Troubleshooting and Managing the Difficult Airway

 

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ABSTRACT

Difficult airways are an inevitable part of the delivery of emergency and critical care. Failure to achieve or restore a patent airway can lead, in a matter of minutes, to hypoxic neurological injury and death in critically ill patients. As with many conditions, the keys to success in a moment of crisis are forethought and preparation. Clinicians should be able to recognize risk factors for difficult airways and plan accordingly. In the face of failed direct laryngoscopy, a variety of rescue techniques are available. Familiarity with many strategies, and practiced dexterity with one or two, should be part of every intensivist's plan for the management of this life-threatening problem.

REFERENCES

• 1 Caplan R A, Benumof J L, Berry F A. Practice guidelines for management of the difficult airway: a report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.  Anesthesiology . 1993;  78 597-602
  PubMedGoogle Scholar
• 2 Crosby E T, Cooper M R, Douglas M J. The unanticipated difficult airway and recommendations for management.  Can J Anesth . 1998;  45 757-776
  CrossrefPubMedGoogle Scholar
• 3 Mascia M F, Mattasko M T. Emergency airway management by anesthesiologists.  Anesthesiology . 1993;  79 A1054
  PubMedGoogle Scholar
• 4 Walls R M, Barton E D, McAfee A T, for the National Emergency Airway Registry Investigators. 2,392 emergency department intubations: First report of the ongoing National Emergency Airway Registry Study (NEAR 97).  Ann Emerg Med . 1999;  34 S14
  PubMedGoogle Scholar
• 5 Walls R M, Luten R C, Murphy M F, Schneider R E, eds.. Manual of Emergency Airway Management.  Philadelphia: Lippincott Williams & Wilkins 2000
  Google Scholar
• 6 Mallampati S R, Gatt S P, Guigino L D. A clinical sign to predict difficult tracheal intubation: a prospective study.  Can Anaesth Soc J . 1985;  32 429-434
  CrossrefPubMedGoogle Scholar
• 7 Bersten A D, Holt A W, Vedig A E. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask.  N Engl J Med . 1991;  325 1825-1830
  PubMedGoogle Scholar
• 8 Pollack C V, Torres M, Alexander L. A feasibility study of the use of bilevel positive airway pressure for respiratory support in the emergency department.  Ann Emerg Med . 1996;  27 189-192
  PubMedGoogle Scholar
• 9 Keenan S P, Kernerman P D, Cook D J. Effect of noninvasive positive pressure ventilation on mortality in patients admitted with acute respiratory failure: a meta-analysis.  Crit Care Med . 1997;  25 1685-1692
  PubMedGoogle Scholar
• 10 Afilalo M, Guttman A, Stern E. Fiberoptic intubation in the emergency department: a case series.  J Emerg Med . 1993;  11 387-391
  CrossrefPubMedGoogle Scholar
• 11 Brain A IJ. Historical aspects and future directions. In: Ferson DZ, Brimacombe JR, Brain AIJ, eds. International Airway Clinics: The Laryngeal Mask Airway 1998 36(2): 1-18
  Google Scholar
• 12 Caplan R, Benumof J L, Berry F A. Practice guidelines for management of the difficult airway: a report by the ASA Task Force on Management of the Difficult Airway.  Anesthesiology . 1993;  78 597-602
  PubMedGoogle Scholar
• 13 Benumof J. Laryngeal mask airway and the ASA difficult airway algorithm.  Anesthesiology . 1996;  84 686-699
  PubMedGoogle Scholar
• 14 Airway and Ventilation Management Working Group of the European Resuscitation Council. Guidelines for the advanced management of the airway and ventilation during resuscitation.  Resuscitation . 1996;  31 201-230
  CrossrefPubMedGoogle Scholar
• 15 Rosenblatt W H, Murphy M. The intubating laryngeal mask: use of a new ventilating-intubating device in the emergency department.  Ann Emerg Med . 1999;  33 234-238
  PubMedGoogle Scholar
• 16 Brimacombe J R, Berry A. Mallampati classification and laryngeal mask insertion.  Anaesthesia . 1993;  48 347
  PubMedGoogle Scholar
• 17 Pollack C V. The laryngeal mask airway: a comprehensive review for the emergency physician.  J Emerg Med . 2001;  20 53-66
  CrossrefPubMedGoogle Scholar
• 18 Asai T, Morris S. The laryngeal mask airway: its features, effects and role.  Can J Anaesth . 1994;  41 930-960
  CrossrefPubMedGoogle Scholar
• 19 Verghese C, Brimacombe J R. Survey of laryngeal mask airway usage in 11,910 patients: safety and efficacy for conventional and nonconventional usage.  Anesth Analg . 1996;  82 129-133
  PubMedGoogle Scholar
• 20 Cooper S D, Benumoff J L, Ozaki Q T. Evaluation of the Bullard laryngoscope using the new intubating stylet: comparison with conventional laryngoscopy.  Anesth Analg . 1994;  79 965-970
  PubMedGoogle Scholar
• 21 Pollack C V, Tiffany B R, Carty J P, Crane D M. Teaching residents new airway management techniques: initial emergency department experience with the Bullard laryngoscope.  Ann Emerg Med . 1998;  32 S13
  PubMedGoogle Scholar
• 22 Ainsworth Q P, Howells T H. Transilluminated tracheal intubation.  Br J Anaesth . 1989;  62 494-497
  PubMedGoogle Scholar
• 23 Hung O R, Pytka S, Morris I. Clinical trial of a new lightwand device (Trachlight) to intubate the trachea.  Anesthesiology . 1995;  83 509-514
  CrossrefPubMedGoogle Scholar
• 24 Ellis D G, Jakymec A, Kaplan R M. Success rates of blind orotracheal intubation using a transillumination technique with a lighted stylet.  Ann Emerg Med . 1986;  15 138-142
  PubMedGoogle Scholar
• 25 Staudinger T, Brugger S, Watschinger B. Emergency intubation with the Combitube: comparison with the endotracheal airway.  Ann Emerg Med . 1993;  22 1573-1575
  CrossrefPubMedGoogle Scholar
• 26 Atherton G, Johnson J. Ability of paramedics to use the Combitube in prehospital cardiac arrest.  Ann Emerg Med . 1993;  22 1263-1268
  PubMedGoogle Scholar
• 27 Yardy N, Hancox D, Strang T. A comparison of two airway aids for emergency use by unskilled personnel: the Combitube and the laryngeal mask.  Anaesthesia . 1999;  54 181-183
  CrossrefPubMedGoogle Scholar
• 28 Goldberg J S. Colorimetric end-tidal carbon dioxide monitoring for tracheal intubation.  Anesth Analg . 1990;  70 191
  PubMedGoogle Scholar
• 29 Pelucio M. Out-of-hospital experience with the syringe esophageal detector device.  Acad Emerg Med . 1997;  4 563
  CrossrefPubMedGoogle Scholar
• 30 Bozeman W P. Esophageal detector device versus detection of end-tidal carbon dioxide level in emergency intubation.  Ann Emerg Med . 1996;  27 5953
  PubMedGoogle Scholar