- Oxygenation and ventilation are key goals
ation on endotracheal intubation. Bag- of airway management and are commonly
mask ventilation (BMV) may be a critical achieved by bag-mask ventilation (BMV),
first step in oxygenating a patient before endotracheal intubation, or both. BMV in
and/or between intubation attempts. particular is a critical airway management
• The bag-valve mask (BVM) device (man- skill. In some studies, BMV has been shown
ual resuscitator), with a good face-mask to be no less effective than endotracheal
seal, may be used passively (without pos- intubation or extraglottic device use. 1–3 How-
itive pressure ventilation) in the sponta- ever, in spite of its importance, formal train-
neously breathing patient, to deliver close ing in BMV technique is often lacking,4 with
to 100% oxygen. studies showing poor performance and reten-
• If needed, in the patient still demonstrat- tion of the technique in hospital personnel. 5
ing respiratory effort, assisted bag-mask This problem can be compounded by the
ventilation may be performed, timed to delegation of BMV to a less skilled team
deliver a positive pressure breath with the member, together with an inappropriate fix-
patient’s inspiratory effort. ation on the more invasive technique of
• An adequate jaw thrust, and, where per- endotracheal intubation. As a potentially
mitted, head extension are the keys to effec- life-saving skill, BMV is a critical step in oxy-
tive BMV. genating a patient before and between intu-
• Difficult mask ventilation is usually easily bation attempts. The ability to oxygenate the
resolved by altering technique, including patient with BMV has very specific airway
the early use of an oral airway, combined management implications: in a difficult situ-
with two-person BMV. ation, successful BMV may obviate the need
• Predicted difficulty with BMV may signifi- to employ less familiar rescue oxygenation
cantly impact the decision of how to pro- techniques such as extraglottic device place-
ceed with an intubation. ment or cricothyrotomy.
33
34 CHAPTER 4
䉴 OXYGEN SUPPLY 䉴 OXYGEN DELIVERY
Indications for instituting oxygen (O2) therapy First-line therapy in managing the acutely ill
appear in Table 4–1. Often taken for granted, patient almost always involves oxygen delivery.
the clinician must ensure that the oxygen This may be provided passively if the patient
supply is intact and functioning. Assuming has a patent airway and sufficient respiratory
oxygen is being supplied without deliberately effort, or actively, via positive pressure ventila-
checking on each occasion an airway intervention (PPV). PPV in turn can be delivered by
tion is undertaken, will eventually result in a BMV, noninvasive positive pressure ventilation
patient being managed on room air! Malposi- (NPPV) or via an extraglottic device or endotra-
tions of the proximal end of oxygen tubing cheal tube.
include the following:
䉴 OXYGEN DELIVERY DEVICES—
• Appropriately attached to the oxygen outlet, PASSIVE
but without the oxygen flowmeter being
turned on. Oxygen is a drug and needs to be treated with
• Attached to the neighboring medical air outlet. respect, but it rarely causes harm in the acutely
• Attached to the suction outlet. ill patient. Where indicated, it should be deliv-
• On the floor. ered in precise concentrations. Whenever pos-
• Attached to an empty oxygen cylinder. sible, its use should be monitored with a pulse
oximeter. Oxygen delivery devices can be cate-
Oxygen can be supplied via pipeline from a gorized as low (variable performance) or
central gas supply to wall- or ceiling-mounted high (fixed performance) flow. Low flow
outlets, or from portable cylinders. Oxygen devices such as nasal cannulae, simple face
cylinders vary in size from the large tanks car- masks and nonrebreathing face masks deliver
ried in ambulances to smaller, more portable oxygen at less than the patient’s peak inspira-
tanks used for transport within a hospital or for tory flow rate. Inspired oxygen concentration
individual patients. will thus vary with the patient’s pattern of
breathing. In contrast, high flow devices such as
the Venturi face mask deliver oxygen at a rate
in excess of the patient’s peak inspiratory flow
rate, and allow for more precise titration of the
inspired oxygen concentration.
䉴 TABLE 4–1 INDICATIONS FOR INSTITUTION
OF OXYGEN THERAPY.
Cardiac and respiratory arrest Nasal Cannulae

Hypoxemia (PaO2 <60; SaO2 <90%)
Systemic hypotension (BP <100 mm Hg
Applied to the nostrils, nasal cannulae can be
systolic)
Low cardiac output and metabolic acidosis
used to modestly increase the fractional inspired
(Bicarbonate <18 mmol/l) concentration of oxygen (FiO2). Using the dead
Respiratory distress (RR >24/minute in the space of the nasopharynx as a reservoir for oxy-
adult) gen, the delivered FiO2 is never precisely known,
as it will vary with the patient’s minute ventila-
Source: Fulmer JD, Snider GL. American College of tion, inspiratory flow rate, and oxygen flow rate.
Chest Physicians (ACCP)—National Heart, Lung, and
Blood Institute (NHLBI) Conference on Oxygen While nasal prongs have their use in a patient
Therapy. Arch Intern Med. 1984;144:1645–55. who is mildly ill, limitation of the maximum
OXYGEN DELIVERY DEVICES AND BAG-MASK VENTILATION 35
deliverable FiO2 make their use in patients the delivered FiO2 with the addition of a reser-
requiring advanced airway support unadvisable. voir bag and two valves (Fig. 4–1). Supplied
High-flow O2 delivery by nasal prongs is uncom- oxygen is directed into the reservoir bag (which
fortable and quickly dries the nasopharynx. must be unraveled when taken out of the pack-
age). A valve positioned between the mask and
the reservoir bag allows 100% O2 to enter the
Simple Face Mask
face mask during patient inspiration, but pre-
vents flow back into the reservoir bag during
Encompassing mouth and nose, application of
exhalation. A second one-way valve located
oxygen at 6–10 liters per minute (LPM) through
over one of the two exhalation ports allows
a simple face mask will result in a delivered
exhalation through the port, while preventing
FiO2 of 30%–50%. As the patient’s peak inspi-
entrainment of room air on inspiration. With a
ratory flow exceeds that of the supplied oxy-
tight mask seal and minimal entrained room air,
gen, dilution of oxygen by room air entrained
delivered FiO2 approaches 80%. It should be
around the mask edges and through exhala-
noted that supplied oxygen flow for the nonre-
tion ports will occur, limiting delivered FiO2.
breathing face mask must be adjusted so that
Exhalation of gas is through these same exha-
the reservoir bag never completely collapses
lation ports. There is little control of the actual
(i.e., >10–15 LPM) during the patient’s inspira-
inspired FiO 2 using this device—it supple-
tion to minimize room-air entrainment.
ments oxygenation, but to a variable degree.
In practice, the spontaneously breathing
Humidification can be added to the setup to
patient receiving face-mask oxygen who is likely
maximize patient comfort.
to require more advanced airway support
should usually have a nonrebreathing face mask
Nonrebreathing Face Mask (NRFM) applied, unless a high FiO2 is contraindicated
(as with an unmonitored patient with advanced
Using a similar face-piece to the simple mask, chronic obstructive pulmonary disease [COPD]).
the nonrebreathing face mask (NRFM) increases Any patient requiring such a high concentration
Figure 4–1. Nonrebreathing face mask (note reservoir bag is inflated).

36 CHAPTER 4
of O2 should be closely observed and monitored Venturi adapters supply an FiO2 between 24%
with the anticipation of the need to proceed to and 50%. Precise control of FiO2 may be desired
endotracheal intubation. when reliable assessment of the alveolar-arterial
(A-a) gradient is needed, or when applying O2
Venturi Mask to certain COPD patients.
Of the devices described in this section, the Ven-

turi mask system allows the most precise control 䉴 OXYGENATION AND
of delivered FiO2. Using the same cone-shaped VENTILATION SYSTEMS—ACTIVE
oxygen mask as the simple face mask, this sys-
tem (Fig. 4–2) incorporates a removable Venturi Noninvasive Positive Pressure
adapter proximal to the oxygen inlet. Wall gas Ventilation
is forced through the Venturi valve, creating a
small jet of oxygen within the device. The jet Noninvasive positive pressure ventilation (NPPV)
creates a negative pressure around it (the Ven- is a method of providing positive pressure venti-
turi effect) that entrains room air at a fixed rate, latory support via a face mask, nasal mask, or
resulting in a predictable mixing of 100% oxy- mouthpiece (as opposed to an endotracheal
gen with room air. The speed of the jet and vol- tube) to selected patients with acute ventilatory
ume of air entrained is controlled by the size of failure. Required equipment varies from a simple
the hole and rate of oxygen flow controlled at continuous positive airway pressure (CPAP)
the source, resulting in a predictable delivered valve, through purpose-made bilevel devices, to
concentration of oxygen. As gas is delivered at full service intensive care unit (ICU) ventilators.
a rate exceeding the patient’s maximum inspi- Positive pressure delivery modes also vary, with
ratory flow rate, changes in breathing do not options extending from simple CPAP to patient-
affect the oxygen concentration delivered. With triggered delivery of set volumes or pressures.
specific oxygen flow rates, different color-coded Bilevel positive airway pressure (BiPAP) ventilation
Figure 4–2. Face mask with Venturi adaptors for different inspired oxygen concentrations.
is used to deliver different pressures during inspi- exhibit an early response to the intervention,8
ration and expiration. and in the subgroup of patients with the follow-
NPPV has been shown to improve outcomes ing associated parameters: pH >7.25, respiratory
in certain patients with acute hypercapneic rate <30, Glasgow Coma Scale (GCS) >11.9 Res-
ventilatory failure. Certainly, there is strong evi- piratory failure patients in extremis require more
dence to support its use in patients with COPD, definitive airway support by way of endotracheal
and to a lesser extent, cardiogenic pulmonary intubation, as patient anxiety and “air hunger”
edema.6,7 Patients with acute respiratory failure may complicate attempted NPPV delivery.
from other causes have shown less benefit, to
date. Improved outcomes in the COPD and pul-
monary edema populations include a reduction The Boussignac CPAP System
in the need for intubation; ICU admissions;
length of hospital stay; and mortality.6,7 Success The Boussignac system (Fig. 4–3) is a newer dis-
is more likely in patients who are younger and posable oxygen delivery device that provides
Figure 4–3. The Boussignac continuous positive airway pressure (CPAP) system provides flow
dependent CPAP and also allows in-line medication nebulization, and suction access without
removal of the mask.
38 CHAPTER 4
flow-dependent CPAP without the need for a flow the workings of the BVM device, as it has a
generator. A standard O2 source and flowmeter number of valves, and needs proper assembly
are used to deliver variable degrees of CPAP accord- to work. Also known as manual resuscitators,
ing to the flow selected. For example, 10 LPM of these devices incorporate a self-inflating bag, a
oxygen flow provides 2.5–3.0 cm H2O of CPAP; one-way bag inlet valve, and a nonrebreathing
15 LPM provides 4.5–5.0 cm H2O; and 25 LPM patient valve. The patient valve end features a
provides 8.5–10.0 cm H2O of CPAP. The delivered universal connector with a 22-mm outside diam-
FiO2 will depend on respiratory rate and tidal vol- eter (OD), which fits standard face masks, and
ume (generally, a minute ventilation <15 LPM a 15-mm internal diameter (ID) that connects to
delivers 70%–100% FiO2).10 A nebulizer can be standard endotracheal tubes, extraglottic devices,
added to the system for medication administra- and cricothyrotomy or tracheostomy cannulae.
tion, and a suction catheter can be passed with An oxygen inlet port is located on the bag inlet
the mask in place. valve end to accept the oxygen source tubing.
To enable 100% oxygen delivery, oxygen flow
must be adjusted to ensure the attached reservoir
Bag-Valve Mask Ventilation bag never fully collapses.
Systems The face mask used in conjunction with the
manual resuscitator is generally made of rubber
The bag-valve mask (BVM) ventilation device or plastic, and may incorporate an inflatable
(Fig. 4–4) is used to manually deliver positive cuff around its margin to better conform to the
pressure through an applied face mask, extra- patient’s facial anatomy. The tight seal thus
glottic device or endotracheal tube. The former afforded is mandatory when the manual resus-
would be an initial step in an apneic or hypoven- citator is being used for PPV, but is also useful
tilating patient, and is almost always indicated in the spontaneously breathing patient, as the
prior to, or during intubation of an ill patient. good seal obtained ensures delivery of close to
The clinician should be intimately familiar with 100% oxygen.
Figure 4–4. Bag-valve mask (BVM) manual resuscitator.

Adult-sized manual resuscitators are sup- Oropharyngeal Airways

plied with a 1600 mL self-inflating bag; child
size 500 mL; and infant 240 mL. The pediatric DESCRIPTION
sized BVM devices may have an additional Oropharyngeal airways (OPAs) (Fig. 4–6) help
valve just proximal to the face mask—a pres- alleviate functional airway obstruction caused
sure limiting or “pop-off” valve. This is cali- by relaxation of the tongue against the soft
brated to release applied airway pressure at palate. They are most often used as an adjunct
approximately 40 cm H2O, to help prevent baro- to BMV of an obtunded or unconscious patient.
trauma. In clinical situations where there is a Made of plastic, the component parts are a
recognized airway obstruction that is not read- curved hollow lumen (in the Guedel version),
ily reversible (e.g., epiglottis, croup, airway proximal flange which abuts the patient’s lips,
edema, severe asthma), the pop-off valve may and proximal bite block which doubles as a
need to be controlled manually to ensure con- color-coded size indicator.
tinued lung inflation.
SIZING
OPAs are sized by length in centimeters, and are
available in sizes for all ages. Choosing the appro-
priate size is important, as too long an OPA may
䉴 ADJUNCTS TO BVM DEVICES— precipitate laryngospasm or create obstruction,
OROPHARYNGEAL AND
while if too small, it may be ineffective.11 Although
NASOPHARYNGEAL AIRWAYS
never formally validated, many clinicians approx-
imate correct OPA length by placing it alongside
Designed to alleviate obstruction caused by pos-
the patient’s cheek: from the corner of the lips,
terior relaxation of the tongue against soft palate
the tip of the OPA should reach the angle of the
or the soft palate against the posterior pharynx,
mandible (Fig. 4–7).12 A typical adult female will
both oral and nasal airways help create a patent
take an 8-cm OPA, and an adult male, 9 or 10 cm.
channel for ventilation. Correctly placed, the
distal end of each device should be located USE
beyond the soft palate and base of tongue, just The OPA should be inserted inverted, (i.e., with
above the epiglottis (Fig. 4–5). its concave surface directed cephalad) and advanced
Figure 4–5. The oropharygneal airway (OPA) when correctly placed is positioned behind the
tongue and cephalad to the epiglottis.
40 CHAPTER 4
Figure 4–6. Adult-sized oropharyngeal airways.
until the distal tip will proceed no further in the posterior tongue displacement into the
inverted position. At that point, the OPA is rotated hypopharynx during OPA placement. Alterna-
180°, so that the concavity faces caudad. tively, it can be inserted noninverted with a
Advancement continues around the curve of the tongue depressor to manage the tongue: this is
tongue until fully inserted. Inverted insertion the preferred technique in infants and younger
helps avoid worsening obstruction caused by children, to help avoid trauma to delicate tissues.
Figure 4–7. Sizing an oropharyngeal airway on an airway training manikin.

PRECAUTIONS AND CONTRAINDICATIONS SIZING

OPAs are not well tolerated in the awake or semi- Adult NPAs are generally sized by their internal
conscious patient with intact airway reflexes, diameter (ID) in mm. Typical adult sizes for
where insertion may stimulate gagging, vomit- small, medium, and large NPAs are 6, 7, and 8 mm
ing and aspiration or laryngospasm. In addi- ID, respectively. One commonly used (but non-
tion, care must be taken to rule out a foreign validated) sizing method is to use an NPA of a
body in the oropharynx prior to OPA insertion. length corresponding to the distance from nose
tip to the tragus of the ear. A second method,
whereby an NPA is used of a diameter equal to
Nasopharyngeal Airways that of the patient’s fifth finger was not found to
functionally correlate well when studied.13 Siz-
DESCRIPTION ing based on patient height makes more
A nasopharyngeal airway (NPA) may be a use- anatomic sense, resulting in a recommendation
ful option when trismus precludes OPA inser- for a 6 mm ID NPA for an average adult female
tion, and may be better tolerated than an OPA and 7 mm for an average male.14
in the awake or semiconscious patient with
intact airway reflexes. While effective at allevi- USE
ating functional airway obstruction, downsides The NPA is lubricated and advanced into the
to the NPA include transient patient discomfort patient’s nostril, perpendicular to the face,
during insertion and the potential for causing resulting in passage along the floor of the major
epistaxis. NPAs, also known as “nasal trumpets”, nasal airway. A slight twisting motion can be
are made from soft material such as latex or sil- used during insertion. If significant resistance is
icon, have a hollow interior, beveled leading encountered, insertion should be attempted
edge, and a proximal flange to abut the patient’s through the other nostril. Insertion continues
nostril (Fig. 4–8). until the flange of the NPA abuts the nasal ala.
Figure 4–8. Nasopharyngeal airways.

42 CHAPTER 4
PRECAUTIONS AND CONTRAINDICATIONS • Snoring inspiratory efforts (with functional

NPA use is relatively contraindicated in known airway obstruction) or inspiratory and/or
bleeding diathesis, including heparinized, war- expiratory stridor (with pathologic changes
farinized, or recently thrombolyzed patients, in the area of the glottis).
and in suspected cribriform plate fracture. How- • Paradoxical breathing: a “rocking” motion of
ever, this latter directive has been made on the chest and abdomen, whereby the abdomen
basis of only a few case reports:15,16 in the head- rises with attempted inspiration, and the
injured patient, common sense dictates balanc- chest falls.
ing the substantial risk of hypoxemia with the • Indrawing above the sternal notch and
benefits of cautiously obtaining a patent airway, between the ribs.
if an oral airway can’t be used. • Voice changes.
Response to the Obstructed

䉴 THE INITIAL APPROACH TO THE Airway: Airway Opening Maneuvers
AIRWAY
Although the potential causes of airway obstruc-
Basic Life Support (BLS) teaching mandates tion are many, the following initial airway clear-
assessing the unconscious patient for (a) respon- ing maneuvers are appropriate to try in most
siveness, (b) airway patency, and (c) adequacy patients:
of respiratory effort, by looking for chest rise,
and listening and feeling for air egress from the • Head extension at the atlanto-occipital
patient’s mouth and nose.17 The patient with no joint on the neck (omit in the patient where
evidence of effective gas exchange may or may C-spine precautions are in effect). As seen in
not still be making respiratory efforts against an Figs. 4–9 A and B, as the head is extended,
obstructed upper airway. functional obstruction is alleviated as the
epiglottis and tongue are elevated off the
posterior pharyngeal wall.
Recognition of the Obstructed • Jaw lift/thrust—similar changes but with a
Airway greater effect occur with jaw thrust or lift
(Fig. 4–10). Figs. 4–11 A and B dramatically
Airway obstruction may be complete or par- demonstrate the effect of a jaw lift in mov-
tial. The patient with a completely obstructed ing the obstructing tongue away from both
airway will be unable to speak, and as hypoxia the palate and the posterior pharyngeal wall
ensues, will rapidly lose consciousness and to obtain a patent airway in an unconscious
cease breathing. Partial airway obstruction may patient. This is easy to understand because
be functional, due to the soft palate, tongue, the tongue is anchored to the mandible—
and epiglottis falling back toward or against the lifting the mandible lifts the tongue.
posterior pharynx, or due to pathologic • Chin lift—combines head extension and
changes occurring within the lumen of the air- jaw thrust.
way (e.g., foreign body, tumor, or infection) or
externally compressing the airway (e.g., neck If simple airway opening maneuvers do
hematoma). not result in a return to a spontaneous, unob-
The patient with signs of partial airway structed pattern of ventilation, or even if they
obstruction may be recognized by some or all do, but the patient remains hypoxic, consider
of the following signs: the following:
A B
Figures 4–9. Lateral fluoroscopic views of an unconscious patient. In (A), the airway is
initially functionally obstructed. With head extension in the same patient, (B), a patent
airway (arrow) is created as tongue and epiglottis are elevated away from the posterior
pharyngeal wall.
Figure 4–10. A jaw thrust being demonstrated on an airway management trainer.

44 CHAPTER 4
A B
Figures 4–11. Lateral fluoroscopic views of an unconscious patient. (A) The airway is func-
tionally obstructed. (B) With a jaw thrust in the same patient, a widely patent upper airway
(arrow) is created.
• Insertion of an oral (if airway reflexes per- face. The lower border of the mask’s cuff is first
mit) and/or nasal airway. applied to the groove between the lower lip and
• Assisted BMV. the chin, after which the mask can be placed down
• Endotracheal intubation. across the nasal bridge. The thumb and index fin-
ger of the clinician’s hand applies sufficient pres-
Often the clinician will progress through the sure on the face mask to achieve a good seal
first two options while preparing for endotra- (Fig. 4–12). Note, however, that sealing pressure
cheal intubation. must be achieved without excessive downward
pressure on the patient’s mandible, as this may
䉴 BAG-MASK VENTILATION worsen functional obstruction—rather, the mandible
is lifted to meet the mask. Small adjustments to
As outlined previously, BMV is a crucial, yet the position of the mask on the patient’s face (e.g.,
frequently poorly taught skill, which must with small movements to left or right) are made
be mastered by the clinician with acute-care as needed to achieve a seal.
responsibilities.
AIRWAY OPENING
Bag-Mask Ventilation: Components The ring and long fingers grasp the bony ridge of
of Routine Technique the patient’s mandible, and, if practical, the fifth
finger hooks under the angle of the mandible.
There are three important components to proper These three digits provide counterpressure to the
BMV technique: mask seal, airway opening, and digits applying the mask to the face, but also
ventilation. apply an upward lift to the mandible to help per-
form an airway opening jaw thrust. Note that
MASK SEAL these three fingers should not be placed directly
An appropriately sized face mask is attached to under the patient’s chin, as midline pressure under
the bag-mask device and applied to the patient’s the chin can contribute to airway obstruction. This
Figure 4–12. Bag-mask ventilation: The thumb and index digits apply pressure to attain a seal
of the mask against the patient’s face, while the third, fourth, and fifth fingers lift the jaw up into
the mask.
latter directive is particularly important in small ventilated. A simple “look, listen, and feel” approach
children and infants. Concomitantly, the entire to assessing adequacy of BMV is outlined below:
hand also attempts to keep the head extended (if
no C-spine precautions). Look for:
• Chest expansion. This is best assessed by
VENTILATION observing the patient’s chest immediately
The clinician’s opposite hand is free to gently below the clavicles. Chest expansion in this
squeeze the self-inflating bag. Volumes should location reflects underlying lung expansion,
be delivered with attention to the patient’s sta- whereas movement of the lower thorax can
tus: if apneic, the patient should be gently ven- be apparent simply with gastric insufflation,
tilated at a rate of 10–15 breaths per minute, at even in the presence of complete airway
a tidal volume of 5–6 mL/kg, or 500 mL in the obstruction.
average adult.18 In the patient still demonstrat- • Reservoir bag filling from the O2 source.
ing respiratory effort, assisted BMV should be • Improving pulse oximeter reading.
performed, with timing of the positive pressure • Improvement in the patient’s color.
breath to the patient’s inspiratory effort. If the patient
is tachypneic, it will be appropriate to simply Listen for:
deliver an assisted breath with every third or fourth • Any hiss of escaping air caused by a poorly
patient inspiration. sealed face mask.
• The pulse oximeter tone, indicative of the
Assessing Adequacy of Bag-Mask SaO2.
Ventilation
Feel for:
In “bagging” a patient, the clinician must assess • Compliance of the self-inflating bag. If airway
whether the patient is in fact being adequately obstruction persists, the bag will be hard to
46 CHAPTER 4
squeeze. Other intrathoracic pathology, such E. If cricoid pressure is being applied, ease up
as bronchospasm or pneumothorax can also on, or release it.
cause increased resistance and decreased F. Consider a mask change (size or type) if seal
compliance. is an issue.
• Leaking air against one’s hand from a poorly G.. Rule out foreign body in the airway.
sealed face mask. H. Consider a “rescue” ventilation device, for
example, an extraglottic device such as an
Assessing the efficacy of BMV must continue LMA or Combitube.
as long as the patient is being bagged, as it is a I. Consider an early attempt at intubation.
very dynamic process. Small adjustments to the
position of the mask, degree of head tilt or jaw lift Steps A, B, and C, as listed above, should
are continuously needed during BMV. Changes in occur almost simultaneously and very early in
the patient’s condition (for example, administered the DMV situation. DMV is often due simply to
paralytic agents wearing off) or clinician fatigue the failure to adequately open a functionally
can also impact BMV effectiveness. obstructed airway. Attempted ventilation against
this obstruction results in a leak at the mask/face
interface, often resulting in the clinician’s attempt-
䉴 RESPONSE TO DIFFICULT BMV ing to remedy the problem by pushing down
SITUATIONS harder on the mask to attain a seal. This can
worsen an already obstructed airway. Rather, what
With appropriate technique, significant diffi-
must occur is a more pronounced jaw lift or thrust,
culty with BMV is rarely encountered in the
with resultant airway opening occurring as ante-
absence of airway pathology. The most experi-
rior movement of the mandible elevates the
enced person present should establish adequate
tongue, epiglottis, and soft palate away from the
airway opening and initiate and assess ease of
posterior pharyngeal wall. This is best performed
BMV. Difficult BMV (DMV) is often defined as
with the aid of a second person. Two-person mask
the inability to maintain an oxygen saturation
ventilation is easy to perform and is often much
above 90% with good technique. DMV requires
more effective than one person BMV. As shown
a staged response. Although one response to a
in Figs. 4–13, 4–14, and 4–15, the 2-person tech-
difficult BMV situation is to proceed to intuba-
nique can be performed in a number of ways.20
tion, DMV may itself predict difficulty with laryn-
Cricoid pressure can cause difficulty with
goscopy and/or intubation.19 Good BMV skills
both BMV and laryngoscopy. Excessive cricoid
and an approach to DMV are crucial skills in
pressure (as may be applied during a rapid-
ensuring oxygenation of a patient prior to, or
sequence intubation [RSI]) may distort the air-
between laryngoscopy attempts.
way and result in a partial or even complete
obstruction. This is especially true in a young
A Staged Response to child. If significant difficulty with BMV is encoun-
Difficult BMV tered during application of cricoid pressure, the
assistant should transiently ease (initially by 50%)
A. Reposition the head by performing an or release the applied pressure.
exaggerated head tilt/chin lift (if not con- It may become apparent once BMV is under-
traindicated). way that the chosen mask size is incorrect. This
B. Perform an aggressive jaw thrust. is often the case when initial mask sizing occurred
C. Insert an oropharyngeal airway (and/or a with the patient’s dentures in place. Especially
nasopharyngeal airway). with encountered difficulty, the improved seal
D. Perform a two-person mask ventilation allowed by an appropriately sized mask makes
technique. the change worthwhile.
Figure 4–13. Two-person bag-mask ventilation. The primary clinician applies the mask while a
second person squeezes the self-inflating bag.
The decision to move to a rescue device such on the other hand, DMV is encountered in the
as an LMA or Combitube will depend on the setting of an already failed attempt at intubation,
patient’s clinical status and whether direct laryn- placement of a rescue ventilation device such as
goscopy (DL) has yet been attempted. If there an LMA should be considered. Direct laryn-
has been no initial attempt at DL, it may be appro- goscopy is also the method of choice to rule out
priate to proceed with an intubation attempt. If, obstructing lesions, including foreign bodies.
Figure 4–14. Two-person bag-mask ventilation, showing an alternative mask grip for the
primary clinician.
48 CHAPTER 4
Figure 4–15. Two-person bag-mask ventilation. With this technique, the original clinician
continues one-person BMV, while the second person simply performs an aggressive jaw thrust.
problems of range of motion in the neck and

䉴 PREDICTION OF DIFFICULT BMV
the temporomandibular joint. Age is also associ-
Various patient features are helpful in predicting ated with loss of teeth and soft tissue elasticity and
difficult mask ventilation.19, 21 As part of the for- tone. Placement of an OPA or NPA and a good
mal airway examination of the patient, these fac- mask seal will help overcome these problems.
tors should be assessed. The following are features Toothless: The teeth play a role in maintaining
that can create difficulty with BMV—together, they facial architecture. In the edentulous patient,
form the simple mnemonic22 “BOOTS.” tissue collapse in the cheeks allows a leak to
occur at the corners of the mouth and makes a
Beard: A thick beard can create difficulty in good mask seal difficult. “Gathering” the cheek
obtaining a good mask seal. Application of up with the hypothenar aspect of the mask-
water-soluble gel will help to minimize air holding hand while simultaneously tilting the
escaping between hair. Other anatomic varia- mask a little toward the contralateral side will
tions or patient pathology, such as extreme help. Alternatively, an assistant can be dele-
trauma to the mandible, may also preclude a gated to hold the cheek up against the side of
mask seal. the mask (ideally one size smaller than usual).
Obesity: In an obese patient, difficult BMV can Early use of an OPA will help. Placement of
be encountered owing to decreased chest wall bunched up gauze in the buccal pouch of the
and diaphragmatic compliance, decreased abil- cheeks on either side of the oral airway may
ity to extend the head, and redundant soft tis- help with mask seal by puffing out the cheeks.
sue in the pharynx. Some clinicians elect to leave dentures in dur-
ing BMV to help maintain facial architecture.
Older: Age >55 can be associated with DMV. Neither dentures nor gauze should be left in the
This is likely multifactorial and may be related to intubated patient.
Sounds: A number of conditions associated rescue oxygenation via an extraglottic device

with abnormal upper and lower airway sounds or cricothyrotomy (see Chap. 12).
may cause difficulty with BMV.
A history of snoring has been correlated One last implication of predicted difficulty
with DMV.21 As with the obese patient, this may with BMV is the automatic need for an addi-
be associated with redundant oropharyngeal tional assistant, assuming a high probability of
tissues. Early placement of an OPA, and main- requiring a two-person technique.
taining a head-extended position will help.
Stridor is almost always a sign of patho-
logic airway obstruction and should be consid- 䉴 BMV TIPS AND PEARLS
ered an ominous sign. Any patient presenting
with inspiratory or expiratory stridor should be Ideal Head and Neck Positioning
considered as potentially very difficult or impos- for BMV
sible to bag-mask ventilate.
The patient with “stiff”, poorly compliant Ideally, for BMV, the head and upper neck
lungs, (often associated with wheezing or rales) should be extended23 (a) to attain a more direct
will present increased resistance to bag-mask path for the delivered volumes from face to tra-
ventilation and requires higher than normal chea, (b) to maintain longitudinal tension on
insufflation pressure. the lumen of the upper airway24 and possibly,
The presence of two or more of the factors (c) to increase retrolingual and retropalatal
presented above significantly increases the space.25 When studied, no additional benefit
potential for DMV.21 The true incidence of DMV was noted with elevation of the occiput (i.e.,
in the emergency department (ED) is not clear the “sniff” position) compared with simple head
but is likely greater than that seen with the tilt starting in the neutral position.23
elective surgical population. In the operating
room, DMV has been reported to occur in up Gastric Insufflation
to 5–8% of elective surgical patients.19, 21 Inter-
estingly, the DMV rate is twice as high (15.5%) Protracted periods of BMV or poor technique
in patients who were also described as difficult (e.g., delivering breaths during the expiratory
intubations.19 phase of the patient’s respiratory cycle; not
Prediction of difficulty with BMV is an maintaining an adequately open upper airway;
important component of the airway assessment, or using excessive tidal volumes or positive
as BMV remains the “go to” method of gas exchange pressure) can lead to insufflation of the esoph-
both before and between intubation attempts. It agus and stomach. Gastric distention in turn
also represents a vital decision node in airway presents two problems:
management in two ways:
• It predisposes to regurgitation of gastric con-
A. Decision making: Anticipated difficulty tents, potentially leading to aspiration, with
with BMV may point to the need for an its sequellae.
awake technique for intubation, especially • Particularly in children, but also in adults,
if difficulty with laryngoscopy is also pre- massive gastric distention can significantly
dicted (see Chap. 11). elevate and interfere with movement of the
B. Defining the failed airway: In the setting diaphragm, in turn creating further difficulty
of failed intubation, the inability to maintain with BMV by impacting respiratory system
the SaO2 >90% with BMV defines failed compliance. In extreme cases, gastric rupture
oxygenation, mandating proceeding with can occur.
50 CHAPTER 4
Gastric insufflation can be avoided by care- be paid to allowing sufficient time for exhala-
ful attention to delivered tidal volumes, employ- tion during BMV. Failure to do this may result
ing the lowest ventilation pressures possible in a buildup of intrathoracic pressure, which in
(below 20 cm H2O), and using airway adjuncts turn risks both cardiovascular collapse and baro-
such as the OPA and NPA. Evidence is emerg- trauma. Pressure may also be alleviated simply
ing that especially in the cardiac arrest patient, by intermittently releasing the seal made by the
lower esophageal sphincter pressure decreases mask against the face.
rapidly from the normal 20 cm H2O to as little
as 5 cm H2O, underscoring the need to mini-
mize applied insufflation pressures.26 Applica- Cervical Spine Precautions
tion of cricoid pressure (see below) can also be and BMV
considered. Although most patients can be ade-
quately oxygenated and ventilated using good, BMV can be performed safely in the patient who
well-timed BMV technique, some gastric insuf- is considered at risk for a cervical spine (C-spine)
flation is inevitable. BMV should therefore be injury, for example, the unconscious trauma
viewed as a “bridging” procedure to be used for patient. However, radiologic studies have
a limited period of time. If clinically significant shown that movement of the C-spine with BMV
gastric distention is suspected, an oro- or naso- is as much or more than that occurring with
gastric tube should be passed to decompress laryngoscopic endotracheal intubation.31–34 As
the stomach. such, during BMV, manual in-line neck stabi-
lization (MILNS) should be applied. Head tilt
should be omitted: jaw lift is the only airway-
Cricoid Pressure and BMV
opening maneuver that should be used.
Posterior pressure on the cricoid cartilage com-
presses the esophagus between the cartilagi-
The Clinician with Small or
nous ring of the cricoid and the body of the
Tiring Hands
C6 vertebra. It is often used to prevent passive
regurgitation of gastric contents during rapid-
A one-person technique may be difficult or
sequence intubation, but can also be consid-
impossible for the clinician with smaller hands,
ered in the unconscious patient during BMV to
or a clinician of average stature dealing with a
reduce inadvertent insufflation of air into the
very large patient. In such situations, early use of
stomach,27 as discussed above. However, it must
a two-person technique should be considered.
be appreciated that cricoid pressure can cause
difficulty with BMV,28, 29 especially if applied at
excessive pressures or in an upward direction.30
If this is suspected, it should be at least tran- Laryngospasm
siently released, to determine if that is the cause
of difficulty. Laryngospasm is a tight and complete adduction
of the vocal cords. It sometimes occurs in response
to attempted airway manipulation in deeply
“AutoPEEP” sedated patients, and may be more common in
the pediatric patient. Its effects can be dramatic,
The patient with reactive airways disease experi- with an almost total inability to bag-mask venti-
ences air trapping and difficulty with exhalation. late the patient. If this is suspected, application
In all patients, but particularly those with known of CPAP with the BVM device will often help
or suspected air trapping disease, attention must break the spasm: simply continue to apply a tight
seal with the mask, while maintaining light but 6. Caples SM, Gay PC. Noninvasive positive pressure
continuous positive pressure on the bag. Severe ventilation in the intensive care unit: a concise
or recalcitrant cases may require a small dose of review. Crit Care Med. 2005;33(11):2651–2658.
skeletal muscle relaxant, for example, succinyl- 7. Masip J, Roque M, Sanchez B, et al. Noninvasive
choline 20 mg in the adult patient. ventilation in acute cardiogenic pulmonary edema:
systematic review and meta-analysis. JAMA.
2005;294(24):3124–3130.
䉴 SUMMARY 8. Mehta S, Hill NS. Noninvasive ventilation.
Am J Respir Crit Care Med. 2001;163(2):540–577.
All clinicians with airway management respon- 9. Confalonieri M, Garuti G, Cattaruzza MS, et al. A chart
of failure risk for noninvasive ventilation in patients
sibilities must be able to assess the critically ill
with COPD exacerbation. Eur Respir J. 2005;25(2):
patient for airway patency and adequacy of gas 348–355.
exchange. BLS protocols should be followed to 10. Templier F, Dolveck F, Baer M, et al. Laboratory
open the airway, and if needed, positive-pressure testing measurement of FIO2 delivered by Boussi-
ventilation with BMV instituted. BMV must be gnac CPAP system with an input of 100% oxygen.
learned and practiced, and should not be looked Ann Fr Anesth Reanim. 2003;22(2):103–107.
upon as an easy skill. As the clinician becomes 11. Gabbott DA, Baskett PJ. Management of the airway
familiar with basic BMV, various adjuncts and and ventilation during resuscitation. Br J Anaesth.
additions to BMV can be used, such as PEEP 1997;79(2):159–171.
and “pop-off” valves, depending on the prac- 12. Levitan R, Ochroch EA. Airway management and
tice environment. A formal approach should be direct laryngoscopy. A review and update.
Crit Care Clin. 2000;16(3):373–388.
applied to the difficult BMV situation, and the
13. Roberts K, Porter K. How do you size a nasopha-
predictors of difficult BMV appreciated. Faced ryngeal airway. Resuscitation. 2003;56(1):19–23.
with ongoing difficulty in performing BMV 14. Stoneham MD. The nasopharyngeal airway. Assess-
and/or intubation, the clinician should consider ment of position by fibreoptic laryngoscopy.
placing an extraglottic device such as a laryngeal Anaesthesia. 1993;48(7):575–580.
mask airway or Combitube. 15. Muzzi DA, Losasso TJ, Cucchiara RF. Complication
from a nasopharyngeal airway in a patient with a
basilar skull fracture. Anesthesiology. 1991;74(2):
REFERENCES 366–368.
1. Dorges V, Wenzel V, Knacke P, Gerlach K. Com- 16. Schade K, Borzotta A, Michaels A. Intracranial mal-
parison of different airway management strategies position of nasopharyngeal airway. J Trauma.
to ventilate apneic, nonpreoxygenated patients. 2000;49(5):967–968.
Crit Care Med. 2003;31(3):800–804. 17. Part 4: Adult Basic Life Support. Circulation.
2. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of 2005;112(24_suppl):IV19–IV34.
out-of-hospital pediatric endotracheal intubation 18. Wenzel V, Idris AH, Montgomery WH, et al. Rescue
on survival and neurological outcome: a controlled breathing and bag-mask ventilation. Ann Emerg Med.
clinical trial. JAMA. 9, 2000;283(6):783–790. 2001;37(4 Suppl):S36–S40.
3. Stockinger ZT, McSwain NE, Jr. Prehospital endo- 19. Yildiz TS, Solak M, Toker K. The incidence and risk
tracheal intubation for trauma does not improve factors of difficult mask ventilation. J Anesth.
survival over bag-valve-mask ventilation. J Trauma. 2005;19(1):7–11.
2004;56(3):531–536. 20. Davidovic L, LaCovey D, Pitetti RD. Comparison of
4. Stapleton ER. Basic life support cardiopulmonary 1-versus 2-person bag-valve-mask techniques
resuscitation. Cardiol Clin. 2002;20(1):1–12. for manikin ventilation of infants and children.
5. Martin PD, Cyna AM, Hunter WA, et al. Training Ann Emerg Med. 2005;46(1):37–42.
nursing staff in airway management for resuscita- 21. Langeron O, Masso E, Huraux C, et al. Prediction of
tion. A clinical comparison of the facemask and difficult mask ventilation. Anesthesiology. 2000;92(5):
laryngeal mask. Anaesthesia. 1993;48(1):33–37. 1229–1236.
52 CHAPTER 4
22. Walls RM, Murphy M. Identification of the diffi- 28. Palmer JHM, Ball DR. The effect of cricoid pressure
cult and failed airway. In: Walls RM, ed. Manual on the cricoid cartilage and vocal cords: an endo-
of Emergency Airway Management. 2nd ed. scopic study in anaesthetised patients. Anaesthe-
Philadelphia: Lippincott Willimas and Wilkins; sia. 2000;55(3):263–268.
2004. 29. Hocking G, Roberts FL, Thew ME. Airway obstruc-
23. Morikawa S, Safar P, Decarlo J. Influence of the tion with cricoid pressure and lateral tilt. Anaes-
headjaw position upon upper airway patency. thesia. 2001;56(9):825–828.
Anesthesiology. 1961;22:265–270. 30. Hartsilver EL, Vanner RG. Airway obstruction with
24. Hillman DR, Platt PR, Eastwood PR. The upper air- cricoid pressure. Anaesthesia. 2000;55(3):208–11.
way during anaesthesia. Br J Anaesth. 2003;91(1): 31. Brimacombe J, Keller C, Kunzel KH, et al. Cervical
31–39. spine motion during airway management: a cine-
25. Isono S, Tanaka A, Ishikawa T, et al. Sniffing posi- fluoroscopic study of the posteriorly destabilized
tion improves pharyngeal airway patency in anes- third cervical vertebrae in human cadavers. Anesth
thetized patients with obstructive sleep apnea. Analg. 2000;91(5):1274–1278.
Anesthesiology. 2005;103(3):489–494. 32. Aprahamian C, Thompson BM, Finger WA, et al.
26. Gabrielli A, Wenzel V, Layon AJ, et al. Lower Experimental cervical spine injury model: evalua-
esophageal sphincter pressure measurement dur- tion of airway management and splinting tech-
ing cardiac arrest in humans: potential implications niques. Ann Emerg Med. 1984;13(8):584–587.
for ventilation of the unprotected airway. Anesthe- 33. Donaldson WF 3rd, Heil BV, Donaldson VP, et al.
siology. 2005;103(4):897–899. The effect of airway maneuvers on the unstable
27. Wenzel V, Idris AH, Dorges V, et al. The respiratory C1-C2 segment. A cadaver study. Spine. 1997;22(11):
system during resuscitation: a review of the history, 1215–1218.
risk of infection during assisted ventilation, respi- 34. Hauswald M, Sklar DP, Tandberg D, et al. Cervical
ratory mechanics, and ventilation strategies for spine movement during airway management:
patients with an unprotected airway. Resuscitation. cinefluoroscopic appraisal in human cadavers.
2001;49(2):123–134. Am J Emerg Med. 1991;9(6):535–538.
Chapter 5
Tracheal Intubation by Direct
Laryngoscopy
䉴 KEY POINTS • Cervical spine immobilization will often

lead to an “epiglottis-only,” Grade 3 view
• Direct laryngoscopy remains the proce- during direct laryngoscopy.
dural standard for emergency intubation. • To avoid patient morbidity, esophageal
• The clinician should always psychologi- intubations must be immediately recognized
cally prepare for a difficult airway, in an and corrected.
attempt to “anticipate the unanticipated.”
• Special attention must be paid to positioning 䉴 INTRODUCTION
the morbidly obese patient to facilitate
direct laryngoscopy. This chapter will review direct laryngoscopy and
• Cricoid pressure and external laryngeal intubation, including the initial response to
manipulation (ELM) are two separate encountered difficulty. Direct laryngoscopy (DL)
maneuvers done on two separate structures, is so named because it results ideally in direct
for different purposes. line-of-sight visualization of the glottis (Fig. 5–1).
• Failure to engage the hyoepiglottic liga- While DL is only one method of facilitating defin-
ment in the vallecula is a probable cause itive airway management, it is still the procedural
of the novice failing to achieve an ade- standard for intubation in emergencies, and as
quate view during direct laryngoscopy. such is deserving of a detailed discussion. Alter-
• Head lift, two-handed laryngoscopy native intubation techniques, including blind naso-
and ELM represent three ways to use tracheal intubation, are discussed in later chapters.
two hands on the first intubation
attempt (“3–2–1”). 䉴 PREPARATION FOR
• Beware the “pseudolarynx,” especially in ENDOTRACHEAL INTUBATION
young children.
• A tracheal tube introducer (“bougie”) or The adage that “your first shot is your best shot”
fiberoptic stylet can be used on the first is very applicable to laryngoscopy and intuba-
intubation attempt when “best look” direct tion. Prior to proceeding with any intubation, it
laryngoscopy has failed to yield an ade- is essential that the following preparations have
quate view. been undertaken:
53
54 CHAPTER 5
Figure 5–1. Direct laryngoscopy is so-named as it affords a direct line-of-sight view from the
clinician’s eye to the laryngeal inlet.
A. Equipment should be assembled and imme- F. Personnel: Airway management is not a

diately available for management of either a one-person job. At least one assistant is nec-
standard or unanticipated very difficult airway. essary to help, guided by specific directions.
If possible, this equipment should be pre- If problems are anticipated, this should be
pared prior to the patient’s arrival. Ideally, a communicated to the team, and roles assigned
dedicated airway equipment cart with all before getting started.
the necessary tools, checked daily, should
be a fixture in most acute-care areas. 䉴 EQUIPMENT FOR TRACHEAL
B. The patient and clinician performing the INTUBATION
intubation should be positioned in the
optimal (allowable) position for direct laryn- A well-equipped airway cart is not useful unless
goscopy. it is at the bedside and its contents are familiar.
C. The patient has been optimally preoxy- The following mnemonic may be helpful to
genated. ensure that essential pieces of equipment are
D. Large-bore intravenous (IV) access has immediately available: STOP “I” “C” BARS.
been obtained and a fluid bolus delivered,
when appropriate. Suction—Rigid tonsillar suction is vital, turned
E. Drugs needed to facilitate airway manage- on and placed in close proximity to the
ment are available. Care should be taken to patient’s head. If there is a high likelihood
match the drug type and dosage with the of encountering copious amounts of blood
patient and any acute or underlying chronic or regurgitated matter, two running suctions
conditions. are not excessive. The suction tubing must
TRACHEAL INTUBATION BY DIRECT LARYNGOSCOPY 55
be connected to an appropriate wall unit. just proximal to the cuff1 (Fig. 5–2). For pedi-
The rigid suction catheter should be checked atric patients, the Broselow tape can be con-
to see if it has a thumb port that must be sulted for appropriate ETT sizing.
occluded to work effectively. Oxygen and positive pressure—A manual
Tubes—An appropriately sized endotracheal resuscitator with oxygen reservoir bag,
tube (ETT, e.g., adult female 7.0; adult male attached to high flow O2, should be avail-
8.0 internal diameter, [ID]) is prepared, as able. As the only source of positive pressure
well as a tube a half or full size smaller. ventilation, this device should be checked
Rarely is a larger tube size required in an by occluding the patient end with a finger
adult patient. A 10 cc syringe is attached to and squeezing the self-inflating bag, feeling
the pilot line, and the cuff integrity checked for the positive pressure thus developed.
by fully inflating, then deflating it. The ETT The reservoir bag should be distended.
tip can be lubricated with 2% lidocaine jelly Pharmacology—All the drugs that could possi-
or other water soluble lubricant. For all emer- bly be needed should be drawn up and
gency intubations, a lubricated stylet should labeled. This may include drugs needed for
be inserted into the ETT. If a curved Mac- topical airway anesthesia, IV sedation, or
intosh blade is used, the stylet curve should rapid-sequence intubation (RSI), including
not exceed the default curvature of the ETT. induction agent and muscle relaxant. The
Alternatively, and in particular for a straight armamentarium should always include an
blade, a “straight to cuff” shape will be ben- agent to treat postintubation hypotension—
eficial, whereby the tube is styletted merely instituting positive pressure ventila-
straight, with a 25–35° upward bend placed tion can interfere with venous return and
Figure 5–2. “Straight to cuff” stylet preparation of the ETT (above) compared to natural curve
(below).
56 CHAPTER 5
cause hypotension, particularly in the vol- for the infrequent failed intubation or failed
ume-depleted patient. oxygenation (Chap. 12) situation.
Intravenous access—Good IV access (ideally Surgical (i.e., cricothyrotomy) technique—For
18G or larger) should be in situ, free- most intubations, simply knowing the equip-
flowing and not on a pump. It is rare that ment’s location and how to use it is adequate
a patient will not benefit from a fluid bolus preparation. However, for anticipated very
of 10–20 mL/kg prior to intubation. difficult situations, it may be appropriate to
Connect to monitors and Confirmation—During have this equipment out and opened: a com-
intubation, the patient should ideally be mon- ponent of the so-called “double set-up”.
itored with an electrocardiogram (ECG) tracing,
noninvasive blood pressure cuff (cycling at 䉴 POSITIONING FOR
intervals of no longer than 3 minutes), and a LARYNGOSCOPY AND
pulse oximeter. In addition, objective means INTUBATION
for confirming tracheal location of the ETT
should be available, for example, capnometry The clinician should be optimally positioned
and/or an esophageal detector device. before an intubation attempt, as should the patient.
Blades and Bougie—The laryngoscope should
be checked for bright light intensity. Sev- Clinician Positioning
eral blades should be available. The #3 Mac-
intosh (curved) blade will be useful as a Comparisons of the posture of experienced and
default blade, with the #4 for larger males. novice laryngoscopists have observed the fol-
To those familiar with it, a straight blade lowing: experienced clinicians stand further
(e.g., Miller, Phillips, or Wisconsin) can be back, with straighter backs and arms,2 and hold
a useful primary or alternative blade. A tra- the laryngoscope closer to the base of the
cheal tube introducer (bougie) should be blade 3 (Fig. 5–3). During direct laryngoscopy,
within easy reach during all emergency intu- the laryngoscopist’s arm should be only mod-
bation attempts. estly flexed at the elbow and adducted, and not
Alternative intubation device—In addition to bent at right angles and abducted. Better mechan-
the bougie, during every emergency intuba- ical advantage is then developed by the applica-
tion attempt, equipment for an alternative tion of a more in-line axial force through the arm
intubation technique should be available for to the handle of the laryngoscope. Once a view
immediate use. Examples include the LMA of the laryngeal inlet is obtained, some clinicians
FastrachTM (Intubating Laryngeal Mask Air- elect to keep the arm adducted against the trunk
way [ILMA]), fiberoptic optical stylet, or Tra- for additional support. This position of the arm is
chlight. These devices all require prepara- consistent with the optimal distance from the
tion by someone familiar with their use. If laryngoscopist’s eye to the patient’s glottis of
the patient is being bag-mask ventilated approximately 16–18 inches. Attention to clinician
with difficulty in between intubation positioning may help deliver favorable mechanical
attempts, the primary clinician will not be and visual advantage during laryngoscopy.
available to prepare this equipment.
Rescue oxygenation technique—A Laryngeal Patient Positioning
Mask Airway (e.g., LMA ClassicTM, ProSeal,
Supreme, or Fastrach), Combitube, or other Three aspects of patient positioning are crucial.
extraglottic device is useful as a rescue oxy- Failure to observe these positioning principles
genation tool. One such device should be may make obtaining a good view at laryn-
sized for the patient and within arm’s reach goscopy more difficult.
Figure 5–3. Clinician positioning during direct laryngoscopy: relatively straight back; modestly
flexed, adducted elbow, and a grip on the laryngoscope handle close to the blade.
A. “Up-down,” referring to stretcher height. B. “North-south”: the patient’s head should

Often overlooked, the patient should be at the be positioned as close as possible to the
appropriate height—with the middle of the upper (“north”) end of the stretcher.
patient’s head at the level of the clinician’s belt C. “Sniff,” that is, head and neck positioning.
buckle. Classic teaching suggests placing the head
58 CHAPTER 5
and neck in the “sniffing” position for direct patient’s occiput and/or lifting the head dur-
laryngoscopy. When not contraindicated by ing laryngoscopy, using the right hand under
C-spine precautions, this involves flexing the occiput.
the neck at the cervico-thoracic junction,
with extension of the neck at the upper few The axis alignment sought by placing the
cervical vertebrae and head at the occipito- patient in the sniffing position can be exter-
cervical junction. This will help align airway nally referenced. Observing the patient from
axes, in turn helping attain a direct line-of- the side, when the external auditory meatus is
sight view from the clinician’s eye to the laryn- lined up horizontally with the sternal notch, the
geal inlet (Fig. 3–8, Chap. 3). The sniffing patient is generally well positioned for laryn-
position can be attained by placing folded goscopy in a good “sniff” position (Figs. 5–4 A
blankets (about 4”/8 cm high) under the and B). This same “ear-to-sternum” positioning
Figures 5–4. In contrast to the positioning of the patient in the neutral position (A), a line
drawn from the external auditory meatus to the patient’s sternum (“ear to sternum” line) will
give a rough indication of good positioning for direct laryngoscopy (B).
is also key to positioning the morbidly obese Morbid Obesity

patient4 (see next section). While some recent
publications have suggested that cervicotho- Airway management in the morbidly obese
racic flexion is not a necessary component of patient can be difficult in terms of bag-mask ven-
optimal positioning for laryngoscopy,5–7 other tilation (BMV), laryngoscopy and intubation, as
studies challenge this contention by suggest- well as cricothyrotomy. In this population, unless
ing the utility of a head lift8,9 in improving laryn- the patient is well positioned, during laryn-
geal view. goscopy, the handle of the laryngoscope may
abut the chest wall. Specially made short handles
䉴 POSITIONING IN SPECIAL can be used in this situation but are usually unnec-
SITUATIONS essary when the patient is properly positioned.
Such positioning can be attained by building a
C-Spine Precautions ramp with folded blankets (Fig. 5–5). Five to seven
folded blankets are placed under the occiput, 3–5
In the patient requiring C-spine precautions, under the shoulders, and 1–3 under the scapulae.
the sniff position is not an option. DL under This will elevate the face above the chest wall
these conditions will be more difficult, with an and eliminate the concern of the handle hitting
expected incidence of blind, Grade 3 views the chest. During “ramping,” the unsupported
(no part of the glottis visible) of 20%–25%10 arms are allowed to fall to the side, taking with
with application of manual in-line neck stabi- them additional soft tissue from the anterior chest.
lization (MILNS). The incidence of Grade 3 These benefits cannot be accomplished by
views increases to 50% or more10, 11 with a cer- simply raising the head of the bed, nor by just lift-
vical collar applied. For this reason, during ing the head of the obese patient at laryngoscopy.
attempts at laryngoscopy and intubation, Ramping is required in the morbidly obese patient
MILNS should be substituted for the cervical to achieve the previously mentioned “ear to
collar, as the latter increases difficulty by also sternum” positioning4 (Fig. 5–6 A and B).
interfering with mouth opening. Note that the
function of in-line stabilization is as a reminder Pregnancy
to the laryngoscopist to minimize movement,
not necessarily to preclude any movement The patient in advanced stages of pregnancy
whatsoever. must be positioned with a right hip wedge.
Figure 5–5. A “ramp” created with folded blankets for positioning a morbidly obese patient
prior to laryngoscopy.
60 CHAPTER 5
Figure 5–6. A morbidly obese patient (A) before and (B) after positioning on a “ramp” of folded
blankets. Note the “ear-sternum” line before and after.
Tipping the gravid uterus to the left will help pregnant patients in the second and third
avoid compression of the aorta and inferior trimesters should be considered at high risk for
vena cava, which can otherwise cause supine passive regurgitation.
hypotension syndrome. There is also a higher Both morbidly obese and third trimester
incidence of difficult laryngoscopy and intu- pregnant patients have a limited functional
bation in the obstetrical population,12 and residual capacity, and can be expected to
desaturate quickly when rendered apneic, for planned, the patient can be intubated in the sit-
example, during an RSI. ting or semisitting position using DL or other
intubation technique. In this situation, the clin-
The Patient in Extreme Respiratory ician may need to be positioned on a chair at
Distress the patient’s head (Fig. 5–7). If an RSI is planned,
the patient will need to be in the sitting position
The acutely dyspneic patient will not tolerate until loss of consciousness occurs with the
the supine position. If an awake intubation is induction agent.
Figure 5–7. Sitting position direct laryngoscopy. Note laryngoscopist initially guiding laryngoscope
blade with fingers of right hand.
62 CHAPTER 5
The Pediatric Patient while others transmit light from a bulb located
in the handle to the blade tip via a fiberoptic
The neonate, with its large head and occiput bundle. A fiberoptic laryngoscope with a
relative to the thorax, will often end up with the rechargeable battery system is likely the most
neck excessively flexed, if placed supine on a dependable and has the potential to provide the
table. This is the one situation in which a folded brightest lighting. Blades can be reusable or dis-
towel may need to be placed under the shoul- posable. Disposable blades are made of plastic
ders, to decrease lower C-spine flexion to the or steel. As the most important piece of intuba-
same degree that is needed in the adult. The tion equipment, the laryngoscope should be of
toddler and young child (to approximately reliable quality.
age six) will be well-positioned merely placed Familiar to many clinicians, the Macintosh
with the head flat on a table. Above age six, blade (Fig. 5–8) is curved, designed to partially
positioning with the usual towel or folded conform to the shape of the tongue. It is most
blanket under the occiput will be needed. often used by placing the blade tip in the val-
lecula, at the junction of the base of the tongue
and origin of the epiglottis. As the blade tip is
䉴 PREOXYGENATION pressed into this space and lifted, pressure on
the hyoepiglottic ligament will help indirectly
During the preparation phase, the patient lift the epiglottis anteriorly, exposing the
should receive as close to 100% O2 as possible. underlying glottic opening. A size 3 Macintosh
Holding a manual resuscitator (supplying O2 blade will be appropriate in the majority of
at 15 L/min, with a functioning O2 reservoir adult patients, although in larger patients, espe-
system) firmly on the face is ideal. If the cially those with long necks, a Macintosh 4 blade
patient’s spontaneous ventilations are felt to may be needed. Also note that curved blades
be inadequate, timed inspiratory assisted ven- can be used to directly “pick up” or elevate the
tilation may be required. Obviously, in the epiglottis.
apneic patient, positive pressure ventilation Straight laryngoscope blades (Fig. 5–9) such
will be needed. Preoxygenation is a vitally as the Miller, Phillips, or Wisconsin are
important step. Unintentionally omit- designed primarily to displace the tongue to
ting this step puts the patient at risk of the left and directly elevate the epiglottis, thus
profound hypoxemia during attempted exposing the vocal cords. Often used as the
intubation. blades of choice in pediatric patients, they can
also be useful in the adult patient with an “ante-
rior” larynx, small mandible, large tongue, or
䉴 DIRECT LARYNGOSCOPY prominent central incisors. 13 Many straight
blade aficionados prefer its use by a para-
Laryngoscopes and Blades glossal approach, whereby the blade is placed
alongside the tongue, on its right. This
The laryngoscope used for DL consists of a blade approach has been shown to be effective in
and handle: the handle houses the power supply some situations where curved blade laryn-
and sometimes the light source. Generally the goscopy had failed.14
laryngoscope blade snaps on to the top of a Finally, specialty blades exist to help in dif-
handle. Rotating the blade to a position 90° to ficult situations. The McCoy blade, also known
the handle activates the illumination supply, as the levering tip or CLM (Corazelli-London-
which is delivered toward the tip of the blade. McCoy) blade, has the basic shape of the
Some blades have a distal bulb-on-blade design, Macintosh, but in addition, features a levering
Figure 5–8. Macintosh size 3 and 4 (adult) curved blades.
distal tip. When an activating lever is depressed The literature suggests it may be useful in
toward the laryngoscope handle (Figs. 5–10 A converting Grade 3 views to 2 or better, par-
and B), the blade tip levers upward, helping ticularly when caused by applied manual in-line
to elevate the epiglottis (Figs. 5–11 A and B). stabilization.15–18
Figure 5–9. From left to right, Wisconsin, Phillips, and Miller straight blades.
64 CHAPTER 5
A B
Figure 5–10. A, B The McCoy (CLM) blade, (A) in the neutral and (B) partially activated positions.
A B
Figure 5–11. Fluoroscopic images of the McCoy blade (A) before and (B) after partial blade tip
activation (the arrow in both images points to the epiglottis).
Direct Laryngoscopy Technique: and not deferred until difficulty has already
General Comments been encountered.
C. A cross-finger “scissor” technique is useful to
In performing DL, a few points are noteworthy: help open the mouth for initial blade insertion:
the thumb pushes the mandible/lower teeth
A. To successfully perform direct laryngoscopy, caudad to open the mouth, while the index fin-
the clinician must be very familiar with the ger crosses over the thumb to provide counter-
anatomy of the oropharynx and laryngeal pressure on the maxilla/upper teeth (Fig. 5–12).
inlet (reviewed in Chapter 3). A sound D. The laryngoscope handle should be held
knowledge of the anatomy will help the close to the blade. Better mechanical advan-
clinician obtain an optimal view during tage will result and there will be less ten-
laryngoscope blade placement. dency to lever back with the scope.
B. As emphasized earlier, the patient and the E. Following initial blade insertion, the clini-
clinician should be properly positioned, cian’s right hand can be placed under the
with the stretcher elevated, the patient at patient’s occiput: with this hand concomi-
the head of the bed and the head and neck tantly lifting the head, additional lower neck
in the sniff position (if not contraindicated). flexion and head extension can be under-
Optimal positioning should be undertaken taken, (i.e., exaggerated “sniff”), often help-
prior to the first attempt at laryngoscopy, ing to expose the cords during laryngoscopy.
Figure 5–12. Cross-finger mouth opening technique. This will help with oropharyngeal airway,
extraglottic device, and laryngoscope blade insertion.
66 CHAPTER 5
A B C
Figure 5–13. Direct laryngoscopy: Initial blade insertion—(A) on a model, (B) in a human sub-
ject, and (C) under fluoroscopy.
Direct Laryngoscopy Technique: should happen slowly and deliberately, taking

Curved/Macintosh Blade time to identify anatomy at the blade tip—with
adequate preoxygenation, there is no rush.
The laryngoscope handle is held in the left This “identify-as-you-go” technique will help
hand. Dentures, if present, should be removed. avoid placing the blade too far, an error com-
The patient’s mouth is opened with the right monly committed by the novice clinician. As
hand, using the previously described cross- the base of the tongue is approached, some
finger technique. The blade should be inserted traction is exerted along the long axis of the
on the right side of the tongue (Figs. 5–13 A, laryngoscope handle (Figure 5–1) to start com-
B, and C) and is advanced to its base. This pressing the tongue (Figs. 5–14 A, B and C).
A B C
Figures 5–14. A, B, C. Direct laryngoscopy: Blade advancement and tongue compression,

looking for landmarks—(A) on a model, (B) in a human subject, and (C) under fluoroscopy.
A B C
Figures 5–15. Direct laryngoscopy: Identification of epiglottis and blade tip advancement into
vallecula—(A) on a model, (B) in a human subject, and (C) under fluoroscopy.
A view of the epiglottis is sought: it is an placed fully into the vallecula, the blade tip is
important landmark, needed to guide subse- centered, by moving it to the left. This will fur-
quent blade placement. After the epiglottis is ther displace the tongue to the left. With the
identified, the tip of the blade is advanced into blade tip now seated in the vallecula, addi-
the vallecula (the space at the junction of the tional lift can be applied along the longitudi-
base of the tongue and the origin of the epiglottis, nal axis of the laryngoscope handle (Figs. 5–16
Figs. 5–15 A, B, and C). Once the blade is A and B). The handle should generally not
A B
Figure 5–16. (A) Curved blade tip placement in the vallecula, with subsequent traction along
the long axis of the laryngoscope handle (B), indicated by the arrow. Note the resultant indi-
rect elevation of the epiglottis.
68 CHAPTER 5
exceed an angle of about 30° to the floor. Direct Laryngoscopy Technique:

Thus lifting forward along the handle’s axis Straight Blade
has two effects: (a) it will further compress the
tongue out of the way into the submandibular The straight blade is often used to displace
space, and (b) the blade tip will place pressure the tongue laterally, followed by direct lifting
on the underlying hyoepiglottic ligament, in of the epiglottis to expose the larynx (Fig. 5–19).
turn helping to lift the epiglottis, revealing the Using this “paraglossal,” or alongside-the-tongue
vocal cords beneath (Figs. 5–17 A, B and C). It approach, the blade is inserted from the right
should be noted that if a chosen blade is too side of the mouth (Fig. 5–20) and advanced
short to successfully contact the hyoepiglottic along the right margin of the tongue. With the
ligament at the junction of the tongue base and tongue displaced to the left, the jaw is lifted by
epiglottis, the epiglottis may not move up and traction along the axis of the laryngoscope
out of the way (Figs. 5–18 A and B). If this is handle. Two schools of thought exist about sub-
suspected, a longer blade should be used. sequent glottic exposure: one suggests advancing
Failure to engage the hyoepiglottic ligament in the blade as far as it will go (i.e., down the
the vallecula is a probable cause of the novice upper esophagus), then withdrawing until the
failing to achieve an adequate view during direct cords “pop” into view, while the other espouses
laryngoscopy. Conversely, too long a blade an “identify as you go” method, as is the case
can occasionally trap and downfold the with curved blade placement. With this latter
epiglottis, artificially creating a Grade 3 view. technique, once the epiglottis is identified, the
The laryngoscope should never be levered blade tip is “scooped” beneath the epiglottis to
back while attempting to attain a view at laryn- achieve its direct elevation (Fig. 5–21).
goscopy. This puts the upper teeth at risk of The view of the cords at the blade tip with
damage, and also decreases the space available straight blade laryngoscopy is often combined
for initial tube passage through the mouth. with a restricted space at the right lateral corner
A B C
Figure 5–17. Direct laryngoscopy: Blade lift together with caudad pressure on hyoepiglottic lig-
ament to elevate epiglottis and expose underlying laryngeal inlet—(A) on a model, (B) in a
human subject, and (C) by fluoroscopy.
Figure 5–18. A, B. (A) Failure to advance the blade tip completely into the vallecula
(arrow) results in no contact with the hyoepiglottic ligament, with resultant failure to indirectly
lift the epiglottis. (B) With the blade tip correctly located in the vallecula, contact with the
hyoepiglottic ligament results in good indirect lifting of the epiglottis.
of the mouth. Passage of the ETT under these cir- bougie may help to overcome this restriction at
cumstances may obscure the view of the cords. the proximal position of the blade. For primary
This may be overcome by having an assistant passage of a styletted ETT, the distal tube should
apply lateral traction to the lip at the corner of be bent upward just proximal to the cuff by no
the mouth, thus creating room for ETT passage more than 35°, as more acute angulation is asso-
from the right. Alternatively, prior passage of a ciated with difficult tube passage.1
Figure 5–19. Straight blade laryngoscopy with the epiglottis being directly lifted to allow direct
visualization of the glottis.
Figure 5–20. Straight blade insertion at the Figure 5–21. Direct elevation of the epiglottis
right side of the mouth as part of a paraglos- using the Phillips straight blade for a paraglossal
sal approach to direct laryngoscopy. approach to direct laryngoscopy.
䉴 PASSING THE ENDOTRACHEAL advanced to about 21 cm at the teeth. Once posi-

TUBE (ETT) tioned, the tube is held with one hand, the laryn-
goscope removed, and the cuff inflated with 5–8
The prepared tube, with lubricated stylet in place, mL of air. The syringe is detached and the stylet
should be passed by an assistant to the clinician’s removed from the tube (if not already done).
open right hand, thereby avoiding the need to Objective confirmation of the correct (endotra-
interrupt direct visualization of cords. With cheal) location of the ETT should then be under-
curved blade use, the ETT should be placed from taken, and positive pressure ventilation (PPV)
the right side of the patient’s mouth, with its con- instituted at a controlled rate.
cavity initially facing to the right (“three o’clock”), Note that occasionally, in the confusion sur-
to avoid obscuring the view of the cords. As the rounding intubation, the ETT cuff is not inflated.
tip of the tube approaches the cords, the ETT is This may result in the failure of typical objec-
rotated counterclockwise (to the “12 o’clock” positive and subjective signs of endotracheal intu-
tion), naturally bringing its tip anterior. When bation, including end-tidal carbon dioxide
using a straight blade, the tube is passed from the (ETCO2) detection, chest rise, and breath sounds
extreme right, with the distal ETT tip pointed with positive pressure. Conversely, cuff overin-
back toward the midline laryngeal inlet. In the flation is also undesirable and can be avoided by
spontaneously breathing patient, the tube should seeking the “minimum-leak” pressure after the
be passed during inspiration to avoid trauma to tube position has been confirmed. This is done
the cords. Remember that one of the most during PPV by gradually withdrawing air from
important signs of a properly placed tube is the cuff, one milliliter (mL) at a time, until a leak
to watch it go through the cords (Fig. 5–22). is heard: at that point, the cuff is reinflated by
Tube passage should occur slowly enough to be one additional mL. This maneuver will help
able to satisfactorily visually confirm it has indeed avoid excessive cuff pressure with resultant
passed between the cords. The tube should be ischemia of the tracheal mucosa.
Figure 5–22. Visualization of the ETT being passed between the cords, from the right side of
the mouth.
72 CHAPTER 5
Although the authors advocate the use of allow ongoing visualization of the cords
a stylet for every intubation, the applied curve during ETT placement.
should not be exaggerated (i.e., “hockey- • If intubation has been undertaken in the
sticked”) for either curved or straight blade use. face of a poorly visualized glottic open-
This excessive bend, commonly advocated, ing, applying downward (posterior) pres-
was historically used to help intubate the sure on the ETT while continuing to apply
poorly visualized larynx. The authors contend an upward lift on the laryngoscope (the
that other techniques and adjuncts (i.e., head “Ford maneuver”) may sometimes allow
lift, external laryngeal manipulation [ELM], visualization of posterior elements of the
bougie, or fiberoptic stylet) deal more effec- larynx.
tively with the poorly visualized larynx. Fur- • Beware the “pseudolarynx,” especially in
thermore, the use of a hockey-stick type bend young children. When strong upward trac-
may lead to difficulty with forward tube pas- tion is exerted on the tip of a long blade,
sage down the trachea,1 as the ETT tip may get the esophageal opening can become elon-
caught anteriorly on the cricoid or a tracheal gated. As the stretched mucosa becomes
cartilaginous ring. ischemic, the lateral walls of this opening
can become “blanched,” potentially look-
ing like true or false cords to the inexpe-
䉴 CONFIRMATION OF ETT
rienced clinician. This point underscores
LOCATION
the necessity of being very familiar with
Following intubation, confirmation of the tra- the anatomy of the laryngeal inlet, from the
cheal location of the ETT is obviously vital. pearly white appearance and shape of the
Unrecognized esophageal intubations still cords superiorly, to the expected paired
occur, sometimes with lethal results. In general, posterior cartilages framing the inlet
it can be said that there are objective19 and inferiorly.
more subjective means of confirming ETT loca-
tion. For every intubation, at least two objec- End-Tidal Carbon Dioxide (ETCO2)
tive criteria of ETT location should be met. Detection
ETCO 2 detection to confirm endotracheal
intubation has rapidly become a standard of
Objective Methods of Confirming
care in emergency airway management. The
Endotracheal Tube Location
technique provides a simple and inexpensive
method of confirming correct endotracheal, as
Observing the ETT Go Through
opposed to esophageal tube placement. A dis-
the Cords
posable CO2 detector is simply placed in-line at
If the ETT is visualized going between the cords
the ETT connector (in the patient with a cardiac
(Fig. 5–22), it must be in the correct place. A few
output). The presence of exhaled CO2 will be
additional comments on this otherwise simplistic
indicated by a change in color, for example,
statement are in order:
from purple to yellow (Fig. 5–23).
• This is such an important confirmatory Continuously reading capnographs are being
sign that the ETT should be placed slowly used increasingly in out-of-operating room (OR)
and deliberately, allowing time to con- environments, using infrared spectrometry to
sciously confirm that the ETT is indeed measure and display carbon dioxide concentra-
visible between the cords. tion in inspired and expired gas. This enables
• This is the reason the ETT should be monitoring of mechanical ventilation and proce-
inserted from the right side of the mouth—to dural sedation. Under normal circumstances, gas
Figure 5–23. Easy Cap II colorimetric end-tidal CO2 detection will result in a color change from
purple to yellow. A pediatric version is available for patients <15 kg.
sampled at the end of expiration (the ETCO2) beverages; or (c) the patient has ingested
closely approximates the arterial pCO2. The com- sodium bicarbonate–containing antacids, which,
bination of pulse oximetry with capnography can combined with stomach hydrochloric acid, can
non-invasively provide the near-equivalent of result in CO2 release.20 However, in all of these
real-time arterial blood-gas analysis. situations, rapid washout of CO2 should occur:
However, like oximetry, capnography has hence the recommendation to only attach the
important limitations. Of particular signifi- ETCO2 detector after several breaths have
cance in the emergency intubation is the obser- already been delivered (the “six-breath rule”),
vation that profound shock (or cardiac arrest) to help improve sensitivity and specificity.
may lead to significant pulmonary hypoperfu-
sion and reduced (or absent) CO2 delivery from Esophageal Detector Devices
tissue to lung. This obviously limits the utility of The principle behind esophageal detector
capnography to confirm endotracheal intuba- device (EDD) use is that the esophagus col-
tion in arrested patients. However, capnography lapses when a negative pressure is applied to its
is not completely useless during resuscitation: it lumen, whereas the trachea does not.21 EDDs
has been shown to be an effective early indi- come in two forms:
cator of the return of circulation after success-
ful resuscitation from cardiac arrest. • A 60 cc catheter-tipped (Toomey) syringe
can be used. Normally used for aspirating
ETCO2 DETECTION EFFECTIVENESS or irrigating foley catheters or nasogastric
False positive readings (i.e., tube in esophagus, tubes, the tip of such a syringe can be forced
yet color change still occurs) can occur in three into the end of the ETT connector after intu-
situations: (a) CO2 has been washed in to the bation (Fig. 5–24). The syringe plunger is
esophagus during previous bag-mask ventila- aspirated and released. If the plunger stays
tion; (b) the patient has ingested carbonated out, there is no negative pressure, implying
74 CHAPTER 5
Figure 5–24. A Toomey syringe used as an esophageal detector device.
it has aspirated air out of the tracheal air- • A second type of EDD uses a rubber bulb
space and the tube is correctly sited. If the proximally on a syringe (akin to and some-
plunger slides back to near its original times called a “turkey baster”), which
position, the ETT is in the esophagus. In returns to inflated conformation sponta-
the latter situation, the esophagus has col- neously after being squeezed. The bulb is
lapsed around the ETT tip with aspiration, squeezed and the device attached to the
creating a vacuum. Purpose-made syringes ETT. If it refills quickly (with air from the
with 15 mm connectors for easy ETT tracheal airspace), the ETT is in the tra-
attachment are available commercially, at chea. If it stays depressed or refills slowly,
greater cost. the ETT is in the esophagus.
EDD EFFECTIVENESS fiberoptic bronchoscope, or semimalleable

Esophageal detector devices have been shown fiberoptic stylet can be considered a fourth
to be very sensitive and specific, at least in objective sign of tracheal intubation (Fig. 5–25).
healthy patients.22 They should be considered
a good choice to help objectively confirm cor- Subjective (Clinical) Signs
rect ETT placement in the arrested patient, of Tracheal Intubation
where ETCO 2 detectors may be unreliable.
False negative results (i.e., tube is in trachea, Clinical signs of successful tracheal intubation
syringe does not easily aspirate, or bulb fails to have been classically relied upon to confirm
inflate) may occur with a tube obstructed with tracheal ETT location in out-of-OR intubations.
mucus or secretions; with severe bron- While these signs should still be sought, they
chospasm; in the morbidly obese patient; and should complement the objective signs as delin-
in other conditions, such as pulmonary edema, eated above, and not be substituted for them.
which cause markedly decreased dead space.20
• Chest Auscultation. Although the chest
While still accurate in detecting esophageal intu-
should be observed for expansion and
bation after intentional moderate gastric insuf-
auscultated following intubation, gener-
flation, the EDD may fail after massive gastric
ally speaking, this should not be relied
insufflation.22 This suggests that in contrast to
upon to confirm endotracheal intuba-
the “6-breath rule” for the ETCO2 detector, an
tion.23 For example, in the scenario where
EDD should be used before any further ventila-
a patient has been intubated via an “awake”
tion occurs through a newly placed ETT.
technique using topical airway anesthesia,
the spontaneously breathing patient may
Visualization of Tracheal Rings continue to have breath sounds and chest
Visualization of tracheal cartilaginous rings, expansion, even in face of an esophageal
and/or carina through the ETT with a flexible intubation. Auscultation is obviously still
Figure 5–25. Tracheal cartilaginous rings and the carina, as seen though a fiberoptic bron-
choscope passed down an endotracheal tube.
76 CHAPTER 5
useful, as long as this limitation is appreci- • Chest x-ray. An anterior-posterior

ated, but should be used mainly to rule out portable chest x-ray will not distinguish
right mainstem intubation or previously trachea from esophagus. It may be useful
missed pneumothorax. to confirm correct depth of the ETT and to
• Increasing oxygen saturation. In a well rule out pneumothorax or other chest
preoxygenated patient, oxygen desatura- pathology.
tion following apnea can take up to 8 min-
To reiterate, while the clinical signs are good
utes. In addition, slow processors in some
to see, and should be sought, correct positioning
older pulse oximeters take a while to react
of the ETT in the trachea should always be with
to and indicate increasing (or decreasing)
two of the objective signs, for example, visu-
oxygen saturation.
alization of tube between cords and either
• BVM device compliance. After intuba-
ETCO2 detection (with perfusing rhythm), or an
tion, if the initial compliance of the BVM
esophageal detector device (patient in cardiac
bag is poor (i.e., it is hard to squeeze), an
arrest).
esophageal intubation should be sus-
pected. Note that significant bron-
䉴 DIFFICULT DIRECT
chospasm can create the same effect with
LARYNGOSCOPY
a correctly sited ETT, however.
• Vapor or misting on the inside of the
The remainder of this chapter discusses the ini-
ETT on expiration. This is not a reliable
tial response to difficult direct laryngoscopy.
sign of tracheal intubation, as ETT misting
Note that difficult laryngoscopy does not always
can also occur with esophageal tube
imply difficult tracheal intubation: even with
placement.24,25
no view of the glottic opening visible, a bougie
• The patient can no longer speak. If the
may allow easy first-attempt intubation with
patient was groaning before intubation and
blind passage beneath the epiglottis. Con-
is still groaning after intubation, the tube is
versely, difficult intubation can still occur with
probably misplaced! With a tracheally placed
a full view of the cords, as may be the case in a
ETT, with cuff inflated, vocalization cannot
patient with subglottic stenosis.
occur.
• Auscultation over the stomach. If
Defining Difficult Laryngoscopy
sounds are heard coincident with delivery
of positive pressure ventilation on aus-
DL usually results in visualization of all, or
cultation of the epigastrium, esophageal at least part of the glottic opening. Simply
intubation should be suspected. The sug- put, difficult laryngoscopy refers to the Cor-
gestion by some to leave the esophageal mack Grade 3 or 4 view, 26 where the view
ETT in situ during a reintubation attempt
of the glottic opening is obscured (Fig. 3–11,
may be impractical, as it crowds the oral
Chap. 3).
cavity and, more importantly, precludes
optimal oxygenation/ ventilation by mask
between attempts. Response to Difficult Direct
• Heart rate and BP normalize. A hypoxic Laryngoscopy
patient may become hyper- or hypotensive
and initially tachycardic. Bradycardia occurs Maximizing the chances of first pass success
as a later sign of profound hypoxia in adults, at DL and intubation is important since, as
although earlier in children. Such continued discussed in Chap. 12, patient morbidity and
worsening of vital signs suggests an mortality climbs with multiple attempts at
esophageal intubation. emergency intubation.27 As such, the clinician
should always perform optimal DL on the first Muscle Relaxant

attempt, with the expectation of obtaining a If an RSI technique is in use, the muscle relax-
good view, using all the components of “best ant should have had time to onset. Inexperi-
look” laryngoscopy. These components, some enced clinicians sometimes fail to wait the 45–60
of which have already been discussed, are seconds required for full effect from an intubat-
reviewed below and summarized in Table 5–1. ing dose of skeletal muscle relaxant.
Patient Positioning
Epiglottis Control
• Stretcher at the correct height; patient at
The epiglottis must be identified and controlled,
head of stretcher.
with advancement of the curved blade tip fully
• Patient is in sniff position, if not con-
into the vallecula, or by direct lifting.
traindicated.
Appropriate Laryngoscope Lift
Clinician Positioning Forward traction should be applied along the
• Clinician is positioned with a relatively long axis of the laryngoscope handle. With the left
straight back, and a slightly flexed, hand already holding the base of the laryngo-
adducted laryngoscopy arm. scope handle, if necessary, the right hand can be
• Laryngoscope is held towards the blade. placed further up the handle (Fig. 5–26). This
two-handed approach, although rarely needed,
helps in applying the appropriate lifting force, and
tends to promote traction in the appropriate direc-
tion, along the long axis of the laryngoscope han-
䉴 TABLE 5–1 COMPONENTS OF “BEST LOOK” dle, thus decreasing any tendency to lever the
LARYNGOSCOPY laryngoscope. Once the view of the glottic
• Patient positioning optimized: patient at opening is attained, the left arm can be adducted
head of bed; stretcher height good; against the clinician’s trunk to help maintain a
ear-sternum line optimized unless lifting force long enough to place the ETT with
contraindicated. the right hand. Alternatively, an assistant’s
• Optimal muscle relaxation has occurred, hand placed under the head can help main-
if used. tain the view during ETT placement.
• Laryngoscopist’s positioning optimized:
Laryngoscope held towards blade; back
Head Lift
straight, arm modestly flexed and adducted
+/- stabilized on trunk. Performing a head lift during laryngoscopy,
• Appropriate blade tip location: With indi- when not contraindicated by C-spine precau-
rect epiglottis lift, blade tip in vallecula is tions, may improve the view of the laryngeal
contacting hyoepiglottic ligament. inlet.8,9 During laryngoscopy, the clinician’s
• Appropriate laryngoscope lift: along axis right hand is placed under the occiput and lifts
of the handle. Use second hand if needed. the head upwards, keeping the face parallel to
• Head lift: Use right hand to lift head (if not the floor (Fig. 5–27). This increases lower neck
contraindicated) during laryngoscopy. flexion, while also increasing extension of the
• ELM/BURP: to bring the laryngeal inlet into head and the upper C-spine, resulting in a more
view.
pronounced “sniffing” position. Indeed, it can
• Consider whether cricoid pressure is
be thought of as “customizing” patient head and
adversely affecting the view.
• Use adjunct to DL, e.g., bougie (tracheal neck positioning to exactly that needed for an
tube introducer) or fiberoptic stylet. optimal view. Once this optimal view has been
obtained, an assistant’s hand replaces the
78 CHAPTER 5
Figure 5–26. Direct laryngoscopy with a second hand aiding the lift along the long axis of the
laryngoscope handle.
clinician’s under the occiput, freeing up the External Laryngeal Manipulation

clinician’s right hand to place the endotracheal (ELM) or “BURP”
tube. Head lift, and/or assisted traction on the Posterior and cephalad pressure applied to the
laryngoscope handle with a second hand, may thyroid (synonymous with laryngeal) cartilage
help in situations where the clinician of lesser during DL will often improve glottic exposure.
stature is faced with intubating a larger patient. This maneuver is referred to as BURP 28
Figure 5–27. Direct laryngoscopy with concomitant head lift.

