Managing the Obese Difficult Airway

I’ve put together a detailed article on managing the obese pateint who needs intubation. This population is reknowned for having increased risks of complications and adverse outcomes related to intubation, so we hope you find the article useful next time you’re faced with this very difficult resuscitation situation. It’s quite a long article, but has some great links to all of the best online airway resources we’ve found, photos, mnemonics, flowcharts and some of the latest tips from the leaders in Emergency Resuscitation.

Managing the Obese Difficult Airway

Andy

2 Responses to Managing the Obese Difficult Airway

  1. rfdsdoc December 17, 2011 at 9:43 am #

    hi Andy.I enjoyed your article on airway management of the obese patient. well done. this patient group engenders a certain fear when it comes to emergency airway management. the fear comes from two assumptions. firstly that intubation will be difficult. secondly that hypoxia will develop very quickly with onset of apnoea. your article addresses these two fears with several strategies. Having used some of these strategies during retrieval I can attest to their benefit. Paul Mayo is correct. What anaesthetists do in the OT may not work at all or be impractical outside the OT. What your article did not mention is the technique of RSA espoused by Dr Darren Braude of the USA. I have used this successfully on a number of predicted difficult airways on retrieval, including obese patients and it is well suited for emergency airway managment. Its a very useful bridging technique towards a safer and more controlled intubation especially in the critically hypoxic patient. good job once again

  2. rfdsdoc December 17, 2011 at 8:14 pm #

    thanks for asking Andy! RSA is a novel technique, not familiar to many, but grounded in the principles of RSI. check out Dr Braude’s excellent demo video at http://www.airway911.com!Its a great intro. Basically you setup as for RSI but instead of trying to intubate the trachea, you drop in your LMA or SGA device, improve oxygenation with PEEP etc, drain the stomach if you are using a LMA that can do that…then once things a physiologically better, proceed to intubation…or not!
    yes you can leave the LMA in and ventilate on that alone…if it is working fine

    Rocuronium has an advantage over sux in RSA as it gives you more time to optimise the position of the LMA. intriguingly you could just use sedative only for placing the LMA. Propofol and fentanyl is pretty standard LMA anaesthetic. However if you are not familar with RSA, I would do exactly what you would do for RSI..sedative, sux, Fasciculate, LMa goes in…if happy with position give your rocuronium in preparation for your next step of intubation. At least now you know that you can ventilate successfully with a LMA..so if your intubation fails you can fall back to a secure technique that you know works..because you have tested it as your first step.
    I recommend using second generation LMA…the SUpreme , the AirQ blocker, the iGel. all are disposable and cost between $40- 70 ea. all have a gastric drain port. I carry Supremes in my car emergency kit and no longer have intubating gear. its eitherthe supreme or a surgical airway in my planning for a roadside trauma attendance. Dont let anaesthesia influence your decision as they have different priorities for buying LMAs..generally they want reuseable ones suited for elective cases.
    Now the next stage in RSA if you are keen to maximise operational resilience is to learn to intubate via the LMA you have just inserted. This is one thing I will credit that anaesthetists for doing very well and publishing research on. However the technique was first taught to me by Levitan himself.
    You will need to use a LMA, SGA that is designed to intubate via.I recommend either the Fastrach ILMA disposable,$120 ea, or the iGel or AirQ blocker. Using a classic LMA type device will only be frustrating! Scott has excellent podcasts from Jim DuCanto and Daniel Cook, both anaesthetists on technique to intubate via a LMA, SGA. it does involve spending more money on another device like the LevitanFPS stylet to allow a visually guided intubation technique via the LMA but its well worth it. It is not a hard technique to learn but takes about 15-20 attempts to achieve good success rates of over 95%. Thats the same with a Fastrach ILMA

    Having said all that you dont even need to go that far!You can simply use the LMA you have already for RSA, drop it in, improve the patients condition, then when you are ready, remove the LMA and try to intubate. Ifyou fail,simply reinsert the same LMA that you know is working and you can then decide to ventilate on LMA alone whilst waiting for backup…Braude has cases where they have left LMA in for transfer via helicopter, or to CT scanner and then to ICU withthe longesttime being around 24hrs or so….or you can decide to proceed to a surgical airway under LMA anesthetic support. A RFDS colleague of mine in Perth did one of these last year..just watch out for the spray of blood coming out once you breach the anterior tracheal wall! remember to tell your assistant to hold ventilation via lma when you are about to cut into the trachea..or at least ensure you are wearing proper PPE including goggles!
    Hope that helps Andy.

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