Prehospital Management of

Difficult Airways
5.1.2016

LEARNING Objectives

 Understand what makes management of an airway difficult.

 Learn the different mnemonics and acronyms to help determine when
an airway will be difficult.
Know which tools to use for different airway difficulties.

KEY Terms
Cricothyrotomy: An emergency incision into the larynx, performed to open the
airway of a person who’s unable to be ventilated.

Denitrogenation: The elimination of nitrogen from the lungs and body tissues

during a period of ventilation with pure oxygen.

Patent: Open and unblocked.

A difficult airway is one in which the EMS provider identifies potential attributes
of the patient that would make it difficult to utilize a bag-valve mask (BVM),
insert an extraglottic airway, perform a laryngoscopy, and/or perform surgical
airway interventions.1 It’s the ability to appropriately assess the patient’s airway
that allows providers to predict which will be difficult, optimize their first
attempt and ensure the highest likelihood of success when managing a patient’s
airway. Thorough airway assessments help drive your clinical decision-making
and help determine the tools you choose to wield when managing a particular
airway.

DIFFICULT BVM VENTILATION

The airway literature has identified numerous attributes that are likely to cause
some difficulty for the clinician to adequately ventilate a patient with a BVM.
Using the mnemonic “MOANS” allows providers to quickly recall potential issues
so they can attempt to compensate. (See Table 1.) Successful BVM ventilation
is dependent on a patent airway, a good mask seal and appropriate ventilation.
Anything that impedes any of these components will cause the provider to have
a difficult time ventilating their patient with a BVM.

The current body of evidence suggests that men and patients with a partially or
non-visible uvula (Mallampati class 3 or 4) are more difficult to ventilate with a
bag-mask device.1,2 Issues that inhibit a mask seal cause air to leak, making
ventilations more difficult. Factors such as the presence of a beard and/or
debris such as blood, dirt, vomit, etc. around the landmarks that the mask is
placed can cause complications, but there are ways providers can improve their
ability to deliver effective ventilations. One major improvement, which really
should be done anytime the resources are available, is to utilize a second
provider during BVM ventilations. By having one provider hold a mask seal and
the other squeeze the bag, the providers can more easily ensure the best
possible seal, which will minimize air leaks. Beyond the utilization of a second
provider, if the crew takes a moment to wipe off any potential debris, the
provider holding a mask seal is less likely to slide and will be able to hold a
more secure mask seal.
With BLS airway adjuncts, EMS providers often limit themselves to an
oropharyngeal or nasopharyngeal airway adjunct. These devices aren’t mutually
exclusive.3 It’s perfectly reasonable to place two nasopharyngeal airways in
along with an oropharyngeal airway to help optimize airway patency. While
ventilating obese patients, placing them in a ramped position (stacking blankets
behind the patient’s upper body and head until the tragus aligns with the sternal
notch) helps reduce the pressure on the diaphragm and makes it easier for the
provider to ventilate.Obesity is also associated with difficult BVM ventilations.
With obese patients or late-stage pregnant women, the mass of tissue can place
pressure on the chest and diaphragm, which inhibits chest rise with the
traditional amount of pressure exerted by a provider squeezing a bag (50-100
cmH2O). Providers can improve their ventilation techniques for obese patients
by utilizing airway adjuncts, utilizing two providers, and adjusting the patient’s
position.

The “O” in MOANS can also stand for “obstructions” such as foreign bodies or
pathophysiologic obstructions from specific disorders. Partial or complete
obstructions, in the upper or lower airway, can make it difficult and potentially
impossible for providers to deliver effective ventilations. This can be identified
during your assessment while listening to breath sounds, even without a
stethoscope at times in severe cases. Upper airway sounds include sonorous
respirations, gurgling and stridor, while lower airway sounds include wheezes,
crackles or ronchi.

