If Intubation Is Difficult

If Intubation Is Difficult

If the intubation proves difficult, cricoid pressure is maintained and the patient is gently ventilated with oxygen until another intubation attempt can be performed. If intubation is still unsuccessful, spontaneous ventilation should be allowed to return and an awake intubation performed.

• Intubation is unexpectedly difficult. Ensure that the cricoid pressure is not pushing the larynx to one side. If it is, move the larynx and cricoid cartilage by moving your assistant's hand to the correct position. Do not release cricoid pressure. If the suxamethonium needs to be repeated remember to give atropine before the second dose to avoid bradycardia, and ventilate the patient gently to prevent hypoxia. Maintain cricoid pressure at all times. If intubation proves impossible then carry on as described under failed intubation.
• Failed intubation: If intubation proves impossible then it is best to accept the situation and adopt an alternative anesthetic technique instead of wasting time with repeated intubation attempts. The possible options are to continue with a mask anaesthetic (provided the airway is easy to maintain while keeping a cricoid pressure) or to wake the patient up after turning them on their side.
• The cricoid cartilage is difficult to identify: Using firm pressure with your index finger follow a line down the front of the neck from the front of the mandible. The first 'solid' structure you meet is the hyoid bone, followed by the thyroid cartilage (Adam's apple) which is much more prominent in males. Immediately below this you will feel a gap between the cricoid and thyroid cartilages (the cricothyroid ligament) and then the cricoid cartilage. Encourage your assistants to practice finding the cricoid cartilage on other colleagues until they are confident.
• The patient regurgitates despite the application of cricoid pressure: If there is only a small quantity of fluid suck it out of the pharynx and intubate the patient. Use a suction catheter to aspirate the trachea after intubation. If there is copious fluid then the patient should be turned on to the side and placed head down to protect the airway. Suction the pharynx and then intubate the patient.