(backward, upward and to the laryngoscopist’s ELM (done to improve the view of the laryngeal
right pressure) or ELM. ELM represents a less inlet at laryngoscopy). Cricoid pressure and
prescribed manipulation of the thyroid cartilage, ELM are two separate maneuvers, applied
still aimed at bringing the glottic inlet into view to two separate structures, for different
(Fig. 5–28). This highly effective maneuver purposes. Excessive cricoid pressure, or the
should be a reflex response whenever a poor combination of ELM with cricoid pressure, may
view is obtained at laryngoscopy. in fact worsen the view during laryn-
The initial attempt at ELM should be done goscopy.32–34 When faced with a Grade 3 or 4
by the clinician, who gets immediate feedback on view at DL (e.g., during an RSI), cricoid pres-
its effectiveness. If ELM is deemed beneficial, an sure can be transiently eased or released to see
assistant will then have to reproduce the effect if the view improves.
while the clinician places the endotracheal tube. Several studies looking at the efficacy of
The clinician may need to verbally or manually ELM/BURP 29–32 concluded that ELM improved
guide the assistant’s fingers on the thyroid car- the laryngoscopic view by one whole grade in
tilage, until the optimal view is reproduced. most patients initially rated Grade 2 or 3. Of inter-
est, in two studies, all patients presenting a Grade
3 (epiglottis only) view were converted to Grade
ELM EFFECTIVENESS 1 or 2 with ELM.29, 31 These manipulations were
It should be noted that confusion exists in the effective with both curved and straight blade
minds of some about the function of cricoid laryngoscopy.31 This literature strongly supports
pressure or Sellick’s maneuver (done to prevent the use of this maneuver during any laryn-
passive regurgitation of stomach contents), and goscopy where a suboptimal view is obtained.
Figure 5–28. External Laryngeal Manipulation (ELM), or Backward, Upward to the Right Pres-
sure (“BURP”) to help expose the cords at direct laryngoscopy.
80 CHAPTER 5
Note that the strategies outlined in (E) and Although many clinicians are adept at blindly
(F) and (G) above represent three ways to use “hooking” a styletted ETT under the epiglottis in
two hands on the first attempt (“3–2–1”), and the Grade 3 situation, use of the bougie holds
reflect the concept of DL being a two-handed the following advantages:
procedure.
• Relative to the size of the glottic opening,
the bougie is smaller in diameter than an
Use of an Adjunct to Direct ETT, increasing chances of successful blind
Laryngoscopy tracheal access.
Use of a tracheal tube introducer (bougie) or • Following blind passage, tactile feedback is
fiberoptic stylet can also be undertaken during transmitted from the bougie to the clinician’s
the first attempt at direct laryngoscopy, when fingers, helping to indicate successful tra-
faced with an obscured view despite optimal cheal access before tube passage (discussed
technique. These devices are discussed in more in more detail below).
detail in the following sections. • Most importantly, when compared directly
to blind placement of a styletted ETT in the
Consideration of a Change of Blade grade 3 situation, success using the bougie
Type, Length, or Location is significantly higher.35
For a second attempt at DL, a blade change can
be considered, if it is likely to help.
Bougie Description
䉴 ADJUNCTS TO DIRECT Made in different disposable and reusable ver-

LARYNGOSCOPY: THE sions by multiple manufacturers, bougies are
TRACHEAL TUBE INTRODUCER approximately 60–70 cm long, accept a 5.5 or
(BOUGIE) 6.0 mm ID or larger ETT, and have a distal
upward-bending coudé tip (Fig. 5–29). Most
If optimal laryngoscopy with head lift or ELM have markings on the shaft indicating 10 cm
has failed to yield a good view of the glottic distances. Many users advocate creating addi-
opening, the tracheal tube introducer (also tional temporary curvature by bending the
known as the gum elastic bougie, Eschmann distal third of the bougie in a circle, to bring
stylet, or simply the bougie) can be a valuable the tip into contact with the 30 cm marker just
adjunct to DL. It can be beneficial in the fol- before use.36
lowing situations: Strictly speaking, the gum elastic bougie is
none of those things: the reusable version is
• Grade 3 (epiglottis only) view: A bougie
(latex free) woven polyester; it is not elastic, nor
can be used to gently blindly access the tra-
is it a dilating bougie!37 While a better term is
chea, with subsequent tube passage over it.
the tracheal tube introducer, the bougie termi-
• Poor Grade 2 view: When only the poste-
nology will be retained in this narrative as it
rior cartilages or interarytenoid notch are
remains the commonly used name.
visible, tube passage can still be difficult.
Prior passage of the bougie above the carti-
lages will help ease tube passage.
• As a general intubation aid: For example, Bougie Use
a bougie may help address difficult tube pas-
sage with straight blade use due to restricted If a Grade 3 view is encountered, persistent after
space at the corner of the mouth. ELM and head lift, the bougie is picked up,
with the undersurface of the epiglottis

(Figs. 5–30 and 5–31). Often a slight “pop” will
be felt as it advances through the glottic opening,
whereupon it is further advanced. Two tactile
phenomena can then be sought to confirm that
endotracheal, and not esophageal placement,
has been achieved.
• Firstly, once the bougie tip has passed
through the cords and is being advanced
down the trachea, a fine “click-click” sen-
sation may often (>90% of the time)38 be
appreciated, as the tip runs over the tracheal
cartilaginous rings. Experience suggests,
however, that this sensation can vary con-
siderably from patient to patient, from noth-
ing more than a feeling of fine sandpaper in
some, to a fairly overt click-click in others.
Figure 5–29. The distal coudé tip, angled at No such sensation is generally obtained if
35º, of various brands of single- and multiuse
advancing down the esophagus.
bougie.
• The second sign suggesting tracheal place-
ment of the bougie is that with continued
and holding it at around the 20-cm mark, it advancement, resistance will be encoun-
is gently placed via the corner of the mouth tered as it “holds up” in a small distal
and advanced towards the midline beneath airway. This holdup will occur at about the
the epiglottis, seeking to keep its tip in contact 30 cm mark (plus or minus 5 cm in the adult)
Figure 5–30. Placement of the angled tip of the bougie under the epiglottis into the trachea.
82 CHAPTER 5
Figure 5–31. The tip of the bougie is placed blindly beneath the epiglottis, keeping its tip
midline and anterior.
(Fig. 5–32) and is a consistent finding if the is advanced over the bougie (Fig. 5–33), to help
bougie is correctly placed in the trachea.38 control the tongue, elevate the epiglottis, and
If the bougie can still be advanced at 40 cm straighten the axes. Once the tube has been
or more, it is most likely in esophagus. placed in the trachea, the laryngoscope blade is
Bougie hold-up, if sought, should be done removed and, while holding the ETT firmly, the
gently in order to avoid trauma to the lower bougie is removed. Note that if successfully used
bronchi, and should probably be avoided if in a Grade 3 situation, one of the “gold stan-
the clinician already suspects successful tra- dards” of endotracheal placement will be lacking:
cheal access based on tracheal clicks. having visualized the ETT passing through the
• Softer, third and fourth signs of successful cords. Thus, ETCO2 and/or EDD confirmation
tracheal access are coughing or bucking in of ETT placement is even more vital.
the incompletely paralyzed patient, and a
slight tendency for the bougie to twist Bougie Troubleshooting
clockwise in the clinician’s fingers as it hits
carina and heads down the right mainstem Although bougie use is most often straightfor-
bronchus. ward, a few problems can be encountered:
Once the bougie is suspected to have been A. Failure to access the trachea. The situa-
successfully placed in the trachea, the ETT can tion where the epiglottis has been elevated,
then be advanced over it. It is preferable to con- but fails to reveal any aspect of the glottis
tinue performing laryngoscopy as the ETT (so-called Grade 3A, Fig. 3–12, Chap. 3) is
sitting on the posterior pharyngeal wall,

bougie use may be less successful. In this
situation, the epiglottis can be directly ele-
vated with a longer curved blade, or a
straight blade, whereupon the bougie can
be used. Alternatively, the tip of some of
the newer, stiffer, single-use bougies can
be used to directly lift the epiglottis, to
enable a brief view of posterior cartilages
and to confirm that the bougie has been
advanced above them.
C. Failure to advance the tube over the tra-
cheally placed bougie. Occasionally, the
tube fails to pass easily over the bougie and
through the cords. Most often this is due
to the leading edge of the ETT’s bevel catching
up on the right vocal fold. Three maneuvers
will help avoid this occurrence:
• Ongoing laryngoscopy during tube pas-
sage over the bougie.39
• A counterclockwise rotation of the
ETT by 90° during tube passage.39
Experienced laryngoscopists often do
Figure 5–32. As the bougie is advanced, this routinely during bougie-aided intu-
obtaining a tactile sensation from tracheal bation, to rotate the leading edge of the
rings and a holdup close to the 30 cm marking bevel away from the right vocal fold.
(arrow) suggests successful tracheal access. • Use of a smaller ETT (half or a full size
less than usual).
ideal for bougie use. However, occasionally Bougie Effectiveness

the bougie tip fails to slip easily through the
cords. While continuing optimal laryn- ROUTINE AND DIFFICULT AIRWAY
goscopy, the bougie should be rotated MANAGEMENT
slightly to left or right, while maintaining The bougie is a valuable adjunct. In the authors’
gentle forward pressure. This will help the experience with the device, patients presenting
tip slip off the right or left true or false vocal Grade 3 laryngoscopic views are routinely intu-
fold or away from the anterior commissure. bated on the first attempt with the bougie. In a
Successful tracheal access following these published series studying 100 patients with sim-
maneuvers is often heralded by a slight ulated Grade 3 laryngoscopies, bougie use
“popping” sensation, as the bougie slides resulted in a 96% successful intubation rate after
off the obstructing structure and advances two attempts, in contrast to the 66% success rate
through the cords. attained with attempted blind placement of a
B. Posteriorly directed epiglottis. In situ- styletted endotracheal tube.35 A second study
ations where the epiglottis fails to lift at all reported on bougie use as part of a predefined
with laryngoscopy, and is pointed down- algorithm for elective surgical patients presenting
wards (Grade 3B, Fig. 3–12, Chap. 3) or is with an unanticipated difficult airway. In this
84 CHAPTER 5
Figure 5–33. The endotracheal tube is railroaded over the bougie during ongoing laryn-
goscopy (to help control tongue and epiglottis).
population, bougie use resulted in a 90% intu- study has demonstrated a higher success rate with
bation success rate by the second attempt.40 bougie-aided, compared to simple DL in the
Successful use of the bougie has also been C-spine precaution situation.45
reported in the prehospital environment,41 The bougie is an effective, inexpensive, and
although with a lower success rate. Bougie use simple-to-use adjunct to direct laryngoscopy.
during rapid-sequence intubation with applied The authors believe there should be a “bougie
cricoid pressure has been shown to facilitate on the chest” prior to all emergency intubations,
successful tube placement in restricted view sit- to facilitate quick ETT placement in difficult
uations.42 Finally, a number of case reports and situations.
series document the bougie’s successful use in
the difficult airway.38, 39, 43, 44 It should be noted 䉴 ADJUNCTS TO DIRECT
that the bougie may not be well tolerated in the LARYNGOSCOPY: FIBEROPTIC
“awake” or lightly sedated patient: it is most STYLETS
appropriately used during an RSI or in a deeply
obtunded patient. Semirigid fiberoptic stylets incorporate a
fiberoptic bundle allowing indirect visualization
C-SPINE PRECAUTIONS via a proximal eyepiece. The ETT is ensleeved
The bougie may be helpful during intubation over the fiberoptic stylet, and the distal end of
by DL with applied manual MILNS. Movement the stylet is positioned at the leading edge of
of the C-spine can be minimized by seeking to the ETT. Faced with a Grade 3 view at laryn-
obtain no more than a view of the posterior car- goscopy, the fiberoptic stylet/ETT assembly can
tilages at laryngoscopy, placing the bougie be placed beneath the tip of the epiglottis during
above them, then passing the tube. At least one ongoing laryngoscopy, whereupon a view of
the cords is sought through the instrument’s useful in the situation in which a posteriorly
eyepiece. The ETT is then advanced through pointing or long epiglottis is encountered. As
the cords under indirect vision. In experienced previously reviewed, the levering tip (McCoy/
hands, fiberoptic stylets may be particularly use- CLM) blade may help in Grade 3 situations,
ful in Grade 3B or -4 views, where bougie use especially those caused by C-spine precautions.
is less successful. As the price of these devices
continues to drop, fiberoptic stylets may become
a more common adjunct for use in difficult, and Changing the Same Blade’s Tip
even routine, attempts at direct laryngoscopy. to a Different Location
Further information on their use and effective-
ness appears in Chap. 6. Although the dogma is pervasive that one must
directly elevate (i.e., “pick up”) the epiglottis
with the straight blade and indirectly lift it (tip
䉴 CHANGING THE BLADE placement in the vallecula) with the curved
blade, one should feel free to do whatever
Note that the above maneuvers can all be per- works. For example, a long curved blade can be
formed during the first or second attempt at used to directly elevate the epiglottis.
laryngoscopy. Between attempts, the patient
should be reoxygenated by BMV to ensure that a
failed oxygenation situation does not exist. For
a second or subsequent attempt, a blade 䉴 POSTINTUBATION CARE
change can be considered, although it should AND COMPLICATIONS
only be done with a specific objective in mind.
Care
Changing to a Longer Blade
After tube placement, the cuff should be inflated
and the stylet removed. Endotracheal placement
Changing to a longer blade may be appropriate
should be confirmed by objective means, as dis-
in a long-necked individual, or when attempting
cussed above. Cricoid pressure, if applied, can
to directly pick up a long, floppy epiglottis. In
then be released. Clinical signs such as chest
addition, if the curved blade in use is too short
rise, breath sound auscultation, and oxygen sat-
to be fully advanced into the vallecula, and thus
uration should also be assessed. Vital signs
fails to contact the underlying hyoepiglottic lig-
should be reassessed, especially the blood
ament (Figs. 5–18 A and B), the epiglottis may
pressure. The tube should be secured, initially
not elevate up and out of the way. One hint that
with the clinician’s hand, and subsequently with
this may be the case is when direct laryngoscopy,
tape, tie, or a commercial fixation device. If twill
with the appropriate lift, fails to mobilize the
tie is used, care must be taken to ensure the ties
epiglottis at all. Faced with this finding, a change
are not excessively tight around the patient’s
to a longer blade can be considered.
neck, particularly in the head-injured patient.
Use of a bite block should be considered, to
Changing to a Different Type avoid the patient’s biting down and occluding
of Blade the tube. A chest x-ray should be obtained, not to
determine success of intubation, but to locate
A change to a different blade type can be con- the tube in relation to the carina, and as part of
sidered by the clinician skilled in its use, par- patient assessment. Paralysis may be initiated,
ticularly if there’s a good chance it will help. or continued after intubation, if indicated, with
Changing to a straight blade may be particularly one of several agents used in conjunction with an
86 CHAPTER 5
appropriate sedative-hypnotic and narcotic anal- • Hypotension. Postintubation hypotension

gesic. Finally, ETT cuff pressure can be adjusted can be caused by administered medications,
to the “minimum leak” position. relief of high sympathetic tone, or the insti-
tution of positive pressure ventilation,
Complications of Endotracheal especially in the volume depleted patient.
Intubation Special mention should be made of auto-
PEEP. If adequate time is not allowed for
Although everyone breathes a sigh of relief after expiration, especially in the patient with air-
the ETT is placed and its correct position has been trapping pathology (e.g., bronchospasm,
confirmed, problems can still be encountered: COPD) resulting “breath stacking” (increased
intrathoracic pressure; decreased venous
• Esophageal intubation. To avoid patient
return) can rapidly result in cardiovascular
morbidity, esophageal intubations must be
collapse.
immediately recognized and corrected. The
topic has been reviewed above.
• Accidental extubation. There are many
documented instances of morbidity and 䉴 DIRECT LARYNGOSCOPY
mortality attributable to accidental extuba- EFFECTIVENESS
tion. This aspect of airway management is
ROUTINE AND DIFFICULT AIRWAY
particularly relevant in the emergency
MANAGEMENT
patient, as numerous transfers will occur
Published data suggests that successful laryn-
following intubation (e.g., to diagnostic
geal exposure using DL occurs in all but 2%–8%
imaging, the OR, intensive care unit (ICU),
of cases in elective surgical populations.12 Of
or interfacility transfer): classically a time
the cases where no aspect of the laryngeal inlet
of high risk for accidental extubation. Tube
can be identified, most are Grade 3 (epiglottis
ties, or commercially available products for
only) views, and as outlined above, can be suc-
securing the tube are preferred, as blood,
sweat, and regurgitated matter may make cessfully dealt with using the bougie.
tape a less effective option.
• Endobronchial intubation. Observation SKILLS ACQUISITION
and auscultation of the chest will help rule DL has a significant learning curve. Studies sug-
out endobronchial intubation, as will a chest gest that the learning curve flattens after about
x-ray. The printed numbers on the side of 50 laryngoscopies have been performed.46–48
the ETT should be observed to ensure the Instructional videos on laryngeal anatomy deliv-
tube is not positioned too deep in the ered as part of a training program have been
patient, prior to fixation. shown to improve success rates in novices.49
• High airway pressures. High airway pres- Training using human patient simulators has
sures encountered after intubation may be also been shown to be effective for novices
due to ETT, or patient factors. Tube factors learning to perform DL and intubation.50 Such
include occlusion by thick secretions, pul- studies suggest that in time, well-designed pro-
monary edema, blood, or vomitus. A suction grams combining both multimedia presentations
catheter can be passed to help assess and patient simulators may improve the subse-
tube patency, or preferably, the tube should quent learning curve of DL on human subjects.
be changed, if occlusion is suspected.
Patient factors are numerous and include C-SPINE PRECAUTIONS
esophageal or endobronchial intubation, Cervical spine injury is present in approximately
bronchospasm, and pneumo/hemothorax. 2% of blunt trauma victims: this risk trebles in
patients with a GCS of 8 or less.51–53 In the at- technique and the destination airway anatomy
risk patient, C-spine precautions should be are key.
observed. That being said, the risk of iatrogenic Pediatric ETCO2 detectors are available and
spinal cord injury during DL is extraordinarily should be used.
low. 54 As previously stated, application of In terms of response to difficult DL, the prin-
manual in-line stabilization can be expected to ciples discussed above are equally applicable to
increase difficulty with direct laryngoscopy. the pediatric patient. Repositioning the head
Although alternative intubation techniques may help, as may external laryngeal manipula-
such as rigid or flexible fiberscopes have been tion (in the neonate this latter maneuver can be
espoused as being preferable to DL in this set- done with the fifth finger of the hand holding
ting, no evidence exists demonstrating a supe- the laryngoscope!). Pediatric bougies accom-
rior clinical outcome with their use over direct modating a minimum ETT size of 3.5 mm ID are
laryngoscopy.53 Carefully performed DL for available.
intubation of the at-risk blunt trauma victim is The pediatric population have relatively high
considered acceptable practice and within the oxygen consumptions and as such may desaturate
standard of care.53,54 Use of the levering tip quickly during attempts at intubation. On the
blade15–17 and/or exposure of no more than the other hand, as mentioned earlier, they tend to
posterior cartilages at laryngoscopy, followed be quite easy to bag-mask ventilate.
by a bougie-assisted intubation45 may help min-
imize difficulty and movement.
䉴 PREDICTORS OF DIFFICULT
䉴 PEDIATRIC INTUBATION DIRECT LARYNGOSCOPY
The greatest impediment to successful intubation As is the case with bag-mask ventilation, there
in the pediatric population is the anxiety of the are anatomic predictors of difficult direct laryn-
clinician. Compared to the general adult emer- goscopy, and a quick assessment of these fac-
gency department population, intubation in tors should be undertaken before proceeding.
children, although less frequently required, is Although it has been pointed out that the emer-
usually easier. Principles of DL in pediatric gency patient requiring intubation will still need
patients are similar to those in the adult. Prepa- intubation whether or not difficulty has been
ration is also similar, aided by sizing choices predicted, we contend that an airway exam
made with reference to the Broselow tape or a should be undertaken for the following reasons:
chart. Generally, an ETT one-half size larger and
• Predictors of difficulty may point to the ideal
smaller than the expected size should be imme-
approach to the intubation.
diately available. Although classically, uncuffed
• Predicted difficulty mandates additional
tubes have been used in the smaller child, this
preparation: extra help should be sought,
directive may change with time. Positioning
and adjuncts to direct laryngoscopy as well
issues have been previously discussed. Preoxy-
as alternative intubation devices and rescue
genation may be difficult in the uncooperative
oxygenation equipment must be immedi-
child, but should always be attempted.
ately available.
While many clinicians espouse routine use
of the straight blade in the young child due Numerous studies have attempted to corre-
to the frequent occurrence of a long, floppy late laryngoscopic grade with external anatomic
epiglottis, other experienced clinicians use features.55–59 Most studies conclude that exami-
the curved blade for all ages in the pediatric nation of more than one feature will increase the
population. Again, familiarity with the chosen chances of predicting difficulty.56, 60–62 However,
88 CHAPTER 5
it should be stressed that even with a detailed air- tongue will create difficulty in obtaining line-of-
way exam, not all patients presenting difficult sight view of the larynx. The laryngoscope blade
laryngoscopy will be predicted in advance. The functions to displace and/or compress the
airway examination, while sensitive, is not tongue into the submandibular space and also
specific, and has a low positive predictive helps lift the jaw anteriorly. Thus, laryngoscopy
value.12 In addition, it may not be possible, or may be predicted to be difficult both in the
practical, to perform many of these assessment patient with a hypoplastic mandible, as little space
techniques in the patient requiring emergency is available into which to compress the tongue,
intubation.63 as well as in a patient with poor jaw mobility.
The importance of head and neck positioning
on lining up the oral and pharyngeal/tracheal
Anatomic Factors Important has been addressed in Chap. 3. Figs. 3–7 A and
to Direct Laryngoscopy B help illustrate the effect of introducing the
“sniff” position (head extension, lower neck
A simple diagram (Fig. 5–34) from Cormack and flexion) in helping to create line-of-sight visual-
Lehane’s paper26 illustrates many of the anatomic ization of the glottis. Such positioning moves
features needed for ease of attaining a direct the axes towards closer alignment, but not totally:
line-of-sight view of the glottic opening. Arrow the laryngoscope blade then completes the job
1 in Fig. 5–34 indicates that an anteriorly and/or by lifting the jaw anteriorly and displacing the
superiorly positioned larynx will hide the glottic tongue into the submandibular space, enabling
opening behind the tongue and epiglottis, creat- direct line-of-sight visualization.
ing more difficulty. Arrow 2 shows how promi-
nent upper incisors create difficulty, and also
indirectly reflects mouth opening as a factor. “MMAP”ing the Airway
Arrow 3 in Fig. 5–34 illustrates that a prominent
The foregoing anatomic considerations can be
used to deduce predictors of difficult laryn-
goscopy. The mnemonic64 MMAP can be used
as a reminder of these predictors:
2
1 M: Mallampati classification
M: Measurements (3–3–1)
A: A-O (Atlanto-Occipital) extension—
3 ability to extend the head and flex the
lower neck
P: Pathology: any evidence of pathologic
airway obstruction which may create dif-
ficulty with laryngoscopy
A. Mallampati Class. Assessment of the Mal-

Figure 5–34. The anatomic obstacles to
lampati class requires an awake, sitting,
attaining a direct line-of-sight view of the glottic
opening. Arrow 1: An anteriorly and/or supe-
cooperative, patient (e.g., the patient in res-
riorly positioned larynx. Arrow 2: Prominent piratory distress or about to receive proce-
upper incisors and limited mouth opening. dural sedation). The patient should be asked
Arrow 3: A prominent tongue. (From Cormack26, for maximum mouth opening, and to
with permission.) extrude the tongue without phonating.65
Class I Class II Class III Class IV
Figure 5–35. Mallampati classes I–IV.
The class obtained is dependent on what • Jaw protrusion: Anterior jaw protru-
structures can be seen (Fig. 5–35). This test sion occurs during direct laryngoscopy,
reflects both mouth opening and the rela- helping move the tongue and epiglottis
tive prominence of the tongue in the anteriorly and out of the line-of-sight.
oropharynx: as discussed above, difficulty Jaw protrusion can be assessed at the
displacing or compressing the tongue out bedside by asking the cooperative
of the way at laryngoscopy can increase dif- patient to move the lower teeth in front
ficulty. Mallampati originally described of the upper teeth. At least 1 cm of jaw
3 views, however, a modified classification protrusion is desirable. Alternatively,
describing 4 views is more commonly cited.66 the upper lip bite test can be used. The
Class I and II are generally correlated with patient is asked to cover the upper lip
easy direct laryngoscopy, while III and IV with the bottom incisors. This has been
are more suggestive of difficulty.66 This shown to provide additional information
assessment is often not possible in the patient but, alone, the inability to do this cannot
requiring emergency airway management. reliably predict difficult laryngoscopy.67,68
B. Measurements. The 3–3–1 measurements C. Atlanto-Occipital extension. In the
can be used to assess other aspects of the absence of C-spine precautions, the patient’s
patient’s airway anatomy. ability to flex the neck at the cervico-thoracic
• Thyromental span: Ideally 3 finger- junction and extend the head at the atlanto-
breadths should fit under the patient’s occipital junction should be assessed. Obvi-
chin between the superior border of the ously, this step should be omitted in the
thyroid cartilage and the mentum of the patient with C-spine precautions, and
chin. Fewer than three (of the patient’s assumed to be one factor that makes laryn-
own fingers) can portend difficulty with goscopy in this patient population more
laryngoscopy, due to an inadequate difficult.
space into which to compress the tongue D. Pathology. Airway obstruction as a patho-
with the laryngoscope blade. logic condition deserves special mention.
• Mouth opening: The patient should The patient with pathologic airway obstruc-
also have 3 fingerbreadths of mouth tion may be difficult to intubate, even with
opening. Adequate mouth opening is external anatomic features otherwise sug-
needed for blade insertion and rotation gesting an easy intubation. Airway obstruc-
into the pharynx. tion can result from medical (e.g., angioedema,
90 CHAPTER 5
airway infections, tumors) or traumatic (e.g., 2. Walker JD. Posture used by anaesthetists during laryn-
burns, penetrating or blunt neck trauma) goscopy. Br J Anaesth. 2002;89(5):772–774.
conditions. Under such circumstances, con- 3. Matthews AJ, Johnson CJ, Goodman NW. Body
cern exists over not knowing what the glottis posture during simulated tracheal intubation.
Anaesthesia. 1998;53(4):331–334.
will look like at direct laryngoscopy: whether
4. Collins JS, Lemmens HJ, Brodsky JB, et al. Laryn-
normal structures will be identifiable, or in the
goscopy and morbid obesity: a comparison of the
expected location. There is also concern that “sniff” and “ramped” positions. Obes Surg.
patient compensation related to muscle tone, 2004;14(9):1171–1175.
intact reflexes, and positioning may be the 5. Adnet F, Baillard C, Borron SW, et al. Random-
only factors preventing complete obstruction. ized study comparing the “sniffing position” with
Such patients can be identified, (a) by his- simple head extension for laryngoscopic view in
tory, and (b) by inspiratory stridor, loudest elective surgery patients. Anesthesiology. 2001;95(4):
(on auscultation) at the larynx. Strong con- 836–841.
sideration should be given to securing the 6. Adnet F, Borron SW, Lapostolle F, et al. The three
airway using an awake technique in these axis alignment theory and the “sniffing position”:
perpetuation of an anatomic myth? Anesthesiology.
situations, when feasible. Significant upper
1999;91(6):1964–1965.
airway pathology is a relative contraindication
7. Hirsch NP, Smith GB, Adnet F. Historical perspec-
to RSI. tive of the “sniffing position”. Anesthesiology.
2000;93(5):1366–1367.
䉴 SUMMARY 8. Levitan RM, Mechem CC, Ochroch EA, et al. Head-
elevated laryngoscopy position: improving laryn-
Most intubations in emergencies are performed geal exposure during laryngoscopy by increasing
using direct laryngoscopy. DL retains the advan- head elevation. Ann Emerg Med. 2003;41(3):
tage of direct visualization of the laryngeal inlet, 322–330.
with immediate confirmation of tube passage 9. Hochman, II, Zeitels SM, Heaton JT. Analysis of
through the cords in many cases, and the ability the forces and position required for direct laryn-
goscopic exposure of the anterior vocal folds.
to evaluate the oropharynx for foreign material
Ann Otol Rhinol Laryngol. 1999;108(8):715–724.
in the same setting. DL is a core skill to the
10. Heath KJ. The effect of laryngoscopy of different cer-
acute-care clinician. Done properly, with a vical spine immobilisation techniques. Anaesthesia.
knowledgeable appreciation of the anatomy, it 1994;49(10):843–845.
will be successful most of the time. However, as 11. MacQuarrie K, Hung OR, Law JA. Tracheal intuba-
with BMV, having a good approach to difficult tion using Bullard laryngoscope for patients with a
laryngoscopy, predicted or not, is also needed. simulated difficult airway. Can J Anaesth.
Finally, even though its utility may be limited in 1999;46(8):760–765.
the emergency setting, an airway exam looking 12. Crosby ET, Cooper RM, Douglas MJ, et al. The unan-
for predictors of difficult laryngoscopic intuba- ticipated difficult airway with recommendations for
tion is still warranted to help determine the best management. Can J Anaesth. 1998;45(8):757–776.
13. Benumof JL. Difficult laryngoscopy: obtaining the
approach to the intubation, and to anticipate
best view. Can J Anaesth. 1994;41(5 Pt 1):361–365.
the need for help and preparation of additional
14. Henderson JJ. The use of paraglossal straight blade
equipment. laryngoscopy in difficult tracheal intubation.
Anaesthesia. 1997;52(6):552–560.
REFERENCES 15. Uchida T, Hikawa Y, Saito Y, et al. The McCoy lev-
ering laryngoscope in patients with limited neck
1. Levitan RM, Pisaturo JT, Kinkle WC, et al. Stylet bend extension. Can J Anaesth. 1997;44(6):674–676.
angles and tracheal tube passage using a straight- 16. Gabbott DA. Laryngoscopy using the McCoy laryn-
to-cuff shape. Acad Emerg Med. 2006;13(12): goscope after application of a cervical collar. Anaes-
1255–1258. thesia. 1996;51(9):812–814.
17. Laurent SC, de Melo AE, Alexander-Williams JM. 32. Levitan RM, Kinkle WC, Levin WJ, et al. Laryngeal
The use of the McCoy laryngoscope in patients view during laryngoscopy: a randomized trial com-
with simulated cervical spine injuries. Anaesthesia. paring cricoid pressure, backward–upward-
1996;51(1):74–75. rightward pressure, and bimanual laryngoscopy.
18. Bilgin H, Bozkurt M. Tracheal intubation using the Ann Emerg Med. 2006;47(6):548–555.
ILMA, C-Trach or McCoy laryngoscope in patients 33. Haslam N, Parker L, Duggan JE. Effect of cricoid
with simulated cervical spine injury. Anaesthesia. pressure on the view at laryngoscopy. Anaesthesia.
2006;61(7):685–691. 2005;60(1):41–47.
19. ACEP. Verification of endotracheal tube placement. 34. Snider DD, Clarke D, Finucane BT. The “BURP”
Ann Emerg Med. 2002;40(5):551–552. maneuver worsens the glottic view when applied
20. Salem MR. Verification of endotracheal tube in combination with cricoid pressure. Can J Anaesth.
position. Anesthesiol Clin North America. 2005;52(1):100–104.
2001;19(4):813–839. 35. Gataure PS, Vaughan RS, Latto IP. Simulated diffi-
21. Donahue PL. The oesophageal detector device. An cult intubation. Comparison of the gum elastic
assessment of accuracy and ease of use by para- bougie and the stylet. Anaesthesia. 1996;51(10):
medics. Anaesthesia. 1994;49(10):863–865. 935–938.
22. Andres AH, Langenstein H. The esophageal 36. Hodzovic I, Wilkes AR, Latto IP. To shape or not
detector device is unreliable when the stomach has to shape...simulated bougie-assisted difficult
been ventilated. Anesthesiology. 1999;91(2):566–568. intubation in a manikin. Anaesthesia. 2003;58(8):
23. Cooper GM, McClure JH. Maternal deaths from 792–797.
anaesthesia. An extract from Why Mothers Die 37. Viswanathan S, Campbell C, Wood DG, et al. The
2000–2002, the Confidential Enquiries into Maternal Eschmann Tracheal Tube Introducer. (Gum elastic
Deaths in the United Kingdom: Chapter 9: Anaes- bougie). Anesthesiol Rev. 1992;19(6):29–34.
thesia. Br J Anaesth. 2005;94(4):417–423. 38. Kidd JF, Dyson A, Latto IP. Successful difficult intu-
24. Kelly JJ, Eynon CA, Kaplan JL, et al. Use of tube bation. Use of the gum elastic bougie. Anaesthesia.
condensation as an indicator of endotracheal 1988;43(6):437–438.
tube placement. Ann Emerg Med. 1998;31(5): 39. Dogra S, Falconer R, Latto IP. Successful difficult
575–578. intubation. Tracheal tube placement over a gum-
25. Angelotti T, Weiss EL, Lemmens HJ, et al. Verifica- elastic bougie. Anaesthesia. 1990;45(9):774–776.
tion of endotracheal tube placement by prehospi- 40. Combes X, Le Roux B, Suen P, et al. Unanticipated
tal providers: is a portable fiberoptic bronchoscope difficult airway in anesthetized patients: prospec-
of value? Air Med J. 2006;25(2):74–78; discussion tive validation of a management algorithm.
78–80. Anesthesiology. 2004;100(5):1146–1150.
26. Cormack RS, Lehane J. Difficult tracheal intubation 41. Jabre P, Combes X, Leroux B, et al. Use of gum
in obstetrics. Anaesthesia. 1984;39(11):1105–1111. elastic bougie for prehospital difficult intubation.
27. Mort TC. Emergency tracheal intubation: complica- Am J Emerg Med. 2005;23(4):552–555.
tions associated with repeated laryngoscopic 42. Noguchi T, Koga K, Shiga Y, et al. The gum elastic
attempts. Anesth Analg. 2004;99(2):607–613. bougie eases tracheal intubation while applying
28. Knill RL. Difficult laryngoscopy made easy with cricoid pressure compared to a stylet. Can J
a “BURP”. Can J Anaesth. 1993;40(3):279–282. Anaesth. 2003;50(7):712–717.
29. Takahata O, Kubota M, Mamiya K, et al. The effi- 43. Morton G, Chileshe B, Baxter P. Gum elastic bougie
cacy of the “BURP” maneuver during a difficult in the hole technique. Anaesthesia. 2002;57(10):
laryngoscopy. Anesth Analg. 1997;84(2):419–421. 1037–1038.
30. Ochroch EA, Levitan RM. A videographic analysis 44. Combes X, Dumerat M, Dhonneur G. Emergency
of laryngeal exposure comparing the articulating gum elastic bougie-assisted tracheal intubation in
laryngoscope and external laryngeal manipulation. four patients with upper airway distortion.
Anesth Analg. 2001;92(1):267–270. Can J Anaesth. 2004;51(10):1022–1024.
31. Benumof JL, Cooper SD. Quantitative improve- 45. Nolan JP, Wilson ME. Orotracheal intubation in
ment in laryngoscopic view by optimal external patients with potential cervical spine injuries. An
laryngeal manipulation. J Clin Anesth. 1996;8(2): indication for the gum elastic bougie. Anaesthesia.
136–140. 1993;48(7):630–633.
92 CHAPTER 5
46. Charuluxananan S, Kyokong O, Somboonviboon 58. Rose DK, Cohen MM. The airway: problems and
W, et al. Learning manual skills in spinal anesthesia predictions in 18,500 patients. Can J Anaesth.
and orotracheal intubation: is there any recom- 1994;41(5 Pt 1):372–383.
mended number of cases for anesthesia residency 59. Tse JC, Rimm EB, Hussain A. Predicting difficult
training program? J Med Assoc Thai. 2001;84 Suppl endotracheal intubation in surgical patients sched-
1:S251–255. uled for general anesthesia: a prospective blind
47. Konrad C, Schupfer G, Wietlisbach M, et al. Learn- study. Anesth Analg. 1995;81(2):254–258.
ing manual skills in anesthesiology: Is there a rec- 60. Arne J, Descoins P, Fusciardi J, et al. Preoperative
ommended number of cases for anesthetic pro- assessment for difficult intubation in general and
cedures? Anesth Analg. 1998;86(3):635–639. ENT surgery: predictive value of a clinical multi-
48. Mulcaster JT, Mills J, Hung OR, et al. Laryngo- variate risk index. Br J Anaesth. 1998;80(2):
scopic intubation: learning and performance. 140–146.
Anesthesiology. 2003;98(1):23–27. 61. el-Ganzouri AR, McCarthy RJ, Tuman KJ, et al. Pre-
49. Levitan RM, Goldman TS, Bryan DA, et al. Train- operative airway assessment: predictive value of a
ing with video imaging improves the initial intuba- multivariate risk index. Anesth Analg. 1996;82(6):
tion success rates of paramedic trainees in an oper- 1197–1204.
ating room setting. Ann Emerg Med. 2001;37(1): 62. Saghaei M, Safavi MR. Prediction of prolonged laryn-
46–50. goscopy. Anaesthesia. 2001;56(12):1198–1201.
50. Hall RE, Plant JR, Bands CJ, et al. Human patient 63. Levitan RM, Everett WW, Ochroch EA. Limitations
simulation is effective for teaching paramedic stu- of difficult airway prediction in patients intubated
dents endotracheal intubation. Acad Emerg Med. in the emergency department. Ann Emerg Med.
2005;12(9):850–855. 2004;44(4):307–313.
51. Holly LT, Kelly DF, Counelis GJ, et al. Cervical spine 64. Walls RM, Murphy M. Identification of the difficult
trauma associated with moderate and severe head and failed airway. In: Walls RM, ed. Manual of
injury: incidence, risk factors, and injury character- Emergency Airway Management. 2nd ed.
istics. J Neurosurg. 2002;96(3 Suppl):285–291. Philadelphia: Lippincott Willimas and Wilkins;
52. Demetriades D, Charalambides K, Chahwan S, et 2004;70–81.
al. Nonskeletal cervical spine injuries: epidemiology 65. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical
and diagnostic pitfalls. J Trauma. 2000;48(4): sign to predict difficult tracheal intubation: a
724–727. prospective study. Can Anaesth Soc J. 1985;
53. Crosby ET. Airway management in adults after cer- 32(4):429–434.
vical spine trauma. Anesthesiology. 2006;104(6): 66. Samsoon GL, Young JR. Difficult tracheal intubation:
1293–1318. a retrospective study. Anaesthesia. 1987;42(5):
54. Manoach S, Paladino L. Manual In-Line Stabiliza- 487–490.
tion for Acute Airway Management of Suspected 67. Eberhart LH, Arndt C, Cierpka T, et al. The reliabil-
Cervical Spine Injury: Historical Review and Cur- ity and validity of the upper lip bite test compared
rent Questions. Ann Emerg Med. 2007. with the Mallampati classification to predict diffi-
55. Oates JD, Macleod AD, Oates PD, et al. Compari- cult laryngoscopy: an external prospective evalua-
son of two methods for predicting difficult intubation. Anesth Analg. 2005;101(1):284–289.
tion. Br J Anaesth. 1991;66(3):305–309. 68. Khan ZH, Kashfi A, Ebrahimkhani E. A compari-
56. Reed MJ, Dunn MJ, McKeown DW. Can an airway son of the upper lip bite test (a simple new
assessment score predict difficulty at intubation technique) with modified Mallampati classification
in the emergency department? Emerg Med J. in predicting difficulty in endotracheal intubation:
2005;22(2):99–102. a prospective blinded study. Anesth Analg.
57. Rocke DA, Murray WB, Rout CC, et al. Relative risk 2003;96(2):595–599.
analysis of factors associated with difficult intuba-
tion in obstetric anesthesia. Anesthesiology.
1992;77(1):67–73.
Chapter 6
Alternative Intubation
Techniques
䉴 KEY POINTS 䉴 INTRODUCTION TO ALTERNATIVE

INTUBATION DEVICES AND
• Repeated direct laryngoscopy (DL) attempts TECHNIQUES
can lead to increasing upper airway
trauma, and ultimately to a situation where Difficult tracheal intubation may be defined as
mask ventilation may also be difficult or any of:
impossible.
• If ‘best look’ laryngoscopy, including use A. More than two attempts made with the same
of an adjunct such as the bougie, or pos- laryngoscope blade.
sibly a blade change, has failed after one B. A change in blade or use of an adjunct (e.g.,
or two attempts, it is reasonable to switch the bougie) is required.
to an alternative intubation technique. C. Use of an alternative intubation technique.1
• As an alternative intubating technique, the
LMA FastrachTM has an advantage in that it An appropriate response to anticipated diffi-
can also be used to oxygenate and venti- cult tracheal intubation requires forethought and
late the patient. planning. However, not all difficult intubation
• Lightwand (e.g. Trachlight™) use is not situations can be or are predicted beforehand:
limited by blood and secretions in the air- some patients with no anatomic features sug-
way. However, consistent successful use gestive of difficult laryngoscopy and intubation
requires experience. may still be challenging. Faced with difficult
• Fiberoptic stylets can be used on their own laryngoscopy, it is not acceptable in contempo-
as true ‘alternative intubation’ instruments, rary practice to repeatedly attempt to blindly
or can be used as adjuncts to direct laryn- pass an endotracheal tube under the epiglottis,
goscopy. hoping it will pass. Evidence of increased mor-
• Navigation of any fiberoptic instrument bidity with multiple attempts at laryngoscopy is
through the airway is contingent on advanc- mounting, especially with three or more
ing the device through a patent airway lumen. attempts.2 The anatomic or pathologic conditions
• Videolaryngoscopy provides views of the rendering direct laryngoscopy difficult (e.g., poor
glottic opening which are often superior neck mobility, limited jaw opening, or prominent
to those obtained with conventional direct upper teeth) will not improve over time. Rather,
laryngoscopy. repeated attempts can cause increasing airway
93
94 CHAPTER 6
trauma, with bleeding, edema, or laryngospasm techniques. Many devices presented in this
ultimately leading to a situation where mask chapter are available at reasonable cost, have
ventilation may also be difficult or impossible. favorable learning curves, and some published
If “best look” laryngoscopy, including use of evidence. The decision of which device to
adjuncts such as the bougie, and possibly a acquire should also take into account the oppor-
blade change, have failed after one or two tunity to practice in the controlled setting of the
attempts, it is preferable to switch to an alter- operating room (OR). Collaboration with local
native intubation technique. Alternative intu- anesthesiologists in choosing a device already
bation devices tend to conform better to in use in the OR will facilitate skill maintenance
anatomic axes of the airway, and will often opportunities.
permit easier tracheal intubation in patients who Both the Laryngeal Mask Airway (LMA)
otherwise present significant difficulty with Fastrach™, also known as the intubating
direct laryngoscopy. Before proceeding to an laryngeal mask airway (LMA North America
alternative intubation technique, ease of bag- Inc., San Diego, CA, Fig. 6–1) and the Trach-
mask ventilation (BMV) should be assessed and light lighted stylet (Laerdal Medical Corp, Wap-
the patient reoxygenated, as necessary. pingers Falls, NY, Fig. 6–2) have an extensive
A number of good alternative intubating history of use in the OR setting and have rea-
tools and techniques exist. The clinician should sonable supporting evidence as effective diffi-
become familiar with one, or possibly two such cult airway tools.3,4 A third class of alternative
Figure 6–1. The LMA FastrachTM. (With permission from LMA

North America Inc.).
ALTERNATIVE INTUBATION TECHNIQUES 95
Figure 6–2. The Trachlight.
intubation device is the rigid or flexible fiberop- scope and the Shikani Optical Stylet, [SOS],
tic instrument. To date, skill requirements and Clarus Medical, St. Paul, MN, Fig. 6–3). In addi-
cost have limited the use of these latter instru- tion, video-based instruments such as the
ments for out-of-OR emergency intubations. Glidescope (Verathon Medical [Canada], Burnaby,
However, more affordable options in this cate- BC, Fig. 6–4) are gaining in popularity and are
gory are emerging in the form of portable semi- increasingly being used as alternative intuba-
rigid fiberoptic stylets (e.g., the Levitan FPS tion devices out of the OR.
Figure 6–3. The Seeing Optical Stylet, SOS (above) attached to dedicated lightsource and the
Levitan FPS optical stylet (below) attached to a “Greenline” handle. Both have an endotracheal
tube preloaded for use.
96 CHAPTER 6
Figure 6–4. Glidescope video system.
䉴 LMA FASTRACHTM designed to elevate the epiglottis up and away

from the path of the advancing ETT.
LMA FastrachTM Description At present, the LMA FastrachTM is available
only in large child to adult sizes, equivalent to
The LMA FastrachTM was introduced after publi- LMA ClassicTM sizes 3–5. Single-use versions are
cation of numerous case reports describing also available. Sizing is generally inscribed on
fiberoptic-aided intubation through the LMA the LMA FastrachTM itself, and listed on the pack-
ClassicTM, using small endotracheal tubes (ETTs). aging. Alternatively, a manufacturer’s reference
One obvious advantage of the LMA FastrachTM card can be used for sizing and cuff inflation
as an alternative intubating technique is that it volumes. The size 3 LMA-FastrachTM is designed
can be used to oxygenate and ventilate the for use in patients of 30–50 kg; size 4, patients
patient, either between intubation attempts or of 50–70 kg, while the size 5 is used for patients
used as a rescue oxygenation device.5 Indeed, above 70 kg. Dedicated reusable, silicon-based,
for a given volume of air in the cuff, there is evi- wire reinforced endotracheal tubes are sup-
dence that it provides a better seal than the LMA plied by the manufacturer for use with the LMA
ClassicTM.4 It is similar to the original LMA ClassicTM FastrachTM. The flexibility of these tubes helps
in the appearance of the distal cuff, however dif- negotiate curves of two opposing directions
fers in having a shorter, wider, L-shaped rigid during passage through the LMA FastrachTM bar-
stainless steel barrel (Fig. 6–5). The barrel rel and into the patient.4 They also feature a
attaches to a guiding handle, allowing for device bevel extending to the midline, to discourage
insertion without placement of the clinician’s tube hang-up during advancement. Although
fingers into the patient’s mouth. A prominence at LMA FastrachTM intubation has also been
the junction of the mask and barrel is designed described using well-lubricated standard ETTs
to direct the ETT centrally. The LMA FastrachTM (up to size 8.0) advanced in a reverse curve
also has a stiff bar lying across the mask aperture, direction,6,7 their use is not recommended by
Handle
Air
tube
Inflation Epiglottic
indicator elevating bar
Valve balloon
Cuff
Inflation
line
Figure 6–5. LMA FastrachTM. (With permission LMA North America).
the manufacturer, out of concern of possible LMA FastrachTM Use

laryngeal trauma.
The LMA FastrachTM is used with the head and
LMA FastrachTM Preparation neck in the neutral position. The following steps
are undertaken.
Selection of the appropriately-sized LMA FastrachTM
is important, as incorrect mask sizing may
impact both ease of ventilation and success of FastrachTM Insertion and Positioning
blind intubation.8 As with the LMA ClassicTM (see A. The LMA FastrachTM is inserted into the
Chap. 7), insertion of the Fastrach is with the patient’s mouth so that the lubricated pos-
cuff fully deflated (Fig. 6–6). The posterior terior aspect of the mask tip is flat against
aspect of the cuff should be well lubricated the hard palate (Fig. 6–7).
with a water-soluble lubricant. The tube inlet B. The mask is then carefully rotated down
and outlet of the Fastrach airway barrel into the pharynx, maintaining pressure
should also be well lubricated, as should the against the hard palate and posterior pha-
endotracheal tube itself. Clinical experience ryngeal wall (Fig. 6–8).
suggests lubrication of the airway barrel is even C. Once seated in the pharynx, the cuff is
more crucial for the disposable versions. inflated with a volume of air sufficient to
98 CHAPTER 6
Figure 6–7. The LMA FastrachTM is inserted

and advanced along the hard palate. (With
permission LMA North America).
Figure 6–6. The LMA FastrachTM is prepared

for insertion by posterior lubrication and fully
deflating its cuff while pressing down on a flat
surface. (With permission from LMA North
America).
achieve a good seal (or else [size of mask – 1]

× 10).
D. At this point, many clinicians routinely per-
form an “up-down” maneuver, whereby the
inflated mask is rotated back out of the
patient by 6 cm, a jaw lift performed, and
the mask readvanced 6 cm. This maneuver
will help release an epiglottis which may
have been downfolded during the initial
insertion (Fig. 6–9).
E. The Fastrach is then attached to the man-
ual resuscitator device, ventilation is
assessed, and the patient reoxygenated
(Fig. 6–10). Figure 6–8. The Fastrach has been rotated
F. The next step is to seek the position of best down into the pharynx. (With permission LMA
ventilation. While manually ventilating the North America).
6 cm max
Do not swing
out more than 6 cm
(normal adult)
then replace
A. The downfolded B. Using the inflated

epiglottis mask as a hook to
elevate
the epiglottis
“up movement”
C. Replacing mask
“down movement’’
Figure 6–9. An “up-down” maneuver is performed to relieve potential obstruction by a down

folded epiglottis. A jaw lift is performed and the inflated mask is rotated back out of the patient
by 6 cm, then readvanced 6 cm. (With permission LMA North America).
patient, the LMA FastrachTM is manipulated pressures of 20–25 cm H2O). This step, the
forward or backward in 1-cm increments first of the two-step Chandy maneuver, is
until the position at which maximal chest helpful in assuring the mask is placed in opti-
rise occurs with minimal leak (at applied mal position for subsequent tube passage.
100 CHAPTER 6
ETT depth
marker
Figure 6–10. A manual resuscitator is

attached to the Fastrach, seeking the point of
maximum chest rise with ventilation. (With
permission LMA North America).
Fastrach Intubation
A. The silicone-based tube is marked with a
vertical black line which should face pos-
teriorly toward the clinician: this orients
the distal end of the ETT correctly to facil-
itate passage through the cords. The lubri-
cated ETT is inserted through the Fastrach
airway barrel. At 15-cm (indicated by a B
transverse line on the supplied tube, Figure 6–11. A While holding the Fastrach,
(Fig. 6–11 A, arrow) the distal end of the the dedicated ETT is advanced, with vertical
tube has reached the epiglottic elevating black line facing posteriorly, until the transverse
bar. As the ETT exits the Fastrach barrel black line on the ETT (arrow) is about to enter
into the Fastrach barrel. B At this point, the
and raises the epiglottic elevating bar,
Fastrach handle (and entire mask) should be
some resistance will be encountered: how- lifted vertically (the second step of the “Chandy
ever, the resistance should decrease by maneuver,” to help apply the Fastrach to the
the time the tube has been advanced glottic opening and optimize tube delivery.
1.5-cm beyond the transverse line. (With permission LMA North America).
B. At this point, the Fastrach handle (and entire LMA FastrachTM Troubleshooting
mask) should be lifted vertically (the second
step of the Chandy maneuver, Fig. 6–11 B), Maneuvers to help prevent and respond to dif-
to help increase seal pressure and ensure ficulty with tube passage in the face of appar-
optimal alignment of the axes of the tra- ent good LMA FastrachTM positioning have been
chea and the ETT. Most often, the tube described. These include the following.
passes easily into the trachea. After intuba-
tion, objective (i.e., end-tidal CO2, or an Prevention
esophageal detector device) signs of endo- As already discussed, three maneuvers to help
tracheal placement of the ETT are sought, prevent difficult tube passage are (a) withdraw-
together with clinical confirmation. ing and reinserting the inflated mask 6 cm (pos-
sibly releasing a down-folded obstructing
epiglottis); (b) finding the minimum leak posi-
Fastrach Removal tion of best ventilation of the mask before
A. After confirmation of successful intuba- attempting intubation; and (c) vertically lifting
tion, the LMA Fastrach TM itself can be the mask during attempted tube passage.
removed. However, in a difficult airway
situation, where the LMA FastrachTM has
Response
been successfully used as a “plan B” alter-
If resistance to ETT passage occurs in spite of
native intubation device, if the clinician is
the above maneuvers, a change of mask size
unfamiliar with the mask removal process,
may be needed. This will be indicated by not-
it can be left in place until more experi-
ing where resistance to ETT advancement is
enced personnel are available for its
encountered, with reference to the transverse
removal. However, if the mask is left in-
15-cm black line on the ETT.
situ following successful intubation, its
cuff should be deflated, arrangements • A larger mask may be needed if resistance to
should be made for its timely removal ETT advancement is encountered about 3-cm
(e.g., within 4 hours), and the patient beyond the transverse line. In this situation,
should be kept well sedated. the epiglottic elevating bar may be too prox-
B. To remove the LMA FastrachTM, the mask imal to contact and elevate the epiglottis. The
cuff is deflated, and a stabilizer rod (sup- tube may be impacting the vallecula, above
plied with the Fastrach) is placed at the the epiglottis.
proximal end of the reinforced ETT (after • A smaller mask may be indicated if resistance
removing the 15-mm ETT connector) to keep is encountered just millimeters beyond the
the tube in place as the Fastrach is pulled transverse line. In this situation, the epiglot-
back. As the mask is withdrawn, once the tic elevating bar may be jammed too far dis-
ETT is visible issuing distally from the tally, behind the posterior cartilages.
mask, the tube is grasped and stabilized as
mask removal is completed. The ETT’s Combination Use with Other Devices
15 mm connector is then reinserted, and Intubation through the LMA FastrachTM can be
ventilation of the patient is resumed. It facilitated with adjuvant use of the Trachlight9
should be noted that the ETT cuff may (with the internal wire stylet removed), or flexi-
remain inflated at all times during this ble fiberoptic devices.
process. Fastrach mask removal is some- Relative contraindications to blind intuba-
what finicky, and should be done by an tion through the LMA FastrachTM include a
experienced user. known foreign body in the upper airway or
102 CHAPTER 6
trachea; upper airway or upper esophageal FastrachTM insertion, of unknown clinical signifi-
pathology; traumatic tracheal disruption, and cance.4 In-line immobilization, the presence of a
significant upper airway infection. However, cervical collar, and cricoid pressure all appear to
indirect visualization using flexible fiberoptic adversely affect LMA FastrachTM insertion, venti-
devices may allow LMA FastrachTM-guided intu- lation, and blind intubation success rates.4
bation in some airway pathology situations.
䉴 THE AIRQ AND AIRQ REUSABLE
LMA Fastrach Effectiveness
A second extraglottic device which can be used
ROUTINE AND DIFFICULT AIRWAY for both ventilation and intubation is the AirQ
MANAGEMENT (Mercury Medical, Clearwater, FL, Fig. 6–12).
After almost a decade of clinical use and study, The AirQ is available in disposable (AirQ) and
the LMA FastrachTM is supported by substantial reusable (AirQ Reusable, formerly known as the
narrative in the literature. Many case reports Cookgas Intubating Laryngeal Airway [ILA]) for-
and case series attest to its effectiveness in dif- mats. The AirQ is available in sizes for use in
ficult airway situations in both the emergency patients weighing 10 kg and up. The reusable
department (ED)10,11 and the OR.7,12 Successful version is autoclavable, can be used up to 40 times,
Fastrach mask insertion and ventilation occurs and is designed for use with regular ETTs of size
in over 95% of cases and subsequent blind intu- 5.0–8.5 mm ID. To date the manufacturer’s
bation succeeds in around 90% of cases.4 There instructions advise tracheal intubation through
is no significant difference in overall or first the AirQ with adjunctive use of a flexible or
attempt intubation success rates between patients semirigid fiberscope, tracheal tube introducer,
with normal or abnormal airway anatomy.4 airway exchange catheter, or lighted stylet.
Using the lightwand as a guide to facilitate LMA A dedicated removal stylet is available to help
FastrachTM intubation significantly increases stabilize the ETT in the patient as the mask is
overall, and first-attempt success rate.4 removed following intubation. The disposable
LMA FastrachTM facilitated intubation has AirQ is available in four color-coded sizes.
been successfully described in a number of case
series of awake (topically anesthetized) 䉴 THE LIGHTWAND (E.G.,
patients,13,14 and in one series of morbidly obese TRACHLIGHT)
patients (with a 96% success rate).15
SKILLS ACQUISITION Trachlight Description

A high rate of success in achieving LMA FastrachTM
insertion and ventilation has been reported in Lightwand use takes advantage of soft tissue
the hands of novice users: a 98% overall success transillumination in the neck, together with
rate, 81–96% on the first attempt.4 Compared to the anterior location of the trachea relative to
the LMA ClassicTM, a higher rate of successful the esophagus. Placed at or through the glottic
ventilation has been reported with the LMA opening based on an initial “educated guess” as
FastrachTM.16 Despite the high reported success to its position, the operator will see a well-
rates, as is the case with many airway devices, defined, circumscribed, transilluminated glow
inexperience with the LMA FastrachTM use is just below the thyroid cartilage as the endotra-
associated with failure to intubate.17 cheal tube-bearing lighted stylet emerges
through the cords and below the cartilage
C-SPINE PRECAUTIONS (Fig. 6–13). In contrast, if the lighted stylet has
Radiographic studies have shown a small amount been placed in the esophagus, a diffuse, minimal,
of movement of the upper C-spine during LMA or no glow will be seen.
Figure 6–12. The AirQ Reusable (formerly known as the Cookgas Intubating Laryngeal Airway)
Courtesy of Mercury Medical, Clearwater, FL.
Figure 6–13. With correct initial positioning of the Trachlight, a well-defined, circumscribed
transilluminated glow is seen in the anterior neck.
104 CHAPTER 6
While lightwands have existed for many contraindication to its use. Examples of such
decades, the Trachlight version of the lightwand abnormalities include laryngeal infectious or
represents a considerable improvement over inflammatory disorders such as epiglottitis; laryn-
earlier versions. It consists of a reusable, battery- geal or tracheal abnormalities such as polyps or
powered handle and a separate flexible wand. The tumors; or foreign body in the airway.18
wand, with a distal light and retractable internal The Trachlight is available in adult, pedi-
wire stylet for rigidity, attaches to longitudinal atric, and neonatal sizes. The handle is a multiple-
grooves on the handle, via a connector on its use item, while each wand can be resterilized
proximal end. This connector can be moved up and used up to 10 times.
or down the handle to accommodate tubes of
different lengths. A locking clamp on the han- Trachlight Preparation
dle secures a standard endotracheal tube con-
nector. The internal stylet, housed within the A small endotracheal tube should be chosen,
wand, allows initially for sufficient stiffness to for example, 6.5–7.0 mm ID for an adult female,
shape the wand to the needed 90° bend, but or 7.0–7.5 mm ID for adult male patients. Cut-
can be withdrawn once the trachea is ting the endotracheal tube at the 27-cm mark
accessed, rendering the tube pliable for easy and then replacing the ETT connector will
advancement. improve control of the device, yet leave plenty
The lightwand requires minimal mouth of tube external to the patient’s mouth for
opening and is actually ideally used with the securing. Good lubrication with a silicone- or
head and neck in the neutral position. Its suc- water-based lubricant should be applied to the
cessful use is not limited by blood and secre- outside of the wand as well as the internal stylet.
tions in the airway. However, as with the LMA The internal stylet is then advanced as far as it
Fastrach, it should be appreciated that as a can go into the wand by snapping it into place
blind technique, the presence of pathologic in its U-shaped housing (Fig. 6–14). The wand
abnormalities in the airway represents a relative should be connected to the grooves on the
Figure 6–14. The U-shaped housing (arrow) in to which the Trachlight’s internal stylet must be
snapped.
By pressing the release arm on the wand

connector (Fig. 6–17), the distal light tip of the
wand is advanced to a position just proximal
to the bevel of the ETT (Fig. 6–18). The
ETT/wand assembly is then bent acutely to an
angle of 90° at the level of the indicator (the
“bend here”) mark on the wand (Fig. 6–19).
The light source should again be checked. The
light will begin blinking after 30 seconds to
minimize heat generation, although this can
also be taken as a reminder to reoxygenate the
patient.
Trachlight Use
Figure 6–15. The wand is attached to the With any blind technique, the operator should
rail on the Trachlight handle. maintain a mental image of the anatomy through
which the device is traveling, and the Trachlight
handle by depressing a release arm on its prox- is no exception. The Trachlight is used with the
imal end (Fig. 6–15), and the light turned on supine patient’s head in a neutral position.19
and checked. The ETT should be loaded on to A jaw lift is performed with the clinician’s non-
the Trachlight wand by pushing the ETT’s 15-mm dominant hand to elevate the tongue and
connector into the locking clamp on the handle, epiglottis away from the posterior pharynx,
and closing the clamp lever (Fig. 6–16). allowing clear passage for lightwand advancement
Figure 6–16. The clamp lever which secures the endotracheal tube’s 15-mm connector to the
Trachlight handle.
106 CHAPTER 6
Figure 6–17. Depressing the release arm on the wand allows its movement up and down the
Trachlight handle rail, needed to position the wand tip at the end of the ETT.
Figure 6–18. The Trachlight tip is placed just proximal to the bevel of the ETT by moving it up
or down the handle rail.
Figure 6–19. “Bend here” marking on the Trachlight shaft, indicating the location to place an
acute 90º bend.
(Figure 6–20 A and B). The assembled Trach- lifted slightly and advanced in the midline,
light is inserted from the side of the mouth (Fig- seeking a bright, circumscribed glow just below
ure 6–21), and rotated medially to an upright the laryngeal prominence.
position in the midline (Figure 6–22), so that the Once the glow is obtained, the internal wire
distal end ends up in the hypopharynx. This ini- stylet is retracted 6–10 cm (not removed
tial insertion technique helps maintain the 90° entirely), and the entire ETT/wand assembly is
bend in the ETT/wand. The Trachlight is then advanced (Figures 6–23 A and B). During
Figure 6–20. A. Lateral fluoroscopic view of the airway in an obtunded patient. B. In the same
patient, a jaw lift allows for free passage of the Trachlight through an unobstructed lumen.
108 CHAPTER 6
Figure 6–21. Trachlight insertion is with a jaw lift, from the side of the mouth.
Figure 6–22. Still holding a jaw lift, the Trachlight is rotated upright in the midline.
Figure 6–23. Once a bright, midline glow is obtained (A), the Trachlight’s internal wire stylet is
withdrawn (B), and the tube/wand assembly is advanced.
109
110 CHAPTER 6
advancement, the glow will visibly travel caudad The Trachlight can be used in ambient room
in the anterior neck: once at or just below the lighting, although this obviously varies with
sternal notch, the tube can be assumed to be the brightness of the lighting and patient neck
properly positioned.20,21 The locking clamp is soft tissue thickness. One published series
then released and the Trachlight is withdrawn reported successful use in ambient lighting in
from the firmly held endotracheal tube. Endo- 88% of cases. 23 However, if difficulty is
tracheal location should be confirmed with encountered (or anticipated) in perceiving a
capnography. glow, room lighting should be reduced.19,24
Trachlight use in the presence of cricoid pres-
Trachlight Troubleshooting sure, as would be applied during a rapid-
sequence intubation (RSI), has been reported
Failure to obtain a glow in the appropriate mid- to take longer, and have a lower first attempt
line location suggests malpositioning. It should success rate,25 although successful Trachlight
be confirmed that the wire stylet is well-seated in use is higher in patients who are paralyzed.26
its U-shaped housing proximally, as lateral direc- Combination use of the lightwand to facili-
tional control of the ETT tip will otherwise be tate intubation via the LMA ClassicTM,27 LMA
lost. If too posterior (esophageal), there will be FastrachTM,9 and direct laryngoscopy28,29 has
minimal or no glow appreciable, and the tip of been reported to good effect. In one of these
the stylet should be redirected more anteriorly, studies, the lightwand was used as an adjunct
either by lifting up on the entire device, or rock- to direct laryngoscopy in 350 patients with sim-
ing it slightly backwards. Too lateral a tip location ulated Grade 3 views: 78% of patients were
is suggested by a glow off the midline, lateral to successfully intubated on the first, and all by
the thyroid cartilage. Minor left/right reposition- the third attempt.28 Lightwand-facilitated naso-
ing should be attempted. In fact, as the tip of the tracheal intubation is also well described and
lightwand is rotated slightly from left to right, effective in experienced hands.19,30,31
often a “flash” of light may be seen proceeding
down the trachea as the light tip sweeps across Trachlight Effectiveness
the laryngeal inlet. This will help orient the clini-
cian to the location of the cords and trachea. ROUTINE AND DIFFICULT AIRWAY
Occasionally, difficulty with tube passage MANAGEMENT
may be encountered after obtaining the correct In experienced hands, the Trachlight is very
circumscribed glow in the midline of the neck: effective. One of the largest published series on
the tube fails to advance as the internal wire Trachlight intubation in routine surgical patients
stylet is withdrawn. This occurs as the leading reported a 98% success rate, most on the first
edge of the tube abuts anterior or lateral tra- attempt. In contrast to direct laryngoscopy, time
cheal wall, where it may be impinging on a car- to intubation and success with the Trachlight in
tilaginous ring. In these circumstances, the entire this series was not correlated with any of the
Trachlight/tube assembly can be transiently usual anatomic predictors of difficult intuba-
rotated to the right, such that the Trachlight tion.23 A second study by the same group in
handle ends up almost parallel to the floor. This patients with predictors or a history of difficult
will often release the “hang-up”, allowing for laryngoscopy documented a 99% intubation suc-
forward passage of the tube. This phenomenon cess rate with the Trachlight.3
will be encountered less often if the tube is (a)
loaded “inverted” (with the tube’s concavity SKILLS ACQUISITION
facing opposite the bend of the wand) and (b) Manikin32,33 and human34 studies using novice
softened in warm water before use.22 personnel have generally shown a higher success
rate with direct laryngoscopy, compared to Scope (Clarus Medical LLC, Minneapolis, MN).
Trachlight use. One other study using anesthe- The SOS is a semirigid stylet containing fiberop-
sia personnel unfamiliar with the Trachlight tic illumination and viewing bundles, which
showed a significantly higher success rate in the connects to a handle containing a halogen light
final 10 of 30 Trachlight intubations.35 Realisti- source (Fig. 6–3). An adapter is also available
cally, the Trachlight is a device requiring expe- enabling its use with a regular laryngoscope
rience for consistently successful use, and should handle. Attached to the stylet is a sliding “tube-
be chosen as a primary alternative intubation stop” connector which accepts the proximal end
technique by clinicians having the opportunity of an endotracheal tube. This connector also
to become familiar with its use, for example, in has a removable attachment which allows con-
the elective setting of the OR. nection to oxygen tubing. The SOS is available
in one adult and one pediatric size.
C-SPINE PRECAUTIONS Manufactured by the same company as the
The Trachlight is an attractive choice for the SOS, the Levitan FPS (“First Pass Success”) scope
intubation of a patient with C-spine precautions, features a similar semimalleable optical stylet
as it is ideally used with the head and neck in and fixed-focus eyepiece. As a shorter and
the neutral position.18,19 Two studies36,37 com- simpler version of the SOS, it was designed pri-
paring Trachlight use with direct laryngoscopy, marily to serve as an adjunct to direct laryn-
one with applied in-line stabilization, have goscopy. A precut tube is loaded on the stylet
shown less C-spine movement with Trachlight and seated proximally in a fixed fitting that
use. When compared with the LMA FastrachTM accepts the ETT’s 15-mm connector. A small
in patients with applied in-line stabilization, the hole in the side of this fitting allows for the
Trachlight resulted in faster intubation times and application of (low-flow) oxygen down the ETT
a higher success rate.38 via a removable connector.39 The factory shape
of the stylet includes a distal 35° bend to facili-
tate its use as an adjunct to direct laryngoscopy
(DL). Power is supplied from any “Greenline”
䉴 FIBEROPTIC STYLETS
compatible handle or a separate light-emitting
diode light source. Cleaning is similar to that
Designed for use from within an ensleeved
required for a laryngoscope blade. The reduced
endotracheal tube, fiberoptic stylets allow indi-
number of fiberoptic bundles in the Levitan FPS
rect visualization through a proximal eyepiece,
scope has helped lower manufacturing costs,
via a fiberoptic bundle. These devices can be
while not compromising image quality.
used on their own as true “alternative intuba-
Other examples of fiberoptic optical stylets
tion” instruments, or can be used as adjuncts to
exist. The Bonfils Retromolar Intubation
direct laryngoscopy. Compared to flexible
Endoscope (Karl Storz Endoscopy, Culver City,
fiberoptic devices, fiberoptic stylets are rela-
CA) is available in adult and pediatric sizes,
tively easy to use, portable, more robust, and
and features a fixed 40° anterior distal curva-
significantly less expensive. Published literature
ture. It is supplied in a battery-powered
on the use of these tools is limited, but growing
as user experience increases. portable version as well as with an integrated
coupling for video-based use via a dedicated
Airway Management Trolley. Also from Karl
Fiberoptic Stylet Description Storz, the Brambrinck Intubation Endo-
scope is designed specifically for pediatric use.
Two examples of fiberoptic stylet are the The StyletScope (FSS, Nihon Kohden Corp.,
Shikani Optical Stylet (SOS) and Levitan FPS Tokyo, Japan) has a lever adjacent to its proximal
112 CHAPTER 6
handle, activation of which results in variable recessed within the distal end of the ETT, pro-
anterior flexion of the distal stylet (with its tecting it from secretions and minimizing the
ensleeved tube), to angles of up to 75°. The potential for loss of view from the instrument
Foley Airway Stylet (FAST, Clarus Medical abutting mucosal tissue.
LLC, Minneapolis, MN) is a flexible optical The distal end of the fiberoptic stylet should
stylet, compatible with the SOS handle, designed be bent (semimalleable scopes only) according
specifically to visually aid LMA Fastrach T M to the planned method of use: for use as an
intubation. adjunct to direct laryngoscopy, it should have
35–40° of anterior angulation just proximal to
Fiberoptic Stylet Preparation the ETT cuff. If stand-alone use is planned, the
angle should be increased to 60–75° for a mid-
When using a fiberoptic stylet (or other alterna- line approach, or left at 35–40° for an over-the-
tive intubation device) in a difficult airway molar approach.
situation, the use of a slightly smaller ETT may An antifogging agent can be applied to the
facilitate endotracheal intubation. The tube is distal end of the stylet, or it may be heated by
loaded over the stylet, with its proximal 15-mm placement in a bottle of warm water. One of
connector placed snugly in the movable tube these antifogging maneuvers should ideally be
holder (SOS and Bonfils) or fixed (Levitan FPS) undertaken, otherwise placement of a cold
proximal ETT fitting (Fig. 6–24). In the case of instrument in a patient will result in a view
the SOS and Bonfils stylets, the tube holder is obscured by fogging.
adjusted up or down the stylet shaft to locate
the tip of the stylet 1-cm proximal to the end of Fiberoptic Stylet Use
the ETT, while with the Levitan FPS, a loaded
ETT cut to the appropriate length (27.5 cm) Fiberoptic Stylet Use as an Adjunct to
should automatically result in the appropriate Direct Laryngoscopy
stylet tip location within the ETT. This position- A fiberoptic stylet prepared with an ensleeved
ing allows the tip of the device to be slightly tube can be used if difficulty is encountered
Figure 6–24. Proximal tube stops for Shikani SOS (above) and Levitan FPS (below).
with direct laryngoscopy. If a Cormack Grade 3 natively, the laryngoscope can be maintained in
(epiglottis only) view persists despite “best look” position while a briefed assistant advances the
laryngoscopy, while retaining that view with ETT off the stylet. Once the ETT is placed, the
ongoing laryngoscopy, the tip of the scope/tube fiberoptic stylet is withdrawn from the tube by
assembly is placed, under direct vision, close forward rotation. After cuff inflation, the posi-
to, but slightly below and away from the tip of tion of the ETT is confirmed with a second objec-
the epiglottis (“tip-to-tip,” Fig. 6–25 A).39 This tive method.
position can be retained by resting the tube gen- In the very rare situation in which a Cormack
tly against the upper teeth while the clinician Grade 4 (no identifiable structures) view is
then transfers from direct vision to indirect obtained at direct laryngoscopy, the fiberoptic
fiberoptic visualization through the scope eye- stylet/tube assembly can be advanced along the
piece. Once the glottic opening has been iden- laryngoscope blade, using the blade as a guide
tified, the ETT/scope assembly is advanced until the epiglottis is visualized through the
through the cords. During this advancement, to eyepiece. Appropriate maneuvers are then per-
conform to the axis of the trachea, the proximal formed to advance the tube beneath the epiglot-
(eyepiece) end of the scope will have to be tis and through the cords.
gradually rotated downward. After the trachea To attain and maintain skills with the device,
has been accessed, the laryngoscope can be some clinicians have espoused the use of optical
removed. While visualization through the eye- stylets with every intubation attempt39: if the
piece is maintained, the left hand can now be cords are easily visualized with direct laryn-
used to slide the ETT away from the tube holder goscopy, the tube can be advanced in regular
housing, and further on down the trachea. Alter- fashion with the fiberoptic stylet acting as a
A B
Figure 6–25. The Levitan FPS is placed under direct vision with aid of a laryngoscope. Once
the scope’s distal tip is positioned under the tip of the epiglottis (A), visualization of the glottic
inlet is sought through the eyepiece and the instrument then advanced through the cords (B).
114 CHAPTER 6
standard malleable stylet, but if a Grade 3 or the tube is further advanced off the stylet down
worse view is obtained, the fiberoptic stylet/tube the trachea.
assembly can be used to aid indirect visualization
of, and passage through the glottic opening, as
described above. Awake Intubation Using a Fiberoptic
Stylet
Fiberoptic stylets may be used in the sitting,
Stand-Alone Fiberoptic Stylet Use cooperative patient for an awake tracheal intu-
Fiberoptic stylets can also be used on their own. bation, using a face-to-face approach.40 Follow-
With such stand-alone use, the distal curvature ing appropriate application of topical airway
of semimalleable versions should be increased anesthesia (Chap. 8), gentle tongue traction is
for the midline approach, as mentioned above. applied by an assistant. The stylet with pre-
The scope should be antifogged and the patient’s loaded ETT is guided through the mouth in the
oropharynx suctioned. While performing a jaw midline, and advanced behind the tongue, until
lift (Fig. 6–26) with the nondominant hand, the its tip disappears. At this point, the long axis of
scope is inserted either in the midline over the the scope will be parallel to the floor. The clin-
tongue or via a more lateral approach, over the ician then looks through the proximal eye-
molars. A midline insertion will involve the clin- piece and seeks the anatomic landmark of the
ician’s significantly bending over the patient to epiglottis, leading to the glottic opening. In the
access the scope’s eyepiece (Figure 6–27). stand-alone manner described earlier, the distal
Anatomic landmarks are then sought as the tip of the tube/ stylet assembly is navigated to
scope is advanced: uvula, base of tongue, then and through the glottic opening into the
epiglottis and cords with a midline approach, or proximal trachea. The tube is then further
epiglottis then cords with an over-the-molar advanced off the stylet, and the scope is
approach. The tube/stylet assembly can be gen- removed by forward rotation of the proximal end
tly advanced through the cords, at which point back toward the patient’s chest.
Figure 6–26. The Shikani SOS is inserted from the side of the mouth, advanced over the
molars, and then rotated upright.
Figure 6–27. While maintaining a jaw lift, the user looks through the proximal eyepiece of the
SOS in an attempt to view the glottic structures.
Fiberoptic Stylet Troubleshooting mechanism with most of these instruments.

Blood, secretions, and vomitus will make use
• Getting “lost.” It should be appreciated that of an indirect fiberoptic system difficult. For
navigation of any fiberoptic instrument this reason, fiberoptic scope use should
through the airway is contingent on advancing always be preceded by suctioning of the
the device through a patent airway lumen. oropharynx. Also, as blood and secretions
While an awake patient will maintain air- will pool posteriorly, the scope should be
way patency, an obtunded or relaxed patient kept anterior in the airway during navigation
(as during an RSI) must have a patent lumen toward the laryngeal inlet. The difficulty which
created by a laryngoscope blade, with a jaw blood and secretions can cause with the use
thrust, or gentle tongue traction during the of a fiberoptic scope points to the need for its
procedure. The stylet should not be blindly early use, before the airway has been trauma-
advanced if no lumen is appreciable. In the tized by multiple intubation attempts!
event that orientation is lost (often manifested
by “pink-out”), the scope should be partially
withdrawn until an anatomic landmark (e.g., Fiberoptic Stylet Effectiveness
uvula or epiglottis) can be reidentified and at
that point, advancement can resume. ROUTINE AND DIFFICULT AIRWAY
• Fogging. If fogging is encountered once the MANAGEMENT
stylet is already in use, briefly holding the Shikani studied 120 patients, 74 of them chil-
stylet tip against the patient’s buccal mucosa dren, including 7 patients with Cormack Grade
will help clear the view. 3 or 4 views. All patients in the series, including
• Blood and secretions. It should be under- 5 awake patients, were successfully intubated
stood that there is no integrated suction with the scope, 88% on the first attempt. Five of
116 CHAPTER 6
the seven Grade 3 and 4 patients required con- be used as an adjunct to the core skill of direct
comitant direct laryngoscopy.41 Bein et al.42 laryngoscopy may contribute to an easier learn-
studied use of the Bonfils fiberoptic stylet in ing curve.
80 patients with predictors of difficult DL, com-
paring it to LMA Fastrach use. Thirty-nine of C-SPINE PRECAUTIONS
40 patients randomized to the Bonfils were intu- In a study comparing intubation using Macin-
bated on the first attempt, in contrast to a 70% tosh blade direct laryngoscopy with the Bon-
first attempt success rate for the Fastrach. fils stylet, Bullard laryngoscope, or LMA Fas-
A second study looked at Bonfils use after failed trach, each of the Bonfils, Bullard, and Fastrach
DL. In 25 patients recruited following two failed DL resulted in significantly less C-spine movement
attempts, 88% were successfully intubated with than Macintosh blade-facilitated intubation,
the Bonfils at the first attempt, and all but one although Bonfils and Fastrach intubations took
(96%) by the second attempt.43 Evans and significantly longer than those using the Mac-
coworkers compared the SOS to the bougie in a intosh and Bullard blades.50 A second study,
manikin study with a fixed Grade 3 view. In this also using fluoroscopy to assess C-spine
model, the SOS resulted in faster intubation movement, found that Bonfils intubations
times than the bougie, with significantly fewer caused significantly less extension of the
esophageal intubations.44 A second manikin upper C-spine than Macintosh laryngoscope-
study, this one comparing the bougie with aided intubations.51
the Levitan FPS scope, showed the fiberoptic
scope to be significantly more successful than 䉴 VIDEOLARYNGOSCOPY
the bougie in managing a simulated Grade 3B
view,45 but did not demonstrate a significant Displaying the view obtained at laryngoscopy
difference in intubation success in a simulated on a video monitor has a number of advantages:
Grade 3A view. The latter finding has been con-
firmed in a subsequent human study using sim- • Display of an enlarged, panoramic viewing
ulated Grade 3 views in elective surgical field.52
patients, in which the bougie was found to be • In those devices using integrated video tech-
equally effective to the Levitan FPS scope.46 nology on rigid blades, as the camera is
Finally, a recently published case series has located toward the distal end of the blade,
documented successful use of the Bonfils in six an improved view may be obtained com-
patients in whom difficulty had been encoun- pared to direct laryngoscopy.
tered in the prehsopital setting.47 • Aids in teaching.
• Assisting personnel can see the results of their
SKILLS ACQUISITION manipulations, for example, external laryn-
These devices are relatively easy to learn on geal manipulation (ELM).
manikins, as dealing with “pink out” is rarely • The procedure can be digitally stored for
an issue, and the upper airway lumen is widely documentation, teaching, or research pur-
patent. Skill transfer to the live setting is likely poses.
to be more challenging. One study looking at • The user is at a greater distance away from
the learning curve of the Bonfils stylet suggested the patient’s face, decreasing the chance of
that proficiency was attained after 20–25 intu- exposure to potentially infectious respiratory
bations.48 Other studies with fiberoptic stylets secretions and spray.
have reported that most of the failed intubations
occurred within the first 10 uses of the Video technology can be applied in two
device.41,49 The fact that the fiberoptic stylet can ways: (a) using an adapter, a video camera
can be attached to the eyepiece of conven- (10 kg and up), and small (1.5 kg and up)
tional fiberoptic devices such as the Shikani, sizes, and can be sterilized. More recently
Levitan FPS, Bullard, or flexible fiberoptic introduced versions of the GVL include the
bronchoscopes, or (b) integrated video is used GVL Ranger, which is a compact, battery-
as the primary viewing mechanism (e.g., the based unit, and the GVL Cobalt, which fea-
Glidescope). tures a reusable internal video baton for
placement within large or small-sized dispos-
able blades.
The Glidescope The GVL is inserted orally in the midline. As
the scope is advanced, the uvula, base of tongue
Commercially introduced in 2002, the and then epiglottis will be visualized on the
Glidescope® (GVL®) is a video laryngoscope screen, helping to retain orientation to the mid-
which has become increasingly available in line. Although the blade is designed to be placed
and out of the OR, as an alternative intubation above the epiglottis in the vallecula, in contrast
device. The one-piece blade and handle is to direct laryngoscopy, the blade tip need not
made of a durable medical-grade plastic. The be advanced completely into the glossoepiglot-
blade has a vertical profile of 14.5 mm, a 60° tic fold: a more proximal tip location allows a
bend midblade, and distally, houses a minia- wider field of view and more room for ETT
ture video camera and light-emitting diode manipulation (Fig. 6–28). A styletted ETT is
(LED) light source. The image obtained by the inserted immediately on the right side of the
camera is projected by cable to a liquid-crystal blade and is navigated to the laryngeal inlet
display (LCD) color monitor. A heating element under indirect visualization on the LCD screen.
covering the camera provides effective antifog- An accompanying nonmalleable, reusable stylet
g device has been turned on for has been made available by the manufacturer to
10–30 seconds. The reusable blades are avail- facilitate tube passage (Fig. 6–29), or a regular
able in large (patients 30 kg and up), midsize malleable stylet can be used, angled at about 60°
Figure 6–28. Glidescope video system use.