Sonorous respirations usually imply that the tongue is blocking the airway,
necessitating the provider to reposition the patient’s airway and utilize some
basic airway adjuncts. Gurgling is the result of fluid in the upper airway of a
spontaneously breathing patient that the provider can attempt to control with
suction. Stridor is caused from a narrowing of the upper airway. If it’s a foreign
body, the provider can try manual thrusts to remove it or attempt to manually
remove it with Magill forceps if it’s visible. However, if it’s a pathophysiological
obstruction along the lines of laryngeal edema, the provider should try to treat
any potential causes of the edema in hopes of reversing it as well as prepare for
an intubation along with the possibility of a surgical cricothyrotomy.

Wheezes are caused by bronchoconstriction and may benefit from the

introduction of bronchodilators into the ventilation circuit. Crackles occur when
fluid fills the bases of the lower airway, whereas ronchi occurs when thick,
viscous secretions block a part of the lower airway. Although best ventilation
practices include the use of a positive end expiratory pressure (PEEP) valve on
the exhalation port of the BVM, patients with crackles or ronchi present would
benefit from higher levels of PEEP to help keep the alveoli open and push fluid
out.

The “A” and the “N” in the mnemonic stand for “age” and “no teeth.” Older
patients are typically more difficult to ventilate due to physiological changes
with the aging process. As patients age they lose muscle tone and tissue
elasticity, making it difficult to form a mask seal. Utilizing two-provider BVM
ventilation can mitigate this along with evaluating the mask size. Since the
maxillary and mandibular structures may reduce in size with the aging process,
a standard adult mask may be too large for some older patients. 4 Using a
pediatric mask may help to achieve an appropriate seal.

Another issue with mask seal comes from the absence of teeth. If dentures are
in place and secure, their presence will help the provider form a better seal.
However, if they’re loose, they can become an airway obstruction. Providers
must use their clinical judgment to evaluate the risks of leaving dentures in
compared to the risks of ventilating the edentulous patient with a BVM.

The last portion of the MOANS mnemonic refers to “stiff and snoring,” which
have been discussed briefly. Snoring can usually be rectified with an airway
adjunct along with repositioning the patient. It’s beneficial to know if they have
a history of sleep apnea before ventilations are attempted, but the information
may not be available.

“Stiff” refers to patients with a condition that’s likely to reduce airway

compliance such as acute respiratory distress syndrome, pneumonia, pulmonary
edema, etc. Providers can utilize mainstream capnography between the mask
and the bag to evaluate inhaled and exhaled carbon dioxide as long as they’re
able to maintain a secure mask seal.

Capnography may help in your clinical decision-making, but you’ll likely feel the
compliance issues as soon as you attempt to ventilate the patient. Stiff lungs
may necessitate higher PEEP and are at a higher risk of pneumothorax.
The LEMONS mnemonic is utilized in the Difficult Airway Course and in
Advanced Trauma Life Support as a tool to help providers anticipate potentially
difficult airways. This assessment is crucial in helping the intubator determine
what tools to use as well as what backup options they should have ready and
available.DIFFICULT LARYNGOSCOPY

“Looking externally” is something that’s done innately as providers walk to the

patient. Although this assessment is often done in seconds, there’s an
abundance of information to process, none of which should be ignored. This
portion of the assessment is what formulates a provider’s gestalt, or general
impression, about an airway. If something feels off because of the presence of
blood, a goiter or other anatomic abnormality, or a variety of issues, it may be
picked up while you’re looking externally. Don’t limit yourself to just looking-
palpate the airway as well.

“Evaluating” the intubating geometry of the patient is done using the 3-3-2 rule.
The first “3” assesses the mouth opening by measuring the patient’s index,
middle and ring finger between the upper and lower incisors. If the patient fails
this portion, another provider can help improve the intubator’s view by gently
pulling on the right-hand corner of the patient’s mouth.5 The second “3” refers
to the distance between the mental protuberance and the hyoid bone in
comparison to the width of the patient’s index, middle and ring finger. This
assessment determines if the patient’s mandible is long enough to adequately
displace the patient’s tongue into the submandibular space. If the patient fails
this assessment then there’s a high likelihood the patient’s tongue may be
difficult to displace and obstruct the provider’s view.

