Unexpected Difficult Intubation Research Articles

A different airway management in double lumen tube intubation due to unexpected difficult airway

A difficult airway is when an experienced anesthesiologist has difficulty in providing ventilation with a mask and/or endotracheal intubation. In cases where intubation cannot be achieved with laryngoscopy, devices such as laryngeal mask airway (LMA) or fiberoptic bronchoscope (FOB) can greatly contribute to the management of the difficult airway. This process may be further complicated when direct laryngoscopy and DLT intubation fail. In this case, the first goal should be to reach the airway. For this purpose, a single-lumen tube can be used first. Although there is not yet a clear algorithm for difficult intubation in DLT insertion, the gum elastic bougie (GEB) is widely used in clinical practice for this purpose. In this case report, we wanted to highlight two of our cases in which we encountered unexpected difficult intubation and we achieved successful endobronchial intubation with FOB-guided GEB through the LMA.

Unexpected Difficult Intubation caused by Undiagnosed Laryngeal Tuberculosis in a Patient Requiring Pericardiectomy for Tuberculosis Pericarditis: A Case Report

Airway management is a critical aspect of anesthesia, and difficulties in endotracheal intubation can lead to life threatening complications. While an anticipated difficult intubation can be managed with proper preparation and planning, unexpected difficult intubation can be a challenging situation even to skilled anesthesiologists. We experienced unexpected difficult intubation in a 66-year-old male patient with known tuberculosis pericarditis scheduled for elective pericardiectomy surgery. Multiple intubation attempts were made using various techniques, and successful intubation was achieved with a smaller diameter endotracheal tube. Surgery was uneventful and post-operative evaluation of the airway confirmed laryngeal tuberculosis. This case highlights the importance of vigilance in managing unexpected difficult intubation, especially in patients with a history of tuberculosis or immunosuppressive conditions. Prompt recognition of airway stenosis and appropriate interventions are crucial in securing the airway patency to minimize complications in patients with undiagnosed tuberculosis laryngitis.

Prevalence of Obstructive Sleep Apnea in Patients with Difficult Intubation: Looking for Evidence?

BACKGROUND: The link between obstructive sleep apnea and difficult intubation needs to be fully investigated and made clear. If a compromised airway can be anticipated and managed; it can lessen the likelihood of adverse consequences. AIM: The aim of this study was to investigate the incidence, severity, and possible association of obstructive sleep apnea in individuals with unexpected difficult endotracheal intubation and their associated clinical and polysomnographic findings. METHODS: Thirty patients referred for examination after difficult endotracheal intubation were enrolled in the study group, while 30 cases from the sleep laboratory unit database with a history of surgical intervention without difficult intubation were randomly selected for the control group. Documentation was obtained for the office clinical examination and fiber-optic nasopharyngolaryngoscopy assessment by Muller maneuver. The inspected upper airway was graded clinically using the Modified Mallampati technique. A comprehensive polysomnographic assessment was done overnight. The available data from the anesthetic record, as well as those derived from clinical and polysomnographic examination, such as age, sex, Body mass index, M Mallampati score, clinical positive findings, Cormack and Lehane grade, Apnea-Hypopnea Index (AHI), desaturation index, and average O2%, were statistically analyzed. RESULTS: The mean ± SD of the AHI of the study group was (29.7 ± 16.1) while in the control group, it was (13.1 ± 9.9), and the difference was of statistical significance (p < 0.001). The grading of the severity of obstructive sleep apnea (OSA) was significantly different between both groups, with 53.3% of the studied cases having severe OSA and the rest having moderate (26.7%) or mild OSA (13.3%). The desaturation index was significantly higher in the study group (28.9 ± 17.4) than the control group (10.2 ± 7.4), while the average O2% saturation was significantly lower among cases (91.8 ± 6.2). The mean modified Mallampati score was significantly higher among cases with grade III-CL, and the significance was also noticed in class IV. CONCLUSION: OSA is a major risk factor for difficult airway management and OSA patients are more likely to have difficult intubations. Patients who underwent a difficult intubation had a higher incidence and severity of OSA compared to the control group. OSA severity and higher modified Mallampati scores were independently related.

Unexpected difficult intubation with a double-lumen tube in a case of asymptomatic vallecular cyst.