118 CHAPTER 6
palatoglossal arch. Thereafter, the clinician’s

vision can be transferred to the screen and indi-
rect, videoscopic ETT navigation can occur to
and through the cords. Alternatively, some clin-
icians prefer to place the ETT into the patient’s
pharynx prior to insertion of the GVL blade.55
The Berci-Kaplan DCI Video

Laryngoscope
The Berci-Kaplan DCI video laryngoscope (Karl

Storz Endoscopy, Culver City, CA) is a hybrid of
fiberoptic and video technology: an image-light
Figure 6–29. Dedicated rigid stylet (below)
for use with the Glidescope. bundle in a laryngoscope blade delivers an
image to a video camera located in the handle
of what otherwise looks like a regular direct
laryngoscope. A cable attaches the device to a
just proximal to the cuff.53,54 Once the tip of the cart-based camera-control unit, and also delivers
ETT has been passed through the cords, the light from the remote light source. The image
stylet should be withdrawn 2 inches (4 cm), obtained is displayed on a video monitor.
whereupon the tube can be further advanced Macintosh # 3, Mac 4, adult- and pediatric-sized
off the stylet down the trachea.55 Miller, and Dörges blades are available for use
There is a growing literature on the use of with the system. This system offers the advan-
this device, primarily in the OR setting. It is tage of being a familiar intubation technique
clear that the GVL does provide good and often and may deliver a superior view of the laryn-
superior views of the glottic opening when geal inlet compared to that obtained with direct
compared with conventional laryngoscopy, laryngoscopy.52
including a high rate of conversion of Cormack
Grade 3 (epiglottis only) views to Grade 2 or The LMA CTrach
better.53,54,56,57 However, somewhat longer intu-
bation times have been reported with the GVL The LMA CTrach (LMA North America Inc, San
compared to DL, even in the setting of Grade 1 Diego CA) is a version of the previously discussed
views by DL, possibly related to user inexperi- LMA FastrachTM which adds video-guidance
ence with tube delivery.54,57–59 capability (Fig. 6–30). Looking otherwise like
The GVL has been successfully used for the LMA FastrachTM, the CTrach mask contains
awake intubations in adults.60 C-spine motion fiberoptic bundles for light and image transmis-
during GVL use has been compared, using flu- sion, emerging at the distal end of the airway
oroscopy, to that incurred with Macintosh blade barrel. In addition, a removable viewing moni-
DL. Motion with GVL use was less than that tor (the CTrach Viewer) attaches to the CTrach
incurred by Macintosh laryngoscopy at only one handle by way of a magnetic latch connector.
(C2-5) of 4 neck levels studied.37 The battery-powered viewer is rechargeable,
There are some recent reports of upper and provides controls for focusing and image
airway trauma during GVL use.55,61,62 This sug- adjustment. For use, the CTrach Viewer is
gests that especially in the patient with a smaller detached, and the mask is deflated, lubricated
oral cavity, awareness of the ETT tip location posteriorly, and antifogged with application of
must be maintained as it is advanced, ideally by an appropriate solution to the fiberoptic lenses.
direct vision of the ETT until it has passed the Mask insertion is identical to the technique used
Figure 6–30. The LMA CTrach. (With permission from LMA

North America).
for the LMA FastrachTM, with the head and neck attained, even after manipulation.63,64 a num-
in a neutral position. Once seated, the mask is ber of corrective maneuvers will help to attain
inflated and the patient ventilated. The CTrach or improve the view of the laryngeal inlet.65–68
viewer is then turned on and attached to the As with the LMA Fastrach TM, the “up-down”
magnetic latch connector on the mask, while (withdrawing the inflated mask 6 cm, then
firmly holding the CTrach handle. The mask is readvancing it) will often help release a down-
then manipulated as needed to attain a clear folded epiglottis.65,66,68 If only the posterior
image of the glottic opening. For intubation, cartilages are visualized, withdrawing the
while lifting vertically on the CTrach handle mask 1-cm and lifting will improve the view.65
(i.e., the Chandy maneuver, as described for The need for medial-lateral corrections of the
LMA FastrachTM intubation), the dedicated sili- mask can also be visualized on the screen.66
cone-based ETT is advanced through the cords Once a good view is attained, intubation usu-
under indirect vision. The ETT cuff is inflated, ally succeeds, and even with poor visualiza-
and tube position confirmed. The viewer is then tion, successful intubation follows in some
detached, whereupon the CTrach mask can be cases.63–65 In published series, CTrach use has
removed in identical fashion to the Fastrach, permitted visualization of the larynx and suc-
leaving the ETT in situ. cessful intubation in most patients presenting
At the time of writing, early published clini- Grade 3 or worse views at direct laryn-
cal experience with the CTrach suggests a high goscopy.63, 64, 68 Other case reports and series
rate of successful mask insertion and patient have detailed successful CTrach intubation in
ventilation, as with the LMA-Fastrach TM .63,64 very difficult situations,68 even when the LMA
Although a view of the cords is not always easily FastrachTM had failed.69
120 CHAPTER 6
The McGrath Video Laryngoscope attached 1.7-inch video screen. The screen tilts
and rotates on the handle to optimize the view-
The McGrath video laryngoscope Series 5 (LMA ing angle for the clinician. The blade is some-
North America, San Diego, CA) is an additional what adjustable in length for different patients,
example of a video-based device (Fig. 6–31). and is designed for use with a single-use
The scope features a rubberized handle with an disposable plastic sleeve. The entire unit is
portable, and operates using a single AA bat-
tery. As with the Glidescope, once the laryn-
geal inlet has been indirectly visualized, the
clinician guides a styletted tube toward and
through the cords. Early experience suggests
easy McGrath blade insertion and a good view
of the larynx, even in patients with predictors
of difficult direct laryngoscopy.70 As with the
Glidescope, tube passage to and through the
larynx can be challenging until the learning
curve is ascended.70 A similar intubation tech-
nique to that described above for the
Glidescope should be successful.
䉴 OTHER RIGID AND FLEXIBLE

FIBEROPTIC AND OPTICAL
INSTRUMENTS
Rigid Fiberoptic Devices
Other rigid fiberoptic scopes exist. Some have

attained a small but loyal following, mainly in
the OR setting, however due to expense or unfa-
vorable learning curves, as a group, they are
rarely used in out-of-OR settings. One such is
the Bullard laryngoscope (Fig. 6–32), an
L-shaped rigid fiberoptic laryngoscope. The
Bullard has a blade enabling good tongue con-
trol, and a choice of two dedicated attached
stylets to facilitate tube passage. With or without
the attached stylet, tube passage can be difficult,
however, and this fact has limited its popular-
ity over the years. The Bullard has been shown
to result in less cervical spine movement than
that caused by Macintosh or Miller laryn-
goscopy,71 although the clinical significance of
this finding is unclear. Similar J- or L-shaped
Figure 6–31. The McGrath Video laryngo- rigid fiberoptic scopes include the UpsherScope
scope Series 5. Ultra and the WuScope System.
Figure 6–32. Bullard laryngoscope.
Rigid Optical Device: The Airtraq Early manikin studies comparing the Airtraq
to Macintosh direct laryngoscopy have shown a
The Airtraq optical laryngoscope (King Sys- favorable learning curve for novice72 and inex-
tems Corp., Noblesville, IN) is a single-use, L- perienced73 clinicians. With “difficult airway”
shaped device which uses a series of mirrors to simulator features activated, tracheal intubation
deliver an image of the laryngeal inlet to a prox- has required less time and fewer attempts by
imal eyepiece (Fig. 6–33). Insertion of the experienced clinicians using the Airtraq, com-
device begins with the handle parallel to the pared to Macintosh laryngoscopy.74 In elective
patient’s chest. As the blade is advanced into surgical patients with no predictors of difficult
the oropharynx, it is rotated down and around laryngoscopy, performance of the Airtraq was
the tongue, with the clinician looking through the comparable to Macintosh DL.75 With known dif-
eyepiece to visualize airway structures. The blade ficult laryngoscopy, however, the Airtraq was
tip is placed into the vallecula and the cords successful in providing a view and enabling
centered in the viewfinder, whereupon the preintubation in a series of 8 elective surgical
loaded ETT is advanced into the trachea via a patients in whom a Cormack Lehane Grade 4
built-in tube delivery channel. The ETT is then laryngoscopy had been encountered.76
separated from the delivery channel to the side,
and while holding the tube in place, the scope Flexible Fiberoptic and Video
is rotated back out of the patient. At the time of Devices
writing, the Airtraq was available in two sizes:
“Regular,” accommodating tube sizes 7.0–8.5 mm Flexible fiberoptic or video-based broncho-
ID, and “Small Adult”, appropriate for use with scopes have been the mainstay of difficult
ETTs of size 6.0–7.5 mm ID. airway management in the OR. Most awake
122 CHAPTER 6
Figure 6–33. Airtraq optical laryngoscope (single-use).
intubations are performed with flexible fiberop- 䉴 PEDIATRIC ALTERNATIVE

tic bronchoscopes in this setting, although many INTUBATION OPTIONS
of the other techniques and devices described
in this and other chapters (including direct For those departments or environments having
laryngoscopy) can also be used on the awake care of pediatric patients in their mandate,
patient. Unfortunately, flexible fiberoptic- or when choosing equipment, consideration
videobronchoscopes are expensive to attain should be directed toward whether it is avail-
and maintain, and skills acquisition is also an able in pediatric sizes. It must be emphasized
issue, resulting in these instruments rarely being that most children without congenital dys-
used for intubation by non-anesthesia clini- morphisms can be successfully intubated
cians. Having said this, flexible fiberoptic scopes with direct laryngoscopy and can almost
can be used in various capacities, including always be easily bag-mask ventilated. How-
nasopharyngoscopic upper airway assess- ever, in the event that difficulty is encoun-
ment, or flexible fiberoptic guided intubation tered with direct laryngoscopy, the follow-
through the LMA Fastrach T M or AirQ extra- ing is a summary of the availability of
glottic devices. With time, flexible fiberoptic pediatric versions of the devices discussed
intubation may become a more commonly above:
used technique for awake intubation of the
difficult airway patient in out-of-OR locations, • LMA FastrachTM. At the time of writing, the
by non-anesthesia personnel. For more details smallest reusable or disposable Fastrach avail-
on the technique, the reader is referred to able is the adult #3, appropriate for use in
reviews77 in other publications. patients weighing 30–50 kg.
• AirQ. The smallest size is the 1.5, for use in the question of how they compare to best look
patients weighing 10–20 kg. DL (i.e., using head lift, ELM, and adjuncts such
• Trachlight. The Trachlight is available in two as the bougie). However, case reports, case
pediatric sizes (child and infant). Clinicians series, and studies of patients with actual dif-
experienced with Trachlight use in children ficult airways do suggest their utility in diffi-
have commented that, while effective, the cult situations (although often, in the hands
thin necks of the very young make it difficult of expert users). Certainly, moving on to an
to distinguish the glow of a tube correctly alternative intubation device after a best look
placed in the trachea from incorrect laryngoscopy has failed is preferable to multi-
esophageal placement. This is particularly ple futile attempts at direct laryngoscopic intu-
problematic in infants. bation. Which alternative intubation device
• Fiberoptic Stylets. The SOS is available in a or devices the clinician chooses to become
pediatric size, 27 cm in length and accepting familiar with will depend on individual or
tubes down to 2.5 mm ID. One small case institutional preference. However, no matter
series has described its successful use in four which device, the clinician must make the effort
children with various dysmorphisms.78 The to gain experience by using it in lower-acuity
Bonfils Retromolar Intubation Endoscope in or routine situations until competence and
the pediatric/ small adult size will accept tube confidence in its use are attained.
sizes from 4.0 to 5.5 mm ID, while the Bram-
brinck Intubation Endoscope (both marketed
by Karl Storz) will accept a minimum tube REFERENCES
size of 2.5 mm ID.
1. Crosby ET, Cooper RM, Douglas MJ, et al. The unan-
• Video laryngoscopes. The mid-size (mini-
ticipated difficult airway with recommendations for
mum patient weight, 10 kg) and small (patient management. Can J Anaesth. 1998;45(8):757–776.
weight, 1.5 kg) Glidescope blades are 2. Mort TC. Emergency tracheal intubation: complica-
appropriate for pediatric use. Pediatric and tions associated with repeated laryngoscopic
neonatal blades are available for use with attempts. Anesth Analg. 2004;99(2):607–613, table
the Berci-Kaplan DCI Video Laryngoscope. of contents.
• Other devices. The Bullard laryngoscope is 3. Hung OR, Pytka S, Morris I, Murphy M, Stewart RD.
available in child and neonatal blade sizes, Lightwand intubation: II—Clinical trial of a new
while flexible fiberoptic bronchoscopes are lightwand for tracheal intubation in patients
available in an array of pediatric sizes, com- with difficult airways. Can J Anaesth. 1995;42(9):
826–830.
patible with flexible fiberoptic intubation of
4. Brimacombe JR. Intubating LMA for airway intuba-
even infants. tion. Laryngeal Mask Anesthesia: Principles and
Practice. Second ed. Philadelphia: Saunders;
䉴 SUMMARY 2005:469–504.
5. Reardon RF, Martel M. The intubating laryngeal mask
Many alternative intubation devices are avail- airway: suggestions for use in the emergency depart-
ment. Acad Emerg Med. 2001;8(8):833–838.
able. They differ in their degree of history, pub-
6. Lu PP, Yang CH, Ho AC, Shyr MH. The intubating
lished evidence of their effectiveness, cost, and LMA: a comparison of insertion techniques with
whether they are blind techniques or allow conventional tracheal tubes. Can J Anaesth.
indirect vision. Most are probably similar in their 2000;47(9):849–853.
learning curve and success rates in difficult sit- 7. Joo H, Rose K. Fastrach—a new intubating laryn-
uations. Unfortunately, many clinical trials of geal mask airway: successful use in patients
these devices have been performed in compar- with difficult airways. Can J Anaesth. 1998;45(3):
ison to conventional DL, leaving unanswered 253–256.
124 CHAPTER 6
8. Kihara S, Yaguchi Y, Brimacombe J, Watanabe S, 20. Stewart RD, LaRosee A, Kaplan RM, Ilkhanipour K.
Taguchi N, Hosoya N. Intubating laryngeal mask Correct positioning of an endotracheal tube using
airway size selection: a randomized triple crossover a flexible lighted stylet. Crit Care Med. 1990;
study in paralyzed, anesthetized male and female 18(1):97–99.
adult patients. Anesth Analg. 2002;94(4):1023–1027. 21. Locker GJ, Staudinger T, Knapp S, et al. Assess-
9. Fan KH, Hung OR, Agro F. A comparative study of ment of the proper depth of endotracheal
tracheal intubation using an intubating laryn- tube placement with the Trachlight. J Clin Anesth.
geal mask (Fastrach) alone or together with a 1998;10(5):389–393.
lightwand (Trachlight). J Clin Anesth. 2000;12(8): 22. Hung OR, Tibbet JS, Cheng R, Law JA. Proper
581–585. preparation of the Trachlight and endotracheal tube
10. Martel M, Reardon RF, Cochrane J. Initial experience to facilitate intubation. Can J Anaesth. 2006;53(1):
of emergency physicians using the intubating laryn- 107–108.
geal mask airway: a case series. Acad Emerg Med. 23. Hung OR, Pytka S, Morris I, et al. Clinical trial of
2001;8(8):815–822. a new lightwand device (Trachlight) to intubate
11. Rosenblatt WH, Murphy M. The intubating laryngeal the trachea. Anesthesiology. 1995;83(3):509–514.
mask: use of a new ventilating-intubating device 24. Iwama H, Ohmori S, Kaneko T, Watanabe K.
in the emergency department. Ann Emerg Med. Ambient light requirements for successful intuba-
1999;33(2):234–238. tion with the Trachlight in adults. Anaesthesia.
12. Watson NC, Hokanson M, Maltby JR, Todesco JM. 1997;52(8):801.
The intubating laryngeal mask airway in failed 25. Hodgson RE, Gopalan PD, Burrows RC, Zuma K.
fibreoptic intubation. Can J Anaesth. 1999;46(4): Effect of cricoid pressure on the success of endo-
376–378. tracheal intubation with a lightwand. Anesthesiology.
13. Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn 2001;94(2):259–262.
I, Ovassapian A. Use of the intubating LMA-Fastrach 26. Masso E, Sabate S, Hinojosa M, Vila P, Canet J,
in 254 patients with difficult-to-manage airways. Langeron O. Lightwand tracheal intubation with
Anesthesiology. 2001;95(5):1175–1181. and without muscle relaxation. Anesthesiology.
14. Shung J, Avidan MS, Ing R, Klein DC, Pott L. Awake 2006;104(2):249–254.
intubation of the difficult airway with the 27. Agro F, Brimacombe J, Carassiti M, Morelli A,
intubating laryngeal mask airway. Anaesthesia. Giampalmo M, Cataldo R. Use of a lighted stylet
1998;53(7):645–649. for intubation via the laryngeal mask airway.
15. Frappier J, Guenoun T, Journois D, et al. Airway Can J Anaesth. 1998;45(6):556–560.
management using the intubating laryngeal mask 28. Agro F, Benumof JL, Carassiti M, Cataldo R, Gher-
airway for the morbidly obese patient. Anesth Analg. ardi S, Barzoi G. Efficacy of a combined technique
2003;96(5):1510–1515. using the Trachlight together with direct laryn-
16. Choyce A, Avidan MS, Shariff A, Del Aguila M, goscopy under simulated difficult airway conditions
Radcliffe JJ, Chan T. A comparison of the intubat- in 350 anesthetized patients. Can J Anaesth.
ing and standard laryngeal mask airways for 2002;49(5):525–526.
airway management by inexperienced personnel. 29. Wada H, Nakamura K, Nishiike S, Seki S, Tsuchida
Anaesthesia. 2001;56(4):357–360. H. [The combined use of laryngoscope and Trach-
17. Baskett PJ, Parr MJ, Nolan JP. The intubating light: another option for endotracheal intubation
laryngeal mask. Results of a multicentre trial with in patients with large epiglottic cysts]. Masui.
experience of 500 cases. Anaesthesia. 1998;53(12): 2006;55(4):468–470.
1174–1179. 30. Agro F, Brimacombe J, Marchionni L, Carassiti M,
18. Agro F, Hung OR, Cataldo R, Carassiti M, Gherardi Cataldo R. Nasal intubation with the Trachlight.
S. Lightwand intubation using the Trachlight: a Can J Anaesth. 1999;46(9):907–908.
brief review of current knowledge. Can J Anaesth. 31. Favaro R, Tordiglione P, Di Lascio F, et al. Effective
2001; 48(6):592–599. nasotracheal intubation using a modified transillumi-
19. Hung OR, Stewart RD. Lightwand intubation: I—a nation technique. Can J Anaesth. 2002;49(1):91–95.
new lightwand device. Can J Anaesth. 1995;42 32. Margolis GS, Menegazzi J, Abdlehak M, Delbridge
(9):820–825. TR. The efficacy of a standard training program for
transillumination-guided endotracheal intubation. 45. Kovacs G, Law JA, McCrossin C. A comparison of

Acad Emerg Med. 1996;3(4):371–377. a fiberoptic stylet and a bougie as adjuncts to direct
33. Wik L, Naess AC, Steen PA. Intubation with laryn- laryngoscopy in a manikin simulated difficult
goscope versus transillumination performed by airway. Ann Emerg Med. 2007 [E pub ahead of
paramedic students on manikins and cadavers. print].
Resuscitation. 1997;33(3):215–218. 46. Greenland KB, Liu G, Tan H, Edwards M, Irwin
34. Soh CR, Kong CF, Kong CS, Ip–Yam PC, Chin E, MG. Comparison of the Levitan FPS Scope and
Goh MH. Tracheal intubation by novice staff: the the single-use bougie for simulated difficult
direct vision laryngoscope or the lighted stylet intubation in anaesthetised patients. Anaesthesia.
(Trachlight)? Emerg Med J. 2002;19(4):292–294. 2007;62(5):509–515.
35. Yamamoto T, Aoyama K, Takenaka I, Kadoya T, 47. Byhahn C, Meininger D, Walcher F, Hofstetter C,
Uehara H. [Light-guided tracheal intubation using a Zwissler B. Prehospital emergency endotracheal
Trachlight: causes of difficulty and skill acquisi- intubation using the Bonfils intubation fiberscope.
tion]. Masui. 1999;48(6):672–677. Eur J Emerg Med. 2007;14(1):43–46.
36. Konishi A, Kikuchi K, Sasui M. [Cervival spine 48. Halligan M, Charters P. Learning curve for the Bon-
movement during light-guided orotracheal intuba- fils intubation fibrescope. British Journal of Anaes-
tion with lightwand stylet (Trachlight)]. Masui. thesia. 2003;90:826P.
1998;47(1):94–97. 49. Halligan M, Charters P. A clinical evaluation of
37. Turkstra TP, Craen RA, Pelz DM, Gelb AW. Cervical the Bonfils Intubation Fibrescope. Anaesthesia.
spine motion: a fluoroscopic comparison during 2003;58(11):1087–1091.
intubation with lighted stylet, GlideScope, and Mac- 50. Wahlen BM, Gercek E. Three-dimensional cervi-
intosh laryngoscope. Anesth Analg. 2005;101(3): cal spine movement during intubation using the
910–915. Macintosh and Bullard laryngoscopes, the bon-
38. Inoue Y, Koga K, Shigematsu A. A comparison of fils fibrescope and the intubating laryngeal
two tracheal intubation techniques with Trachlight mask airway. Eur J Anaesthesiol. 2004;21(11):
and Fastrach in patients with cervical spine disor- 907–913.
ders. Anesth Analg. 2002;94(3):667–671. 51. Rudolph C, Schneider JP, Wallenborn J, Schaffrani-
39. Levitan RM. Design rationale and intended use of etz L. Movement of the upper cervical spine during
a short optical stylet for routine fiberoptic aug- laryngoscopy: a comparison of the Bonfils intu-
mentation of emergency laryngoscopy. Am J Emerg bation fibrescope and the Macintosh laryngoscope.
Med. 2006;24(4):490–495. Anaesthesia. 2005;60(7):668–672.
40. Kovacs G, Law AJ, Petrie D. Awake fiberoptic intu- 52. Kaplan MB, Ward D, Hagberg CA, Berci G, Hagiike
bation using an optical stylet in an anticipated diffi- M. Seeing is believing: the importance of video laryn-
cult airway. Ann Emerg Med. 2007;49(1):81–83. goscopy in teaching and in managing the difficult
41. Shikani AH. New “seeing” stylet-scope and airway. Surg Endosc. 2006;20 Suppl 2:S479–483.
method for the management of the difficult airway. 53. Agro F, Barzoi G, Montecchia F. Tracheal intuba-
Otolaryngol Head Neck Surg. 1999;120(1):113–116. tion using a Macintosh laryngoscope or a GlideScope
42. Bein B, Worthmann F, Scholz J, et al. A comparison in 15 patients with cervical spine immobilization.
of the intubating laryngeal mask airway and the Br J Anaesth. 2003;90(5):705–706.
Bonfils intubation fibrescope in patients with pre- 54. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA.
dicted difficult airways. Anaesthesia. 2004;59(7): Early clinical experience with a new videolaryngo-
668–674. scope (GlideScope) in 728 patients. Can J Anaesth.
43. Bein B, Yan M, Tonner PH, Scholz J, Steinfath M, 2005;52(2):191–198.
Dorges V. Tracheal intubation using the Bonfils 55. Cooper RM. Complications associated with the use
intubation fibrescope after failed direct laryn- of the GlideScope videolaryngoscope. Can J Anaesth.
goscopy. Anaesthesia. 2004;59(12):1207–1209. 2007;54(1):54–57.
44. Evans A, Morris S, Petterson J, Hall JE. A compari- 56. Hsiao WT, Lin YH, Wu HS, Chen CL. Does a new
son of the Seeing Optical Stylet and the gum elas- videolaryngoscope (glidescope) provide better
tic bougie in simulated difficult tracheal intubation: glottic exposure? Acta Anaesthesiol Taiwan.
a manikin study. Anaesthesia. 2006;61(5):478–481. 2005;43(3):147–151.
126 CHAPTER 6
57. Sun DA, Warriner CB, Parsons DG, Klein R, 69. Goldman AJ, Rosenblatt WH. Use of the fibreoptic
Umedaly HS, Moult M. The GlideScope Video intubating LMA-CTrach in two patients with diffi-
Laryngoscope: randomized clinical trial in cult airways. Anaesthesia. 2006;61(6): 601–603.
200 patients. Br J Anaesth. 2005;94(3):381–384. 70. Shippey B, Ray D, McKeown D. Case series: the
58. Rai MR, Dering A, Verghese C. The Glidescope McGrath videolaryngoscope—an initial clinical
system: a clinical assessment of performance. evaluation. Can J Anaesth. 2007;54(4):307–313.
Anaesthesia. 2005;60(1):60–64. 71. Watts AD, Gelb AW, Bach DB, Pelz DM. Compari-
59. Cooper RM. The GlideScope videolaryngoscope. son of the Bullard and Macintosh laryngoscopes
Anaesthesia. 2005;60(10):1042. for endotracheal intubation of patients with a
60. Doyle DJ. Awake intubation using the GlideScope potential cervical spine injury. Anesthesiology.
video laryngoscope: initial experience in four cases. 1997;87(6):1335–1342.
Can J Anaesth. 2004;51(5):520–521. 72. Maharaj CH, Costello JF, Higgins BD, Harte BH,
61. Malik AM, Frogel JK. Anterior tonsillar pillar perfo- Laffey JG. Learning and performance of tracheal
ration during GlideScope video laryngoscopy. intubation by novice personnel: a comparison of
Anesth Analg. 2007;104(6):1610–1611; discussion the Airtraq and Macintosh laryngoscope. Anaesthesia.
1611. 2006;61(7):671–677.
62. Hsu WT, Hsu SC, Lee YL, Huang JS, Chen CL. Pen- 73. Maharaj CH, Ni Chonghaile M, Higgins BD, Harte
etrating injury of the soft palate during GlideScope BH, Laffey JG. Tracheal intubation by inexperienced
intubation. Anesth Analg. 2007;104(6): 1609–1610; medical residents using the Airtraq and Macintosh
discussion 1611. laryngoscopes—a manikin study. Am J Emerg Med.
63. Timmermann A, Russo S, Graf BM. Evaluation of 2006;24(7):769–774.
the CTrach—an intubating LMA with inte- 74. Maharaj CH, Higgins BD, Harte BH, Laffey JG.
grated fibreoptic system. Br J Anaesth. 2006;96(4): Evaluation of intubation using the Airtraq or
516–521. Macintosh laryngoscope by anaesthetists in
64. Liu EH, Goy RW, Chen FG. The LMA CTrach, a easy and simulated difficult laryngoscopy—a
new laryngeal mask airway for endotracheal intu- manikin study. Anaesthesia. 2006;61(5):469–477.
bation under vision: evaluation in 100 patients. 75. Maharaj CH, O’Croinin D, Curley G, Harte BH, Laffey
Br J Anaesth. 2006;96(3):396–400. JG. A comparison of tracheal intubation using
65. Liu EH, Goy RW, Chen FG. An evaluation of poor the Airtraq or the Macintosh laryngoscope in
LMA CTrach views with a fibreoptic laryngoscope routine airway management: a randomised, con-
and the effectiveness of corrective measures. trolled clinical trial. Anaesthesia. 2006;61(11):
Br J Anaesth. 2006;97(6):878–882. 1093–1099.
66. Dhonneur G, Ndoko SK, Yavchitz A, et al. Tracheal 76. Maharaj CH, Costello JF, McDonnell JG, Harte BH,
intubation of morbidly obese patients: LMA CTrach Laffey JG. The Airtraq as a rescue airway device
vs direct laryngoscopy. Br J Anaesth. 2006;97(5): following failed direct laryngoscopy: a case series.
742–745. Anaesthesia. 2007;62(6):598–601.
67. Timmermann A, Russo S, Natge U, Heuer J, Graf 77. Morris IR. Fibreoptic intubation. Can J Anaesth.
BM. [LMA CTrachtrade mark : initial experiences 1994;41(10):996–1007; discussion 1007–1008.
in patients with difficult-to-manage airways.]. 78. Shukry M, Hanson RD, Koveleskie JR, Ramadhyani
Anaesthesist. 2006;55(5):528–534. U. Management of the difficult pediatric airway
68. Goldman AJ, Rosenblatt WH. The LMA CTrach in with Shikani Optical Stylet. Paediatr Anaesth.
airway resuscitation: six case reports. Anaesthesia. 2005;15(4):342–345.
2006;61(10):975–977.
Chapter 7
Rescue Oxygenation
䉴 KEY POINTS 䉴 INTRODUCTION TO RESCUE

OXYGENATION
• Failed oxygenation may be defined as the
inability to tracheally intubate the patient Following a failed intubation attempt using
in conjunction with failure to maintain direct laryngoscopy or an alternative intubating
oxygen saturation above 90% with bag technique, ease of bag mask ventilation (BMV)
mask ventilation. should be assessed, and the patient reoxygenated
• Failed oxygenation implies the immediate as needed. As discussed in more detail in Chap.
need to proceed with cricothyrotomy, 12, as long as oxygenation with BMV is non-
although a brief attempt at extraglottic problematic, additional attempts at tracheal
device (EGD) placement should occur intubation can then be made. However, total
first. attempts at intubation should be limited in this
• By successfully enabling rescue oxygenation, setting, as patient morbidity and mortality climbs
EGD use will often preclude the need for a with three or more attempts.1 After three attempts
cricothyrotomy at intubation, unless a more experienced clini-
• Widespread clinical experience and a sig- cian has arrived or additional equipment is
nificant body of literature support the use obtained, oxygenation should revert to BMV or
of EGDs such as the Laryngeal Mask may proceed with the placement of an extra-
Airway or Combitube as a primary and glottic device (EGD) while plans are made for
rescue airway. definitive care. In the more ominous situation
• The LMA FastrachTM is an effective rescue where tracheal intubation has failed and the
EGD that also provides a means of facili- patient can’t be oxygenated with BMV, the so-
tating blind endotracheal intubation. called “can’t intubate/can’t oxygenate” scenario,
• Extraglottic devices will not necessarily preparations should be made to rapidly pro-
work if obstructing pathology exists at or ceed with a cricothyrotomy. However, even
below the cords. in this scenario, a quick trial of EGD placement
• As an alternative to an open surgical is usually warranted before proceeding with the
cricothyrotomy, kits are available containing cricothyrotomy, as reoxygenation of the patient
cuffed cannulae for percutaneous, needle- often results. Indeed, since their introduction,
guided insertion. EGDs have enabled rescue oxygenation in many
127
128 CHAPTER 7
failed airway situations, returning the patient to personnel,2–4 and most versions require no addi-
a “you have time” scenario whereby cricothyro- tional tools for placement. Now available in a
tomy can be avoided. Additional expertise or number of reusable and disposable formats,
equipment can then be obtained for successful the LMA consists of a plastic airway tube
oral or nasal intubation, or if tracheostomy is attached distally to a cuffed, inflatable mask.
elected, it can be performed under more con- When properly seated in the pharynx, the
trolled conditions. inflated cuff forms a seal around the laryngeal
Extraglottic devices (alternatively termed inlet, enabling ventilation from immediately
supraglottic devices), well-known examples of above the cords, while bypassing more proxi-
which include the Laryngeal Mask Airway mal sources of obstruction.
(LMA; LMA North America Inc, San Diego, CA) Relative contraindications to LMA use
and the Esophageal-Tracheal Combitube include a high risk of passive regurgitation of
(ETC; Tyco-Kendall-Sheridan, Mansfield, MA) gastric contents; the need for high airway ven-
are so-named as they enable ventilation from tilation pressures, and pathology that would
outside (i.e., above) the cords. Unlike bag mask prevent, or be aggravated by its insertion.5
ventilation, however, these devices sit distal to However, none of these conditions preclude an
where a relaxed soft palate and tongue may fall attempt at LMA use as a rescue device in an
back to obstruct the airway, and as such are more emergency, failed oxygenation situation.
likely to result in successful patient oxygenation
and ventilation. Equally, their extraglottic loca-
tion also represents a potential limitation to EGD LMA Devices: Description
effectiveness, when obstructing pathology is
present at or below the cords. Thus, while wide- LMA ClassicTM and Unique
spread availability and use of EGDs may have The original LMA was introduced in 1988 and
diminished the need for cricothyrotomy, any has now been used well over 100 million times.
clinician with airway management responsibili- It remains in widespread use in its reusable for-
ties should still be prepared to rapidly perform mat, the LMA ClassicTM (Fig. 7–1), and a more
a cricothyrotomy to access the airway below the recently introduced disposable version, the LMA
cords. Unique. Both versions are latex-free and consist
This chapter will describe equipment and of a large-bore airway tube with proximal stan-
techniques for rescue oxygenation using dard 15-mm connector, and a bowl-shaped dis-
EGDs and cricothyrotomy. More information tal cuff which is inflated via a valve on an infla-
on decision-making about when to use these tion line. With the opening of its lumen facing
techniques appears in Chap. 12. the laryngeal inlet, the mask conforms to the
shape of the pharynx. Both the LMA ClassicTM
and Unique are available in a full range of sizes,
䉴 THE LARYNGEAL MASK AIRWAY from neonatal to large adult.
(LMA)
LMA ProSeal
Available for clinical use since the late 1980s, The LMA ProSeal (Fig. 7–2) was introduced in
the LMA has an established place as a device 2000. This version of the LMA includes a drain
to provide a hands-free airway in routine oper- tube, which originates from an orifice in the
ating room (OR) cases. It has also been suc- distal tip of the mask cuff and travels proxi-
cessfully used on many occasions in airway mally alongside the airway lumen. The drain
emergencies, both in and out of the OR. It is tube is designed to accept a catheter which can
reasonably easy to insert, even by unskilled be used for suctioning esophageal contents.
RESCUE OXYGENATION 129
Figure 7–1. The LMA Classic.
The cuff of the LMA ProSeal has also under- block has also been added. With its improved
gone modifications, including the addition of a seal and provision for gastric tube placement,
posterior component (only in the adult sizes) to the ProSeal offers more protection of the airway
better conform to the shape of the pharynx. against aspiration of gastric contents, and allows
These cuff modifications allow for an airway ventilation at higher airway pressures, perhaps
seal pressure up to 10 cm H2O higher than that making it a better choice than the LMA Clas-
of the LMA ClassicTM.5 A built-in proximal bite sicTM or Unique for use in emergencies.
Figure 7–2. The LMA ProSeal.

130 CHAPTER 7
LMA Supreme LMA Devices: Preparation for Use

The single-use LMA Supreme (Fig. 7–3) is a
recent addition to the LMA family. It features an In general, the largest-sized LMA compatible
L-shaped airway tube, a modified cuff to enable with insertion should be selected. Studies in
ventilation at higher airway pressures, a second adults indicate that the use of larger sizes sig-
lumen for esophageal drainage, and a proximal nificantly improves seal efficacy with no
bite block. At the time of writing, no published increased insertion difficulty. 5 As a general
literature was available on this device. However, rule, a size 5 mask should be chosen for an
designed for easy insertion (L-shaped tube), airway average adult male, and size 4 for an average
protection (presence of esophageal drainage adult female. Appropriate pediatric sizing can
lumen), and ventilation at higher airway pres- be estimated by patient weight. The classicTM
sures (cuff design), this device has the potential insertion technique recommended by the
to become a good choice of single-use EGD for manufacturer is to insert the mask with the
the emergency patient. cuff fully deflated (Fig. 7–4). For cuff defla-
tion, while aspirating air via a syringe attached
LMA FastrachTM and CTrach to the inflation line, the mask should be
The L-shaped LMA FastrachTM and its similarly pressed down against a flat surface, as this
shaped video-based sibling, the LMA CTrach, will help maintain the appropriate cuff shape.
were designed to enable blind or video-aided Prior to insertion, the posterior surface of the
intubation, respectively. However, both are also mask should be lubricated with a water-soluble
effective as rescue oxygenation and ventilation lubricant. The LMA ProSeal is supplied with
devices, with a high first attempt insertion and an L-shaped insertion tool: if this is used, the
successful ventilation rate. The LMA FastrachTM distal end of the tool should be introduced
has been shown to have an oropharyngeal leak into the strap at the junction of cuff and tube.
pressure 5–10 cm H2O higher than the LMA The airway and drain tubes are then bent
ClassicTM.5 As they were designed to also facili- around its convex surface, and proximally,
tate intubation, these devices have been dis- the airway tube is snapped into a matching
cussed in more detail in Chap. 6. slot5 (Fig. 7–5).
Figure 7–3. The LMA Supreme.

the operator’s forefinger at the junction of the

tube with the inflatable cuff. Once the tip of the
inserting forefinger has passed the upper teeth,
pushing cephalad on the mask with this digit
(Figs. 7–6 to 7–8) during further advancement
will encourage the LMA to take on the curve of
the hard palate, increasing the ease of negotiat-
ing the turn down into the pharynx. The LMA is
then advanced gently until resistance is encoun-
tered. Once placed, the LMA cuff is inflated using
the recommended cuff volume printed on the
side of the LMA barrel, or simply using the cuff
volume formula “(LMA size–1) × 10.” Note that
some authorities prefer to initially inflate the cuff
with only 2/3 of this recommended volume, with
additional inflation used only to overcome a poor
Figure 7–4. The LMA is prepared for use by seal.5 However, for use in emergency, failed
fully deflating the cuff of air while pressing the airway situations, the full recommended vol-
mask against a flat surface. ume should be used primarily. The proximal
connector of the LMA is attached to a manual
resuscitator, and ventilation attempted: appropri-
LMA Devices: Insertion Techniques ate chest rise and bag compliance with positive
pressure ventilation suggest correct placement.
LMA ClassicTM and Unique Many modified insertion techniques have
To ease LMA placement, the head should be been suggested for the LMA ClassicTM, reflecting
extended, when not contraindicated. Through an the fact that placement does not always succeed
opened mouth, the mask is inserted midline, with on the first attempt. One study found similar
Figure 7–5. An L-shaped insertion tool can be used to facilitate correct placement of the LMA
ProSeal.
132 CHAPTER 7
Figure 7–8. Once in place, the LMA cuff is

inflated (With permission, LMA North America).
LMA Supreme
The LMA Supreme can be inserted without intra-
Figure 7–6. LMA Classic insertion begins by
oral finger use. Held at its proximal end, while
inserting the mask tip behind the upper teeth
(With permission, LMA North America). applying a jaw lift, it is simply rotated into the
patient, down and around the tongue, following
the curve of the hard palate.
success rates when placing the single-use LMA
Unique with or without intraoral finger use.6 In LMA ProSeal
general, however, the manufacturer’s recom- A few insertion techniques have been described
mended technique for the LMA ClassicTM and for the LMA ProSeal:
Unique is the most reliable and should be used
for the initial insertion attempt. • Mask insertion with intraoral finger use, iden-
tical to that described above for the LMA
ClassicTM;
• Insertion with the supplied rigid insertion tool.
When the ProSeal is loaded on the insertion
tool, it can be inserted in similar fashion to the
LMA FastrachTM or CTrach (see next section);
• Bougie-guided: the non-coudé-tip end of a
bougie is passed through the drainage tube
of the LMA ProSeal. Laryngoscopy is per-
formed, and the bougie is passed deliberately
into the upper esophagus. The bougie then
acts as a guide during subsequent ProSeal
insertion, to help correctly situate its tip in the
upper esophagus
Figure 7–7. As the LMA is advanced, the LMA FastrachTM and CTrach
index finger pushes the mask cephalad Both these devices, as well as the ProSeal
against the hard palate (With permission, LMA when using the rigid insertion tool, can be
North America). inserted while holding the external guiding
handle. A jaw lift is performed, the mask tip is scenario, one analysis of 21 case reports5 and a
inserted behind the upper teeth, whereupon the descriptive study of 17 cases7 reported success
mask is rotated down into the pharynx, follow- in establishing ventilation using the LMA in 92%
ing and maintaining pressure against the palate. and 94% of cases, respectively. Similar efficacy
Cricoid pressure impedes successful place- of LMA devices in the difficult airway has been
ment of an LMA,5 and should be at least tran- reported in the pediatric population.5
siently released during LMA placement. After
the LMA is correctly situated, cricoid pressure SKILLS ACQUISITION
can be reapplied, but should only be maintained Good success rates have been achieved by
if it does not impede ventilation. novices with LMA placement in human patients
after appropriate manikin training.6 However,
LMA Devices: Troubleshooting as common sense would suggest, there is evi-
dence that with more experience, success rates
Difficulty is occasionally encountered in negoti- increase.5
ating the turn into the pharynx, particularly with
attempted LMA ClassicTM placement. The fol- C-SPINE PRECAUTIONS
lowing strategies can be used in response: In a study of various airway devices using a
cadaver with a posteriorly destabilized C3 ver-
• Lateral approach: Advancing the LMA from tebra, LMA ClassicTM insertion and LMA FastrachTM
the side of the oral cavity, aiming toward the insertion with subsequent intubation resulted in
midline, sometimes results in successful movement comparable to both laryngoscopic
passage into the pharynx; intubation and facemask ventilation.8 LMA inser-
• Cuff partially inflated: Partially inflating the tion would also be expected to be more difficult
cuff may result in a softer leading edge to the in situations where head extension is con-
advancing LMA, potentially helping naviga- traindicated. Some movement of the intact upper
tion “around the corner” into the pharynx;5 C-spine has been shown with LMA FastrachTM
• Laryngoscope-aided: If difficulty is still insertion and intubation8,9 although this is of
encountered, use of the direct laryngoscope uncertain clinical significance and does not pre-
to control soft tissues enables the LMA to be clude use of this or other EGD for rescue oxy-
directly placed into the pharynx. genation, if other techniques have failed.
LMA Devices: Clinical Effectiveness

䉴 THE ESOPHAGEAL-TRACHEAL
ROUTINE AND DIFFICULT AIRWAY COMBITUBE (ETC)
MANAGEMENT
Data for the LMA ClassicTM derived largely from The Combitube (Fig. 7–9) is another EGD with
an OR population, using the standard insertion an extensive history of use, primarily in the pre-
technique, suggests first-attempt and overall hospital resuscitation setting. It has also been
success rates of 87% and 98%, respectively. In used in-hospital as a rescue ventilation device,
the difficult airway population, ease of LMA both in and out of the OR. As with the LMA, it
insertion is independent of both Mallampati and is easily used by inexperienced personnel. Its
Cormack-Lehane scoring.5 Both the LMA Clas- strength lies in the ability to achieve patient ven-
sicTM and LMA FastrachTM have high success rates tilation irrespective of its location: esophagus or
in achieving ventilation in patients with predicted trachea. The Combitube may be placed blindly
and unanticipated difficult airways, including or using a laryngoscope for soft tissue control.
patients who could not be intubated, or could With blind placement, esophageal placement of
not be intubated or ventilated.5 In this latter the Combitube will occur in over 90% of cases.5
134 CHAPTER 7
Figure 7–9. The Esophageal-Tracheal Combitube (ETC).
The ETC is available in two sizes, the Com- upper esophagus, and the more proximal and
bitube (41 French) and the Combitube SA larger pharyngeal cuff seals the oro- and
(37 French). Manufacturer recommendations nasopharynx. Applied ventilation through the
are for use of the larger Combitube in patients blind-ending esophageal lumen (labeled No. 1
over 5 ft (152 cm), although a number of authors and blue in color) exits through multiple fenes-
have observed that the smaller Combitube SA trations between the inflated distal and proxi-
works well in patients from 4–6 ft (122–183 cm) mal cuffs and travels through the cords into the
in height.10,11 At the time of writing, there was trachea (Fig. 7–10). With tracheal placement,
no pediatric version. ventilation would occur distally, through the
As with other blind techniques, Combitube other lumen (labeled No. 2, Fig. 7–11) as with a
use may be relatively contraindicated in the pres- regular endotracheal tube.
ence of airway pathology. Reports of esophageal When situated in the esophagus, the inflated
perforation with its use exist,12, 13 possibly in distal cuff helps protect the hypopharynx from
the context of an excessive volume of air gastric contents,11 and the open tracheal lumen
having been injected into the distal, esophageal can be suctioned for liquid matter. Equally, the
cuff. Finally, it is important to recognize that as more proximal pharyngeal cuff also provides
with the LMA, the Combitube ventilates from an reasonable protection from tracheal soiling by
extraglottic position when located in the esoph- oral cavity contents (e.g., blood).14 Oropharyn-
agus, so will not necessarily work if obstructing geal leak pressure is 25–40 cm H2O.
pathology exists at or below the cords.
Combitube Preparation for Use
Combitube Description
The device is removed from its packaging and
Designed for blind insertion, the Combitube both cuffs are checked, then fully deflated. Some
consists of a double-lumened tube, with a distal clinicians elect to bend the Combitube anteriorly
and more proximal cuff. With the more likely to 90° or more for a few seconds prior to
esophageal placement, the distal cuff seals the insertion, (the “Lipp maneuver”) to augment
Figure 7–10. Ventilation pathway when the Figure 7–11. Ventilation is through lumen
Combitube is located in the esophagus, No. 2 when the Combitube is located in the
through lumen No. 1. trachea.
the curve and help it to better conform to the

shape of the oropharyngeal curve.
Combitube Insertion
The Combitube is ideally inserted in conjunction

with direct laryngoscopy (Fig. 7–12), to help
control the tongue and improve the angle of
insertion. However, for blind placement, slight
head extension and a jaw lift will help (Fig. 7–13).
The Combitube is advanced gently through the
mouth in a curved, downward motion. Once in
the posterior pharynx, further advancement
should ideally be with the distal end of the device
parallel to the patient’s anterior chest wall, and
not angled further posteriorly. Once inserted,
two transverse lines appearing proximally on the
Combitube should be adjacent to the upper
teeth or alveolar ridges. During emergency use,
once placed, the two cuffs are inflated: first the
proximal (pharyngeal) occluding cuff (Com-
bitube SA 85 mL; Combitube 100 mL) using the
blue pilot balloon (labeled “No. 1”). The distal
(esophageal) cuff is then inflated (Combitube Figure 7–12. A laryngoscope may help with
SA 5–12 mL; Combitube 5–15 mL) using the Combitube placement.
136 CHAPTER 7
case, the Combitube will act as a regular ETT,

and the proximal cuff can be deflated.
Combitube Troubleshooting
If suboptimal ventilation is obtained through

both lumens, most often the Combitube is
located too far distally, and the pharyngeal cuff
is occluding the laryngeal inlet. In this situa-
tion, the Combitube should be pulled back in
small (1 cm) increments, up to a total of 3 cm,
until ventilation succeeds through the blue,
esophageal lumen.
Combitube Clinical Effectiveness
ROUTINE AND DIFFICULT AIRWAY

MANAGEMENT
Published success rates for Combitube inser-
tion and ventilation are 97–99% for in-hospital
populations.5 Slightly higher success rates in
the surgical population occur with laryngoscope-
Figures 7–13. A jaw lift and head extension
guided placement. In the prehospital setting,
are performed to aid blind Combitube insertion. rescue ventilation with the Combitube fol-
lowing failed laryngoscopic intubation has
been reported to be successful in 75–100% of
white pilot balloon (labeled “No. 2”). Particu-
cases.15–18
larly for the distal cuff, overinflation should be
avoided, as esophageal rupture can otherwise
C-SPINE PRECAUTIONS
occur.12 Once a seal has been achieved and
Combitube insertion has been shown to have a
the correct lumen identified, many clinicians
lower success rate in patients wearing a rigid cer-
remove air from the proximal cuff until the
vical collar19 although most failures could be cor-
“minimum leak” volume is found, to help avoid
rected using adjunctive laryngoscopy. However,
danger of mucosal damage.
once placed, the presence of a C-collar does not
Ventilation through the Combitube should
impede ventilation through a Combitube.20 In a
first be attempted through the blue lumen,
cadaver model with a destabilized C3 segment,
labeled “No. 1”, which will allow ventilation from
Combitube insertion caused movement compa-
an esophageal location. End-tidal CO2 detection
rable to oral intubation with direct laryngoscopy,
will help confirm the correct lumen, as will the
and exceeded that caused by LMA FastrachTM
clinical signs of chest rise, breath sounds with
intubation or LMA ClassicTM placement.8
positive pressure, and manual resuscitator bag
compliance. If this is judged not to be the correct
lumen, ventilation should be attempted through 䉴 NEWER EXTRAGLOTTIC DEVICES
the other, clear lumen (labeled “No. 2”). This
will be the correct lumen on the rare occasion In recent years, numerous new extraglottic
that tracheal placement has occurred. In this devices have been introduced. Many, but not
all, are single-use items. Some have more is deflated, and, holding the device proximally,
accompanying narrative in the literature than the tip is inserted behind the upper teeth. Fol-
others, however early experience looks promis- lowing the hard and soft palate, it is then rotated
ing for many in terms of ease of insertion and down into the pharynx. The Aura extraglottic
effectiveness. As many hospitals are trending airways are available in adult and pediatric
toward the use of disposable equipment, the (Table 7–1) sizes. Early data suggests a good
clinician should be prepared to be presented first attempt success rate, and an oropharyngeal
with an unfamiliar device from time to time! leak pressure of 18–25 cm H2O.24,25
The disposable Portex Soft-Seal laryngeal The King Laryngeal Tube (LT; King Sys-
mask (Smiths Medical, Inc., St. Paul, MN) is tems Corporation, Noblesville, IN, Fig. 7–16)
similar in shape to the LMA Unique, but with a consists of an airway tube with two cuffs: one
blunter distal cuff, a deeper bowl, wider airway distal, to seal the esophagus, and one proximal
tube, and no mask aperture bars.21 Compared midway up the tube, to seal the oro- and
to the LMA Unique or ClassicTM, the Soft-Seal nasopharynx. Between the two cuffs are multi-
has similar reported insertion success rates, ple ventilation apertures. As with the Com-
oropharyngeal leak pressure,22,23 and ease of bitube, ventilation emerges from these apertures,
ventilation.24 The Soft-Seal (Fig. 7–14) is avail- between the proximal pharyngeal and distal
able in adult and pediatric sizes. esophageal cuffs. Unlike the Combitube, infla-
Ambu (Ambu Inc., Glen Burnie, MD) also tion of both cuffs occurs through a single pilot
markets an extraglottic airway in both reusable line. The LT is available in adult and pediatric
(the Aura40) and disposable (the AuraOnce) sizes, in reusable (LT) and disposable (LT-D)
formats (Fig. 7–15). It differs from the LMA versions. A disposable version with a separate
ClassicTM/Unique and Portex Soft-Seal in having gastric drainage channel (LTS-D) is also avail-
a premolded L-shaped airway tube proximal to able. Insertion is begun with the head and neck
the distal cuff. The cuff is manufactured from a in the ‘sniffing’ position, with concomitant
soft material and has a reinforced tip to resist jaw lift. The lubricated LT is inserted through
bending during insertion. For insertion, the cuff the mouth and advanced behind the base of
Figure 7–14. The Portex Soft Seal laryngeal.

Figure 7–15. The Ambu AuraOnce.
䉴 TABLE 7–1 SAMPLE PEDIATRIC OPTIONS OF EXTRAGLOTTIC DEVICE (EGD)
Device Mask Size(s) Patient Size Guidelines

TM
LMA Classic and LMA Unique 1 Neonates/infants up to 5 kg
11/2 Infants 5–10 kg
2 Infants/children 10–20 kg
21/2 Children 20–30 kg
3 Children 30–50 kg
LMA ProSeal 11/2 Infants 5–10 kg
21/2 Children 20–30 kg
LMA Fastrach™ 3 Children 30–50 kg
AirQ 1.5 Children 10–20 kg
2.5 Children 20–50 kg
Ambu Aura40 and AuraOnce 1 <5 kg
11/2 5–10 kg
2 10–20 kg
21/2 20–30 kg
3 30–50 kg
Portex Soft-Seal Laryngeal Mask 1 Neonates/infants up to 5 kg
1.5 Infants 5–10 kg
2 Infants/children10–20 kg
2.5 Children 20–30 kg
Combitube SA 4–6 ft, 122–186 cm in height
King LT, LT-D, and LTS-D 0 Newborn, <5 kg
1 Infants, 5–12 kg
2 Children, 12–25 kg
3 Small adult, 122–155 cm
138
Figure 7–16. The King LTS-D.
the tongue. It is advanced until (a) resistance is operating rooms increases the opportunity for
encountered, or (b) the connector base is obtaining experience in the nonemergency
aligned with teeth or gums. The cuffs are then setting.
inflated (Size 3–45 to 60 mL; size 4–60 to 80 mL;
size 5–70 to 90 mL). A self-inflating manual
resuscitator is attached, and if necessary, the LT 䉴 CRICOTHYROTOMY
can be slowly withdrawn until easy ventilation
is achieved. Studies of ease and success of inser- Rarely, access to the airway below the vocal
tion have been favorable, with a quoted suc- cords will be necessary as the primary approach
cess rate of 97%–100%.26 Comparison studies to obtaining an airway. More commonly,
with the LMA ClassicTM have generally shown cricothyrotomy follows the failure of attempts
equivalent efficacy.26 to secure the airway from above the cords, cou-
Other EGDs continue to be introduced, for pled with an inability to oxygenate the patient
example, the cuffed Cobra Perilaryngeal by bag-mask ventilation or EGD: the failed oxy-
Airway (Engineered Medical Systems Inc, genation (can’t intubate, can’t oxygenate) sit-
Indianapolis, IN) and the cuffless SLIPA (Slipa uation. In most cases, emergency access is
Medical Ltd, London, UK) and I-gel (Intersur- obtained through the cricothyroid membrane,
gical Ltd., Wokingham, UK) airways. Indeed, as this location is generally easy to locate by
it is probably safe to say that each passing external palpation, and may be less vascular
year will see additional devices come to market. than more distal locations. Needle; percuta-
While some may have a price advantage over neous needle-guided cannula, and open surgical
more traditional extraglottic devices, it must cricothyrotomy have been used, with varying
be said that the burden of proof lies on the success.
new devices to have their safety and efficacy All clinicians with airway management
demonstrated before their routine use can responsibilities must be prepared with the will,
be espoused over EGDs with a long his- the knowledge, and the equipment to perform
tory of safe use. In addition, using an EGD a cricothyrotomy in a can’t intubate/can’t oxy-
that is in common use in an institution’s genate situation.
140 CHAPTER 7
Needle Cricothyrotomy commonly available in out-of-OR settings. For

these and other reasons, including a lack of air-
Needle cricothyrotomy is a technique with sig- way protection against aspiration of gastric con-
nificant limitations to its effectiveness and safety, tents and catheter kinking or dislodgement, many
and at least in the adult population, is falling out authorities now consider needle cricothyrotomy
of favor. Most often performed with a large-bore to be the least desirable option for infraglottic
intravenous or similar purpose-made catheter, rescue oxygenation in the adult patient.27, 28 More
ventilation and oxygenation is attempted either detailed description of adult techniques will thus
via intermittent application of low-flow oxygen be limited to percutaneous needle-guided can-
(at 15 L/min) or by jet ventilation at pressures of nula and open surgical cricothyrotomy.
45–50 lb/in2.27 However, bench and animal
research suggests that ventilation (although
admittedly less important than oxygenation) may Percutaneous Needle-Guided
be ineffectual with low-flow oxygen via this Cannula Cricothyrotomy
route, particularly in the face of complete
proximal airway obstruction.27 Conversely, use Commercial kits are now available containing
of jet ventilation, while more effective in achieving equipment for needle-guided placement of a
good ventilation, has a substantial risk of wide-bore cuffed cannula via the cricothyroid
barotrauma. In addition, jet ventilators are not membrane (Fig. 7–17). Many of these kits originally
Introducer needle
Scalpel Syringe
18 gage appropriate length
TFE catheter introducer needle

18 gage appropriate length
Amplatz extra stiff wire guide

0.038 inch diameter stainless steel, appropriate length with flexible tip
Curved dilator
Radiopaque appropriate size and length
Deflated Inflated
airway catheter airway catheter
polyvinylchloride
On end view
Set consists of items shown above and cloth tracheostomy tape strip for fixation of airway catheter.
Figure 7–17. Contents of the Melker Emergency Cricothyrotomy Catheter Set. (Cook Critical
Care, Bloomington, IN)
contained uncuffed cannulae of varying caliber, assembly is “railroaded” over the wire into the
introducing the possibility of resultant inade- trachea. Note that during this process, the outer
quate ventilation.29 The preferred cuffed can- cannula must be held tightly onto the inner dila-
nula allows the airway to be secured and pro- tor (Fig. 7–22), as the dilator will otherwise back
tected against aspiration of gastric contents and away from the cannula, causing difficulty in pas-
permits adequate ventilation in the face of sage of the blunt end of the cannula. Once the
decreased pulmonary compliance, even with an cannula is seated in the trachea, the dilator and
airway patent from above. Examples of such kits wire are removed together. The cuff is inflated
are the Melker Emergency Cricothyrotomy with 8–10 mL of air (Fig. 7–23), and the cannula’s
Catheter Set (Cook Medical, Inc., Bloomington, connector is attached directly to a manual resus-
IN) and the PCK – Portex® Cricothyroidotomy citator device. False passage can occur, so usual
Kit (PCK, Smiths Medical Inc., St. Paul, MN). objective means of confirming endotracheal
The Melker uses a familiar Seldinger over-the-wire placement must be sought, with CO2 monitoring
placement technique, while the PCK uses Veress as the gold standard.
needle technology to indicate successful airway The cuffed Melker cricothyrotomy cannula
access. has an inner diameter (ID) of 5.5 mm. Use of
the older uncuffed Melker cannulae, particu-
larly in the patient with decreased lung or chest
Needle-Guided Cricothyrotomy
wall compliance, may result in applied positive
Technique: Melker
pressure preferentially exiting the mouth and
The patient is ideally placed with the head and
nose. The obvious solution is exclusive use of
neck in the extended position, to help with
anatomy identification and access. The cricothy- the cuffed version, however faced with the fore-
roid membrane is palpated and the area is going situation, squeezing the nostrils, holding
the mouth firmly closed during ventilation, or
prepped. In an obese neck where landmark
packing the hypopharynx with moist gauze
identification is difficult, a small midline vertical
have all been described as temporizing solu-
incision can be made to better identify the mem-
tions,29 together with rapid conversion to open
brane, and indeed, some espouse routine place-
ment of a small vertical skin nick over the cricothyrotomy or formal tracheostomy. Both
cricothyroid membrane prior to needle inser- latter options permit a cuffed tube to be placed.
tion. A catheter/introducer needle attached to a Mastering the Melker can easily be done in
syringe is advanced through the cricothyroid a manikin-type setting. The learning curve flat-
membrane in a caudad direction, with continuous tens after five insertions in manikins, with no
aspiration (Fig. 7–18). Tracheal entry will be sug- further accuracy or shortening of placement time
gested by free aspiration of air into the syringe. (about 40 seconds) attained after this.30 Effec-
The catheter is then advanced off the introducer tiveness of skills transfer from a manikin to the
needle into the trachea, and the needle is human in an emergency setting is unknown.
removed (Fig. 7–19). Through the catheter, a
wire is advanced several centimeters into the Needle-Guided Cricothyrotomy
trachea. Note that the supplied wire has a stiff Technique: PCK
and a supple end: the nontraumatic supple end The PCK device is packaged assembled, with a
should be advanced into the patient. The Veress needle and ensleeved dilator placed
catheter is removed, leaving only the wire in the through the cuffed 6-mm ID cannula. For use,
trachea (Fig. 7–20). If not already done, a small after identification of the cricothyroid mem-
vertical incision is now made with a scalpel blade brane, the manufacturer recommends making a
in the skin alongside the entry point of the wire 2-cm horizontal incision through the overlying
(Fig. 7–21). Subsequently, the dilator/cannula skin. The cricothyroid membrane is reidentified
Figure 7–18. The catheter introducer needle/
syringe assembly is advanced through the Figure 7–20. The pliable end of the supplied
cricothyroid membrane. Tracheal access is wire is passed through the catheter into the
indicated by free aspiration of air. trachea, after which the catheter is removed
over the wire.
Figure 7–19. Once tracheal access is Figure 7–21. If not already done, a small
achieved, the catheter is advanced off the incision is made along the wire through the
needle into the trachea. cricothyroid membrane.
142
by palpation in the wound. From an initial

position above and perpendicular to the
cricothyroid membrane, the needle tip of the
cannula/dilator/needle assembly is advanced
posteriorly through the cricothyroid membrane.
As long as the needle tip remains in contact
with tissue, a red indicator will be visible in the
needle hub (Fig. 7–24). Once the red indicator
flag disappears, indicating tracheal entry, the
assembly is carefully advanced further until con-
tact with the posterior aspect of the cricoid ring
is signaled by reappearance of the indicator. At
that point, the assembly is angled caudad and
advanced 1–2 cm. The needle is then removed,
and the outer cannula is advanced off the dilator.
Once the cannula is fully advanced, the dilator
is removed, the cuff is inflated, and positioning
is verified in the usual fashion.
Figure 7–22. Holding the cannula and

curved dilator together, the assembly is
passed caudad over the wire, through the
cricothyroid membrane.
Figure 7–24. The PCK needle cricothyro-

tomy device. As long as the needle tip remains
in contact with tissue, a red indicator will be
Figure 7–23. The cuff is inflated, and can- visible in the needle hub. With entry into the
nula position in the trachea is confirmed with free lumen of the trachea, the red indicator
the usual objective criteria. disappears.
144 CHAPTER 7
䉴 OPEN (SURGICAL) A 3-cm vertical midline incision is made over

CRICOTHYROTOMY the cricothyroid membrane, using a number 11
blade (Fig. 7–27). The cricothyroid membrane is
For those familiar with the anatomy and then reidentified by palpation in the wound,
skilled in the procedure, an open cricothyro- again with the index finger (Fig. 7–28). A transverse
tomy offers the benefit of placement of a incision is then made through the cricothyroid
cuffed endotracheal or tracheostomy tube. It membrane (Fig. 7–29). Once incised, a tracheal
can be done quickly, with only a few instru- hook is inserted and positioned superiorly to
ments (Fig. 7–25). A tray with the needed stabilize the thyroid cartilage, and is handed off
sterilized surgical equipment should be avail- to an assistant (Fig. 7–30), who provides upward
able and stored with other airway equipment. traction. A Trousseau tracheal dilator can then
Commercially available kits containing equip- be inserted into the incision with its arms
ment for both percutaneous needle-guided opened inferiorly and superiorly to enlarge the
and open surgical approaches are now in the vertical opening in the cricothyroid membrane
market.31 (Figure 7–31). The chosen cannula (e.g., Shiley
In the classical open surgical approach, the #4 trachesostomy cannula or #6.0 mm ID ETT) is
clinician stands beside the patient, face to face, then placed between the arms of the dilator
at the level of the shoulders. The patient’s head (Fig. 7–32), whereupon the dilator/cannula
and neck should be extended. To proceed, the (or ETT) complex is rotated counterclockwise
fingers of the clinician’s nondominant hand are 90° down and into the trachea, all in one move-
placed on the thyroid cartilage. The long finger ment (Fig. 7–33). The Trousseau dilator is then
and thumb of this hand remain on the thyroid removed, and the cannula or ETT cuff is inflated.
cartilage, while the index finger palpates the An ETT can now be connected directly to a stan-
cricothyroid membrane (Fig. 7–26) dard manual resuscitator device and intratracheal
Figure 7–25. Equipment required for an open cricothyrotomy. From left to right: a scalpel han-
dle, # 11 blade, tracheal hook, Trousseau dilator, #4 Shiley tracheostomy tube, 10-cc syringe.
Figure 7–28. The index finger re-palpates

the cricothyroid membrane within the
wound.
Figure 7–26. With thumb and long finger
stabilizing the thyroid cartilage, the index
finger palpates the cricothyroid membrane. Early complications of cricothyrotomy
include bleeding, incorrect or unsuccessful
tube placement, cricoid cartilage fracture,
obstruction and subcutaneous emphysema.
position confirmed in the usual fashion. A Shiley Rarely, laryngeal, esophageal, or mediastinal
tracheostomy tube will have to have its inner injury can occur. Pneumothorax, pneumome-
dilator removed and replaced with the inner diastinum, and aspiration are also infrequent
cannula. Once tracheal placement has been complications. After the situation has stabilized,
confirmed, the tracheal hook is removed, and a cricothyrotomy should be replaced either by
the cannula or ETT is secured. intubation from above, or by conversion to a
formal tracheostomy. This will help minimize
Figure 7–27. A 3-cm vertical incision is made Figure 7–29. A horizontal incision is then
over the cricothyroid membrane. made in the cricothyroid membrane.
146 CHAPTER 7
Figure 7–32. A #4 tracheostomy tube is

Figure 7–30. A tracheal hook picks up
placed between the arms of the Trousseau
and stabilizes the inferior border of the
dilator, into the cricothyrotomy opening.
thyroid cartilage, and is passed off to an
assistant.
bation has failed and difficulty is encountered in

vocal cord morbidity or the occurrence of sub-
maintaining oxygen saturation with BMV, rescue
glottic stenosis at the level of the cricoid ring.
oxygenation can be achieved with both extra-
glottic devices as well as via transtracheal access.
䉴 PEDIATRIC OPTIONS FOR RESCUE
OXYGENATION
Extraglottic Device Use in the
Pediatric Patient
At the outset, it must be said that a failed oxy-
genation situation is very unusual in the pediatric
Most of the extraglottic devices on the market
population, due in no small measure to the fact
are available in pediatric sizes. Some are avail-
that this population is almost always easy to bag-
able in a full array of sizes while others are
mask ventilate. However, as in the adult, if intu-
Figure 7–33. The Trousseau dilator and tube

Figure 7–31. A Trousseau dilator is placed in are rotated 90° counter-clockwise, and the
the cricothyrotomy, and is used to enlarge cannula is concurrently advanced down the
the opening, vertically. trachea.
suitable for use only in larger children (Table 7-1). tomy Kit, Smiths Medical, St. Paul MN) is avail-
As with adults, case reports attest to success- able with uncuffed cannulae in sizes of 3, 4,
ful ventilation achieved by EGD use after BMV and 5 mm ID.
had failed.5
Pediatric Cricothyrotomy 䉴 PREDICTING DIFFICULT RESCUE

OXYGENATION
Cricothyrotomy is not performed in children
under the age of eight. In this age group, there As is the case with predictors of difficult
is no developed space between the cricoid ring bag-mask ventilation and difficult laryngo-
and the thyroid cartilage. In addition, signifi- scopic intubation, the clinician should evaluate
cant narrowing occurs at the level of the cricoid whether rescue oxygenation via EGD or
ring, which could impede cannula passage in cricothyrotomy is predicted to succeed. This
an emergency. Thirdly, as the cricoid ring is nec- is of particular importance when a rapid-
essary to help maintain patency of an otherwise sequence intubation (RSI) is contemplated in
substantially membranous trachea, its fracture
during attempted cricothyrotomy could jeopar-
dize subsequent airway patency. For these
reasons, if trans-tracheal access is required in an
emergency in the patient under 8, it should be
obtained below the cricoid ring.
In keeping with the rare nature of the event,
there is very little literature on emergency
cricothyrotomy or tracheotomy in children.
Most clinicians would avoid an open surgical
technique in a pediatric emergency owing to
poor landmarks and the vascularity of the area.
Two other options exist:
• Needle cricothyrotomy or tracheotomy
with ventilation through an attached pedi-
atric-sized manual resuscitator. A large-bore
IV catheter can be used to access the trachea,
and is connected to the manual resuscitator
in one of two ways: (a) insertion of the con-
nector of a 3.0 mm ID ETT into the IV catheter
hub or (b) attaching the barrel of a 3 cc
syringe, then pushing the connector of a 7.0
mm ID ETT into the end of the syringe barrel
(Figure 7–34). Both options then permit
attachment of a manual resuscitator via the
15-mm ETT connector. Manual ventilation
ensues with 100% oxygen. The chest must
be observed for deflation between ventila- Figure 7–34. Needle cricothyrotomy set-up
tions, to avoid the risk of barotrauma. using a large-bore IV, the barrel of a 3-cc
• A pediatric cricothyrotomy kit (e.g., the syringe attached to the connector of a 7.0 ETT.
Pedia-Trake Pediatric Emergency Cricothyro- The assembly is attached to a BVM device.
148 CHAPTER 7
the uncooperative patient with predictors of dif- EGD use, assessment of the patient for pre-
ficult bag mask ventilation as well as difficult dictors of difficult cricothyrotomy is impor-
laryngoscopy (see Chap. 11). tant, particularly if difficulty with laryngoscopy
as well as BMV is predicted. Difficulty can
Predictors of Difficult Extraglottic occur if there are impediments to identifying
Device Use the location of the cricothyroid membrane, or
even if its location is evident, if problems are
Simply expressed, EGD use can fail due to an anticipated in accessing the trachea through it.
inability to place the device into or through the The mnemonic “DART” can help recall these
mouth; or even if it has been advanced through predictors.
the oral cavity, it can’t be seated in front of the
Distortion of the anatomy from trauma,
laryngeal inlet. Thirdly, even if seated well in
expanding neck hematoma, infection, or
front of the laryngeal inlet, adequate ventilation
other pathology.
through the EGD may fail owing to obstructing
Access problems from obesity or extreme neck
pathology at or below the glottis, or poor lung
flexion (e.g., ankylosing spondylitis).
compliance.
Radiation therapy to the neck area in the past.
Alternatively, the mnemonic “MOODS” may
Tumors.
be useful to help recall predictors of difficulty in
achieving EGD rescue ventilation:
If RSI is being contemplated in an uncoop-
erative patient with predictors of difficult laryn-
Mouth Opening limitation. Mouth opening
goscopy and difficult bag-mask ventilation,
may be functionally impaired by trismus
before proceeding, the clinician should locate
and a clenched jaw, or anatomically by TMJ
the cricothyroid membrane by palpation. Some
pathology.
situations will mandate a formal “double setup”,
Obstruction at or below the glottic opening.
whereby RSI is undertaken only once the
Glottic edema, foreign body, tumor, or sub-
cricothyroid membrane has already been
glottic conditions can all preclude successful
marked and prepped, and equipment and per-
ventilation via an EGD.
sonnel are available for immediate cricothyro-
Distortion, displacement, or disruption of the
tomy should failed oxygenation ensue.
airway. Displacement or distortion of the
laryngeal inlet by pathology such as a
neck hematoma, blunt trauma, or radiation 䉴 SUMMARY
changes may make it difficult to seat the
EGD directly in the path of the glottic With application of a consistent approach to
opening. difficult bag-mask ventilation and difficult
Stiff lungs (e.g., bronchospasm) and/or chest laryngoscopy, failed intubation or failed oxy-
wall. Bronchospasm or chest wall compro- genation scenarios will be only infrequently
mise due to conditions such as morbid obe- encountered. However, when the need arises,
sity may cause EGDs to fail, as many (but extraglottic device use has transformed the air-
not all) have oropharyngeal leak pressures way management landscape away from the
of 25 cm H2O or less. old “can’t intubate—cut the neck” directive.
That being said, every clinician with a practice
Predictors of Difficult Cricothyrotomy mandate that includes airway management
should be familiar with indications for, and
The default course of action in a failed oxy- knowledge of how to rapidly perform a
genation scenario is cricothyrotomy. As with cricothyrotomy.
REFERENCES the use of the Esophageal-Tracheal Combitube.

Can J Anaesth. 1998;45(1):76–80.
1. Mort TC. Emergency tracheal intubation: complica- 13. Klein H, Williamson M, Sue-Ling HM, Vucevic M,
tions associated with repeated laryngoscopic Quinn AC. Esophageal rupture associated with the
attempts. Anesth Analg. 2004;99(2):607–613, table use of the Combitube. Anesth Analg. 1997;85(4):
of contents. 937–939.
2. Davies PR, Tighe SQ, Greenslade GL, Evans GH. 14. Mercer MH. An assessment of protection of the air-
Laryngeal mask airway and tracheal tube insertion way from aspiration of oropharyngeal contents
by unskilled personnel. Lancet. 1990;336(8721): using the Combitube airway. Resuscitation.
977–979. 2001;51(2):135–138.
3. Levitan RM, Ochroch EA, Stuart S, Hollander JE. 15. Davis DP, Valentine C, Ochs M, Vilke GM, Hoyt DB.
Use of the intubating laryngeal mask airway by med- The Combitube as a salvage airway device for para-
ical and nonmedical personnel. Am J Emerg Med. medic rapid sequence intubation. Ann Emerg Med.
2000;18(1):12–16. 2003;42(5):697–704.
4. Yardy N, Hancox D, Strang T. A comparison of two 16. Calkins TR, Miller K, Langdorf MI. Success and
airway aids for emergency use by unskilled per- complication rates with prehospital placement
sonnel. The Combitube and laryngeal mask. of an esophageal-tracheal combitube as a
Anaesthesia. 1999;54(2):181–183. rescue airway. Prehospital Disaster Med.
5. Brimacombe JR. Laryngeal Mask Anesthesia 2006;21(2 Suppl 2):97–100.
Principles and Practice. 2nd ed. Philadelphia: 17. Staudinger T, Brugger S, Roggla M, et al. [Compar-
Saunders; 2005. ison of the Combitube with the endotracheal
6. Brimacombe J, Keller C. Insertion of the LMA- tube in cardiopulmonary resuscitation in the
Unique with and without digital intraoral manipu- prehospital phase]. Wien Klin Wochenschr.
lation by inexperienced personnel after manikin- 1994;106(13):412–415.
only training. J Emerg Med. 2004;26(1):1–5. 18. Blostein PA, Koestner AJ, Hoak S. Failed rapid
7. Parmet JL, Colonna-Romano P, Horrow JC, Miller F, sequence intubation in trauma patients: esophageal
Gonzales J, Rosenberg H. The laryngeal mask airway tracheal combitube is a useful adjunct. J Trauma.
reliably provides rescue ventilation in cases of 1998;44(3):534–537.
unanticipated difficult tracheal intubation along 19. Mercer MH, Gabbott DA. Insertion of the Com-
with difficult mask ventilation. Anesth Analg. bitube airway with the cervical spine immobilised
1998;87(3):661–665. in a rigid cervical collar. Anaesthesia. 1998;53(10):
8. Brimacombe J, Keller C, Kunzel KH, Gaber O, 971–974.
Boehler M, Puhringer F. Cervical spine motion 20. Mercer MH, Gabbott DA. The influence of neck
during airway management: a cinefluoroscopic position on ventilation using the Combitube
study of the posteriorly destabilized third cervical airway. Anaesthesia. 1998;53(2):146–150.
vertebrae in human cadavers. Anesth Analg. 21. Brimacombe J, von Goedecke A, Keller C, Brima-
2000;91(5):1274–1278. combe L, Brimacombe M. The laryngeal mask
9. Keller C, Brimacombe J, Keller K. Pressures exerted airway Unique versus the Soft Seal laryngeal
against the cervical vertebrae by the standard and mask: a randomized, crossover study in paralyzed,
intubating laryngeal mask airways: a randomized, anesthetized patients. Anesth Analg. 2004;99(5):1
controlled, cross-over study in fresh cadavers. 560–1563; table of contents.
Anesth Analg. 1999;89(5):1296–1300. 22. Hanning SJ, McCulloch TJ, Orr B, Anderson SP.
10. Levitan RM, Frass M. The Combitube as rescue A comparison of the oropharyngeal leak pressure
device: recommended use of the small adult size between the reusable Classic laryngeal mask airway
for all patients six feet tall or shorter. Ann Emerg Med. and the single-use Soft Seal laryngeal mask airway.
2004;44(1):92; author reply 92–93. Anaesth Intensive Care. 2006;34(2):237–239.
11. Urtubia RM, Aguila CM, Cumsille MA. Combitube: 23. Francksen H, Bein B, Cavus E, et al. Comparison
a study for proper use. Anesth Analg. 2000;90(4): of LMA Unique, Ambu laryngeal mask and Soft
958–962. Seal laryngeal mask during routine surgical proce-
12. Vezina D, Lessard MR, Bussieres J, Topping C, dures. Eur J Anaesthesiol. 2006:1–7.
Trepanier CA. Complications associated with
150 CHAPTER 7
24. Tan MG, Chin ER, Kong CS, Chan YH, Ip-Yam PC. 28. Frerk C, Frampton C. Cricothyroidotomy; time for
Comparison of the re-usable LMA Classic and two change. Anaesthesia. 2006;61(10):921–923.
single-use laryngeal masks (LMA Unique and Soft- 29. Sulaiman L, Tighe SQ, Nelson RA. Surgical vs
Seal) in airway management by novice personnel. wire-guided cricothyroidotomy: a randomised
Anaesth Intensive Care. 2005;33(6):739–743. crossover study of cuffed and uncuffed tra-
25. Sudhir G, Redfern D, Hall JE, Wilkes AR, Cann C. cheal tube insertion. Anaesthesia. 2006;61(6):
A comparison of the disposable Ambu 565–570.
AuraOnce(trade mark) Laryngeal Mask with the 30. Wong DT, Prabhu AJ, Coloma M, Imasogie N,
reusable LMA Classic(trade mark) laryngeal mask Chung FF. What is the minimum training required
airway. Anaesthesia. 2007;62(7):719–722. for successful cricothyroidotomy?: a study in man-
26. Asai T, Shingu K. The laryngeal tube. Br J Anaesth. nequins. Anesthesiology. 2003;98(2):349–353.
2005;95(6):729–736. 31. Melker JS, Gabrielli A. Melker cricothyrotomy kit:
27. Scrase I, Woollard M. Needle vs surgical cricothy- an alternative to the surgical technique. Ann Otol
roidotomy: a short cut to effective ventilation. Rhinol Laryngol. 2005;114(7):525–528.
Anaesthesia. 2006;61(10):962–974.
Chapter 8
How to do Awake Tracheal
Intubations—Oral and Nasal
䉴 KEY POINTS the right hand, will aid in performing awake

direct laryngoscopy.
• If a difficult airway is considered likely • Acute-care clinicians should be as compe-
and clinically significant, an “awake” tent in performing an awake intubation as
approach should be considered, if patient they are in performing a rapid-sequence
cooperation permits. intubation.
• An awake approach describes an intubation
technique facilitated by upper airway anes- 䉴 GENERAL CONSIDERATIONS
thesia applied topically or with nerve blocks, FOR THE AWAKE TRACHEAL
with or without light doses of sedation. INTUBATION
• Although commonly used, “deep seda-
tion” should never be counted upon to Generally, tracheal intubations are performed
“relax” or alleviate clenched teeth, nor in one of three ways:
should it be used to compensate for poor
topical airway anesthesia. • Using rapid-sequence intubation (RSI)
• In general, awake intubation should pro- • With an “awake” technique, following appli-
ceed by the route with which the clinician cation of topical airway anesthesia
has the most comfort and the greatest • Facilitated by deep sedation, but without
experience. pharmacologic paralysis
• Local anesthetics can be topically applied
in ointment, jelly, nebulized or atomized The occasional patient will require a primary
forms through mouth or nose. Nerve surgical airway. Advantages and disadvantages
blocks and transtracheal injection are also of each route appear in Table 8–1 and are dis-
options. cussed further in Chap. 11.
• If blood pressure permits, an awake intu- The American Society of Anesthesiologists’
bation can be performed in the semisitting (ASA) difficult airway algorithm is predicated
or sitting position. upon the clinician first assessing the “likeli-
• ‘Precision’ laryngoscopy, whereby the hood and clinical impact” of encountering dif-
operator carefully guides a laryngoscope ficulty.1 If a difficult airway is considered likely
blade into the mouth using the digits of and clinically significant, the algorithm suggests
151
152 CHAPTER 8
an awake approach. An awake approach to The Advantages of Awake Tracheal

the airway generally describes an intuba- Intubation
tion technique facilitated by upper airway
anesthesia applied topically or with nerve As reviewed in Table 8–1, in a conscious patient,
blocks, in combination with light (e.g., anxi- an awake tracheal intubation delivers the fol-
olytic) doses of sedation. “Awake” in the con- lowing advantages:
text of emergency airway management is
perhaps a misnomer, as the patient requiring • The patient continues to breathe sponta-
emergency tracheal intubation often has an neously.
impaired level of consciousness (LOC). How- • The patient continues to maintain a patent
ever, “awake intubation”, even in the patient airway.
with a depressed LOC, is distinct from tradi- • The patient continues to protect the airway
tional procedural sedation, where the patient’s against aspiration of gastric contents.
LOC might be intentionally altered in an • Light (or omitted) doses of sedative/hyp-
attempt to overcome resistance to laryn- notic agent will generally not present the
goscopy. This latter technique of using deep same risk of hypotension as those used
sedation without paralysis, although still com- for RSI.
monly practiced, has none of the benefits of
either awake or rapid sequence (RSI) approaches
to tracheal intubation: indeed, the use of deep Patient Cooperation and Awake
sedation is referred to by some as “tiger” country Tracheal Intubation
in airway management.2
Currently, RSI is both the most common pri- A degree of patient cooperation is required for
mary and secondary rescue approach used to an awake intubation. This may exclude a sig-
facilitate tracheal intubation in emergency nificant proportion of patients requiring emer-
departments (EDs) in North America.3 The lit- gency tracheal intubation. Indeed, the coopera-
erature supports the use of RSI in the hands of tion issue is one which has made the use of RSI
trained and experienced emergency physicians so widespread in EDs. Patient cooperation fig-
(EPs).4 The decision to use RSI follows an ures prominently in the decision-making
assessment of the likelihood of encountering process on how to proceed with tracheal intu-
difficulty during the process. In face of pre- bation (Fig. 11–3, Chap. 11). However, a blanket
dicted difficulty, awake intubation becomes an dismissal of a patient’s ability to cooperate with
attractive alternative that may provide a wider an awake intubation is also not appropriate:
margin of safety in many instances. Unfortu- patients will and can cooperate more often than
nately, skillful awake tracheal intubation commonly perceived. The “actively” uncooper-
receives little attention in the emergency med- ative, physically agitated patient will often not
icine (EM) literature or practice. This may relate be rendered cooperative by any means. However,
to a combination of lack of perceived need, other patients can be described as “passively”
patient cooperation issues, or deficits in awake uncooperative (e.g., the patient in respiratory
intubation skills teaching and experience. failure), and will often permit airway topicaliza-
As with RSI, acute-care clinicians should be tion and awake instrumentation. Patients in the
competent and experienced in performing an early stages of upper airway obstruction are
awake intubation. This chapter will review the usually mentating normally and are ideal can-
awake intubation process using either the oral didates for an awake approach, as discussed
or nasal route. below.
䉴 TABLE 8–1 COMPARISON OF DIFFERENT METHODS OF PROCEEDING WITH TRACHEAL INTUBATION
Intubation Method Advantages Disadvantages

Awake intubation • Patient continues to: • Clinician perception of patient discomfort.
䡩 Breathe spontaneously • Requires an element of patient cooperation.
䡩 Maintain • As with RSI, requires training in indications,
䡩 Protect performing airway anesthesia and direct
. . .his or her airway. laryngoscopic or indirect fiber/videoscopic
• “No bridges burned”. techniques.
• Avoids adverse effects of RSI medications.
• Avoids risk of hypoxemia during transition
from spontaneous respirations to taking
over positive pressure ventilation.
Deep sedation • Perception of a sense of security: • Often gives a false sense of security.
153
“I haven’t burned any bridges by giving • Retains many of the downsides of RSI while not
a muscle relaxant. . .” delivering the upside of facilitated conditions.
• May help control an uncooperative patient. • Undesirable reflexes intact:
• Perception of a more humane procedure. 䡩 gag/vomiting
䡩 laryngospasm
• No guarantee that deep sedative doses will leave
the patient breathing spontaneously or maintaining
an airway.
• Airway protection ablated in a full stomach patient,
often with no applied cricoid pressure.
• Deep sedative doses of medication can still hemo-
dynamically “crash” the patient.
• Scientific literature clearly documents less optimal
intubating conditions using only deep sedation.35–37
(Continued)
䉴 TABLE 8–1 COMPARISON OF DIFFERENT METHODS OF PROCEEDING WITH TRACHEAL INTUBATION (Continued)
Intubation Method Advantages Disadvantages

RSI • Skeletal muscle relaxation facilitates • Induction drugs may cause profound drop in blood
conditions for direct laryngoscopy. pressure, for example, in shock states.
• Application of cricoid pressure may • Not all physicians are adequately
decrease risk of aspiration. trained in or comfortable using RSI.
• Not dependent on patient cooperation. • “Rescue RSI” not appropriate for all uncooperative
• Drugs may help control undesirable patients, for example, those with obstructing airway
physiologic responses, for example, ICP, HR. pathology.
154
• High success rates in experienced hands.4 • Succinylcholine will not always wear off in time to
have patient resume spontaneous ventilation before
life-threatening hypoxemia occurs in “can’t intubate,
can’t oxygenate” situations.
• Fear of “what if I can’t intubate or ventilate?”
• Requires intimate knowledge of all drugs and
contraindications to technique.
Awake tracheotomy or • In the patient presenting with obstructing • Requires requisite surgical skills and equipment.
cricothyrotomy airway pathology, less risk of losing the
airway during application of topical airway
anesthesia or attempted tube passage
from above.
HOW TO DO AWAKE TRACHEAL INTUBATIONS—ORAL AND NASAL 155
When and Why to do an Awake Oral or Nasal Route?

