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Difficult intubation

Created: 14/2/2006

Rule number one:

Get help and remain calm.

Manoeuvres to aid intubation:

  • Re-positioning: neck flexed 35o onto chest and 15o face extension
  • Laryngoscopy technique: external larygeal pressure
  • gum elastic bougie: most important aid (60 cm long, 5 mm diameter)
  • Stylet: especially when larynx anterior
  • Light wand
  • Alternative blades: Miller, McCoy, polio, Huffman prism
  • Laryngeal mask airway (LMA): use to oxygenate while waking up
  • Use of intubating LMA to maintain anaesthesia
  • Use of LMA to intubate the trachea
  • Blind nasal intubation
  • Retrograde intubation
  • Awake intubation

Failed intubation (see DAS guidelines below)

  • Call for help
  • 3-4 attempts with some of the manoeuvres described
  • Maintain cricoid
  • Tilt table head down and suction as necessary
  • Insert oral airway and ventilate with 100% O2
  • Wake patient up
  • If ventilation difficult, try LMA; if still no ventilation, and if laryngospasm excluded use crico-thyroid puncture using 14 G cannula

Confirmation of correct tube placement

  • Direct visualisation
  • Auscultation for breath sounds
  • Chest movement
  • Feel of reservoir bag
  • CO2 detectors
  • Oesophageal detectors: withdraw air freely from trachea but the oesophagus will collapse


False negative:

  • Equipment failure
  • Disconnection
  • Kinked gas sampling tube
  • Kinked tracheal tube
  • Dilution of expired gas by high fresh gas flow
  • Severe airway obstruction
  • Poor pulmonary perfusion

False positive

  • Tube in oesophagus after exhaled gases forced into stomach
  • Tube in oesophagus after fizzy drinks
  • Distal end of tube in pharynx

Difficult Airway Society Guidelines (UK)

 Click here to view the latest DAS guidelines

 Click here to download latest DAS guidleines onto your handheld (requires isilo)

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