Vallecular cyst (VC) can cause difficult intubation. If a double-lumentube (DLT) has to be placed, difficulty in tracheal intubation becomes more complicated. The gum elastic bougie (GEB) is a widely used device for facilitating tracheal intubation.However, there is not enough study with DLT to make a predictionfor success of GEB-guided intubation. Here, we aimed to describe our approach during unexpected difficult intubation due to VC in a patient required DLT insertion. We emphasize that, in case of confronting a patient with asymptomatic VC as a cause of difficult intubation, a successful DLT intubation is possible by sliding endobronchial lumen of DLT over pediatric GEB.

Bir Anesteziyoloğun Korkulu Rüyası: Entübasyon Sonrası Trakea Rüptürü

Endotracheal intubation is a relatively easy procedure, however, complications may occur due to this easy procedure. Practitioners should be ready for unexpected difficult intubation and treat in the lights of guidelines. We herein describe a 48 years old female tracheal rupture case which was diagnosed intraoperatively and treated immediately after diagnosis. Although tracheal rupture after intubation is very rare; respiratory insufficiency, emphysema, even death may happen as a result. Clinical suspicion is the first and the most important step at the diagnosis of the ruptures. An emergency bronchoscopy, chest X-ray and computerized tomography of thorax are necessary for diagnosis of the type and the extention of the laseration. In the literature conservative and surgical therapies are both appropriate for treatment of membranous tracheal rupture. In this case report, the causes of tracheal rupture after unexpected difficult intubation and its treatment approach are explained.

Difficult airway management practice changes after introduction of the GlideScope videolaryngoscope: A retrospective cohort study.

Introduction of the GlideScope videolaryngoscope caused a change in use of other devices for difficult airway management. The influence of the GlideScope videolaryngoscope on changes in the indications for and the frequency of use of flexible fibreoptic-assisted intubation and other difficult airway management techniques. Retrospective cohort study. Tertiary care referral centre. Two periods of equal length (647 days each) before and after introducing the GlideScope were compared. Information about patients who were intubated using nondirect laryngoscopic techniques were analysed. Data were retrieved from the anaesthesia and hospital information management systems. Difficult airway management techniques were used in 235/8306 (2.8%) patients before and in 480/8517 (5.6%) (P < 0.0001) patients after the introduction of the GlideScope. There was an overall 44.4% reduction in use of flexible fibreoptic bronchoscopy after GlideScope introduction [before 149/8306 (1.8%); after 85/8517 (1.0%), P < 0.0001]. The GlideScope replaced flexible fibreoptic bronchoscopy in most cases with expected and unexpected difficult intubation. In patients with limited mouth opening, flexible fibreoptic bronchoscopy was still mostly the first choice after the introduction of the GlideScope. There was a 70% reduction in the use of other difficult intubation techniques after the introduction of the GlideScope [before 84/8306 (1.0%); after 22/8517 (0.3%), P < 0.0001)]. The GlideScope videolaryngoscope replaced flexible fibreoptic bronchoscopy for most patients with expected and unexpected difficult intubation. In the case of limited mouth opening, flexible fibreoptic bronchoscopy was still the first choice after the introduction of the GlideScope. The reduced use of flexible fibreoptic bronchoscopy raises concerns that residents may not be adequately trained in this essential airway management technique. GlideScope use was disproportionately greater than the reduction in the use of flexible fibreoptic bronchoscopy and other difficult intubation techniques. This may be attributed to resident teaching and use in patients with low-to-moderate suspicion of difficult intubation.

Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists.

SummarySevere acute respiratory syndrome‐corona virus‐2, which causes coronavirus disease 2019 (COVID‐19), is highly contagious. Airway management of patients with COVID‐19 is high risk to staff and patients. We aimed to develop principles for airway management of patients with COVID‐19 to encourage safe, accurate and swift performance. This consensus statement has been brought together at short notice to advise on airway management for patients with COVID‐19, drawing on published literature and immediately available information from clinicians and experts. Recommendations on the prevention of contamination of healthcare workers, the choice of staff involved in airway management, the training required and the selection of equipment are discussed. The fundamental principles of airway management in these settings are described for: emergency tracheal intubation; predicted or unexpected difficult tracheal intubation; cardiac arrest; anaesthetic care; and tracheal extubation. We provide figures to support clinicians in safe airway management of patients with COVID‐19. The advice in this document is designed to be adapted in line with local workplace policies.