Tracheal Intubation
In general, awake tracheal intubation should
There are three broad reasons to consider an proceed by the route with which the clinician
awake tracheal intubation in emergencies: has the most comfort and the greatest experi-
ence. For most, this will mean an oral approach.
A. Predicted difficult airway. An awake Blind nasotracheal intubation (BNTI) may be
intubation should be considered primarily considered an option when the patient’s
if a question exists about whether the mouth opening is restricted and RSI is con-
clinician can easily take over what the traindicated. However, BNTI has relative con-
patient is presently doing for him- or her- traindications in certain trauma patients, more
self. Especially if difficulty is predicted complications, and a lower success rate than
in both intubating the patient and main- RSI.4 With either route (oral or nasal), attempts
taining oxygenation with either bag-mask should be made to topically anesthetize the
or a rescue oxygenation technique, then airway.
awake intubation should be considered.
A classic scenario would include the patient
with obstructing pathologic changes in the Tools for Awake Tracheal
airway. Intubation
B. Predicted exaggerated hypotensive
response to induction medications used Almost any intubating device can be used for an
for RSI. Some patients present with signif- awake intubation. Most awake intubations in
icant hemodynamic instability and concern the operating room (OR) are performed using
may exist over the effects of RSI induction a flexible fiberoptic bronchoscope. However,
agents on the blood pressure. While careful direct laryngoscopy, a familiar technique,
choice of induction agent and dose, together can also be used and realistically would be
with a fluid bolus, will often enable safe used for most awake intubations in the emer-
conduct of an RSI in this situation, an gency, out-of-OR setting. Other tools used for
awake intubation is a second option to help awake intubations include video-based and
maintain blood pressure during tracheal rigid or semi-rigid fiberoptic scopes.5 A descrip-
intubation. tion of fiberoptic stylet use in the awake patient
C. RSI not needed: the arrested, critically appears in Chap. 6.
ill, or intrinsically sedated patient: Many
patients requiring intubation in emergen-
cies have a markedly decreased LOC as part
of their presenting condition. Such patients 䉴 TOPICAL AIRWAY ANESTHESIA
may be arrested, critically ill, or intrinsically
sedated by their presenting condition, such The very presence of so many different pub-
as hypercarbia due to respiratory failure. lished techniques of applying topical airway
While not truly “awake” or overtly cooper- anesthesia bears witness to the fact that there
ative, these patients will often not resist a is probably no one best agent or technique.
primary laryngoscopy. This indication is Local anesthetics can be topically applied in
particularly relevant in the profoundly ointment, jelly, nebulized and atomized forms
hypotensive or arrested patient. In contrast, through the mouth or nose. Nerve blocks and
the unconscious head-injured patient is still transtracheal injection of local anesthetic are
best intubated with RSI. also options.
156 CHAPTER 8
Review of Airway Innervation nerve. Tracheal anesthesia can be attained with

inhalation or application of atomized local anes-
The glossopharyngeal nerve innervates the pos- thetic, or a transcricothyroid membrane injec-
terior third of the tongue down to and including tion of local anesthetic.
the vallecula, as well as the soft palate and
palatoglossal folds (Fig. 3–10, Chap. 3). A “gag”
response will be elicited if the laryngoscope Topical Airway Anesthesia for
blade touches or applies pressure to sensitive Orotracheal Intubation
structures innervated by this nerve. These struc-
tures can be blocked with topically applied local Adequate anesthesia for awake oral intubation
anesthetics. The inferior aspect of the epiglottis using direct laryngoscopy can be achieved with
and the larynx above the cords are supplied by anesthetic agents applied mainly to the distrib-
the internal branch of the superior laryngeal ution of the glossopharyngeal nerve (Fig. 3–10,
nerve (SLN). Touch or pressure to these struc- Chap. 3). Lidocaine can be used as a sole agent:
tures without anesthesia can stimulate reflex once applied to the mucosa, it will have maxi-
glottic closure. The SLN can also be blocked top- mal effect in 2–5 minutes, and will act for
ically by application of local anesthetic in the about 20 minutes. Lidocaine ointment (in a 5%
region of the piriform recesses, located on either concentration) or jelly (2% concentration)
side of the laryngeal inlet. Alternatively, it can be (Fig. 8–1) is applied with a tongue depressor
blocked by injecting a small volume of local from the front to back of the tongue, targeting
anesthetic (e.g., 2 mL of lidocaine 2%) in the especially the posterior third. The ointment, if
proximity of the nerve as it pierces the thyrohy- used, is quite thick and must be applied slowly,
oid membrane near the lateral edges of the hyoid allowing it to “melt” on the tongue surface
bone. Below the cords, sensation is provided by (Fig. 8–2). The 2% jelly is easier to apply and will
the recurrent laryngeal branch of the vagus usually be adequate. The very cooperative
Figure 8–1. Lidocaine ointment (in a 5% concentration) or jelly (2% concentration) may be
applied with a tongue depressor.
patient can also be coached to “gargle and

swish” liquid 4% lidocaine. Thereafter, other sen-
sitive areas, including the soft palate, posterior
pharynx, tonsillar pillars and hypopharynx
should be targeted, using a “spray as you go”
technique (Fig. 8–3). Lidocaine endotracheal
spray (in a 10% concentration = 10 mg/spray;
not currently available in the USA) can be used,
or 4% lidocaine administered by an atomizing
device. Atomizers include the venerable DeV-
ilbiss atomizer (Fig. 8–4) and the newer Mucosal
Atomization Devices (e.g., MADgic®, [Wolfe
Tory Medical Inc., Salt Lake City, UT], Fig. 8–5).
Although the above regimen will generally
allow for awake direct laryngoscopy, if time
permits, additional doses of local anesthetic
can be applied to progressively deeper struc-
tures (e.g., the laryngeal inlet). Gradually
deeper insertion of the laryngoscope blade will
help expose the epiglottis, and then glottic
opening for additional sprays of anesthetic
Figure 8–2. Lidocaine ointment once placed agent (Fig. 8–6). Oxygen can be readministered
on a tongue depressor is applied to the pos- as required in between doses.
terior third of the tongue.
Figure 8–3. The soft palate, posterior pharynx, tonsillar pillars, and hypopharynx should be tar-
geted, using a “spray as you go” technique.
158 CHAPTER 8
Figure 8–4. DeVilbiss atomizer.
Alternatively, 4 mL of 4% lidocaine with or time (10–15 minutes) and a degree of patient

without neosynephrine 0.5% (1 mL) can be neb- cooperation.
ulized and delivered either by mask or a mouth However applied, care should be taken to
piece (Fig. 8–7). This technique requires some ensure that the maximum recommended dose
of lidocaine (5–7 mg/kg) is not exceeded.
Topical Airway Anesthesia for

Nasotracheal Intubation
A. Vasoconstriction of the nasal mucosa can

be achieved with phenylephrine 0.5% or
oxymetazoline drops. Compared with cocaine
for the prevention of epistaxis, studies sug-
gest that phenylephrine and oxymetazoline
are no less effective (although other studies
have failed to show any advantage over
saline).6–9
B. The nares can be anesthetized by applying
2% lidocaine jelly to, and inserting a nasopha-
ryngeal airway, or using a cotton pledget
soaked with 2% lidocaine with epinephrine.
Alternatively, one of the previously men-
tioned atomizing devices (e.g., DeVilbiss or
MAD® Nasal) can be used.
C. The pharynx is anesthetized with lidocaine
spray, as described in the above section on
“oral” anesthesia.
D. Lidocaine can be simultaneously delivered
to oral and nasal cavities by nebulizer mask.
Figure 8–5. Mucosal Atomization Device Although an easy modality to use, results are
(MADgic®, courtesy of Wolfe Tory Medical Inc., usually not as good as those obtained with
Salt Lake City, UT). more focused application of local anesthetic.
Figure 8–6. Deeper structures may be targeted with topical airway anesthesia during the
awake laryngoscopy.
Figure 8–7. A mask or mouth-piece may be used to administer aerosolized lidocaine.

160 CHAPTER 8
䉴 SEDATION FOR THE AWAKE potential, and its tendency to increase secre-
INTUBATION tions, some clinicians have suggested that
ketamine may not be an ideal sedative agent
Light sedation is the intended state for awake for awake intubation. Other sedative agents
intubation. It represents a depth of sedation with potential application to awake intuba-
characterized by anxiolysis, and possibly tion include remifentanil and dexmedetomi-
decreased pain perception, yet the patient is dine (Chap. 13).
readily rousable with verbal or at most, light B. Age differences. The elderly require less
physical stimulation. The patient is able to main- drug to achieve sedation, while children
tain protective airway reflexes and a patent in general require comparatively more
airway, and should be at no risk of becoming (in mg/kg).
apneic. No sedation is also an option, and may C. Physiological differences. The patient
be most appropriate for the patient presenting with high sympathetic tone (frequently the
with a tenuous airway due to obstructing airway case in the emergency intubation popula-
pathology. tion) is highly sensitive to low doses of
Deep sedation represents a state of sedative agents.
unconsciousness which may impair the D. Pathological differences. The neurologi-
patient’s respiratory drive and ability to protect cally impaired patient, for example, has
the airway. Deep sedation can be an unintended lower requirements.
complication of light sedation. Consequences of E. Reversal agents. Although more often
unintended deep sedation include vomiting and required in nonairway procedural sedation,
aspiration with airway instrumentation, laryn- reversal agents (Flumazenil and Naloxone)
gospasm, and apnea. It should also be recog- should be readily available for benzodi-
nized that sedation alone rarely produces patient azepines and opioids, respectively.
cooperation in the actively combative patient.
Although commonly used, deep sedation should Note that the mainstay of the awake intu-
never be counted upon to relax or alleviate bation is topical airway anesthesia. Sedatives,
clenched teeth, nor should it be used to com- anxiolytics, or narcotics should be used only
pensate for poor topical airway anesthesia. as needed. An awake intubation should be
just that! Additional sedation can be adminis-
Sedation Pearls tered, if needed, as soon as the patient has
been successfully intubated and tube position is
A. Titrate to effect. Individuals respond dif- confirmed.
ferently to the same medication dosages.
Small doses should be used initially, for 䉴 AWAKE INTUBATION USING
example, in a 70-kg patient: midazolam DIRECT LARYNGOSCOPY
0.25–1 mg/dose and/or fentanyl 25–50 µg/
dose, repeated as needed. Other agents to If blood pressure permits, an awake intubation
consider would include haloperidol (2–5 mg/ should be performed in the semisitting or sitting
dose) or ketamine (20–40 mg/dose). This position. This will be mandatory for the patient
latter agent produces a state of dissociative in respiratory distress, who will be very reluc-
amnesia and tends to leave protective airway tant to lie supine. If needed, the clinician can
reflexes intact. However, by sensitizing the stand on a stool or a chair. Once the patient has
upper airway, ketamine has the theoreti- been prepared, laryngoscopy begins. “Preci-
cal potential to induce laryngospasm (pri- sion” laryngoscopy, whereby the operator care-
marily seen in young children). With this fully guides the laryngoscope blade into the
mouth using the digits of the right hand (Fig. 8–8), should maintain visual contact with the cords,
will aid in keeping the blade in the lumen of the while having a coached assistant place the endo-
oral cavity, avoiding contact with sensitive mucosa tracheal tube (ETT) in his or her hand in the
until absolutely necessary. As the blade reaches correct orientation. Expeditious intubation
the back of the oral cavity, gentle tongue com- should then occur while the cords are abducted
pression will begin, aiming to visualize the during patient inspiration. If the cords are tran-
epiglottis. The patient can experience some siently adducted, the clinician should pause with
“pressure” at this stage. Once the epiglottis is the ETT poised at the cords until abduction
seen, the blade is positioned, centered, in the occurs. As used in the accompanying figures,
vallecula (Fig. 8–9). At this point, the patient curved blade (Macintosh) laryngoscopy is
should be warned that transient discomfort will recommended for awake laryngoscopy, as a
be felt during the increased pressure caused by direct lift of the SLN-innervated undersurface of
the laryngoscope “lift” needed to expose the the epiglottis could otherwise stimulate reflex
cords (Figure 8–10). Once seen, the clinician glottic closure.
Figure 8–8. “Precision” laryngoscopy, whereby the operator carefully guides the laryngoscope
blade into the mouth using the digits of the right hand.
162 CHAPTER 8
Figure 8–9. Once the epiglottis is seen, the blade can be positioned, centered in the vallecula.
䉴 AWAKE ORAL INTUBATION—A avoidance of struggling against the laryngo-

GENERIC APPROACH scope blade.
C. Topical airway anesthesia should be
A. Preoxygenation with a nonrebreathing applied, as described above. Sedation can
face mask or manual resuscitator should be titrated to effect, recognizing the need
occur for 2–5 minutes (as time permits). for ongoing patient cooperation.
Supplemental oxygen should be continued, D. Awake direct laryngoscopy is performed,
as possible, during the application of topical as described above. Unpleasant as this may
airway anesthesia. sound, it is often well tolerated.
B. Preparation of monitors, oxygen, BVM E. The tube location is confirmed. Once
device, suction, ETTs, stylet, laryngoscope intubated, the ETT cuff is inflated. Often,
and blades, drugs, alternative intubation the patient will cough, and expiratory flow
options and rescue devices should be com- can be felt and heard issuing from the prox-
plete. Note that psychological prepara- imal tube. The patient should not be able
tion should be performed with the mentating to vocalize. However, objective confirma-
patient: the patient should be told the ratio- tion of placement with an ETCO2 detector
nale for the procedure and what to expect, should still be sought. The patient should
with reassurance. The patient’s coopera- be reassured that the procedure has been
tion should be elicited (if possible) with successfully completed, that he won’t be
mouth opening, tongue protrusion, and able to talk.
Figure 8–10. Once the blade is positioned in the vallecula, an appropriate lift will expose the
cords.
F. Additional analgesia and sedation should implied in its name, BNTI is performed without
be introduced, as blood pressure permits. direct visualization of the laryngeal inlet, in a
Vital signs should be rechecked. spontaneously breathing patient. Guided by
breath sounds, a regular endotracheal tube is
placed through the nose and advanced into the
䉴 BLIND NASOTRACHEAL trachea. Corrective maneuvers, if needed, are
INTUBATION (BNTI) suggested by clinical signs. BNTI may be an
option to consider in a patient with predictors
BNTI Introduction of significant difficulty when RSI is relatively
contraindicated and/or cooperation with an
BNTI has become increasingly rare in contem- awake oral intubation may not be expected.
porary practice. This is appropriate, as it can be All contraindications to BNTI (including
technically challenging, has a higher complica- apnea) are relative, and include upper airway
tion rate, and compared to RSI, is less frequently foreign bodies, bleeding diathesis (including
successful.4 However, it is also a technique that heparinized, warfarinized, or recently throm-
“occasionally, in cases where laryngoscopy is bolyzed patients), or obstructing airway pathol-
difficult, [may permit] a nasal tube [to] enter the ogy. Midface and/or basal skull fracture 11
trachea blindly with remarkable ease.”10 As is has historically been included as a relative
164 CHAPTER 8
contraindication to BNTI, based on a small num- motion (e.g., 90° to the left) should allow pas-
ber of case reports of accidental intracranial sage. As the ETT is advanced, fogging will be
passage of nasogastric12-15 or nasotracheal seen and breath sounds should be heard from
tubes.16–18 However, other published reports the end of the tube. The ETT is further advanced,
have failed to demonstrate adverse outcomes with the clinician’s ear near the proximal end of
following nasal intubation in this same popu- the ETT, monitoring breath sounds. Maximal
lation in the prehospital, 19,20 ED, 19 or OR breath sounds will be heard when the ETT is at
settings.19,21 the glottic opening. The ETT should then be
quickly advanced through the cords during
BNTI Technique inspiration, when the cords are maximally
abducted. The cuff is inflated, and tube position
As with any other technique, all needed equip- confirmed in the usual objective fashion. The
ment should be assembled. An uncut ETT one ETT should be sited at approximately 28 cm at
full size smaller than would normally be used the nares in males and 26 cm in females.
for orotracheal intubation should be selected, for
example, 6.5–7.0-mm internal diameter (ID) for
a female or 7.0–7.5-mm ID for a male. Both BNTI Troubleshooting
nostrils should be medicated with local anes-
thetic with or without a vasoconstrictor, as detailed Due to the intrinsic shape of the ETT and the
earlier in this chapter. A nasopharyngeal airway path traveled as it is advanced through the
covered in lidocaine jelly or ointment can help nasopharynx, the tube is often perfectly directed
with application of the anesthetic while also up toward the larynx. However, one of four
assessing the nasal passage for patency. An malpositions can occur.23 Diagnosis of a mal-
attempt should also be made to apply local anes- position should be possible by evaluating
thetic to the pharynx (if feasible) in a manner sim- (a) breath sounds through the tube; (b) resis-
ilar to that previously described for the oral tance to forward tube passage; and (c) palpation
approach. or observation of tube impingement in the ante-
The head and neck should be placed in the rior neck. Corrective maneuvers include directing
“sniffing” position.10 The well-lubricated tube the tube more anteriorly (by extending the head)
should be placed in the right nostril (if the option or posteriorly (by lifting then flexing the head);
exists), with the bevel facing the septum. This or by directing it laterally (by twisting the tube to
tube orientation keeps the leading edge of the left or right), as needed. Diagnostic features of,
ETT’s bevel away from the vascular Kiessel- and corrective maneuvers needed for the four
bach’s plexus on the nasal septum. Other clini- BNTI malpositions appear in Table 8–2.
cians advocate preferentially using the most Continued difficulty in spite of these correc-
patent nostril. The tube should be directed infe- tive maneuvers can occasionally be addressed by
riorly, along the floor of the nasal passage, to some of the suggestions in the next section,
stay within the major nasal airway, beneath the useful in the patient requiring C-spine precautions.
inferior turbinate. This will also direct the tube
away from the thin bone of the more superiorly
located cribriform plate.22 A gentle twisting Performing BNTI with C-Spine
motion during tube advancement will help Precautions
avoid obstruction.
There will be some resistance in the poste- For BNTI in the patient requiring manual in-line
rior nasopharynx (as is the case when inserting a neck stabilization, head extension is not an
nasogastric tube). Gentle pressure and a twisting option if additional anterior direction of the tube
䉴 TABLE 8–2 BLIND NASAL INTUBATION: DIAGNOSING AND CORRECTING MALPOSITIONS
Resistance
to Forward Neck Corrective
Malposition Breath Sounds Passage Palpation Maneuver
(None: Correct Present None Nothing None needed
location) palpable
Caught up on Present Present Nothing Flex head slightly (for
adducted cords, palpable anterior commissure
anterior hang-up), rotate tube
commissure, slightly, and readvance
or cricoid
Caught up in Muffled or Present Tube tip in Withdraw, flex head
vallecula absent midline of slightly, do jaw lift and
neck readvance
Piriform sinus Muffled or Present Tube tip felt in Withdraw slightly, rotate
absent lateral neck tube in contralateral
direction, readvance
Esophagus Absent None Nothing Withdraw tube until breath
palpable sounds heard, extend
head, readvance tube
is needed. The following three maneuvers can maneuver can also be used with Trachlight
be used as alternatives: guidance, using the device with its inner
stylet removed.
A. Backward pressure can be applied to the
thyroid cartilage (akin to external laryngeal Although the “sniffing” position has long
manipulation (ELM) performed to improve been thought to be the ideal position for BNTI,10
the view at direct laryngoscopy), to “bring the neutral position with cuff inflation appears
the larynx to the tube”. to result in similar success rates.29
B. If available, an Endotrol® tube24–26
(Mallinckrodt Inc., St. Louis, MO) can be
used. This tube has a directable tip, con- BNTI Complications
trolled by a small loop near its proximal end
(Fig. 8–11). By pulling on the loop, the ETT In addition to failure to intubate, complications
tip is flexed, causing it to move anteriorly. of BNTI may include epistaxis and bacteremia.
C. With the tube sitting in the oropharynx, Epistaxis severe enough to interfere with intu-
inflation of the ETT cuff with 10–15 mL of bation or require posterior nasal packing is
air will elevate the ETT tip up and toward unusual, occurring in less than 2.5% of cases.8,30,31
the laryngeal inlet. The tube is then Moderate bleeding, usually described as blood
advanced until resistance is encountered, visible in, or enough to suction from the poste-
with loud breath sounds. The cuff is deflated rior pharynx, occurs more often, in up to 14%
to allow tube passage through the cords, of cases.8,9,30,31 This latter degree of bleeding
and is reinflated once tracheal intubation would be unlikely to interfere with intubation
has been successfully completed.27, 28 This attempts, however.
166 CHAPTER 8
24–26
Figure 8–11. Endotrol tube (Mallinckrodt Inc., St. Louis, MO).
Bacteremia occurred with nasotracheal with a suspected C-spine injury. In fact, nei-
intubation32 in 5.5% of patients in one OR ther neurologic outcome nor C-spine move-
series. Retropharyngeal perforation, with a risk ment with BNTI in this population has been
of submucosal false passage, has been shown to differ from that resulting from oral
described.30 As previously mentioned, intracra- intubation by direct laryngoscopy.34 Currently,
nial endotracheal tube passage has also been known or suspected C-spine injury is not by
reported.16–18 itself considered an indication for nasotracheal
intubation, blind or otherwise.
BNTI Effectiveness
ROUTINE AND DIFFICULT AIRWAY 䉴 SUMMARY

MANAGEMENT
In the hands of seasoned clinicians, BNTI suc- Compared with RSI, awake intubation may be
cess rates of up to 92% have been reported in perceived as a more technically challenging pro-
both routine and difficult airway situa- cedure. In contrast to RSI, an element of patient
tions.11,30,31 Other series have reported first cooperation is needed to successfully manage a
attempt success rates of 55%–61% in the hands patient’s airway using an awake approach.
of novices “within a reasonable time frame.” Awake intubation is a necessary skill and should
11,33
Both overall and first-attempt success rates not become a vanishing art. Success is linked
are lower than those reported using other tech- not only to patient selection but also to the
niques.4,33 deliberate acquisition and maintenance of
awake intubation skills. Clinicians should be as
C-SPINE PRECAUTIONS competent and comfortable in performing an
Historically, BNTI was advocated as the awake tracheal intubation as they are in per-
method of choice for intubation of the patient forming an RSI.
REFERENCES 14. Gregory JA, Turner PT, Reynolds AF. A complica-

tion of nasogastric intubation: intracranial penetra-
1. Practice guidelines for management of the difficult tion. J Trauma. 1978;18(12):823–824.
airway: an updated report by the American Society
15. Bouzarth WF. Intracranial nasogastric tube inser-
of Anesthesiologists Task Force on Management
tion. J Trauma. 1978;18(12):818–819.
of the Difficult Airway. Anesthesiology. 2003;98(5):
16. Horellou MF, Mathe D, Feiss P. A hazard of naso-tra-
1269–1277.
cheal intubation. Anaesthesia. 1978;33(1): 73–74.
2. Donati F. Tracheal intubation: unconsciousness,
17. Cameron D, Lupton BA. Inadvertent brain pene-
analgesia and muscle relaxation. Can J Anaesth.
tration during neonatal nasotracheal intubation.
2003;50(2):99–103.
Arch Dis Child. 1993;69(1 Spec No):79–80.
3. Sagarin MJ, Barton ED, Chng YM, et al. Airway man-
18. Marlow TJ, Goltra DD, Jr., Schabel SI. Intracranial
agement by US and Canadian emergency medi-
placement of a nasotracheal tube after facial frac-
cine residents: a multicenter analysis of more
ture: a rare complication. J Emerg Med. 1997;15(2):
than 6,000 endotracheal intubation attempts. Ann
187–191.
Emerg Med. 2005;46(4):328–336.
4. Kovacs G, Law JA, Ross J, et al. Acute airway 19. Rosen CL, Wolfe RE, Chew SE, et al. Blind nasotra-
management in the emergency department by cheal intubation in the presence of facial trauma.
non-anesthesiologists. Can J Anaesth. 2004;51(2): J Emerg Med. 1997;15(2): 141–145.
174–180. 20. Rhee KJ, Muntz CB, Donald PJ, et al. Does naso-
5. Kovacs G, Law JA, Petrie D. Awake fiberoptic intu- tracheal intubation increase complications in
bation using an optical stylet in an anticipated dif- patients with skull base fractures? Ann Emerg Med.
ficult airway. Ann Emerg Med. 2007;49(1):81–83. 1993;22(7):1145–1147.
6. Gross JB, Hartigan ML, Schaffer DW. A suitable 21. Bahr W, Stoll P. Nasal intubation in the presence
substitute for 4% cocaine before blind nasotracheal of frontobasal fractures: a retrospective study.
intubation: 3% lidocaine-0.25% phenylephrine J Oral Maxillofac Surg. 1992;50(5):445–447.
nasal spray. Anesth Analg. 1984;63(10):915–918. 22. Goodisson DW, Shaw GM, Snape L. Intracranial
7. Latorre F, Otter W, Kleemann PP, et al. Cocaine or intubation in patients with maxillofacial injuries
phenylephrine/lignocaine for nasal fibreoptic intu- associated with base of skull fractures? J Trauma.
bation? European Journal of Anaesthesiology. 2001;50(2):363–366.
1996;13:577–581. 23. Jacoby J. Nasal endotracheal intubation by an
8. Katz RI, Hovagim AR, Finkelstein HS, et al. A com- external visual technic. Anesth Analg. 1970;49(5):
parison of cocaine, lidocaine with epinephrine, and 731–739.
oxymetazoline for prevention of epistaxis on naso- 24. Asai T. Endotrol tube for blind nasotracheal intu-
tracheal intubation. J Clin Anesth. 1990;2(1):16–20. bation. Anaesthesia. 1996;51(5):507.
9. Rector FT, DeNuccio DJ, Alden MA. A comparison 25. Hooker EA, Hagan S, Coleman R, et al. Directional-
of cocaine, oxymetazoline, and saline for nasotra- tip endotracheal tubes for blind nasotracheal intu-
cheal intubation. Aana J. 1987;55(1):49–54. bation. Acad Emerg Med. 1996;3(6):586–589.
10. Magill IW, Macintosh R, Hewer CL, et al. Lest we 26. O’Connor R E, Megargel RE, Schnyder ME, et al.
forget. A historic meeting of the Section of Anaes- Paramedic success rate for blind nasotracheal intu-
thetics of Royal Society of Medicine on 6 Decemeber bation is improved with the use of an endotracheal
1974. Divynyl ether. Anaesthesia. 1975;30(5): tube with directional tip control. Ann Emerg Med.
630–632. 2000;36(4):328–332.
11. Iserson KV. Blind nasotracheal intubation. 27. van Elstraete AC, Pennant JH, Gajraj NM, et al. Tra-
Ann Emerg Med. 1981;10(9):468–471. cheal tube cuff inflation as an aid to blind nasotra-
12. Fremstad JD, Martin SH. Lethal complication cheal intubation. Br J Anaesth. 1993;70(6): 691–693.
from insertion of nasogastric tube after severe 28. Gorback MS. Inflation of the endotracheal tube
basilar skull fracture. J Trauma. 1978;18(12): cuff as an aid to blind nasal endotracheal intuba-
820–822. tion. Anesth Analg. 1987;66(9):916–917.
13. Fletcher SA, Henderson LT, Miner ME, et al. The 29. Chung YT, Sun MS, Wu HS. Blind nasotracheal
successful surgical removal of intracranial nasogas- intubation is facilitated by neutral head position
tric tubes. J Trauma. 1987;27(8): 948–952. and endotracheal tube cuff inflation in spontaneously
168 CHAPTER 8
breathing patients. Can J Anaesth. 2003;50(5): 35. Lieutaud T, Billard V, Khalaf H, et al. Muscle relax-
511–513. ation and increasing doses of propofol improve
30. Tintinalli JE, Claffey J. Complications of nasotracheal intubating conditions. Can J Anaesth. 2003;50(2):
intubation. Ann Emerg Med. 1981;10(3): 142–144. 121–126.
31. Danzl DF, Thomas DM. Nasotracheal intubations 36. Erhan E, Ugur G, Gunusen I, et al. Propofol—not
in the emergency department. Crit Care Med. thiopental or etomidate—with remifentanil
1980;8(11):677–682. provides adequate intubating conditions in the
32. Dinner M, Tjeuw M, Artusio JF, Jr. Bacteremia absence of neuromuscular blockade. Can J
as a complication of nasotracheal intubation. Anaesth. 2003;50(2):108–115.
Anesth Analg. 1987;66(5):460–462. 37. Collins L, Prentice J, Vaghadia H. Tracheal intuba-
33. Roppolo LP, Vilke GM, Chan TC, et al. Nasotra- tion of outpatients with and without muscle relax-
cheal intubation in the emergency department, ants. Can J Anaesth. 2000;47(5):427–432.
revisited. J Emerg Med. 1999;17(5):791–799.
34. Crosby ET. Airway management in adults after
cervical spine trauma. Anesthesiology. 2006;104(6):
1293–1318.
Chapter 9
Rapid Sequence Intubation—
Why and How to do it
䉴 KEY POINTS 䉴 INTRODUCTION TO RAPID-

SEQUENCE INTUBATION (RSI)
• For clinicians with the requisite skills,
rapid-sequence intubation should Historically, the term “RSI” has referred to Rapid
become the method of choice for tra- Sequence Induction (of anesthesia), used to
cheal intubation in emergencies, unless minimize the risk of aspiration in surgical
contraindicated. patients felt to have a “full stomach.” In emer-
• The emergency medicine literature sug- gency medicine the term RSI refers to Rapid
gests high success rates and low mor- Sequence Intubation (RSI). The difference in
bidity with the use of RSI in experienced semantics refers to a different end-point: in the
hands. operating room (OR), patients are intubated to
• “Successful” tracheal intubation does not provide anesthesia, while in the emergency
by itself necessarily represent a successful department (ED), patients are anesthetized to
outcome. facilitate tracheal intubation.1
• The evidence favoring pretreatment med- Rapid sequence induction was originally
ications is not compelling. Emphasis described in the anesthesia literature as a method
should instead be placed on preventing of airway management undertaken to minimize
hypoxia and hypotension. the risk of aspiration in parturients undergoing
• If rapid oxygen desaturation occurs (or is emergency Caesarean section.2 Despite initial
likely to occur) with onset of apnea controversy, RSI has now also become part of
during an RSI, gentle bag-mask ventilation everyday emergency medicine (EM) practice. RSI
can and should be performed while in emergency care involves the use of a combi-
awaiting onset of the muscle relaxant. nation of specific pharmacologic agents to obtain
• Cricoid pressure has the potential to optimal conditions for tracheal intubation.
impair the view at laryngoscopy, cause RSI use has been shown to increase the like-
difficulty with bag-mask ventilation (BMV) lihood of successful tracheal intubation and
and impair extraglottic device (EGD) decrease complications when compared to
placement. other methods, in most settings.3 However,
• Laryngoscopy and intubation should pro- these results assume trained and experienced
ceed only once the muscle relaxant has clinicians who have learned the process and are
taken effect. familiar with the drugs used.
169
170 CHAPTER 9
Unless contraindicated, RSI should be strongly Trauma Life Support (ATLS) now supports the
considered for emergency intubations. Relative use of RSI to facilitate airway management in
contraindications to RSI include the following: trauma patients.4 As a means of securing the
airway, RSI holds the following advantages,
A. Inadequate prerequisite clinician fac- reproduced here from Table 8–1:
tors: The clinician performing RSI must
have the necessary knowledge and skills. • RSI is not dependent on patient cooperation
Needed airway equipment and trained help and, with appropriate preparation, can usu-
must also be available. ally be expeditiously performed.
B. Anticipated difficult airway: RSI should • Skeletal muscle relaxation facilitates condi-
be avoided if difficult tracheal intubation is tions for direct laryngoscopy and intubation.
predicted, especially if bag-mask ventilation • Application of cricoid pressure may decrease
(BMV) may also be problematic. In this sit- the risk of aspiration.
uation, an “awake” intubation should be • Drugs used during RSI may help control
considered, if the patient can cooperate. In undesirable physiologic responses to laryn-
particular, the patient presenting with goscopy and intubation such as gagging, or
obstructing airway pathology should rarely increases in intracranial pressure (ICP), heart
be intubated using RSI. rate, or blood pressure.
C. Unnecessary: RSI may not be needed in • RSI has a high success rate in experienced
situations where “facilitation” is not needed, hands.
for example, in the arrested patient.
However, much as RSI will most often facil-
In most cases, RSI will facilitate emergency itate intubation, it is just as important to appre-
intubations. However, the decision to proceed ciate when it may not be the technique of first
with RSI should follow an airway assessment, choice. Used in the wrong patient (e.g., the
and in the face of predictors of significant diffi- patient presenting with obstructing airway
culty, should only proceed if lack of patient pathology), adverse effects can include a failed
cooperation precludes an awake attempt. In airway, “can’t intubate, can’t oxygenate” situa-
addition, if RSI is undertaken in the patient with tion. Morbidity can also occur with use of an
predictors of difficulty, rescue oxygenation tech- incorrect choice or dosage of induction med-
niques such as extraglottic device use or ication. The practicing clinician adopting RSI
cricothyrotomy must be predicted to succeed. use must therefore make the effort to attain
As discussed in more detail in Chap. 11, the the needed cognitive and psychomotor airway
benefit of proceeding with RSI in the face of dif- skills. A number of established educational
ficulty should outweigh the risk of encountering programs exist to help attain and augment these
a failed airway situation. It is also important to skills. Additional experience in the use of RSI med-
appreciate that RSI is only one way to facilitate ications can often be obtained in hospital ORs.
tracheal intubation, and that intubation in turn
is only one facet of airway management. 䉴 RSI IN EMERGENCIES: WHAT IS
THE CURRENT STATE OF
EVIDENCE?
䉴 RSI IN EMERGENCIES: WHY
USE IT? Many reports have described various institu-
tions’ experiences with RSI in the ED.5–10 Despite
RSI is being used increasingly in emergency the growing evidence to support its use, RSI is
departments and selected other settings. As an still not routinely practiced in many hospital
example of its broader dissemination, Advanced EDs, particularly outside teaching centers. There
RAPID SEQUENCE INTUBATION—WHY AND HOW TO DO IT 171
also remains a resistance to RSI use in emer- Data from prospective, randomized con-
gency settings outside the ED. Various percep- trolled trials comparing RSI to other approaches
tions have been cited for this and might for tracheal intubation in the ED is not available.
include: However, available data does support the use of
RSI by emergency physicians as both an effec-
• “Administration of paralytics outside of an tive and safe method to facilitate intubation.5–10
OR is dangerous.” On the other hand, the use of deep sedation
• “Nonanesthesiologists have no role giving alone to facilitate tracheal intubation remains
anesthetic drugs.” very common outside the OR. This practice con-
• “RSI is unnecessary.” tinues despite growing literature consistently
• “What if I can’t see the cords after the patient demonstrating that even with potent combina-
is paralyzed?” tions of sedatives and narcotic (without paralytics)
• “Midazolam or propofol are safer because the in the hands of experienced clinicians, optimal
patient maintains spontaneous ventilation.’’ intubating conditions occur in less than 50% of
cases.3,13–16 Most of these studies were done in
In the 1970s and into the early 1980s, oro- elective surgical, physiologically normal patients.
tracheal intubation was performed chiefly in The acutely ill emergency patient would likely
patients in cardiopulmonary arrest, while the respond quite differently, with such large doses
nasotracheal route was used in spontaneously of sedatives and narcotics creating a more
breathing patients requiring intubation. Anes- dangerous combination of apnea, hypotension
thesiologists were commonly summoned to the and suboptimal intubating conditions.
ED to aid in airway management. Over subse- Most of the EM literature on RSI originates
quent years, more data began to appear describing from relatively large volume centers and in that
RSI use in the ED.3 Gradually, RSI began to be setting, success rates approaching 100% are
claimed by EM as a method of airway manage- reported. Although this data is important, it
ment within their domain of practice. By the tends to minimize the concept of airway man-
late 1990s, over 95% of U.S. emergency medi- agement as a process. Ten to twenty percent of
cine teaching programs reported routine use of ED RSIs require more than one attempt at tra-
neuromuscular blocking agents to facilitate cheal intubation.3,5–10 With each attempt there is
intubation.11 In 1997, 15 years after the first pub- an increasing potential for complications.17 The
lished use of succinylcholine in the ED, the exact nature and rate of complications from
American College of Emergency Physicians emergency intubation are inconsistently
(ACEP) made a Policy Statement on RSI, which reported in the literature. Thus, the true inci-
included the following statements: dence of process-related adverse events such as
hypotension and hypoxia related to emergency
• “Physicians performing RSI should possess airway management is not clear. “Successful”
training, knowledge, and experience in the tracheal intubation does not necessarily repre-
techniques and pharmacologic agents used to sent a successful outcome by itself, if, for exam-
perform RSI. ple, significant hypoxia has occurred during the
• “Neuromuscular blocking agents and appro- process. RSI is simply one tool to aid successful
priate sedative and induction agents should airway management, along with good planning,
be immediately available in the ED and acces- preparation, and a timely response to both antic-
sible to all physicians who perform RSI in ipated and unanticipated clinical events.
the ED. Throughout the process, it is important to main-
• “Quality review and patient monitoring tain a “bigger picture” perspective and ensure
should be addressed when policies about RSI patient oxygenation is maintained, for example,
are developed in the ED.”12 with BMV between attempts.
172 CHAPTER 9
䉴 RSI: DEFINITION AND THE two, are needed to help, guided by specific
PROCESS directions. The assistants should be briefed
about the location of the cricoid cartilage and
Rapid sequence intubation is a process that need for cricoid pressure. If difficulty is antici-
involves pharmacologically inducing uncon- pated, this should be communicated to the
sciousness and paralyzing the patient in a team, together with the planned response to
manner that facilitates tracheal intubation, while difficult laryngoscopy, recognizing that more
minimizing the risk of aspiration using applica- than one attempt at laryngoscopy may be
tion of cricoid pressure. “Rapid-sequence” refers required.
to the fact that the induction agent and the neu- Equipment: Needed equipment should
romuscular blocker are given in quick succes- be assembled. The previously presented
sion, and are not titrated to effect. In addition, mnemonic STOP “I” “C” BARS (Chap. 5) can
“rapid” can refer to the fact that one is taking serve as a reminder of the basics needed for
the patient from a conscious state (with the routine and potentially difficult tracheal intu-
airway protected by the patient) to the place- bations. Suction should be running and imme-
ment of a tube in the trachea with the cuff diately available.
inflated (when the airway is again protected, Medications. All medications needed for
this time by the ETT cuff) with as little intervening pretreatment (if used), induction, and neuro-
time as possible. muscular blockade should be drawn up and
The following discussion assumes that a labeled. Rescue vasopressor agents such as
decision has been made to undertake an RSI, ephedrine or phenylephrine for bolus injection
and presents the process from that point to should be drawn up and available to manage
postintubation. postintubation hypotension.
Positioning. The patient and clinician should
be optimally positioned for the situation.
䉴 RSI: HOW TO DO IT
The RSI process involves several steps:

Preoxygenation
A. Preparation.
B. Preoxygenation. Administration of 100% oxygen for 3–5 minutes
C. Fluid preloading and pretreatment. in a normal healthy adult will result in “nitro-
D. Induction and pharmacologic paralysis. gen washout” and the establishment of an
E. Application of cricoid pressure. oxygen reservoir using the functional resid-
F. Intubation and confirmation of tube placement. ual capacity (FRC). A similar effect can be
G. Postintubation management. achieved by having the patient take 4–8 deep
(vital capacity) breaths of 100% oxygen over
a one minute period. 18 Preoxygenation will
Preparation prolong the time available for tracheal intu-
bation before oxygen desaturation occurs.
This involves preparation of the patient and FRC is compromised in situations such as obe-
equipment, as discussed in Chap. 5. To review, sity and advanced stages of pregnancy. In
the following elements are important in preparing addition, in critically ill patients and children,
for RSI: oxygen consumption is increased, leading to
Personnel: Airway management is not a more rapid desaturation. Time to desatura-
one-person job. At least one assistant, and ideally tion may be delayed in some of these patients
by preoxygenating them in the “head-up” Induction and Pharmacologic

position.19 Paralysis
In the spontaneously breathing patient,
preoxygenation is best performed by tightly In this step, a potent sedative-hypnotic (e.g.,
applying the mask of a manual resuscitator to propofol, etomidate, or thiopental) or other
the face. Classic teaching of RSI usually agent such as the dissociative amnestic keta-
includes avoidance of positive pressure venti- mine is given with the goal of inducing uncon-
lation with the manual resuscitator during pre- sciousness. This should be done with the cor-
oxygenation to avoid insufflating the stomach. rect dose of an agent with rapid onset and with
However, if the patient’s spontaneous ventila- a side effect profile that minimizes exacerbating
tion is inadequate and/or the patient’s oxygen the patient’s underlying condition. Dosing of
saturation does not improve with passive induction agents is based on the patient’s weight
oxygen delivery, then assisted BMV is appro- and is adjusted down (or up) in consideration
priate to preoxygenate the patient. Assisted BMV of the following factors:
during preoxygenation may also be appropriate
in the patient in whom a difficult airway is sus- • Age: Dosing is adjusted upward for the pedi-
pected. In this situation, briefly attempting BMV atric patient, and downward for the older
before proceeding with RSI helps to test (a) patient.
appropriate mask fit and (b) effective delivery • Volume status: Dosage should be adjusted
of positive pressure ventilation before commit- downward in the hypovolemic patient. In the
ting to paralyzing the patient. profoundly hypovolemic and hypotensive
patient, induction agents, even in small
doses, may be poorly tolerated.
Fluid Loading and Pretreatment • Patient co-morbidities: The patient with a
depressed level of consciousness may need
The pretreatment step involves the use of med- less induction agent, as is the case for a
ications to prevent adverse physiologic effects patient in a cardiogenic or other shock state.
resulting from laryngoscopy, or the use of
succinylcholine. Historically, the term “pretreat- Administration of an induction agent is
ment” has referred to the use of lidocaine, fen- followed in rapid sequence by a muscle
tanyl, a defasciculation agent or atropine (in relaxant. Succinylcholine or rocuronium are
children) given at least 3 minutes prior to induc- most often used (see Table 9–1), and both take
tion. However, as discussed in more detail in time to onset. Many clinicians make the mis-
Chap. 13, no outcome data firmly supports the take of trying to intubate before complete
use of these agents, although their administra- paralysis has occurred or become too hurried
tion probably does not cause harm. On the other after the onset of apnea despite stable oxygen
hand, hypotension and hypoxia are still relatively saturation. Succinylcholine usually takes
common adverse events during emergency 45 seconds to act fully, and rocuronium (in a
tracheal intubation using RSI. 4,20,21 For dose of 1.0 mg/kg) closer to 1 minute. The
these reasons the only two routinely mandible should open easily. In the adequately
mandatory interventions required in preoxygenated patient, there is no need to bag
the pretreatment phase of an RSI are the patient. However, if rapid oxygen desatura-
the administration of 100% oxygen to tion occurs (or is likely to occur) with onset of
prevent desaturation and a fluid bolus of apnea, gentle BMV can and should be undertaken,
10–20 mL/kg, in an attempt to minimize with continued application of cricoid pressure
postintubation hypotension. to prevent gastric insufflation.
174 CHAPTER 9
䉴 TABLE 9–1 ADVANTAGES OF SUCCINYLCHOLINE AND ROCURONIUM FOR RSI
The Debate: Succinylcholine or Rocuronium for intubation? Clinicians are divided on which
neuromuscular blocker to use for RSI in emergencies. Advantages of each are presented below:
Favoring the use of Succinylcholine Favoring the use of Rocuronium
• Rapid onset and favorable intubating • Longer duration of action of rocuronium allows orderly
conditions. transition from Plan A to Plan B or C if difficulty is
encountered.
• Perception of rapid offset: patient • In a failed oxygenation situation, both succinylcholine
resumes spontaneous ventilation in a and rocuronium may take sufficiently long to wear
failed airway situation. off that irreversible hypoxic brain damage may have
occurred before spontaneous ventilation resumes.
• Rocuronium has slightly longer onset • Rocuronium has a favorable side effect profile
time, especially if underdosed. compared to succinylcholine, especially for use in
the patient where no history is available.
• Many clinicians are more • [A separate agent for the rapid reversal of
familiar with succinylcholine. rocuronium is on the horizon].
Application of Cricoid Pressure if the patient vomits. Cricoid pressure

should continue until the ETT has been
Immediately before RSI begins, the assis- placed, the cuff inflated, and objective
tant should locate and apply light pressure confirmation of its correct location has
(10 Newtons [N]) on the cricoid cartilage. As occurred.
the patient becomes unconscious during Note that much as cricoid pressure may be
RSI, cricoid pressure (the Sellick maneuver) considered standard of care for RSI in the
∗
is increased to 30N (3 kg). 23 Posterior pres- full stomach patient, the published evi-
sure is applied on the cricoid with the dence supporting its use as an effective
thumb, index, and long fingers. The cricoid preventative measure is scant. Certainly,
cartilage is a complete ring, so applied back- vigorous cricoid pressure has the potential
ward pressure should secondarily occlude to impair the view at laryngoscopy,24–26 cause
the esophagus, while not occluding the air- obstruction to BMV,27–30 and impair extraglot-
way. This pressure theoretically prevents tic device (EGD) placement.23 These risks
passive regurgitation of gastric contents and should be balanced against the perceived ben-
also prevents gastric insufflation in the efits of cricoid pressure during RSI. Cer-
unconscious patient should BMV be under- tainly, if substantial difficulty is encountered
taken. It is important to not apply full cricoid with BMV or laryngoscopy during RSI,
pressure in awake patients, and to release it cricoid pressure should be transiently
released to determine if it is causing or con-
tributing to difficulty. By the same token, as
∗
30N of applied force can be simulated using a 20 mL the distal tip of most EGDs sits in the upper
syringe. The plunger is withdrawn to the 20 mL mark, and esophagus, cricoid pressure should also be
its distal (Luer-lok) end occluded. The force needed to then
depress the plunger from the 20 mL mark to 10 mL will at least temporarily released during their
approximate 30N.22 placement.
Intubation and Confirmation following differences are important age-related

of Tube Placement considerations in RSI.
After onset of the muscle relaxant, laryn- A. If using succinylcholine, a dose of 2 mg/kg
goscopy and intubation should be performed. should be used. Although atropine pre-
“Best look” laryngoscopy should always be treatment has historically been used in chil-
undertaken, as described in Chap. 5. An assistant dren less than 6 years of age, its use as a
should hand the clinician the ETT in the correct prophylactic measure to prevent secondary
orientation, so that the cords are continuously bradydysrhythmias has been challenged in
visualized once seen. Laryngoscopy and intu- the literature.31–34
bation should take less than 30–45 seconds in B. Apnea time after succinylcholine adminis-
most patients. tration will be considerably less in the
young child due to a higher volume of
drug distribution and shorter redistribu-
tion times.
Postintubation Management C. Basal oxygen consumption in children is
twice that of adults, so that rapid oxygen
After tube placement, the cuff should be desaturation should be anticipated.
inflated immediately to minimize the period
of time with an unprotected airway. If used,
the stylet should be removed, if not already
done. Cricoid pressure is released only after SAMPLE RSIs
tracheal location of the ETT has been con-
firmed. The chest is auscultated for equality of Table 9–2 contains sample timelines of an
breath sounds, and the tube is secured. RSI performed in an adult and a pediatric
A postinduction set of vital signs should be patient.
obtained early, with particular reference to the
blood pressure.
In the event of inadvertent esophageal
intubation, cricoid pressure should be main- SUMMARY
tained throughout the reintubation process,
unless it was thought to be contributing to Successful RSI is all about planning. Patient
difficulty. assessment allows determination of whether
The ETT should be well secured and con- RSI can safely be undertaken. Medications
sideration given to postintubation sedation. must be prepared, helpers briefed and
equipment readied for what may be a rou-
tine or difficult intubation. Most often, RSI
results in expeditious and safe tube place-
䉴 PEDIATRIC RSI DIFFERENCES ment. However, the clinician must recognize
that applied cricoid pressure can create dif-
Once again, it is important to emphasize that ficulty with laryngoscopy, BMV and EGD
similarities of basic concepts in pediatric placement: if difficulty is encountered with
airway management outweigh the differences these maneuvers, cricoid pressure should be
from those used in the adult. Armed with transiently released. Postintubation care
these basic concepts, and the help of a should initially emphasize confirmation of
Broselow tape, the clinician should be able to tube placement and reassessment of blood
successfully manage the pediatric airway. The pressure.
176 CHAPTER 9
䉴 TABLE 9–2 SAMPLE RSIs
Sample RSIs in an Adult and Pediatric Patient

Adult: 75 kg, Systolic BP 140/ Pediatric: 20 kg, Systolic BP 100/
Time 0
Pretreat with fluid bolus. Pretreat with fluid bolus (10–20 mL/kg).
Preoxygenate while preparing. If used, atropine 0.02 mg/kg (minimum 0.1 mg).
Plan for difficulty. Preoxygenate while preparing.
Position the patient. Plan for difficulty.
Position the patient.
Time 3 minutes
Pharmacologic induction: choice of. . . Pharmacologic induction: choice of. . .
• Propofol 150 mg • Ketamine 1–2 mg/kg
• Thiopental 250 mg • Propofol 2–3 mg/kg
• Ketamine 120 mg • Thiopental 3–7 mg/kg
• Etomidate 20 mg • Etomidate 0.3 mg/kg
followed immediately by. . .
Muscle relaxation: Muscle relaxation:
• Succinylcholine 120 mg or. . . • Succinylcholine 2 mg/kg
• Rocuronium 80 mg • Rocuronium 1 mg/kg
• Doses must be adjusted according to weight, hemodynamics, level of consciousness and age.
• Cricoid pressure applied when patient rendered unconscious
Time 3 minutes 45 seconds
Perform laryngoscopy and tracheal intubation, then post intubation care:
• Objective confirmation of endotracheal location.
• Release cricoid pressure.
• Reassess blood pressure.
• Secure ETT and consider ongoing sedation requirements.
REFERENCES 5. Simpson J, Munro PT, Graham CA. Rapid sequence

intubation in the emergency department: 5 year
1. Dronen S. Rapid–sequence intubation: a safe trends. Emerg Med J. 2006;23(1):54–56.
but ill-defined procedure. Acad Emerg Med. 6. Sagarin MJ, Barton ED, Chng YM, et al. Airway man-
1999;6(1):1–2. agement by US and Canadian emergency medi-
2. Stept WJ, Safar P. Rapid induction-intubation cine residents: a multicenter analysis of more than
for prevention of gastric-content aspiration. 6,000 endotracheal intubation attempts. Ann
Anesth Analg. 1970;49(4):633–636. Emerg Med. 2005;46(4):328–336.
3. Kovacs G, Law JA, Ross J, et al. Acute airway 7. Graham CA, Beard D, Henry JM, et al. Rapid
management in the emergency department by sequence intubation of trauma patients in Scot-
non-anesthesiologists. Can J Anaesth. 2004;51(2): land. J Trauma. 2004;56(5):1123–1126.
174–180. 8. Levitan RM, Rosenblatt B, Meiner EM, et al. Alter-
4. Advanced Trauma Life Support for physicians: nating day emergency medicine and anesthesia
American College of Surgeons Committee on resident responsibility for management of the
Trauma. Chicago; 2004. trauma airway: a study of laryngoscopy performance
and intubation success. Ann Emerg Med. 21. Mort TC. Preoxygenation in critically ill
2004;43(1):48–53. patients requiring emergency tracheal intubation.
9. Bushra JS, McNeil B, Wald DA, et al. A comparison Crit Care Med. 2005;33(11):2672–2675.
of trauma intubations managed by anesthesiolo- 22. Wilson NP. No pressure! Just feel the force.
gists and emergency physicians. Acad Emerg Med. Anaesthesia. 2003;58(11):1135–1136.
2004;11(1):66–70. 23. Brimacombe JR, Berry AM. Cricoid pressure.
10. Sakles JC, Laurin EG, Rantapaa AA, et al. Airway Can J Anaesth. 1997;44(4):414–425.
management in the emergency department: a 24. Levitan RM, Kinkle WC, Levin WJ, et al. Laryngeal
one–year study of 610 tracheal intubations. view during laryngoscopy: a randomized trial com-
Ann Emerg Med. 1998;31(3):325–332. paring cricoid pressure, backward-upward-right-
11. Ma OJ, Bentley B, 2nd, Debehnke DJ. Airway man- ward pressure, and bimanual laryngoscopy. Ann
agement practices in emergency medicine resi- Emerg Med. 2006;47(6):548–555.
dencies. Am J Emerg Med. 1995;13(5):501–504. 25. Snider DD, Clarke D, Finucane BT. The “BURP”
12. Rapid-sequence intubation. American College maneuver worsens the glottic view when
of Emergency Physicians. Ann Emerg Med. applied in combination with cricoid pressure.
1997;29(4):573. Can J Anaesth. 2005;52(1):100–104.
13. Collins L, Prentice J, Vaghadia H. Tracheal intuba- 26. Haslam N, Parker L, Duggan JE. Effect of cricoid
tion of outpatients with and without muscle relax- pressure on the view at laryngoscopy. Anaesthesia.
ants. Can J Anaesth. 2000;47(5):427–432. 2005;60(1):41–47.
14. Lieutaud T, Billard V, Khalaf H, et al. Muscle relax- 27. Hocking G, Roberts FL, Thew ME. Airway obstruc-
ation and increasing doses of propofol improve tion with cricoid pressure and lateral tilt.
intubating conditions. Can J Anaesth. 2003;50(2): Anaesthesia. 2001;56(9):825–828.
121–126. 28. Hartsilver EL, Vanner RG. Airway obstruction
15. Erhan E, Ugur G, Gunusen I, et al. Propofol—not with cricoid pressure. Anaesthesia. 2000;55(3):
thiopental or etomidate—with remifentanil pro- 208–211.
vides adequate intubating conditions in the 29. Mac GPJH, Ball DR. The effect of cricoid pressure
absence of neuromuscular blockade. Can J on the cricoid cartilage and vocal cords: an
Anaesth. 2003;50(2):108–115. endoscopic study in anaesthetised patients.
16. Naguib M, Samarkandi A, Riad W, et al. Optimal Anaesthesia. 2000;55(3):263–268.
dose of succinylcholine revisited. Anesthesiology. 30. Butler J, Sen A. Best evidence topic report. Cricoid
2003;99(5):1045–1049. pressure in emergency rapid sequence induction.
17. Mort TC. Emergency tracheal intubation: complica- Emerg Med J. 2005;22(11):815–816.
tions associated with repeated laryngoscopic 31. Rothrock SG, Pagane J. Pediatric rapid sequence
attempts. Anesth Analg. 2004;99(2):607–613, table intubation incidence of reflex bradycardia
of contents. and effects of pretreatment with atropine.
18. Baraka AS, Taha SK, Aouad MT, et al. Preoxygena- Pediatr Emerg Care. 2005;21(9):637–638.
tion: comparison of maximal breathing and tidal 32. Fleming B, McCollough M, Henderson HO. Myth:
volume breathing techniques. Anesthesiology. Atropine should be administered before suc-
1999;91(3):612–616. cinylcholine for neonatal and pediatric intuba-
19. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygena- tion. Can J Emerg Med. 2005;7(2):114–117.
tion is more effective in the 25 degrees head-up 33. McAuliffe G, Bissonnette B, Boutin C. Should the
position than in the supine position in severely routine use of atropine before succinylcholine
obese patients: a randomized controlled study. in children be reconsidered? Can J Anaesth.
Anesthesiology. 2005;102(6):1110–1115; discus- 1995;42(8):724–729.
sion 1115A. 34. Fastle RK, Roback MG. Pediatric rapid sequence
20. Dunford JV, Davis DP, Ochs M, et al. Incidence of intubation: incidence of reflex bradycardia
transient hypoxia and pulse rate reactivity during and effects of pretreatment with atropine.
paramedic rapid sequence intubation. Ann Emerg Pediatr Emerg Care. 2004;20(10):651–655.
Med. 2003;42(6):721–728.
Chapter 10
Postintubation Management
䉴 KEY POINTS 䉴 THE IMMEDIATE

POSTINTUBATION PERIOD
• In the well preoxygenated patient,
oxygen desaturation can be a relatively Once the endotracheal tube (ETT) has been
late event following an esophageal placed and its correct tracheal location con-
intubation. firmed, everyone’s relief is palpable. However,
• The heat of the moment leads even expe- despite the fact that the most stressful part of
rienced clinicians to occasionally advance the resuscitation is completed, significant
the tube too far once they’ve seen it go airway management concerns remain. This
through the cords. chapter reviews issues which should be
• Hypotension is common immediately addressed following tracheal intubation.
postintubation, particularly if rapid-sequence
intubation (RSI) was employed. However,
Confirmation of Endotracheal Tube
full fluid resuscitation is frequently
Placement
not possible prior to an emergency
intubation.
After intubation, the immediate priority is to
• Preexisting hypovolemia will make hypoten-
confirm the correct tracheal location of the ETT.
sion more likely with institution of positive
As discussed in more detail in Chapter 5, objec-
pressure ventilation.
tive means of confirmation of tracheal intubation
• Postintubation sedation should begin
should include visualization of the ETT passing
before the patient “awakens” from the RSI.
between the cords, as well as end-tidal CO2
• If a patient receiving positive pressure
(ETCO2) detection or use of an esophageal
ventilation is at risk for pneumothorax
detector device. The clinician must appreciate
(e.g., rib fractures, significant pulmonary
the advantages and limitations of these methods.
contusion), serious consideration should
In the well preoxygenated patient of normal body
be given to placement of a chest tube prior
habitus, oxygen desaturation can be a relatively
to transport.
late event following an esophageal intubation.1
• Accidental extubation can occur during
patient transfer. As difficult as it may have
been to intubate the patient in the emer- ETT Depth
gency department (ED), it will be much
more difficult in the confined space of an After confirming tracheal placement of the ETT,
ambulance or helicopter. the tube’s tip should be confirmed to be above
179
180 CHAPTER 10
the carina. Endobronchial intubation is all too • Cotton twill tape is a cheap and effective
common in the operating room (OR), intensive method of securing the ETT. Care must be
care unit (ICU), and emergency department taken to ensure that the encircling tape is
(ED).2,3 The heat of the moment leads even not too tight, particularly in the head-
experienced clinicians to occasionally advance injured patient. A small piece of waterproof
the tube too far once they’ve seen it go through tape placed over the twill where it contacts
the cords! As inattention by an assistant can also the ETT will help prevent accidental tube
allow distal migration of the tube during prepa- advancement.
rations for it being secured to the patient, the • Several single-use commercial ETT clamp-
intubating clinician should ensure its fixation like devices are effective and safe.4 These
before moving on to other aspects of patient products sometimes also double as a bite
care. Endobronchial intubation has potentially block.
serious side effects, including hypoxia, baro-
trauma, and even direct trauma to the lower
airway.3 The ETT should be visually inspected Initiation of Positive Pressure
to confirm its depth (20–22 cm at the teeth in Ventilation
adults) using the numeric markings printed on
its outer surface. Endobronchial intubation is Following tracheal intubation, manual ventila-
avoided in the younger pediatric patient by tion should be initiated to evaluate lung com-
aligning the distal transverse marking on pliance. Indeed, in many cases, a ventilator may
uncuffed ETTs with the vocal cords. Ausculta- not be immediately available. However, while
tion (which should not be relied upon as a sole manually ventilating the patient, it is essential to
method of confirming ETT placement) should ensure that the patient is not being inad-
always be performed following intubation and vertently hyperventilated. This is particularly
unequal breath sounds explained. While the important in the asthmatic or chronic obstruc-
most frequent cause of unilaterally diminished tive pulmonary disease (COPD) patient, as it
air entry will be an endobronchial intubation, can lead to hypotension and/or barotrauma
pneumothorax or hemothorax must also be through breath stacking and “auto-PEEP.” Acci-
considered, particularly in the trauma patient. dental hyperventilation is also undesirable in
A chest x-ray will help identify such pathology, the head-injured patient without appropriate
in addition to confirming that the ETT tip is above indications. Most self-inflating manual resuscita-
the carina. After any changes in the patient’s tors contain a volume of 1600 mL. Completely
position, auscultation should again be performed compressing the bag during manual ventilation
to confirm the ETT’s location above the carina. with both hands will therefore deliver an exces-
sive tidal volume. A more appropriate volume
Securing the ETT of closer to 700 mL will be delivered if the clin-
ician simply touches the thumb and opposing
Following confirmation of appropriate ETT posi- finger together through the bag with one hand
tioning, the tube must be secured to the patient. while bagging.
This can be done in a number of different ways: The initial FiO2 should be set high (100%)
and subsequently weaned downward by titra-
• Adhesive tape is often used in the elective tion to pulse oximetry or arterial blood-gas
surgical setting, but is suboptimal for most monitoring.
emergency patients. Perspiration, blood, Note that shortly after tracheal intubation and
vomitus, and other body liquids may inter- initiation of positive pressure ventilation, the
fere with tape adherence. ETT may require suctioning. Proper bronchial
POSTINTUBATION MANAGEMENT 181
toilet at this time will help reduce airway resis- involves some degree of approximation. Even
tance during subsequent mechanical ventilation, in the hands of a seasoned clinician, patients
and in the spontaneously breathing patient, it requiring urgent tracheal intubation frequently
can decrease the work of breathing. experience transient hypotension.
This hypotension is generally limited to
10–15 minutes and most often does not result in
Blood Pressure Recheck any significant sequellae. However, in certain
patients, most notably those with head injuries,
The patient’s blood pressure should be the effects of even transient hypotension can be
checked immediately after intubation and devastating.8 Patients with stenotic vascular
frequently (i.e., every 1–3 minutes) for the first lesions such as severe carotid artery disease,
15 minutes postintubation or until hemodynamics coronary artery (particularly severe left main)
have stabilized. This is a vital component of disease, and aortic valvular stenosis also tend to
airway management and is frequently over- tolerate hypotension poorly.7 In addition, the
looked in emergencies. Hypotension is common patient in advanced stages of pregnancy, or any
following tracheal intubation, particularly if RSI patient already significantly hypotensive can ill
was employed.5,6 Several mechanisms have afford a further drop in blood pressure.
been described,7 including the following: Management of postintubation hypotension
is best initiated with fluid administration. A crys-
• Direct negative inotropic and vasodilating talloid bolus of 10–20 mL/kg will help prevent
effects of RSI induction agents. or treat such hypotension. In addition, bolus doses
• The effect of positive pressure ventilation on of short-acting vasopressors such as ephedrine
impeding venous return to the heart, partic- 5–10 mg IV or phenylephrine 40–100 µg IV
ularly in the volume depleted patient. (in the adult patient) may be given. Both agents
• In the patient with respiratory distress or crit- generally have a duration of action of 5–10 minutes,
ical illness, as the work of breathing is less- and they may be repeated two to three times if
ened by tracheal intubation and institution of needed. They both require diluting before
mechanical ventilation, the accompanying use. More prolonged hypotension is often the
catecholamine excess is alleviated. result of the underlying disease process requiring
• Pneumothorax is a consideration, particularly tracheal intubation and should be treated as
in the trauma patient with rib fractures or the such.
asthmatic/COPD patient. In the patient with
a pneumothorax, onset of positive pressure
can lead to a tension pneumothorax with car-
Postintubation Hypertension
diovascular collapse.
Although hypotension is more common, hyper-
tension (often with tachycardia) may be
Treatment of Postintubation observed following tracheal intubation. This
Hypotension response is generally self-limited and usually of
little consequence. However, treatment is indi-
Careful assessment and replenishment of any cated in patients with aneurysmal disease and
volume deficit and appropriate induction drug significant coronary artery disease. If a paralytic
dosing will help minimize postintubation agent had been used to facilitate intubation,
hypotension. However, full fluid resuscitation is hypertension and tachycardia could signal
frequently not possible prior to an emergency patient awareness while paralyzed, indicating
intubation. In addition, drug dosing always the need for more sedative/hypnotic agent.
182 CHAPTER 10
Postintubation hypertension is best treated ini- These sedative agents have no analgesic
tially with additional doses of induction agent properties. Concomitant administration of a nar-
(with the exception of ketamine, which could cotic is often necessary. Both sedative and anal-
exacerbate the situation). Commonly used gesic agents need to be titrated to effect with
benzodiazepines or opioids, either alone or in appropriate adjustment of drug doses and/or
combination, can also be used (e.g., midazolam dosing intervals. Be aware, however, that the
1–2 mg or fentanyl 50–100 µg, in the adult combined use of narcotic and benzodiazepine
patient). A beta blocker such as metoprolol can can lead to hypotension. Examples of narcotic
be used effectively to control tachycardia. analgesics include:
Esmolol, an ultrashort acting beta blocking
agent, may be used as an alternative to meto- • Fentanyl: 0.5–2.0 µg/kg q 20–30 min prn
prolol in doses of 0.5–1 mg/kg. (e.g., 50–100 µg in a 70-kg patient)
It goes without saying that hemodynamic • Morphine: 0.025–0.1 mg/kg q 20–30 min prn
alterations can only be treated if they are (e.g., 2–5 mg in a 70-kg patient)
observed. All patients being intubated should
ideally have continuous electrocardiographic In most circumstances, initial control of the
(ECG), pulse oximetry and noninvasive blood patient after tracheal intubation can be obtained
pressure (NIBP) or arterial line monitoring. without the use of muscle relaxants. However,
occasionally ongoing muscle relaxation may be
required to help manage ventilation or prevent
䉴 POSTINTUBATION SEDATION accidental extubation with transfers or as a result
AND PARALYSIS of uncontrolled patient movement. As long as
the clinician has clinically and objectively con-
Tracheal intubation in emergencies is often chal- firmed ETT location, the use of maintenance
lenging and rarely defines a management end- neuromuscular blockade is rarely a problem.
point. Most drugs used to facilitate intubation Postintubation paralysis can be obtained and
are short acting. When needed, postintubation maintained with the following:
sedation should begin before the patient ‘awakens’
from the RSI. The choice of sedative will depend • Rocuronium: 0.6 mg/kg load, then 0.1–0.2 mg/
on: kg q 20–30 min prn (e.g., 50 mg load fol-
lowed by 10–20 mg q 30 min prn in a
• Clinician comfort and familiarity with seda- 70-kg patient)
tive agents. • Vecuronium: 0.1 mg/kg load, then 0.01 mg q
• Patient hemodynamics. 30–45 min prn (e.g., 7 mg load followed by
• Anticipated natural history of the underlying 1 mg q 30–45 min prn in a 70-kg patient)
illness.
• Time and transport issues. Note that muscle relaxants have no seda-
tive or amnestic properties. If muscle relax-
Examples of choices for postintubation ants are deemed necessary after intubation, or if
sedation include: rocuronium was used for intubation (with its
duration of 30 minutes or more), it is essential
• Midazolam: 0.025–0.05 mg/kg IV q 30–60 min to co-administer some form of sedative/amnestic
(e.g., 2–5 mg in a 70-kg patient). medication. Unfortunately, in the paralyzed
• Propofol: 25–100 µg/kg/min (10–40 mL/h in patient there is no way to be assured of an ade-
a 70-kg patient) by infusion. A 0.2–0.6 mg/kg quate level of sedation. Although blood pres-
bolus may be necessary initially. sure and heart rate are crude indicators of a
patient’s level of awareness, they must be used include stiff lungs (e.g., asthma, COPD, conges-
together with knowledge of dosages and tive heart failure, lung contusion, aspiration,
expected durations of the administered seda- anaphylaxis, or pulmonary embolus); or extra-
tives. On this latter point, it should be noted parenchymal issues causing decreased compli-
that patients who are critically ill and/or in shock ance (e.g., pneumo- or hemothorax, obesity or
have lower sedative/hypnotic requirements. In distended stomach/abdomen). Problems with
this population, a small dose should be given the ventilator circuit or ETT, including endo-
initially, with subsequent doses titrated to effect, bronchial intubation, ETT kinking, or mucus
while monitoring blood pressure. plugging, should be ruled out. Coughing or
bucking on the tube (“fighting the vent”) may
also result in high airway pressures. Coughing
䉴 THE VENTILATED PATIENT may be an indication that the ETT has migrated
distally and is touching the carina. Peak pres-
A detailed discussion of mechanical ventilation sures exceeding 35 cm H2O increase the risk of
is beyond the scope of this monograph. In emer- barotrauma.
gency airway management, the priority is always Adjustment of tidal volume, respiratory rate,
to ensure oxygenation and maintain perfusion: and flow rate may be required to reduce peak
this does not generally necessitate knowledge airway pressure. By varying flow rates, the inspi-
of complex ventilation strategies. Respiratory ration:expiration time (I:E ratio) may also be
therapists are an important resource for manipulated in an attempt to lower airway pres-
problem-solving ventilator issues. A brief sures. The I:E ratio is usually set at 1:2, although
overview of modes of ventilation follows. the expiratory time may need to be increased in
air trapping situations such as severe asthma.
Assist Control (AC) Decreasing the respiratory rate will also allow
more time for expiration and may help lower
Following RSI, most patients will require assist airway pressures. Most patients can tolerate an
control (AC) ventilation. With AC, the ventilator increase in CO2 (“permissive hypercapnia”) sec-
does most of the work. To initiate AC, a basic ondary to decreased minute ventilation, so that
strategy is to simply set the tidal volume and the limiting factor in adjusting ventilator para-
rate (i.e., the minute ventilation). Typical initial meters will be primarily that needed to maintain
settings would be a tidal volume of 8–10 cc/kg oxygenation. Bear in mind, however, that there
with a rate of 10 breaths per minute. As the are some situations in which CO2 management
muscle relaxant wears off and the patient initi- is in fact critical, as in the patient with increased
ates an additional breath, he will get the pre- intracranial pressure (ICP) and signs of hernia-
scribed tidal volume at a respiratory rate he tion. Finally, occasionally it will be necessary to
dictates. However, with no spontaneous breath- ventilate with peak airway pressures over 35 cm
ing, the minimum prescribed volume and rate H2O to maintain acceptable gas exchange. In
are maintained. This mode of ventilation is these situations, one should be prepared to
designed to give the patient a complete rest from urgently manage barotrauma by decompression,
the work of breathing. As such, ideally, the patient if required.
should not be initiating any spontaneous breaths.
Airway pressures should be monitored in
the ventilated patient. In patients with normal Assisted Ventilation
lungs, the peak airway pressure should be less
than 25 cm H2O with the foregoing settings. Assisted ventilation requires the patient to have
Common causes of increased airway pressures some respiratory drive. There are many assisted
184 CHAPTER 10
ventilation methodologies. Some forms provide hemodynamic effects more consistently and
a set amount of positive pressure (e.g., pressure may also increase risk of barotrauma.9 PEEP
support ventilation) when the ventilator senses may also impair cerebral venous drainage and
an inspiratory effort by the patient, while others should be used with caution in the head-injured
ensure a minimum number of breaths per patient, as it may interfere with cerebral perfu-
minute. Assisted ventilation is commonly used sion pressure by both increasing ICP and low-
in the ICU, particularly for weaning patients. It ering arterial blood pressure.
is generally better tolerated, with a lower occur- PEEP may help reduce atelectasis and, in
rence of fighting the ventilator. Such modes of this respect, most patients benefit from its
ventilation can also be used to gradually application at a low level (e.g., 5 cm H2O).
increase the patient’s work of breathing over PEEP is particularly useful in patients with
time. pulmonary edema, and the morbidly obese.
Pressure support ventilation (PSV) is one of Relative contraindications to PEEP include
the simplest forms of assisted ventilation and in marked hypotension or hypovolemia; airway
the patient with good respiratory drive and normal pressures in excess of 35 cm H2O; uncorrected
or near-normal lungs, can be used to simply intrathoracic pathology (pneumo- or hemotho-
help the patient overcome the resistance of rax); and increased ICP.
breathing through an ETT. PSV of 5–10 cm H2O
is usually sufficient for this purpose. As an
example, PSV would be a good ventilatory mode Titration of PaO2 and PaCO2
for the patient intubated strictly for airway pro-
tection, but who is breathing adequately. PSV The goal of ventilation is to maintain oxygena-
could also be used for the patient intubated to tion and to eliminate CO2. Oxygenation can be
overcome airway obstruction at or above the approximated with pulse oximetry but this is
level of the glottis. Higher levels of pressure sup- only accurate over a small range of values. Due
port can be used, in certain circumstances, to to the shape of the oxygen-hemoglobin dissoci-
help the spontaneously breathing patient main- ation curve, the patient’s oxygenation status
tain adequate tidal volumes. Other types of assist (PaO2) can actually deteriorate considerably
mode ventilation may be appropriate if the clin- before being reflected by the oxygen saturation
ician in charge is knowledgeable in their use. (SaO2): the patient being ventilated with an FiO2
of 1.0 may deteriorate from a PaO2 of 400 mm
Hg to a PaO2 of 100 mm Hg with an unchanged
Positive End—Expiratory Pressure SaO2 of 100%. In some patients it may be diffi-
(PEEP) cult or impossible to obtain an SaO2 reading at
all due to hypothermia, hypotension, or periph-
Positive end–expiratory pressure (PEEP) is a eral vascular disease. In this situation, FiO2 will
strategy used to improve oxygenation by have to be titrated to PaO2 readings obtained
alveolar recruitment and increasing functional from arterial blood gases.
residual capacity (FRC). It has complex physio- CO2 elimination is the other half of the ven-
logic implications, including the potential to tilation equation and is particularly important
lower blood pressure through its adverse effect in the patient with increased ICP. The colorometric
on venous return to the heart.7 This relates to devices used to confirm successful ETT
the amount of applied PEEP and is not usually a placement do not allow ongoing quantitative
significant problem under 10 cm H2O pressure measurement of CO 2 . Some clinical settings
unless the patient is hypovolemic. Higher levels may have capnographic monitoring which will
of PEEP (i.e., 10–20 cm H2O) will cause adverse measure and continuously display ETCO2. The
relationship between ETCO2 and PaCO2 (typi- A. Proper placement of the ETT in the trachea
cally the ETCO2 is 5 mm Hg lower than actual and above the carina should be reconfirmed.
PaCO2) generally remains constant in the para- B. Accidental extubation is obviously a major
lyzed, mechanically ventilated patient without risk to the patient en route. As difficult as it
significant lung pathology, as long as hemody- may have been to intubate the patient in the
namic and ventilatory parameters remain ED, it will be more difficult in the confined
unchanged.10,11 In the manually ventilated space of an ambulance or helicopter. Metic-
patient or with a rapidly changing respiratory ulous attention should be paid to securing
rate, this relationship is too volatile to be accu- the tube, as deaths have followed accidental
rate. In the stable patient, ETCO2 and SaO2 can extubation.
be used to monitor gas exchange, although C. Paralysis should be strongly considered to
blood gases should be repeated if there are help prevent extubation during transport.
major changes in hemodynamics or ventilation A single dose of nondepolarizing muscle
parameters. Although it is becoming more com- relaxant, with accompanying sedation, is
monly available, continuous ETCO2 monitoring appropriate for anticipated transport times
is still not commonly used in EDs.12 of under an hour. Longer transports may
require additional doses to ensure adequate
relaxation.
䉴 TRANSPORT ISSUES D. For short trips, a bolus of sedative/amnestic
can be given prior to transport. Longer trips
Transporting the critically ill, intubated patient will require additional doses or an infusion.
poses several challenges. The following airway E. If the patient is receiving positive pressure
issues should be considered prior to transport: ventilation and is at risk for pneumothorax
䉴 TABLE 10–1 THE EFFECT OF ALTITUDE ON PARTIAL PRESSURES OF OXYGEN
It is important to remember that the partial pressure of inspired oxygen decreases with altitude. The
cabins of commercial aircraft are usually pressurized to the equivalent of 8000 feet, which translates
to a patient alveolar PO2 of 75 mm Hg and an O2 saturation of 92%–93%. Clinicians who live at alti-
tudes significantly above sea level and those who must transport critically ill patients by air (or those
who think they can relax on a commercial flight!) need to be aware of Boyle’s law, which simply states
that as ambient pressure decreases, gas volume increases and therefore the density of that gas
decreases.
Partial pressures of oxygen in dry air for representative pressure altitudes

Altitude (ft) Atmospheric Pressure (mm Hg) Ambient O2 (mm Hg)
0 760 159
5000 632 133
10000 523 110
12000 483 101
13000 465 97
14000 447 94
15000 429 90
20000 350 73
25000 282 59
186 CHAPTER 10
(e.g., rib fractures; significant pulmonary 3. McCoy EP, Russell WJ, Webb RK. Accidental
contusion), serious consideration should be bronchial intubation. An analysis of AIMS incident
given to placement of a chest tube prior to reports from 1988 to 1994 inclusive. Anaesthesia.
transport. 1997;52(1):24–31.
4. Lovett PB, Flaxman A, Sturmann KM, et al. The
F. During patient transport, the administered
insecure airway: a comparison of knots and com-
FiO2 should be 100%. This high FiO2 will
mercial devices for securing endotracheal tubes.
provide an extra margin of safety in case of BMC Emerg Med. 2006;6:7.
an accidental extubation, and if the trans- 5. Franklin C, Samuel J, Hu TC. Life-threatening
port is by air, it will help compensate for hypotension associated with emergency intubation
the decrease in ambient partial pressure of and the initiation of mechanical ventilation.
oxygen with altitude (Table 10-1). Am J Emerg Med. 1994;12(4):425–428.
G. Water should be considered for ETT cuff 6. Shafi S, Gentilello L. Pre-hospital endotracheal intu-
inflation for an air transport if cabin pres- bation and positive pressure ventilation is associ-
sure will be an issue, as air-filled cuffs can ated with hypotension and decreased survival
expand at altitude. in hypovolemic trauma patients: an analysis of
the National Trauma Data Bank. J Trauma.
2005;59(5):1140–1145; discussion 1145–1147.
䉴 SUMMARY 7. Horak J, Weiss S. Emergent management of the
airway. New pharmacology and the control of
Tracheal intubation alone does not define an comorbidities in cardiac disease, ischemia, and
endpoint in airway management. Although a valvular heart disease. Crit Care Clin. 2000;16(3):
priority, airway management is just one compo- 411–427.
nent in the resuscitation of the acutely ill patient. 8. Brain Trauma Foundation; American Association of
The managing clinician should remain vigilant Neurological Surgeons; Joint Section on Neuro-
throughout the process of care and pay close trauma and Critical Care. Resuscitation of blood
attention to the postintubation period. Hypoten- pressure and oxygenation. J Neurotrauma.
sion is common and often requires intervention. 2000;17(6–7):471–478.
9. Carroll GC, Tuman KJ, Braverman B, et al. Minimal
Sedation is almost always indicated and paralysis
positive end-expiratory pressure (PEEP) may be
should be used when needed to optimize gas
“best PEEP”. Chest. 1988;93(5):1020–1025.
exchange, or protect the patient from accidental 10. Mackersie RC, Karagianes TG. Use of end-tidal
extubation. carbon dioxide tension for monitoring induced
hypocapnia in head-injured patients. Crit Care Med.
REFERENCES 1990;18(7):764–765.
11. Kerr ME, Zempsky J, Sereika S, et al. Relationship
1. Benumof JL, Dagg R, Benumof R. Critical hemo- between arterial carbon dioxide and end-tidal car-
globin desaturation will occur before return to bon dioxide in mechanically ventilated adults with
an unparalyzed state following 1 mg/kg severe head trauma. Crit Care Med. 1996;24(5):
intravenous succinylcholine. Anesthesiology. 785–790.
1997;87(4):979–982. 12. Deiorio NM. Continuous end-tidal carbon dioxide
2. Szekely SM, Webb RK, Williamson JA, et al. The monitoring for confirmation of endotracheal tube
Australian Incident Monitoring Study. Problems placement is neither widely available nor consis-
related to the endotracheal tube: an analysis of tently applied by emergency physicians. Emerg
2000 incident reports. Anaesth Intensive Care. Med J. 2005;22(7):490–493.
1993;21(5):611–616.
Chapter 11
Approach to Tracheal Intubation
䉴 KEY POINTS impart useful information, but does not

guarantee a subsequent view of the laryn-
• The risk for the inexperienced clinician geal inlet in the anesthetized patient.
of proceeding with intubation must be
balanced against the benefit of awaiting
the arrival of more experienced help, 䉴 INTRODUCTION
especially if difficulty is anticipated.
• Difficult laryngoscopy in one clinician’s The indications for endotracheal intubation
hands may be less difficult in another’s. have been reviewed in Chap. 2. For the patient
• Whatever the makeup of the assembled requiring intubation in an emergency, assuming
team, there needs to be a common an attending clinician with requisite knowl-
understanding of the language of airway edge and skills, the next step is to decide how
management. best to proceed with the intubation. This deci-
• Recognizing the potential for difficult intu- sion will be predicated upon the following
bation should trigger appropriate early factors:
calls for help, heightened vigilance, and
improved preparedness. A. The airway evaluation. Evaluating the
• The uncooperative patient will often patient for predictors of difficulty with laryn-
need a rapid-sequence intubation (RSI), goscopic intubation, bag-mask ventilation
even in face of predictors of difficult and rescue oxygenation (referring to use of
laryngoscopy. an extraglottic device [EGD] or cricothyro-
• Relatively large doses of a sedative- tomy) is of primary importance in deciding
hypnotic agent alone do not create intu- how to proceed.
bating conditions as favorable as those B. Presenting system pathophysiology.
using RSI with neuromuscular blockade. Anticipated patient response to drugs used
• Proceeding with RSI in the uncooperative for rapid-sequence intubation (RSI) may
patient with predictors of both difficult intu- also impact the decision.
bation and difficult bag-mask ventilation C. Patient cooperation. The overtly uncoop-
(BMV) is risky. Extra preparations are erative patient will usually require an RSI,
needed. whereas a more cooperative patient may be
• Obtaining a view of the epiglottis as part able to tolerate an awake intubation, if dif-
of an “awake look” laryngoscopy may ficulty is predicted.
187
188 CHAPTER 11
䉴 THE AIRWAY EVALUATION 䉴 TABLE 11–2 PREDICTING DIFFICULT

BAG-MASK VENTILATION
General Comments Consider whether there may be difficulty
with attaining a mask seal on the patient’s
Most patients requiring airway management in face, or, if a mask seal is attained, if there
emergencies will need to be intubated. Most will be difficulty controlling collapsing soft
intubations in emergencies are facilitated by tissues in the naso-, oro-, or laryngophar-
direct laryngoscopy, so a good starting point for ynx, or, if a patent upper airway has been
the airway evaluation is to seek predictors of obtained, whether obstructing pathology
at or below the cords, or poor compliance
difficult direct laryngoscopy. This has been
of the lungs/chest wall will cause difficulty.
discussed in more detail in Chap. 5, but as a
Alternatively, the mnemonic “BOOTS” can
review, these predictors appear in Table 11–1. be used:
The airway evaluation should not stop there, B—Beard and other mask seal issues
however. Bag-mask ventilation (BMV) may O—Obesity
be needed prior to, or between intubation O—Older (age >55 years)
attempts, so a formal assessment of predictors of T—Toothless
difficulty with BMV should also be undertaken. S—Sounds: Snoring; Stridor (obstructing
These predictors appear in Table 11–2 and have airway pathology); Stiff lungs (wheezing;
been discussed in more detail in Chap. 4. Finally, rales)
if a failed airway is encountered at any point,
rescue oxygenation may need to be undertaken
with placement of an EGD or cricothyrotomy, so
the patient should also be evaluated for the pre- of difficulty with rescue oxygenation are
dicted success of these maneuvers. Predictors reviewed in Table 11–3 and Chap. 7.
Note that predicted difficult intubation by
direct laryngoscopy (DL) may not equate to
predicted difficult intubation using a different
device. For those familiar with their use,
䉴 TABLE 11–1 PREDICTING DIFFICULT DIRECT
LARYNGOSCOPY
alternative intubation devices such as the
LMA-Fastrach, lightwand, or rigid fiberoptic- or
Consider whether there will be a problem video-based instruments may enable successful
inserting the laryngoscope blade into the intubation of the patient with traditional predic-
patient’s mouth, or once inserted, if difficulty tors of difficult direct laryngoscopy. While most
will be encountered displacing the tongue emergency intubations are in fact facilitated by
out of the line-of-sight, or if the tongue has direct laryngoscopy, proceeding with RSI in the
been controlled, whether the larynx will be
patient with predicted difficulty will be less intim-
in an abnormal location, or
unrecognizable.
idating if alternatives to DL are predicted to suc-
Alternatively, the mnemonic “MMAP” can be ceed, and the clinician is skilled in their use.
used:
M—Mallampati classification The Dimensions of Difficulty Triangle
M—Measurements: minimum of 3 finger-
breadths of mouth opening; 3 of thyromental
The concept of evaluating the patient in all three
span, and 1 cm of jaw protrusion
A—Atlantooccipital (i.e., head and upper
“dimensions1 of difficulty” in airway manage-
neck) extension ment can be represented by the three apices of
P—Obstructing airway pathology a triangle2 (Fig. 11–1). This visually illustrates
the concept that if difficulty is anticipated in
APPROACH TO TRACHEAL INTUBATION 189
䉴 TABLE 11–3 PREDICTING DIFFICULT RESCUE OXYGENATION
Difficult Extraglottic Device Use Difficult Cricothyrotomy

Consider whether there may be difficulty Consider whether there will be difficulty with
inserting the device through the patient’s identification of the cricothyroid membrane,
mouth, or having inserted it, whether there or having identified its location, whether there
will be a problem seating the device in front will be trouble accessing the trachea through it.
of the laryngeal inlet, or even if well seated,
whether obstructing pathology at the cords, or The mnemonic “DART” can also be used:
poor compliance of the lungs or chest wall
will preclude effective ventilation due to
“pop-off” pressure being exceeded.
Alternatively, the mnemonic “MOODS” can D—Distortion of the overlying anatomy due to
be used: blunt trauma, hematoma or infection
MO—Mouth opening limited A—Access issues due to obesity, or inability to
O—Obstructing pathology at or below the cords extend head and neck
D—Displacement, Distortion or Disruption of the
upper or lower airway R—History of neck radiation
S—Stiff lungs or chest wall T—Tumor
any one apex, before proceeding with an intu- be predicted in a C-spine immobilized patient,
bation technique that ablates the patient’s spon- successful intubation should be possible with
taneous respirations, success must be predicted basic maneuvers such as external laryngeal
with oxygenation in at least one, and preferably manipulation (ELM) and use of the bougie. In
both other apices. this same patient, BMV and rescue oxygenation
It should be emphasized that predicted dif- with an EGD should be nonproblematic. In con-
ficulty with airway management lies on a spec- trast, the patient with obstructing upper airway
trum from “moderately difficult” to “very difficult pathology presents a very difficult situation.
or impossible.” Moderate difficulty should be Here, all three points on the “dimensions of dif-
overcome by fairly routine techniques. For ficulty” triangle (BMV, laryngoscopy and intu-
example, although difficult laryngoscopy may bation, and rescue oxygenation with an EGD)
may fail if RSI is undertaken. This suggests the
need to consider an awake intubation.
Laryngoscopy and
intubation
A NOTE ON THE LIMITATIONS TO PREDICTIONS
When encountered, many difficult airways are
reported as unanticipated. With the prediction
Oxygenation by…
of an “easy ride” never being guaranteed, the
clinician should be prepared for difficulty during
Bag-mask Rescue oxygenation every emergency intubation. Indeed, the value
ventilation techniques of even trying to predict difficulty in emergen-
Figure 11–1. The three “dimensions of diffi- cies has been questioned, on this basis. 3–7
culty” of airway management. An adaptation However, the airway assessment is still impor-
of Sakles’ triangle.2 tant and should be done, for two reasons:
190 CHAPTER 11
• Information yielded from the airway assess- to proceeding. In most cases, this translates to a
ment will help point to the safest method for preintubation fluid bolus and judicious drug
proceeding with the intubation. dosing. However, in certain situations (e.g., the
• Doing an active and deliberate airway profoundly hypotensive or hypovolemic patient)
assessment becomes a “cognitive forcing it may be appropriate to consider avoiding sys-
strategy.”8 Even if no difficulty is predicted temic drugs altogether in favor of proceeding
as a result of the assessment, it will help with an “awake” (i.e., non-RSI) intubation.
heighten vigilance and improve prepared-
ness. The literature supports the use of System at Risk
such cognitive forcing strategies as a
means of reducing medical error in emer- Occasionally, the presenting patient pathophys-
gency situations.8 iology impacts the decision-making process. For
example, the patient presenting with suspected
increased intracranial pressure (ICP) may best
䉴 PRESENTING SYSTEM be intubated by RSI, as induction medications
PHYSIOLOGY may help attenuate adverse effects of laryn-
goscopy and intubation on ICP. A second
The airway assessment, as outlined above, attempts example is the patient in status asthmaticus, in
to identify anatomic obstacles to physically secur- whom RSI using higher dose ketamine as an
ing the airway. However, system physiology induction agent may aid with bronchodilation.
issues should also be considered. Specifically,
attention should be directed to two areas: 䉴 PATIENT COOPERATION
• Hemodynamic status Especially with predictors of a difficult airway,

• System at risk an assessment of the patient’s ability to cooper-
ate should be made, as an awake intubation
generally requires an element of cooperation.
Hemodynamic Status Commonly, because of toxicologic, pathophys-
iologic (including hypoxia) or neuroanatomic
One of the most common adverse responses to derangement, patients requiring emergency
intubation of the acutely ill patient is hypoten- intubation are not able to cooperate. However,
sion. This is most commonly due to direct patient cooperation should be perceived as a
effects of induction or sedative drugs, in addi- continuum.
tion to the relief of high sympathetic tone and As depicted in Fig. 11–2, at one end of the
adverse effects of positive pressure ventilation spectrum is the actively uncooperative patient,
on venous return. The clinician must consider and at the other, the awake and cooperative
and prepare for these predictable effects prior patient.
Actively uncooperative: e.g., Passively uncooperative “Could be cooperative”: Awake and

clenched teeth or combative e.g., “nearly or newly” dead may obtain cooperation with cooperative
explanation or pharmacotherapy
Figure 11–2. The continuum of patient cooperation.

