Clinical review: Management of difficult airways

Olivier Langeron,Julien Amour,Frédéric Aubrun,Benoît Vivien

doi:10.1186/cc5112

Abstract

Difficulties or failure in airway management are still important factors in morbidity and mortality related to anesthesia and intensive care. A patent and secure airway is essential to manage anesthetized or critically ill patients. Oxygenation maintenance during tracheal intubation is the cornerstone of difficult airway management and is always emphasized in guidelines. The occurrence of respiratory adverse events has decreased in claims for injuries due to inadequate airway management mainly at induction of anesthesia. Nevertheless, claim reports emphasize that airway emergencies, tracheal extubation and/or recovery of anesthesia phases are still associated with death or brain damage, indicating that additional educational support and management strategies to improve patient safety are required. The present brief review analyses specific problems of airway management related to difficult tracheal intubation and to difficult mask ventilation prediction. The review will focus on basic airway management including preoxygenation, and on some oxygenation and tracheal intubation techniques that may be performed to solve a difficult airway.

Highlights

Difficulties or failure in airway management are still important factors in morbidity and mortality related to anesthesia [1,2,3,4]
The occurrence of respiratory adverse events has decreased in claims for injuries due to inadequate ventilation and, to a lesser extent, for injuries due to esophageal intubation, as a result of better monitoring with pulse oxymetry and capnography use [1]
Difficult tracheal intubation (DTI), remains relatively constant among anesthesiarelated patient injuries, and is the third most common respiratory-related event leading to death and brain damage in the American Society of Anesthesiologists closed claims analysis [1]

Summary

Introduction

Difficulties or failure in airway management are still important factors in morbidity and mortality related to anesthesia [1,2,3,4]. Preoxygenation in hypoxemic patients using noninvasive ventilation, with a pressure support mode adjusted to obtain an expired tidal volume of 7–10 ml/kg with a positive end-expiratory pressure level of 5 cmH2O during 3 minutes, was recently reported in a prospective randomized study to be significantly more effective at reducing arterial oxygen desaturation during tracheal intubation than the usual method [35]. When the positive end-expiratory pressure (+10 cmH2O) was applied during anesthesia induction, a greater safety margin to control the airway in morbidly obese patients was observed in comparison with induction without the positive end-expiratory pressure, increasing the nonhypoxic apnea duration [37] At this stage, it is important to distinguish the two main clinical situations of DAM: anticipated DTI and unanticipated. This technique has to be incorporated into DAM, and, like cricothyroidotomy, may solve a glottic or subglottic problem such as a tumor, an abscess or a hematoma [5,6,7,8,9]

Conclusion

Cheney FW

31. Benumof JL

Findings

40. Benumof JL