W1 Difficult Airway Management for Intensivists
Supraglottic Airway Placement: Before Procedure
Indications
Equipment
After Procedure
Suggested Reading
Bougie-Assisted Intubation: Before Procedure
Indications

Figure W1-2 Lehane Cormack laryngeal view grading system with the Cook-Yentis modifications, grade I→IV.

Figure W1-3 Cook-Yentis grade IIb laryngeal view with direct laryngoscopy achieves a very high success rate with bougie-assisted intubation.

Figure W1-4 Cook-Yentis grade IIIa view with direct laryngoscopy achieves a respectable success rate with bougie-assisted intubation, especially when compared to blind passing of the endotracheal tube “around the corner.”
Equipment
Anatomy
Though the bougie is capable of assisting intubation in nearly all airway situations except when “no view” is possible, it is most commonly used as an adjunct with Grade IIb, IIIa, and IIIb laryngeal views. Even when the laryngoscopy reveals a full view (grade I), the bougie may be useful when the hypopharyngeal opening is narrow (OSA, obesity, swelling) and passing the ETT may actually obstruct the view of the glottic opening. In this case, the narrower, more colorful tracheal tube introducer can be passed into the trachea with little visual obstruction taking place. Conversely, the floppy epiglottis is a challenge that may be technically difficult with many different airway adjuncts. The bougie may either be used to elevate the floppy epiglottis or be maneuvered around by virtue of the Coude tip. Though useful, the success rate is often less than 50%, and other alternatives may be needed (intubating laryngeal mask airway [ILMA], videolaryngoscope [VL], fiberoptic bronchoscope [FOB]) (Figure W1-7).

Figure W1-7 A grade IIIb view; floppy or overhanging epiglottis is relatively uncommon but may be difficult to navigate around with a variety of airway adjuncts. The bougie may be used to elevate the epiglottis and navigate into the trachea, but the success rate is substantially lower in the grade IIIb setting (30%-50%) compared to a grade IIIa (only leading edge of epiglottis visible, 80%-90%).
Procedure

Figure W1-8 Endotracheal tube (ETT) being passed over tracheal tube introducer (TTI, bougie) and getting hung up on the epiglottis and arytenoid. Continued advancement should be discouraged. Simply withdraw 1 to 2 cm, rotate ETT counterclockwise about 90 degrees, and readvance. VC, vocal cord.
After Procedure
Postprocedure Care
Complications
Suggested Reading
Use of the Intubating Model of the LMA for Emergency Airway Rescue (Fastrach) ILMA: Before Procedure
Anatomy
In general, placement of the ILMA can be performed in the exaggerated “sniff” position or the other extreme, a neutral cervical spine. The ILMA is lubricated and then passed along the roof of the mouth across the hard to soft palate, encouraging smooth advancement along the posterior throat so as to minimize getting hung up on the epiglottis or causing its downfolding. The distal tip of the ILMA typically comes to lie with its distal tip in the cricopharyngeal region. Unfortunately, the cuff end may buckle over on itself, come to lie over the glottic opening, or be displaced in a contorted position that impedes effective ventilation and oxygenation (Figures W1-9 through W1-16).

Figure W1-9 Deflate the cuff, and lubricate with a water-soluble lubricant on the posterior surface. The lubricated intubating laryngeal mask airway is passed over the hard to soft palate along the posterior pharyngeal wall to the point where gentle resistance is felt.

Figure W1-10 Swing the mask into place in a circular movement, maintaining contact against the palate and posterior wall of the pharynx. Do not use the handle as a lever.

Figure W1-11 Inflate the mask, without holding the tube or handle, with approximately 10 to 20 mL of airway to seal the airway. Apply a manual bag or anesthesia circuit to the intubating laryngeal mask airway (ILMA) and verify ventilation. If no ventilation (leak or resistance), assume misplacement of ILMA or downfolding of the epiglottis. Manipulate the ILMA in an up-and-down or in-and-out maneuver to optimize position. Recheck ventilation, and adjust location of the ILMA to optimize ventilation. Do not attempt passing the endotracheal tube until effective ventilation is ensured.

Figure W1-12 Hold the intubating laryngeal mask airway (ILMA) handle while gently inserting the lubricated endotracheal tube (ETT) into the airway shaft. The provided ILMA-ETT is best suited for this, though a well-lubricated standard ETT may be used with fiberoptic guidance or may be used (with proper training and experience) blindly by inserting it “backwards,” meaning the concave curve of the ETT faces the nose as it is advanced into the ILMA shaft.

Figure W1-13 Advance the endotracheal tube (ETT), inflate the cuff, and confirm intubation. If unable to pass, ensure adequate lubrication. If resistance is felt, the intubating laryngeal mask airway (ILMA) may be malpositioned or may have entrapped the epiglottis and thus may block the ETT advancement. Try the in-and-out maneuver to reposition the ILMA and free up the epiglottis if applicable.

Figure W1-14 Remove the endotracheal tube (ETT) connector, and place the provided stabilizing rod onto the end of the ETT. Then ease the intubating laryngeal mask airway (ILMA) over the existing ETT and rod by gently swinging the handle caudally (keeping the ETT stable in position) until the ETT can be grasped at the level of the incisors.

Figure W1-15 Remove the stabilizing rod, and gently unthread the inflation line and pilot balloon of the endotracheal tube (ETT). Replace the ETT connector, and confirm ventilation and position per standard intubation procedures. If the intubating laryngeal mask airway (ILMA) has been used on a very challenging airway or the patient is unstable, delay removal of the ILMA from the existing ETT until stabilization takes place. Extubation of the airway is possible, so this maneuver should only be performed by those skilled in its execution.
Procedure
After Procedure
Postprocedure Care
Outcomes and Evidence
Suggested Reading
Retrograde Wire Intubation: Before Procedure
Indications
Anatomy
The cricothyroid membrane is located between the superior thyroid cartilage and the inferior cricoid ring. The cricothyroid membrane is located just 1.5 to 2 cm below the vocal cords, so care must be practiced when advancing a needle caudad, as the underside of the vocal cords could be impaled. Passing the ETT over the wire or obturator/wire may be met with resistance at the 16- to 17-cm depth, as the ETT tip may impinge on the vocal cords or arytenoids. This is the inherent danger of passing the ETT blindly over the wire or obturator/wire assembly. The location of the distal tip (having met resistance) may or may not be at the position below the vocal cords. This is the challenge of the retrograde wire method; knowing the location of the ETT tip is unknown when the decision is made to remove the wire. If the ETT tip is erroneously positioned above the glottis, then the access to the airway is denied with wire removal; hence, the advantage of using the FOB as an intubation guide (Figure W1-17).