A. The actively uncooperative patient may be • Haloperidol, titrated to effect, can be used
physically combative, or may have clenched in divided doses of 2.5–5 mg IV.
teeth secondary to a decreased level of con- • Other agents may prove useful in this con-
sciousness (LOC). For the physically combative text in the future, including the newer
patient, an awake approach will not be feasi- alpha-2 receptor agonist dexmedetomidine.
ble without varying degrees of physical
restraint, which is rarely indicated. The patient These agents are discussed further in Chap. 13.
deemed actively uncooperative on the sole Failure to respond to such medications would
basis of clenched teeth may tolerate an place the patient in the more actively uncoop-
attempt at blind nasal intubation. However, erative category.
such a patient will usually require an RSI,
even with predictors of difficult laryngoscopy. D. The awake and cooperative patient. Many
In this situation, however, predicted ease of patients with difficult airways present in this
BMV and/or rescue oxygenation is impera- state, including those with upper airway
tive. Balancing the risk of a failed airway (i.e., pathology.
can’t intubate, or can’t intubate, can’t oxy-
genate) against the benefit of rapidly securing All except the “actively uncooperative” patient
the airway is at the crux of this difficult may allow the option of awake (i.e., non-RSI)
decision. intubation. It goes without saying that waiting
B. The passively uncooperative patient will for an actively uncooperative patient to med-
exhibit little or no resistance to an attempted ically deteriorate to the point of being mori-
airway maneuver, but neither is cooperation bund and only passively uncooperative is not
offered. Two categories exist: (a) the arrested, good practice!
or nearly dead patient requiring no pharma-
cologic adjuncts to facilitate intubation, and
(b) the intrinsically sedated patient. An exam- 䉴 PROCEEDING WITH INTUBATION:
ple of the latter category would be a patient A REVIEW OF THE CHOICES
hypercarbic due to respiratory failure.
Topical airway anesthesia, combined with Most emergency intubations are performed
the patient’s drowsiness may allow a non-RSI awake, or using RSI. Advantages and disadvan-
approach, even if not truly “awake” or tages of each route, together with a more
cooperative. detailed description of the techniques have been
C. The “could be cooperative” patient may in presented in Chaps. 8 and 9. However, to rede-
fact cooperate with an awake intubation fine the terms for consideration in this chapter,
when an explanation is presented (bluntly or the following choices are available:
with sympathy). Alternatively, the patient
may be controllable with medications such A. Awake intubation. Although the term is
as ketamine or haloperidol: poor, “awake” describes a technique in
• Ketamine can be used in titrated doses which the mainstays of patient preparation
of 0.25–0.5 mg/kg IV. Ketamine’s advan- for intubation include topical airway anes-
tage lies in its tendency to not interfere thesia and light (if any) sedation. Although
with maintenance of spontaneous ventila- rarely used in contemporary practice, blind
tion. Detractors point to increased secre- nasal intubation would be included in this
tions and propensity to laryngospasm. category.
However, the risk of laryngospasm is low B. Rapid-sequence intubation (RSI). Fol-
(<1%), and it occurs predominantly in lowing appropriate preparation, RSI involves
young children.9 the administration of predetermined doses
192 CHAPTER 11
of an induction agent and muscle relaxant the technique, availability of equipment and
in rapid succession, application of cricoid drugs, and trained assistants. For the clinician
pressure and quick placement of an endo- less comfortable with RSI, an assessment of
tracheal tube. patient cooperation should be made. As long
C. Primary surgical airway. Primary cricothy- as the patient is not actively uncooperative, this
rotomy or tracheotomy may occasionally be may add the option of an awake intubation
necessary in certain airway emergencies (Fig. 11–3, track 1).
(e.g., severe facial trauma, or advanced airway
infections).
Uncooperative Patient
As previously mentioned, a relatively large For the actively uncooperative patient with no
dose of a sedative agent by itself does not cre- predictors of difficulty, RSI is indicated for rapid
ate intubating conditions as favorable as those control of the patient and optimal intubating
obtained with RSI using neuromuscular conditions (Fig. 11–3, track 2).
blockade,10–13 nor is this approach safer than
RSI. In fact, deep sedation used alone signifi- Difficulty Predicted
cantly decreases protective reflexes and can be
detrimental to the hemodynamic status of the Preamble
patient, without necessarily improving ease of Algorithms developed for the elective surgical
intubation. Most contemporary airway manage- setting often suggest simply proceeding with
ment education programs are discouraging the awake intubation if difficulty is predicted. How-
sole use of deep sedation to facilitate intubation. ever, for the emergency, out-of-operating room
(OR) environment, these algorithms often fail to
account for situation acuity, or whether the
patient is able to cooperate with an awake intu-
䉴 PROCEEDING WITH INTUBATION: bation attempt. Patient cooperation is the next
THE APPROACH TO TRACHEAL algorithm branch point requiring consideration
INTUBATION ALGORITHM for the patient with predictors of difficulty.
Choosing how to proceed is predicated upon iden- Difficulty Predicted: Cooperative

tifying predictors of difficulty during patient assess- Patient
ment. Identified difficulty represents the first branch
point in the “Approach to Tracheal Intubation” A. The decision. Especially in the patient with
algorithm (Fig. 11–3), to which the reader is invited an airway exam suggesting possible diffi-
to refer during the ensuing discussion. Note that culty with BMV as well as laryngoscopic
this algorithm is presented as a guide (not intubation, an awake approach should be
doctrine), and is meant to facilitate safe decision- considered, if patient cooperation permits
making before the procedure has begun. (Fig. 11–3, track 3). This is the “gold stan-
dard” in such patients: the adage “no
bridges have been burned” applies, in that
No Difficulty Predicted these patients continue to breathe for them-
selves, and can maintain and protect their
Cooperative Patient own airways. This is definitely the preferred
If no difficulty is predicted in any facet of airway route with obstructing airway pathology, as
management, most clinicians would choose to proceeding with RSI runs the risk of creating
proceed with an RSI for emergency intuba- a “can’t intubate, can’t oxygenate” situa-
tions. However, this assumes familiarity with tion. It may also include the patient with no
Patient assessment: Anatomy and presenting

pathophysiology1
No difficulty predicted Difficulty airway predicted
Cooperative2 Uncooperative3 Cooperative2 Uncooperative3
Assess likelihood of
“Awake”4 or RSI6 RSI5 “Awake”4
successful
oxygenation if
(Track 1) (Track 2) (Track 3)
intubation fails6
BMV and rescue BMV and/or rescue

oxygenation predicted oxygenation not
successful predicted successful
RSI7 Other options8
(Track 4) (Track 5)
Figure 11–3. Approach to Tracheal Intubation Algorithm.

(1) Patient assessment includes an evaluation of anticipated difficulty with (a) laryngoscopy and intubation;
(b) bag-mask ventilation; and (c) rescue oxygenation with an extraglottic device (EGD) or cricothyrotomy.
The patient’s physiologic status should also be considered, including hemodynamic status and the primary
underlying presenting condition (heart, head, lungs etc.)
(2) The ‘cooperative’ patient in this context may be fully awake and cooperative; ‘could be’ cooper-
ative with pharmacologic agents or a reassuring explanation; or passively uncooperative, whereby no
significant resistance will be offered to a non-RSI technique.
(3) For the uncooperative patient with an anticipated difficult airway, help should be sought early. Can
the patient be ‘bridge’ oxygenated until help comes? The actively uncooperative patient presents very
different considerations than the passively uncooperative patient.
(4) An ‘awake’ intubation refers merely to an intubation facilitated by topical airway anesthesia with,
or without small amounts of sedative agent, as distinct from rapid-sequence intubation. Thus, the term
‘awake’ in this context may also refer to the intubation of a deeply obtunded patient, as long as a for-
mal RSI, facilitated by muscle relaxants, is not being undertaken.
(5) Both RSI and awake techniques require similar manual skills. RSI additionally requires a sound
knowledge of airway pharmacology and a clear plan for dealing with the difficult airway. Any RSI
undertaken in the face of predicted difficulty should be done with adequate preparation including avail-
ability and briefing of extra helpers, and alternative intubation techniques and rescue oxygenation
devices, and the skill to use them.
(6) This should include an assessment of whether BMV and ideally both of a rescue EGD and cricothy-
rotomy are predicted to succeed in achieving oxygenation.
(7) This situation is far from ideal and is only done if the benefit of expeditious intubation outweighs
the risk of a failed airway with attendant need for cricothyrotomy. RSI undertaken in the face of pre-
dicted difficulty should ideally be undertaken when additional help and equipment are available, with
the expectation to proceed to EGD placement or cricothyrotomy. In general, RSI should only be
undertaken if moderate difficulty with DL is expected, and is not a recommended first-line approach
when upper airway pathology is suspected.
(8) Other options: see discussion in text.
194 CHAPTER 11
anatomic predictors of difficult intubation, (with EGD and/or cricothyrotomy) are pre-
but simply difficult physiology (e.g., signif- dicted to succeed, RSI may be the most
icant hypotension), in whom avoiding desta- appropriate option (Fig. 11–3, track 4). Note
bilizing induction agents may be desirable. that the margin of safety of this route
B. Preparation and Execution. For the awake includes a favorable assessment of two of
intubation, communication should be estab- the three apices of the dimensions of difficulty
lished with the patient, topical airway anes- triangle (Fig. 11–1) predicting successful
thesia should be administered, and the oxygenation (i.e., BMV and rescue oxy-
patient positioned as comfortably as possible. genation). Extra preparations will have to
In general, the procedure should employ be undertaken (see below). Two provisos
an alternative (e.g., fiberoptic) intubation apply to using RSI in this situation:
approach, especially if significant difficulty • Proceeding with RSI is only appropriate
is anticipated with direct laryngoscopy.14 for the patient with predicted moderately
Conversely, the patient undergoing an awake difficult laryngoscopy. Practically speak-
intubation for any other aspect of predicted ing, this refers to the patient in whom there
difficulty (e.g. significant hemodynamic is still a reasonably good chance that ‘best
instability) may well be successfully intu- look’ laryngoscopic intubation (Table
bated with direct laryngoscopy. The chosen 12–2), including ELM, head lift, adjunctive
approach will obviously depend on clinician use of a bougie or fiberoptic stylet, or a
skill and equipment availability. blade change will succeed. An additional
margin of safety is provided by the clini-
Difficulty Predicted: Uncooperative cian skilled in the use of an alternative
Patient intubation device, such as the LMA Fas-
The question in this situation is “...faced with a trach, lightwand, or fiberoptic- or video-
patient in whom I have predicted difficulty, but based instrument.
who is unable to cooperate with an awake intu- • Secondly, it is critical to determine whether
bation, can I safely proceed with RSI?” The any signs or symptoms of obstructing
patient with predictors of difficult airway man- airway pathology are present. In addi-
agement who is actively uncooperative presents tion to dyspnea, signs of pathological
a therapeutic conundrum. Use of RSI is obvi- upper airway obstruction often include
ously desirable in such a patient to gain control stridor and/ or altered voice. Stridor in par-
of the situation. However, before proceeding ticular indicates an airway that is already
with RSI and rendering a breathing patient critically narrowed. The concern in these
apneic, one must be reasonably certain that if patients is that by administering sedative
intubation fails, one can take over oxygenation or induction agents, a tenuous airway
with BMV, or if BMV fails, that rescue oxygen being maintained by patient effort will
will succeed with EGD placement or cricothy- be lost: with obstructing pathology,
rotomy. Thus, based on the bedside airway landmarks can be obscured at laryn-
evaluation, a judgment of predicted success of goscopy, and BMV can be impossible.
all these maneuvers is crucial. Thus, the patient population with
obstructing airway pathology should
OXYGENATION PREDICTED TO SUCCEED generally not undergo RSI.
B. Preparation and Execution. Despite the
IF INTUBATION FAILS
prediction of easy BMV, laryngoscopy has
A. The Decision. In the uncooperative patient been assessed as being at least moderately
in whom difficult laryngoscopy is anticipated, difficult. If RSI is undertaken, the following
but in whom BMV and rescue oxygenation preparations should occur:
• Extra help should be summoned. the risk of performing the intubation may
• A variety of blades should be available, outweigh its benefit. As such, the best
and a styleted, small endotracheal tube course of action may be to await the arrival
(ETT) prepared. The patient should be well of additional expertise or equipment.
preoxygenated. “Best Look” laryngoscopy • Calling for additional expertise. Suc-
should be employed, including optimal cessful intubation is aided not only by
allowable positioning and ELM. favorable patient anatomy, but also the
• A bougie or fiberoptic stylet should be clinician’s skill and experience: laryn-
available for immediate use. goscopy which seems difficult in one per-
• An alternative intubation device should be son’s hands may be less so in another’s.
prepared for use in case direct laryn- The help of a colleague who has more
goscopy fails after one or two attempts. expertise should be sought. If an unco-
• An EGD should be prepared for failed intu- operative patient is not in immediate dan-
bation or failed oxygenation situations ger, then assisted positive pressure oxy-
(Chapter 12). Cricothyrotomy equipment genation (e.g., with BMV, noninvasive
should be available. positive pressure ventilation or EGD such
• All of the above-mentioned equipment as the LMA or Combitube) may allow
should be appropriately sized for the time for help to arrive. Conversely, if the
patient, out of the package, lubricated, and situation allows, the patient may be
physically arranged on a nearby work sur- transferred unintubated to a location
face in the order of anticipated usage. where additional expertise or equip-
• Assistants should be briefed about the order ment is available. This may include
of transition from direct laryngoscopy to transfer to an OR for intubation facili-
alternative technique to rescue oxygena- tated by inhalational induction of
tion device, both to clarify the plan in the anesthesia, while maintaining sponta-
clinician’s mind and to inform the team. neous ventilation.
• Seeking additional information. It
OXYGENATION NOT PREDICTED TO EASILY may be possible to obtain more objec-
SUCCEED IF INTUBATION FAILS tive information about ease of BMV or
laryngoscopy. Especially in the “pas-
A. The Decision. The final situation to sively uncooperative” patient or with the
address is the difficult airway patient, who is assistance of small doses of a sedative
uncooperative, and in whom oxygenation agent, it may be possible to place a mask
may be difficult if intubation fails (Fig. 11–3, and gently assist the patient’s sponta-
track 5). This will be an unusual situation, neous respirations with a manual resus-
and places the clinician “between a rock citator to get a feeling for ease of BMV.
and a hard place,” with only an array of Secondly, if feasible, it may be possible to
suboptimal choices! Recognizing that the perform an “awake look” direct laryn-
risk-benefit balance has now completely goscopy, seeking additional information
shifted, one of the following options may be on the following:
appropriate: 䡩 Ease of blade insertion and tongue con-
• Deferring intubation. Not all indica- trol (can the entire epiglottis, and even
tions for emergency intubation are of the posterior cartilages be easily seen or
equal acuity. If significant difficulty is pre- is only the tip of the epiglottis visible?).
dicted in a patient with a lower priority 䡩 Mobility of the epiglottis (is it easily ele-
indication for intubation (i.e., airway pro- vated, or applied to the posterior pha-
tection, or predicted clinical deterioration), ryngeal wall?).
196 CHAPTER 11
䡩 Location and state of the laryngeal inlet option may be to “give it your best shot.”
(is it in the expected midline location, This may involve proceeding with RSI,
or is it displaced? Is there evidence of with a “double set-up” (see B. Prepara-
edema of laryngeal inlet structures?). tion and Execution, below), fully prepared
This last can also be assessed with and intending to proceed directly to
nasopharyngoscopy. cricothyrotomy if intubation is unsuccess-
The “awake look” should be interpreted ful and failed oxygenation ensues. In this
with caution: no evidence backs the sim- situation, one may be proceeding with RSI
plistic contention that “if the epiglottis can be with only the cricothyrotomy option of
seen, RSI can be performed, as the view the “rescue oxygenation” apex (Fig. 11–1)
should be better with a muscle relaxant.” available. To do this, the clinician must be
Finally, if by chance or skill, the laryngeal inlet confident that the benefit of rapidly secur-
happens to be visualized during an awake ing the airway by intubation outweighs
look, a small tube could potentially quickly the risk of encountering a failed airway.
be placed. • Primary surgical airway, be it cricothy-
• Pharmacologic restraint. Sedative agents rotomy or tracheostomy. An awake surgi-
(e.g. ketamine) can be used in an attempt cal airway (see next section), with con-
to render the patient cooperative enough tinued spontaneous respirations, is
to proceed with an awake intubation. theoretically an option. Generally, this
However, this approach is not without will be difficult without an element of
risk, and in the patient uncooperative due patient cooperation.
to an underlying organic etiology, these B. Preparation and Execution. Proceeding
agents may not reliably result in a suffi- with RSI in the uncooperative patient with
ciently cooperative state to allow formal predictors of both difficult intubation and dif-
awake intubation or awake look laryn- ficult BMV is risky. This risk is compounded
goscopy. Furthermore, sedating a patient if rescue oxygenation is also predicted to
with obstructing airway pathology may be difficult. Preparations should occur as
result in the loss of a marginally patent described in the previous section. However,
airway. in addition, this is the situation where a
• Blind nasal intubation. Described and double set-up may be appropriate, whereby
discussed in more detail in Chap. 8, blind the cricothyroid membrane has already been
nasal intubations, anecdotally, have identified, marked, prepped, and an indi-
bailed out many grateful clinicians over vidual with appropriate equipment is ready
the years, faced with what initially to rapidly proceed to cricothyrotomy.
appeared to be an impossible situation!
Blind techniques, including blind nasal
intubation, should generally not be 䉴 PRIMARY SURGICAL AIRWAY
attempted in the setting of inflammation,
infection, or trauma at the level of the On rare occasions, intubation from above the
cords or epiglottis. It may, however, cords will be impossible. Examples include
enable intubation in a patient whose lack patients with advanced airway infections,
of cooperation is limited to clenched teeth. laryngeal tumors, thermal injury, or severe
• Proceeding with RSI with a reduced facial trauma. Awake primary cricothyrotomy
margin of safety. On occasion, in the or tracheostomy may be the best choice when
patient who is obstructing, actively unco- a skilled set of hands is available at the
operative, and about to die, the only bedside.
䉴 SUMMARY laryngoscopy in West Africans. Can J Anaesth.

2005;52(3):291–296.
4. Randell T. Prediction of difficult intubation.
Patient assessment is crucial for deciding the
Acta Anaesthesiol Scand. 1996;40(8 Pt 2):
best approach to the emergency intubation. If
1016–1023.
no difficulty is predicted, generally, RSI is the 5. Rose DK, Cohen MM. The airway: problems and
preferred technique. As presented in the predictions in 18,500 patients. Can J Anaesth.
Approach to Tracheal Intubation algorithm, for 1994;41(5 Pt 1):372–383.
predicted difficulty with intubation, patient 6. Shiga T, Wajima Z, Inoue T, et al. Predicting diffi-
cooperation must be considered, as well as the cult intubation in apparently normal patients: a
likelihood of successful oxygenation using BMV meta-analysis of bedside screening test perfor-
or rescue techniques. The cooperative patient mance. Anesthesiology. 2005;103(2):429–437.
with predictors of difficult intubation may toler- 7. Levitan RM, Everett WW, Ochroch EA. Limitations
ate an awake intubation. The uncooperative of difficult airway prediction in patients intubated
in the emergency department. Ann Emerg Med.
patient with predictors of moderate difficulty
2004;44(4):307–313.
with intubation, but in whom BMV and/or res-
8. Croskerry P. Cognitive forcing strategies in clinical
cue oxygenation techniques (EGD or cricothy- decisionmaking. Ann Emerg Med. 2003;41(1):
rotomy) are predicted to be successful, may 110–120.
require RSI. The unusual case where significant 9. Green SM, Krauss B. Clinical practice guideline for
difficulty is predicted in all facets of airway man- emergency department ketamine dissociative seda-
agement requires extra help and preparation. tion in children. Ann Emerg Med. 2004;44(5):
Although predictions are often fraught with 460–471.
error, an explicit cognitive attempt to identify 10. Lieutaud T, Billard V, Khalaf H, et al. Muscle relax-
such barriers may help the clinician to “expect ation and increasing doses of propofol improve
the unexpected” during emergency airway intubating conditions. Can J Anaesth. 2003;50(2):
121–126.
management.
11. McNeil IA, Culbert B, Russell I. Comparison of
intubating conditions following propofol and
succinylcholine with propofol and remifentanil
REFERENCES 2 micrograms kg-1 or 4 micrograms kg-1. Br J
1. Murphy M, Hung O, Launcelott G, et al. Predicting Anaesth. 2000;85(4):623–625.
the difficult laryngoscopic intubation: are we on 12. McKeating K, Bali IM, Dundee JW. The effects of
the right track? Can J Anaesth. 2005;52(3):231–235. thiopentone and propofol on upper airway
2. Walls RM, Murphy M. Identification of the difficult integrity. Anaesthesia. 1988;43(8):638–640.
and failed airway. In: Walls RM, ed. Manual of 13. Donati F. Tracheal intubation: unconsciousness,
Emergency Airway Management. 2nd ed. Philadel- analgesia and muscle relaxation. Can J Anaesth.
phia: Lippincott Willimas and Wilkins; 2004;70–81. Feb 2003;50(2):99–103.
3. Merah NA, Wong DT, Ffoulkes-Crabbe DJ, et al. 14. Kovacs G, Law JA, Petrie D. Awake fiberoptic intu-
Modified Mallampati test, thyromental distance and bation using an optical stylet in an anticipated dif-
inter-incisor gap are the best predictors of difficult ficult airway. Ann Emerg Med. 2007;49(1):81–83.
Chapter 12
Response to an Encountered
Difficult Airway
䉴 KEY POINTS • Which alternative intubation, “go to” device

is chosen will depend on availability and
• The failed airway is defined in one of two clinician preference, skill, and experience.
ways: (a) failed intubation (can’t intu- • Some rescue oxygenation devices may
bate, CAN oxygenate) is defined simply by provide more protection against aspira-
a failure to intubate after three attempts, or tion of gastric contents than others, but
(b) failed oxygenation (can’t intubate, none are as effective in this regard as a
CANNOT oxygenate), which is the failure to cuffed endotracheal tube, which is still the
intubate in conjunction with a failure to oxy- desired end point.
genate with bag-mask ventilation (BMV). • In a failed oxygenation situation, the
• Multiple intubation attempts (defined as default maneuver is cricothyrotomy. Any
three or more) have been associated with attempt at rescue oxygenation with extra-
significant complications and poor patient glottic device (EGD) placement must be
outcomes. brief, and must not delay the onset of
• All too often in difficult or failed airway cricothyrotomy.
scenarios, fixation occurs on intubation
attempts, at the expense of attention to
maintaining oxygenation with bag-mask 䉴 INTRODUCTION TO THE
ventilation. ENCOUNTERED DIFFICULT
• Before the first attempt at laryngoscopy, a AIRWAY
plan for encountered difficulty should
have been mentally rehearsed, all equip- The identification of, and approach to the
ment assembled, and assistants briefed. patient with the anticipated difficult airway has
• In response to a Grade 3 or 4 view at laryn- been presented in Chap. 11. This chapter will
goscopy, all components of “best look” review how to respond to the difficult airway
laryngoscopy should be undertaken. once encountered at laryngoscopy or with
• A blade change need not be an automatic attempted bag-mask ventilation (BMV). Airway
response to a difficult laryngoscopy situa- management literature often refers to the sit-
tion, and should be undertaken only with uation where difficult laryngoscopy has
a specific goal in mind. been encountered as “unanticipated.” However,
199
200 CHAPTER 12
especially for the emergency intubation of an •. more than two attempts with the same
actively uncooperative patient, rapid-sequence blade;
intubation (RSI) may need to be undertaken even • a change in blade or use of an adjunct to
with predictors of difficulty. Ensuing difficult a direct laryngoscope (e.g., bougie); or
laryngoscopy is thus not unanticipated, but • use of an alternative intubation device or
rather, may be addressed by good preparation technique following failed intubation with
and a plan for an orderly approach to the direct laryngoscopy.”2
situation.
The Failed Airway
䉴 DEFINITIONS Failure to intubate and/or failure to oxygenate

with BMV represent decision nodes in airway
The Difficult Airway management that require urgent action. There
are two pathways that define the failed airway:
Clear definitions of both the difficult and failed
airway are needed to help the clinician identify A. Failed intubation is defined by the failure
when different strategies must be employed. The to intubate the patient after three attempts
American Society of Anesthesiologists (ASA) by an experienced clinician (i.e., can’t intu-
Task Force has used the term difficult airway bate, CAN oxygenate).
to describe difficulty with mask ventilation, dif- B. Failed oxygenation assumes that in addi-
ficulty with tracheal intubation, or both.1 This tion to a failed attempt at intubation, the
definition is broad and meant for a “convention- patient cannot be oxygenated (i.e., to an
ally trained anesthesiologist.” For our purposes, SaO2 of 90% or more) with BMV (i.e., can’t
a difficult airway can be similarly defined, but in intubate, CAN’T oxygenate).
the hands of the most experienced clinician at
the bedside. However, it is important to keep in
mind that when using this definition, the likeli- 䉴 INCIDENCE OF THE DIFFICULT
hood of encountering a difficult airway will often AIRWAY
vary according to the experience of the clinician.
Other important definitions include the Difficult laryngoscopy (i.e., a Cormack Grade 3
following: or 4 view) has been reported to occur in 2%–8%
of cases in the operating room (OR) setting.2
A. Difficult bag-mask ventilation (BMV) Corresponding literature derived from out-of-
occurs when “it is not possible for the unas- OR settings such as the emergency department
sisted clinician to maintain oxygen satura- (ED) is limited. One study has reported an
tion (SaO2) >90% using 100% oxygen and inability to visualize the cords in 14% of trauma
positive pressure mask ventilation in a patients,4 while other reports have pegged the
patient whose SaO2 was >90% before clini- likelihood of a Grade 3 or worse view in patients
cian intervention.”2 undergoing manual in-line neck stabilization at
B. Difficult laryngoscopy is a Grade 3 or 4 closer to 25%.5 First attempt failure occurs in
view according to Cormack and Lehane3 between 10 and 23% of RSI cases in the ED,
grading, and does not necessarily imply dif- while the need for more than two attempts, at
ficult intubation. 3%, is significantly less.4,6,7 It should be noted that
C. Difficult intubation may be defined as “a the published incidence of difficult intubation is
situation where an experienced laryngo- only a fraction of difficult laryngoscopy. While a
scopist, using direct laryngoscopy, requires: “can’t intubate, can’t oxygenate” situation is very
RESPONSE TO AN ENCOUNTERED DIFFICULT AIRWAY 201
unusual in the OR (1–3/10,000),2 failure to main- 䉴 TABLE 12–1 STAGED RESPONSE TO

tain SaO2 above 90% with BMV as part of an RSI DIFFICULT BAG-MASK VENTILATION
in the emergency setting is more common.8 For- • Perform exaggerated head tilt/chin lift if
tunately, as the common end point of the failed not contraindicated by C-spine precautions.
airway, the incidence of ED cricothyrotomy is • Do an exaggerated jaw thrust, lifting the
reported to be less than 1%.6,7 mandible anteriorly into the mask.
• Consider insertion of oral and/or nasopha-
ryngeal airway.
• Perform two-person bag-mask technique
䉴 THE DANGER OF MULTIPLE • If cricoid pressure is being applied, ease
INTUBATION ATTEMPTS up on, or release it.
• Consider a mask change (size or type) if
Multiple intubation attempts (defined as three seal is an issue.
or more) have been associated with significant • Rule out foreign body in the airway.
complications, and ultimately poor patient out- • Consider placing a rescue oxygenation
comes. Multiple attempts may result in failed device, e.g., extraglottic device such as an
oxygenation as trauma to the laryngeal inlet LMA.
caused by laryngoscope blade manipulations or • Consider an early attempt at intubation.
blind attempts at tube passage result in bleeding,
laryngospasm, and edema. In a review of 2833
patients intubated in an emergency, out-of-OR 䉴 RESPONSE TO DIFFICULT DIRECT
setting, the need for three or more attempts was LARYNGOSCOPY (DL)
associated with severe hypoxemia (14 times that
observed for fewer than three attempts); For the reasons previously presented, total intu-
esophageal intubation (6 times); regurgitation bation attempts should be limited. As such, the
(7 times); aspiration (4 times); bradycardia clinician should maximize the chances of success
(4 times); and cardiac arrest (7 times).9 Of note, with the first, and if needed, each succeeding
only 20% of patients in this series had under- attempt. Before the first attempt at laryngoscopy,
gone intubation facilitated by RSI. a plan for difficult laryngoscopy should be men-
tally rehearsed, all equipment assembled, and
assistants briefed on what to expect and how
䉴 RESPONSE TO DIFFICULT they can help (e.g., with immobilization, two-
BAG-MASK VENTILATION person BMV, cricoid pressure, external laryn-
geal manipulation [ELM] etc.). The position of
An appropriate response to difficult BMV is out- both the patient and clinician should be opti-
lined in Table 12–1. The reader is referred to mized, and an appropriately sized blade selected.
Chap. 4 for a more detailed review of the topic. If a skeletal muscle relaxant is used, it must be
However, it should be reemphasized that oxy- given time to act.
genation by BMV is a core skill, and must be
properly performed in a difficult situation. All
too often in difficult or failed airway scenarios, Initial Response to Difficult DL
fixation occurs on attempted intubation, at the
expense of attention to maintaining oxygena- If a Grade 3 or 4 view is obtained at laryngoscopy,
tion with BMV. Early placement of an oral all components of “best look” laryngoscopy
airway, combined with two-person BMV will should be undertaken, as outlined in Table 12–2.
generally be effective in the difficult mask ven- In addition to optimal technique, ELM and
tilation situation. adjunctive use of the bougie or fiberoptic stylet
202 CHAPTER 12
should be attempted. Further discussion on pre-oxygenates the patient for the second
“best look” laryngoscopy is presented in attempt and delivers vital information to
Chap. 5. When properly prepared, all of the the clinician: if the patient can be easily
items in Table 12–2 can be performed during oxygenated with mask ventilation, the clin-
the first attempt at laryngoscopy. It should be ician may take comfort that a failed oxy-
noted that while the bougie is a useful adjunct genation situation does not yet exist, and
in a Grade 3A (epiglottis elevated) case, it is less time is available for another intubation attempt
likely to be successful in a Grade 3B or Grade (Fig. 12–1).
4 situation (see Fig. 3–12). In these latter cases, • Consideration should be given to the status
a fiberoptic stylet may be a better adjunct to DL, of the muscle relaxant, if in use: rocuro-
or an alternative, non-DL technique can be used. nium or other nondepolarizing agent will
Before a second attempt, a few points should act long enough for multiple attempts at
be noted: laryngoscopy, whereas if succinylcholine is
in use, the second attempt should not be
• A call for help should be initiated as soon as excessively delayed, as the medication
difficulty has been encountered. wears off quickly.
• The emergency patient should be bag-mask • If direct laryngoscopy (DL) has failed during
ventilated with 100% O2 between attempts, an awake intubation, the need for additional
even if an RSI is underway. Cricoid pressure, topical airway anesthesia or (judicious) seda-
if in use, can be maintained. BMV re- and tion should be assessed.
Second and Subsequent Attempts

䉴 TABLE 12–2 COMPONENTS OF “BEST at DL
LOOK” DIRECT LARYNGOSCOPY
• Patient positioning optimized: Stretcher With experience, many clinicians will recognize
height appropriate; patient at head of bed; after a single attempt that successful intubation
ear-sternum line optimized (“sniff” position) using DL is unlikely, and may choose to move
unless contraindicated. on to an alternative intubation technique. Given
• Optimal muscle relaxation, if used. the increasing morbidity with multiple intuba-
• Laryngoscopist’s positioning optimized: tion attempts, a second or subsequent attempt
Laryngoscope held at base of handle;
at DL should be undertaken only if something
back straight, arm modestly flexed or
stabilized on trunk.
different can be done, for example:
• Appropriate blade tip location: With indi-
rect epiglottis lift, blade tip in vallecula is • To complete a previously untried component
contacting hyo-epiglottic ligament. of best look DL.
• Appropriate laryngoscope lift: Occurs • A muscle relaxant has been introduced, or
along axis of the handle, with use of a redosed.
second hand if needed. • Additional topical airway anesthesia or seda-
• Head lift: With use of the right hand (if not tion has been added, for an awake intubation.
contraindicated) during laryngoscopy. • A blade change is attempted.
• ELM: To bring the laryngeal inlet into view. • A more experienced colleague takes over.
• Consideration of whether cricoid pressure
is adversely affecting the view.
• Use of an adjunct to DL, e.g., bougie
A blade change need not be an automatic
(tracheal tube introducer) or fiberoptic response to a difficult laryngoscopy situation, and
optical stylet. should be undertaken only with a specific goal in
mind. Such situations may include the following:
First attempt at laryngoscopy/intubation fails1
Perform optimal Bag-mask ventilation2
Can Oxygenate with BMV Cannot oxygenate with BMV
You have time!3 You have NO time!7
Second intubation attempt: Failed Oxygenation8

• “Best look” with bougie or F/O stylet while rapidly preparing for
• Consider a blade change4, or... cricothyrotomy, make one quick attempt
• Move to alternative technique5 at placing a rescue EGD
Fails Fails Succeeds
Oxygenation with BMV still non- If the single attempt at EGD rescue
problematic oxygenation fails, proceed without delay
to cricothyrotomy9
Third intubation attempt:
• Different clinician
• Alternative intubation technique5
Fails
3 failed attempts at intubation defines
Failed intubation6
• Revert to BMV or place a rescue
oxygenation EGD
Once the situation has stabilized and the

Succeeds patient is oxygenated, make
arrangements for definitive care10
Postintubation care
Figure 12–1. Encountered Difficult Airway algorithm.

(1) All components of 'Best Look' laryngoscopy should be performed during the first and any subsequent
laryngoscopy attempts (Table 12–2).
(2) Optimal bag-mask ventilation (BMV) includes use of an oral airway, jaw lift, and two-person mask ventila-
tion (Table 12–1).
(3) As long as oxygenation is possible via BMV between attempts, you have time. Consideration should occur
as to why the first attempt failed, and how chances of success can be increased during a second attempt.
(4) A longer curved blade may be helpful to better engage the hyoepiglottic ligament or ‘pick up’ the epiglot-
tis; a straight blade may help displace the tongue and directly lift the epiglottis, and a levering tip (e.g., McCoy
or CLM) blade may help in C-spine precaution situations.
(5) Alternative intubation techniques include the LMA Fastrach, Lightwand, and indirect rigid or flexible fiberop-
tic or video devices.
(6) In the ‘failed intubation ' routine, placement of a rescue oxygenation (e.g., extraglottic) device is considered
after three attempts.
(7) The inability to oxygenate the patient with BMV, in conjunction with failed intubation, even after only a sin-
gle attempt, defines failed oxygenation. You have no time for further intubation attempts.
(8) With failed oxygenation, the default action is cricothyrotomy. While preparations are being made for the
cricothyrotomy, placement of a rescue extraglottic device may be quickly attempted.
(9) Cricothyrotomy may be performed by open surgical or percutaneous needle-guided cannula techniques.
(10) Definitive care must be arranged, by obtaining additional equipment or expertise from colleagues, or
transferring the patient.
203
204 CHAPTER 12
• If it is suspected that the blade was not long (e.g., by using it in anticipated easy intubations,
enough to control the epiglottis, (e.g., by failing or in the OR), and (b) move on to using the
to completely advance into the vallecula and device early, while muscle relaxation, if used, is
engage the hyoepiglottic ligament) a longer still acting, and the airway has not been bloodied
blade can be used. or otherwise traumatized. The alternative intu-
• If the epiglottis is long and “floppy,” the tip bation devices all have an associated learning
of the laryngoscope blade (straight or curve: success rates will depend on the individ-
curved) can be repositioned to directly lift it. ual clinician’s skill. However, in experienced
• A different blade may best handle certain hands, they will often succeed where DL has
anatomic conditions. As noted in Chap. 5, a failed. All clinicians who regularly manage air-
straight blade used by a paraglossal route ways should have skills in using at least one
can convert a Grade 3 view to Grade 2 or alternative intubation technique.
better,10 particularly in the patient with a
small mandible, prominent upper central
incisors, or a long floppy epiglottis. The 䉴 RECOGNITION OF AND
levering-tip McCoy/CLM blade may also be RESPONSE TO THE FAILED
useful in converting Grade 3 views to 1 or 2, AIRWAY
particularly in the patient undergoing manual
in-line neck stabilization.11–13 As previously outlined, the failed airway is
defined in one of two ways: (a) failed intuba-
tion, defined simply by a failure to intubate
䉴 MOVING ON TO AN
after three attempts, or (b) failed oxygena-
ALTERNATIVE, NON-DL
tion—failure to intubate in conjunction with a
INTUBATION TECHNIQUE
failure to oxygenate using BMV. Admittedly,
these are two very different scenarios, sitting on
Following a second failed attempt at intubation,
two different arms of the Encountered Difficult
the patient should again be oxygenated with
Airway algorithm (Fig. 12–1). In the former sit-
BMV. As long as mask ventilation continues to
uation (can’t intubate, CAN oxygenate), one is
be nonproblematic, a third attempt at intubation
still dealing with an oxygenated patient, and in
can be considered. However, after two failed
the latter situation (can’t intubate, CAN’T oxy-
attempts at intubation using best look DL, a third
genate), a hypoxic one.
attempt at laryngoscopic intubation is rarely
warranted, unless a more skilled clinician has
arrived. Rather, an alternative intubation Failed Airway (1): Failed Intubation
technique should now be considered. Alterna-
tive intubation devices and techniques have The failed intubation definition of the failed
been discussed in more detail in Chap. 6. Which airway, represented on the left-hand arm of the
alternative, “go to” device is chosen will depend Encountered Difficult Airway algorithm (Fig. 12–1)
on availability and clinician preference, skill, exists for the following reasons:
and experience. The Fastrach LMA (ILMA) has
the advantage of being both an alternative intu- A. Failure to intubate after three attempts on
bation and rescue oxygenation device. The Tra- the part of any one clinician should be a
chlight lighted stylet and increasingly, fiberoptic warning sign to stop, take stock, and
and video-based devices are also available. The reassess the situation. Otherwise, “fixation
latter devices have the advantage of allowing error” can set in, with a harried clinician
indirect visualization of the laryngeal inlet. focused excessively on the intubation,
Regardless of the instrument chosen, the clini- while losing sight of the “bigger picture” of
cian must (a) attain skill in use of the device ensuring patient oxygenation.
B. As previously presented, multiple intuba- undertaken. As always, common sense should

tion attempts are associated with increasing prevail.
morbidity. At its worst, multiple attempts
could eventually cause trauma, edema, and Failed Airway (2): Failed
bleeding to the extent that mask ventilation Oxygenation
now becomes impossible.
C. Neuromuscular blockade may have worn The inability to oxygenate the patient with mask
off, and a decision will have to be made ventilation or via an endotracheal tube is an
about allowing the patient to resume spon- emergency situation. This scenario is repre-
taneous ventilation with no further doses of sented on the right-hand side of the Encoun-
muscle relaxant or conversely, whether a tered Difficult Airway Algorithm (Fig. 12–1).
second dose should be given. Without doubt, the default intervention for this
failed oxygenation situation is cricothyro-
After a third failed attempt, the patient tomy. Too often, in can’t intubate, can’t oxy-
should again be ventilated by BMV to reoxygenate scenarios, a cricothyrotomy is started after
genate and indeed, confirm that the patient can the patient is no longer viable. This underscores
still be mask ventilated. At this point, although the importance of recognizing a failed oxygena-
BMV can continue indefinitely, we espouse tion situation, with its implication (cricothyro-
placing a rescue oxygenation device, in the tomy). Access to the lower airway through the
form of an extraglottic device (EGD). These cricothyroid membrane can be by open surgical
devices have been discussed in Chap. 7. They or percutaneous, needle-guided cannula tech-
confer a number of advantages: once placed, niques, as discussed in more detail in Chap. 7.
they generally enable easier positive pressure Two provisos apply to the failed oxygena-
ventilation of the patient, often with just one tion scenario:
hand; they deliver positive pressure ventilation
from just outside the laryngeal inlet, and thirdly, A. Before declaring a failed oxygenation situa-
gastric insufflation is likely to be less than that tion, an aggressive response to difficult BMV
incurred with BMV. Some devices (Combitube, should have been undertaken. As men-
King LTS-D, LMA ProSeal, or Supreme) may pro- tioned earlier, this includes an oral airway
vide more protection against aspiration of gas- and two-person technique (Table 12–1).
tric contents than others, although probably B. In most situations, before cricothyrotomy, a
none are as effective in this regard as a cuffed brief detour to EGD placement should be
endotracheal tube, which is still the ultimately attempted. Many case reports and anecdotes
desired end point. Although most extraglottic attest to the effectiveness of extraglottic
devices will require transient release of any devices such as LMAs or the Combitube in
applied cricoid pressure during their insertion, establishing a patent airway in failed oxy-
it can be reapplied following successful place- genation situations, allowing successful
ment. Once oxygenation is confirmed and the reoxygenation of the patient. EGDs may
situation has stabilized, definitive care should succeed where BMV has failed for the fol-
be arranged. lowing reasons:
Note that clinical judgment should be • No mask-to-face seal issues.
applied to the directive to limit intubation • No clinician hand size to patient face size
attempts to three. For example, if a more expe- disparity issues.
rienced colleague has arrived, a fourth attempt • Positive pressure ventilation (PPV) is
may be warranted by that clinician, or simi- delivered from immediately in front of
larly, if an adjunct such as a bougie has now the cords, bypassing more proximal sites
become available, a further attempt may be of functional obstruction.
206 CHAPTER 12
• Improved delivery of PPV immediately in 䉴 ARRANGING FOR DEFINITIVE

front of cords may help break laryn- CARE AFTER A FAILED AIRWAY
gospasm, if contributory to the situation.
Generally, the desired endpoint in the failed air-
EGDs may not succeed in oxygenating and
way situation will remain placement of a cuffed
ventilating the patient with pathology or obstruc-
tracheal tube below the cords. Thus, following
tion at or below the cords. However, sporadic
successful “rescue” of a failed airway situation
case reports are emerging of successful oxy-
with an EGD or cricothyrotomy, arrangements
genation with EGDs even in such situations
must be made for intubation or tracheostomy.
(e.g., airway burns, anaphylaxis, neck
This may involve bringing additional equipment
hematoma), where they may not have been antic-
and/or expertise to the now oxygenated patient,
ipated to work.14–17 If EGD placement is suc-
or moving the patient to the location of the
cessful in a failed oxygenation situation, cricothy-
expertise or equipment. Alternatively, the
rotomy can be avoided, and definitive care should
“breathing room” afforded the original clinician
be arranged. It must be emphasized, however,
may allow for reevaluation of whether anything
that in the failed oxygenation situation, the EGD
can be further optimized for another intubation
placement attempt must be brief, and must not
attempt, or conversely, whether the intubation
delay the onset of cricothyrotomy. In prac-
was really needed in the first place. Some of
tice, this translates to a single attempt at EGD
these points are expanded upon below:
insertion while the cricothyrotomy package is
being opened.
• Additional expertise: No clinician, no matter
Finally, the occasional patient may present
how experienced or capable, can easily han-
with pathology rendering airway access from
dle every situation. Consideration should be
above the cords obviously impossible from the
given to where help can be obtained. It may
outset. These patients may require a primary
be a colleague or other health-care provider
cricothyrotomy or tracheostomy.
with equal or greater experience: for exam-
ple, an emergency physician, intensivist, anes-
䉴 “BARS” thesia provider, surgeon, respiratory therapist,
or paramedic.
The mnemonic “BARS” represents a simple • Additional equipment: Other intubation
reminder of the foregoing step-wise progression, devices not initially available may be obtain-
once difficult laryngoscopy has been encountered: able from other areas of the hospital, such as
the operating room. Flexible fiberoptic or
Best look laryngoscopy, including BURP video-bronchoscopes may enable intubation
(ELM), through or alongside an extraglottic device,
Bougie and Blade change; or alongside a cricothyrotomy cannula. Other
Maximum 1-2 attempts, then proceed to... options include retrograde intubation or con-
Alternative intubation technique; version to a formal tracheostomy.
Maximum total of three intubation • Consideration of patient transfer unin-
attempts via any technique, then place... tubated: After the situation has stabilized,
Rescue oxygenation device, for example, risk/benefit analysis may now suggest trans-
EGD; ferring the patient unintubated. This is an
For failed oxygenation at any point intimidating concept, however, it may be
unrelieved by EGD placement, rapidly better to transfer an unintubated, oxygenated
perform... patient with an EGD than one who has aspi-
Surgical airway (cricothyrotomy). rated and has a bloodied and edematous
airway from inappropriate multiple intuba- REFERENCES

tion attempts!
1. Practice guidelines for management of the difficult
• Reevaluation of the indication for intu- airway: an updated report by the American Society
bation: In an emergency, most often the of Anesthesiologists Task Force on Management of
patient will still require intubation, but occa- the Difficult Airway. Anesthesiology. 2003;98(5):
sionally, the risk of persisting with attempted 1269–1277.
intubation for a less pressing indication, such 2. Crosby ET, Cooper RM, Douglas MJ, et al. The
as airway protection, may now exceed its unanticipated difficult airway with recommenda-
benefit, especially if the patient is anticipated tions for management. Can J Anaesth. 1998;45(8):
to recover over the short term. 757–776.
• Consider the status of muscle relaxation: 3. Cormack RS, Lehane J. Difficult tracheal intubation
in obstetrics. Anaesthesia. 1984;39(11):1105–11.
Once the situation has stabilized with an oxy-
4. Graham CA, Beard D, Henry JM, et al. Rapid
genated patient, if a muscle relaxant had been
sequence intubation of trauma patients in Scot-
used, it may be appropriate to allow it to wear land. J Trauma. 2004;56(5):1123–1126.
off, or to reverse it. This may allow resump- 5. Heath KJ. The effect on laryngoscopy of different
tion of spontaneous ventilation. Conversely, cervical spine immobilisation techniques. Anaes-
consideration can be given to the merits of thesia. 1994;49(10):843–845.
giving an additional dose of relaxant. 6. Sagarin MJ, Barton ED, Chng YM, et al. Airway
management by US and Canadian emergency med-
icine residents: a multicenter analysis of more than
6,000 endotracheal intubation attempts. Ann
Emerg Med. 2005;46(4):328–336.
䉴 SUMMARY: FAILED AIRWAY 7. Levitan RM, Rosenblatt B, Meiner EM, et al. Alter-
nating day emergency medicine and anesthesia
The appropriate identification of, and response resident responsibility for management of the
to the failed airway is of paramount importance. trauma airway: a study of laryngoscopy perfor-
Decisions revolve largely around the ability to mance and intubation success. Ann Emerg Med.
oxygenate the patient with BMV, once again 2004;43(1):48–53.
underscoring the importance of this seemingly 8. Simpson J, Munro PT, Graham CA. Rapid sequence
intubation in the emergency department: 5 year
basic skill. If a failed intubation is encountered
trends. Emerg Med J. 2006;23(1):54–56.
in the setting of easy mask ventilation and oxy-
9. Mort TC. Emergency tracheal intubation: complica-
genation, up to two further attempts can be tions associated with repeated laryngoscopic
made at intubation, unless additional expertise attempts. Anesth Analg. 2004;99(2):607–613.
or equipment has become available. Beyond 10. Henderson JJ. The use of paraglossal straight blade
this, the failed intubation definition of the laryngoscopy in difficult tracheal intubation.
failed airway applies, and oxygenation should Anaesthesia. 1997;52(6):552–560.
be maintained with BMV or by placement of 11. Uchida T, Hikawa Y, Saito Y, et al. The McCoy
an EGD, while arrangements are made for levering laryngoscope in patients with limited
definitive airway management. Failed oxy- neck extension. Can J Anaesth. 1997;44(6):
genation is defined by a failure to intubate, 674–676.
12. Laurent SC, de Melo AE, Alexander-Williams JM.
even after only a single attempt, if adequate
The use of the McCoy laryngoscope in patients
oxygenation cannot be achieved with BMV.
with simulated cervical spine injuries. Anaesthesia.
Immediate cricothyrotomy is the correct response 1996;51(1):74–75.
to a failed oxygenation situation, with a single, 13. Gabbott DA. Laryngoscopy using the McCoy laryn-
brief attempt at EGD placement, while prepa- goscope after application of a cervical collar.
rations are being made to proceed with the Anaesthesia. 1996;51(9):812–814.
cricothyrotomy.
208 CHAPTER 12
14. Martin R, Girouard Y, Cote DJ. Use of a laryngeal • Manual resuscitator face masks, #3–6
mask in acute airway obstruction after carotid • Nasopharyngeal airways, #7, 8, 9
endarterectomy. Can J Anaesth. 2002;49(8): • Oropharyngeal airways: 8, 9, 10 cm
890. • Water-soluble lubricant
15. Jones DA, Geraghty IF. Emergency management of
upper airway obstruction due to a rapidly expanding
B. Nasal intubation:
haematoma in the neck. Br J Hosp Med.7–20
1995;53(11):589–590. • Endotrol tubes, #6.0–8.0, for blind nasal
16. King CJ, Davey AJ, Chandradeva K. Emergency use intubation
of the laryngeal mask airway in severe upper airway • Phenylephrine 0.5% nasal spray; lido-
obstruction caused by supraglottic oedema. caine 4% liquid; lidocaine 2% gel
Br J Anaesth. 1995;75(6):785–786.
17. Shaw IC, Welchew EA, Harrison BJ, et al. Complete C. Oral Intubation:
airway obstruction during awake fibreoptic intuba- • Endotracheal tubes, (cuffed) 5.0, 5.5, 6.0,
tion. Anaesthesia. 1997;52(6):582–585. 6.5, 7.0, 7.5, 8.0, 8.5 mm internal diameter
18. Levitan RM, Kush S, Hollander JE. Devices for dif- • Stylets, size 14 French
ficult airway management in academic emergency
• Laryngoscope handles, regular and short
departments: results of a national survey. Ann
length
Emerg Med. 1999;33(6):694–698.
19. McGuire GP, Wong DT. Airway management: con- • Laryngoscope blades, curved (Macintosh)
tents of a difficult intubation cart. Can J Anaesth. #3 and 4; straight (e.g., Miller) #2 and 3;
1999;46(2):190–191. +/− levering tip blades (e.g., CLM/McCoy)
#3 and 4
• Laryngoscope charger and/or spare batteries
• Tracheal tube introducer (“bougie”)
䉴 APPENDIX: CONTENTS OF AN • +/− Fiberoptic optical stylet (e.g., Levitan
EMERGENCY AIRWAY AND/OR FPS, Shikani, or Bonfils)
DIFFICULT AIRWAY CART
D. Alternative Intubation Techniques:
It makes sense to have a dedicated airway • At least one of:
cart18,19 incorporating all equipment that could 䡩 LMA Fastrach (Intubating Laryngeal
possibly be needed for emergency airway man- Mask Airway), #3,4,5 (with manufac-
agement. Organization of the cart is at the dis- turer sizing card). Dedicated LMA Fas-
cretion of the unit in question, however a trach tubes, sizes 6.0, 6.5, 7.0, 7.5, 8.0
logical means of storage will help locate needed (and stabilizer)
equipment in a hurry. Consideration should be 䡩 Lightwand (e.g., Trachlight): handle
given to standardizing cart organization with and wands
units elsewhere in the hospital, for example, the 䡩 Other fiberoptic or video-based intuba-
intensive care unit (ICU) or the OR. tion device
• Trachlight and fiberoptic or video-based
device batteries and battery compartment
Sample adult airway cart contents access tools.
A. Mask ventilation: E. Rescue ventilation devices:

• Oxygen tank • At least one of:
• Oxygen tubing 䡩 Combitube, #37 and #41
• Oxygen face masks, simple and nonre- 䡩 Laryngeal Masks (e.g., Classic, Unique,
breathing Proseal, or Supreme #3, 4, 5 (manufac-
• Manual resuscitator with reservoir bag turer sizing card)
䡩 Other extraglottic device, according to Sample Pediatric Equipment

institutional preference
Note: Departments with significant pediatric
F. Surgical: volumes may wish to consider organizing equip-
• Needle-guided percutaneous cricothyro- ment in a color-coded fashion according to
tomy set, for example, Melker or PCK, Broselow tape sizes.
with cuffed cannula
• Surgical cricothyrotomy equipment: scalpel • Broselow tape
handle, #11 blade, tracheal hook, Trousseau • Oxygen masks: newborn, pediatric
dilator, #6.0 ETT, Shiley cuffed tracheostomy • Manual resuscitator with infant and child-
(#4) tubes sized masks
• Oral airways: 3.5, 5, 6, 7 cm
G. Other Equipment: • Laryngoscope blades: straight (e.g., Miller) 0,
• End-tidal CO2 (ETCO2) detector 1, 2; & curved (Macintosh) 1,2, and 3
• Twill tape • ETT: uncuffed—2, 2.5; cuffed and uncuffed—
• Esophageal detector device (EDD), for 3, 3.5, 4, 4.5; cuffed—5, 5.5, 6, 6.5, 7
example, 60 cc catheter-tip (Toomey) syringe • Stylet: 6 Fr, 8 Fr
• 10 cc syringes for cuff inflation • Bougie: pediatric
• Suction catheters: rigid tonsillar (e.g., • LMA: 1, 1.5, 2, 2.5, 3; or other pediatric extra-
Yankauer) and flexible endotracheal tube glottic devices
suction catheters • +/- Lightwand: infant and child sizes
• Magill forceps • +/- Pediatric fiberoptic stylet: Shikani or
• Bite blocks Brambrinck
• Adult airway exchange catheter • Small Magill forceps
• Materials for application of topical airway • ETCO2 detector, pediatric size
anesthesia: tongue depressors; Mucosal • #18, #16, and #14 G IV catheters for cricothy-
Atomization Device (e.g., MADgic®) or rotomy
DeVilbiss atomizer; Jackson forceps; cotton
pledgelets; Lidocaine 10% spray, 2% gel, Finally, the presence of an “airway drug kit”
5% ointment, 4% liquid with all the necessary pharmacologic agents, in
one location, is highly recommended.
Chapter 13
Airway Pharmacology
䉴 KEY POINTS and respiratory consequences, in the at-risk

patient.
• For the patient requiring emergency • Succinylcholine remains in widespread
airway management, preservation of oxy- use for several reasons: (a) it has a very
genation and blood pressure often takes rapid onset; (b) it usually has a very short
priority over attenuation of undesirable duration of action; and (c) clinicians are
reflexes. familiar with its use.
• There is strong evidence that in the head- • Rocuronium use avoids the need to con-
injured patient, hypoxia or hypotension sider many of the contraindications to, and
occurring during patient resuscitation can precautions associated with succinyl-
significantly increase mortality. choline use.
• Ketamine produces excellent amnesia and • A decrease in blood pressure is common
is the only induction agent to also provide following induction and intubation.
analgesia. • The initial response to hypotension from
• Although ketamine can indirectly raise almost any cause should be circulatory
blood pressure by sympathetic nervous volume expansion. However, clinicians
system stimulation, intrinsically, it is a should also be comfortable with the indica-
myocardial depressant. tions for, and use of short-acting vasopressors.
• Etomidate is remarkable for its stable
hemodynamic effects and has become the
induction agent of choice in many North 䉴 INTRODUCTION
American emergency departments.
• Etomidate does cause adrenal suppression. Airway management, including endotracheal
Unless risk/benefit assessment suggests intubation, requires a competent understanding
otherwise, an alternative agent should be of airway pharmacology. A small number of
used for induction in the septic patient. medications are used to facilitate airway man-
• In airway management, the primary role agement, for various indications as shown in
of midazolam is as a light sedative for the Table 13–1. Successful airway intervention
patient undergoing an awake intubation. without patient compromise requires a good
• The advantageous effects of pretreat- working knowledge of these agents, together
ment agents must be balanced against with an appreciation of expected physiological
their potential adverse hemodynamic responses to manipulation of the airway.
211
212 CHAPTER 13
䉴 TABLE 13–1 MEDICATIONS COMMONLY USED FOR AIRWAY MANAGEMENT
Procedure Medication Type Indication Sample Medications
Awake intubation Topically applied or Airway anesthesia for Lidocaine spray,

regionally injected awake intubation jelly, ointment,
local anesthetic injectable
agents
Awake intubation Adjuvant sedative Anxiolysis, analgesia, Benzodiazepines,
agents and sedation during Opioids, Buty
awake intubation rophenones,
Propofol, Ketamine
Awake intubation Opioid and Use in case of overdose Naloxone,
benzodiazepine of opioid or Flumazenil
anatogonists benzodiazepine
Rapid-sequence “Pretreatment” agents Attenuation of undesirable Atropine, Lidocaine,
intubation physiologic reflexes Opioids, Neuromus-
during laryngoscopy cular blockers
and intubation
Rapid-sequence Induction agents and Induction of unconsciousness Etomidate, Propofol,
intubation neuromuscular (control of ICP), and Thiopental,
blockers subsequent skeletal muscle Ketamine.
relaxation to facilitate Succinylcholine,
laryngoscopy Rocuronium
Rapid-sequence Miscellaneous rescue Treatment of Dantrolene
intubation agents succinylcholine-induced
malignant hyperthermia
Awake or Rescue vasopressor Treatment of postintubation Ephedrine,
rapid-sequence and other agents hypotension Phenylephrine
intubation
䉴 THE PHYSIOLOGIC RESPONSE generally healthier, elective surgical patients.

TO LARYNGOSCOPY AND For the patient requiring emergency airway
INTUBATION management, preservation of oxygenation and
blood pressure often takes priority over atten-
Laryngoscopy and intubation are powerful uation of undesirable reflexes.
stimuli that can provoke intense physiologic Stimulation of the oropharynx and upper
responses from multiple body systems.1,2 These airway activates both arms of the autonomic
responses, including hypertension, tachycardia, nervous system. In adults, the sympathetic
increased intracranial pressure (ICP), and bron- response usually predominates, with an increase
choconstriction, are generally transient, and of in circulating levels of catecholamines. In young
little consequence in most individuals. How- children (and some adults) airway instrumenta-
ever, for some patients, if these responses are tion may cause a predominately vagal response,
not attenuated, significant morbidity may ensue. including bradycardia.
It should be appreciated that most of the data It is important to note that intubation tech-
supporting the attenuation of these adverse niques other than direct laryngoscopy will
physiologic responses has been gathered from still elicit these responses.3 Systems primarily
AIRWAY PHARMACOLOGY 213
affected by direct laryngoscopy and/or intuba- and/or vasoactive agents. However, in the
tion include the cardiovascular, respiratory, volume-depleted emergency patient, any pressor
and central nervous systems. When indi- response to laryngoscopy and intubation may by
cated, local anesthesia and systemic medica- counteracted by the vasodilating and negative
tions can be used to minimize these undesirable inotropic effects of induction agents. Such a drop
effects. The following sections will review the in blood pressure during a resuscitation can be
responses in question. associated with increased morbidity and mortality.5
The best approach must take into consideration
Cardiovascular Response to the individual patient, the experience of the
Laryngoscopy and Intubation physician, and the available medications.
Laryngoscopy and intubation causes an increase

in both sympathetic and sympathoadrenal Respiratory System Response to
activity. This usually results in transient hyper- Laryngoscopy and Intubation
tension and tachycardia, correlating with a rise
in catecholamine levels. Under “light general Coughing, laryngospasm, and bronchospasm
anesthesia,” systolic blood pressure has been are all potential responses to airway manipula-
shown to rise an average of 53 mm Hg in tion. Laryngospasm may be more common in
response to laryngoscopy and intubation, while the pediatric population. Gagging may lead to
the heart rate increases by 23 beats per minute.1 vomiting and potential aspiration. All of these
In smokers and individuals with preexisting responses are more likely in the inadequately
hypertension, the rise in blood pressure can be anesthetized patient and those with underlying
more pronounced.4 In healthy patients, these respiratory pathology.
hemodynamic effects are usually of little conse- Coughing, gagging, and laryngospasm can
quence. However, patients in whom attenuation be abolished with the use of neuromuscular
of this pressor response may be important include: blocking agents. Bronchospasm does not
respond to muscle relaxants since these agents
• The patient with coronary artery disease. do not block smooth muscle receptors in the
Significant rises in heart rate and blood pres- airways. Bronchoconstriction can be attenuated
sure (BP) could result in myocardial ischemia by deep anesthesia and the use of drugs that
due to increased myocardial oxygen demand. promote bronchial smooth muscle relaxation.
• The patient with an unruptured cerebral Obviously, hypoxia and hypercarbia are
or aortic aneurysm, or aortic dissection. potential complications of laryngoscopy and
A dramatic increase in mean arterial pressure intubation, especially if prolonged attempts at
(MAP) could lead to aneurysm rupture or intubation are made without intervening bag-
worsening dissection, respectively. mask ventilation (BMV).
• Patients with significant preexisting
hypertension, including women with Central Nervous System Response
pregnancy-induced hypertension. Further to Laryngoscopy and Intubation
increases in BP could overcome the limits of
cerebral autoregulation and potentially lead Laryngoscopy and intubation results in a tran-
to increased ICP or cerebral hemorrhage sient rise in ICP.1 This increase in ICP may be
a direct response to central nervous system
The pressor response to laryngoscopy and (CNS) stimulation, causing an increase in cere-
intubation can be attenuated by one of a number bral blood flow (CBF). ICP may also rise if sys-
of drug regimens, including deep anesthesia temic blood pressure is profoundly raised
214 CHAPTER 13
and/or venous outflow is obstructed (e.g., by There is some evidence suggesting that use
straining or coughing). Although this is of of induction sedative/hypnotics as part of an
little consequence in most individuals, in RSI actually improves intubating conditions and
patients in whom ICP is already elevated or in decreases time needed to perform RSI.7,8 How-
whom cerebral autoregulation is impaired, ever, this data is difficult to interpret and may in
these effects could complicate an already dan- part simply reflect the rapid onset and potency
gerous situation. of the sedative/hypnotic compensating for
As discussed in more detail in Chap. 14, the attempted intubation before full onset of neu-
focus in management of the patient with trau- romuscular blockade.
matic brain injury has shifted from simply In determining the appropriate dosage of
preventing an ICP rise with endotracheal induction agent, several factors must be consid-
intubation, to maintenance of cerebral perfu- ered. These include:
sion pressure (CPP). CPP is determined by the
difference between mean arterial pressure (MAP) A. Patient weight: Drug dosing is based pri-
and the ICP, that is, CPP = MAP – ICP. There is marily on patient weight. The appropriate
now evidence that in the head-injured loading dose of an agent is largely depen-
patient, hypoxia or hypotension occurring dent on the volume of distribution. The
during patient resuscitation can signifi- volume of distribution reflects the medica-
cantly increase mortality.6 Therefore, the tion’s lipid solubility. How the drug is dis-
importance of avoiding a lowered MAP during tributed in turn impacts the decision to dose
intubation may assume greater clinical signifi- based on ideal body weight (IBW) or total
cance than a transient increase in ICP. body weight (TBW).9 With obesity, both lean
Although deep anesthesia can block the and fat mass increase, but fat increases pro-
direct effect of laryngoscopy and intubation on portionally more. Clinical data on how to dose
ICP, this approach can also result in a signifi- induction sedative/hypnotics in obese patients
cant decrease in MAP and CPP. In the head- is limited. For propofol and thiopental, the
injured patient, a pre-intubation fluid bolus and recommendation is for dosing based on TBW.9
special care in choosing the dosage of induc- However, for many drugs, the situation is
tion medication is needed to help avoid signifi- indefinite. For this reason, many clinicians
cant drops in CPP. dose agents based on a weight that lies
somewhere between IBW and TBW.
B. Age: With the exception of neonates, anes-
䉴 INDUCTION SEDATIVE/ thetic requirements decrease with advancing
HYPNOTICS age. An 80-year old will typically require only
half the induction dose of a 20-year old.
Induction sedative/hypnotics are used pri- C. Hemodynamics: Hypotension is common
marily to induce unconsciousness in the following intubation. One study quotes a
patient as part of an RSI. In lower doses, 25% incidence of life-threatening hypoten-
some can also be used as sedative agents. In sion in the initial phase of mechanical ven-
modern practice it is accepted that, except in tilation.10 It is important to note that all
unusual circumstances, the use of muscle relax- induction sedative/hypnotics can cause a
ants requires the concomitant use of an induc- drop in blood pressure. As this is more dra-
tion agent to ensure lack of awareness. To this matic in patients with preexisting hypov-
extent, induction sedative/hypnotics are gener- olemia, volume status must be taken into
ally considered a mandatory component of RSI, account when determining the dose of
at all ages. induction agent.
D. Level of Consciousness: The purpose of a decrease in blood pressure following a

using an induction sedative/hypnotic is to bolus dose. For this reason, a fluid bolus is
induce a state of unconsciousness and commonly given before its administration. In
amnesia. If this is already present, either patients with hypovolemia or impaired heart
from drugs (e.g., the overdose patient) or function, this drop in blood pressure can be
pathology (e.g., the head-injured, hypoten- quite marked. The hemodynamic effects are
sive, or arrested patient), the need for addi- more pronounced in the elderly, in whom
tional induction agent is diminished (but the dose should also be lowered.
often still necessary). This can sometimes Although propofol lowers ICP, a decrease in
be a difficult decision, as airway manipula- CPP can still result from its administration,
tion is intensely stimulating and especially because of its adverse effect on blood pres-
in an overdose situation may “awaken” an sure. This decrease in CPP may be particularly
apparently unconscious patient. Provided detrimental in the head-injured patient who is
the hemodynamics will tolerate it, the also hypovolemic and has impaired autoregula-
authors would generally recommend admin- tion. Propofol may offer a degree of cerebral
istration of an induction sedative/hypnotic protection,13 but the clinical significance of this
(even to the unconscious patient) whenever is unknown.
muscle relaxants are used. Prolonged high-dose propofol infusions
have been associated with poor outcomes in the
ICU setting. This phenomenon, called “propofol
Propofol infusion syndrome” has been described mainly
in children but recently also in adults.12 As such,
Propofol is an intravenous sedative/hypnotic caution should be exercised when propofol
agent that works primarily via gamma amino infusions are to be administered in high doses
butyric acid (GABA) receptors to produce hyp- for more than 48 hours. The manufacturer does
nosis.11,12 Propofol has become popular because not recommend propofol for long-term seda-
of its rapid onset and short clinical duration in pediatric ICU patients.14 For emergency
tion. Recovery from the effects of propofol is intubations and to facilitate procedures, how-
notable for the lack of residual sedation. ever, even in children, propofol has been safely
Propofol causes a dose-dependent decrease used outside the OR.15
in level of consciousness. Small doses Propofol may cause pain on injection. This
(0.25–0.5 mg/kg) result in sedation while larger can be minimized by injecting into a large vein.
doses (1–3 mg/kg) are used to induce uncon- The addition of 1–2 cc of 1% lidocaine to the
sciousness. Propofol does not possess syringe of propofol just prior to injection may
intrinsic analgesic properties and although also decrease discomfort.
it may produce amnesia, this effect is not as reli- Propofol is supplied as a 10 mg/mL emul-
able as that seen with the benzodiazepines. Fol- sion containing 10% soybean oil and 1.2% puri-
lowing a bolus of 2 mg/kg to a healthy adult, fied egg phosphatide. In theory, individuals
unconsciousness is generally produced within with egg or soybean allergies could be sensi-
30 seconds, with recovery taking 5–15 minutes. tive, but in practice, allergic reactions to propofol
As a potent respiratory depressant, apnea is are exceedingly rare. This preparation has been
common following an induction dose. Propofol shown to be a growth medium for certain
decreases airway reflexes to intubation in a microorganisms, so that sterile technique should
dose-dependent manner. be utilized when handling propofol: it should be
Propofol is a myocardial depressant and also drawn up immediately before use and unused
results in peripheral vasodilation. This results in portions discarded.14
216 CHAPTER 13
PROPOFOL AS A SEDATIVE AGENT a dose-dependent CNS depression, ranging from

