Advanced Airway Management: Difficult and Failed Airway

Airway Management Summary

Key Questions After Failed Intubation

Is the patient oxygenated?
Can oxygenation be improved?
Were conditions ideal?
Can view/technique be improved?
Are there alternatives?
Is surgical airway needed?

Oxygenation Priority

Patients need oxygen, not a tube
Max 3 intubation attempts (DAS guidelines)
Cease attempts if SpO₂ ≤92%
Reoxygenate before further attempts

Improving Oxygenation

Apnoeic oxygenation if airway clear
Bag-mask ventilation (reduce cricoid if needed)
Supraglottic airway device (SAD) as rescue

Improving Intubation Conditions

Ensure full muscle relaxation
Use appropriate tube size
Have smaller tubes available
Consider intubating bougie

Improving Laryngeal View

Clear secretions with suction
Optimize head position
Adjust/release cricoid pressure
External laryngeal manipulation (BURP)
Alternative laryngoscope/videolaryngoscope

CICO Situation

Insert SAD immediately
Needle cricothyroidotomy
Surgical cricothyroidotomy
Tracheostomy

Initial Assessment After Failed Intubation

During a failed first attempt at intubation during RSI, the fundamental questions are:

Oxygenation Status

Is the patient oxygenated sufficiently to enable further attempts at intubation safely?
If not, can oxygenation be improved?

Technical Factors

Were the intubating conditions ideal?
Can the laryngeal view be improved?
Can the intubation technique be improved?

Contingency Planning

Should further attempts fail, are there suitable alternatives?
Should further attempts fail, is a surgical airway necessary and possible?

Ensuring Oxygenation

Fundamental Principle

Patients need oxygen, not a tube. Maintain adequate arterial blood saturation during all airway interventions.

The Difficult Airway Society guidelines recommend a maximum of three attempts at intubation
Continuous SpO₂ monitoring is essential
Cease intubation attempts and reoxygenate before SpO₂ reaches 92% (the steep part of the oxyhemoglobin dissociation curve)
Delegate a team member to monitor and announce when SpO₂ reaches 92%
Critical desaturation should be avoided where possible, even when oxygenation failure prompted intubation

Improving Oxygenation

Apnoeic Oxygenation

If the airway is clear, apnoeic oxygenation may assist in delaying arterial blood desaturation.

Bag-Mask Ventilation

If the patient is still paralyzed, bag-mask ventilation is the first choice.

Maintain cricoid pressure initially
If ventilation proves difficult, reduce or release it under direct vision

Supraglottic Airway Device (SAD)

If SpO₂ continues to decrease despite optimal bag-mask ventilation, the first rescue technique of choice is to insert a SAD.

Improving Intubating Conditions

Muscle Relaxation

Attempting intubation in the presence of muscle tone will cause problems: either failure to see the larynx because of gagging or failure to pass the tracheal tube because of cord closure.

Do not attempt laryngoscopy until the muscle relaxant is fully effective
For suxamethonium: wait until after fasciculations have stopped
Loss of jaw tone indicates onset of relaxation
If conditions are not optimal, maintain oxygenation while awaiting muscle relaxation
Use a malleable stylet for better tube direction (remove if using intubating bougie)
Avoid tubes that are too large for the larynx
Have tubes 1-2 sizes smaller immediately available
Consider using an intubating bougie (coude-tipped single-use tracheal tube introducer preferred)

Improving Laryngeal View and Intubation Technique

Golden Rule

Always make the first attempt, the best attempt.

Interventions to Improve View

Clear secretions, blood or debris rapidly with a wide-bore suction device
Ensure optimal positioning - head fully extended at atlanto-occipital joint with neck flexed
Reduce or release cricoid pressure - continue laryngoscopy to observe effect on view and detect regurgitation
External manipulation of the larynx - Backwards, Upwards and Rightwards Pressure (BURP) manoeuvre by an assistant
Use an alternative laryngoscope - McCoy blade or videolaryngoscope
Change practitioner - fresh perspective and technique

Failed First Attempt Mnemonic: O HELP

O - Oxygenation

Ensure adequate oxygenation before further attempts

H - Head Elevation

Optimize patient positioning

E - External Manipulation

BURP manoeuvre on the larynx

L - Laryngoscope Change

Try different blade or videolaryngoscope

P - Pal (Call for Assistance)

Get help from experienced colleagues

"Can't Intubate, Can Oxygenate" Situation

If repeat laryngoscopy fails, but oxygenation is maintained, consider:

Respiratory Status

Is spontaneous breathing present?
Is ventilation adequate?

Airway Assessment

Is the airway still at risk?
Is intubation the only option at this time?

Management Considerations

After suxamethonium without opioid, neuromuscular function likely recovering
Synchronize ventilatory assistance with spontaneous respiration
Gradual return to pre-RSI state if appropriate
Assess urgency based on airway risk and respiratory adequacy
Choose between continuing intubation sequence or maintaining airway without intubation
Consider alternative techniques by experienced practitioners:
- Fibreoptic methods
- Retrograde techniques
- Intubating laryngeal masks
- Light wands

"Can't Intubate, Can't Oxygenate" (CICO) Situation

Emergency Situation

If repeat laryngoscopy fails and oxygenation is not maintained, immediate action is required.

First Rescue Technique

Insert supraglottic airway device (SAD) - the primary rescue technique of choice

If SAD Fails

Proceed to advanced rescue techniques for ventilation:

Needle cricothyroidotomy
Surgical cricothyroidotomy
Tracheostomy

Decision Making in CICO

Time is critical - rapid sequential progression through options
Use the technique with which you are most familiar and skilled
Team preparation and regular training improves outcomes
Have all necessary equipment readily available and checked

Preparation and Prevention

Pre-Intubation Assessment

Perform thorough airway assessment before RSI
Identify predictors of difficult airway:
- Mallampati score III or IV
- Limited mouth opening (<3cm)
- Short thyromental distance (<6cm)
- Limited neck mobility
- Obesity or anatomical abnormalities
Have a backup plan for difficult airway scenarios

Equipment Preparation

Ensure all airway equipment is available and functioning
Have multiple sizes of endotracheal tubes available
Prepare alternative devices (videolaryngoscope, bougie, SAD)
Have emergency surgical airway equipment readily accessible
Use a standardized checklist before each intubation

Team Preparation

Clearly assign roles before procedure
Establish clear communication plan
Review emergency protocols regularly
Practice difficult airway scenarios through simulation