Difficult Airway Algorithm

Question 1

“BOOTS” for predicting a difficult airway

Answer 1

• Beard
• Obese
• Older
• Toothless
• Sounds (snoring etc)

Question 2

“OBESE-M” for predicting difficult masking

Answer 2

• Obese
• Beard
• Edentulous
• Snores
• Elderly
• Mallempati 3 or 4

Question 3

Criteria associated with difficult airway

Answer 3

• Large upper encisors or small insicor distance
• Strong overbite
• Inability to protrude mandilbe (upper-lip bite test)
• Mallampati 3 or 4
• Large tongue
• Marrow or high-arched palate
• Short thyromental distance
• excessive mandibular soft tissue
• short, thick neck
• decreased cervidal ROM

Question 4

Which questions, when answered “yes” should you proceed to an awake intubation?

Answer 4

• Suspected difficult laryngoscopy?
• suspected difficult ventilation with mask or supraglottic airway?
• significant risk of aspiration?
• increased risk of rapid desaturation?
• suspected difficult emergency invasive airway?

Any “yes” proceed to awake intubation

Question 5

What should you do when your awake intubation fails?

Answer 5

Consider other options or postpone the case

optimize oxygenation throughout

Question 6

What should you do if you have a failed intubation attempt after induction of GA?

Answer 6

• Limit attempts (prevent lots of swelling)
• call for help
• mask ventilate

Question 7

What should you do if you CAN mask ventilate but you have already failed a DL?

Answer 7

non-emergency pathway
- keep ventilating and oxygenating
- consider waking the pt up?
- consider alternative intubation approaches (video or fiberoptic?)

if at any time you cannot mask, or they start to desat, do the emergency airway pathway

Question 8

What do you do if you failed DL and you CANNOT mask ventilate?

Answer 8

• Consider a supraglottic airway?
• if failed, do emergency airway
• attempt alternate intubation as you prepare for emergency airway