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 ventilationTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Apfelbaum JL, Hagberg CA, Caplan RA, et al. 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 2013; 118:251.
- Cook TM, Woodall N, Frerk C, Fourth National Audit Project. 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. Br J Anaesth 2011; 106:617.
- Woodall NM, Cook TM. National census of airway management techniques used for anaesthesia in the UK: first phase of the Fourth National Audit Project at the Royal College of Anaesthetists. Br J Anaesth 2011; 106:266.
- Law JA, Broemling N, Cooper RM, et al. The difficult airway with recommendations for management--part 2--the anticipated difficult airway. Can J Anaesth 2013; 60:1119.
- Frova G, Sorbello M. Algorithms for difficult airway management: a review. Minerva Anestesiol 2009; 75:201.
- Berkow LC, Greenberg RS, Kan KH, et al. Need for emergency surgical airway reduced by a comprehensive difficult airway program. Anesth Analg 2009; 109:1860.
- Crosby ET. An evidence-based approach to airway management: is there a role for clinical practice guidelines? Anaesthesia 2011; 66 Suppl 2:112.
- Rosenblatt WH. The Airway Approach Algorithm: a decision tree for organizing preoperative airway information. J Clin Anesth 2004; 16:312.
- Peterson GN, Domino KB, Caplan RA, et al. Management of the difficult airway: a closed claims analysis. Anesthesiology 2005; 103:33.
- Saxena N. Airway management plan in patients with difficult airways having regional anesthesia. J Anaesthesiol Clin Pharmacol 2013; 29:558.
- Parmet JL, Colonna-Romano P, Horrow JC, et al. The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated difficult tracheal intubation along with difficult mask ventilation. Anesth Analg 1998; 87:661.
- Zhou YF, Zhu SJ, Zhu SM, An XX. Anesthetic management of emergent critical tracheal stenosis. J Zhejiang Univ Sci B 2007; 8:522.
- Jeon HK, So YK, Yang JH, Jeong HS. Extracorporeal oxygenation support for curative surgery in a patient with papillary thyroid carcinoma invading the trachea. J Laryngol Otol 2009; 123:807.
- Tyagi I, Goyal A, Syal R, et al. Emergency cardiopulmonary bypass for impassable airway. J Laryngol Otol 2006; 120:687.
- Sendasgupta C, Sengupta G, Ghosh K, et al. Femoro-femoral cardiopulmonary bypass for the resection of an anterior mediastinal mass. Indian J Anaesth 2010; 54:565.
- Belmont MJ, Wax MK, DeSouza FN. The difficult airway: cardiopulmonary bypass--the ultimate solution. Head Neck 1998; 20:266.
- Baraka AS, Taha SK, Aouad MT, et al. Preoxygenation: comparison of maximal breathing and tidal volume breathing techniques. Anesthesiology 1999; 91:612.
- Gagnon C, Fortier LP, Donati F. When a leak is unavoidable, preoxygenation is equally ineffective with vital capacity or tidal volume breathing. Can J Anaesth 2006; 53:86.
- Gambee AM, Hertzka RE, Fisher DM. Preoxygenation techniques: comparison of three minutes and four breaths. Anesth Analg 1987; 66:468.
- Nimmagadda U, Chiravuri SD, Salem MR, et al. Preoxygenation with tidal volume and deep breathing techniques: the impact of duration of breathing and fresh gas flow. Anesth Analg 2001; 92:1337.
- Pandit JJ, Duncan T, Robbins PA. Total oxygen uptake with two maximal breathing techniques and the tidal volume breathing technique: a physiologic study of preoxygenation. Anesthesiology 2003; 99:841.
- Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology 2005; 102:1110.
- Difficult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, et al. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012; 67:318.
- Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 2012; 59:165.
- Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth 2010; 22:164.
- Taha SK, Siddik-Sayyid SM, El-Khatib MF, et al. Nasopharyngeal oxygen insufflation following pre-oxygenation using the four deep breath technique. Anaesthesia 2006; 61:427.
- Sakles JC, Mosier JM, Patanwala AE, et al. First Pass Success Without Hypoxemia Is Increased With the Use of Apneic Oxygenation During Rapid Sequence Intubation in the Emergency Department. Acad Emerg Med 2016; 23:703.
- Collins JS, Lemmens HJ, Brodsky JB, et al. Laryngoscopy and morbid obesity: a comparison of the "sniff" and "ramped" positions. Obes Surg 2004; 14:1171.
- Ikeda A, Isono S, Sato Y, et al. Effects of muscle relaxants on mask ventilation in anesthetized persons with normal upper airway anatomy. Anesthesiology 2012; 117:487.
- Goodwin MW, Pandit JJ, Hames K, et al. The effect of neuromuscular blockade on the efficiency of mask ventilation of the lungs. Anaesthesia 2003; 58:60.
- Warters RD, Szabo TA, Spinale FG, et al. The effect of neuromuscular blockade on mask ventilation. Anaesthesia 2011; 66:163.
- Naguib M, Samarkandi AH, El-Din ME, et al. The dose of succinylcholine required for excellent endotracheal intubating conditions. Anesth Analg 2006; 102:151.
- Magorian T, Flannery KB, Miller RD. Comparison of rocuronium, succinylcholine, and vecuronium for rapid-sequence induction of anesthesia in adult patients. Anesthesiology 1993; 79:913.
- Klemola UM, Mennander S, Saarnivaara L. Tracheal intubation without the use of muscle relaxants: remifentanil or alfentanil in combination with propofol. Acta Anaesthesiol Scand 2000; 44:465.
- Trabold F, Casetta M, Duranteau J, et al. Propofol and remifentanil for intubation without muscle relaxant: the effect of the order of injection. Acta Anaesthesiol Scand 2004; 48:35.
- Bouvet L, Stoian A, Rimmelé T, et al. Optimal remifentanil dosage for providing excellent intubating conditions when co-administered with a single standard dose of propofol. Anaesthesia 2009; 64:719.
- Lee C, Jahr JS, Candiotti KA, et al. Reversal of profound neuromuscular block by sugammadex administered three minutes after rocuronium: a comparison with spontaneous recovery from succinylcholine. Anesthesiology 2009; 110:1020.
- Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology 2009; 110:891.
- Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004; 99:607.
- Kheterpal S, Healy D, Aziz MF, et al. Incidence, predictors, and outcome of difficult mask ventilation combined with difficult laryngoscopy: a report from the multicenter perioperative outcomes group. Anesthesiology 2013; 119:1360.
- Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth 1998; 80:767.
- Rose DK, Cohen MM, Wigglesworth DF, DeBoer DP. Critical respiratory events in the postanesthesia care unit. Patient, surgical, and anesthetic factors. Anesthesiology 1994; 81:410.
- Cheney FW, Posner KL, Lee LA, et al. Trends in anesthesia-related death and brain damage: A closed claims analysis. Anesthesiology 2006; 105:1081.
- Lienhart A, Auroy Y, Péquignot F, et al. Survey of anesthesia-related mortality in France. Anesthesiology 2006; 105:1087.
- 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