VALIDITY OF CERTAIN BEDSIDE TESTS IN PREDICTING DIFFICULT ENDOTRACHEAL INTUBATION

Unexpected difficult endotracheal intubation remains the main concern of anesthesiologists. This study aimed to compare validity and role of 7 bedside techniques of assessment used in predicting difficult intubation. This prospective study included 80 patients scheduled for surgery. Before induction of anesthesia, bedside tests for predicting difficult intubation were done, these tests are: Prayer sign, Thyromental distance, Mallampati test, The inter incisor distance, Palm print test, Upper lip bite test, and Wilson scoring system. During induction of anesthesia, laryngoscopic view was evaluated. Values for each test were calculated and compared. The results showed that, the highest sensitivity (62.5%) was for Mallampati and thyromental distance but despite that, they differed in their specificity and predictive values. Upper lip bite was 12.5% sensitive but had one of the highest specificity alongside with Mallampati test. Thyromental distance was 34.7% specific. Mallampati classes of more than class I was strongly associated with difficult intubation. The mouth gap of more than 4 cm was marginally associated with difficult intubation. The predictor Wilson showed a significant association with difficult intubation if the score exceeded 3.5. The upper lip bite of more than class I was slightly associated with difficult intubation. In conclusion, Mallampati classification and thyromental distance are superior to other available tests to predict difficult intubation, performing these two tests alone is relatively adequate to predict intubation difficulty. Keywords: Difficult endotracheal intubation, The inter incisor distance, Wilson scoring system, Mallampati test, Palm print test, Prayer sign, Upper lip bite test, and Thyromental distance.

Evaluation of the Airtraq video laryngoscope as a rescue device after difficult direct laryngoscopy

Abstract Background and objectives Unexpected difficult tracheal intubation and failure to intubate are among the leading causes of anaesthesia-related morbidity and mortality. This study was undertaken to evaluate the effectiveness of the Airtraq video laryngoscope for tracheal intubation after difficult direct laryngoscopy. Methods 75 patients undergoing elective surgery under general anaesthesia and whose direct laryngoscopy by a senior anaesthesiologist exhibited Cormack–Lehane grade 2b, 3 or 4 were enrolled. Results The Glottic view was improved in all patients when using the Airtraq video laryngoscope, compared with Macintosh laryngoscope. The view was improved by 2 degrees in 17.3% of the cases, by three in 60% and by four grades in 22.7% (p Conclusions Tracheal intubation using the Airtraq was effective, simple and safe in patients with difficult laryngoscopy. These results confirm that the Airtraq is a reliable video laryngoscope as a rescue device in cases of difficult laryngeal view with direct laryngoscopy.

Unexpected difficult intubation: A case report

Unexpected difficult intubation: A case report

The use of the C-MAC videolaryngoscope for awake intubation in patients with a predicted extremely difficult airway: case series.

The C-MAC videolaryngoscope was evaluated for intubation in patients with predicted extremely difficult airway. The presented cases are patients with neoplasm tumors in larynx. In all cases, awake intubation using C-MAC videolaryngoscope was performed in patients breathing spontaneously, under local anaesthesia, with oxygen administered via nasal catheter. All intubations were successful and uneventful. The pre-surgery examination (CT scans and fiberscope laryngeal examination) was compared with view of larynx obtained during laryngoscopy. Based on my experience, I assume that C-MAC videolaryngoscope is a very useful tool for anaesthesiologists and can be applied not only for unexpected difficult intubation but also for predicted difficult airway. Moreover, it could be used as an additional diagnosis tool before larynx surgery. The view obtained with the C-MAC videlaryngoscope corresponds with larynx examination performed before surgery, and could potentially reveal more details.

