Difficult airway algorithm?

[studiousme]

Hi!
I’m confused about one step of Ron Wall’s difficult airway algorithm despite googling and reading. It says “intubation predicted to be successful” which to me is the inverse of asking ‘is this predicted to be to be a difficult airway’...which by default is affirmative at this point given that we are already within the difficult airway algorithm! LOL. If not, what other criteria (besides LEMON) should be applied at this stage of the algorithm? Any thoughts? Thanks!

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[deleted547339]

Hi!
I’m confused about one step of Ron Wall’s difficult airway algorithm despite googling and reading. It says “intubation predicted to be successful” which to me is the inverse of asking ‘is this predicted to be to be a difficult airway’...which by default is affirmative at this point given that we are already within the difficult airway algorithm! LOL. If not, what other criteria (besides LEMON) should be applied at this stage of the algorithm? Any thoughts? Thanks!

There’s physiology and anatomy. Intubation a patient with ILD OB high-flow plus NRB makes me much more nervous than intubating a “difficult airway.” Anatomically difficult, I keep awake and fiberoptic or VL with topicalization.

To my knowledge, the shock trauma difficult airway algorithm is the only one actually validated.

In my mind, everything hinges on bagability. If you can bag, you’re cool. If you have problems bagging, oral and nasal airway are your go to. Once you can’t bag, you start rapidly going through subsequent steps. Really, it depends why you fail. Bad positioning? Blade to small? Etc. The short and dirty way I think about it is ETT->bougie->LMA. Still can’t oxygenate, cric.

The tough thing is that the algorithm is kind of like ACLS or ATLS. It works great under high stress or for novices, but it doesn’t necessarily guide an expert.

 

[TheTruckGuy]

The biggest thing about the difficult airway algorithm, in my mind, is to have the tools ready to go from step to step. Most of us know the steps, we just don't plan for it, or don't make the logical moves from step to step.

Also I think more ER docs need to be willing to go to an LMA sooner, in my opinion. Or we need to keep intubating LMAs in our airway carts.

 

[Zebra Hunter]

The biggest thing about the difficult airway algorithm, in my mind, is to have the tools ready to go from step to step. Most of us know the steps, we just don't plan for it, or don't make the logical moves from step to step.

Also I think more ER docs need to be willing to go to an LMA sooner, in my opinion. Or we need to keep intubating LMAs in our airway carts.

Meh, bad airways that require you to place an LMA happen maybe once every 5-10 years as an attending, and almost all of those situations are immediately recognizable as terrible airways. If I’m putting in an LMA in a non-CPR situation, it is because I am setting up to cric. I have only had to do that once, and we cric’d the patient successfully. Might be more commonly done in trauma centers, but for most community attendings, this is rare as heck to actually need an LMA.

 

[TooMuchResearch]

Happens more often for me, but I seem to run into situations with patients I can't appropriately prep for intubation without PEEP and someone forgot to stock the PEEP valves for the BVM.

Meh, bad airways that require you to place an LMA happen maybe once every 5-10 years as an attending, and almost all of those situations are immediately recognizable as terrible airways. If I’m putting in an LMA in a non-CPR situation, it is because I am setting up to cric. I have only had to do that once, and we cric’d the patient successfully. Might be more commonly done in trauma centers, but for most community attendings, this is rare as heck to actually need an LMA.

 

[Fox800]

At my last job, the powers that be got rid of the backup airway sets (intubating LMAs) "because we never use them and they have to get autoclaved". They had BVMs, bougies, an older Glidescope, and scalpels. No fiberoptic equipment, no backup airway devices. YOYOMF

This is at a medium-sized hospital, largest hospital system in the state.

 

[Groove]

We have a difficult airway cart which I highly recommend. We have LMAs, bougies, McGrath, Fiberoptic Intubating stylet, ETTs, cric kit, surgical trach kit, nasal trumpets, etc.. We keep it in our trauma bay but you can roll it anywhere in the ED very quickly. We started using it after a GSW came in one night and nothing was stocked or where it should have been and it was a gigantic cluster F.

Practice your backup devices. I can’t count how many times a cheap bougie or LMA has saved my ass or given me enough time to figure out a difficult airway scenario. Don’t forget patient positioning. I got called upstairs to a floor code a few weeks ago that ICU couldn’t get intubated and our hospitalist director was trying for the third time with a glide scope to intubate with no avail. They could bag fine, so I knew I had time. I spent about 30-60 secs properly positioning them, ramping them up, and then took a look with a blade and intubated easily with a bougie.

Don’t be afraid to cric In a fail to intubate, fail to ventilate scenario. You all know how to do it and even if you haven’t done it on a real patient, you’ve done it on mannequins and on cadavers. I read a study one time that even in the uninitiated, there’s an overwhelming success rate. So, even if you haven’t done one in a real patient, chances are over 90% that you’ll complete it successfully once you start. On that note, don’t waste time feeling for cartilaginous landmarks on an obese person. Just cut. Once your through platysma and adipose, sink your fingers in and you’ll be able to feel landmarks much more easily.

Always plan for failure. I can’t stress this enough. I always have an LMA or bougie in the room and know exactly where my cric kit is located (Or blade and 6.5 ETT) and/or video laryngoscope or bronch. It’s always the patients you least expect that have the most problems. (Ok, maybe not all the time but MANY of the times.)

 

[deleted547339]

Meh, bad airways that require you to place an LMA happen maybe once every 5-10 years as an attending, and almost all of those situations are immediately recognizable as terrible airways. If I’m putting in an LMA in a non-CPR situation, it is because I am setting up to cric. I have only had to do that once, and we cric’d the patient successfully. Might be more commonly done in trauma centers, but for most community attendings, this is rare as heck to actually need an LMA.

Depends on where you work. There was a paper in annals recently that looked at the number of intubations performed annually per attending - the number had some huge outliers/variation I had an intubation I had to use a bronch on recently and someone in my department got cric’ed last month, but we intubate >1/day. Fat also doesn’t begin to describe my patient population.

 

[docB]

One thing I've noticed over the years is that a lot of people just starting out focus too much on an algorithm. The problem with this is that failed airways happen for various reasons. The real goal is to become facile enough with all the tools in the toolbox to be able to change it up on the fly based on what you're seeing (or not seeing). For example switching to video is great if it's too anterior but it's useless if you have a great view of an edematous airway or no view because the posterior oropharynx is full of goo. Don't get me wrong. I'm not putting an algorithmic approach down. Everyone needs that early on, especially when an initial no go still gets your heart rate up. But real competence means flexibility.

 

[deleted59964]

hi all,

visiting here because I'm bored with the anaesthesia board at the moment.
I'm an Australian anaesthesiologist.

most of us use this model as a cognitive aid ... it has the benefit of simplicity and reflects what experts do in real practice.

The Vortex Approach

TO AIRWAY MANAGEMENT

vortexapproach.org

to the OP ... I haven't looked at that model, but it is very possible to have a difficult airway in which intubation is predicted to be successful.

a potentially difficult airway is a cover all phrase that can relate to anticipated difficulty with bag mask ventilation - eg fat and beard, difficult supraglottic airway eg. glottic mass, oropharyngeal cancer, syndromic upper airway etc. or difficult intubation.

sometimes airways look horrendous but intubation can actually be expected to be easy - classic example - patient has no teeth

 

[studiousme]

thank you ALL for your helpful comments!