22.12a The Difficult Airway

As an EMS practitioner, you will be expected to be able to effectively manage patients when establishing and maintaining an airway that is or may be difficult.

It has been estimated that 1 of 10 endotracheal intubations can be classified as difficult, and intubation can be impossible in 1 of 100 patients when conventional techniques (including straight blade, ELM, and introducers) are attempted.

It is important, however, to think globally in terms of difficult airways rather than considering only difficult intubation.

The concept of the difficult airway includes difficult BVM ventilation, difficult airway physiology, difficult extraglottic airway placement and ventilation, difficult intubation, and difficult cricothyrotomy.

The following are clinical situations in which an EMS practitioner anticipates or experiences difficulty.

Difficult BVM ventilation: a n EMS practitioner anticipates or experiences difficulty maintaining adequate tidal volume despite using basic airway adjuncts, and two-person technique.

Difficult airway physiology: an EMS practitioner anticipates or experiences difficulty achieving adequate preoxygenation and resuscitation (typically the goals are higher than 93 percent for 3 minutes, SBP higher than 100, shock index less than 0.9) despite using appropriate positioning and oxygenation strategies.

Difficult extraglottic airway: an EMS practitioner anticipates or experiences difficulty inserting or ventilating with an extraglottic airway device.

Difficult intubation: an EMS practitioner anticipates or experiences difficulty in visualizing the vocal cords or posterior cartilages within one optimal attempt and without the patient developing hypoxemia.

Difficult cricothyrotomy: an EMS practitioner anticipates or experiences difficult obtaining a surgical airway in less than 60 seconds.

Difficult airway: an EMS practitioner anticipates or experiences difficulty with any critical portion of airway management, including BVM ventilation, physiology, extraglottic airway placement, endotracheal intubation, or surgical cricothyrotomy.