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27 October 2009

The Failed Airway !! (EAM part 5)

The Failed AirwayAlthough none of us wants to be in a “failed” airway situation, it will happen eventually to all of us. There are basically 2 scenarios, 1) can’t intubate but can ventilate with a BVM or 2) can’t intubate and can’t ventilate. In the first situation, one is at least able to maintain reasonable ventilation and oxygenation. However, the risk of aspiration increases as bagging continues. Even with adequate Sellick’s maneuver, some air will leak into the stomach causing gastric distension and eventually vomiting. The second situation is more desperate and if a decision is not made in seconds, the patient will die. Usually this involves one of two possibilities depending on time. The first is the creation of an immediate surgical airway either by cricothyrotomy, or percutaneous transtracheal jet ventilation.

If you do not have the transtracheal jet ventilation already set up before hand, you can not use this as you will NEVER be able to assemble the equipment in time to save the patients life. Neither of these options are viable in the pediatric patient and surgical airways should not be undertaken in children below the age of puberty! The second possibility is to use an airway adjunct. Obviously you need to have access to these adjuncts before the crisis arises. Adjuncts include the Combitube©, laryngeal mask airway, fiberoptic laryngoscopically assisted intubation, lighted stylette intubation, retrograde intubation using a cricoid puncture technique and wire, digital intubation and others. The success rates are dependent on availability of the equipment and operator training and experience. The time to plan for a failed airway is now, not in the crisis of the moment when it happens. The patient will pay for your lack of preparation!

Reference
Advanced Emergency Airway Management Walls RM, Luten RC, Murphy ME, Schneider RE. 1997

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