Propofol can be used as an agent to blunt aware- sedation to pharmacologic coma. Thiopental
ness for an ‘awake’ intubation, but does not has a rapid onset with clinical effects seen within
address anxiety or discomfort associated with about 30 seconds. Following a single dose,
the procedure in the way that benzodiazepines recovery generally takes 5–10 minutes. Recov-
or narcotics, respectively, are able to do. If used ery may be substantially longer following
for sedation, propofol should be administered repeated doses or infusions.
in small doses (e.g., 0.25 mg/kg), maintaining Thiopental is a potent respiratory depres-
verbal contact with the patient. In the critically sant, and apnea is the norm following an induc-
ill patient, even when used in small doses, it tion dose. This agent has also been associated
can cause loss of consciousness and hypoten- with clinically relevant histamine release, which
sion. Use of propofol to achieve a state of deep may induce bronchospasm. In fact, the manu-
sedation for intubation will impair protective facturer lists status asthmaticus as an absolute
airway reflexes, while not providing the facili- contraindication.16 Despite this, thiopental has
tated conditions provided by RSI with a muscle been used successfully in the management of
relaxant. severe asthma.17
Thiopental, like propofol, causes a decrease
SUMMARY in ICP and cerebral oxygen consumption, the-
Drug: Propofol. oretically making it an attractive choice for use
Drug type: Anesthetic induction sedative/ in the brain-injured patient. As with propofol,
hypnotic. however, care must be taken to not lower ICP
Indication: Induction of unconsciousness; at the expense of a profound reduction in
sedation. blood pressure, as thiopental is also a potent
Contraindications: Uncorrected shock states myocardial depressant. In the presence of
are relative contraindications, at least requiring hypovolemia, a significant drop in blood pres-
a significant decrease in dose. Pediatric long- sure can result.
term infusions are contraindicated. The dose of thiopental for RSI is 3–5 mg/kg,
Dose: Induction dose is 1–3 mg/kg (average although this dose should be lowered in elderly
75 kg = 150 mg). Dosage should be decreased or hypovolemic patients. It is supplied as a
in the elderly and volume-depleted patient. powder, which must be dissolved in sterile water
Onset/Duration: Onset is ~30 seconds. Clinical to produce a 2.5% solution (25 mg/mL). The
duration is 5–15 minutes. resulting solution is highly alkaline and care must
Potential Complications: Hypotension and be taken to avoid interstitial or intraarterial injec-
apnea; pain on injection. tion. Care must also be taken to avoid direct inter-
action with acidic solutions (e.g., most of the
Thiopental neuromuscular blockers) as this may result in
precipitation and loss of intravenous (IV) access.
Thiopental is a barbiturate sedative/hypnotic,
and until the introduction of propofol, it was THIOPENTAL AS A SEDATIVE AGENT
the primary agent used for induction of general Thiopental is not generally used as a sedative
anesthesia. Despite the popularity of propofol, agent to facilitate awake intubations.
thiopental is still widely used in many operating
rooms (ORs) and emergency departments (EDs). SUMMARY
The barbiturates exert their main effect by Drug: Thiopental.
binding to and potentiating GABA receptors in Drug type: Anesthetic induction agent; sedative/
the central nervous system (CNS). They produce hypnotic.
Indication: Induction of unconsciousness. dose may still result in apnea. Ketamine may
Contraindications: Uncorrected shock states result in an increase in secretions, an effect
are relative contraindications that require a which can be managed (although rarely indi-
marked decrease in dose. cated) by pretreatment with a drying agent such
Dose: Dose is 3–5 mg/kg (average 75 kg = 250 as glycopyrrolate or atropine. In addition, keta-
mg), depending on hemodynamics. mine when used alone (i.e., not part of an RSI)
Onset/Duration: Onset is about 30 seconds. has been associated with laryngospasm.18,20
Clinical duration is 5–10 minutes. This may be more common in infants, to the
Potential complications: Hypotension and extent that ketamine sedation may be con-
apnea. traindicated under 3 months of age.20
SNS stimulation is also responsible for an
increase in heart rate (by about 20%) and blood
Ketamine
pressure (a rise of around 25 mm Hg) with ket-
amine use. Care should thus be exercised in
Ketamine is unique among the sedative/hyp-
patients with coronary artery disease, as
notic agents in both its mechanism of action
ketamine has the potential to aggravate myocar-
and its clinical effects. Ketamine produces a
dial ischemia. Due to its ability to raise blood
state of “dissociative amnesia,” referring to a
pressure, it has been suggested that ketamine
dissociation occuring between the thalamocortical
would be particularly suited for use in patients
and limbic systems on electroencephalogram
with unstable hemodynamics. It must be
(EEG). Clinically, the result is a catatonic state
remembered, however, that the hemodynamic
in which the eyes often remain open, with obvi-
effects are secondary to SNS stimulation and
ous nystagmus. The patient may sporadically
that intrinsically, ketamine is in fact a myocar-
move, but nonpurposefully, and not generally
dial depressant. Thus, ketamine could theoreti-
in reaction to painful stimuli. Ketamine pro-
cally lower blood pressure in patients who are
duces excellent amnesia and is the only
already maximally sympathetically stimulated.
induction agent to also provide analgesia.
Therefore, as with all induction seda-
Ketamine may exert some of its analgesic prop-
tive/hypnotics, caution should be used in
erties via opioid receptors, although these
patients with severe shock, and the induc-
effects are not consistently antagonized by
tion dosage reduced.
naloxone.18
Much controversy has centered around the
Ketamine has a centrally stimulating
use of ketamine in patients with intracranial
effect on the sympathetic nervous system
pathology. Historically, ketamine has been con-
(SNS) by decreasing catecholamine reuptake.
sidered to be contraindicated in patients with
These effects are responsible for many of the
decreased intracranial compliance due to
observed clinical effects. For example, via SNS
reports that it could increase ICP and increase
stimulation, ketamine relaxes bronchial smooth
cerebral oxygen demand. However, the data
muscle, in turn causing a decrease in airway
upon which these recommendations were made
resistance and improved pulmonary compli-
did not involve patients with traumatic brain
ance. At higher doses, ketamine may also act
injury.21 Indeed, more recent data using human
directly to relax bronchial smooth muscle,
and animal subjects suggest that low-dose bolus
although clinical benefit has not been clearly
ketamine may have a beneficial effect on CPP
demonstrated.18,19 These effects make ketamine
in this setting.21,22 When used in conjunction
a particularly attractive agent for induction
with a GABA agonist (such as propofol or mida-
of the patient with acute bronchospasm.
zolam), ketamine has actually been shown to
Ketamine tends to preserve ventilatory drive,
lower ICP.23 A cerebral protective effect has
although a large, rapidly administered bolus
218 CHAPTER 13
been shown with ketamine use in animals, pos- of 0.25–0.5 mg/kg, it has the advantage of main-
sibly mediated through NMDA receptor blockade, tained respiratory drive and good analgesia. How-
and a similar effect is being investigated in ever, it can also increase secretions, which as
humans and appears to show promise.22 How- mentioned can increase the risk of laryngospasm,
ever, at this time, ketamine cannot be recom- particularly in the pediatric patient. A theoreti-
mended for routine use in patients at risk of cal risk of under-dosing relates to ketamine’s
increased ICP, unless they also are also hypoten- use as a “street drug,” where it may induce, or
sive (in relative or absolute terms), in which worsen an intoxicated, uncooperative state.
case ketamine’s hemodynamic effects may help
preserve CPP. SUMMARY
Ketamine has been associated with unpleasant Drug: Ketamine.
emergence reactions characterized by “bad Drug type: Anesthetic induction agent, seda-
dreams,” disorientation and perceptual distur- tive/hypnotic, analgesic.
bances.18 This is relatively uncommon in chil- Indication: Induction of unconsciousness,
dren and seems in part to be related to the “state especially for patients with severe bron-
of mind” at the time of the drug’s administra- chospasm or unstable hemodynamics. Seda-
tion.18,20,24 At least in children, this phenomenon tive to facilitate non-RSI intubations.
is not reduced by concomitant administration of Contraindications: Known coronary artery
benzodiazepines.18,20,24,25 Emergence reactions disease or an elevated ICP are relative con-
are not generally a consideration in the patient traindications (see text).
requiring RSI in emergencies. Dose: Dose is 1–2 mg/kg IV (average 75 kg =
Ketamine is supplied as either a 10 or 50 100 mg).
mg/mL solution. The induction dose of keta- Onset/Duration: Onset is within 60 seconds.
mine is 1-2 mg/kg as an IV bolus. Onset time is Clinical duration is 15–20 minutes.
generally within 1 minute and clinical duration Potential Complications: Increase in heart
is 15–20 minutes. A lower dose should be used rate (HR) and BP, with potential myocar-
for the patient in profound shock. Conversely, dial ischemia. Increase in ICP. Emergence
the higher end of the dose range should be reactions.
used if bronchodilation is the goal.
An “off-label” combination of ketamine with
propofol (each in 10 mg/mL concentrations) Etomidate
drawn up in a single syringe (“ketafol”) has been
used in recent years, primarily for procedural Etomidate is a sedative-hypnotic which has
sedation in emergency departments.26,27 The been available for use in the United States since
mixture has also been used as an induction 1983. Its mechanism of action probably
agent for RSI, with at least a theoretic advantage involves GABA receptors, although it has a dif-
of maintenance of stable hemodynamics. ferent drug-receptor interaction than that seen
with the barbiturates and propofol. As with
other induction agents, it has a predictably
KETAMINE AS A SEDATIVE AGENT rapid onset and short duration of action (5–15
Ketamine is usually administered as a single minutes following a standard induction dose).
predetermined dose to achieve a state of disas- Etomidate has become the induction seda-
sociation. However, smaller doses of ketamine tive/hypnotic of choice in many EDs through-
can be used as a sedative for awake intubation out North America.28
or “awake look” laryngoscopy in the uncooper- Etomidate is remarkable for its hemo-
ative patient. Used in this way, in divided doses dynamic stability.29,30 This makes it particularly
suited for RSI in the multitrauma patient. With thought to be relevant only in patients receiving
the usual induction dose of 0.2–0.3 mg/kg there maintenance infusions, it has now been clearly
is generally no significant change in heart rate or demonstrated, lasting from 12–24 hours, follow-
reduction in blood pressure (BP). Even in the ing a single dose.35 Historically, the clinical rel-
patient presenting with a systolic blood pres- evance of this was not clear, and proponents of
sure below 100, use of etomidate for RSI appears etomidate argued that the benefits of hemody-
to result in considerable hemodynamic stabil- namic stability during RSI outweighed the risks
ity.30 Hypotension can occur, but does so with of adrenal suppression. However, the debate
much less frequency compared to other agents, has been rekindled by the potential clinical sig-
including midazolam.31 In situations of extreme nificance of adrenal suppression in the septic
hypovolemia and/or hypotension, the dose of patient.36,37 In this population, steroid replace-
etomidate (as with all induction agents) should ment therapy has been shown to have a sur-
be reduced. vival benefit.39 As such, concern has been raised
Spontaneous ventilation is better preserved that additional adrenal suppression caused by
with etomidate use than with the barbiturates, etomidate in already suppressed septic patients
but apnea is still common after an induction could lead to a worse outcome.40 Conflicting
dose. Ventilatory depression is more common data exists on the induction agent choice in
when adjuvant agents (especially opioids) are patients with septic shock.38 Until further evi-
used with etomidate. This is of little concern dence is available, it appears prudent to avoid
during an RSI. etomidate use in the sepsis population as long
Etomidate will lower ICP and decrease cere- as appropriate alternative agents are available.
bral oxygen requirements. However, of some If etomidate is used in a septic patient, this
concern are a few studies indicating a worsen- should be communicated to the critical care
ing of cerebral ischemia with etomidate team. In such cases a baseline cortisol level and
administration in operative patients undergo- a cosyntropin stimulation test (CST) should be
ing subsequent temporary cerebral arterial performed to guide subsequent critical care
occlusion.13,32,33 These results at best suggest decisions on replacement therapy.33 Although
that etomidate does not have a neuroprotective the suggestion has been made that steroids be
effect. In the patient at risk for cerebral empirically administered in replacement doses
ischemia, this knowledge must be balanced until these laboratory results are available, there
against etomidate’s upside of hemodynamic is little prospective evidence to support the prac-
stability and potential for maintenance of cere- tice at this time.36,41
bral perfusion pressure. Clinicians should be aware of these risk/
Etomidate can cause myoclonus but has not benefit issues when considering the use of
been shown to induce seizures.34 It does not have etomidate. As the status of etomidate as a “one
any analgesic properties and does not block the drug fits all” induction agent has been ques-
pressor response to intubation. In patients in tioned, further study of its safety in the critically
whom a blood pressure increase is a concern ill patient is needed.
(e.g., the patient with a cerebral aneurysm) use
of adjunctive agents may be considered to block
this response. Other side effects may include ETOMIDATE AS A SEDATIVE AGENT
pain on injection and nausea and vomiting on Etomidate is being used increasingly as an alter-
emergence.34 native to propofol for sedation in the ED.42 How-
Much of the debate surrounding etomidate ever, even in low doses, it can cause vomiting
use in the critically ill patient surrounds its and myoclonus. As with propofol, use of eto-
potential to cause adrenal suppression. Initially midate for deep sedation to facilitate endotracheal
220 CHAPTER 13
intubation will not provide conditions as favor- similar manner, with the main differences
able as those using RSI with a muscle relaxant. related to their individual pharmacokinetic
properties. The effects of the BDZs may be
SUMMARY reversed by Flumazenil (Anexate®), a specific
Drug: Etomidate. BDZ receptor antagonist.
Drug type: Anesthetic induction agent, seda- Used alone and in low doses, BDZs usually
tive/hypnotic. have minimal effect on hemodynamics. How-
Indication: Induction of unconsciousness, ever, although they do not appear to act directly
especially in patients with unstable hemo- as myocardial depressants, they may reduce SNS
dynamics. tone and secondarily result in a blood pressure
Contraindications: Known hypersensitivity. drop. This effect may be significant if high sym-
Septic shock is a relative contraindication. pathetic tone is a predominant factor in pre-
Dose: Dose is 0.2–0.3 mg/kg IV (average 75 kg = serving blood pressure.
20mg). The BDZs may also cause respiratory depres-
Onset/Duration: Onset is within 30 seconds. sion. This is rarely a problem if used alone in
Clinical duration is 5–10 minutes. low doses for sedation, although higher doses
Potential Complications: Hypotension and can result in apnea. Both the cardiovascular and
apnea. Adrenal suppression. respiratory side effects are more pronounced if
BDZs are used in conjunction with other agents,
䉴 ADJUNCTIVE AGENTS such as opioids.
Clinician familiarity with these drugs has
Adjunctive agents are usually given in the “pre- made them a common choice for sedation in
treatment” phase of an RSI, or used to facilitate patients undergoing airway management.
an awake intubation (or “awake look” laryn-
goscopy). The evidence supporting use of these Midazolam
pretreatment agents in RSI is relatively poor. Midazolam has become a popular agent for
When performing an RSI, it is important to keep sedation in the setting of emergency airway
in mind that the pharmacologic goal is to rapidly management. It has also been used as an induc-
and safely induce a state of unconsciousness tion agent to facilitate RSI both in the ED and
and paralysis to facilitate endotracheal intuba- the prehospital setting.31,43,44
tion. The use of additional medications may or Compared to its predecessor diazepam
may not always be necessary, warranted, or (Valium®), midazolam is 2–3 times more potent,
desirable. has a faster onset and shorter time to recovery.
Clinical effect is generally seen approximately
Benzodiazepines 1–2 minutes following an IV bolus. Onset time
is dose-dependent and can be shortened by
The benzodiazepines (BDZs) are sedative-hypnotic using larger doses. Although quick, midazo-
drugs that exert their main effect via GABA lam’s onset time is still substantially slower
receptors in the CNS. The effect of this binding than that of the induction sedative/hypnotics
is dose-related and includes sedation, anxiolysis, previously discussed.45 In addition, compared
amnesia, and centrally mediated muscle relax- to other induction agents, midazolam does not
ation. At low doses the effect is mainly seda- produce unconsciousness with the same degree
tion, anxiolysis and amnesia, while higher of predictability.45 These reasons, together with
doses can be employed to induce general potential adverse effects on blood pressure, limit
anesthesia. Of note, the BDZs do not have the usefulness of midazolam as an induction
primary analgesic properties. All BDZs act in a agent.
The general anesthetic induction dose of Contraindications: Uncorrected shock states

midazolam is 0.1–0.3 mg/kg. This equates to are relative contraindications that require a
7–21 mg of midazolam for a 70-kg adult. At decrease in dose.
these higher doses, the onset time is quicker, Dose: Dose is 0.025–0.05 mg/kg IV for seda-
but still not as rapid as the previously discussed tion, and 0.1–0.3 mg/kg IV for induction.
induction agents. Clinicians frequently under- Onset/Duration: Onset is 1–2 minutes. Clini-
dose midazolam when using it as an induction cal duration is 15–20 minutes.
agent.44 Potential Complications: Hypotension and
There is a misconception that midazolam is apnea.
hemodynamically benign. In fact, data exists
showing that midazolam causes dose-related Butyrophenones
hypotension when used for RSI.46 Even at low
doses, compared with etomidate, hypotension Butyrophenones, including haloperidol and
occurs much more frequently with midazolam droperidol are phenothiazine-like agents with
use for RSI.31 a long history of clinical use. In the context of
Smaller doses of midazolam may be used airway management, they can sometimes be
for sedation, especially if used in conjunction used for “chemical restraint,” whereby an oth-
with other drugs. The recommended dose erwise mildly uncooperative patient may be
range for light sedation is 0.025–0.05 mg/kg, rendered outwardly tranquil, immobile, and
with the higher doses used to sedate the apparently indifferent to the surroundings.
already intubated patient (e.g., 2–5 mg for Although theoretically of use in facilitating an
the average adult). To avoid oversedation, “awake” intubation, these agents are less likely
one should wait at least 2 minutes between to be successful in the actively uncooperative,
doses. critically ill patient in need of emergency airway
In airway management, the primary role of management.
midazolam is as a light sedative for the patient
undergoing an awake intubation. Although its Haloperidol
slower onset time limits the drug’s usefulness as Haloperidol can be used by intravenous or intra-
a primary induction agent for RSI, it can be used muscular routes. To help control an unruly
as a co-induction agent to help ensure amnesia. patient, it is commonly used in combination
Midazolam may also be useful in providing post- with a benzodiazepine.
intubation sedation and amnesia.
Midazolam is supplied as either 1 mg/mL or SUMMARY
5 mg/mL concentrations, in a variety of vial Drug: Haloperidol.
sizes. Flumazenil can be used to reverse the Drug type: Antipsychotic/sedative.
effect of benzodiazepines (e.g., 0.3 mg, repeating
Indication: Chemical restraint.
0.5 mg q 1 minute to maximum of 3 mg). Contraindications: Hypersensitivity; Parkin-
Flumazenil should be avoided in conditions that son’s disease.
predispose the patient to seizures. Dose: Dose is 2–5 mg IV, repeated prn. Intra-
muscular (IM) dose is 5–10 mg. May be
SUMMARY combined with midazolam or lorazepam
Drug: Midazolam. in a ratio of 5:1 (e.g., haloperidol 5 mg/
Drug type: Benzodiazepine. Sedative, anxi- lorazepam 1 mg).
olytic, hypnotic. Onset/Duration: Onset is within 5 minutes
Indications: Sedation, amnesia, anxiolysis, co- (intravenous) or 20 minutes (intramuscular).
induction agent. Clinical duration is 1–2 hours.
222 CHAPTER 13
Potential Complications: Extrapyramidal effects; Opioids do not decrease myocardial con-

hypotension and dysrhythmias (rarely). tractility, nor do they directly cause a decrease
in blood pressure. They may, however, result in
hypotension secondary to a decrease in sympa-
Dexmedetomidine thetic tone. As with the BDZs, caution should
be exercised in the patient running on “sympa-
Dexmedetomidine is a relatively new alpha-2 thetic overdrive.”
receptor agonist, currently approved for seda- Although opioids blunt the hemodynamic
tion in an intensive care setting. Delivered by response to intubation, the dosages required for
infusion in an initial dose of 1 µg/kg over 10 complete blunting tend to be large. Opioids do
minutes, followed by ongoing infusion at not intrinsically raise ICP, however by causing
0.2–0.7 µg/kg/h, it is remarkable for not signif- the spontaneously breathing patient to hypoven-
icantly suppressing ventilatory drive. Case tilate, they can cause a secondary rise in PaCO2,
reports and series47, 48 are appearing on its use in turn resulting in a rise in ICP. The effects of
to facilitate awake intubations in the OR set- the opioids can be reversed with naloxone, a
ting. In time, its use for this indication may specific opioid receptor antagonist.
expand to the uncooperative patient outside
the OR. NARCOTICS AS AN ADJUNCT TO AWAKE
INTUBATION
Small doses of narcotics such as fentanyl may
Opioids be a useful adjunct to “awake” intubation. As
potent analgesics, narcotics help attenuate the
The term opiate refers to the group of drugs discomfort associated with laryngoscopy, and
derived from opium, while opioid refers to all also help obtund the cough reflex to insertion
exogenous substances that bind to opioid of the endotracheal tube in the trachea. Fen-
receptors. There are four main classes of tanyl used in this capacity can be given in doses
opioid receptor, and multiple subclasses within of 25–50 µg (in an average-sized adult) at a
each class. time, repeated as needed. The newer short-
The major effect of opioids is to produce acting narcotic Remifentanil is making
dose-dependent analgesia and sedation. The inroads as an adjunct to awake intubation in
major side effects are also mediated by receptor the OR, delivered in small bolus doses and/or
binding and include respiratory depression, by infusion.
pruritis, and ileus. Nausea and vomiting are
also important side effects of the opioids, but Morphine
may not necessarily be related to specific receptor Morphine is the prototypical opioid agent.
binding. It is important to remember that the Although it is an excellent analgesic, it has sev-
opioids do not possess intrinsic amnestic eral features that make it unattractive as a phar-
properties, nor do they cause muscle macologic aid in airway management. It has a
relaxation. relatively slow onset time, taking up to 15 minutes
Opioid medications cause a dose-dependent for peak effect following an IV injection. In addi-
decrease in minute ventilation, primarily by a tion, morphine can result in histamine release,
decrease in respiratory rate. Large or bolus doses making it undesirable for use in patients with
may result in apnea, especially when used in asthma, and contributing to a tendency to drop
conjunction with other sedatives. Opioids blunt blood pressure. Morphine’s role in airway man-
airway reflexes (especially the cough reflex) in agement is essentially limited to postintubation
a dose-dependent fashion. sedation and analgesia.
SUMMARY Contraindications: Uncorrected shock states

Drug: Morphine. are relative contraindications; if used, a
Drug type: Opioid analgesic. decrease in dose is required.
Indication: Analgesia. Dose: Dose is 1–3 µg/kg IV. (Average pretreat-
Contraindications: Uncorrected shock states ment dose 75 kg = 150 µg)
are relative contraindications; if used, a Onset/Duration: Onset is less than 1 minute.
decrease in dose will be required. Clinical duration is 1 hour.
Dose: Dose is 0.05–0.1 mg/kg IV (average 75 kg Potential complications: Apnea. Hypotension.
= 5 mg).
Onset/Duration: Onset is within 5–15 minutes. Lidocaine
Clinical duration is 1–2 hours.
Lidocaine as Pretreatment Agent
Potential Complications: Hypotension and
Intravenous lidocaine has been espoused as a
apnea. Histamine release.
pretreatment agent to block the pressor response,
Fentanyl attenuate the rise in ICP, and suppress the cough
Fentanyl is a synthetic opioid agent that is sig- or bronchospastic reflex that may accompany
nificantly more potent than morphine. It results laryngoscopy and intubation.53 However, a
in minimal histamine release and has a rapid number of reports have questioned the benefit
onset (30–60 seconds after an IV bolus) and rel- of IV lidocaine for these indications.54–56 Cer-
atively short duration of action. These features tainly there is no clear evidence of its benefit as
make it a suitable adjunct for RSI. a pretreatment agent for RSI in head-injured
To completely block the pressor response to patients,56 although it is possible that future
laryngoscopy and intubation, relatively large work may reveal a neuroprotective effect.13
doses (≥6 µg/kg49–51) of fentanyl are needed. While lidocaine may inhibit the cough reflex,
These larger doses are rarely used for emergency compelling evidence of its efficacy as a pretreat-
intubations, due to concerns of potential hemo- ment agent in the bronchospastic patient is simi-
dynamic compromise. Large doses of fentanyl larly lacking, although it is probably not harmful.
may also cause bradycardia secondary to a If attenuation of the pressor response to laryn-
blunting of the baroreceptor heart rate reflex, goscopy and intubation is important, alterna-
although this bradycardia will respond to tives to IV lidocaine include an appropriate dose
atropine, if necessary. If used as an adjunctive of induction sedative/hypnotic, together with
medication for RSI, fentanyl is generally given in pretreatment using a potent opioid or a short-
the pretreatment phase, before administration of acting beta-blocker such as esmolol.54,55 Caution
the induction sedative/hypnotic. In this context, must be used with these latter approaches,to
1–3 µg/kg of fentanyl has been shown to some- avoid hypotension in at-risk patients.
what attenuate the hemodynamic and respiratory
responses to intubation.49, 51, 52 The theoretic value Lidocaine for Airway Anesthesia
of this pretreatment effect must be balanced Applied Topically or by Regional
against the potential hemodynamic and respira- Nerve Block
tory consequences (e.g., premature hypoxia) in the Lidocaine is the mainstay of topically-applied
at-risk patient. Fentanyl is supplied as a 50 µg/mL airway anesthesia for awake intubation in many
solution and is available in a variety of vial sizes. institutions. Many formulations of lidocaine exist,
including jelly, ointment, viscous, and liquid, in
SUMMARY varying concentrations. Lidocaine can be applied
Drug: Fentanyl. topically to the airway by “gargle and swish” of
Drug type: Opioid analgesic. the liquid and/or viscous formulations; tongue
Indication: Analgesia. Sedation. depressor application of the ointment or gel to
224 CHAPTER 13
the tongue; cotton pledgets held in forceps to even in pediatrics, and its routine use has been
access deeper structures such as the piriform questioned.57–60 In a study performed at a large
recesses; atomizer or metered-dose sprayer; or pediatric ED, atropine pretreatment had no effect
direct injection through the cricothyroid mem- on the incidence of bradycardia post-RSI.60
brane. The injectable formulation (e.g., 2%) can Although still widely used as a pretreatment agent
be used for regional percutaneous nerve blocks. in infant RSI, the lack of evidence documenting
its efficacy in preventing laryngoscopy and intu-
SUMMARY bation-related bradydysrhythmias, together with
Drug: Lidocaine. its potential adverse effects do not support its
Drug type: Local anesthetic. use outside the context of administration of a
Indication: Intravenous: Historically, attenu- second dose of succinylcholine.57,58 If used, the
ation of pressor response or cough reflex recommended dose in pediatric practice is
to intubation. Applied topically, via 0.01–0.02 mg/kg, with a minimum dose of
cricothyroid injection or percutaneous 0.1 mg and a maximum dose of 1 mg.
nerve block: Airway anesthesia for awake Regardless of whether a practitioner adheres
intubation. to these guidelines, atropine should be imme-
Contraindications: Hypersensitivity to amide- diately available in the event that the patient
type local anesthetics. develops symptomatic bradycardia following
Dose—IV use: Dose is 1–1.5 mg/kg IV (average intubation. It is also recommended that atropine
75 kg = 100 mg). be used in both adults and children prior
Onset/Duration: Onset is 1–3 minutes. Dura- to giving a second dose of succinylcholine
tion is ~ 20 minutes. (discussed in the next section).
Potential Complications: Symptoms of local
anesthetic toxicity. Hypotension. Seizures. SUMMARY
Drug: Atropine.
Drug type: Anticholinergic/antimuscarinic.
Atropine Indication: Bradycardia. Prophylaxis prior to
repeated doses of succinylcholine or histor-
Atropine is an anticholinergic agent. More specifically, pretreatment in pediatrics.
ically, it is an antimuscarinic agent, meaning that Contraindications: Glaucoma is a relative con-
it blocks the effects of acetylcholine at mus- traindication, as is any situation in which
carinic receptors. These receptors are found in tachycardia may be undesirable.
the heart, salivary glands, and the smooth muscle Dose: Dose is .01–.02 mg/kg IV (average 75 kg =
of the respiratory, gastrointestinal (GI), and gen- 0.5 −1 mg).
itourinary (GU) tracts. Clinically, atropine results Onset/Duration: Onset is within 1 minute.
in an increase in heart rate, decrease in secre- Clinical duration is 20–30 minutes.
tions, and potential bronchodilation. In toxic Potential Complications: Tachycardia. Cen-
doses, atropine can exert a central effect and tral anticholinergic syndrome.
cause sedation, amnesia, and confusion (i.e.,
central anticholinergic syndrome). Defasciculating Agents
Historically, atropine was administered
almost universally as a preinduction agent to pro- The issues surrounding the administration of
tect against excessive vagal responses to induc- small doses of nondepolarizing muscle relax-
tion and intubation. With currently available ants to suppress muscle fasciculation associated
drugs, this is rarely necessary in adult patients. In with succinylcholine use are discussed in the
fact, there is limited data to support this practice upcoming section on succinylcholine.
䉴 NEUROMUSCULAR BLOCKERS minutes, whereupon they are rapidly metabo-

(MUSCLE RELAXANTS) lized by pseudocholinesterase in the blood
stream. The duration of muscle relaxation fol-
The use of muscle relaxants to facilitate RSI has lowing a single dose of 1–2 mg/kg is typically
become standard practice in most of the larger 5–10 minutes, although initial return of spon-
EDs throughout North America.61 As discussed taneous respiration will often occur in less than
elsewhere in the text, there is now ample evi- 5 minutes.
dence to demonstrate the increased success and Adequate intubating conditions are consis-
safety with this technique.62 However, it remains tently achieved in less than 1 minute following
critically important for practitioners who admin- an IV bolus 1–2 mg/kg of succinylcholine. When
ister neuromuscular blockers as part of an RSI dosing succinylcholine, it is better to err on the
to be very knowledgeable in all their effects side of giving a larger dose, as the majority of
(intended and adverse) and to be skilled in the the adverse reactions are not dose dependent
mechanics of airway management. and the larger dose assures rapid onset and
There are two classes of muscle relaxant: good skeletal muscle relaxation. The short dura-
depolarizing and nondepolarizing. Succinyl- tion of action is a potential benefit in the OR
choline remains the only depolarizing agent setting, where it may be possible to awaken the
available for clinical use. While there are many patient if intubation proves to be impossible.
non-depolarizing agents on the market, when However, this is usually not an option for
given in conventional doses, only rocuronium patients requiring intubation in emergencies,
is appropriate for RSI, due to its rapid onset. thus making the short duration of action less
beneficial in this setting. In addition, it should
be noted that following a dose of 1 mg/kg of
Depolarizing Muscle Relaxants: succinylcholine, resumption of spontaneous
Succinylcholine ventilation will not necessarily occur quickly
enough to prevent critical oxygen desaturation
Succinylcholine is a commonly used neuromus- if a failed oxygenation (“can’t intubate/can’t oxy-
cular blocker for RSI in emergencies. It has mul- genate”) situation develops.63
tiple side effects, some of which, although Some data suggests that smaller doses (e.g.,
extremely rare, are potentially serious. Notwith- 0.6 mg/kg) of succinylcholine can produce intu-
standing, succinylcholine remains in wide- bating conditions equivalent to those obtained
spread use, for three reasons: (a) it has a very with conventional doses, but with the advan-
rapid onset; (b) it usually has a very short dura- tage of an earlier return of spontaneous ventila-
tion of action, and (c) many clinicians are familiar tion.64,65 However, onset of paralysis may be
with its use. delayed and, as mentioned, the clinical signifi-
Succinylcholine works by mimicking the cance of an early return to spontaneous respi-
effects of acetylcholine on receptors at the neu- rations in the emergency setting is not clear.
romuscular junction, causing membrane depo- Succinylcholine administration can result in
larization. Unlike acetylcholine, succinylcholine a transient rise (0.5–1 mEq/L) of serum potas-
remains bound to these receptors for a substan- sium. This is of little consequence in most indi-
tially longer time, thereby preventing normal viduals. However, in patients presenting with
repolarization of the muscle membrane. This preexisting hyperkalemia, this additional rise
results clinically in a short period of muscle fas- may be enough to cause electrocardiographic
ciculation, followed by skeletal muscle relax- changes, or even result in asystole.
ation. The succinylcholine molecules dissociate Damaged or denervated muscle may respond
from the acetylcholine receptors after several by developing new acetylcholine receptors that
226 CHAPTER 13
are located outside the neuromuscular junction. likely due to an increase in afferent activity
Stimulation of these extrajunctional receptors by caused by muscle spindle firing. However, while
succinylcholine may result in an exaggerated succinylcholine may cause a transient rise in
release of potassium from the muscle, and induce ICP in brain tumor patients, there is no direct
hyperkalemic cardiac arrest.66 Patients with evidence that succinylcholine similarly increases
major crush injuries, burns, stroke, or spinal the ICP of brain-injured patients.69 In brain
cord injuries may exhibit this exaggerated tumor patients undergoing elective surgery, two
release of potassium. However, as it takes at studies have shown an attenuation of a suc-
least 24 hours for injured muscle to express new cinylcholine-induced rise in ICP with nondepo-
receptors, these patients are generally not at risk larizing agent pretreatment.70, 71 However, to
when they initially present as emergencies. The date there is no similar data supporting the use
duration of the sensitivity is unclear and may in of defasciculating agents prior to succinylcholine
part depend on the extent of abnormal tissue.66 use in brain-injured patients. In practice, suc-
Patients with certain genetic muscular disorders cinylcholine is commonly used to facilitate intu-
such as muscular dystrophy may also respond to bation in this population.72
succinylcholine administration with an exagger- Succinylcholine is a known trigger for malig-
ated release of potassium. In clinical situations nant hyperthermia (MH). MH is an inherited
where this response may occur, or if an elevated metabolic disease of skeletal muscle. When
potassium level may already exist (e.g., a patient susceptible individuals are exposed to succinyl-
with known history of renal failure requiring choline and/or volatile anesthetics they may
intubation before blood chemistry results are “trigger” this life-threatening condition. MH is
available), an alternative to succinylcholine characterized by generalized muscle contrac-
should be used. tions, tachycardia, hypercarbia, tachypnea,
Succinylcholine may cause cardiac dysrhyth- hypoxia, mixed respiratory and metabolic aci-
mias. Bradydysrhythmias are most common and dosis, arrhythmias, and (a late sign), hyperthermia.
are more likely following a repeat dose of suc- Dantrolene (starting at 2.5 mg/kg) is the defin-
cinylcholine. In this regard, it is recommended itive treatment and should be administered
that atropine be administered prior to giving early when the diagnosis is suspected, in con-
a second dose of succinylcholine, even in a junction with supportive management. Fortu-
tachycardic patient. nately, MH is rare, occurring in 1 in 50,000
Succinylcholine has been shown to increase adult anesthetics, although the susceptibility in
intraocular pressure (IOP). However, in patients the general population may be as high as 1 in
with open eye injuries, no adverse effects from 2000.73
succinylcholine administration have been Succinylcholine may result in masseter
reported, despite extensive use.67 Coughing and muscle rigidity (MMR). This is more common
straining during intubation will raise intraocular in children and occurs most often when used in
pressure significantly more than succinylcholine conjunction with a volatile anesthetic, although
use alone. Rocuronium may be a better choice it has also been described in the ED setting.74
for patients with open-eye injuries, in that during Generally, this rigidity can be overcome, and it
RSI, compared to succinylcholine, it has been usually subsides spontaneously in 2–3 minutes.
shown to significantly decrease the percentage MMR may be associated with MH.
of change from baseline IOP.68 The effects of succinylcholine will be pro-
Although published study results are contra- longed in patients who have abnormal pseudo-
dictory, succinylcholine may cause an increase cholinesterase. In the most severe form of
in ICP. Any rise in ICP does not appear to be pseudocholinesterase deficiency, the effects of
related to muscle fasciculations, and is more succinylcholine may last 6–12 hours.
Other adverse effects possible with suc- Dose: Dose is 1–2 mg/kg IV (average 75 kg =
cinylcholine use include histamine release and 120 mg).
the potential for allergic reactions. Succinyl- Onset/Duration: Onset is less than 1 minute.
choline has been associated with generalized Clinical duration is 5–10 minutes.
myalgias after administration, although this Potential Complications: Hypoxia, hypercar-
phenomenon is usually not relevant in the bia, hyperkalemic arrest, malignant hyper-
patient requiring emergency intubation. These thermia, prolonged paralysis, myalgias.
myalgias occur more frequently in young
people with a large muscle mass. It may be related
to fasciculations but is not reliably prevented by Nondepolarizing Muscle Relaxants
pretreatment with a nondepolarizing agent.75
The issue of pretreatment with a small dose The nondepolarizing muscle relaxants act as
(one-tenth of an intubating dose) of nondepo- competitive antagonists to acetylcholine at the
larizing muscle relaxant prior to succinylcholine neuromuscular junction. They do not stimulate
administration remains unclear. Pretreatment acetylcholine receptors: rather, they block the bind-
in this fashion does not protect against MH, ing of acetylcholine. Their effects may be
MMR, hyperkalemia, dysrhythmias, or pro- antagonized by increasing the concentration of
longed muscle relaxation secondary to pseudo- acetylcholine at the neuromuscular junction
cholinesterase deficiency. The effect on ICP is with agents that inhibit acetylcholine break-
unknown but is likely of little clinical signifi- down (see section on neuromuscular blocker
cance.69 Pretreatment does necessitate a larger reversal agents). Their side effect profile is fairly
dose of succinylcholine (1.5 mg/kg) and may limited and the main differences between the
decrease the quality of muscle relaxation agents relate to pharmacodynamics.
achieved.72 Pretreatment also adds another step
to the RSI process and adds the potential for pre- Rocuronium
mature muscle relaxation, especially if a larger Rocuronium is being used with increasing fre-
dose is given in error. quency in the emergency setting as part of RSI
Succinylcholine provides rapid onset of and when indicated, for post-intubation neuro-
skeletal muscle relaxation allowing for muscular blockade. In larger doses (e.g., 1 mg/kg),
excellent intubating conditions, with rapid it has a similar onset time and produces intu-
offset. However, as outlined above, it is also bating conditions comparable to those achieved
a drug with a number of potentially serious following a 1 mg/kg dose of succinylcholine.76
side effects. Before using succinylcholine, However, this dose of rocuronium will produce
the clinician must be familiar with con- clinical paralysis that may last up to 1 hour.
traindications to its use. While the extended duration of action may
cause anxiety in some clinicians, others prefer
SUMMARY this longer period of neuromuscular blockade
Drug: Succinylcholine. as it produces good conditions for BMV and
Drug type: Depolarizing muscle relaxant. repeat intubation attempts, should difficulty
Indication: Skeletal muscle relaxation for RSI. be encountered (See Table 9–1, Chap. 9). In
Contraindications: Predicted inability to either addition, the use of rocuronium avoids the
mask ventilate or intubate. Hyperkalemia. need to consider the many contraindications
Malignant hyperthermia. Patients 24 hours and precautions associated with succinylcholine
or more postburn or denervation injury. use. Smaller doses of rocuronium may be used
Pseudocholinesterase deficiency is a relative to maintain relaxation in the postintubation
contraindication. period, if needed.
228 CHAPTER 13
Rocuronium is devoid of cardiac effects. It is Onset/Duration: Onset is within 1.5–3 minutes.

supplied as a 10 mg/mL solution in a 5 mL vial. Clinical duration is 45–90 minutes, depending
on dose.
SUMMARY Potential complications: Hypoxia, hypercarbia.
Drug: Rocuronium.
Drug type: Nondepolarizing muscle relaxant. Pancuronium
Indication: Skeletal muscle relaxation for RSI, Pancuronium is a long-acting nondepolarizing
or post-intubation paralysis. muscle relaxant with a relatively slow onset of
Contraindications: Predicted inability to either action. Clinical relaxation lasts at least an hour.
bag-mask ventilate or intubate. Pancuronium has fallen out of favor with many
Dose: Dose is 1 mg/kg IV (average 75 kg = clinicians due to concerns of residual subclinical
80 mg). paralysis that may increase post-operative
Onset/Duration: Onset is within 1–1.5 minutes. respiratory complications when used in the
Clinical duration is 45–80 minutes, depending OR setting.
on dose administered. Pancuronium consistently causes an
Potential Complications: Hypoxia, hypercar- increase in heart rate and rarely, may result in
bia. Pain on injection. dysrhythmias. This effect may make pancuro-
nium an undesirable agent for use in patients
Vecuronium with coronary artery disease, as well as other
Vecuronium is an intermediate-acting nondepo- patients in whom tachycardia is considered an
larizing muscle relaxant. An intubating dose of important early warning of hemodynamic
0.1 mg/kg will produce adequate intubating con- decompensation.
ditions within 3 minutes, with effects lasting Pancuronium has no role to play in RSI
about 45 minutes. Larger doses of up to 0.3 mg/kg because of its slow onset. It can be considered
may decrease the onset time required to intu- for post-intubation paralysis if the duration of
bate to 1.5 minutes, however clinical relaxation paralysis is not of concern.
may persist for up to 3 hours. Vecuronium Pancuronium is supplied as a 2 mg/ml
has no cardiac effects and does not stimulate solution.
histamine release. Since the introduction of
rocuronium, the role of vecuronium in airway SUMMARY
management is limited largely to postintubation Drug: Pancuronium
management. Drug type: Nondepolarizing muscle relaxant.
Vecuronium is supplied as a powder and Indication: Pretreatment agent before suc-
must be reconstituted with water or saline to cinylcholine administration. Skeletal muscle
produce a solution of either 1 or 2 mg/kg. relaxation post-intubation.
Contraindications: Predicted inability to either
SUMMARY bag-mask ventilate or intubate.
Drug: Vecuronium. Dose: Intubating dose is 0.1 mg/kg IV (average
Drug type: Nondepolarizing muscle relaxant. 75 kg = 8 mg initially; 1–2 mg for mainte-
Indication: Skeletal muscle relaxation post- nance of post-intubation paralysis). As a pre-
intubation. treatment agent before succinylcholine,
Contraindications: Predicted inability to either .01 mg/kg (average = 0.5–1.0 mg).
bag mask ventilate or intubate. Onset/Duration: Onset is within 5 minutes.
Dose: Intubating dose is 0.1–0.3 mg/kg IV Clinical duration is 60–90 minutes.
(average 75 kg = 8 mg initially; 2–4 mg for Potential Complications: Hypoxia, hypercarbia,
maintenance of post-intubation paralysis). tachycardia.
䉴 OTHER AGENTS The drug works by chemically “encapsulating”

rocuronium molecules, thus dissociating them
Neuromuscular Blockade Reversal from the acetylcholine receptor and thereby
Agents reversing the neuromuscular blockade.78, 81
Early studies suggest that it will be able to
Residual effects of the nondepolarizing agents reverse profound rocuronium-induced neuro-
may be reversed by administration of an anti- muscular blockade within 3 minutes. 79,80,82
cholinesterase agent. However, it must be This effect is confined to rocuronium and when
appreciated that a substantial amount of tested has not worked with atracurium or
spontaneous recovery must already have mivacurium, 79 two other nondepolarizing
occurred before these drugs can be used neuromuscular blockers. The drug is hemo-
to reverse the residual paralyzing effects dynamically inert,78 and no concomitant use
of a nondepolarizing agent. Ideally, this of an anticholinergic agent is needed.81 The
is determined by use of a nerve stimulator potential of this agent to rapidly reverse neu-
monitor. The time required for this initial romuscular blockade induced by rocuronium
spontaneous recovery is dose-dependent and in failed oxygenation (can’t intubate/can’t oxy-
depends on the relaxant used, but tends to be genate) situations may add an additional layer
at least 20–30 minutes. This is obviously too of safety to RSI.
long to wait for return of spontaneous ventila-
tion should intubation and oxygenation prove
impossible. Neostigmine and Edrophonium
Neuromuscular reversal agents are rarely Neostigmine and edrophonium are two anti-
used in the context of emergency airway man- cholinesterase agents commonly used by anes-
agement. Their one possible use may be to thesiologists to reverse residual muscle paralysis
reverse residual neuromuscular blockade in the in surgical patients. Neostigmine is the more
already intubated patient in order to facilitate a commonly used agent, combined with atropine
complete neurologic assessment. or glycopyrrolate. Exceeding the recommended
These agents inhibit acetylcholinesterase maximal dose may actually result in a more pro-
throughout the body and therefore result in an longed neuromuscular block. Edrophonium has
accumulation of acetylcholine at both mus- a somewhat more rapid onset than neostigmine,
carinic and nicotinic receptors (at the neuro- and is used in a dose of 0.5–1.0 mg/kg, also
muscular junction). The effects on the mus- with concomitant atropine or glycopyrrolate
carinic receptors cause a predictable decrease administration.
in heart rate, increased secretions and gut
mobility, and pupillary constriction. Therefore,
concurrent administration of an antimuscarinic SUMMARY
agent such as atropine or glycopyrrolate should Drug: Neostigmine.
occur, which will help limit the clinical effects of Drug type: Anticholinesterase.
these agents, as desired, to the neuromuscular Indication: Reversal of residual nondepolarizing
junction. agent neuromuscular blockade.
A new compound not on the market at the Contraindications: Complete neuromuscular
time of publication of this text is Sugam- blockade without any spontaneous recovery.
madex (Org 25969; modified gamma- Dose: Dose is 0.04–0.06 mg/kg IV (average
cyclodextrin). This drug looks promising as a 75 kg = 3–5 mg, used with concomitant
rapid-reversal agent for rocuronium, even from atropine 1–2 mg or glycopyrrolate 0.6–
deep levels of neuromuscular blockade.77–80 1.0 mg).
230 CHAPTER 13
Onset/Duration: Onset is within 1.5–3 minutes. adrenergic receptors. It is commonly used in

Clinical duration is several hours. the OR, although its use in out-of-OR emer-
Potential Complications: Bradycardia. Abdom- gency intubations is less well established. It
inal discomfort. results in an increase in heart rate and blood
pressure. In doses of 5–10 mg IV, it may be useful
Vasopressors and Inotropes to temporarily support the blood pressure while
(Rescue Drugs) the effects of the induction sedative/hypnotic
wear off and any volume deficit is corrected.
A decrease in blood pressure is not uncommon Ephedrine’s effects generally last 5–10 minutes.
following induction and intubation. Reasons for This temporary support may be particularly
this include: important in head-injured patients, where even
transient hypotension can lead to worsened out-
• Direct negative inotropic and peripherally come. If there is no improvement after 20–25
vasodilating effects of pretreatment agents mg, then the etiology of the hypotension should
and/or induction sedative/hypnotics. be reexamined and the need for a more potent
• Decreased venous return secondary to initia- vasopressor or inotrope (e.g., phenylephrine,
tion of positive pressure ventilation, accentu- dopamine, or epinephrine) should be consid-
ated by the volume-depleted state of many ered. Ephedrine is supplied as 50 mg in a 1 mL
patients requiring emergency intubation. ampoule. It should be diluted before use to a
• Relief of high sympathetic tone from admin- concentration of 5 mg/mL, for example, by
istration of anxiolytic/sedative medications. adding the contents of the vial to 9 mL of saline
• Less commonly, a tension pneumothorax, in a 10 cc syringe.
particularly in the setting of trauma, or in
patients with lung disease. SUMMARY
Drug: Ephedrine.
The presence of preexisting hypovolemia Drug type: Vasopressor.
will make any of the above effects more pro- Indication: To attain a transient increase in
nounced. The initial response to hypoten- blood pressure.
sion of almost any cause should be volume Contraindications: Elevated BP and/or heart
expansion (e.g., 10–20 mL/kg). This should be rate. Contraindicated in the presence of
followed by a quick clinical assessment, looking monoamine oxidase (MAO) inhibitors.
for a correctable etiology. However, because of Dose: Dose is 5–10 mg IV.
hypotension-associated morbidity/mortality Onset/Duration: Onset is within 1 minute.
(e.g., in the head-injured patient), administra- Clinical duration is 5–10 minutes.
tion of a temporizing corrective medication Potential Complications: Tachycardia. Hyper-
may be beneficial while a cause is sought. Exam- tension. Aggravation of myocardial ischemia.
ples include short-acting vasopressors such Tachyphylaxis, that is, repeat doses will be
as ephedrine and phenylephrine. Many clini- less effective.
cians espouse having at least one of these two
drugs diluted and ready for administration Phenylephrine
during every RSI. As a direct-acting alpha agonist, phenylephrine
is a potent peripheral vasoconstrictor. It
Ephedrine causes an increase in blood pressure with
Ephedrine is a vasopressor which acts indirectly no direct effect on heart rate. However, a
on alpha-1 receptors by causing noradrenaline reflex slowing of heart rate is often seen due
release, and directly, through action on beta to baroreceptor stimulation by the increase in
systemic blood pressure. Phenylephrine is a very spontaneously breathing volunteers receiving

potent vasopressor and is supplied in a highly the drug.83 The initial dose is 2.5 mg/kg. If MH
concentrated form (10 mg in a 1-mL vial). It is suspected, the initial dosage of dantrolene
must be diluted prior to use. The 10 mg/1 mL should be given and a consult obtained from
vial can be diluted by injecting its contents into Anesthesia for help with ongoing management.
a 100 mL bag of saline to yield a 100 µg/mL Dantrolene is supplied in vials of only 20 mg,
solution, or the same vial injected into a 250 mL and must be reconstituted with sterile water.
bag will yield a 40 µg/mL solution. It is typically Dantrolene should be stocked in any institution
administered in doses starting at 40–100 µg IV. where succinylcholine is used.
Onset is within 1 minute, and the dose can be
doubled every 1–2 minutes, titrating to effect. As SUMMARY
with ephedrine, its effect lasts about 5–10 minutes. Drug: Dantrolene.
Both drugs are commonly used in the OR Drug type: Skeletal muscle relaxant.
setting. Indication: To treat suspected malignant hyper-
Phenylephrine as a vasopressor may be thermia.
preferable for use in the patient in whom an Contraindications: None, when used for an
increase in heart rate is undesirable (e.g., a MH crisis.
patient with ischemic heart disease). Dose: 2.5 mg/kg IV (Average 75 kg = 200 mg,
which is 10 vials). Should be repeated, as
SUMMARY needed, every 5 minutes to maximum
Drug: Phenylephrine. 20 mg/kg or until hypermetabolic symptoms
Drug type: Vasopressor. subside. If no clinical response, the diagnosis
Indication: To attain a transient increase in should be questioned.
blood pressure. Onset/Duration: Onset of action is within
Contraindications: Elevated BP. 5 minutes.
Dose: 40–100 µg IV. Potential Complications: Skeletal muscle
Onset/Duration: Onset is within 1 minute. weakness. Calcium channel blockers should
Clinical duration is 5–10 minutes. be avoided if dantrolene has been used.
Potential Complications: Bradycardia. Hyper-
tension. Aggravation of myocardial ischemia.
䉴 SUMMARY AND FINAL WORDS
OF CAUTION
Dantrolene
Many factors affect the appropriate use of
Dantrolene is a direct-acting skeletal muscle injectable medications, including patient weight,
relaxant, although it acts intracellularly and with age, co-morbidities, volume status, and level of
no paralyzing effect at the neuromuscular junc- consciousness. Clinician experience is also
tion. Dantrolene is the only therapeutic agent invaluable in making drug choices and choosing
available for treatment of malignant hyperther- dosages. The drug indications and dosages
mia (MH). If MH is suspected following suc- outlined in this text should therefore be used
cinylcholine use, dantrolene should be given, only as a guide.
as if unrecognized and untreated, MH has a Intravenously injected agents act quickly.
mortality of over 70%. Side effects of dantro- The clinician using these drugs must have a
lene are few—although it can cause some solid knowledge of their indications, con-
skeletal muscle weakness, no respiratory traindications, dosing, and expected clinical
impairment was reported in one study of awake, effect. It is incumbent on the clinician to
232 CHAPTER 13
read, seek the advice and experience of col- relationships, and drug delivery. Curr Med Chem.
leagues, and ideally observe the use of these 2000;7(2):249–271.
medications in elective settings (e.g., the OR) 12. Vasile B, Rasulo F, Candiani A, et al. The patho-
prior to using them in critically ill patients. physiology of propofol infusion syndrome: a sim-
ple name for a complex syndrome. Intensive Care
Med. 2003;29(9):1417–1425.
13. Hans P, Bonhomme V. Neuroprotection with
REFERENCES anaesthetic agents. Curr Opin Anaesthesiol.
1. Kaplan JD, Schuster DP. Physiologic consequences 2001;14(5):491–496.
of tracheal intubation. Clin Chest Med. 1991; 14. Proporol Injection 10 mg/ml Product Monograph.
12(3):425–432. Montreal, QC, Canada: Hospira Healthcare Corpo-
2. Shribman AJ, Smith G, Achola KJ. Cardiovascular ration.
and catecholamine responses to laryngoscopy with 15. Wheeler DS, Vaux KK, Ponaman ML, et al. The safe
and without tracheal intubation. Br J Anaesth. and effective use of propofol sedation in children
1987;59(3):295–299. undergoing diagnostic and therapeutic proce-
3. Takahashi S, Mizutani T, Miyabe M, et al. Hemo- dures: experience in a pediatric ICU and a review
dynamic responses to tracheal intubation with of the literature. Pediatr Emerg Care. 2003;19(6):
laryngoscope versus lightwand intubating device 385–392.
(Trachlight) in adults with normal airway. Anesth 16. Pentothal Product Monograph. Vaughan, ON,
Analg. 2002;95(2):480–484. Canada: Abbot Laboratories Limited.
4. Laxton CH, Milner Q, Murphy PJ. Haemodynamic 17. Grunberg G, Cohen JD, Keslin J, et al. Facilitation
changes after tracheal intubation in cigarette smok- of mechanical ventilation in status asthmaticus
ers compared with non–smokers. Br J Anaesth. with continuous intravenous thiopental. Chest.
1999;82(3):442–443. 1991;99(5):1216–1219.
5. Shafi S, Gentilello L. Hypotension does not increase 18. Cromhout A. Ketamine: its use in the emergency
mortality in brain-injured patients more than it department. Emerg Med (Fremantle). 2003;15(2):
does in non-brain-injured patients. J Trauma. 155–159.
2005;59(4):830–834; discussion 834–835. 19. Brown RH, Wagner EM. Mechanisms of bron-
6. The Brain Trauma Foundation. The American Asso- choprotection by anesthetic induction agents:
ciation of Neurological Surgeons. The Joint Section propofol versus ketamine. Anesthesiology. 1999;
on Neurotrauma and Critical Care. Resuscitation of 90(3):822–828.
blood pressure and oxygenation. J Neurotrauma. 20. Green SM, Krauss B. Clinical practice guideline for
2000;17(6–7):471–478. emergency department ketamine dissociative seda-
7. Sivilotti ML, Filbin MR, Murray HE, et al. Does the tion in children. Ann Emerg Med. 2004;44(5):
sedative agent facilitate emergency rapid sequence 460–471.
intubation? Acad Emerg Med. 2003;10(6):612–620. 21. Sehdev RS, Symmons DA, Kindl K. Ketamine for
8. Sivilotti ML, Ducharme J. Randomized, double- rapid sequence induction in patients with head
blind study on sedatives and hemodynamics dur- injury in the emergency department. Emerg Med
ing rapid-sequence intubation in the emergency Australas. 2006;18(1):37–44.
department: the SHRED Study. Ann Emerg Med. 22. Himmelseher S, Durieux ME. Revising a dogma:
1998;31(3):313–324. ketamine for patients with neurological injury?
9. Casati A, Putzu M. Anesthesia in the obese patient: Anesth Analg. 2005;101(2):524–534.
pharmacokinetic considerations. J Clin Anesth. 23. Albanese J, Arnaud S, Rey M, et al. Ketamine
2005;17(2):134–145. decreases intracranial pressure and electroen-
10. Franklin C, Samuel J, Hu TC. Life-threatening cephalographic activity in traumatic brain injury
hypotension associated with emergency intubation patients during propofol sedation. Anesthesiology.
and the initiation of mechanical ventilation. 1997;87(6):1328–1334.
Am J Emerg Med. 1994;12(4):425–428. 24. Sherwin TS, Green SM, Khan A, et al. Does adjunc-
11. Trapani G, Altomare C, Liso G, et al. Propofol in tive midazolam reduce recovery agitation after
anesthesia. Mechanism of action, structure-activity ketamine sedation for pediatric procedures? A
randomized, double-blind, placebo-controlled trial. 36. Jackson WL, Jr. Should we use etomidate as an
Ann Emerg Med. 2000;35(3):229–238. induction agent for endotracheal intubation in
25. Wathen JE, Roback MG, Mackenzie T, et al. Does patients with septic shock?: a critical appraisal.
midazolam alter the clinical effects of intra- Chest. 2005;127(3):1031–1038.
venous ketamine sedation in children? 37. Murray H, Marik PE. Etomidate for endotracheal
A double-blind, randomized, controlled, emer- intubation in sepsis: acknowledging the good while
gency department trial. Ann Emerg Med. accepting the bad. Chest. 2005;127(3):707–709.
2000;36(6):579–588. 38. Ray DC, McKeown DW. Effect of induction agent
26. Loh G, Dalen D. Low-dose ketamine in addition to on vasopressor and steroid use, and outcome in
propofol for procedural sedation and analgesia in patients with septic shock. Crit Care. 2007;
the emergency department. Ann Pharmacother. 11(3):R56.
2007;41(3):485–492. 39. Annane D, Sebille V, Charpentier C, et al. Effect of
27. Willman EV, Andolfatto G. A prospective evaluation treatment with low doses of hydrocortisone and
of “ketofol” (ketamine/propofol combination) for fludrocortisone on mortality in patients with septic
procedural sedation and analgesia in the emergency shock. JAMA. 2002;288(7):862–871.
department. Ann Emerg Med. 2007;49(1):23–30. 40. Lipiner–Friedman D, Sprung CL, Laterre PF, et al.
28. Oglesby AJ. Should etomidate be the induction Adrenal function in sepsis: the retrospective
agent of choice for rapid sequence intubation in Corticus cohort study. Crit Care Med. 2007;35(4):
emergency department? Emerg Med J. 2004;21(6): 1012–1018.
655–659. 41. Zed PJ, Mabasa VH, Slavik RS, et al. Etomidate for
29. Bramwell KJ, Haizlip J, Pribble C, et al. The effect rapid sequence intubation in the emergency
of etomidate on intracranial pressure and systemic department: Is adrenal suppression a concern? Can
blood pressure in pediatric patients with severe J Emerg Med. 2006;8(5):347–350.
traumatic brain injury. Pediatr Emerg Care. 42. Miner JR, Danahy M, Moch A, et al. Randomized
2006;22(2):90–93. clinical trial of etomidate versus propofol for pro-
30. Zed PJ, Abu-Laban RB, Harrison DW. Intubating cedural sedation in the emergency department.
conditions and hemodynamic effects of etomidate Ann Emerg Med. 2007;49(1):15–22.
for rapid sequence intubation in the emergency 43. Swanson ER, Fosnocht DE, Jensen SC. Comparison
department: an observational cohort study. of etomidate and midazolam for prehospital rapid-
Acad Emerg Med. 2006;13(4):378–383. sequence intubation. Prehosp Emerg Care.
31. Choi YF, Wong TW, Lau CC. Midazolam is more 2004;8(3):273–279.
likely to cause hypotension than etomidate in emer- 44. Sagarin MJ, Barton ED, Sakles JC, et al. Underdos-
gency department rapid sequence intubation. ing of midazolam in emergency endotracheal intu-
Emerg Med J. 2004;21(6):700–702. bation. Acad Emerg Med. 2003;10(4):329–338.
32. Hoffman WE, Charbel FT, Edelman G, et al. Com- 45. Reves JG, Fragen RJ, Vinik HR, et al. Midazolam:
parison of the effect of etomidate and desflurane pharmacology and uses. Anesthesiology. 1985;62(3):
on brain tissue gases and pH during prolonged 310–324.
middle cerebral artery occlusion. Anesthesiology. 46. Davis DP, Kimbro TA, Vilke GM. The use of mida-
1998;88(5):1188–1194. zolam for prehospital rapid-sequence intubation
33. Edelman GJ, Hoffman WE, Charbel FT. Cerebral may be associated with a dose-related increase in
hypoxia after etomidate administration and tem- hypotension. Prehosp Emerg Care. 2001;5(2):
porary cerebral artery occlusion. Anesth Analg. 163–168.
1997;85(4):821–825. 47. Avitsian R, Lin J, Lotto M, et al. Dexmedetomidine
34. Bergen JM, Smith DC. A review of etomidate for and awake fiberoptic intubation for possible cervi-
rapid sequence intubation in the emergency cal spine myelopathy: a clinical series. J Neurosurg
department. J Emerg Med. 1997;15(2):221–230. Anesthesiol. 2005;17(2):97–99.
35. Schenarts CL, Burton JH, Riker RR. Adrenocortical 48. Bergese SD, Khabiri B, Roberts WD, et al.
dysfunction following etomidate induction in Dexmedetomidine for conscious sedation in diffi-
emergency department patients. Acad Emerg Med. cult awake fiberoptic intubation cases. J Clin
2001;8(1):1–7. Anesth. 2007;19(2):141–144.
234 CHAPTER 13
49. Kautto UM. Attenuation of the circulatory response 61. Sagarin MJ, Barton ED, Chng YM, et al. Airway man-
to laryngoscopy and intubation by fentanyl. Acta agement by US and Canadian emergency medi-
Anaesthesiol Scand. 1982;26(3):217–221. cine residents: a multicenter analysis of more than
50. Murkin JM, Moldenhauer CC, Hug CC, Jr. High- 6,000 endotracheal intubation attempts. Ann
dose fentanyl for rapid induction of anaesthesia in Emerg Med. 2005;46(4):328–336.
patients with coronary artery disease. Can Anaesth 62. Kovacs G, Law JA, Ross J, et al. Acute airway man-
Soc J. 1985;32(4):320–325. agement in the emergency department by
51. Adachi YU, Satomoto M, Higuchi H, et al. Fentanyl non–anesthesiologists. Can J Anaesth. 2004;51(2):
attenuates the hemodynamic response to endotra- 174–180.
cheal intubation more than the response to laryn- 63. Benumof JL, Dagg R, Benumof R. Critical hemo-
goscopy. Anesth Analg. 2002;95(1):233–237. globin desaturation will occur before return to an
52. Splinter WM, Cervenko F. Haemodynamic unparalyzed state following 1 mg/kg intra-
responses to laryngoscopy and tracheal intubation venous succinylcholine. Anesthesiology. 1997;87(4):
in geriatric patients: effects of fentanyl, lidocaine 979–982.
and thiopentone. Can J Anaesth. 1989;36(4): 64. El-Orbany MI, Joseph NJ, Salem MR, et al. The neu-
370–376. romuscular effects and tracheal intubation condi-
53. Lev R, Rosen P. Prophylactic lidocaine use preintu- tions after small doses of succinylcholine. Anesth
bation: a review. J Emerg Med. 1994;12(4):499–506. Analg. 2004;98(6):1680–1685.
54. Kindler CH, Schumacher PG, Schneider MC, et al. 65. Naguib M, Samarkandi A, Riad W, et al. Optimal
Effects of intravenous lidocaine and/or esmolol on dose of succinylcholine revisited. Anesthesiology.
hemodynamic responses to laryngoscopy and intu- 2003;99(5):1045–1049.
bation: a double-blind, controlled clinical trial. J 66. Martyn JA, Richtsfeld M. Succinylcholine-induced
Clin Anesth. 1996;8(6):491–496. hyperkalemia in acquired pathologic states:
55. Feng CK, Chan KH, Liu KN, et al. A comparison of etiologic factors and molecular mechanisms.
lidocaine, fentanyl, and esmolol for attenuation of Anesthesiology. 2006;104(1):158–169.
cardiovascular response to laryngoscopy and tra- 67. Libonati MM, Leahy JJ, Ellison N. The use of suc-
cheal intubation. Acta Anaesthesiol Sin. 1996;34(2): cinylcholine in open eye surgery. Anesthesiology.
61–67. 1985;62(5):637–640.
56. Robinson N, Clancy M. In patients with head injury 68. Vinik HR. Intraocular pressure changes during
undergoing rapid sequence intubation, does pre- rapid sequence induction and intubation: a com-
treatment with intravenous lignocaine/lidocaine parison of rocuronium, atracurium, and succinyl-
lead to an improved neurological outcome? choline. J Clin Anesth. 1999;11(2):95–100.
A review of the literature. Emerg Med J. 69. Clancy M, Halford S, Walls R, et al. In patients
2001;18(6):453–457. with head injuries who undergo rapid sequence
57. Rothrock SG, Pagane J. Pediatric rapid sequence intubation using succinylcholine, does pretreat-
intubation incidence of reflex bradycardia and ment with a competitive neuromuscular blocking
effects of pretreatment with atropine. Pediatr agent improve outcome? A literature review.
Emerg Care. 2005;21(9):637–638. Emerg Med J. 2001;18(5):373–375.
58. Fleming B, McCollough M, Henderson HO. Myth: 70. Stirt JA, Grosslight KR, Bedford RF, et al.
Atropine should be administered before suc- “Defasciculation” with metocurine prevents
cinylcholine for neonatal and pediatric intuba- succinylcholine-induced increases in intracranial
tion. Cjem. 2005;7(2):114–117. pressure. Anesthesiology. 1987;67(1):50–53.
59. McAuliffe G, Bissonnette B, Boutin C. Should the 71. Minton MD, Grosslight K, Stirt JA, et al. Increases
routine use of atropine before succinylcholine in intracranial pressure from succinylcholine:
in children be reconsidered? Can J Anaesth. prevention by prior nondepolarizing blockade.
1995;42(8):724–729. Anesthesiology. 1986;65(2):165–169.
60. Fastle RK, Roback MG. Pediatric rapid sequence 72. Silber SH. Rapid sequence intubation in adults with
intubation: incidence of reflex bradycardia elevated intracranial pressure: a survey of emer-
and effects of pretreatment with atropine. gency medicine residency programs. Am J Emerg
Pediatr Emerg Care. 2004;20(10):651–655. Med. 1997;15(3):263–267.
73. Ali SZ, Taguchi A, Rosenberg H. Malignant hyper- 79. de Boer HD, van Egmond J, van de Pol F, et al.
thermia. Best Pract Res Clin Anaesthesiol. Sugammadex, a new reversal agent for neuromus-
2003;17(4):519–533. cular block induced by rocuronium in the anaes-
74. Gill M, Graeme K, Guenterberg K. Masseter spasm thetized Rhesus monkey. Br J Anaesth.
after succinylcholine administration. J Emerg Med. 2006;96(4):473–479.
2005;29(2):167–171. 80. Shields M, Giovannelli M, Mirakhur RK, et al. Org
75. Martin R, Carrier J, Pirlet M, et al. Rocuronium is the 25969 (sugammadex), a selective relaxant binding
best non–depolarizing relaxant to prevent suc- agent for antagonism of prolonged rocuronium–
cinylcholine fasciculations and myalgia. Can J induced neuromuscular block. Br J Anaesth.
Anaesth. 1998;45(6):521–525. 2006;96(1):36–43.
76. McCourt KC, Salmela L, Mirakhur RK, et al. Com- 81. Suzuki T. [Sugammadex (Org 25969, modified
parison of rocuronium and suxamethonium for use gamma-cyclodextrin)]. Masui. 2006;55(7):834–840.
during rapid sequence induction of anaesthesia. 82. Sparr HJ, Vermeyen KM, Beaufort AM, et al. Early
Anaesthesia. 1998;53(9):867–871. reversal of profound rocuronium-induced neuro-
77. Gijsenbergh F, Ramael S, Houwing N, et al. First muscular blockade by sugammadex in a random-
human exposure of Org 25969, a novel agent to ized multicenter study: efficacy, safety, and
reverse the action of rocuronium bromide. pharmacokinetics. Anesthesiology. 2007;106(5):
Anesthesiology. 2005;103(4):695–703. 935–943.
78. de Boer HD, van Egmond J, van de Pol F, et al. 83. Krause T, Gerbershagen MU, Fiege M, et al.
Reversal of profound rocuronium neuromuscular Dantrolene—a review of its pharmacology, thera-
blockade by sugammadex in anesthetized rhesus peutic use and new developments. Anaesthesia.
monkeys. Anesthesiology. 2006;104(4):718–723. 2004;59(4):364–373.
Chapter 14
Central Nervous System
Emergencies
䉴 INTRODUCTION Traumatic brain injury remains the primary

cause of death in trauma and contributes signif-
Central nervous system emergencies may result icantly to the overall burden of injury to society,
from a wide variety of pathologies. To maxi- in both human and economic terms.1,2 The
mize the chances for a good outcome, the acute- major priority in assessing the head-injured
care clinician should be knowledgeable about patient is to identify any surgically correctable
intracranial physiology, its response to resuscita- focal neurological deficits. However, it is also
tive maneuvers, and how commonly used med- clear that relatively basic resuscitative interven-
ications impact intracranial pressure dynamics. tions, including optimal oxygenation and
preservation of cerebral perfusion pressure
(CPP) help prevent significant secondary brain
䉴 Case 14.1 injury, and decrease mortality.3–6
A 24-year-old male went off the road while • It has been clearly demonstrated that even
riding his bicycle during a triathlon. Despite transient hypoxia or hypotension in the
wearing a helmet, he suffered a head injury severely head-injured patient may as much
and was brought into the emergency depart- as double mortality.6–8
ment (ED) actively seizing. His preseizure • In perhaps no other injury is the end-organ
scene Glasgow Coma Scale (GCS) was report- (brain) more adversely affected by compro-
edly 10. In the ED, the patient was on a back- mise of the basic elements of resuscitative
board, with a cervical collar in place. There care.
was a significant amount of blood present
around the mouth and he had an obvious The patient presenting with neurologic
nasal injury. The seizures had begun 10 minutes impairment or blunt trauma to the torso must
prior to arrival, and the patient’s teeth were also be suspected of spinal cord injury until
clenched. The paramedics, who were a Basic proven otherwise. The probability of associated
Life Support (BLS) crew, had given him cervical spine injury triples if the patient has a
diazepam 10 mg without effect. In the ED, the craniofacial injury9 and/or a GCS of 8 or less.10,11
patient’s GCS was now 8. His heart rate was To avoid secondary cervical spinal cord injury,
120, BP 175/95, and SaO2 was 94% on a non- cervical immobilization should be maintained
rebreathing mask. during airway management.
237
238 CHAPTER 14
䉴 PHYSIOLOGIC CONSIDERATIONS • A clinical approximation of ICP in a (nonse-

dated) patient with TBI can be estimated, as
Historically, management of the patient with follows:
increased intracranial pressure (ICP) has focused 䡩 A drowsy and confused (GCS 13–15) patient,
on the principle that the cranium has a fixed volume ICP = 20 mm Hg.
that must accommodate brain, blood, and cere- 䡩 An unconscious (GCS <8) patient, ICP =
brospinal fluid (CSF). With an increase in vol- 30 mm Hg.17
ume in one component (e.g., tumor, or extravas-
cular blood clot), some compensation will occur Other major determinants of CBF and cere-
initially, for example, by shifting CSF to the spinal bral blood volume are the arterial tensions of
canal, and blood away from venous sinuses. oxygen and carbon dioxide. When the PaO2
However, once compensatory mechanisms drops below 50 mm Hg, CBF and cerebral
become exhausted, ICP will rise. Raised ICP blood volume increase rapidly, with the
eventually causes reduced local tissue blood potential for increased ICP. CBF also reacts to
flow, and ultimately, brain herniation and death. PaCO 2 , with raised levels causing cerebral
The normal brain is able to protect against vasodilation, while conversely, hyperventila-
compromised cerebral blood flow (CBF) by tion-induced hypocapnia will cause cerebral
autoregulation, whereby CBF remains constant vasoconstriction, which can in turn lead to
over a wide range of mean arterial pressures cerebral ischemia.
(MAPs). However, in the injured brain, this capacity
to autoregulate is at least somewhat diminished, • Once used automatically for the patient with
so that a lowered MAP may significantly lower TBI, routine hyperventilation is no longer
cerebral blood flow, leading to secondary brain espoused, as worse patient outcomes have
injury. Conversely, if autoregulation remains been noted with its indiscriminant use.18
intact, a lowered MAP may lead to compensatory
cerebral vasodilation in the effort to maintain CBF, These poor outcomes are most likely related
which in turn can increase ICP from the resulting to several physiologic factors. CBF is already
raised cerebral blood volume. Thus, a lowered significantly decreased in the TBI patient for the
MAP is probably always detrimental in the patient first day following injury, and there is a risk that
with traumatic brain injury (TBI).12 further, hyperventilation-induced cerebral vaso-
The importance of MAP in maintaining CBF constriction could lead to cerebral ischemia. In
is such that CPP has become the target clinical addition, ventilatory dynamics required to
variable to monitor and manage in the TBI achieve hyperventilation can have adverse
patient.3–5,6,13,14 CPP is defined as the differ- effects on venous return, cardiac output, and in
ence between MAP and the ICP (i.e., CPP = MAP turn, MAP. Finally, with hypocapnia, the oxyhe-
– ICP). As a normal ICP is around 10 mm Hg, moglobin dissociation curve shifts to the left,
∗
and a normal MAP is 90, a normal CPP is making oxygen less available to tissues.
approximately 80 mm Hg. In the brain-injured
patient, inadequate CPP is considered to be less • In contemporary practice, the patient with
than 60–70 mm Hg.15,16 ICP is often increased TBI should be ventilated to target the lower
in the patient with TBI, so that if accompanied levels of normocapnia (i.e., 35 mm Hg),
by a low MAP, significant compromise of CPP with short-term hyperventilation reserved
will occur. for signs of acute neurological deteriora-
tion such as cerebral herniation with pos-
∗
MAP = diastolic blood pressure + 1/3(systolic – diastolic turing and asymmetrically or bilaterally
blood pressure). Thus, a blood pressure of 120/80 = 80 +
1/3(40) = MAP of 92 dilated pupils.19
CENTRAL NERVOUS SYSTEM EMERGENCIES 239
䉴 PHARMACOLOGIC • In this seizing, hypertensive patient, propofol

