Overall approach to a difficult airway

• Always ask for help!
• The goal is oxygenation, not intubation
• Your first attempt is your best attempt
• Don’t panic!

Preoperative Assessment (check out Episode 1 of the series for a review!)

• Identify risk factors for a potentially difficult airway:
  • Difficult ventilation
  • Difficult intubation
  • Difficulty with patient cooperation/consent
  • Difficult cricothyrotomy
• One of the best predictors of a difficult airway is a history of difficult airway

Scenario 1: Can't intubate, can ventilate

• Return to BMV (bag-mask ventilation) to stabilize the patient and give yourself time
• Try something new with each attempt:
  • Switch to a more experienced operator
  • Optimize patient position
  • Ask an assistant to apply BURP (backwards upwards rightwards pressure)
  • Try with different equipment (such as a different size ETT, a Bougie, or videolaryngoscope)
• Minimize the number of attempts (max. 3)
• Consider using a supraglottic airway device or waking the patient up

Scenario 2: Can't intubate, difficult ventilation

• Improve BMV technique:
  • Use an oropharyngeal or nasopharyngeal airway
  • Optimize patient position
  • Ensure the mask has a tight seal, use 2 hands and ask someone else to bag
• Try inserting a supraglottic airway device
• Once oxygenation is achieved, consider your options for establishing an airway or waking the patient up

Scenario 3: Can't intubate, can't oxygenate

• Recognize the problem and communicate with the team
• Proceed with cricothyrotomy / surgical airway

Difficult Airway Society Guidelines:

• https://das.uk.com/guidelines/das_intubation_guidelines

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