Failed Airway

Question 1

What are the primary actions in failed airway management?

Answer 1

1. Call for help.
2. Get difficult airway cart.
3. Increase FiO₂ to 100%.
4. Attempt face mask ventilation with two hands while assistant ventilates with anesthesia circuit or bag-valve-mask.
5. If mask ventilation fails, attempt ventilation with supraglottic airway (SGA).
6. Verify adequate ventilation with:
   
   • Consistent ETCO₂ waveform capnography.
   • Bilateral chest rise.
   • Equal and bilateral lung sounds.

Question 2

What to do if ventilation is inadequate?

Answer 2

Priority: Oxygenation — Continuously monitor ETCO₂ and SpO₂.

1. Attempt video laryngoscopy if direct laryngoscopy fails and SpO₂ is not critically low (< 90%).
2. Confirm paralysis (see Medications).
3. Consider one final attempt with face mask ventilation.
4. Prepare for needle, wire-guided, or surgical cricothyrotomy.
5. Identify and sterilize cricothyroid membrane (CTM).
6. Place cricothyrotomy.
7. Confirm ventilation with consistent ETCO₂ waveform, chest rise, and bilateral lung sounds.
8. Facilitate exhalation through jaw thrust, oral/nasal airway, or SGA.

Question 3

What are the secondary actions if ventilation is adequate?

Answer 3

1. Continuously monitor ventilation adequacy.
2. Consider awakening the patient.
3. Limit intubation attempts to three or fewer.
4. Administer sedative hypnotic and neuromuscular blocker (see Medications).
5. Use airway adjuncts for intubation (see Table 4-1).

Options for intubation:
- Intubation through SGA using flexible intubating bronchoscope.
- Video laryngoscopy with bougie stylet.