A Comparative Study of Intubating Conditions between PropofolFentanyl-Midazolam and Propofol-Fentanyl-Lignocaine Groups without Neuromuscular Blocking Agents

A Comparative Study of Intubating Conditions between PropofolFentanyl-Midazolam and Propofol-Fentanyl-Lignocaine Groups without Neuromuscular Blocking Agents

Unexpectedly difficult airway

Introduction: Difficult airway is defined as ‘clinical situation where an experienced anesthesiologist has difficulty in ventilation patient’s facial mask difficulty in tracheal intubation or loth’ The assessment of the airway is one of the first and key step in anesthetit preoperative examination, and determined strategy to plan positioning of patients, equipment, technology and medicine. There are few difficult airway predictors: obesity, deformities of the jaw and neck, macroglossia, interincisor small space, prominent chest, large breasts, small tireomental distance. The most commonly used Mallampati, wherein the class 3 and 4 predictors of difficult intubation. The most useful is a combination of tests, there is no perfect predictor for assessing airway difficulties, unexpected difficult intubation in practice occur from time to time. Objective: Case report of unanticipated difficult intubation, analysis procedures and measures taken. Materials and method: A descriptive method, the data from the anesthetic records. Case report: A 62 year old female patient, weighing 50 kg and a height of 160 cm, is preparing for the planned operation, with the diagnosis: Tumor ovarii dextri per magna. Without significant comorbidity. In assessing the airway, patient had sufficient mobility of the neck, tireomental distance, Mallampati class 2, not obese, only interincisor space limits of about 3 cm. The possibility for difficult ntubation is not anticipated. After premedication, the patient is positioned in a horizontal position. After the introduction of anesthesia, ventilation facial mask was good. After aplication short acting depolarizing muscle relaxants, access to laryngoscopy. It is observed that a large epiglottis is impossible to raise, and plicae vocalis were unavailable for visualization. Endotracheal intubation was attempted in 3 times. After the failure, the supraglottic device laryngeal mask was placed. Laryngeal mask was not positioned satisfactorily to achiev the correct ventilation. Because insufflation of air in the stomach and unsatisfactory ventilation, we made a decision to postpone the surgery for a few days. The patient wakes up, breathe spontaneously. All data, with detailed descriptions were recorded in the anesthetic card. Confronted with the unanticipated difficult intubation, anesthetic team is thoroughly prepared for delayed surgery, and changes the strategy for airway management. The patient is placed in the anti-Trendeleburg position, the head is elevated, thus the axes of the upper airway and allows a better visualization of anatomical structures. One anesthesiologist approach to direct laryngoscopy, and other performed BURP maneuver (Backward, Upward, Rightward Pressure), approaching structures of the larynx, and allows visualization of the successful intubation. Discussion and conclusion: The Guide Association for difficult airway from 2015 emphasis on careful planning and detailed knowledge of the entire team with the strategy of securing the airway. The positioning of the head and neck must be optimized from the start to make the first intubation attempt successful. Equipment for difficult intubation must be easily accessible. All the difficulties must bedetaily noted in the medical records, which is of great importance for the anesthesiologist and patient with possible following surgery.

Abstract PR585

Background & Objectives: Anesthesiologists from high-income countries are increasingly interested in global humanitarian missions in LMLRCs, and airway management skills are required in adequate emergencies management. There is growing evidence of the successfully use of Airtraq to assist both expected and unexpected difficult intubation scenarios, and we hypothesize if it would be an optimal device in LMICs. Materials & Methods: Between 2014 and 2016 we accomplish 600 preanesthesia evaluations, and carried out a retrospective review of difficult intubations situations occurred in the 200 procedures performed at the Auberge de l’Amour Redempteur hospital, Dangbo, Benin. Individual data points included age, sex, surgical indication and procedure, airway device employed, and outcomes. Results: In adults, the most common surgical indication were both giant inguinal hernia and giant goiter. We found Airway-related symptoms in 85% goiter patients (13), with predictive factors of difficult intubation in 100% (16). Airway management of thyroid surgeries were performed with Airtraq and Frova extraglottic device without complications.Conclusion: More than 230 million surgical procedures are annually performed in the world, 8.1 million (3.5%) in LMLRCs. Difficult airway management is especially important in these contest. DAS 2015 guidelines remember human factors issues contributed to adverse outcomes in 40% of the instances reported to the NAP4, and explicitly indicate that in Unanticipated Difficult Intubations cases reported Airtraq was used most frequently. Endotracheal intubation is a lifesaving procedure, but a difficult skill to learn and requires a great deal of clinical experience to master. Videolaryngoscopes offer an improved view compared with conventional laryngoscopy,and all anaesthetists should be trained to use, and have immediate access to a videolaryngoscope. Airtraq have proved advantages over the direct laryngoscope, portable, resistant, economical and cost-effective. And this review of 16 goiter LMICs procedures provides valuable insight into the opinnion that Airtraq should be a gold standar in airway management LMLRCs. Disclosure of Interest: None declared