If available, the provider should also consider the use of a hyper-angulated

blade on a video laryngoscope, which are designed to go around the airway
anatomy, eliminating the need to displace the tongue. If the patient fails this
test due to their baseline anatomy, the provider can consider utilizing a straight
blade inserted it into the right paraglossal space, which provides a view to the
right of the blade without the tongue present. If the patient failed due to an
underlying pathology (e.g., infection, Ludwig’s angina, etc.), then the intubation
should be attempted by the most experienced provider and a cricothyrotomy kit
should be available prior to attempting the intubation.

The final “2” of this section measures the distance of the glottis opening by
comparing the width of the patient’s index and middle finger to the distance
between the hyoid bone and the thyroid notch. If the patient fails this
assessment then the provider should anticipate the patient’s glottis opening to
be anterior.
“Mallampati” classifications can be a useful tool for providers who have rapid
sequence intubation (RSI) capabilities, it’s unreasonable to obtain in the
unconscious patient. The Mallampati classifications require the patient to open
their mouth and stick out their tongue. The system is classified from the
anticipated least difficult intubation, labeled as a class 1, where the provider can
see the patient’s soft palate, fauces, complete uvula and pillars, through the
anticipated most difficult intubation, labeled a class 4, where none of the
traditional landmarks are visible and the provider can only see hard palate.
Essentially, the less uvula that the provider sees, the more difficult the
intubation will be.

In unconscious patients, providers should utilize the Cormack-Lehane grading

system during laryngoscopy. (See Figure 1.) In this system, a grade 1 has a full
glottis view, a grade 2 has a partial glottis view, a grade 3 only has a view of
the epiglottis, and a grade 4 lacks a view of the glottis or epiglottis. The use of
a gumelastic bougie is extremely beneficial for grade 3 views because the coude
tip can get under the epiglottis and advance into the trachea. Grade 4 views
shouldn’t be attempted unless the view can be improved.

Figure 1: The Cormack-Lehane grading scale

One method for improving the view is through the use of external laryngeal
manipulation. With external laryngeal manipulation, the intubator has their
laryngoscope in their right hand, an additional provider has their index and
thumb grasping the larynx, and then the intubator places their right hand on
the hand of their assistant. This allows the intubator to manipulate their
assistance hand and the patient’s larynx towards the direction that they feel
would be most likely bring the glottis into the intubator’s view. Once the optimal
view is obtained, the assistant holds the position while the intubator grabs an
endotracheal tube and passes it through the glottis opening.
The coude tip of the bougie can go underneath the epiglottis while
angling itself to go toward the glottic opening.

The issues of “obstruction” don’t vary much from the issues discussed with
ventilation. Ultimately, if they weren’t resolved with the BVM, the provider must
plan to accommodate for them. If gurgling is heard during ventilations then the
provider may consider attempting to obtain a glottis view with their
laryngoscope in their left hand while inserting a hard suction with the right hand
and having an endotracheal tube within reach to switch out with the suction. If
stridor is heard, the most experienced intubator should attempt to perform the
laryngoscopy. If the cause is from a foreign body, attempts should be made to
visualize and remove the obstruction with Magills. If an injury or illness is
causing laryngeal edema, then the intubator can consider attempting to pass a
gumelastic bougie through the vocal cords in hopes that they may be able to
pass an endotracheal tube, even a small one, through the swollen cords.
Regardless of the provider’s experience, the equipment needed for a surgical
cricothyrotomy should be out and ready for use.

“Neck mobility” may be from an acute injury or a chronic disorder. Although the
underlying cause may change the provider’s capabilities, the optimal
management will likely be the same. When providers are attempting to intubate
a patient who requires cervical spine immobilization, the provider must be
cautious and avoid unnecessarily manipulating the patient’s neck.

In patients with underlying chronic disorders, such as rheumatoid arthritis,

providers may not have the physical capability of manipulating the patient’s
neck. The use of a hyper-angulated blade on a video laryngoscope is the
optimal device for either subset of patients with neck mobility issues. Because
the blade is designed to go around the airway anatomy, the provider doesn’t
have to manipulate the neck much at all while intubating.

