**5. Suggested airway management technique**

#### **5.1 Preoxygenation**

Preoxygenation is critical to success and safety of emergency intubation, especially when rapid sequence induction and intubation (RSI) is used. The best way to provide high fraction of inspired oxygen (FiO2; 100) for preoxygenation is by using a standard reservoir facemask with the oxygen flow rate set as high as possible. Patients should be preoxygenated for 3 min or 8 maximal capacity breaths if time is short. It is best to preoxygenate patients in a head-elevated position or in reverse Trendelenburg, especially if the patient is obese. Apneic oxygenation is a relatively new concept that can help prevent oxygen desaturation during RSI. This is best accomplished by placing a nasal cannula (with an oxygen flow rate more than 15 L/min) under the facemask during preoxygenation and leaving it in place during intubation [16].

Patients may be classified into the following three groups when deciding how to intubate:

• Group 1 (G1): Those at low risk of difficulty.


Patients with low risk of difficulty G1: Needs direct laryngoscopy and standard equipment with usual backup.

Patients with a higher risk of difficulty and uncertainty G2: Different plans should be ready, including video laryngoscopy (VL), suitable laryngeal masks (LMA) and emergent surgical airway.

Patients who are known difficult G3: Awake technique and spontaneous ventilation are maintained; fiberoptic intubation or elective surgical airway (tracheostomy).

#### **5.2 Awake fiberoptic intubation**

The technique has the advantage that patient is breathing throughout, however it has many disadvantages and limitations when used for management of patients with airway trauma.

The airway visualization is challenging with ongoing haemorrhage, the use of local anaesthetic is difficult due to trauma and hemorrhage and the procedure itself needs cooperative patient and expert anaesthesiologist.

When airway management is beyond emergency situations, the patient is stable with SpO2 > 90% and in operating theater, the following situations should be considered:

#### **5.3 Patients with full stomach**

In general, all patients with trauma should be managed as with full stomach until proved otherwise. The risk of regurgitation and aspiration of food or swallowed and ingested blood is high.

Evacuating the contents of the stomach may be tried by the insertion of nasogastric tube before starting airway management in cooperative patients and in the absence of contraindications as mid face fractures. Applying cricoid pressure in not indicated any more with induction of anaesthesia in patients with trauma [17, 18] as it may itself hamper endotracheal tube insertion, may cause rupture oesophagus and its efficiency is suspected [19, 20].

#### **5.4 Patients with C-spine injury**

Any patient with trauma to the head and neck is considered to have C-spine injury till proved otherwise [21, 22].

Those patients are kept in neck collar and cervical spine inline stabilization during insertion of endotracheal tube to prevent neck movement, which may worsen intubating conditions [8].

Indirect video laryngoscopy (**Figure 3**) is proved to be useful compared to conventional direct laryngoscopy in some studies, when used for patients who need to be immobilized during intubation [23–25].

#### **5.5 Nature of injury and decision making**

According to the nature of maxillofacial trauma and the previous classification to six criteria either single or mixed, the decision of endotracheal intubation and

**59**

space (**Figure 4**).

**Figure 3.**

fractures [29].

**5.6 Submental orotracheal tube intubation**

*Airway Trauma: Assessment and Management DOI: http://dx.doi.org/10.5772/intechopen.96894*

whether oral or nasal and the possibility to do surgical airway should be discussed before starting the procedure between the attending anaesthesiologist and surgeon. The level of experience with airway management should be the highest in the hospital especially with G2 and G3 patients. Nasal intubation is preferred by most of maxillofacial surgeons especially when the mouth is closed at the end of surgery by maxilla-mandibular fixation (MMF) [26]; however it is contraindicated in patients with mid-face and base of the skull fractures [27]. Decongestant nasal drops have to be used to reduce nasal vascularity before insertion of nasotracheal tube, secure the tube position by a loose stitch to the columella of the nose [28], oral insertion of the tube is fixed strongly by tape with tincture benzoin or by submental insertion as both anaesthesia and surgery teams share the same work

*Indirect videolaryngoscopy with permission from Verathon, Inc., Bothell, WA.*

The technique was described to give the surgeon full access to the oral cavity and is indicated in patients with mid-face comminuted fracture, when nasal intubation is contraindicated, or in those patients who require restoration of the occlusion and

The technique is contraindicated in inpatients with comminuted mandibular

their condition permits extubating patients at the end of surgery [29].

*Airway Trauma: Assessment and Management DOI: http://dx.doi.org/10.5772/intechopen.96894*

*Special Considerations in Human Airway Management*

difficult.

(tracheostomy).

with airway trauma.

considered:

equipment with usual backup.

(LMA) and emergent surgical airway.

**5.2 Awake fiberoptic intubation**

**5.3 Patients with full stomach**

lowed and ingested blood is high.

and its efficiency is suspected [19, 20].

**5.4 Patients with C-spine injury**

injury till proved otherwise [21, 22].

to be immobilized during intubation [23–25].

**5.5 Nature of injury and decision making**

intubating conditions [8].

needs cooperative patient and expert anaesthesiologist.

• Group 2 (G2): Those at higher risk of difficulty (as the real difficulty is uncertain).

Patients with low risk of difficulty G1: Needs direct laryngoscopy and standard

The technique has the advantage that patient is breathing throughout, however it has many disadvantages and limitations when used for management of patients

The airway visualization is challenging with ongoing haemorrhage, the use of local anaesthetic is difficult due to trauma and hemorrhage and the procedure itself

When airway management is beyond emergency situations, the patient is stable

In general, all patients with trauma should be managed as with full stomach until proved otherwise. The risk of regurgitation and aspiration of food or swal-

Evacuating the contents of the stomach may be tried by the insertion of nasogastric tube before starting airway management in cooperative patients and in the absence of contraindications as mid face fractures. Applying cricoid pressure in not indicated any more with induction of anaesthesia in patients with trauma [17, 18] as it may itself hamper endotracheal tube insertion, may cause rupture oesophagus

Any patient with trauma to the head and neck is considered to have C-spine

Indirect video laryngoscopy (**Figure 3**) is proved to be useful compared to conventional direct laryngoscopy in some studies, when used for patients who need

Those patients are kept in neck collar and cervical spine inline stabilization during insertion of endotracheal tube to prevent neck movement, which may worsen

According to the nature of maxillofacial trauma and the previous classification to six criteria either single or mixed, the decision of endotracheal intubation and

with SpO2 > 90% and in operating theater, the following situations should be

Patients with a higher risk of difficulty and uncertainty G2: Different plans should be ready, including video laryngoscopy (VL), suitable laryngeal masks

Patients who are known difficult G3: Awake technique and spontaneous ventilation are maintained; fiberoptic intubation or elective surgical airway

• Group 3 (G3): Those with known airway difficulty or are highly likely to be

**58**

```
Figure 3.
Indirect videolaryngoscopy with permission from Verathon, Inc., Bothell, WA.
```
whether oral or nasal and the possibility to do surgical airway should be discussed before starting the procedure between the attending anaesthesiologist and surgeon. The level of experience with airway management should be the highest in the hospital especially with G2 and G3 patients. Nasal intubation is preferred by most of maxillofacial surgeons especially when the mouth is closed at the end of surgery by maxilla-mandibular fixation (MMF) [26]; however it is contraindicated in patients with mid-face and base of the skull fractures [27]. Decongestant nasal drops have to be used to reduce nasal vascularity before insertion of nasotracheal tube, secure the tube position by a loose stitch to the columella of the nose [28], oral insertion of the tube is fixed strongly by tape with tincture benzoin or by submental insertion as both anaesthesia and surgery teams share the same work space (**Figure 4**).