CONSIDERATIONS (1–2 mg/kg) or thiopental (3–4 mg/kg) could
be considered for induction.
The goal of rapid sequence intubation (RSI) in • The use of etomidate (0.2–0.3 mg/kg) can be
the critically ill patient is to facilitate intubation considered, as it has been shown to decrease
as a means of maintaining or improving gas ICP while maintaining MAP.26–28 However,
exchange in a manner that does not further as discussed in Chap. 13, its use may render
compromise end-organ perfusion. Unless con- the at-risk brain less tolerant of ischemia.
traindicated, RSI is generally the preferred route • In the head-injured patient with concomi-
for intubation of the patient with TBI, as drugs tant hypotension, ketamine may also
used during RSI may have a beneficial effect on be considered as an induction agent for
ICP, and a lack of cooperation generally pre- RSI.29,30
cludes an awake approach.
Ketamine use in the patient with increased
ICP remains somewhat controversial.31 In gen-
“Pretreatment” agents eral, it may be appropriate to avoid its use in
the hypertensive head-injured patient. However,
Pretreatment medications have been espoused its ability to preserve, or increase blood pres-
during RSI of the patient with TBI to help atten- sure and offer some neuroprotective effects
uate a further rise in ICP due to (a) laryngoscopy (currently being studied), may be useful in the
and intubation or (b) other administered med- trauma patient.
ications.
• Pretreatment with agents (e.g., narcotics or Neuromuscular Blockers

lidocaine) to prevent the “pressor” response
to laryngoscopy and intubation, including a Both succinylcholine and rocuronium are appro-
rise in ICP, is of questionable clinical value priate agents to use for RSI in the TBI patient.
and not without the risk of contributing to
postintubation hypotension.20–22
• Pretreatment with small doses of nondepo- Rescue Vasopressors
larizing neuromuscular blockers to prevent
a possible ICP rise associated with succinyl- For RSI of the patient with TBI, it is particularly
choline use is also falling out of favor.22,23 important to have a short-acting vasopressor
Indeed, a number of studies have failed to such as ephedrine or phenylephrine drawn up,
demonstrate any increase in ICP with suc- to treat any postintubation hypotension.
cinylcholine use in the TBI patient.24,25
Induction Sedative/Hypnotics 䉴 TECHNICAL CONSIDERATIONS
The most important clinically relevant factors in Airway Management Decisions

pharmacologic decision making in the patient
with traumatic brain injury relate to the need to The patient described in Case 14–1 has probable
avoid hypoxia and hypotension. Although the eti- intracranial pathology and a declining level of
ology of postintubation hypotension is multifac- consciousness. Tracheal intubation is indi-
torial, the choice and dosage of induction seda- cated for predicted clinical course, and for air-
tive/hypnotic is often a major contributing factor. way protection.
240 CHAPTER 14
• Although often used for the purpose, a GCS • The presence of a cervical collar can increase
of 8 or less does not always correlate with an ICP in the TBI patient.46–48
absence of protective airway reflexes,32–35
and on its own should rarely be used to dic- As always, the decision to perform an RSI
tate the need to intubate. should be based on predicted difficulty, patient
cooperation, and clinician skill and knowledge.
The GCS was developed and subsequently RSI is safe and is generally the preferred
validated primarily as a tool for predicting out- method of facilitating intubation in the trauma
comes in head-injured patients.36,37 Interrater patient.39,49–52 RSI is not contraindicated in cases
agreement is relatively poor and its use as a of suspected or known c-spine injury.41,53
prospective decision tool to intubate is even
less grounded in science.38 However, this does Intubation and Postintubation
not negate the value of monitoring the level of Considerations
consciousness by GCS, or other method, as an
important contributory factor in the decision to During preparations for intubation of the patient
intubate the trachea. presented in Case 14–1, the stretcher may be
The blunt trauma patient should always be tilted somewhat head-up, to promote cerebral
assumed to have a cervical spine injury and will venous drainage. A fluid bolus should be con-
require immobilization until this is ruled out. The sidered, to help avoid a drop in blood pressure
true incidence of secondary spinal cord injury peri-intubation, and the patient should be well
caused by emergent airway management is preoxygenated. Assistants should be coached in
unknown, however reported cases are extremely anticipation of their tasks, including application
rare.39–41 An inappropriate fear of causing a cord of MILNS, and cricoid pressure. If only because
injury may lead to a delay in airway manage- of the MILNS, difficulty should be anticipated,
ment, which is likely to pose a more significant and preparations should include immediate
risk to the head-injured patient. availability of a bougie, and an alternative intu-
bation technique, such as an LMA Fastrach, Tra-
• A cervical collar will predictably make chlight, fiberoptic stylet, or videolaryngoscope.
direct laryngoscopy difficult by limiting RSI medications should be drawn up, as should
range of motion of both the neck and vasopressors to treat transient postintubation
mandible.39,40,42–44 hypotension. As close monitoring of blood pres-
sure will be needed during and after intubation,
The incidence of Cormack-Lehane Grade 3 a noninvasive cuff should be set to cycle at
(epiglottis only) views encountered at direct 1–3 minute intervals.
laryngoscopy has been reported to be up to 60%
when a cervical collar is in place.43–45 Before an • If located at the patient’s head, the assistant
intubation proceeds, the anterior portion of the applying MILNS should be positioned out of
collar should be removed, and replaced with the laryngoscopist’s way, to the left.
manual in-line neck stabilization (MILNS). In • MILNS must be maintained even during
addition to facilitating laryngoscopy, this will BMV, as this can cause as much movement
provide for easier access to the thyroid cartilage of the cervical spine as laryngoscopy.
for external laryngeal manipulation (ELM) and • Apnea times should be limited in the head-
the cricoid cartilage for the Sellick maneuver. injured patient during intubation attempts
to avoid the adverse effects of hypercarbia.
• With the substitution of MILNS for the cervical • ELM and/or a bougie should be used early
collar, the incidence of grade 3 views at laryn- (i.e., on the first attempt), if difficult laryn-
goscopy drops to 20%–25% of cases.43,44 goscopy is encountered.
• Very often, a view of only the interarytenoid 3. Balestreri M, Czosnyka M, Hutchinson P, et al.
notch or posterior cartilages is obtained dur- Impact of intracranial pressure and cerebral per-
ing laryngoscopy in the presence of MILNS. The fusion pressure on severe disability and mortality
bougie can be passed above the notch, and after head injury. Neurocrit. Care. 2006;4(1):
8–13.
the endotracheal tube advanced over the bougie.
4. The Brain Trauma F. The American Association of
• A change to a straight or levering tip blade
Neurological Surgeons. The Joint Section on Neu-
can be considered if the initial “best look” rotrauma and Critical Care. Guidelines for cerebral
laryngoscopy fails.54–57 perfusion pressure. J Neurotrauma. 2000;17(6–7):
507–511.
Following intubation, tube position should 5. Ling GS, Neal CJ. Maintaining cerebral perfusion
be objectively confirmed, cricoid pressure pressure is a worthy clinical goal. Neurocrit. Care.
released, and the cervical collar replaced. The 2005;2(1):75–81.
blood pressure should be rechecked, and 6. The Brain Trauma F. The American Association of
additional fluid and vasopressor given, if low. Neurological Surgeons. The American Association
However, if the blood pressure is intact, or once of Neurological Surgeons. The Joint Section on
Neurotrauma and Critical Care. Resuscitation of
it recovers, a head-up (reverse Trendelenberg)
blood pressure and oxygenation. J Neurotrauma.
position should be resumed, or considered, to
2000;17(6–7):471–478.
promote venous drainage. The endotracheal 7. Chestnut RM, Marshall LF, Klauber MR, et al. The
tube (ETT) should be affixed to the patient, role of secondary brain injury in determining out-
although tightly encircling ties around the neck come from severe head injury. J. Trauma. 1993;34(2):
should be avoided. The clinician should ensure 216–222.
that the patient is not being inadvertently 8. Dunford JV, Davis DP, Ochs M, et al. Incidence
hyperventilated: this is best accomplished with of transient hypoxia and pulse rate reactivity dur-
quantitative end tidal CO2 monitoring, or the ing paramedic rapid sequence intubation. Ann
judicious utilization of blood gases. Emerg Med. 2003;42(6):721–728.
9. Hackl W, Hausberger K, Sailer R, et al. Prevalence
of cervical spine injuries in patients with facial
䉴 SUMMARY trauma. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2001;92(4):370–376.
The patient with known or suspected CNS injury 10. Holly LT, Kelly DF, Counelis GJ, et al. Cervical spine
must be treated with particular attention to main- trauma associated with moderate and severe head
tenance of cerebral perfusion pressure, and the injury: incidence, risk factors, and injury character-
avoidance of hypoxemia. Manual in-line stabi- istics. J Neurosurg. 2002;96(3 Suppl):285–291.
lization should be maintained after removal of 11. Demetriades D, Charalambides K, Chahwan S, et al.
Nonskeletal cervical spine injuries: epidemiology
the cervical collar, and extra preparations should
and diagnostic pitfalls. J Trauma. 2000;48(4):
be made for an anticipated difficult laryngoscopy.
724–727.
12. Bouma GJ, Muizelaar JP, Bandoh K, et al. Blood
pressure and intracranial pressure-volume dynam-
REFERENCES
ics in severe head injury: relationship with cerebral
1. Thurman DJ, Alverson C, Dunn KA, et al. Trau- blood flow. J Neurosurg. 1992;77(1):15–19.
matic brain injury in the United States: a public 13. Rose JC, Mayer SA. Optimizing blood pressure in
health perspective. J Head Trauma Rehabil. neurological emergencies. Neurocrit. Care. 2004;1(3):
1999;14(6):602–615. 287–299.
2. Langlois JA, Rutland-Brown W, Thomas KE. Trau- 14. Myburgh JA. Driving cerebral perfusion pressure
matic Brain Injury in the United States: Emer- with pressors: how, which, when? Crit Care Resusc.
gency Department Visits, Hospitalizations, and 2005;7(3):200–205.
Deaths. Atlanta GA Centers for Diseae Control and 15. Chan KH, Miller JD, Dearden NM, et al. The effect
Prevention, National Center for Injury Prevention of changes in cerebral perfusion pressure upon
and Control; 2004. middle cerebral artery blood flow velocity and
242 CHAPTER 14
jugular bulb venous oxygen saturation after severe blood pressure in pediatric patients with severe
brain injury. J Neurosurg. 1992;77(1):55–61. traumatic brain injury. Pediatr Emerg Care.
16. The Brain Trauma Foundation. The American Asso- 2006;22(2):90–93.
ciation of Neurological Surgeons. The Joint Section 27. Modica PA, Tempelhoff R. Intracranial pressure
on Neurotrauma and Critical Care. Guidelines for during induction of anaesthesia and tracheal intu-
cerebral perfusion pressure. J Neurotrauma. bation with etomidate–induced EEG burst sup-
2000;17(6–7):507–511. pression. Can J Anaesth. 1992;39(3):236–241.
17. Walters FJM. Intracranial pressure and cerebral 28. Moss E, Powell D, Gibson RM, et al. Effect of
blood blow. Update in Anaesthesia: Physiology; etomidate on intracranial pressure and cerebral
1998. perfusion pressure. Br J Anaesth. 1979;51(4):
18. Muizelaar JP, Marmarou A, Ward JD, et al. Adverse 347–352.
effects of prolonged hyperventilation in patients 29. Sehdev RS, Symmons DA, Kindl K. Ketamine for
with severe head injury: a randomized clinical trial. rapid sequence induction in patients with head
J Neurosurg. 1991;75(5):731–739. injury in the emergency department. Emerg Med
19. The Brain Trauma F. The American Association of Australas. 2006;18(1):37–44.
Neurological Surgeons. The Joint Section on Neu- 30. Himmelseher S, Durieux ME. Revising a dogma:
rotrauma and Critical Care. Initial Management. ketamine for patients with neurological injury?
J Neurotrauma. 2000;17(6–7):463–469. Anesth Analg. 2005;101(2):524–534, table.
20. Feng CK, Chan KH, Liu KN, et al. A comparison of 31. Sehdev RS, Symmons DA, Kindl K. Ketamine for
lidocaine, fentanyl, and esmolol for attenuation of rapid sequence induction in patients with head
cardiovascular response to laryngoscopy and injury in the emergency department. Emerg Med
tracheal intubation. Acta Anaesthesiol. Sin. Australas. 2006;18(1):37–44.
1996;34(2):61–67. 32. Moulton C, Pennycook AG. Relation between
21. Robinson N, Clancy M. In patients with head injury Glasgow coma score and cough reflex. Lancet.
undergoing rapid sequence intubation, does pre- 1994;343(8908):1261–1262.
treatment with intravenous lignocaine/lidocaine 33. Kolb JC, Galli RL. No gag rule for intubation.
lead to an improved neurological outcome? Ann Emerg Med. 1995;26(4):529–530.
A review of the literature. Emerg Med J. 2001;18(6): 34. Moulton C, Pennycook A, Makower R. Relation
453–457. between Glasgow coma scale and the gag reflex.
22. Bozeman WP, Idris AH. Intracranial pressure Bmj. 1991;303(6812):1240–1241.
changes during rapid sequence intubation: a swine 35. Davies AE, Stone SP, Kidd D, et al. Pharyngeal sen-
model. J Trauma. 2005;58(2):278–283. sation and gag reflex in healthy subjects. The
23. Clancy M, Halford S, Walls R, et al. In patients with Lancet. 1995;345(8948):487–488.
head injuries who undergo rapid sequence intuba- 36. Teasdale G, Jennett B. Assessment of coma and
tion using succinylcholine, does pretreatment with impaired consciousness. A practical scale. Lancet.
a competitive neuromuscular blocking agent 1974;2(7872):81–84.
improve outcome? A literature review. Emerg Med 37. Teasdale GM, Pettigrew LE, Wilson JT, et al. Ana-
J. 2001;18(5):373–375. lyzing outcome of treatment of severe head injury:
24. Brown MM, Parr MJ, Manara AR. The effect of sux- a review and update on advancing the use of the
amethonium on intracranial pressure and cerebral Glasgow Outcome Scale. J Neurotrauma.
perfusion pressure in patients with severe head 1998;15(8):587–597.
injuries following blunt trauma. Eur J Anaesthesiol. 38. Gill MR, Reiley DG, Green SM. Interrater reliability
1996;13(5):474–477. of Glasgow Coma Scale scores in the emergency
25. Kovarik WD, Mayberg TS, Lam AM, et al. Succinyl- department. Ann Emerg Med. 2004;43(2):215–223.
choline does not change intracranial pressure, cere- 39. Crosby E. Airway management after upper cervical
bral blood flow velocity, or the electroencephalo- spine injury: what have we learned? Can J Anaesth.
gram in patients with neurologic injury. Anesth 2002;49(7):733–744.
Analg. 1994;78(3):469–473. 40. Crosby ET. Airway management in adults after
26. Bramwell KJ, Haizlip J, Pribble C, et al. The effect cervical spine trauma. Anesthesiology. 104(6):
of etomidate on intracranial pressure and systemic 1293–1318.
41. Manoach S, Paladino L. Manual In-Line Stabiliza- 50. Levitan RM, Rosenblatt B, Meiner EM, et al. Alter-
tion for Acute Airway Management of Suspected nating day emergency medicine and anesthesia
Cervical Spine Injury: Historical Review and Cur- resident responsibility for management of the
rent Questions. Ann Emerg Med. 2007. trauma airway: a study of laryngoscopy perfor-
42. Ollerton JE, Parr MJ, Harrison K, et al. Potential cer- mance and intubation success. Ann Emerg Med.
vical spine injury and difficult airway management 2004;43(1):48–53.
for emergency intubation of trauma adults in the 51. Sagarin MJ, Barton ED, Chng YM, et al. Airway
emergency department—a systematic review. Management by US and Canadian Emergency Med-
Emerg Med J. 2006;23(1):3–11. icine Residents: A Multicenter Analysis of
43. Heath KJ. The effect of laryngoscopy of different More Than 6,000 Endotracheal Intubation Attempts.
cervical spine immobilisation techniques. Anaes- Ann Emerg Med. 2005;46(4):328–336.
thesia. 1994;49(10):843–845. 52. Graham CA, Beard D, Henry JM, et al. Rapid
44. Nolan JP, Wilson ME. Orotracheal intubation in sequence intubation of trauma patients in Scotland.
patients with potential cervical spine injuries. An J Trauma. 2004;56(5):1123–1126.
indication for the gum elastic bougie. Anaesthesia. 53. Ghafoor AU, Martin TW, Gopalakrishnan S, et al.
1993;48(7):630–633. Caring for the patients with cervical spine injuries:
45. MacQuarrie K, Hung OR, Law JA. Tracheal intuba- what have we learned? J Clin Anesth.
tion using Bullard laryngoscope for patients with 2005;17(8):640–649.
a simulated difficult airway. Can J Anaesth. 54. Gerling MC, Davis DP, Hamilton RS, et al. Effects of
1999;46(8):760–765. cervical spine immobilization technique and laryn-
46. Davies G, Deakin C, Wilson A. The effect of a rigid goscope blade selection on an unstable cervical
collar on intracranial pressure. Injury. 1996;27(9): spine in a cadaver model of intubation. Ann Emerg
647–649. Med. 2000;36(4):293–300.
47. Kolb JC, Summers RL, Galli RL. Cervical collar- 55. Gabbott DA. Laryngoscopy using the McCoy laryn-
induced changes in intracranial pressure. goscope after application of a cervical collar. Anaes-
Am J Emerg Med. 1999;17(2):135–137. thesia. 1996;51(9):812–814.
48. Mobbs RJ, Stoodley MA, Fuller J. Effect of cervical 56. Laurent SC, de Melo AE, Alexander–Williams JM.
hard collar on intracranial pressure after head The use of the McCoy laryngoscope in patients
injury. ANZ J Surg. 2002;72(6):389–391. with simulated cervical spine injuries. Anaesthesia.
49. Bushra JS, McNeil B, Wald DA, et al. A comparison 1996;51(1):74–75.
of trauma intubations managed by anesthesiolo- 57. Uchida T, Hikawa Y, Saito Y, et al. The McCoy lev-
gists and emergency physicians. Acad Emerg Med. ering laryngoscope in patients with limited neck
2004;11(1):66–70. extension. Can J Anaesth. 1997;44(6):674–676.
Chapter 15
Cardiovascular Emergencies
䉴 INTRODUCTION Physiologic Considerations
The critically ill patient is dependent on the The patient presented in Case 15–1 may be
integrity of the cardiovascular system to maintain placed at risk of myocardial ischemia related to
perfusion and deliver oxygen to vital tissue beds. the stress of laryngoscopy and intubation. This
Many patients requiring emergency airway inter- physiologic stress is mediated primarily through
vention will have a degree of coronary artery sympathetic nervous system stimulation and can
disease. In the patient with suspected or known include an increase in HR and BP. Both responses
ischemic heart disease (IHD), including an acute can increase myocardial oxygen demand, poten-
coronary syndrome (ACS), the general principle of tially causing or worsening myocardial ischemia.
management is to retain a favorable balance Conversely, significant hypotension (as can hap-
between myocardial oxygen supply and demand. pen with the use of rapid-sequence intubation
[RSI] sedative/hypnotics) can compromise coro-
䉴 ISCHEMIC HEART DISEASE nary perfusion pressure and also potentially exac-
erbate myocardial ischemia. With reference to the
cardiovascular system, physiologic goals in man-
aging this patient’s airway include the following:
䉴 Case 15.1
An intoxicated and confused 64-year-old • Attenuation or control of patient hemody-
man presented after a low-velocity single namics with judicious pharmacological
vehicle crash resulting from an unexplained intervention, seeking:
䡩 Minimal increase in heart rate.
“blackout.” In the emergency department
䡩 Minimal variation in blood pressure.
(ED), his blood pressure (BP) was 140/90,
heart rate (HR) 100, respiratory rate (RR) 18,
and his oxygen saturation (SaO2) was 99% • Optimization of cardiac function in the pres-
on a nonrebreathing facemask. Due to a ence of possible hypovolemia or compro-
depressed level of consciousness, the question mised ventricular function.
of tracheal intubation for “airway protec-
tion” arose, especially in the context of exam- Pharmacologic Considerations
ination within a computed tomography (CT)
suite. His spouse mentioned that he had suf- Many publications in the anesthesiology litera-
fered two heart attacks and still experienced ture have described methods of blunting the sym-
frequent angina. Blood glucose was normal. pathetic response to laryngoscopy and intubation
245
246 CHAPTER 15
with the use of pretreatment agents.1–4 How- myocardial ischemia, and should usually
ever, it is important to realize that the majority be given, to help avoid post-intubation
of this data has been gathered in the setting of hypotension.
stable patients in a non-emergent setting. Both • Hypotension following tracheal intubation
narcotics and beta blockers have been used as should be aggressively treated with addi-
pretreatment agents in the patient with ischemic tional fluid and vasopressors. Unexpected
heart disease: tachycardia can be treated with esmolol.
• Hypertension, while undesirable if exces-
• Fentanyl will reliably attenuate the HR and sively high, will usually settle on its own.
BP response to laryngoscopy and intubation,
although at doses higher than those tradi-
䉴 CONGESTIVE HEART FAILURE
tionally used for analgesia.
• At lower pretreatment doses (e.g., 1–3 µg/kg),
fentanyl will usually, but less consistently
attenuate the BP, but not necessarily the HR 䉴 Case 15.2
response to intubation.
• Esmolol can be effective in blunting both the A 79-year-old female arrived in the ED in
HR and BP response to laryngoscopy and acute respiratory distress. She was unable to
intubation.3,4 speak more than two words at a time, and
• The benefits of using these agents must be bal- her coarse, rasping breath sounds could be
anced against their risk of compromising coro- heard from the foot of the bed. Her spouse
nary perfusion pressure, or precipitating a gen- reported that she had been complaining of
eral state of hemodynamic decompensation. chest pain for 2 hours, and that she had
• Post-intubation hypotension is best treated begun coughing up pink, frothy sputum just
with small boluses (e.g., 40–100 µg) of before leaving for the hospital. She had a
phenylephrine, to avoid any increase in HR history of Type 2 diabetes and hypertension.
(as may happen with ephedrine). Her electrocardiogram (ECG) showed new
ST segment depression in the precordial
leads. A trial of noninvasive positive pres-
sure ventilation had failed. Her BP was
Technical Considerations 100/60, HR 138, RR 34, and her SaO2 was
83% on a nonrebreathing facemask.
The patient with known or suspected ischemic
heart disease should be well monitored, and
intubated gently, yet expeditiously. As pro- Physiologic Considerations
longed efforts at intubation are associated with
a more pronounced hemodynamic response, The patient in Case 15–2 presented in pul-
equipment preparation and patient positioning monary edema secondary to an acute coronary
should be optimized for “first-pass” success. syndrome. She required tracheal intubation pri-
marily to correct gas exchange by improving
• Vital signs should be closely monitored oxygen delivery. Several considerations should
during and after tracheal intubation, with be addressed:
a noninvasive cuff cycling at 3-minute
intervals. • This patient is in part dependent on sympa-
• An intravenous fluid bolus of 10–20 mL/kg is thetic nervous system tone to compensate for
not contraindicated in the patient with left ventricular (LV) dysfunction.
CARDIOVASCULAR EMERGENCIES 247
• Tachycardia and low normal BP in a patient • These patients are at significant risk for post-
with congestive heart failure and a history intubation hypotension, as relief of the work
of hypertension is a harbinger of cardiovas- of breathing, relative hypocarbia, and decrease
cular collapse. in venous return results in loss of sympathetic
• As always, the goal is to facilitate tracheal tone.
intubation without further compromising the • Reliable vascular access should be in
patient’s hemodynamic status. place, and a short-acting vasopressor such
as phenylephrine diluted and available for
immediate use.
Pharmacologic Considerations In the patient with compromised ventric-
ular function, a slow circulation time will
With or without a pretreatment agent, use of an delay the clinical onset of administered sedative-
induction sedative/hypnotic as part of an RSI hypnotics. The clinician must not fall into
in the patient with compromised ventricular the trap of giving more drug to hasten the
function will negatively affect both myocardial onset time, as a profound drop in BP may
contractility and peripheral vascular tone. Circu- result.
latory collapse may ensue. If the patient is not
actively uncooperative, an awake intubation may
present an attractive strategic option. However, if
an RSI is chosen, great care must be taken in Technical Considerations
choice and dosage of sedative/hypnotic.5 A num-
ber of considerations apply: If intubating with an RSI, the patient should be
left in a position of comfort (often sitting, if
• Although ketamine is intrinsically a nega- dyspneic) until loss of consciousness, if the
tive inotrope, its administration results in BP allows. Immediately upon loss of con-
additional sympathetic nervous system (SNS) sciousness, the stretcher can be lowered to the
stimulation and an increase myocardial oxy- supine position. An awake intubation can be
gen demand. It is therefore potentially prob- done in the semisitting position, to maxi-
lematic in patients with evolving myocardial mize patient comfort and cooperation during
ischemia. the procedure.
• Etomidate will not affect myocardial con-
tractility at usual doses.6 However, a reduced • Pulmonary edema may result in difficult
dose (e.g., 0.15–0.20 mg/kg) should still be mask ventilation. An oral airway and
considered, based on the patient’s age and two-person technique should be employed
presenting vital signs. early.
• Unless used in very modest doses, both thiopental • If possible, a large endotracheal tube should
and propofol could potentially cause cata- be used, in order to facilitate suctioning of
strophic hypotension in this patient by further pulmonary edema fluid.
depressing myocardial contractility and causing • End-tidal CO2 (ETCO2) detection may be
peripheral vasodilation.7 impaired in patients with cardiogenic shock
• Propofol and ketamine can be blended (“off- and pulmonary edema.8
label”) in a 50/50 mix, with greater stability • PEEP (positive end-expiratory pressure) may
than either agent alone, but caution must still be beneficial, but patients in congestive
occur, with use of judicious doses (e.g. 0.1 cc/kg heart failure are very sensitive to its adverse
of the mixture). effects on venous return.
248 CHAPTER 15
䉴 CARDIAC ARREST advantage of minimizing intrathoracic pres-

sure, which could otherwise interfere with
venous return and cardiac output. In addi-
tion, small tidal volumes will help minimize
䉴 Case 15.3 gastric insufflation during bag-mask ventilation
(BMV).
A 53-year-old male sustained a cardiac
Unlike other clinical scenarios, airway man-
arrest in the intensive care unit (ICU). The
agement efforts in the cardiac arrest situation do
day before, he had undergone an abdominal-
not take precedence over attempts to establish
perineal resection of the colon for neoplastic
a return of circulation. Chest compressions are
disease. He had exhibited ST-depression in
essential for providing blood flow during CPR,
the operating room (OR), and in the recov-
and will increase the likelihood of successful
ery room had ECG changes suggestive of
defibrillation.
inferolateral ischemia. Troponin rise was
suggestive of myocardial infarction. He had
• To minimize interruption of compressions,
been sent to the ICU, unintubated, for overnight
intubation can be deferred until the patient
monitoring. The next morning, while talking
has failed to respond to initial CPR and
to his nurse, he suddenly became unrespon-
defibrillation attempts.
sive. The monitor tracing was suggestive of
• If tracheal intubation is undertaken during
ventricular fibrillation, and pulse oximeter
CPR, each attempt should be as brief as pos-
and arterial line tracings had become flat.
sible, occurring only after full preparations
The patient, of average body habitus, had a
have been made.
history of treated hypertension, and Type-2
diabetes mellitus.
Cricoid pressure application during airway
management in the cardiac arrest patient may
help prevent passive regurgitation and aspira-
tion of gastric contents, all the more likely as
Physiologic Considerations lower esophageal sphincter tone relaxes in the
arrested patient,10 as well as during the pre-
Following a sudden ventricular fibrillation car- arrest phase.11 Cricoid pressure may also help
diac arrest, blood oxygen levels will remain in minimize gastric insufflation during bag-mask
a near-normal range for the first few minutes. ventilation.
However, with myocardial and cerebral oxygen
delivery limited by absent cardiac output, chest
compressions should ideally begin without
delay. As the cardiac arrest continues beyond Pharmacologic Considerations
the first few minutes, both compressions and
oxygenation/ventilation are important, as is The arrested patient usually offers little
the case for patients hypoxic at the time of resistance to BMV, laryngoscopic intubation,
arrest. or extraglottic device (EGD) insertion.
During cardiopulmonary resuscitation (CPR), However, if the patient were to retain suffi-
cardiac output is only 25%–33% of normal,9 so cient muscle tone to have a clenched jaw, a
an adequate ventilation-perfusion ratio can skeletal muscle relaxant such as succinyl-
be maintained with much lower tidal vol- choline can be given. Succinylcholine should
umes and respiratory rates than usual. The be avoided if the arrest may have been
lower required minute ventilation has the caused by hyperkalemia.
CARDIOVASCULAR EMERGENCIES 249
Technical Considerations edema or status asthmaticus).12 Unless the

arrest was witnessed, or a return to circulation
For the patient presented in Case 15–3, adult has occurred, an EDD is the preferred method
basic life support recommendations call for for confirming correct ETT placement.
establishing unresponsiveness, performing an Following tracheal intubation or placement
airway opening maneuver, and assessing the of an extraglottic device, chest compressions
patient’s breathing. should no longer be paused for delivery of pos-
itive pressure ventilation (PPV)—compressions
• For the clinician inexperienced in the use of now continue uninterrupted at a rate of 100 per
EGDs or laryngoscopic intubation, BMV can minute, with PPV at 8–10 breaths per minute,
be used for intermittent ventilation throughout using a volume of 500–600 mL in the adult. PPV
a cardiac arrest. at this rate and tidal volume will help avoid
• When performing BMV during breaks in excessive intrathoracic positive pressure, which
chest compressions, two positive pressure could otherwise interfere with venous return.12
ventilations are provided during a brief Following the return of a perfusing rhythm,
(3–4 seconds) pause after every 30 com- 10–12 breaths per minute can be delivered,
pressions.12 Inspiratory time should be lim- although the patient at risk of air-trapping
ited to 1 second and should seek simply to (“auto-PEEP”) should be ventilated at the lower
achieve a visible chest rise (using a volume rate of 6–8 breaths per minute.12
of 6–7 mL/kg).
• EGDs (e.g., Combitube and the LMA) have 䉴 SUMMARY
also been successfully used and studied in
the setting of cardiac arrest.12 No interrup- Intubation of the patient with ischemic heart dis-
tion of chest compressions is required during ease and its sequellae can be challenging.
EGD placement or subsequent ventilation. A significant increase in HR or BP can be detri-
• In skilled hands, laryngoscopic intubation is mental by increasing myocardial oxygen demands,
often easily performed in cardiac arrest. while conversely, hypotension must also be
Interruptions to chest compressions should avoided in order to maintain coronary perfusion
be minimized during any one attempt. pressure. The clinician must walk this tightrope by
• Correct tracheal placement of the ETT in the choosing the best method of proceeding with the
cardiac arrest situation should, as always, intubation, and, if RSI is chosen, the correct dosage
make use of objective confirmatory methods. of an appropriate sedative/hypnotic.
End-tidal CO2 may be unreliable in non-
perfusing states.
REFERENCES
In addition to visualization of the tube going 1. Wiest D. Esmolol. A review of its therapeutic
between cords, an ETCO2 detector or an efficacy and pharmacokinetic characteristics.
esophageal detector device (EDD) can be used. Clin Pharmacokinet. 1995;28(3):190–202.
False negative ETCO2 readings (i.e., no CO2 2. Yuan L, Chia YY, Jan KT, et al. The effect of single
detected despite the ETT being in trachea) may bolus dose of esmolol for controlling the tachycar-
occur in the setting of cardiac arrest for one of dia and hypertension during laryngoscopy and
tracheal intubation. Acta Anaesthesiol Sin. 1994;32(3):
a number of reasons: low blood flow and CO2
147–152.
delivery to the lungs; pulmonary embolus; 3. Feng CK, Chan KH, Liu KN, et al. A comparison of
device contamination with drug or acidic gastric lidocaine, fentanyl, and esmolol for attenuation of
contents; systemic epinephrine bolus; or severe cardiovascular response to laryngoscopy and tracheal
lower airway obstruction (e.g., pulmonary intubation. Acta Anaesthesiol Sin. 1996;34(2):61–67.
250 CHAPTER 15
4. Helfman SM, Gold MI, DeLisser EA, et al. Which 8. Bozeman WP, Hexter D, Liang HK, Kelen GD.
drug prevents tachycardia and hypertension asso- Esophageal detector device versus detection of
ciated with tracheal intubation: lidocaine, fentanyl, end-tidal carbon dioxide level in emergency intu-
or esmolol? Anesth Analg. 1991;72(4):482–486. bation. Ann Emerg Med. 1996;27(5):595–599.
5. Horak J, Weiss S. Emergent management of the 9. Part 4: Adult Basic Life Support. Circulation.
airway. New pharmacology and the control of 2005;112(24):19–34.
comorbidities in cardiac disease, ischemia, and 10. Bowman FP, Menegazzi JJ, Check BD, et al. Lower
valvular heart disease. Crit Care Clin. 2000;16(3): esophageal sphincter pressure during prolonged
411–427. cardiac arrest and resuscitation. Ann Emerg Med.
6. Sprung J, Ogletree-Hughes ML, Moravec CS. The 1995;26(2):216–219.
effects of etomidate on the contractility of failing 11. Gabrielli A, Wenzel V, Layon AJ, et al. Lower
and nonfailing human heart muscle. Anesth Analg. esophageal sphincter pressure measurement during
2000;91(1):68–75. cardiac arrest in humans: potential implications for
7. Rouby JJ, Andreev A, Leger P, et al. Peripheral ventilation of the unprotected airway. Anesthesiology.
vascular effects of thiopental and propofol in 2005;103(4):897–899.
humans with artificial hearts. Anesthesiology. 12. Part 7.1: Adjuncts for Airway Control and Ventilation.
1991;75(1):32–42. Circulation. 2005;112(24):51–57.
Chapter 16
Respiratory Emergencies
䉴 INTRODUCTION
䉴 Case 16.1
Management of a patient presenting with either A 48-year-old man presented to a rural emer-
upper or lower airway pathology can be chal- gency department (ED) with a 3-day history
lenging for any clinician, regardless of experi- of a severe sore throat. Two days before, he
ence. Understanding the etiology of, and having had been seen at an urgent-care clinic and
an approach to the patient in respiratory distress started on amoxicillin. That morning, the
is critical to ensuring a good clinical outcome. patient and his spouse were concerned
because he could not “swallow his own spit”
䉴 OBSTRUCTING UPPER AIRWAY and was making a “funny noise” when he
PATHOLOGY breathed. The patient was conscious, but looked
anxious; he was sitting upright, protruding his
The causes of pathologic upper airway obstruc- jaw, and drooling. His temperature was
tion are listed in Table 16–1. While the etiology 38.8∞C; heart rate (HR) 130; respiratory rate
of obstruction is often self-evident (e.g., trauma (RR) 26; blood pressure (BP) 110/90; and his
or thermal injury), occasionally the cause may oxygen saturation (SaO2) was 96% on room
be more subtle (e.g., previously undiagnosed air. His oral exam showed no pathology. He
laryngeal tumor). had inspiratory stridor.
While the likely diagnosis of adult epiglot-
titis is not difficult in the patient presented in requires a clinician with the appropriate skills.
Case 16–1, the management of such a patient An early call for help should be placed—often
can be either smooth and life-saving, or fraught the best setting for managing this type of patient
with complications, up to and including death. is the operating room (OR), with the presence of
The need for early control of this patient’s both an anesthesiologist and surgeon. However,
airway must be recognized. Delay may result in acuity and clinician availability will often dictate
loss of airway patency due to worsening inflam- where and by whom the patient is managed.
mation and edema.
Securing the airway of a patient with obstruct-
ing pathology can be difficult and anxiety- Physiologic Considerations
provoking, even for expert airway managers.
The adage “take early control of the airway” can The patient with obstructing airway pathology
compete with a strong instinct to “first do no bears special consideration for a number of rea-
harm.” Early, preemptive airway management sons. Substantial narrowing of the airway can
251
252 CHAPTER 16
䉴 TABLE 16–1 CLASSIFICATION OF • Voice changes and stridor apart, the exter-
OBSTRUCTING CONDITIONS OF THE UPPER nal airway examination may look otherwise
AIRWAY normal in the patient with obstructing
Class of airway pathology. In such a patient, addi-
Obstruction Etiology tional information on the state of the laryn-
geal inlet can be obtained by performing
INFECTIOUS Acute epiglottitis/
supraglottitis nasopharyngoscopy with a small flexible
Croup endoscope.
Retropharyngeal abscess • Once present, stridor should be looked upon
Ludwig’s angina as a sign of impending complete airway
INFLAMMATORY Anaphylaxis obstruction.
Angioedema • Patients with obstructing upper airway
MECHANICAL Inhaled foreign body pathology are usually anxious, and often
Tumor (hemorrhage, present sitting upright or leaning forward,
swelling, infection) in an attempt to maintain an open airway
Posttraumatic
and better manage secretions.
strictures
• Obstruction may be relatively fixed (e.g.,
TRAUMATIC Blunt or penetrating
anterior neck trauma tumor or foreign bodies) or dynamic and pro-
Postoperative swelling gressive (e.g., infection; burns; hemorrhage).
or hematoma
Thermal or chemical Pharmacologic Considerations
injury
Generally, an awake approach is preferred for
intubation of the patient with obstructing
airway pathology. Application of topical airway
occur before signs (e.g., stridor) or symptoms anesthesia can proceed as usual. Systemic seda-
(e.g., dyspnea) occur.1 Unfortunately, this tion should ideally be completely avoided, or if
means that on presentation, the patient may be used, should be minimized. If sedation is
close to respiratory extremis or even complete employed, a number of options are available,
obstruction. Especially with advanced stages of with caveats:
pathologic airway obstruction, airway patency
is sometimes maintained only with patient effort. • If used, benzodiazepines, such as midazolam
Interfering with this effort by the administration (e.g., 0.5–1.0 mg in an average adult) must
of sedatives, or proceeding with rapid-sequence be employed very judiciously.
intubation (RSI), can precipitate complete • Ketamine (e.g., 0.25–0.5 mg/kg) can be
obstruction. titrated to effect if needed. Although keta-
mine has the theoretic advantage of mini-
• Regardless of the etiology, inspiratory stridor mizing respiratory depression in otherwise
is a hallmark of the patient with obstructing healthy patients, little data exists on its use in
pathology at or just above the level of the patients with obstructing airway pathology.2
laryngeal inlet. Stridor on expiration sug- • Ketamine has been associated with laryn-
gests obstructing pathology below the cords. gospasm (more frequently described in pedi-
• A change in voice (often described as “muf- atric patients with concurrent respiratory
fled,” or “hot potato”) and odynophagia, with disease)3, 4 and increased respiratory secre-
a normal oral exam, should also raise concern tions, both of which would be very unwel-
of pathology in or around the laryngeal inlet. come in the obstructing patient.
RESPIRATORY EMERGENCIES 253
• In an uncooperative patient, other sedative primary awake tracheostomy using local anes-
medications potentially useful to assist an thesia may be the method of choice. However,
awake intubation may include haloperidol if an attempt at intubation from above is made
or dexmedetomidine. in the patient with obstructing pathology, it
should proceed only with a double set-up,
whereby the cricothyroid membrane has been
Technical Considerations identified, and the needed equipment is avail-
able for immediate cricothyrotomy.
Airway Management Decisions
Obstructing airway pathology has the poten- • Performed with skill on selected, cooperative
tial to create d i fficulty with all “dimen- patients, an awake technique is generally
sions” of airway management: bag-mask safe, usually successful and in the opinion
ventilation (BMV), laryngoscopy and intuba- of many authors, the preferred route when
tion, and rescue oxygenation with an extraglottic significant airway obstruction is present.2,6,7
device (Fig. 11–1). • For the uncooperative patient, (see Approach
to Tracheal Intubation algorithm, Chapter 11,
• As such, in general, the presence of patho- Fig. 11–3, track 5), options include a trial
logical airway obstruction is a relative con- of a sedative such as ketamine; intubation
traindication to RSI. following an inhalational induction of anes-
thesia in the operating room (OR); or awake
A patient in the early stages of upper airway tracheostomy or cricothyrotomy. Rarely, in a
obstruction will often be cooperative, allowing the high acuity situation with an actively unco-
option of an awake approach to intubation operative patient, RSI with a double setup
(see Approach to Tracheal Intubation algorithm, may be needed, with the expectation to pro-
Chapter 11, Fig. 11–3, track 3). The awake ceed to cricothyrotomy without delay, if
approach will allow the patient to maintain a ten- failed oxygenation ensues.
uous airway and, if landmarks are indistinct dur- • Although extraglottic devices would generally
ing the intubation attempt, movement of laryngeal not be expected to work for failed oxygena-
structures (i.e., abduction of edematous cords/ tion with pathologic obstruction at or below the
false cords during inspiration) may afford the clin- cords, there are sporadic case reports of their
ician an additional and valuable landmark. In con- successful use in this situation.8,9
trast, apnea from significant sedation or RSI with
paralysis may cause static edematous structures to Temporizing Measures
obscure all landmarks and further constrict the air- The following temporizing measures may allow
way. In addition to making direct laryngoscopy time for arrival of additional expertise and equip-
difficult or impossible, this will also compromise ment, or transfer of the patient with obstructing
the efficacy of BMV or an extraglottic device (EGD). pathology to another location:
Even small amounts of sedation in the patient with
advanced obstruction can interfere with the mus- • To promote venous drainage, the head of the
cle tone related patency of a tenuous airway.5 bed should be elevated (if the patient has not
With advanced degrees of obstruction, tra- naturally assumed the sitting position).
cheal intubation from above will always be • Heliox (a helium:oxygen mixture in 80:20,
risky, and even with an awake approach, com- 70:30 or 60:40 proportions) can be used.10,11
plete obstruction can occur during the attempt.5 Heliox eases the work of breathing in upper
Because of this, for some patients with an airway obstruction by reducing the
advanced degree of obstructing pathology, a obstruction-related turbulent flow. The
254 CHAPTER 16
more laminar flow thus afforded can symp- ture identifying the glottic opening in the
tomatically improve the patient, but comes awake patient is a suggestion of movement
at the cost of a reduced inspired concentra- on inspiration, or the appearance of bubbles
tion of oxygen. on expiration. A small tube or a bougie can
• For certain inflammatory obstructing condi- be aimed through the hole. Prior passage of
tions, a nebulized epinephrine aerosol may a bougie has the advantage of providing tac-
help temporarily shrink the edematous com- tile feedback to confirm tracheal entry,
ponent.12,13 although in the awake patient it should not
• In certain cases of angioedema, a conserva- be advanced to or beyond the carina.
tive approach including the use of epineph- • In an unconscious, apneic patient with
rine may reverse the obstruction, thereby unidentifiable anatomy at laryngoscopy,
averting the need for intubation. having an assistant perform a single chest
• Well applied BMV may be effective as a tem- compression may sometimes produce a bub-
porizing measure in the face of upper airway ble at the laryngeal inlet, through which a
pathology.14 bougie can be passed.
Surgical Considerations
Intubation and Postintubation The presence of a surgeon at the bedside of an
Considerations obstructing patient should always be a welcome
Intubation of the patient with obstructing sight. If acuity permits, primary awake tra-
airway pathology should proceed with the cheostomy using local anesthesia, performed
patient in a position of comfort (usually sitting). by a skilled clinician is a safe and well-tolerated
option in the patient with advanced airway
• Preoxygenation should be undertaken, even obstruction.15
for an awake intubation.
• As stated, in most cases, preparations should • Emergent surgical access should be via
include a “double setup” for urgent cricothy- the cricothyroid membrane. Tracheostomy,
rotomy, in case the patient completely obstructs although quickly performed by some sur-
during intubation attempts. geons, can take time and should generally
• Equipment preparation should include the be reserved for more controlled scenarios.
availability of small endotracheal tubes and
a bougie. While direct laryngoscopy can be
used for awake intubation, an indirect visu- 䉴 PENETRATING NECK TRAUMA
alization technique, using a rigid or flexible
fiberoptic or video-based device, will be par- Penetrating trauma to the neck can involve the
ticularly useful if availability and clinician upper or lower airway, and bears special men-
expertise permit. tion. Case series reporting experience with pen-
• “Blind” alternatives to direct laryngoscopy, etrating neck injuries have reported very high
such as the LMA Fastrach or Trachlight, are success rates with the use of RSI.7, 16 RSI is, in
relatively contraindicated with distorted airway fact, probably safe in penetrating neck injuries
anatomy. involving no direct or indirect (e.g., distortion
• Topical airway anesthesia and precision of the airway by an adjacent neck hematoma)
direct laryngoscopy, if used, should be per- trauma to the airway. However, clinically identi-
formed as described in Chapter 8. fying these particular injuries before airway man-
• Distorted laryngeal inlet anatomy can be agement is commenced is not always possible
difficult to interpret: sometimes the only fea- or reliable. Although reports of poor outcomes
attributable to RSI use in penetrating neck Physiologic Considerations

trauma (and for that matter, all upper airway
pathology) are relatively rare, this may in part Practically speaking, patients with recurrent
be explained by publication bias. It is a well- reactive airways disease can be distinguished
known phenomenon that “success stories” are on the basis of age as having either asthma
more commonly submitted to and accepted in (in the younger patient), or COPD (in the
peer-reviewed journals.17 Caution should be older patient). Although they share the
exercised before performing RSI in any patient common pathophysiology of lower airway
with a penetrating neck injury, and full prepa- obstruction, their responses to therapies are
rations should be made for encountering a very different.
difficult situation.
• Noninvasive positive pressure ventilation
(NPPV) has proven benefit in the COPD
䉴 LOWER AIRWAY DISEASE patient and may avert the need for endotra-
cheal intubation when employed early.18–20
Lower airway disease of sufficient severity to The evidence for the use of NPPV in the asth-
require intubation may stem from processes matic patient is less clear.21, 22
involving large (e.g., acute exacerbation of
chronic obstructive pulmonary disease [COPD]) The patient presented in Case 16–2 is in
or small (e.g., bronchospasm) conducting air- extreme distress, and any delay in definitive
ways, or lung parenchyma and alveoli (e.g., management may be fatal. In addition to treat-
pneumonia, pulmonary contusion, or pulmonary ment with B-agonists and corticosteroids, other
edema). Many conditions of the lower airway agents such as ketamine and magnesium have
requiring correction of gas exchange can be been advocated as adjunctive therapy in cases
managed conservatively, for example, with of acute severe asthma.23,24 However, these ther-
use of noninvasive positive pressure ventila- apies are unlikely to be effective in the late
tion. Often, the patient requiring intubation stages of respiratory failure. As respiratory muscle
for lower airway pathology is experiencing fatigue ensues, tracheal intubation is indicated
fatigue and a marked deterioration of gas for predicted further clinical deterioration and
exchange. correction of progressive hypoxemia, hypercar-
bia, and the resultant mixed respiratory and
metabolic acidosis.
䉴 Case 16.2
Pharmacologic Considerations
A 19-year-old known asthmatic male pre-
sented by ambulance, in extreme respiratory
Tracheal intubation of the patient with lower
distress. Despite continuous treatment with
airway disease can proceed with an awake
inhaled beta agonists en route to the ED, the
approach or RSI. Generally, RSI is the pre-
patient was now drowsy and unable to speak
ferred route, as placement of an endotracheal
in complete sentences. His breath sounds were
tube (ETT) in a deeply anesthetized patient is
diminished bilaterally and he had paradoxi-
less likely to stimulate further bronchospasm.
cal abdominal respirations. His SaO2 was
Any induction sedative/hypnotic can be used
82% on oxygen via a nonrebreathing face
for induction, although ketamine is the only
mask; he had a RR of 30, HR of 150, and BP
agent that may also provide some bron-
of 150/100.
chodilation.
256 CHAPTER 16
• Although commonly recommended, there is • Extraglottic devices with higher “pop-off”

little evidence to support the use of intra- pressures would be appropriate to have avail-
venous lidocaine as a pretreatment agent able for the patient with poor lung compli-
during RSI in the asthmatic patient.25 ance. Examples include the LMA ProSeal,
• As it bronchodilates in higher doses, keta- LMA Supreme, and Combitube.
mine is the ideal agent for induction of the
patient in status asthmaticus. However, it Intubation and Postintubation
should be noted that most evidence supporting Considerations
its use comes from experience in pediatrics, Airway management considerations in this pop-
as an adjunctive therapy in either the pre- ulation include the following:
or post-intubation phase.26–29
• The deep level of anesthesia needed to pre- • No matter what the cause, the patient in res-
vent further bronchospasm in response to piratory distress often chooses to assume an
laryngoscopy and intubation can be upright position. BP permitting, this position
achieved with a large dose of induction should be retained until the patient under-
sedative/ hypnotic, with or without pretreat- going RSI is rendered unconscious.
ment with a narcotic such as fentanyl. • If an awake intubation is performed on the
• A rapid-onset neuromuscular blocker (suc- patient in respiratory distress, it should be done
cinylcholine or rocuronium) should be used with the patient in a sitting position. As long as
during RSI. Although there is theoretic con- the patient is not confused, awake intubations
cern related to histamine release with some are often well tolerated in this population.
agents (e.g., thiopental; succinylcholine), • In contrast to the patient with obstructing
there is no clinical evidence precluding the upper airway pathology, a larger sized endo-
use of these medications to facilitate intuba- tracheal tube should be used for the patient
tion of the asthmatic. with lower airway pathology: this will
decrease airflow resistance and facilitate
suctioning of secretions.
Technical Considerations • Preoxygenation may be difficult but should
be attempted, including patients known to
As always, an airway assessment should be per- be functioning on the basis of hypoxic drive.
formed. The decision to intubate should ideally • If RSI is chosen, rapid oxygen desaturation
be made before hypoxia, or patient obtundation will occur (and should be anticipated) once
by hypercarbia precludes patient cooperation. apnea occurs. Bag-mask ventilation is essen-
tial, as soon as the patient stops breathing.
Airway Management Decisions • Postintubation hypotension is not uncommon
Direct laryngoscopy with endotracheal intuba- from a combination of hypovolemia from
tion is a potent stimulus for bronchospasm. The insensible losses, loss of sympathetic drive,
least traumatic, most effective means of achieving and the effects of dynamic lung hyperinfla-
endotracheal intubation in the asthmatic in tion on venous return. A fluid bolus may be
extremis is RSI with a deep plane of anesthesia. beneficial before proceeding with the tra-
cheal intubation.
• However, in approaching an asthmatic
requiring endotracheal intubation, it is also Particularly in the patient with lower airway
important to recognize that “tight” lungs diseases, successful placement of an endotra-
may pose an obstacle to both mask ventila- cheal tube is only the beginning of effective man-
tion and extraglottic rescue device use. agement. Postintubation challenges include
decreased compliance, copious secretions, and 䉴 SUMMARY

hypotension.
Patients presenting with acute respiratory dis-
• Stimulation of the carina may cause wors- ease require careful assessment and manage-
ening of bronchospasm, and should be ment choices, specific to the location and nature
avoided by ensuring appropriate location of of the disease process. With upper airway
the ETT tip. obstruction, the most complex decisions revolve
• Ongoing sedation with neuromuscular around the choices made during the preintuba-
blockade will prevent ventilator asynchrony, tion phase, and the technical challenges of pro-
minimize the risk of barotrauma, reduce ceeding with an awake approach to the intuba-
oxygen consumption and diminish CO2 pro- tion. In contrast, in the patient with disease of
duction.27 the lower airway, (e.g., bronchospasm), man-
• “Breath stacking,” or dynamic hyperinfla- agement challenges continue and can be even
tion due to inadequate expiratory time, can greater after tracheal intubation.
significantly raise mean intrathoracic pres-
sure (“auto-PEEP”). This can interfere with
venous return, potentially causing cardio- REFERENCES
vascular collapse or barotrauma. 1. Mason RA, Fielder CP. The obstructed airway in
• The patient intubated for respiratory failure head and neck surgery. Anaesthesia. 1999;54(7):
from pulmonary edema, pneumonia, or 625–628.
COPD may require frequent suctioning. 2. Cload B, Howes D, Sivilotti M, et al. Where is the
ET tube? CJEM. 2006;8 (6):436.
Ventilator strategies to minimize complica- 3. Green SM, Krauss B. Clinical practice guideline for
emergency department ketamine dissociative seda-
tions include the use of permissive hypercapnia
tion in children. Ann Emerg Med. 2004;44(5):
(i.e., controlled hypoventilation) whereby CO2 460–471.
levels of under 90 mm Hg may be accepted,30 4. Cohen VG, Krauss B. Recurrent episodes of
and attention to the expiratory phase of the ven- intractable laryngospasm during dissociative seda-
tilatory cycle. Recommended pressure-control tion with intramuscular ketamine. Pediatr Emerg
ventilator settings27 in status asthmaticus appear Care. 2006;22(4):247–249.
in Table 16–2. 5. McGuire G, el-Beheiry H. Complete upper airway
obstruction during awake fibreoptic intubation in
patients with unstable cervical spine fractures. Can
䉴 TABLE 16–2 RECOMMENDED INITIAL J Anaesth. 1999;46(2):176–178.
VENTILATOR SETTINGS FOR STATUS 6. Kovacs G, Law JA, Petrie D. Awake fiberoptic
ASTHMATICUS intubation using an optical stylet in an antici-
Rate: 10–15 breaths/min pated difficult airway. Ann Emerg Med. 2007;49(1):
Tidal volume: 6–10 mL/kg 81–83.
Minute ventilation: 8–10 L/min 7. Tallon JM, Ahmed JM, Sealy B. Airway manage-
PEEP: none ment in penetrating trauma of the neck in a Cana-
Inspiratory/expiratory ratio: (1:3 dian tertiary trauma centre. Can J Emerg Med, in
Inspiratory flow: (100 L/min press. 2007.
Maintain SaO2 >90% 8. Martin R, Girouard Y, Cote DJ. Use of a laryngeal
Pplat (end-inspiratory plateau pressure) mask in acute airway obstruction after carotid
<35 cm H2O endarterectomy. Can J Anaesth. 2002;49(8):890.
VEI (end-inspired volume above apneic 9. King CJ, Davey AJ, Chandradeva K. Emergency use
FRC) <1.4 L of the laryngeal mask airway in severe upper
airway obstruction caused by supraglottic oedema.
Adapted from Papiris.27 Br J Anaesth. 1995;75(6):785–786.
258 CHAPTER 16
10. Ho AM, Dion PW, Karmakar MK, et al. Use of chronic obstructive pulmonary disease vs. other con-
heliox in critical upper airway obstruction.: Physi- ditions: effectiveness and predictors of failure. Inten-
cal and physiologic considerations in choosing the sive Care Med. 2005;31(4):533–539.
optimal helium:oxygen mix. Resuscitation. 21. Ram FS, Wellington S, Rowe B, et al. Non-invasive
2002;52(3):297–300. positive pressure ventilation for treatment of respi-
11. Smith SW, Biros M. Relief of imminent respiratory ratory failure due to severe acute exacerbations of
failure from upper airway obstruction by use of asthma. Cochrane. Database. Syst. Rev. 2005(3):
helium-oxygen: a case series and brief review. CD004360.
Acad Emerg Med. 1999;6(9):953–956. 22. Agarwal R, Malhotra P, Gupta D. Failure of NIV in
12. MacDonnell SP, Timmins AC, Watson JD. Adrena- acute asthma: case report and a word of caution.
line administered via a nebulizer in adult patients Emerg. Med. J. 2006;23(2):e9.
with upper airway obstruction. Anaesthesia. 23. Silverman RA, Osborn H, Runge J, et al. IV mag-
1995;50(1):35–36. nesium sulfate in the treatment of acute severe
13. Nutman J, Brooks LJ, Deakins KM, et al. Racemic asthma: a multicenter randomized controlled trial.
versus l-epinephrine aerosol in the treatment of Chest. 2002;122(2):489–497.
postextubation laryngeal edema: results from a 24. Rowe BH, Bretzlaff JA, Bourdon C, et al. Intra-
prospective, randomized, double-blind study. Crit venous magnesium sulfate treatment for acute
Care Med. 1994;22(10):1591–1594. asthma in the emergency department: a systematic
14. Ghirga G, Ghirga P, Palazzi C, et al. Bag-mask ven- review of the literature. Ann Emerg Med.
tilation as a temporizing measure in acute infec- 2000;36(3):181–190.
tious upper-airway obstruction: does it really work? 25. Butler J, Jackson R. Best evidence topic report. Lig-
Pediatr Emerg Care. 2001;17(6):444–446. nocaine as a pretreatment to rapid sequence
15. Goldberg D, Bhatti N, Cummings Charles W. Man- intubation in patients with status asthmaticus.
agement of the impaired airway in the adult, Oto- Emerg. Med. J. 2005;22(10):732.
laryngology, Head and Neck Surgery. Philadelphia 26. Cromhout A. Ketamine: its use in the emergency
Mosby;2005. department. Emerg. Med. (Fremantle). 2003;15(2):
16. Mandavia DP, Qualls S, Rokos I. Emergency air- 155–159.
way management in penetrating neck injury. 27. Papiris S, Kotanidou A, Malagari K, et al. Clinical
Ann Emerg Med. 2000;35(3):221–225. review: severe asthma. Crit Care. 2002;6(1):30–44.
17. Moscati R, Jehle D, Ellis D, et al. Positive-outcome 28. Denmark TK, Crane HA, Brown L. Ketamine to
bias: comparison of emergency medicine and gen- avoid mechanical ventilation in severe pediatric
eral medicine literatures. Acad Emerg Med. asthma. J. Emerg. Med. 2006;30(2):163–166.
1994;1(3):267–271. 29. Allen JY, Macias CG. The efficacy of ketamine in
18. Majid A, Hill NS. Noninvasive ventilation for acute pediatric emergency department patients who pre-
respiratory failure. Curr. Opin. Crit Care. 2005;11(1): sent with acute severe asthma. Ann Emerg Med.
77–81. 2005;46(1):43–50.
19. Crummy F, Buchan C, Miller B, et al. The use of 30. Oddo M, Feihl F, Schaller MD, et al. Management
noninvasive mechanical ventilation in COPD with of mechanical ventilation in acute severe asthma:
severe hypercapnic acidosis. Respir. Med. 2006. practical aspects. Intensive Care Med. 2006;32(4):
20. Phua J, Kong K, Lee KH, et al. Noninvasive ventila- 501–510.
tion in hypercapnic acute respiratory failure due to
Chapter 17
The Critically Ill Patient
䉴 INTRODUCTION 䉴 PHYSIOLOGIC CONSIDERATIONS
By definition, virtually all patients requiring The physiologic goal of airway management in
emergency airway management are critically the critically ill patient is to maximize oxygen
ill. Although the circumstances, challenges, delivery and minimize injury at the cellular level.
and outcomes of these cases will always be In the attempt to preserve oxygen delivery to the
patient-specific, certain generalizations can brain and heart in such patients, physiologic com-
be made. In all cases, the goal should be to pensation occurs with vasoconstriction and cate-
predict technical, anatomic, and physiologic cholamine release. However, once such reserves
barriers to safe airway management, and then are exceeded, the patient decompensates, and
take appropriate steps to meet the identified cellular injury occurs. Injured and ischemic cells
challenges. swell, in turn compromising the microcirculation
and preventing clearance of local toxins. This
decompensated state may become irreversible
and lead to multisystem organ failure, despite
䉴 Case 17.1 normalization of the patient’s vital signs.
The patient who is, or may become critically
A 60-year-old male was brought by ambu- ill must be recognized early. Appropriate treat-
lance to the emergency department (ED), com- ment, including aggressive airway management,
plaining of shortness of breath. Earlier in the should be begun without delay, before irre-
day, he had been begun on an oral antibiotic versible changes occur. The clinician should
for a chest infection. He had a past history of anticipate the potential for physiologic decom-
coronary artery disease, hypertension and pensation and attempt to minimize procedurally
chronic bronchitis. In the ED, the patient was related hypotension and worsened hypoxemia.
observed to be an anxious, overweight male,
in marked respiratory distress. His vital signs • Due to his underlying chronic illnesses, the
were as follows: temperature 39.5°C; heart patient described in Case 17–1 has a signif-
rate 120 (sinus tachycardia); blood pressure icantly reduced physiologic reserve.
106/60 mm Hg; respiratory rate 28/minute and • Without appropriate action, his condition
SaO2 of 88% on a nonrebreathing face mask may quickly deteriorate to a decompensated
(NRFM). A portable chest x-ray showed diffuse state.
bilateral pulmonary infiltrates, consistent with • Given his history of chronic hypertension, the
a diagnosis of pneumonia. patient’s blood pressure is inappropriately
259
260 CHAPTER 17
low, quite possibly indicating a state of par- this may equate to simply proceeding with laryn-
tially compensated septic shock. goscopy and intubation there and then—very
• Definitive emergent airway management is often, the patient will offer little resistance. On
needed in this patient to facilitate end-organ occasion, high-acuity situations may also lead to
oxygen delivery. the need for RSI in scenarios where an awake
intubation would have been chosen had time
allowed.
䉴 AIRWAY DECISIONS IN THE
CRITICALLY ILL • Although the patient presented in Case 17–1
requires urgent airway management, his
Appropriate airway management in the critically acuity is such that an airway assessment can
ill patient requires consideration of three major be performed, and appropriate preparations
decision nodes, each of which may be repre- for intubation made, prior to proceeding.
sented as part of a continuum (Fig. 17–1). The
three nodes relate to patient acuity, predicted
difficulty, and patient cooperation.
The Predicted Difficult Airway
The second decision node considers the pre-

Patient Acuity
dicted difficult airway, a topic discussed in
more detail in previous chapters. As always, if
Acuity defines how much time is available to
time permits, an assessment of the patient for
manage the patient’s airway. An arrested, or
predicted difficulty with bag-mask ventilation
rapidly deteriorating (“crashing”), hypoxic
(BMV), laryngoscopy and intubation, and rescue
patient will present fewer airway management
oxygenation via extraglottic device (EGD) or
options than a more stable one. Help is often
cricothyrotomy should occur. However, in the
not available, difficult airway equipment may
critically ill patient, two additional considerations
be some distance away, and trained assistants
apply:
scarce. Although the basic principles of airway
management should still be observed (e.g., pre-
A. Limited oxygen reserves
oxygenation), typically, the patient who is
The critically ill patient often has decreased
rapidly deteriorating will need intervention
oxygen reserves and increased consump-
before optimal conditions are obtained. In very
tion. If the patient is rendered apneic, any
high acuity situations (e.g., the arrested patient),
difficulty with subsequent oxygen
delivery during the transition to positive
pressure ventilation (e.g., by BMV, or via an
Crashing Acuity Sick endotracheal tube) will generally be
very poorly tolerated, with rapid oxygen
desaturation.
This propensity for rapid desaturation in
Can’t Predicted Difficult
oxygenate difficulty laryngoscopy
the critically ill patient should prompt one
of two responses: (a) an “awake” approach
to tracheal intubation, whereby the patient
Actively
Cooperation
Passively helps maintain oxygenation with sponta-
uncooperative uncooperative neous respirations; or (b) if rapid-sequence
intubation (RSI) is undertaken, full prepara-
Figure 17–1. Decision nodes in the critically ill. tions for a difficult situation should occur
THE CRITICALLY ILL PATIENT 261
before proceeding, including the presence Patient Cooperation

of an extra assistant for two-person BMV;
fully prepared primary and alternative intu- The third decision node in the critically ill patient
bation devices, and a rescue EGD. addresses the practical issue of patient coop-
eration. The critically ill patient may be
• The patient in Case 17–1, with his suspected passively uncooperative on the basis of
pulmonary pathology, is likely to have an hypoxemia, hypercarbia (as with the patient in
increased shunt fraction. Obesity and his respiratory failure) or simply hypotension.
shallow breathing will limit his functional Although drowsy, the patient may not actively
residual capacity (FRC). The effectiveness of resist management interventions. This passive
preoxygenation will thus be limited, and he state may allow for an “awake” (i.e., non-RSI)
will desaturate quickly if rendered apneic. approach to intubation, with application of top-
• In the critically ill patient, assisted BMV may ical airway anesthesia. In contrast, an actively
be needed during the preoxygenation phase, uncooperative patient, who is agitated, or has
to improve oxygenation. clenched teeth, will almost always require phar-
• If an RSI is undertaken, BMV should occur macologic relaxation as part of an RSI.
with the onset of apnea (if not already being
assisted), anticipating rapid oxygen desatu- • The assessment of patient cooperation requires
ration. bedside judgment.
• Even without anticipated difficulty, in the • Many experienced clinicians with an appro-
critically ill patient, time available for intu- priate skill set would choose to use an RSI for
bation attempts will be shortened before the patient presented in Case 17–1.
reoxygenation by BMV is needed. Here
again, the critically ill patient is poorly for- Theoretically, for appropriate decision-making
giving of difficulty. at each of the foregoing decision nodes, the
clinician’s skill set should also be considered.
B. Difficult physiology However, as discussed above, situation acuity
The critically ill patient is almost always in the critically ill patient often mandates pro-
significantly volume depleted, and may be ceeding before more expert assistance can be
hypotensive. A patient who is predicted to summoned. It is important to recognize that a
be poorly tolerant of induction sedative/ delay in appropriate airway management in this
hypnotic medications is sometimes best patient population may lead to an irreversible
intubated using an “awake” approach. clinical state, and ultimately, death.
• Especially in the critically ill patient who • With predictors of at least difficult BMV, the
is dyspneic and tachypneic, it is easy to patient in Case 17–1 should have full prepa-
overlook volume status. The patient in rations and a planned response for difficulty,
Case 17–1 (and most critically ill including 2-person BMV with an OPA during
patients) should receive a fluid bolus via ventilation between laryngoscopy attempts.
large-bore IV access prior to intubation, if • Obese patients will desaturate quickly in the
acuity permits. supine position, as will patients with respi-
• For all emergency intubations, but espe- ratory failure.1
cially those in the critically ill, rescue • Once supine, a “ramped” position (see
vasopressors such as ephedrine and Chap.5, figure 5–6) will facilitate airway
phenylephrine should be drawn up and management in the morbidly obese, includ-
ready for administration. ing laryngoscopy.2
262 CHAPTER 17
• Following successful tracheal intubation in non-RSI approach (i.e., proceeding with direct
this patient with COPD, during manual ven- laryngoscopy after applying some topical airway
tilation, adequate time must be allowed for anesthesia) may be easily performed. If RSI is
expiration, to avoid further cardiovascular chosen in a more uncooperative patient with
collapse from air-trapping and “auto-PEEP.” profound shock, the clinician must be aware
that even very small doses of sedative/ hypnotic
medications can have profoundly adverse
䉴 SHOCK STATES hemodynamic effects. As discussed in the next
section, if RSI is undertaken, induction doses
must be reduced.
䉴 Case 17.2
Pharmacologic Considerations in
A 22-year-old man was ejected from his vehi- Shock States
cle in a high speed motor vehicle collision.
He arrived in the ED on a spine board, with Patients in shock are very sensitive to sedative/
a cervical collar in place. He had a GCS of hypnotic agents. Animal studies suggest that in
9, an open fracture of the right femur, a vis- hemorrhagic shock, alterations occur to pharma-
ible contusion on the right side of his chest, cokinetics and pharmacodynamics of both
and abdominal distension. His jaw was narcotics and sedative/hypnotics.3–9 Changes in
clenched shut. Blood pressure was 70/54, heart volumes of distribution and clearances for propo-
rate 134, respiratory rate 34, and SaO2 89% fol,3–5 etomidate,6 fentanyl,7 and remifentanil8
on a NRFM. in hemorrhagic shock result in higher brain drug
concentrations, more rapid onset, and more pro-
found effect.9 In addition, for propofol, the brain
Shock defines a state of inadequate tissue sensitivity to the drug increases.3–5,9 This trans-
perfusion and oxygen delivery. There are a variety lates to decreased dose requirements of at least
of classifications used to describe the severity 50% for narcotics, and even more (up to an
and causes of shock, based on physiologic para- 80%–90% decrease in dosage) for propofol in
meters. the setting of unresuscitated hemorrhagic
shock.9 For propofol, these effects appear to be
• Clinically, shock is most commonly, although partially, but not completely reversed after crys-
not exclusively, recognized by hypotension. talloid resuscitation.5
• In terms of severity, shock may be compen- In contrast to propofol, etomidate has per-
sated (with preserved blood pressure) or formed well in animal studies of hemorrhagic
uncompensated (low blood pressure). shock, with little requirement for dosing adjust-
• Pathology causing shock may arise from ment.6,9 This is in keeping with etomidate’s rep-
problems with the pump (i.e., cardiac), ves- utation for maintenance of stable hemodynamics
sels (i.e., sepsis) or fluid (i.e., hemorrhage). during RSI, and accounts for its widespread
• Diminished venous return, loss of sympa- usage in North American EDs. As discussed in
thetic tone and drugs given during airway Chapter 13, etomidate will cause adrenocortical
management may all contribute to the devel- suppression with a resultant reduced circulating
opment of an uncompensated shock state. cortisol level.10 This has led to calls by some for
restriction of its use in the setting of a critically
Management of shock must always involve ill patient in whom having adequate levels of
fluid resuscitation, regardless of etiology. Severely circulating cortisol is thought to be a determi-
hypotensive patients will be obtunded, and a nant of outcome.11,12
THE CRITICALLY ILL PATIENT 263
䉴 TABLE 17–1 SUGGESTED DOSE RANGES exchange. For safe clinical outcomes to occur,
FOR RSI SEDATIVE/HYPNOTIC AGENTS IN THE tracheal intubation decisions must consider
HYPOTENSIVE PATIENT patient acuity, cooperation, and predicted diffi-
Systolic culty. Irrespective of the approach chosen for
Blood Etomidate Ketamine Propofol intubation, the critically ill patient will always
Pressure (mg/kg) (mg/kg) (mg/kg) require attention to fluid resuscitation, and careful
choice and dosing of adjuvant medications.
100 0.2–0.3 1–1.5 1–2
80–100 0.2 1.0 0.5–1
<80 0.15–0.2 0.5–1.0 0.25–0.5
REFERENCES
1. Dixon BJ, Dixon JB, Carden JR, et al. Preoxygena-
tion is more effective in the 25 degrees head-up
position than in the supine position in severely
Ketamine has traditionally been viewed as obese patients: a randomized controlled study.
an agent of choice for RSI in the presence of Anesthesiology. 2005;102(6):1110–1115.
hypotension, as blood pressure is often main- 2. Collins JS, Lemmens HJ, Brodsky JB, et al. Laryn-
tained, or indirectly raised by sympathetic ner- goscopy and morbid obesity: a comparison of the
vous system stimulation. However, ketamine is “sniff” and “ramped” positions. Obes Surg.
intrinsically a negative inotrope, and may there- 2004;14(9):1171–1175.
fore further lower the blood pressure in the 3. De Paepe P, Belpaire FM, Rosseel MT, et al. Influ-
critically ill, hypotensive patient who is already ence of hypovolemia on the pharmacokinetics and
the electroencephalographic effect of propofol in
using maximum compensatory sympathetic
the rat. Anesthesiology. 2000;93(6):1482–1490.
drive.13 4. Johnson KB, Egan TD, Kern SE, et al. The influ-
Ketamine is usually avoided in head-injured ence of hemorrhagic shock on propofol: a phar-
patients, unless also suspected to be hypo- macokinetic and pharmacodynamic analysis.
volemic or known to be hypotensive. In the Anesthesiology. 2003;99(2):409–420.
profoundly hypotensive, sympathetically driven 5. Johnson KB, Egan TD, Kern SE, et al. Influence of
head-injured patient, ketamine dosage should hemorrhagic shock followed by crystalloid
be reduced.14 Approximate dosage reductions resuscitation on propofol: a pharmacokinetic
for sedative/hypnotic agent use in the hypoten- and pharmacodynamic analysis. Anesthesiology.
sive patient appear in Table 17–1. 2004;101(3):647–659.
Unfortunately, despite best efforts, postin- 6. Johnson KB, Egan TD, Layman J, et al. The influ-
ence of hemorrhagic shock on etomidate: a phar-
tubation hypotension may still ensue in the
macokinetic and pharmacodynamic analysis. Anesth
critically ill patient. The use of bolus doses of Analg. 2003;96(5):1360–1368.
vasopressors as “rescue agents” in the postin- 7. Egan TD, Kuramkote S, Gong G, et al. Fentanyl
tubation phase should be considered to treat pharmacokinetics in hemorrhagic shock: a porcine
transient drops in blood pressure, but should model. Anesthesiology. 1999;91(1):156–166.
never be considered a replacement for volume 8. Johnson KB, Kern SE, Hamber EA, et al. Influence
resuscitation. of hemorrhagic shock on remifentanil: a phar-
macokinetic and pharmacodynamic analysis.
Anesthesiology. 2001;94(2):322–332.
9. Shafer SL. Shock values. Anesthesiology. 2004;
䉴 SUMMARY 101(3):567–568.
10. Schenarts CL, Burton JH, Riker RR. Adrenocortical
The critically ill patient should ideally be iden- dysfunction following etomidate induction in emer-
tified prior to decompensation. Early airway gency department patients. Acad Emerg Med.
management is indicated to ensure effective gas 2001;8(1):1–7.
264 CHAPTER 17
11. Jackson WL Jr. Should we use etomidate as an 13. Weiskopf RB, Bogetz MS, Roizen MF, et al. Car-
induction agent for endotracheal intubation in diovascular and metabolic sequelae of induc-
patients with septic shock?: a critical appraisal. ing anesthesia with ketamine or thiopental in
Chest. 2005;127(3):1031–1038. hypovolemic swine. Anesthesiology. 1984;60(3):
12. den Brinker M, Joosten KF, Liem O, et al. Adrenal 214–219.
insufficiency in meningococcal sepsis: bioavail- 14. Sehdev RS, Symmons DA, Kindl K. Ketamine for
able cortisol levels and impact of interleukin-6 rapid sequence induction in patients with head
levels and intubation with etomidate on adrenal injury in the emergency department. Emerg Med
function and mortality. J Clin Endocrinol Metab. Australas. 2006;18(1):37–44.
2005;90(9):5110–5117.
Chapter 18
The Very Young and the Very
Old Patient
䉴 INTRODUCTION The challenges encountered during airway

management in infants are psychological,
People at the extremes of age often present with physiologic, and anatomic. The presentation
emergencies that require airway intervention. of a “sick” infant, accompanied by distraught
Patients in these age cohorts can present signif- parents, can produce significant and poten-
icant airway management challenges to clini- tially debilitating anxiety for many clinicians.
cians with acute-care responsibilities. Proportionately, far fewer children than adults
present critically ill to the emergency depart-
ment (ED). This fact may limit clinician com-
fort and familiarity with the “when and how”
䉴 THE VERY YOUNG to perform acute airway management. Critically
䉴 Case 18.1
A 9-day-old male infant, born at term fol- SaO2 was 88% on high-flow oxygen by face
lowing an uneventful pregnancy, had been mask. Respirations were irregular and at
discharged from hospital within 48 hours of times gasping. A decision was made to imme-
birth. His 4-year-old brother was recovering diately intubate the trachea. However, the
from an upper respiratory tract infection. attempt at emergency awake intubation was
Within days, the baby had developed a runny abandoned due to patient resistance, and an
nose and cough. The mother set out to return alarming drop in oxygen saturation.
the infant to the hospital, but during the car Having failed to establish an airway by
ride, he became apneic and turned blue. On emergent awake intubation, the decision
arrival, the baby was breathing again but was made to proceed with an RSI. Prior to
had severe indrawing, head bobbing, eye induction, using good bag-mask ventilation
rolling, hypotonia, and visible cyanosis. The (BMV) technique synchronized to the baby’s
triage nurse started oxygen by facemask and efforts, the SaO2 rose to 94%, although the
rushed the baby into the resuscitation area. work of breathing remained extreme.
265
266 CHAPTER 18
ill children, and in particular infants, may For these reasons, it is important to appreciate
rapidly physiologically decompensate (“crump”), that an RSI in infants is really rapid. Preoxy-
mandating immediate attention. Furthermore, genation can usually be accomplished in less
size- and age-related anatomic variations may than 3 minutes. Although the pace following
make recognition and management of this drug injection should be swift, the agents must
decompensated state challenging. still be allowed time to work. If assisted BMV is
required to maintain oxygenation, applied
cricoid pressure may reduce gastric insufflation,
Physiologic Challenges which, in the infant population, can otherwise
cause clinically significant impairment of chest
A number of physiologic challenges directly expansion.6 This may also mandate gastric
impact airway management of the infant. These decompression by naso- or orogastric tube
include the following: following tracheal intubation.5
• High oxygen consumption: Infants have a Anatomic Challenges

relatively high cardiac output, minute volume
of ventilation, and oxygen consumption, to Although infants can generally be intubated
match their high metabolic rate. This equates quite easily by direct laryngoscopy, there are
to rapid arterial desaturation when delivered clinically significant anatomic differences that
oxygen or ventilation is reduced.1,2 must be recognized. Specific techniques may be
• Small oxygen reservoir: Infants have rela- required to overcome these challenges.
tively low-volume lungs, with functional
residual capacities that overlap closing • Acute airway axes: Infants have large heads
capacity. This results in a small oxygen reser- compared to their bodies. When lying flat on
voir and a tendency to ventilation/perfusion a stretcher, both their necks and atlanto-
(V/Q) mismatch, which may in turn reduce occipital (A-O) joints tend to be flexed. This
the effectiveness of preoxygenation.2 positioning, combined with a relatively larger
• Drug dosing: Infants have higher extracel- tongue, means that (in the supine infant) the
lular fluid compartments than older children trachea lies more anteriorly, and at an acute
or adults. This expands the volume of distrib- angle (less than 90°) relative to the axis of
ution for water-soluble drugs such as succinyl- the oral cavity—far from the 180° ultimately
choline. When combined with a high cardiac needed for direct vision! Alignment of
output, this translates to rapid onset and short airway axes in the infant can be achieved in
duration of action of these drugs, together with part simply by extending the head, as the
the need for higher initial doses.3 lower neck is already flexed. Historically, it
• High risk of regurgitation on induction: has been suggested that a rolled towel is
The gastroesophageal junction is often needed under the shoulders of the small
incompetent in infants. The injection of suc- infant, as the proportionally larger head can
cinylcholine can rapidly be followed by otherwise cause excessive flexion at the A-O
regurgitation of large volumes of formula or junction.
breast milk. Despite this, the occurrence of • Large tongue, small jaw: Infants naturally
significant aspiration pneumonitis seems rel- have a degree of glossoptosis—the “large
atively uncommon. However, the use of tongue, small jaw” conundrum. The tongue is
cricoid pressure is still recommended (as part hypertrophied and muscular to facilitate
of a rapid-sequence intubation [RSI]) in an suckling, and cannot be fully displaced into
attempt to minimize this complication.4,5 the relatively small submental space by the
THE VERY YOUNG AND THE VERY OLD PATIENT 267
laryngoscope blade. The laryngoscopist limited. For example, the LMA Fastrach is not
experiences this as an “anterior larynx.” available for use in patients under 30 kg. The
• Prominent preglottic structures: The Bullard laryngoscope, the Glidescope and flex-
laryngeal inlet structures—epiglottis, false ible fiberoptic bronchoscope are available in
cords, and aryepiglottic folds—are promi- sizes consistent with use in the infant. How-
nent, redundant, soft, and highly mobile. To ever, few of these devices have significant
the uninitiated, they look “strange” and can supporting published literature on pediatric
interfere with visualization of the cords, or use. Pediatric fiberoptic stylets are available
passage of the endotracheal tube (ETT). The (e.g., the Shikani Seeing Optical Stylet [SOS]
epiglottis is “retroverted” i.e. angled toward and the Brambrinck), accepting ETTs as small
the posterior pharyngeal wall, increasing the as 2.5 mm ID. The Shikani SOS is supported
probability of a Grade 3 view at laryngoscopy. by some published accounts of success in the
These anatomic variations in part contribute pediatric difficult airway.9,10 The Trachlight,
to the fact that children are more prone to while available in child and infant sizes, has
airway obstruction, be it secondary to appo- not produced results in this population as
sition of normal tissues during sedation, or favorable as those experienced in the adults.11
from an underlying pathologic process.7 Traversing the laryngeal inlet with the Trach-
• The “pseudo-larynx” deception: The light is challenging in the pediatric patient,
cricopharyngeal ring, at the esophageal inlet, and the light transmitted from the trachea is
when distorted by the anterior lift of a laryn- often indistinguishable from that obtained
goscope blade, can become a triangular struc- with esophageal placement.
ture with white side-walls (due to stretch- • Rescue oxygenation devices: Fortunately,
induced mucosal devascularization). This can LMAs and other extraglottic devices are avail-
mimic the appearance of an adult larynx quite able in sizes to fit even a small premature
convincingly. As a result, inadvertent esophageal baby (see Chap.7, Table 7–1). They are eas-
intubation is a common complication for the ily inserted and highly effective. They remain
inexperienced clinician.8 the only proven rescue technique for the
failed infant airway.12,13 The Combitube is
Technical Challenges not available in a pediatric size.
• Surgical Airways: The cricothyroid mem-
Many of the alternative intubation tools used in brane is not developed at this age, so transtra-
adults are not available in infant sizes. For those cheal access would occur below the cricoid
tools that are available, there is less supporting cartilage in the infant. Specialized equipment
literature, compared to their adult congeners. for emergency transtracheal access is very
limited for the infant: the smallest Melker
• Bougie limitations: Pediatric bougies are needle-guided percutaneous cricothyrotomy
rarely used in infants, although they are avail- cannula has an ID of 3.5 mm, while the Pedia-
able, with a distal coudé tip and in a size Trake Pediatric Emergency Cricothyrotomy
small enough to accept an ETT with internal Kit (Smiths Medical MD Inc., St. Paul MN)
diameter (ID) of 3 mm (Cook Medical Inc, contains uncuffed cannulae of 3, 4, and 5 mm
Bloomington, IN). However, many clinicians ID. For the failed oxygenation situation in an
experienced in infant intubation preferentially infant, unrelieved by EGD placement, many
use a styletted ETT, angled as needed. clinicians would proceed with percutaneous
• Few alternatives: As previously mentioned tracheal placement of a 20G (or larger) intra-
in Chap. 6, the choices of proven alternative venous (IV) cannula connected to a self-
intubation tools available in infant sizes are inflating bag (See Chap. 7).
268 CHAPTER 18
Awake Intubation in Infants are probably as safe as uncuffed, pro-

Awake intubation in infants was once popular: vided that tube size, position and cuff
fear of failure to intubate led to a reluctance to pressures are optimized.5
use muscle relaxants. There is a rather per- • Oxygen and positive pressure: A
verse logic in the belief that awake intubation range of suitable pediatric masks should
in infants is a reasonable option because infants be readied and test-fitted to the patient
have less muscular power than adults. Apart during preoxygenation. An oropharyn-
from the obvious ethical issues behind this geal airway, sized by the “corner of mouth
logic, it is also the case that awake intubation to angle of mandible” technique (usually
in infants is generally more difficult, because 5–6 cm or 00–0 size), should be ready.
cooperation is lacking. The current view among Pediatric-sized manual resuscitators are
pediatric emergency physicians and anesthesi- available: to help avoid barotrauma, most
ologists is that in general, RSI is the technique have incorporated “pop-off” valves which
of choice for intubation of infants, unless a can be adjusted to limit applied positive
contraindication (such as known glottic pathology) pressure.
exists. • Pharmacology: Ketamine 2.5 mg/kg,
succinylcholine 2.0 mg/kg, rocuronium
RSI in Infants 1 mg/kg, atropine 0.1 mg, and ephedrine
The indications for and contraindications to RSI 5 mg diluted to 1mg/mL should be drawn
in infants do not differ from those in adults, but up.
the technique does require modification, as • Intravenous Access: Intravenous access
described in the following sections: using a #22G IV catheter should be
obtained. Failing this, an intraosseous nee-
A. Preparation for infant RSI: The standard dle should be inserted. Vascular access by
“STOP IC BARS” mnemonic, previously pre- intravascular or intraosseous routes is
sented in Chap. 5, can also be used in critical to successful pediatric airway
preparing equipment for infant intubation. management, as drugs delivered by the
Some special considerations apply: intramuscular (IM) route are of marginal
• Suction: The suction catheter should be value at best.
of a large size—nothing is more frustrating • Connect to Monitors and Confirma-
than attempting to clear thick secretions tion: At a minimum, a pulse oximeter
through a miniscule suction catheter. and automatic blood pressure (BP) cuff
Nothing smaller than a 10 French catheter set to 3-minute measurement intervals
should be considered, and many clini- must be applied. Optimally, ECG leads
cians recommend using the full size adult should also be applied. A pediatric ETCO2
Yankauer suction tip. detection device, or quantitative CO2
• Tubes: Tracheal tubes should be marked monitoring should be available.
with cord markers (one or more trans- • Blades: Recommended laryngoscope
verse lines on the tube that should be blades for infant intubation are #0 and #1
aligned with the vocal cords) to reduce straight blades, preferably of the Wis-
the risk of right mainstem intubation. #3.0, consin or Flagg design, as these provide
3.5 and 4.0 ID tubes should be ready. more room inside the cross-sectional arc
Most term infants will accept a 3.5 tube. of the blade than the classic Miller blade.
The tubes should be styletted and bent A lightweight, small laryngoscope handle
to the appropriate shape. For infants is preferred, but the adult handle can also
beyond the newborn period, cuffed tubes be used.
• Alternative intubation, rescue oxy- (usually earlier than the adult, that is, in
genation, and surgical airway options about 20–30 seconds).
have been discussed above. A size 0 and • The right hand should extend the atlanto-
1 LMA (or other infant-sized EGD) should occipital joint and open the mouth. The
be prepared for rescue oxygenation, left hand inserts the blade into the right
and the difficult airway cart should be on paraglossal gutter and follows the edge
hand. of the tongue until the epiglottis is seen.
B. Infant RSI: the procedure The epiglottis is then everted, either
• With the monitors applied and the IV directly, by placing the blade beneath the
dripping, preoxygenation is carried out epiglottis and lifting, or indirectly, with
for 3 minutes. The technique of holding blade advancement into the vallecula and
a mask on the face of a frightened child engaging the hyoepiglottic ligament. The
may be difficult, but is not impossible. blade should now be moved towards
Bundling the infant to restrain the arms the middle of the oral cavity to displace
and legs and using a “cradling technique” the tongue to the patient’s left, thereby
(the operator’s arms prevent head move- creating more room for tube insertion on
ment while applying the mask with a two- the right.
hand grip) is usually successful. • Once the cords are visualized, the endo-
• A rapid fluid bolus of 10–20 mL/kg is tracheal tube is inserted, preferably
desirable, and mandatory if there is any from the right corner of the mouth, so as
suspicion of dehydration or shock. An not to occlude the view down the blade.
assistant can push this in during preoxy- The transverse cord marker printed on
genation. the distal ETT is placed at the level of the
• Optimal positioning for laryngoscopy vocal cords, and the position of the tube
should be undertaken, as discussed ear- relative to the upper lip is noted.
lier in this chapter. • If difficulty is encountered in attaining a
• After 3 minutes of preoxygenation, keta- view of the larynx with DL, consideration
mine 2 mg/kg and succinylcholine 2 mg/kg, should be given to easing or releasing
for example, are injected by an assistant, cricoid pressure, performing external
using rapid IV push. Many clinicians have laryngeal manipulation (ELM), or adjusting
historically also used atropine pretreat- the blade tip location.
ment in this context, although, as dis- • The tube is held firmly in place while the
cussed in more detail in Chap.13, evidence self-inflating bag and ETCO2 confirma-
is lacking for this practice. tion device are attached, manual ventila-
• If the lungs are reasonably healthy, and tion is commenced, and correct tracheal
preoxygenation has been successful, the placement confirmed.
RSI can often be completed without per- • Several (relatively) large breaths are
forming BMV. However, as discussed, administered to permit assessment of
rapid desaturation is common. This should chest expansion and auscultation for
be prevented or rapidly remedied with equal air entry.
BMV, with an oropharyngeal airway in • If oxygen saturation is difficult to main-
place. tain, if air entry appears unequal, or if the
• Infants do not always fasciculate—they chest feels “stiff,” the most likely problem
may simply go limp following adminis- is right main-stem bronchial intubation.
tration of succinylcholine. Laryngoscopy Laryngoscopy should be repeated, and
should start once “relaxation” is achieved the ETT withdrawn until the cord marker
270 CHAPTER 18
sits at the appropriate level, prior to re- • Postintubation hypotension should be

taping the tube in place. treated with fluid boluses and pressor
administration.
C. Failed intubation in the infant • Gastric distension due to BMV is common—
• Laryngoscopy should be discontinued following tracheal intubation, a gastric tube
when the SaO2 falls below 90%, or an intu- should be inserted to aid decompression.5
bation attempt approaches 30 seconds. • A chest x-ray should be obtained to con-
• After a failed attempt at intubation, BMV firm ETT positioning above the carina.
should be reestablished, using an oropha- • Suctioning the tube until free of secretions
ryngeal airway if necessary. is essential.
• If the airway can be maintained and BMV • Sedation can be achieved with agents such
is successful, a second dose of succinyl- as midazolam or propofol. Although rare,
choline 2 mg/kg may be administered, or propofol infusion syndrome has been
rocuronium 1 mg/kg. Before giving a sec- described, most commonly associated
ond dose of succinylcholine, atropine 0.1 with prolonged pediatric use in the inten-
mg should be given. sive care unit (ICU) setting.14 Analgesia
• For a second or third attempt at intuba- and further sedation may occur using mor-
tion, a blade change can be considered, phine 0.1 mg/kg/h, or fentanyl 1 µg/kg/h.
as can the use of an alternative intubation
device, if availability and clinician skill
permit. 䉴 THE VERY OLD
• Following three unsuccessful attempts
at intubation, an EGD such as an LMA
should be inserted, the cuff inflated and
ventilation maintained. Alternatively, 䉴 Case 18.2
one may revert to BMV with applied
cricoid pressure, until definitive care can An 82-year-old man arrived in the ED with
be arranged. fever, cough, and confusion. On examina-
tion, he had scattered crackles in both lung
fields and was in severe respiratory distress.
D. Postintubation care in the infant
He had a history of stable angina, arthritis,
• Once the tube is confirmed to be correctly
and hypertension. He had a mild stroke 2
positioned, it should be secured with
years before. His temperature was 38.8°C,
obsessive attention to detail. Skin prepa-
pulse 120, respiratory rate 32/minute, BP
ration with Friar’s Balsam or alcohol is
170/90, and his SaO2 was 82% on a nonre-
recommended to maximize tape adher-
breathing face mask. His chest x-ray showed
ence. The maxilla is a more stable fixation
bilateral pulmonary infiltrates. With a pre-
point than the mandible. Many pediatric
sumptive diagnosis of pneumonia, antibiotic
clinicians fix the tube to both the maxilla
therapy was begun, and a decision was made
and mandible and cover the tape with a
to proceed with tracheal intubation.
second layer of waterproof tape. Alterna-
tively, if available, a commercial fixation
device may be used to secure the tube. As with the infant in the first case, the elderly
• Succinylcholine will wear off in a very short patient poses age-related physiologic and
time (i.e., less than 5 minutes) after admin- anatomic challenges, and is at increased risk for
istration. A longer acting muscle relaxant conditions that will require airway management.
such as rocuronium 1 mg/kg is usually It is sobering to realize that many elderly patients
required, if paralysis is to be maintained. suffer permanent reduction in cerebration even
after well-managed general anesthesia. This is reduced myocardial performance and low
attributed, at least in part, to regional cerebral vascular compliance, the aged are prone to
blood flow problems, related to cerebrovascular swings in BP with physiologic stress. Moder-
disease. ate stress may cause severe BP spikes. Con-
End-of-life issues may complicate tracheal versely, small doses of benzodiazepines,
intubation decisions in the elderly. However, narcotics, and sedative/hypnotics may cause
age alone should never be the sole determinant unexpected unconsciousness and severe
of whether or not to initiate resuscitation. With- hypotension. The hypotension, especially in
holding acute care in the emergency setting is combination with reflex tachycardia, may lead
generally less common than subsequent with- to coronary insufficiency, arrhythmias, cardiac
drawal of therapy, simply because the informa- arrest, stroke, and other organ damage.17,18
tion needed to make these decisions is often
not yet available.15 Understandably, physicians
and families are frequently uncomfortable in Anatomic Challenges
addressing these issues in the acute setting.
However, while the decision to intubate should • Bag-mask ventilation: Loss of subcuta-
consider patient and family wishes, a judgment neous fat in the face, presence of facial hair,
should also be made as to whether the inter- and limited dentition may make mask fit dif-
vention represents futile care. ficult. Dentures, if secure, may be left in place
during BMV, while beards can be slathered
with water-soluble lubricant to facilitate mask
Physiologic Challenges seal.
• Laryngoscopy: Limited mouth opening and
• Pulmonary limitations: As with infants, prominent or asymmetric dentition can make
octogenarians have a relatively low ratio of laryngoscope blade insertion difficult. Tooth
functional residual capacity (FRC) to total loss is always a risk and can be a serious
lung capacity, with closing volumes that may complication where single teeth anchors dental
encroach on normal tidal breathing.16 In prostheses. Dentures should normally be
addition, they may have ongoing conditions removed for laryngoscopy. Reduced atlantooc-
such as chronic obstructive pulmonary dis- cipital and neck mobility due to degenera-
ease (COPD) or restrictive lung disease. tive joint disease may fix the oral-tracheal
These diseases may increase shunt fraction, angle near 90°, interfering with laryngeal
airway closure, air trapping, and dead space. visualization.
This will limit the effectiveness of preoxy-
genation, and places the elderly patient at In contrast to the situation for the very
increased risk of hypoxia and hypercarbia. young, a wide variety of alternatives to direct
• Circulatory limitations: The elderly are laryngoscopy exist for the adult patient. Devices
prone to cerebrovascular, coronary, and previously described such as the LMA Fastrach,
large-vessel atherosclerotic disease. The phys- Trachlight, and various rigid fiberoptic or video-
iologic consequence is a reduction in effective based instruments can be extremely helpful in
organ blood flow, autoregulation, and pres- the patient with reduced jaw or neck mobility.
sure-dependant organ perfusion. Changes
in BP can lead to hypoperfusion, with devas-
tating effects such as stroke or myocardial Technical Challenges
infarction.
• Pharmacologic intolerance: For less well- In general, indications for, and contraindica-
understood reasons, but perhaps linked to tions to RSI and awake intubation in the elderly
272 CHAPTER 18
are the same as those for younger adults. Suc- be on stand-by, and the alternative intu-
cessful awake intubation requires skill and bation device (e.g., LMA Fastrach) with
appropriate patient selection. While an awake which the clinician is most familiar should
approach avoids the hemodynamic conse- be sized and prepared for use. A rescue
quences of induction agents, the unabated pres- oxygenation device, such as a Combitube
sor response to laryngoscopy and intubation or other EGD should also be chosen and
also has the potential to cause harm in certain sized before proceeding with an RSI.
patients. Execution of the RSI procedure does
require modification. B. RSI in the elderly: the procedure
• RSI in the elderly requires a light touch.
A. Preparation for RSI in the elderly The goal throughout the intubation
• Airway assessment: Recognition of the process is to maintain an unchanged
age-related anatomic challenges previ- pulse and BP, while maintaining adequate
ously presented requires preparation oxygenation and ventilation.
for both difficult BMV and difficult laryn- • Because of its hemodynamic stability,
goscopy. etomidate is an attractive choice for RSI
• Equipment should be prepared. The in the elderly. However, as previously
edentulous patient will require a face mask discussed, etomidate will cause adrenal
one or two sizes smaller. A bougie should suppression. Although the clinical signif-
be within reach for use as an adjunct to icance of this effect is unclear, in general,
direct laryngoscopy. etomidate should be avoided in the septic
• Intravenous access and cautious patient when an appropriate alternative
volume loading with 10–20 mL/kg of agent is available. Propofol often pro-
crystalloid is still appropriate, in an duces hypotension, especially if doses
attempt to mitigate the hypotensive effect are not appropriately adjusted downward
of RSI drugs. for the elderly, while the sympathetic
• Preoxygenation should occur, including stimulation caused by ketamine may pro-
assisted BMV, if needed to raise the SaO2. duce unwanted hypertension and tachy-
The conservative use of oxygen for fear cardia. The mixture of propofol and
of adversely affecting the “hypoxic ketamine (widely used off-label in pedi-
drive to breathe” in the COPD patient is atrics) may be of value in the elderly, but
not appropriate in the preintubation published experience is limited.
phase. • It is critical to remain aware of vital signs
• Drug doses for RSI sedative/hypnotics throughout the RSI sequence—this can
should be adjusted downward for the be difficult. Prolonged efforts at intuba-
elderly patient, often by 50% or more. Mus- tion, with attendant vital sign changes,
cle relaxant doses do not require adjust- must be avoided. The laryngoscopist
ment. Pressor drugs such as ephedrine or should abandon the intubation attempt
phenylephrine should always be drawn up before the patient becomes hypoxemic,
for use in maintaining the BP close to the hypercarbic, tachycardic, or hypo- or
patient’s baseline. It is probably better to hypertensive.
err on the side of hypertension, although
tachycardia and profound elevation of BP C. Failed intubation in the elderly
should be avoided. • Again, persistent laryngoscopy is haz-
• Adjuncts, alternative intubation, and ardous to the patient: reoxygenation
rescue devices. The airway cart should should precede any further attempts.
• An alternative intubation technique should 2. Morrison JE, Jr., Collier E, Friesen RH, et al. Pre-
be considered, if “best look” laryngoscopy oxygenation before laryngoscopy in children: how
and the use of an adjunct such as a bougie long is enough? Paediatr. Anaesth. 1998;8(4):
or fiberoptic stylet has failed. A change to 293–298.
3. Meretoja OA, Bissonnette B, Dalens B. Muscle
a longer, or differently shaped (e.g.,
relaxants in Children in Pediatric Anesthesia:
straight or levering tip) blade may be of
Principles and Practice. New York: McGraw-Hill
use in selected patients. Alternative 2002.
device use should consider operator 4. Zelicof-Paul A, Smith-Lockridge A, Schnadower D,
experience and the likelihood of success. et al. Controversies in rapid sequence intubation
It may be more appropriate to temporize in children. Curr. Opin. Pediatr. 2005;17(3):
by proceeding to a rescue EGD in lieu of 355–362.
using an unfamiliar alternative technique, 5. 2005 AHA Guidelines for CPR and ECC. Part 12.
when “best look” laryngoscopy has failed Pediatric Advanced Life Support. Circulation.
after two or three attempts. 2005;112(24 Supplement):167–187.
6. Moynihan RJ, Brock-Utne JG, Archer JH, et al. The
effect of cricoid pressure on preventing gastric
D. Postintubation care in the elderly
insufflation in infants and children. Anesthesiology.
• Successful airway management should
1993;78(4):652–656.
not detract from the recognition that even 7. Goldmann K. Recent developments in airway man-
with a secured airway, the elderly patient agement of the paediatric patient. Curr. Opin.
remains fragile and prone to cerebrovas- Anaesthesiol. 2006;19(3):278–284.
cular and cardiac catastrophe. Airway 8. O’Donnell CP, Kamlin CO, Davis PG, et al. Endo-
management is only the first step in pro- tracheal intubation attempts during neonatal resus-
viding the critically ill elderly patient an citation: success rates, duration, and adverse effects.
opportunity to return to meaningful life. Pediatrics. 2006;117(1):e16–e21.
The aging heart, brain, and kidney need 9. Pfitzner L, Cooper MG, Ho D. The Shikani Seeing
optimal oxygenation and perfusion if Stylet for difficult intubation in children: initial
experience. Anaesth Intensive Care. 2002;30(4):
they are to survive.
462–466.
10. Shukry M, Hanson RD, Koveleskie JR, et al. Man-
agement of the difficult pediatric airway with
䉴 SUMMARY Shikani Optical Stylet. Paediatr. Anaesth.
2005;15(4):342–345.
Most aspects of airway management at the 11. Fisher QA, Tunkel DE. Lightwand intubation of
extremes of life are similar to those needed for infants and children. J. Clin. Anesth. 1997;9(4):
the older child and non-elderly adult. How- 275–279.
12. Bortone L, Ingelmo PM, De Ninno G, et al.
ever, the clinician must be cognizant of the
Randomized controlled trial comparing the
anatomic and physiologic differences which
laryngeal tube and the laryngeal mask in
may be encountered, with the resultant need pediatric patients. Paediatr. Anaesth. 2006;16(3):
to prepare for difficulty and adjust drug dosing 251–257.
appropriately. 13. Grein AJ, Weiner GM. Laryngeal mask airway
versus bag–mask ventilation or endotracheal
intubation for neonatal resuscitation. Cochrane.
Database. Syst. Rev. 2005(2):CD003314.
REFERENCES
14. Fudickar A, Bein B, Tonner PH. Propofol infusion
1. Patel R, Lenczyk M, Hannallah RS, et al. Age and syndrome in anaesthesia and intensive care
the onset of desaturation in apnoeic children. Can. medicine. Curr Opin Anaesthesiol. 2006;19(4):
J. Anaesth. 1994;41(9):771–774. 404–410.
274 CHAPTER 18
15. Iserson KV. Withholding and withdrawing medical 17. John AD, Sieber FE. Age associated issues: geri-
treatment: an emergency medicine perspective. atrics. Anesthesiol. Clin. North America. 2004;22(1):
Ann. Emerg. Med. 1996;28(1):51–54. 45–58.
16. Birnbaumer D, Marx JA, Hockberger RS, et al. The 18. Burton DA, Nicholson G, Hall GM. Anaesthesia in
Elder Patient. Rosen’s Emergency Medicine: Con- elderly patients with neurodegenerative disorders:
cepts and Clinical Practice. Vol 5th: CV Mosby; special considerations. Drugs Aging. 2004;21(4):
2002:2485. 229–242.
Chapter 19
Prehospital Airway
Management Considerations
䉴 GENERAL CONSIDERATIONS criteria, and not limited by departmental or

discipline-related turf battles.
Emergency airway management should be Prehospital care of the patient in case 19-1
performed by a skilled clinician. In this book, will include the following:
the term “clinician” has included both physi-
• Ensuring scene safety.
cian and nonphysician health-care providers.
• Attention to oxygenation, ventilation, and
Depending on the setting, paramedics, nurse
blood pressure.
practitioners, and respiratory technicians may
• Recognizing the potential for cervical spine
be expected to independently manage patients
injury, and taking appropriate precautions.
with acute airway emergencies. As long as they
• Being ready for the unexpected, such as vom-
possess the appropriate knowledge base and
iting or seizure.
procedural skills, this is entirely appropriate.
• Ruling out reversible causes of coma, such as
The practice of airway management should be
hypoglycemia or drug toxicity.
defined by educational and competency-based
• Making decisions about appropriate on-scene
interventions prior to transport.
Without doubt, airway management skills

