Management of the difficult airway for general anesthesia
- William H Rosenblatt, MD
William H Rosenblatt, MD
- Professor of Anesthesiology and of Surgery (Otolaryngology)
- Director, Anesthesia for Otolaryngology
- Yale School of Medicine
- Carlos Artime, MD
Carlos Artime, MD
- Associate Professor of Anesthesiology
- The University of Texas Medical School at Houston
Difficulty with airway management for anesthesia has potentially serious implications, as failure to secure a patent airway can result in hypoxic brain injury or death in a matter of minutes. Early recognition that a patient's airway may be difficult to manage allows the clinician to plan the anesthetic to minimize the potential for serious airway-related morbidity.
In the unanticipated difficult airway, a pre-formulated strategy for airway management may reduce the likelihood of adverse outcomes . Difficulty may occur with facemask ventilation, placement of a supraglottic airway (SGA), laryngoscopy, and tracheal intubation. Other significant airway-related complications include aspiration of gastric contents, laryngospasm, and bronchospasm. These airway problems may occur in combination, leading to serious morbidity and mortality .
This topic will review patient factors that predict difficult airway management, the development of strategies for the initial management of the predicted difficult airway in the operating room environment, management of the unanticipated difficult airway during induction of general anesthesia, and extubation of the patient with a difficult airway. A general approach to airway management and specific techniques and devices used to manage the airway are discussed separately, as is an approach to the difficult airway during emergency intubation. (See "Airway management for induction of general anesthesia" and "Direct laryngoscopy and endotracheal intubation in adults" and "Approach to the difficult airway in adults outside the operating room" and "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults".)
For the purpose of this topic, the difficult airway is defined as the situation in which the anesthesia clinician experiences difficulty with ventilation by mask or supraglottic airway (SGA), difficulty with endotracheal intubation, or both. Specifically:
●Difficult mask or SGA ventilation – Inability of an unassisted anesthesia clinician to maintain oxygenation or reverse signs of inadequate ventilation
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- http://www.rcoa.ac.uk/nap4 (Accessed on November 10, 2014).
- RECOGNITION OF THE DIFFICULT AIRWAY
- PLANNING THE ANESTHETIC APPROACH
- Difficult airway guidelines
- Airway Approach Algorithm
- Regional versus general anesthesia
- Timing of airway control
- - Awake intubation
- - Airway management after induction
- Choice of induction technique
- PLANNING THE AIRWAY MANAGEMENT APPROACH
- Choice of airway device
- Surgical airway
- PREPARATION FOR DIFFICULT AIRWAY MANAGEMENT
- Equipment preparation
- Patient preparation
- SECURING THE AIRWAY
- Induction of anesthesia
- - Intravenous induction
- Induction agents
- Neuromuscular blocking agents
- - Timing of administration
- - Selection of NMBA
- - Inhalation induction
- Mask or supraglottic airway ventilation
- Endotracheal intubation
- Repeated intubation attempts
- THE FAILED AIRWAY
- SUMMARY AND RECOMMENDATIONS