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Chapter 4 - Structured Planning of Airway Management

from Section 1 - Airway Management: Background and Techniques

Published online by Cambridge University Press:  03 October 2020

Tim Cook
Affiliation:
Royal United Hospital, Bath, UK
Michael Seltz Kristensen
Affiliation:
Rigshospitalet, Copenhagen University Hospital, Denmark
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Summary

When airway management is indicated, to avoid a bad outcome, patient safety will be maximised by careful decision making about and careful implementation of the chosen approach. This chapter addresses planning for the safest approach to securing the airway by assessing the patient for anatomical and physiological predictors of difficulty with airway management. When such difficulty is predicted, awake tracheal intubation will often provide the best margin of safety; indications for the procedure are discussed. Equally, when technical difficulty is predicted, the pre-conditions required to safely proceed with airway management after the induction of general anaesthesia are addressed. Predicted or not, difficulty encountered with tracheal intubation or supraglottic airway use in the unconscious patient must be met with a methodical and stepwise approach. This includes calling for help, maintaining patient oxygenation and methodically proceeding from one device type or technique to another, thus avoiding multiple futile attempts with the same device. Failure of a maximum of three attempts at the intended technique (most often tracheal intubation or use of a supraglottic airway) should be taken as an indication to refrain from further attempts, call for help, maintain patient oxygenation and reassess the plan for next steps. Finally, a ‘cannot intubate, cannot oxygenate’ situation is defined by the failure to successfully oxygenate the patient with all of tracheal intubation, face mask ventilation or a supraglottic airway and requires prompt front of neck airway access (‘surgical airway’).

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Publisher: Cambridge University Press
Print publication year: 2020

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References

Further Reading

Amathieu, R, Combes, X, Abdi, W, et al. (2011). An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrach): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology, 114(1), 2533.Google Scholar
ANZCA. (2016). Guidelines for the Management of Evolving Airway Obstruction: Transition to the Can’t Intubate Can’t Oxygenate Emergency [cited 2018 January 22]. Available at: http://www.anzca.edu.au/getattachment/resources/professional-documents/ps61_guideline_airway_cognitive_aid_2016.pdf.Google Scholar
Apfelbaum, JL, Hagberg, CA, Caplan, RA, et al. (2013). Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology, 118(2), 251270.Google ScholarPubMed
Chrimes, N. (2016). The Vortex: a universal ‘high-acuity implementation tool’ for emergency airway management. British Journal of Anaesthesia, 117(Suppl 1), i20i27.CrossRefGoogle ScholarPubMed
Cook, TM, Woodall, N, Frerk, C; Fourth National Audit Project. (2011). Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. British Journal of Anaesthesia, 106(5), 617631.Google Scholar
Cook, TM, Woodall, N, Harper, J, Benger, J; Fourth National Audit Project. (2011). Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. British Journal of Anaesthesia, 106(5), 632642.CrossRefGoogle Scholar
Duggan, LV, Ballantyne Scott, B, Law, JA, Morris, IR, Murphy, MF, Griesdale, DE. (2016). Transtracheal jet ventilation in the ‘can’t intubate can’t oxygenate’ emergency: a systematic review. British Journal of Anaesthesia, 117(Suppl 1), i28i38.CrossRefGoogle ScholarPubMed
Frerk, C, Mitchell, VS, McNarry, AF, et al. (2015). Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia, 115(6), 827848.Google Scholar
Heidegger, T, Hagberg, CA. (2018). Algorithms for management of the difficult airway. In: Hagberg, CA, Artime, CA, Aziz, MF (Eds.), Hagberg and Benumof’s Airway Management. 4th ed. Philadelphia: Elsevier. pp. 203214.Google Scholar
Heidegger, T, Schnider, TW. (2017). ‘Awake’ or ‘sedated’: safe flexible bronchoscopic intubation of the difficult airway. Anesthesia & Analgesia, 124(3), 996997.CrossRefGoogle ScholarPubMed
Heidegger, T, Gerig, HJ, Ulrich, B, Kreienbuhl, G. (2001). Validation of a simple algorithm for tracheal intubation: daily practice is the key to success in emergencies – an analysis of 13,248 intubations. Anesthesia & Analgesia, 92(2), 517522.Google Scholar
Law, JA, Broemling, N, Cooper, RM, et al. (2013). The difficult airway with recommendations for management – part 1 – difficult tracheal intubation encountered in an unconscious/ induced patient. Canadian Journal of Anaesthesia, 60(11), 10891118.Google Scholar
Mosier, JM, Joshi, R, Hypes, C, Pacheco, G, Valenzuela, T, Sakles, JC. (2015). The physiologically difficult airway. The Western Journal of Emergency Medicine, 16(7), 11091117.Google Scholar
Norskov, AK, Rosenstock, CV, Wetterslev, J, Astrup, G, Afshari, A, Lundstrom, LH. (2015). Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia, 70(3), 272281.CrossRefGoogle ScholarPubMed
Piepho, T, Cavus, E, Noppens, R, et al. (2015). S1 guidelines on airway management: Guideline of the German Society of Anesthesiology and Intensive Care Medicine. Anaesthesist, 64(Suppl 1), 2740.Google Scholar
Rosenblatt, W, Ianus, AI, Sukhupragarn, W, Fickenscher, A, Sasaki, C. (2011). Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesthesia & Analgesia, 112(3), 602607.Google Scholar

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