Oxygen saturation levels can drastically reduce the amount of time that
providers have to intubate a patient. Patients who are already ill may start at a
lower saturation and their percentages will drop quickly. Two things that can
help patients maintain oxygen saturations during intubation and quickly improve
oxygen saturations if they’ve dropped are the use of “nasal oxygen during
efforts securing a tube,” known as NO DESAT,6 and a thorough nitrogen
washout. With NO DESAT, the provider initiates oxygen via a nasal cannula at
15 Lpm during the preoxygenation phase. The same nasal cannula is left on at
15 Lpm throughout the intubation. The concept of a nitrogen washout,
or denitrogenation, is that the patient has been breathing ambient air, which
is 79% nitrogen, prior to the provider’s interventions. By ventilating the patient
with high-flow oxygen, the provider is displacing the nitrogen in the lungs and
maximizing the amount of available oxygen. Utilizing these two techniques
together ensures providers have an adequate amount of time to successfully
intubate the patient without putting them at a substantial risk.

The last component of the LEMONS mnemonic is “situation.” Truth be told,

paramedics rarely, arguably never, have to intubate a patient on the floor, in
the back seat of a car, in between the toilet and the wall of a bathroom, or in
any other complex position. The fact is that the likelihood of successful
intubation decreases in these settings. Providers must maintain situational
awareness and evaluate the resources available on scene, the current location
and position of the patient, the length of time the patient must stay in that area
(e.g., prolonged extrication, additional resources required to safely move the
patient, etc.) and any other potential complications that may exist regarding the
patient’s airway before attempting the intubation.

Providers often attempt to work around a scene instead of making the scene
work for them. Move furniture out of the way so providers are as comfortable as
possible while managing an airway. If providers become uncomfortable, grips
will be lost and seals will be broken. Move the patient to an area and position
that’s optimal for the intubator. It’s not unreasonable for EMS providers to place
the patient onto the stretcher and adjust it to a comfortable height for the
intubator.

On scenes where it isn’t possible to move the patient or adjust the environment,
like an extrication, the provider should evaluate if it’s reasonable to manage the
patient’s airway with BLS maneuvers until the patient can be moved. Otherwise,
it may be the most clinically appropriate not to attempt an intubation and go
straight to an extraglottic device. Remember, the only bad airway is the one
that isn’t oxygenating the patient.

CONCLUSION

Assessment and planning are crucial in airway management. Providers must use
every available tool to optimize their first attempt. The decision not to intubate
is often a more difficult and nobler decision then the decision to intubate. Every
case is different and providers must utilize good clinical decision making to
perform the best airway: The one that oxygenates the patient.

REFERENCES

1. Walls RM, Murphy MF: Manual of emergency airway management, fourth

edition. Lippincott Williams & Wilkins: Philadelphia, 2012.
2. Yildiz TS, Sloak M, Toker K. (2005) The incidence and risk factors of difficult
mask ventilation. J Anesth. 2005;19(1):7-11.

3. Perris T, Brudney S, editors: Top tips in anaesthesia. Greenwich Medical

Media: Cambridge, U.K., 2005.

4. Sveikata K, Balciuniene I, Tutkuviene J. Factors influencing face

aging. Stomatologija. 2011;13(4):113-116.

5. Nutbeam T, Daniels R, editors: ABCs of practical procedures. Wiley-Blackwell:

West Sussex, U.K., 2010.

6. Levitan R. (2010.) No DESAT. Emergency Physicians Monthly. Retrieved

March 28, 2016, from www.epmonthly.com/article/no-desat/.

7. Chrimes N, Fritz P. (2013.) The vortex approach: Management of the

unanticipated difficult airway. Rollcage Medic. Retrieved March 28, 2016,
from http://rollcagemedic.yolasite.com/resources/Archived_newsletters/the-
vortex-approach-management-of-the-unanticipated-difficult-airway.pdf.