Understanding Anesthesiology - The Global Regional Anesthesia ...

The Difficult Airway
Airway mismanagement is a leading cause of anesthetic
morbidity and mortality and accounts for close to
half of all serious complications. The best way to prevent
complications of airway management is to be prepared.
Anticipation of the difficult airway (or difficult
intubation) and formulation of a plan to manage it
when it occurs, saves lives.
Anticipated difficult intubation: The use of an alternate
anesthetic technique (regional or local) may be the
most practical approach. If a general anesthetic is chosen,
then airway topicalization and awake intubation
(with fiberoptic bronchoscope) is the preferred technique.
In pediatric patients, neither a regional technique
nor an awake intubation is feasible. In this case,
induction of anesthesia with an inhaled agent such that
the patient retains spontaneous respiration is the safest
approach. Efforts are undertaken to secure the airway
once the child is anesthetized.
Unanticipated difficult intubation, able to ventilate
by mask: In this situation, one calls for help, repositions
the patient and reattempts laryngoscopy. The
guiding principle is to avoid multiple repeated attempts
which can lead to airway trauma and edema resulting
in the loss of the ability to ventilate the patient.
During the subsequent attempts at intubation, the anesthesiologist
considers using alternate airway techniques
(see section on adjuncts) or awakening the patient
to proceed with an awake intubation.
Unanticipated difficult intubation, unable to ventilate
by mask: This is an emergency situation. One calls for
help and attempts to insert an LMA which is likely to
facilitate ventilation even when mask ventilation has
failed. If an airway is not achievable by non-surgical
means, then a surgical airway (either needle cricothyrotomy
or tracheostomy) must not be delayed.
When a difficult airway is encountered, the anesthesiologist
must respond quickly and decisively. As in
many clinical situations which occur infrequently but
are associated with high rates of morbidity and mortality,
the management of the difficult airway is improved
by following well-developed algorithms. The American
Society of Anesthesiologists has published a “Difficult
Airway Algorithm” which is widely accepted as standard
of care. The algorithm is described in a lengthy
document such that a full explanation is beyond the
scope of this manual. The algorithm, as well as other
experts’ interpretations, are readily available on the
internet.
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