䉴 Case 19.1 are necessary in the prehospital setting, with
A 20-year-old male was ejected as the result early support of oxygenation and ventilation
of a high-speed rollover motor vehicle crash for the acutely ill. However, whether this is
(MVC), on a rural highway. When the para- achieved by bag-mask ventilation (BMV) or tra-
medics arrived on the scene, they were faced cheal intubation depends on a number of fac-
with a hypotensive patient who was breathing tors, including, most immediately, anticipated
spontaneously, but with a Glasgow Coma time and type of transport. Local Emergency
Scale (GCS) of 8, and a clenched jaw. The Medical Services (EMS) jurisdictions may also
crew had given a “ten minute head’s up” have established algorithms or protocols.
prior to their arrival at the local emergency The general approach to airway management
department. At that time, they reported vital in the prehospital environment should follow
signs of BP 90/75, HR 100, RR 20, and SaO2 the same principles already espoused in this
98% on a nonrebreathing face mask. text. Appropriate airway management decisions
require consideration of:
275
276 CHAPTER 19
• Clinician factors (knowledge base, psychomotor designing protocols for prehospital airway
skills, equipment, and the availability of trained management providers. Pragmatically, North
assistants). American standards of prehospital care often
• Higher acuity (obtain/maintain an airway, include a higher level of cognitive and skills
and/or correction of gas exchange) versus training in airway management if the providers
lower acuity (airway protection and/or pre- work in an air ambulance program, or as part
dicted clinical deterioration) indications for of a dedicated ground-based critical care trans-
tracheal intubation. port team.
• Patient assessment (anatomy, physiology,
cooperation, and time).
䉴 PREHOSPITAL INDICATIONS FOR
ADVANCED AIRWAY
MANAGEMENT
䉴 CLINICIAN FACTORS
“Advanced” airway management in the context
Prehospital care providers with acute airway of prehospital practice refers primarily to tracheal
management responsibilities should have a cog- intubation. However, in some EMS settings,
nitive level of understanding comparable to that advanced airway management involves the use
of clinicians staffing the emergency department of an extraglottic device (EGD) such as the
(ED). They must understand the indications and Combitube or Laryngeal Mask Airway (LMA). In
contraindications for advanced airway manage- general, however, the indications for tracheal
ment, including tracheal intubation. Providers intubation are as previously discussed in this
should be comfortable in performing an airway text: to obtain or maintain an airway; correct
assessment and predicting difficulty. They gas exchange, protect the airway against aspi-
should be able to choose a safe and effective ration of gastric contents, or for predicted clinical
method to manage the patient’s airway, have deterioration. However, it is important to under-
the procedural skills to competently perform it, stand that each of these indications represents a
and have an approach to difficult situations. very different scenario. The high acuity, apneic
The education of prehospital providers must (e.g., cardiac arrest) patient requires an imme-
also be realistic and should reflect their practice diate, “crash” airway. A patient hypoxic from
mandate. For example, knowledge of rapid- respiratory failure due to congestive heart
sequence intubation (RSI) drug pharmacology failure (CHF) may also be higher acuity and
should be included only if it is within their scope require tracheal intubation, but can often be
of practice. Their procedural skill set will be safely temporized during transport. A head
similarly guided. In an ideal world, training injured patient with a GCS of 8 and an SaO2
objectives for attaining and maintaining proce- of 98% may well require intubation for airway
dural skills in BMV or endotracheal intubation protection, but with less urgency for the interven-
would be identical for all individuals, regardless tion. Predicted clinical deterioration is a similarly
of their professional designation. In practice, lower acuity indication for intubation.
for the prehospital provider, the logistics of
attaining and maintaining these competencies
are often difficult, with the practical pressures 䉴 PATIENT ASSESSMENT
of equipment availability, cost, and the sheer
volume of trainees posing a problem. Medical The three components of patient assessment
directors must understand these limitations discussed in Chap. 11—that is, airway anatomy,
when designing educational and continuous system physiology, and patient cooperation are
quality improvement (CQI) programs, or when very relevant to the prehospital provider.
PREHOSPITAL AIRWAY MANAGEMENT CONSIDERATIONS 277
However, a fourth variable must be emphasized equate to tracheal intubation. In other words,
in the assessment of the patient in a prehospital the technical imperative of “getting the tube”
setting, and this is time. Simply put, when is it should not overshadow the outcome impera-
better to attempt definitive airway management tive of maintaining adequate gas exchange.
on the scene, and when is it better to wait?
• The patient described in Case 19–1 clearly 䉴 CHOOSING A METHOD OF

represents a critically ill, head-injured TRACHEAL INTUBATION
trauma patient who is hemodynamically
compromised. In general, the choices to facilitate tracheal intu-
• He will be immobilized in a cervical collar bation (RSI; non-RSI [i.e., “awake” or deep seda-
and has clenched teeth, which may make tion] and 1º surgical) in the prehospital setting
direct laryngoscopy difficult. Conversely, his are similar to those used in-hospital. Realisti-
patent airway and stable SaO2 create a lower cally, most ground EMS systems are limited by
acuity need for immediate tracheal intuba- training and maintenance of competence issues
tion. to non-RSI intubation choices and/or EGDs such
• If this patient is relatively close to the trauma as the LMA or Combitube.1 Non-RSI choices for
center, then it may be advisable to transport tracheal intubation span the spectrum from truly
while monitoring the patient’s spontaneous “awake” to an intubation facilitated by deep
ventilations and oxygenation status. sedation. The dangers of deep sedation to facil-
• If transport with assisted BMV is required, itate intubation are just as relevant in the pre-
attention to good technique is important, to hospital arena as they are in-hospital. In fact,
avoid gastric insufflation. Otherwise, regur- the use of sedative agents to facilitate airway
gitation could occur, potentially leading to management in the prehospital setting parallels
aspiration and a difficult mask ventilation the history of their use in the ED. Rightly or
scenario. wrongly in the prehospital arena, familiarity with
• In contrast, if the same patient did not have using drugs such as diazepam and morphine in
clenched teeth, had marginal oxygen satu- the context of symptom relief has allowed for a
ration (SaO2<90%) despite assisted BMV, gradual acceptance of their use to facilitate intu-
and was 40 minutes from a trauma center, bation using deep sedation.
then an intubation attempt could be con- Cardiac arrest is the clinical context for up
sidered, if provider skills and protocols to two-thirds of all tracheal intubations in a typ-
allowed. ical ground EMS system.2 For these patients,
there is generally no requirement for pharma-
In either scenario, both “airway protection” cologic adjuncts to facilitate intubation. The
and “predicted clinical deterioration” are legiti- remainder of the EMS patient cohort requiring
mate but lower acuity indications for intubation. airway management tends to be evenly split
However, the chosen approach in the prehos- among respiratory failure, nontraumatic central
pital setting will also be based on the added nervous system (CNS) conditions, trauma, and
issue of transport time. A short transport time, shock states. In general, helicopter Emergency
combined with a predicted difficult airway and Medical Services (HEMS) operations do not
a lower acuity indication for intubation, favors respond to primary cardiac arrest victims and,
skillful BMV en route to the ED, where defini- therefore, deal with a patient population of sim-
tive airway management can occur. Training of ilar complexity to that in the ED. With this
prehospital personnel must thus emphasize that clearly different patient population, and more
optimal airway management does not always manageable provider numbers, educational
278 CHAPTER 19
1.Intubation Patient assessment:

2.Extraglottic Cardiac Airway anatomy and physiology
device arrest transport time
3.BMV
Noncardiac
arrest
No difficulty expected Difficulty expected
Long transport Short transport Long transport Short transport
1. ETI 1. BMV 1. ETI

BMV
2. BMV 2. ETI 2. BMV
Figure 19–1. Approach to airway management for prehospital ground systems.
support is more feasible, which in turn has of competence programs (addressing both
allowed many HEMS programs to introduce RSI cognitive and procedural skills components) for
as a safe management option for use by their prehospital providers, with particular attention
crews. to the avoidance of transient hypoxia and/or
The evidence in the EMS literature supporting hyperventilation.14–16
the use of RSI is scant,3,4 save for some very specific Given this evidence, a well-prepared HEMS
circumstances. For ground EMS systems, several program could use an approach to tracheal intu-
well-conducted studies have consistently shown bation algorithm similar to that previously
worsened, or insignificant differences in out- presented (see Chap.11, Fig. 11–3) in this text.
come in traumatic brain injury patients when However, a prehospital ground system not using
prehospital RSI is used to facilitate endotracheal RSI may require a different approach, as shown
intubation.5–8 Head injury was deliberately in Fig. 19–1.
chosen in these studies, as previous studies had
suggested that optimal and timely oxygenation
of these patients improved outcomes.9 However, 䉴 EQUIPMENT OPTIONS AND THE
despite the lack of efficacy of RSI demonstrated DIFFICULT AIRWAY
in ground-based EMS systems, a distinct pattern
of improved outcomes has in fact emerged in The procedural skills required for successful
the subpopulation of those patients where air BMV and laryngoscopy and intubation are the
medical transport had been utilized.8,10–13 It same for all providers. However, the environmental
would thus appear that the key to improved context of the prehospital setting adds an addi-
outcomes lies in the initial training and maintenance tional layer of complexity to airway management.
Issues of lighting, weather, scene safety and • Alternative intubating devices: the LMA Fas-
location, and the presence of distraught family trach is simple and may provide a reasonable
members often create unique challenges to the prehospital option;18 the Trachlight is a less real-
prehospital care provider. istic option because of skill maintenance issues
Direct laryngoscopy (DL) remains the most and the inability to control environmental light-
appropriate approach to tracheal intubation in ing. Fiberoptic- or video-based devices may be
the prehospital setting, despite its significant useful, but, especially for ground EMS systems,
learning curve. Unlike the blind or indirect visu- cost often precludes outfitting of entire fleets.
alization intubation techniques, DL retains the • Rescue oxygenation devices: the Com-
advantage of enabling the provider to assess the bitube has a long track record in prehospital
oral cavity for presence of foreign material during care, used as a rescue oxygenation device19
the intubation attempt. or as a primary airway, especially in the set-
The approach to the difficult airway in the ting of cardiac arrest.20 An LMA can also be
prehospital setting is similar to that previously used as a primary or rescue device in this
outlined in this text. Difficult tracheal intuba- setting.20,21 Newer EGDs such as the King
tion, once encountered, requires an approach LTS-D and the LMA ProSeal and Supreme
that employs first attempt “best look” laryn- look promising for the prehospital setting
goscopy, including the use of external laryngeal due to their esophageal drainage tubes and
manipulation (ELM) and a bougie. A change in design features enabling higher ventilating
the blade type or length may be useful depending pressures, if needed. However, scientific val-
on the encountered problem. The benefit of idation of their use in the field is still required.
repeated attempts at intubation should always • Surgical airway: many EMS systems now
be weighed against the risk of prolonging the stock needle-guided percutaneous cricothy-
scene time. The advisability of proceeding to an rotomy devices (e.g., the Melker or the Portex
alternative intubation device such as the LMA PCK), which are relatively simple to use.22
Fastrach if laryngoscopic intubation fails is less
clear in the prehospital setting. Indeed, failed Finally, confirmation of correct endotracheal
intubation in this context might be defined by tube (ETT) placement, initially and continu-
two unsuccessful attempts (as opposed to three) ously, is vitally important in the chaotic prehos-
and would usually mean reverting to BMV or an pital environment, as the consequences of an
EGD such as the Combitube or LMA. A falling unrecognized misplaced endotracheal tube are
oxygen saturation after an initial attempt at always devastating. The exact number of unrec-
laryngoscopy should preclude further attempts ognized esophageal intubations in the prehos-
at intubation until the patient’s oxygenation has pital setting is uncertain, as many EMS systems
been corrected by BMV, EGD or ultimately, do not systematically gather this data. Very low
cricothyrotomy. rates are found in systems with specific tube
For the paramedic, although the principles verification protocols, including end-tidal CO2
of airway management are the same, the spec- (ETCO2) monitoring, and ongoing quality
trum of available equipment may not be as wide. improvement programs to ensure compliance.23
However, prehospital systems considering Conversely, unacceptably high rates of esophageal
an RSI program should have several difficult intubation are found when no such protocols
airway devices available: are in place.24
Prehospital care providers can objectively
• The bougie is simple, inexpensive, and confirm correct placement of the ETT in the
proven in the prehospital arena;17 blade same ways previously discussed in this text:
change options should also be available. by visualization of tube going between cords;
280 CHAPTER 19
use of an ETCO2 detector and/or by using a in patients with severe traumatic brain injury.
mechanical esophageal detector device (EDD). J. Trauma. 2003;54(3):444–453.
ETCO2 verification of correct ETT placement 7. Dunford JV, Davis DP, Ochs M, et al. Incidence of
has become the standard of care in the EMS transient hypoxia and pulse rate reactivity during
paramedic rapid sequence intubation. Ann. Emerg.
arena.25 The limitations of each of these tech-
Med. 2003;42(6):721–728.
niques have been previously discussed.
8. Wang HE, Peitzman AB, Cassidy LD, et al. Out-of-
hospital endotracheal intubation and outcome after
traumatic brain injury. Ann. Emerg. Med. 2004;44(5):
䉴 SUMMARY 439–450.
9. Chesnut RM, Marshall LF, Klauber MR, et al. The
role of secondary brain injury in determining out-
Despite the provider’s quiet sigh of relief fol-
come from severe head injury. J. Trauma. 1993;34(2):
lowing ETCO2 detection, it is what has hap-
216–222.
pened up to the point of successful tracheal 10. Ma OJ, Atchley RB, Hatley T, et al. Intubation suc-
intubation that will determine patient outcome. cess rates improve for an air medical program after
Tracheal intubation alone will almost never save implementing the use of neuromuscular blocking
a life, unless it has been done without further agents. Am. J. Emerg. Med. 1998;16(2):125–127.
compromising the patient’s condition. Irrespec- 11. Murphy-Macabobby M, Marshall WJ, Schneider C,
tive of the setting in which airway management et al. Neuromuscular blockade in aeromedical air-
occurs, attention must be directed throughout way management. Ann. Emerg. Med. 1992;21(6):
towards the basics of maintaining oxygenation, 664–668.
ventilation and perfusion. 12. Sing RF, Rotondo MF, Zonies DH, et al. Rapid
sequence induction for intubation by an aeromedical
transport team: a critical analysis. Am. J. Emerg. Med.
1998;16(6):598–602.
REFERENCES
13. Slater EA, Weiss SJ, Ernst AA, et al. Preflight versus
1. Wang HE, Davis DP, Wayne MA, et al. Prehospital en route success and complications of rapid
rapid-sequence intubation—what does the evi- sequence intubation in an air medical service.
dence show? Proceedings from the 2004 National J. Trauma. 1998;45(3):588–592.
Association of EMS Physicians annual meeting. Pre- 14. Davis DP, Douglas DJ, Koenig W, et al. Hyperven-
hosp. Emerg. Care. 2004;8(4):366–377. tilation following aero-medical rapid sequence
2. Wang HE, Kupas DF, Paris PM, et al. Preliminary intubation may be a deliberate response to hypox-
experience with a prospective, multi-centered emia. Resuscitation. 2007;73(3):354–361.
evaluation of out-of-hospital endotracheal intuba- 15. Davis DP, Stern J, Sise MJ, et al. A follow-up analy-
tion. Resuscitation. 2003;58(1): 49–58. sis of factors associated with head-injury mortal-
3. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of ity after paramedic rapid sequence intubation. J
out-of-hospital pediatric endotracheal intubation Trauma. 2005;59(2):486–490.
on survival and neurological outcome: a controlled 16. Davis DP, Fakhry SM, Wang HE, et al. Paramedic
clinical trial. JAMA. 2000;283(6):783–790. rapid sequence intubation for severe traumatic
4. Wang HE, Yealy DM. Out-of-hospital rapid sequence brain injury: perspectives from an expert panel.
intubation: is this really the “success” we envisioned? Prehosp Emerg Care. 2007;11(1):1–8.
Ann. Emerg. Med. 2002;40(2):168–171. 17. Phelan MP, Moscati R, D’Aprix T, et al. Paramedic
5. Bochicchio GV, Ilahi O, Joshi M, et al. Endotra- use of the endotracheal tube introducer in a
cheal intubation in the field does not improve out- difficult airway model. Prehosp. Emerg. Care.
come in trauma patients who present without an 2003;7(2):244–246.
acutely lethal traumatic brain injury. J. Trauma. 18. Swanson ER, Fosnocht DE, Matthews K, et al. Com-
2003;54(2):307–311. parison of the intubating laryngeal mask airway
6. Davis DP, Hoyt DB, Ochs M, et al. The effect of versus laryngoscopy in the Bell 206–L3 EMS heli-
paramedic rapid sequence intubation on outcome copter. Air Med. J. 2004;23(1):36–39.
19. Davis DP, Valentine C, Ochs M, et al. The Com- and surgical cricothyrotomy by prehospital
bitube as a salvage airway device for paramedic personnel. Prehosp. Emerg. Care. 2004;8(4):
rapid sequence intubation. Ann. Emerg. Med. 424–426.
2003;42(5):697–704. 23. Bozeman WP, Hexter D, Liang HK, et al.
20. Rumball CJ, MacDonald D. The PTL, Combitube, Esophageal detector device versus detection of
laryngeal mask, and oral airway: a randomized pre- end-tidal carbon dioxide level in emergency intu-
hospital comparative study of ventilatory device bation. Ann. Emerg. Med. 1996;27(5):595–599.
effectiveness and cost-effectiveness in 470 cases of 24. Katz SH, Falk JL. Misplaced endotracheal tubes
cardiorespiratory arrest. Prehosp. Emerg. Care. by paramedics in an urban emergency medical
1997;1(1):1–10. services system. Ann. Emerg. Med. 2001;37(1):32–37.
21. Hulme J, Perkins GD. Critically injured patients, 25. O’Connor RE, Swor RA. Verification of endotracheal
inaccessible airways, and laryngeal mask airways. tube placement following intubation. National
Emerg. Med. J. 2005;22(10):742–744. Association of EMS Physicians Standards and Clinical
22. Keane MF, Brinsfield KH, Dyer KS, et al. A labo- Practice Committee. Prehosp. Emerg. Care. 1999;
ratory comparison of emergency percutaneous 3(3):248–250.
Chapter 20
Human Factors in Airway
Management
䉴 INTRODUCTION TO HUMAN to define the learning curve for the procedure.2

FACTORS Interestingly, the group who had performed only
five intubations perceived themselves as most
∗
From a patient safety standpoint, airway man- competent in the skill. Presumably, their limited
agement is a key determinant of patient out- exposure had not provided them the opportu-
come. In this book, the emphasis has inevitably nity to encounter difficulty and fully engage the
fallen on two main areas: procedural skills, and three principal domains of human performance:
the knowledge required to safely secure psychomotor, cognitive, and affective.3
an airway. Prepared with a comprehensive
knowledge of anatomy, physiology, equipment
options, and pharmacology, tracheal intubation 䉴 PSYCHOMOTOR PERFORMANCE
proceeds as a complex integration of visual,
motor, and haptic (i.e., touch feedback) skills. Historically, the maxim of skills acquisition in
For the patient, a successful intubation will medicine has been “see one, do one, and teach
be one during which the clinician has avoided one,”1 often on compromised and vulnerable
significant error. However, for the clinician patients. The shortcomings of this approach
(as long as it is recognized), error is a necessary are immediately obvious, and include adverse
component of learning any procedure.1 Failure effects on patient safety. In an attempt to address
and adversity have the potential to make behavior this problem, training using human patient simu-
more robust and adaptive. Indeed, recognizing lators is becoming increasingly common. Indeed,
that errorless practice is an unrealistic goal, the most trainees in airway management techniques
term “quality assurance” has been replaced by will begin their skills acquisition on a manikin
“continuous quality improvement” (CQI). or airway simulator of some sort.
In an unpublished study, investigators queried Unfortunately, psychomotor skills transfer
novice paramedics on their self-perceived com- from simulator to human is hampered by issues
petence in laryngoscopic intubation. The para- of tissue fidelity. Although simulators may be
medics had performed 5, 10, or 20 tracheal anatomically correct, their “tissues” don’t respond
intubations as part of another study seeking to manipulation in the same way human tissue
does. Thus, while psychomotor skills acquisition
in airway management can begin in the simula-
*Personal communication, Orlando Hung, 2006 tion environment, it must then be augmented
283
284 CHAPTER 20
and reinforced in real patients. This in turn pre- “System 1” reasoning will typically impel the
sents logistical (where and when to get the expe- decision maker reflexively toward what is famil-
rience) and ethical (whether elective surgical iar and comfortable; it is the rapid cognitive style
patients should bear the brunt of such training) described in the book Blink as “thinking without
dilemmas. Going forward, there is a signifi- thinking.”9 It is often algorithmic in nature and
cant need for training programs using airway may be achieved through deliberate prepara-
management simulators4 of increased fidelity, tion and rehearsal, in a specific attempt to
coupled with multimedia presentations5 and achieve a stage of “reflexive responsiveness.”
expert instructors. Thus, faced with a Cormack-Lehane Grade 3 view,
Having said this, good psychomotor skills the clinician might “automatically” perform a
may not necessarily translate to improved head lift (if not contraindicated), external laryn-
patient outcomes. Although success in airway geal manipulation (ELM) or reach for a bougie.
management has historically been measured by However, without rehearsal and preprogram-
whether “they got the tube,” the occurrence of ming, this “System 1” type of response may not
process-related adverse events, such as hypoten- be cognitively accessible during times of stress,
sion, hypoxia, or aspiration, are much more and the clinician may simply revert to a lower
likely to influence patient outcome. Fortunately, pattern of untrained behavior: repeated attempts
simulation can also provide a valuable venue at direct laryngoscopy.
for improving cognitive decision making and In contrast, stepping back from the immediate
addressing contextual issues. pull of the situation to reflect on the wider pic-
ture, engage in more analytical thinking, and
consider less obvious consequents is reflective
of “System 2,” and when there is greater uncer-
䉴 COGNITIVE PERFORMANCE
tainty, or less predictability, this might be the
preferred course. 10 Why did head lift, ELM
Spinal reflexes in a transected cord apart, no
and the bougie fail? Was it a problem with
behavioral act can be performed without cognitive
managing the tongue? Would a blade change
input from the brain. The cognitive components
required during the acquisition of procedural skills
are those needed for basic learning processes:
intelligence, alertness, attention, and concentra-
tion. However, once the skills have been
䉴 Case 20.1
acquired and are being maintained, a second Consider a complex patient with a head
cognitive imperative comes into play—that asso- injury and a Glasgow Coma Score of 8, in a
ciated with clinical decision-making. These skills community emergency department. The
are vital in deciding when (or when not) to apply patient was obese, immobilized on a spine
specific airway management strategies. Good board and had significant facial injuries. He
decision-making embraces all aspects of the clin- was hemodynamically stable, with an oxy-
ical milieu, and involves reasoning that mini- gen saturation of 97%. Prior to transfer, the
mizes the potential for harm to the patient.6 The attending physician had spoken to a resi-
mode of clinical reasoning is important: it may dent at the referral trauma center and had
be intuitive, rapid, heuristic, and recognition been advised to intubate the patient. The
primed (“System 1”); or more analytical, delib- attending clinician was a family physician,
erate, reasoned, and deductive (“System 2”).7 working alone, whose last tracheal intuba-
Sometimes, the situation might call for a blend of tion had been performed during a cardiac
the two. It is important to be aware of the arrest over a year previously.
strengths and limitations of each mode.8
HUMAN FACTORS IN AIRWAY MANAGEMENT 285
be helpful? System 2 decision-making may still Simulation training has the potential to
involve reference to an algorithm or decision- remove the negative impact of the affective
tree, but is less prescribed, requires some degree state from the learning process. Some per-
of reflection, and the greater use of judgment. formance anxiety may still occur in a peer-
Obtaining a colleague for help in a difficult sit- observed situation, or when learning is
uation will allow the primary clinician to emo- being evaluated, but for the most part the
tionally and physically “step back” and engage undesirable anxieties of learning on a real
in this type of thought process. patient have been neutralized. The implied
“System 1” thinking (“Glasgow 8, intubate”) “permission to fail” enables learning to pro-
applied to Case 20-1 would not take into account ceed under more optimal conditions.
the complexities of the decisions at hand. More • Clinical Performance. The intrinsic contri-
analytical consideration of the risk/benefit ratio bution of the affective state to the execution
of a relatively inexperienced clinician managing of a psychomotor skill is reflected in the
this patient’s potentially difficult airway, with no Yerkes-Dodson law, which describes the
back-up, represents a “System 2” process. inverted-U relationship between level of
Similar considerations apply widely. Being arousal and performance.12 Arousal is a phys-
trained to perform a complex act is not an indi- iological and psychological state in which
cation to proceed with it, simply because the emotion is crucial. It raises the level of alert-
opportunity has arisen. In the interest of patient ness and readiness to act, although too little
safety, the benefit of the intervention should or too much can adversely affect performance
always outweigh the risk of proceeding. Some- (Fig. 20–1). The corollary of the law is that
times, there is great virtue in reflection, and there must exist an optimal level of arousal
recognition of when not to do something: for any given task.
therein lies the stuff of clinical acumen. In the real-life situation, clinician anxiety
may result in excessive arousal and com-
promised performance. For example, during
a rapid-sequence intubation (RSI), a pro-
䉴 AFFECTIVE PERFORMANCE gressively dropping oxygen saturation that
is audibly broadcast to all resuscitation team
The affective state of a clinician refers to his or
her internal emotional milieu. Rarely are we in
an affect-neutral state—usually there is a greater
or lesser degree of ongoing confidence, energy,
positivity, hesitation, fear, anger, and negativity.
Performance
The affective state is highly relevant to both

learning, and subsequent performance in the
clinical arena.
• Learning. Learning can no sooner proceed
without an appropriate affective state than
it could without cognition. With a negative
affect (e.g., that caused by excessive anxi-
ety), or without the desire and motivation Low Medium High
to learn, the learning process is clearly Arousal
impoverished and will be adversely
Figure 20–1. The Yerkes-Dodson law. The
impacted. Thus, emotional and cognitive relationship between level of arousal and per-
processes are inextricably related.11 formance.12
286 CHAPTER 20
members by a well-meaning helper may • Obtaining, opening, and lubricating equip-

contribute to clinician anxiety, and com- ment needed unexpectedly, for example, a
promise performance. At its worst, “paral- smaller tube for an encountered subglottic
ysis” of cognition and action can occur. In stenosis.
contrast, it is well recognized that a second • Changing bags of intravenous (IV) fluid.
clinician of equal skills or experience, • Making phones calls for help, if needed.
summoned for help, will often success-
fully intubate a patient within seconds of A second assistant should be obtained for
arriving, after an anxious primary clini- the patient with an anticipated difficult airway,
cian had failed. Not being emotionally specifically for the purpose of contributing to a
invested in the situation empowers the two-person bag-mask ventilation (BMV) tech-
second clinician to optimally perform a nique. The original helper will still be needed
basic technique! Other strategies to help for all of the foregoing needs.
allay clinician anxiety are presented in the Less obvious to some clinicians is the
following sections. need for the presence of a qualified colleague
for cognitive and moral support, espe-
cially if difficulty is anticipated. In particular,
䉴 HUMAN FACTORS: TIPS AND the colleague can provide one or more of the
PEARLS following:
A number of human factors tactics found useful • Being a “sounding board” off whom to
over the years by the authors are presented bounce the plan for intubation, and any con-
below. Although little scientific validation exists cerns about anticipated difficulty.
for these tips, most are simply common sense! • Being a very knowledgeable helper who will
know without explanation what is wanted or
needed by the primary clinician.
The Importance of Helpers • Ensuring a confident and supportive envi-
ronment. This is vitally important, and is one
The clinician undertaking airway management strategy that can be used to allay potentially
needs at least one helper. The helper may be counterproductive anxiety. The presence of
needed for a gamut of facilitating activity: a colleague allows the primary clinician to
in effect “offload” some anxiety onto that
• Drawing up, and possibly administering individual.
drugs. • Facilitating the opportunity for “System 2”
• Application of cricoid pressure. reflection.
• Application of external laryngeal manipula- • As an individual less emotionally invested
tion (ELM). in, and thus less anxious about the situation,
• Maintaining a head lift with a hand under the the colleague may be in a better position to
patient’s head, if the view of the larynx was make suggestions and optimally perform
initially obtained by the primary clinician skills.
using a head lift.
• Handing the clinician the ETT in the correct For many clinicians, a colleague may not
orientation, so that direct visual contact with the always be available. However, in the difficult
laryngeal inlet can be maintained, once seen. situation, the importance of the presence of
• Loading a tube over a bougie, then stabilizing qualified help is such that it is worth “thinking
the proximal end of the bougie as the clinician outside the box” for where such help could be
passes the tube. obtained—even calling in a colleague from home.
Even if patient acuity demands proceeding with • Team Briefing. Before proceeding, a verbal
a tracheal intubation before the colleague has briefing of the assembled helpers about the
arrived, simply knowing that help is on the way planned intubation and the transition to
may contribute to relieving anxiety. alternative intubation and rescue oxygena-
A corollary to the foregoing is the need for tion devices can be useful, thus: “O.K., folks,
willingness, empathy and enthusiasm on the we’re doing an RSI (rapid-sequence intuba-
part of those who are called for help. Frequently, tion) here. If I get in there and have trou-
it is only the experienced clinician who can “say ble seeing where I’m going, I’m going to
it like it is” (e.g., “I think I have a tough one need the bougie, which is sitting right here
here—he looks really scary, and I could use a on the patient’s chest. If that doesn’t work,
hand, as soon as you can get here”). Even having I’m going to back out and bag-mask venti-
initiated the call, some clinicians still hesitate to late the patient. If I have trouble with that,
directly request help (e.g., “I’m just calling to I’ll tell you, [Joan], to ease up on the cricoid
give you a “heads-up” that I may need you if pressure, and if that doesn’t help, I’ll pro-
this one turns out to be tough. . .”). When receiv- ceed to a two-person technique, with you,
ing such a call, one should always read between [Bob], squeezing the bag. For a second
the lines—for most clinicians, just initiating the attempt after that, I’m to going use a longer
call means, “please come now,” regardless of blade. If that doesn’t do it, for the third
what’s actually said! attempt I’m going to use the Fastrach LMA,
which is the thing with the metal handle
right here. The Fastrach tube is over there,
The “Visual Roadmap” in a bottle of warm water. If for whatever
reason the patient still isn’t intubated after
Particularly for the patient in whom difficulty is that third attempt, we’re going to call a halt,
anticipated, although the clinician will have ventilate through the Fastrach, and re-think
thought through the approach being planned, things.”
these additional preparations will also help: Apart from the obvious benefit of letting the
team know what to expect, the verbal briefing
• Laying out a “visual roadmap” for the is even more beneficial for the primary clini-
anticipated difficult situation. Equipment cian, as it helps solidify the plan in his or her
should be prepared for both the initial mind; and more importantly, it ensures that a
attempt at tracheal intubation (including the plan really exists!
bougie!), as well as the chosen alternative
intubation method (e.g., an LMA Fastrach,
optical stylet, or videolaryngoscope) and Handling Anxiety During the Event
rescue EGD such as an LMA or Combitube.
These devices should be correctly sized for An intubation attempt can be very anxiety pro-
the patient, out of the packaging, lubricated voking. In an arrested patient, interventional
and ready for use. Furthermore, the airway management is a nonnegotiable part of
devices should all be physically laid out, a resuscitation. Conversely, in the patient who
in order of anticipated usage, on a nearby is conscious and breathing, undertaking an RSI
work surface. This way, in the potentially (thereby rendering the patient apneic, uncon-
stressful situation of a failed intubation scious and with an unprotected airway) places
attempt, no thought will be needed: the the onus on the clinician to effectively assume
go-to device is already sitting there, ready for all of these vital functions—a substantially anx-
use, and prompting the clinician what to do iety invoking paradigm. A good strategy in this
next. It just needs to be picked up and used. situation is to concentrate on the ease and
288 CHAPTER 20
success of BMV. Even with a failed intubation, mentally rehearse failed oxygenation situations
as long as oxygenation can occur with success- where cricothyrotomy may be needed.
ful BMV, really, no problem exists! Other strate-
gies for reassurance include obtaining help,
employment of an accepted management para- Making the Effort
digm, and simply having confidence in one’s
skills and knowledge, including a good As with cricothyrotomy, it is incumbent on the
approach to difficult BMV (Chap. 4). clinician to become skilled in basic and alterna-
tive intubation techniques. The bougie is a basic
adjunct to direct laryngoscopy, yet it takes expe-
The Ego, and When to Park It rience to build up a “mental library” of how the
clicks of the tracheal cartilaginous rings feel in
The clinician should never be concerned that different patients, and where, relative to the
initiating a call for help to a colleague will be teeth, the resistance occurs with bougie
perceived by assistants as a sign of insecurity or advancement into a small distal airway. To this
incompetence. Experienced healthcare staff rec- end, the device should ideally be used in an
ognize a call for help as just the opposite—the array of patients, including those anticipated to
sign of an effective clinician who knows his or be “easy”, to attain the needed experience. The
her limitations and has recognized the chal- same goes for use of a fiberoptic stylet as an
lenges inherent in the situation. It is the inex- adjunct to DL. Similarly, experience is needed
perienced or dangerous clinician who fails to to attain and maintain competence in an alter-
call for help out of concern that he or she will native intubation technique, such as the LMA
“look bad,” and the assisting staff know it! Fastrach or Trachlight. This experience can be
attained on lower acuity patients (anticipated
difficult patients should be treated with a familiar
Overcoming Psychological Barriers technique) or on elective surgical patients in the
operating room (OR). Having said this, arranging
So-called psychological barriers exist for all. In OR time can be “a hassle,” and there will be
the airway management arena, one of the most days that one wishes to simply go to work, and
significant of these barriers may be proceeding complete one’s shift without going to the effort
with a cricothyrotomy. The very words failed of using an unfamiliar technique on low-acuity
oxygenation and can’t intubate or oxygenate cases. This is a trap into which the clinician
can connote personal failure. However, when should not fall: competence in the difficult
indicated, the procedure itself is really no more situation can only be attained by gaining expe-
complex than placing a chest tube or obtaining rience in easier cases.
central venous access. Most cricothyrotomies
are inappropriately delayed until a patient is
no longer viable and the requirement for Getting Hassled
timely intervention is absolute (see Chap. 12).
One should practice the technique regularly As outlined above, lower acuity emergency
(see Chap. 7), so that there is minimal anxiety cases may present an opportunity to seek expe-
about not knowing the steps. With regular rience with less commonly used alternative tech-
practice on part-task simulators and/or cadav- niques. On occasion, some team members may
eric specimens, if available, the technique can state their discomfort with this scenario. In addi-
easily become familiar, and performed in under tion, inconvience to the care team may be
a minute. In addition, it can be beneficial to incurred, as carts require restocking, and
equipment must be cleaned. However, the dictated interventions such as application of

ethical issue of “practicing” on real patients is cricoid pressure during RSI. However, cricoid
a reality of medical practice, and the require- pressure, while standard of care, has never
ment for skills acquisition and maintenance been conclusively proven to improve out-
must be advanced with firmness and resolve. come, while it has definitely been shown to
Obviously, patient safety must remain the cause difficulty with both BMV15–17 and direct
priority when considering the use of less laryngoscopy.18–20 The risk of continued
familiar tools. application of cricoid pressure (i.e., failed
airway) in a difficult airway situation may
The Bigger Picture: Risk-Benefit thus outweigh its benefit (i.e., prevention of
Analysis aspiration). Airway patency and oxygenation
are prioritized before “might regurgitate, and
Airway management is all about risk-benefit might aspirate.”
analysis, and the clinician should never allow A second example of risk-benefit analysis
the risk of an intervention to outweigh its ben- in the full-stomach patient arises when
efit. Common examples of situations where this considering rescue oxygenation options.
may happen during airway management include Certain LMA devices (e.g., the LMA-Classic or
the following: Unique) do not necessarily fully protect the
airway against aspiration of gastric contents.
• The trauma patient with C-spine pre- Knowing this, some may consider their use
cautions: The blunt trauma patient has an contraindicated in the full-stomach patient.
increased risk of associated C-spine injury. However, once again, in a failed airway situ-
However, fear of causing a secondary spinal ation, the benefit of successful rescue oxy-
cord injury during tracheal intubation should genation far outweighs the potential risk of
not interfere with the decision to manage tracheal soiling.
the patient’s airway according to the usual
indications. The post-motor vehicle crash Assessment of risk-benefit analysis can only
(post-MVC) patient who has sustained decel- occur if the clinician is maintaining an overview
eration from high speed, yet does not pre- of the “bigger picture”—so-called situation
awareness. This requires the absence of fixation
sent with a cord injury after extrication and
on one aspect of the paradigm—often direct
transport, is generally unlikely to sustain
laryngoscopy. This is one reason that the failed
further injury during tracheal intubation—
intubation definition of the failed airway (see
particularly when care is taken with the
Chap. 12) has been presented: once three
appropriate application of manual in-line
attempts have been made, even if oxygenation
neck stabilization (MILNS).13 Although MILNS
with BMV is possible, it is time to stop, “re-
will make attaining a view at laryngoscopy
more difficult, it should be applied during group and re-muster,” and reassess things.
the attempt. However, the benefit of allowing
just a few millimeters of movement during an 䉴 SUMMARY
intubation attempt (e.g., to visualize the inter-
arytenoid notch, with bougie use thereafter14) Airway management is often the entry point
may well outweigh the risk of encountering of acute-care management and is a key deter-
a failed airway. minant of a safe patient outcome. At a minimum,
• The “full-stomach” patient: The typical success requires a sound knowledge of relevant
patient requiring emergency intubation is not airway anatomy, physiology, and pharmacology.
fasted. Their “full-stomach’ status will have Complex psychomotor skills must be acquired
290 CHAPTER 20
and maintained for a variety of specialized tech- 9. Gladwell M. Blink: The power of thinking with-
niques. In addition, for safe clinical decision- out thinking. New York: Brown and Company;
making to occur, cognitive and affective barriers 2005.
to success must be appreciated and managed. 10. Mamede S, Schmidt HG, Penafort JC, et al. Reflec-
tive practice in medicine. Fortaleza Brazil Expres-
Ultimately, to improve patient outcomes, educa-
sao Grafica e Editora Ltda; 2006.
tional efforts should address each of the
11. DaMasio A. Descartes’ Error: Emotion, Reason and
psychomotor, cognitive, and affective domains. the Human Brain. Itasca Illinois: Putman; 1994.
While promoting success, these programs should 12. Yerkes RM, Dodson JD. The relation of strength of
also allow supervised failure in a simulated stimulus to rapidity of habit-formation. Journal of
setting, to help maximize the chances of both Comparative Neurology and Psychology. 1908;18(5):
attaining and maintaining the necessary skills for 459–482.
competent airway management. 13. Manoach S, Paladino L. Manual in-line stabilization
for acute airway management of suspected cervi-
cal spine injury: historical review and current
REFERENCES
questions. Ann Emerg Med. 2007.
1. Kovacs G. Procedural skills in medicine: linking 14. Nolan JP, Wilson ME. Orotracheal intubation in
theory to practice. J Emerg Med. 1997;15(3): patients with potential cervical spine injuries. An
387–391. indication for the gum elastic bougie. Anaesthesia.
2. Mulcaster JT, Mills J, Hung OR, et al. Laryngoscopic 1993;48(7):630–633.
intubation: learning and performance. Anesthesiology. 15. Hartsilver EL, Vanner RG. Airway obstruction
2003;98(1):23–27. with cricoid pressure. Anaesthesia. 2000;55(3):
3. Kovacs G, Croskerry P. Clinical decision making: 208–211.
an emergency medicine perspective. Academic 16. Mac GPJH, Ball DR. The effect of cricoid pressure
Emerg Med. 1999;6(9):947–952. on the cricoid cartilage and vocal cords: an
4. Hall RE, Plant JR, Bands CJ, et al. Human patient endoscopic study in anaesthetised patients.
simulation is effective for teaching paramedic stu- Anaesthesia. 2000;55(3):263–268.
dents endotracheal intubation. Acad Emerg Med. 17. Hocking G, Roberts FL, Thew ME. Airway obstruction
2005;12(9):850–855. with cricoid pressure and lateral tilt. Anaesthesia.
5. Levitan RM, Goldman TS, Bryan DA, et al. Train- 2001;56(9):825–828.
ing with video imaging improves the initial intu- 18. Snider DD, Clarke D, Finucane BT. The “BURP”
bation success rates of paramedic trainees in an maneuver worsens the glottic view when applied
operating room setting. Ann Emerg Med. in combination with cricoid pressure. Can J Anaesth.
2001;37(1):46–50. 2005;52(1):100–104.
6. Croskerry P. The theory and practice of clinical 19. Levitan RM, Kinkle WC, Levin WJ, et al. Laryngeal
decision-making. Canadian Journal of Anesthesia. view during laryngoscopy: a randomized trial
2005;52(suppl_1):R1. comparing cricoid pressure, backward-upward-
7. Sloman S. The Empirical Case for Two Systems of rightward pressure, and bimanual laryngoscopy.
Reasoning. Psychological Bulletin. 1996;119 (1):3–22. Ann Emerg Med. 2006;47(6):548–555.
8. Croskerry P. Critical thinking and decisionmaking: 20. Haslam N, Parker L, Duggan JE. Effect of cricoid
avoiding the perils of thin-slicing. Ann Emerg Med. pressure on the view at laryngoscopy. Anaesthesia.
2006;48(6):720–722. 2005;60(1):41–47.
Index
Page numbers followed by f or t indicate figures or tables, respectively.
A in central nervous system Arterial oxygen content (PaO2),

AirQ extraglottic device emergencies, 239–240 14–15, 184–185
in adults, 102, 103f in congestive heat failure, 247 Assist control (AC) ventilation, 183
in pediatric patients, 123, 138t in critical illness, 260–262 Assisted ventilation, 183–184
Airtraq optical laryngoscope, 121, in ischemic heart disease, 246 Asthma
122f in lower airway disease, 256 case presentation, 255
Airway anatomy prehospital. See Prehospital airway pharmacologic considerations,
abnormal, 26–27 management 255–256
axes, 23, 24f, 25f risk-benefit analysis, 289 physiologic considerations, 255
importance, 18 Airway obstruction technical considerations, 256–257,
innervation, 25–26, 26f, 156 case presentation, 251 257t
laryngeal inlet, 21f, 22–23, 23f classification, 251t Atlanto-occipital extension, 89
laryngopharynx, 21–22, 21f in obtunded patient, 20f Atropine, 212t, 224
lower airway, 23 pharmacologic considerations, Awake tracheal intubation
mandible, 20 252–253 advantages, 152, 153t
nasal cavity, 18–19 physiologic considerations, airway innervation considerations,
nasopharynx, 19 251–252 156
oropharynx, 19 pre-intubation maneuvers, 42–44, disadvantages, 153t
in pediatric patients. See Pediatric 43f equipment, 155
patients recognition, 42 general considerations, 151–152
surgical, 24–25, 26f technical considerations, 253–254 indications, 155
upper airway, 18, 19f Airway physiology in infants, 268
Airway management alveolar ventilation, 14 in lower airway disease, 256
core competencies, 1–3, 2t oxygen stores, 16, 17f medications used in, 212t.
goals, 5–6 oxygen transport, 14–16, 15f See also specific medications
human factors in skills acquisition in pediatric patients, 29–31, 266 nasotracheal approach
for Altitude, partial pressure of oxygen cervical spine precautions and,
affective performance, 285–286, and, 185t 164–165, 166, 166f
285f Ambu Aura40, 137, 138t complications, 165–166
anxiety, 287–288 Ambu AuraOnce, 137, 138f, 138t effectiveness, 166
cognitive performance, American College of Emergency introduction, 163–164
284–285 Physicians (ACEP), rapid vs. oral approach, 155
effort needed, 288 sequence intubation policy technique, 164
ego, 288 statement, 171 topical airway anesthesia for, 158
importance of helpers, 286–287 Anemic hypoxia, 16 troubleshooting, 164, 165t
inconvenience, 288–289 Anesthesia, topical oral approach
psychological barriers, 288 for nasotracheal intubation, 158 direct laryngoscopy for, 160–162,
psychomotor performance, for orotracheal intubation, 156–158, 161–163f
283–284 156–159f vs. nasotracheal approach, 155
visual roadmap, 287 Aortic aneurysm/dissection, tracheal procedure, 162–163
initial approach intubation and, 213 sedation for, 160
in airway obstruction, 42–44, 43f, Arterial blood gases, 17 topical airway anesthesia for,
44f, 253 Arterial carbon dioxide (PaCO2), 156–158, 156–159f
in cardiac arrest, 249 184–185 patient cooperation and, 152
291
292 INDEX
B Blood pressure, postintubation, intracranial pressure, 238

Bag-mask ventilation (BMV) 181–182. See also response to tracheal intubation,
assessment of adequacy, 45–46 Hypertension; Hypotension 213–214
in cardiovascular emergencies, 248, Bonfils Retromolar Intubation post-intubation considerations, 241
249 Endoscope, 111. See also Cerebral perfusion pressure
devices for, 38–39, 38f Fiberoptic stylets in central nervous system
difficult BOOTS mnemonic, for BMV difficulty emergencies, 238
predictors of, 48–49, 188t prediction, 48–49, 188t tracheal intubation and, 214
response to, 46–47, 48f, 49f, 201, Bougie. See Tracheal tube introducer Cervical spine precautions
201t Boussignac continuous positive bag-mask ventilation and, 50
in elderly patients, 271 airway pressure system, direct laryngoscopy and, 59
in failed intubation, 205 37–38, 37f Esophageal-Tracheal Combitube
nasopharyngeal airways for, 41–42, Brambrinck Intubation Endoscope, and, 136
41f 111. See also Fiberoptic fiberoptic stylets and, 116
oropharyngeal airways for, 39–41, stylets laryngeal mask airways and, 133
39f, 40f Bullard laryngoscope, 120, 121f, 123 LMA Fastrach and, 102
technique BURP (Backwards, Upwards, risk-benefit analysis, 289
airway opening, 45–46 Rightwards Pressure). See Trachlight and, 111
head and neck positioning, 49 External Laryngeal Chandy maneuver, 99, 100f, 101
mask seal, 44, 45f Manipulation Children. See Pediatric patients
ventilation, 46 Chin lift, 42
tips and pearls C Chronic obstructive pulmonary
“auto-PEEP,” 50 Cardiac arrest disease (COPD)
cervical spine precautions, 50 case presentation, 248 pharmacologic considerations,
clinician with small or tiring pharmacologic considerations, 248 255–256
hands, 50 physiologic considerations, 248 physiologic considerations, 255
cricoid pressure, 50 technical considerations, 249 technical considerations, 256–257
gastric insufflation prevention, Cardiovascular system CLM (Corazelli-London-McCoy)
49–50 emergencies blade, 62–63, 64f
head and neck positioning, 49 cardiac arrest, 248–249 Cobra Perilaryngeal Airway, 139
laryngospasm management, congestive heart failure, 246–247 Combitube. See Esophageal-Tracheal
50–51 ischemic heart disease, 245–246 Combitube
two-person, 46, 47–48f response to tracheal intubation, 213 Congestive heart failure
BARS mnemonic, for response to Case presentations case presentation, 246
difficult laryngoscopy, 206 asthma, 255 pharmacologic considerations, 247
Beard, bag-mask ventilation and, 48 cardiac arrest, 247 physiologic considerations,
Benzodiazepines congestive heart failure, 247 246–247
in awake intubation, 212t critical illness, 259 technical considerations, 247
pharmacology, 220–221 elderly patient, 270 Continuous positive airway pressure,
in respiratory emergencies, 252 infant intubation, 265t Boussignac system, 37–38,
Berci-Kaplan DCI video ischemic heart disease, 245 37f
laryngoscope, 118 prehospital airway management, Cormack-Lehane scale, glottic
Beta blockers, for postintubation 275 visualization, 27, 28f, 29t
hypertension, 182 shock state, 262 Coronary artery disease. See Ischemic
Blind nasotracheal intubation (BNTI) tracheal intubation overview, 8–10 heart disease
cervical spine precautions and, upper airway obstruction, 251 Cricoid cartilage, 21–22
164–165, 166, 166f Central nervous system emergencies Cricoid pressure
complications, 165–166 airway management decisions, in bag-mask ventilation, 50
effectiveness, 166 239–240 in rapid sequence intubation, 174
introduction, 163–164 case presentation, 237 Cricothyrotomy
vs. oral approach, 155 intubation considerations, 214, awake, 154t
technique, 164 240–241 difficult, predictors of, 148, 189t
topical airway anesthesia for, pharmacologic considerations, 217, in failed oxygenation, 205–206
158 239 indications, 139
troubleshooting, 164, 165t physiologic considerations needle, 140
INDEX 293
open, 144–145, 144f, 145–146f in elderly patients, 271 rapid sequence intubation in, 272
in pediatric patients, 147, 147f endotracheal tube passage, 71–72, sedative/hypnotic dosing in, 214
percutaneous needle-guided 71f End-tidal carbon dioxide (ETCO2)
cannula endotracheal tube placement in cardiovascular emergencies, 247,
Melker, 140f, 141, 142–143f confirmation 249
PCK, 141, 143, 143f end-tidal carbon dioxide for confirmation of tracheal
Critical illness detection, 72–73, 73f intubation, 72–73, 73f
airway considerations esophageal detector devices, in mechanical ventilation, 184–185
patient acuity, 260, 260f 73–75, 74f Endotracheal intubation. See Tracheal
patient cooperation, 261–262 observation of passage through intubation
predicted difficulty, 260–261 cords, 71f, 72 Endotrol tube, 165, 166f
case presentation, 259 subjective signs, 75–76 Ephedrine
physiologic considerations, visualization of tracheal rings, 75 pharmacology, 230
259–260 fiberoptic stylets as adjuncts, 84–85, for postintubation hypotension,
Cyanosis, 17 112–114, 113f 181, 239
general considerations, 65, 65f Epinephrine, in respiratory
D laryngoscope and blades, 62–63, emergencies, 254
Dantrolene, 212t, 231 63–64f Esmolol
DART mnemonic, for difficult in pediatric patients. See Pediatric in cardiovascular emergencies, 246
cricothyrotomy prediction, patients for postintubation hypertension,
148, 189t positioning 182
Deep sedation, 160 clinician, 56, 57f Esophageal detector devices, 73–75,
DeVilbiss atomizer, 157, 158f patient 74f
Dexmedetomidine, 222 with cervical spine Esophageal-Tracheal Combitube
Difficult airway precautions, 59 (ETC)
alternative techniques, 204. See also in extreme respiratory distress, cervical spine precautions and, 136
specific techniques 61, 61f device characteristics, 133–134,
in bag-mask ventilation. See Bag- morbidly obese, 59, 59f 134f, 135f
mask ventilation, difficult pediatric, 62 effectiveness, 136
definition, 200 pregnant, 59–60 insertion, 135–136, 135f, 136f
in direct laryngoscopy. See Direct principles, 56–59, 59f in pediatric patients, 138t
laryngoscopy, difficult for prehospital airway preparation for use, 134–135
equipment cart, 208–209 management, 275 troubleshooting, 136
incidence, 200–201 in respiratory distress, 61, 61f Etomidate
management algorithm, 203f straight blade technique, 68–69, 70f in cardiovascular emergencies, 247
multiple attempts, danger of, 201 tracheal tube introducer for in central nervous system
prehospital management, 279 description, 80, 81f emergencies, 239
Diffusion abnormalities, 14 effectiveness, 83–84 in elderly patients, 272
Direct laryngoscopy. See also Tracheal indications, 80 pharmacology, 218–221
intubation technique, 80–82, 81–84f in rapid sequence intubation, 212t
awake, 160–162, 161–163f troubleshooting, 82–83 in shock states, 262, 263t
“best look,” 77t, 202t External laryngeal manipulation
blade changes in, 85 E (ELM), 78–80, 79f
curved/Macintosh blade technique, Edentulous patient, bag-mask Extraglottic devices. See Rescue
66–68, 66–69f ventilation in, 48 oxygenation
difficult Elderly patients
definition, 76 airway management in F
external laryngeal manipulation anatomic challenges, 271 Face masks
for, 78–80, 79f end-of-life issues and, 271 nonrebreathing, 35–36, 35f
head lift for, 77–78, 78f physiologic challenges, 270–271 simple, 35
predictors of, 88–90, 88f, technical challenges, 271–272 Failed airway
89f, 188t bag-mask ventilation in, 48 care following rescue, 206–207
response to, 76–80, 77t, 78f, case presentation, 270 definition, 200
201–204, 203f, 206 failed intubation in, 272–273 in elderly patients, 272–273
effectiveness, 86–87 postintubation care, 273 in pediatric patients, 270
294 INDEX
Failed airway (Cont.): Hypotension L

response to in elderly patients, 271 Laryngeal inlet
in intubation failure, 204–205 postintubation, 181 anatomy, 21f, 22–23, 23f
management algorithm, 203f sedative/hypnotics and, 214 in infants, 267
in oxygenation failure, 205–206 in shock states, 262 views at laryngoscopy
Fentanyl vasopressors for, 230–231 anatomy, 21f
in cardiovascular emergencies, 246 Hypoxia, 15–16 Cormack-Lehane scale, 27, 28t,
pharmacology, 223 Hypoxic hypoxia, 16 29f
for postintubation analgesia, 182 Cormack-Lehane scale, Cook
for postintubation hypertension, I modification, 27, 28t, 29f
182 I-gel airway, 139 POGO score, 27, 30f
Fiberoptic stylets Induction agents, for rapid sequence Laryngeal mask airway (LMA)
cervical spine precautions and, 116 intubation, 173, 176t cervical spine precautions and, 133
description, 95f, 111–112 Infants. See Pediatric patients devices, 128–130, 129f, 130f
effectiveness, 115–116 Intracranial pressure effectiveness, 133
in pediatric patients, 123 in central nervous system insertion techniques, 131–133, 131f,
preparation, 112, 112f emergencies, 238 132f
skills acquisition, 116 pharmacologic considerations for prehospital airway
technique etomidate, 219 management, 279
as adjunct to direct laryngoscopy, muscle relaxants, 239 preparation for use, 130, 131f
84–85, 112–114, 113f pretreatment agents, 239 skills acquisition, 133
awake intubation, 114 sedative/hypnotics, 239 troubleshooting, 133
stand-alone use, 114, 114f thiopental, 216 Laryngopharynx, 21–22, 21f
troubleshooting, 115 vasopressors, 239 Laryngoscopy, direct. See Direct
Fluid administration tracheal intubation and, 213–214 laryngoscopy
for postintubation hypotension, 181 Ischemic heart disease Laryngospasm, in bag-mask
for rapid sequence intubation, 173 case presentation, 245 ventilation, 50–51
Flumazenil, 220, 221 ketamine and, 217 Levitan FPS Scope, 95f, 111, 112f,
Foley Airway Stylet, 112. See also pharmacologic considerations, 113f. See also Fiberoptic
Fiberoptic stylets 245–246 stylets
Functional residual capacity (FRC), 16 physiologic considerations, 213, Lidocaine
245 intravenous, as pretreatment agent,
G technical considerations, 246 212t, 223
Gastric insufflation, bag-mask pharmacology, 224
ventilation and, 49–50 J topical, for airway anesthesia,
Glidescope, 96f, 117–118, 117f, 118f Jaw lift/thrust, 42, 43f, 44f 156–157, 156f, 158, 223–224
Glossopharyngeal nerve, 26, Light sedation, 160
26f, 156 K Lightwands, for tracheal intubation.
Glossoptosis, 27 Ketamine See Trachlight
Glottic visualization, adverse effects, 218 LMA Classic, 128, 129f, 131–132, 132f,
Cormack-Lehane scale, 27, in cardiovascular emergencies, 247 136t
28f, 29f in central nervous system LMA CTrach
emergencies, 239 for rescue oxygenation, 130,
H contraindications, 217 132–133
Haloperidol, 191, 221–222 in pediatric rapid sequence for tracheal intubation, 118–119,
Head extension, 42, 43f intubation, 269 119f
Head trauma. See Central nervous pharmacology, 212t, 217–218 LMA Fastrach
system emergencies in respiratory emergencies, 252 cervical spine precautions and, 102
Heliox, 253–254 as sedative, 218 combination with other devices,
Hemoglobin, in oxygen transport, 14 in shock states, 263, 263t 101–102
Histotoxic hypoxia, 16 in status asthmaticus, 256 description, 94f, 96–97, 97f
Hypertension in uncooperative patient, effectiveness, 102
postintubation, 181–182 191, 218 in failed direct laryngoscopy, 204
preexisting, tracheal intubation King Laryngeal Tube, 137, 138t, 139, insertion and positioning, 97–99,
and, 213 139f 98–100f
INDEX 295
intubation, 100–101, 100f Miller blade, 62, 63f precautions/contraindications, 41

in pediatric patients, 122, 138t MMAP mnemonic, for difficult direct sizing, 39, 40f
for prehospital airway laryngoscopy prediction, use, 39–40
management, 279 188t Oropharynx, 19
preparation, 97, 98f Modified gamma-cyclodextrin, 229 Oxygen capacity, 14
removal, 101 MOODS mnemonic, for difficulty Oxygen consumption (VO2), 15
for rescue oxygenation, 130, prediction with extraglottic Oxygen delivery (DO2), 15
132–133 device, Oxygen saturation (SaO2),
skills acquisition, 102 148, 189t 14, 184
troubleshooting, 101 Morphine, 182, 222–223 Oxygen stores, 16, 17f
LMA ProSeal, 128–129, 129f, 131f, Muscle relaxants. See also specific Oxygen therapy
132, 138t medications active delivery systems
LMA Supreme, 130, 130f, 132 adverse effects, 226 bag-mask ventilation. See Bag-
LMA Unique, 128 in central nervous system mask ventilation
Lower airway emergencies, 239 Boussignac continuous positive
anatomy, 23 in lower airway disease, airway pressure system,
disease. See Asthma; Chronic 256, 257 37–38, 37f
obstructive pulmonary pharmacology, 225–228 noninvasive positive pressure
disease for postintubation paralysis, 182 ventilation, 36–37
for rapid sequence intubation, 173, indications, 34, 34t
M 174t, 176t, 212t passive delivery devices
Macintosh blade Myocardial ischemia. See Ischemic nasal cannulae, 34–35
characteristics, 62, 63f heart disease nonrebreathing face mask,
laryngoscopy using, 66–68, 66–69f 35–36, 35f
MADgic (mucosal atomization N simple face mask, 35
device), 157, 158f Nasal cannulae, 34–35 Venturi mask, 36, 36f
Major nasal airway, 19 Nasal cavity, 18–19, 19f Oxygenation
Malignant hyperthermia, Nasopharyngeal airways monitoring
succinylcholine and, 226 description, 41, 41f arterial blood gases, 17
Mallampati classes, 88–89, 89f precautions/contraindications, 42 cyanosis, 17
Mandible, 20 sizing, 41 pulse oximetry, 17–18
Manual in-line neck stabilization, 240 use, 41 physiology, 14–16, 15f, 17f
Manual resuscitators. See Nasopharynx, 19 rescue. See Rescue oxygenation
Bag-mask ventilation Nasotracheal intubation, blind. See Oxyhemoglobin dissociation curve,
Masseter muscle rigidity, 226 Blind nasotracheal 15f
McCoy blade, 62–63, 64f intubation Oxymetazoline, 158
McGrath Series 5 video laryngoscope, Neck trauma, penetrating, 254–255
120, 120f Needle cricothyrotomy, 140. See also P
Mechanical ventilation Cricothyrotomy PaCO2 (arterial carbon dioxide),
assist control, 183 Neostigmine, 229–230 184–185
assisted, 183–184 Neuromuscular blockers. See Muscle Pancuronium, 228
positive end–expiratory pressure, relaxants PaO2 (arterial oxygen content), 14–15,
184 Noninvasive positive pressure 184–185
titration of PaO2 and PaCO2, ventilation (NPPV), 36–37, Partial pressure of oxygen (PO2),
184–185 255 altitude and, 185t
transport issues, 185–186, 185t Nonrebreathing face mask (NRFM), Patient cooperation, 190–191, 190f,
Melker Emergency Cricothyrotomy 35–36, 35f 261
Catheter Set, 140f, 141, Patient positioning
142–143f O with cervical spine precautions, 59
Metoprolol, 182 Obese patient in extreme respiratory distress, 61,
Midazolam bag-mask ventilation in, 48 61f
induction dose, 221 direct laryngoscopy in, 59, 59f morbidly obese, 59, 59f
pharmacology, 220–221 Opioids, 212t, 222–223 pediatric, 62
for postintubation hypertension, 182 Oropharyngeal airway pregnant, 59–60
as sedative, 182, 221 description, 39, 39f principles, 56–59, 59f
296 INDEX
PCK––Portex Cricothyrotomy Kit, 141, equipment options, 278–279 preparation, 172

143, 143f general considerations, 275–276 timelines, 176t
Pedia-Trake Pediatric Emergency indications for advanced in respiratory emergencies, 254–255
Cricothyrotomy Kit, 147, 267 techniques, 276 Remifentanil, 222
Pediatric patients method selection, 277–278, 278f Rescue oxygenation
airway anatomy, 27–29, 31f, patient assessment, 276–277 cricothyrotomy for. See
266–267 postintubation care, 279–280 Cricothyrotomy
airway management considerations Preoxygenation, 16, 17f extraglottic devices for
anatomic challenges, 266–267 Pressure support ventilation (PSV), Ambu Aura40, 137
physiologic challenges, 266 184 Ambu AuraOnce, 137, 138f
technical challenges, 267 Propofol in cardiovascular emergencies,
airway physiology, 29–31, 266 adverse effects, 215 249
awake intubation in infants, 268 in cardiovascular emergencies, 247 Cobra Perilaryngeal Airway, 139
failed intubation, 270 in central nervous system difficulty with, prediction of,
postintubation care, 270 emergencies, 239 147–148, 189t
rapid sequence intubation, 175 in elderly patients, 272 Esophageal-Tracheal Combitube
preparation, 268–269 pharmacology, 212t, 215–216 for. See Esophageal-Tracheal
procedure, 269–270 as sedative, 182, 216 Combitube
rescue oxygenation in shock states, 262, 263t in failed intubation, 205
cricothyrotomy, 147, 147f Pulse oximetry, 17–18 in failed oxygenation, 205–206
equipment cart, 209 I-gel, 139
extraglottic devices for, R King Laryngeal Tube, 137, 139,
138t, 146–147 Rapid sequence induction, 169 139f
tracheal intubation Rapid sequence intubation (RSI) laryngeal mask airway.
AirQ, 123 advantages, 152t, 170 See Laryngeal mask airway
Bullard laryngoscope, 123 American College of Emergency pediatric options, 138t
direct laryngoscopy, 62, 87 Physicians policy statement, Portex Soft-Seal laryngeal mask,
equipment cart, 209 171 137, 137f
fiberoptic stylets, 123 in congestive heart failure, 247 SLIPA, 139
LMA Fastrach, 122 contraindications, 170, 194 overview, 127–128
Trachlight, 123 in critical illness, 260–261 in prehospital airway management,
video laryngoscopes, 123 definition, 172 279
Phenylephrine disadvantages, 152t, 170 Respiratory system
in cardiovascular emergencies, 246, in elderly patients, 272 emergencies
247 evidence base, 170–171 lower airway disease, 255–257
pharmacology, 230–231 introduction, 169 penetrating neck trauma,
for postintubation hypotension, in lower airway disease, 255 254–255
181, 239, 246 medications used in, 173, 174t, respiratory distress, 61, 61f
for topical airway anesthesia, 158 176t, 212t. See also specific upper airway obstruction,
Phillips blade, 62, 63f medications 251–254
PO2 (partial pressure of oxygen), in pediatric patients, 175, 176t, response to tracheal intubation, 213
altitude and, 185t 268–269 Rocuronium
POGO score, 27, 30f postintubation management, 175 in central nervous system
Portex Soft-Seal laryngeal mask, 137, preprocedure evaluation, 192–194, emergencies, 239
137f, 138t 193f in pediatric patients, 176t
Positive end–expiratory pressure procedure pharmacology, 227–228
(PEEP), 184, 247, 249 cricoid pressure application, for postintubation paralysis, 182
Potassium levels, succinylcholine and, 174 for rapid sequence intubation, 173,
225–226 fluid loading and pretreatment, 174t, 176t, 212t
Pregnant patient, direct laryngoscopy 173
in, 59–60 induction and pharmacologic S
Prehospital airway management paralysis, 173, 174t Sedative/hypnotics. See also specific
case presentation, 275 intubation and confirmation of medications
clinician factors, 276 tube placement, 175 for awake tracheal intubation, 160,
difficult airway approach, 279 preoxygenation, 172–173 212t
INDEX 297
in central nervous system Toomey syringe, as esophageal hypertension treatment,

emergencies, 239 detector device, 73–74, 74f 181–182
dosage considerations, 214–215 Tracheal intubation hypotension treatment, 181
in elderly patients, 272 approach to, 53–54 positive pressure ventilation
in lower airway disease, 256 in cardiac arrest, 249 initiation, 180–181
for rapid sequence intubation, 212t, in central nervous system sedation and paralysis, 182–183
214–215 emergencies, 239–241 tube depth, 179–180
in shock states, 262–263, 263t in congestive heart failure, 247 tube placement confirmation,
Shikani Optical Stylet (SOS), 95f, 111, in critical illness, 260–262 179
112f, 114f, 115f, 267. See in ischemic heart disease, 246 tube securement, 180
also Fiberoptic stylets in lower airway disease, 256–257 postintubation complications, 86
Shock states preprocedure evaluation prehospital. See Prehospital airway
case presentation, 262 airway difficulty, 188–190, management
pharmacologic considerations, 188t, 189f, 189t preoxygenation, 62
262–263, 263t hemodynamic status, 190 technique selection
physiologic considerations, 262 patient cooperation, 190–191, difficulty predicted
Shunt, 14 190f cooperative patient, 192–194
SLIPA airway, 139 primary surgical airway, 196 uncooperative patient,
Snoring, as predictor of difficult bag- systemic risk factors, 190 194–196
mask ventilation, 49 in respiratory distress, 61, 61f no difficulty predicted,
Stagnant hypoxia, 15–16 in shock states, 262–263 192
Status asthmaticus, 255–257, 257t in upper airway obstruction, overview, 191–192, 193f
STOP “I” “C” BARS mnemonic, for 253–254 techniques
tracheal intubation case presentation, 8–10 AirQ, 102, 103f
equipment, 54–56 difficult. See Difficult airway awake. See Awake tracheal
Stridor, as predictor of difficult bag- equipment, 54–56, 55f, 208–209 intubation
mask ventilation, 49 failed. See Failed airway deep sedation, 153t
StyletScope, 111. See also Fiberoptic indications direct laryngoscopy. See Direct
stylets airway protection, 7–8 laryngoscopy
Succinylcholine attainment and maintenance of fiberoptic stylets. See Fiberoptic
adverse effects, 226–227 airway, 6–7 stylets
in cardiovascular emergencies, 248 gas exchange correction, 7 flexible fiberoptic and video
in central nervous system prevention of clinical devices, 121–122
emergencies, 239 deterioration, 8 LMA Fastrach. See LMA Fastrach
in pediatric patients, 175, in pediatric patients. See Pediatric rapid sequence intubation. See
176t, 269 patients Rapid sequence intubation
pharmacology, 225–227 physiologic responses to, 212–214 rigid fiberoptic devices, 120–121,
potassium levels and, 225–226 cardiovascular, 213 121f
for rapid sequence intubation, 173, central nervous system, 213–214 rigid optical device,
174t, 176t, 212t respiratory, 213 121, 122f
Sugammadex, 229 positioning Trachlight. See Trachlight
Superior laryngeal nerve, 26, clinician, 56, 57f videolaryngoscopy. See
26f, 156 patient Videolaryngoscopy
Surgical airway with cervical spine transport issues, 185–186, 185t
anatomy, 24–25, 26f precautions, 59 Tracheal tube introducer (bougie)
for prehospital airway in extreme respiratory distress, description, 80, 81f
management, 279 61, 61f effectiveness, 83–84
morbidly obese, 59, 59f indications, 80
T pediatric, 62 technique, 80–82, 81–84f
Thiopental pregnant, 59–60 troubleshooting, 82–83
in cardiovascular emergencies, 247 principles, 56–59, 59f Tracheotomy, awake, 154t
in central nervous system postintubation care, 85–86. Trachlight
emergencies, 239 See also Mechanical cervical spine precautions and, 111
pharmacology, 216–217 ventilation description, 97f, 102–104, 103f
in rapid sequence intubation, 212t blood pressure check, 181 effectiveness, 110–111
298 INDEX
Trachlight (Cont.): pharmacologic considerations, Ventilation-perfusion (VQ) mismatch,

insertion and use, 105–110, 252–253 14
107–109f physiologic considerations, Venturi mask, 36, 36f
in pediatric patients, 123, 267 251–252 Videolaryngoscopy
preparation, 104–105, technical considerations, 253–254 advantages, 117
104–107f Berci-Kaplan DCI, 118
skills acquisition, 110–111 V Glidescope, 96f, 117–118,
troubleshooting, 110 Vagus nerve, recurrent laryngeal 117f, 118f
Transport, airway issues, branches, 26, 26f, 156 LMA CTrach, 118–119, 119f
185–186 Vasopressors. See also specific McGrath Series 5, 120, 120f
Trousseau tracheal dilator, 144, 146f medications in pediatric patients, 123
in awake and rapid sequence
U intubation, 212t W
Upper airway in central nervous system Wisconsin blade, 62, 63f
anatomy, 18, 19f emergencies, 239
case presentation, 251 pharmacology, 230–231 Y
classification, 251t Vecuronium, 182, 228 Yerkes-Dodson law, 285, 285f

Airway Management in Emergencies

Uploaded by

Copyright:

Available Formats

Airway Management in Emergencies

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Airway Management in Emergencies

Uploaded by

Copyright:

Available Formats

AIRWAY MANAGEMENT

Want to learn more?

Editors and Lead Authors/Contributing Authors ix

GEORGE KOVACS, MD, MHPE, FRCPC J. ADAM LAW, MD, FRCPC

GRAHAM BULLOCK, MD, FRCPC DAVID A PETRIE, MD, FRCPC

PAT CROSKERRY, PHD, MD, CCFP(EM) CHRISTIAN M. SODER, MD, FRCPC

TIM FEDAK, BSC, PHD JANET DAVISON, BFA

䉴 INTRODUCTION TO AIRWAY prepared with the cognitive, psychomotor, and

䉴 TABLE 1–1 AIRWAY MANAGEMENT CORE COMPETENCIES

Cognitive Psychomotor Affective

• Indications for advanced airway • Bag mask ventilation • Crisis Resource

the airway, reinforced by experience, knowl- REFERENCES

䉴 KEY POINTS 䉴 CASE PRESENTATIONS

view endotracheal intubation as the definitive

There are four broad categories of indication for

Correction of Gas Exchange

• Ventricular arrhythmias—may respond to 䉴 Case 2.3

be removed from the supine position, as a

therapy and her condition will worsen as she

䉴 KEY POINTS • When managing a child’s airway, it is impor-

Alveolar Ventilation into the pulmonary venous blood will always

60 Good O2 delivery to tissue

Figure 3–1. The oxyhemoglobin dissociation curve.

10-kg delenburg position. Ambient lighting differences

Arterial Blood Gases

located cribriform plate. The nasal cavity is well

The Laryngopharynx attached by the thyrohyoid membrane to the

of the oral and pharyngeal/tracheal axes then

The Lower Airway

The trachea extends from the inferior border

outside diameter [OD] of a #4 tracheostomy cricoid cartilage initially lies immediately

Figure 3–9. Anterior neck landmarks.

Figure 3–10. Airway innervation. Distribu-

Cormack-Lehane12 Cormack-Lehane Cook13 Modification Description of Cook Alternative Cook

the posterior cartilages), Grade 2B Only posterior cartilages

Figure 3–11. The Cormack-Lehane (C-L) classification of glottic visualization.

Figure 3–13. Percentage of Glottic Opening (POGO) score.

䉴 KEY POINTS 䉴 INTRODUCTION

䉴 OXYGEN SUPPLY 䉴 OXYGEN DELIVERY

Cardiac and respiratory arrest Nasal Cannulae

Figure 4–1. Nonrebreathing face mask (note reservoir bag is inflated).

Of the devices described in this section, the Ven-

Figure 4–4. Bag-valve mask (BVM) manual resuscitator.

Adult-sized manual resuscitators are sup- Oropharyngeal Airways

Figure 4–6. Adult-sized oropharyngeal airways.

Figure 4–7. Sizing an oropharyngeal airway on an airway training manikin.

PRECAUTIONS AND CONTRAINDICATIONS SIZING

Figure 4–8. Nasopharyngeal airways.

PRECAUTIONS AND CONTRAINDICATIONS • Snoring inspiratory efforts (with functional

Response to the Obstructed

Figure 4–10. A jaw thrust being demonstrated on an airway management trainer.

problems of range of motion in the neck and

Sounds: A number of conditions associated rescue oxygenation via an extraglottic device

䉴 KEY POINTS • Cervical spine immobilization will often

A. Equipment should be assembled and imme- F. Personnel: Airway management is not a

A. “Up-down,” referring to stretcher height. B. “North-south”: the patient’s head should

is also key to positioning the morbidly obese Morbid Obesity

Figure 5–8. Macintosh size 3 and 4 (adult) curved blades.

Direct Laryngoscopy Technique: should happen slowly and deliberately, taking

Figures 5–14. A, B, C. Direct laryngoscopy: Blade advancement and tongue compression,