Unexpected Difficulties during Intubation: There is Always Something New and it Could Happen to You

A case report of an unexpected and unexplained difficult intubation due to limited mouth opening that did not exist preoperatively.

Difficult Airway Management in Patients Submitted to General Anesthesia. Is it a Matter of Devices or Predictive Scores?

Background: Incidence of difficult tracheal intubation in elective surgery population varies in a wide range, with estimated pooled frequency of 6.8%. Unanticipated difficult intubation has been reported in 1.5 8.5% of all general anesthesia. Among devices providing indirect laryngoscopy, Truview EVO2 ® offers advantages in terms of glottic exposure, short training, and low cost. Methods: Retrospective review of unexpected difficult intubation among 24.500 patients scheduled for elective surgery under general anesthesia over a 44 months period. Direct laryngoscopy was first performed in all patients, thus, in case of any difficulty encountered, an alternative device was utilized. Incidence and characteristics of difficult intubation are reported. Preoperative airway evaluation parameters have been correlated with intubation difficulty. Results: Difficult tracheal intubation (DTI) was observed in 0.4% (90 patients). Truview laryngoscope has been used in 59 of 90 patients and succeeded in achieving intubation in 75% of cases. Among risk factors for difficult intubation, neither Mallampati class nor Body Mass Index (BMI) were shown to have high predictive value. An El-Ganzouri Risk Index (EGRI) score of 3 has been estimated to represent the cut-off value between easy and difficult intubation. Conclusion: Truview laryngoscope represents a useful tool in case of unexpected difficult intubation, and could be eventually introduced in a difficult airway management algorithm without burden on Unit costs and staff training. DTI predictive scores have been applied in clinical practice but still lack in cut-off values validation. As in our experience the risk score failed in predicting difficult airway, we speculate that the Anesthesiologist’s confidence with one or more alternative intubation devices could obviate the need for predictive scores. patient airway occurs, exposes the patient to the risk of complications basically related to hypoxia. Its incidence has been reported around 1-4% of patients with normal airway and, more recently, in a range of 1.5 8.5% of all general anesthesia [2,3]. Management of unanticipated difficult airways has been standardized in various algorithms, with an increasing need in updating related to development of novel devices [4].

Encountering unexpected difficult airway: relationship with the intubation difficulty scale.

BackgroundAn unexpected difficult intubation can be very challenging and if it is not managed properly, it may expose the encountered patient to significant risks. The intubation difficulty scale (IDS) has been used as a validated method to evaluate a global degree of intubation difficulty. The aims of this study were to evaluate the prevalence and characteristics of unexpected difficult intubation using the IDS.MethodsWe retrospectively reviewed 951 patients undergoing elective surgery in a single medical center. Patients expected to have a difficult intubation or who had history of difficult intubation were excluded. Each patient was assessed by the IDS scoring system with seven variables. Total prevalence of difficult intubation and the contributing individual factors were further analyzed.ResultsFor the 951 patients, the difficult intubation cases presenting IDS > 5 was 5.8% of total cases (n = 55). The prevalence of Cormack-Lehane Grade 3 or 4 was 16.2% (n = 154). Most of the difficult intubation cases were managed by simple additional maneuvers and techniques such as stylet application, additional lifting force and laryngeal pressure.ConclusionsUnexpected difficult airway was present in 5.8% of patients and most was managed effectively. Among the components of IDS, the Cormack-Lehane grade was most sensitive for predicting difficult intubation.

Reporting critical incidents in a tertiary hospital: a historical cohort study of 110,310 procedures.

PurposeInvestigation of adverse events associated with anesthetic procedures is a method of quality control that identifies topics to improve clinical care and patient safety. Most research to date has been based on closed claim registries and anonymous reports which have specific limitations. Therefore, to evaluate a hospital’s reporting system, the present study was designed to describe critical incidents that anesthesiologists voluntarily and non-anonymously reported through an anesthesia information management system.MethodsThis is a historical observational cohort study on patients (age > 18 yr) undergoing anesthetic procedures in a tertiary referral hospital. A 20-item list of complications, as developed by the Netherlands Society of Anesthesiologists, was prospectively completed for each procedure. All critical incidents registered in the anesthesia information management system were then reclassified into 95 different critical incidents in a reproducible way.ResultsThere were 110,310 procedures performed in 65,985 patients, and after excluding 158 reports that did not depict a critical incident, 3,904 critical incidents in 3,807 (3.5%) anesthetic procedures remained. Technical difficulties with regional anesthesia (n = 445; 40 per 10,000 anesthetics; 95% confidence interval [CI], 36 to 44), hypotension (n = 432; 39 per 10,000 anesthetics; 95% CI, 35 to 43), and unexpected difficult intubation (n = 216; 20 per 10,000 anesthetics; 95% CI, 18 to 23) were the most frequently documented critical incidents.ConclusionAccurate measurement and monitoring of critical incidents is crucial for patient safety. Despite the risk of underreporting and probable misclassification of manual reporting systems, our results give a comprehensive overview on the occurrence of voluntarily reported anesthesia-related critical incidents. This overview can direct development of a new reporting system and preventive strategies to decrease the future occurrence of critical incidents.

Identification of ideal preoperative predictors for difficult intubation

Background: Unexpected difficult intubation is probably the result of inadequate preoperative examination of airway and a lack of accurate predictive tests for difficult intubation. Preoperative evaluation forms basis to suspect and be prepared for a difficult airway situation. Aim: The aim of our study was to identify the ideal preoperative predictors of difficult intubation. Materials and Methods: It was a Prospective Observational study done on 350 patients in a community-based hospital. Preoperative airway assessment included: Mallampati Class (MC), Mouth opening (MO), Thyromental distance (TMD), Ability to prognath (AP) and Neck mobility and size (NM). Monitors were attached, anesthesia induced and laryngoscopy performed. Intubation Difficulty Scale (IDS) score was used to grade difficulty in intubation. Results: The overall incidence of Difficult Intubation was 24.6 %. A slight difficulty in 24% (IDS = 1-5) and moderate to major difficulty (IDS >5) in 0.6% cases was noted. Intubation was possible in all the patients. Mallampati class III & Mouth opening was less than 4 cm in about 6% cases and Thyromental distance less than 6 cm in 5.4%. 12.5% were unable to prognath and Neck mobility was restricted in 4.6% patients. Sensitivity and specificity of MC- 16.3 % and 97%, MO- 16.3% and 96.6%, TMD - 12.8% and 97%, AP - 33.3% and 93.9% , NM - 10.5% and 97.3%. Positive and Negative Predictive Values for MC, MO, TMD, AP and NM were 63.6% and 78%, 60.9% and 78%, 57.9 and 77.3 %, 62.8% and 81.9%, 56.3% and 76.9% respectively. Conclusion: We concluded that Mallampati grading and ability to prognath are the most important of the variables studied.

Unexpected Difficult Intubation. Is it a Solvable Problem? Reflections for a Safe Approach

Approximately 4% of tracheal intubations are unexpectedly difficult. In the world annually million people have general anesthesia. In terms of numbers it is perhaps one of the most critical moments of the entire anesthetic procedure. Sophisticated tools, and scientific studies in opposition creates a sometimes very crowded and confusing area in which anesthesiologists, particularly the younger ones, find difficulties when they encounter so many options and are not sure which to choose. If you want a solution to the unexpected difficulties you must find a path reliable, simple and safe by identifying when and how to act and to insert into the training programs of the schools of anesthesia as a basic procedure . The review of the literature, analysis and revision of the tracheal intubation procedure for general anesthesia in elective surgery lead to the conclusion that a combined approach using tools that display the glottic region and instruments that also display the trachea allows the tube to be introduced and placed under vision and resolves the majority of difficult cases.