Anticipated and Unanticipated Difficult Airway: A Practical and Logical Approach; A Narrative Review
AbstractStability of the airway is a fundamental element of acute care medical practice. While airway management is conceptually straightforward, the wide variety of clinical circumstances, patients, and tools can make the task of ensuring a stable, open airway under all clinical conditions extremely challenging. Care providers involved in airway management must therefore not only be technically skilled but also sufficiently flexible to adjust changing the conditions, risk/benefit balances, and goals. One aspect of airway management that requires particular attention is the airway that is difficult to secure or keep patent. For clinical or anatomic reasons, both bag mask ventilation and tracheal intubation in such a patient population may be difficult without specialized expertise or tools. Because adequate oxygen delivery through a patent airway is critical to life support and resuscitative efforts, the risks of inadequate airway management are high, adding to the challenge. One significant advance in difficult airway management is the development of algorithms to standardize the technical approach to successful endotracheal intubation in a patient with a difficult airway. Such algorithms are relatively recent (The American Society of Anesthesiologists difficult airway algorithm updated in 2015), and integrate clinical experience, evidence, and technical expertise into a stepwise approach to anticipated and unanticipated airway challenges.
Auroy Y, Benhamou D, Péquignot F, Bovet M, Jougla E, Lienhart A. Mortality related to anaesthesia in France: analysis of deaths related to airway complications. Anaesthesia. 2009; 64(4):366-70.
Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005; 103(1):33-9.
Artime CA, Hagberg CA. Is there a gold standard for management of the difficult airway? Anesthesiology clinics. 2015; 33(2):233-40.
Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology. 1990; 72(5):828-33.
Li C-W, Li Y-D, Tian H-T, Kong X-G, Chen K. Dexmedetomidine-midazolam versus sufentanil-midazolam for awake fiberoptic nasotracheal intubation: a randomized double-blind study. Chin Med J. 2015; 128(23):3143.
Abdelmalak B, Makary L, Hoban J, Doyle DJ. Dexmedetomidine as sole sedative for awake intubation in management of the critical airway. J Clinical Anesthesia. 2007; 19(5):370-3.
Behringer E, Kristensen M. Evidence for benefit vs novelty in new intubation equipment. Anaesthesia. 2011; 66(s2):57-64.
Dimitriou V, Voyagis GS, Brimacombe JR. Flexible Lightwand–guided Tracheal Intubation with the Intubating Laryngeal Mask Fastrach TMin Adults after Unpredicted Failed Laryngoscope-guided Tracheal Intubation. Anesthesiology: Anesthesiology. 2002; 96(2):296-9.
Gannon K. Mortality associated with anaesthesia. Anaesthesia. 1991; 46(11):962-6.
Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology. 1991; 75(6):1087-110.
Cook T, Scott S, Mihai R. Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995–2007. Anaesthesia. 2010; 65(6):556-63.
Benumof JL. Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology: The Journal of the American Society of Anesthesiologists. 1996; 84(3):686-99.
Mushambi M, Kinsella S, Popat M, Swales H, Ramaswamy K, Winton A, et al. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia. 2015; 70(11):1286-306.
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice Guidelines for Management of the Difficult AirwayAn Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology: Anesthesiology. 2013; 118(2):251-70.
Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology: Anesthesiology. 2012; 116(3):629-36.
Kaminoh Y. Quality assurance in airway management: Education and training for difficult airway management. Masui. 2006; 55(1):33-43.
Hazinski MF, Field JM. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Circulation. 2010; 122(Suppl):S639-S946.
Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report American college of cardiology/American heart association task force on practice guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease) developed in collaboration with the american society of echocardiography, heart rhythm society, international society for adult congenital heart disease, society for cardiovascular angiography and interventions, and society of thoracic surgeons. J Am Coll Cardiol. 2008; 52(23):e143-e263.
Allman K, McIndoe A, Wilson I. Emergencies in anaesthesia: Oxford University Press; 2009.
Han R, Tremper KK, Kheterpal S, O’reilly M. Grading scale for mask ventilation. Anesthesiology. 2004; 101(1):267.
Finucane BT, Tsui BCH, Santora AH. Evaluation of the Airway. Principles of Airway Management. New York, NY: Springer New York; 2011. p. 27-58.
Greenland K, Edwards M, Hutton N, Challis V, Irwin M, Sleigh J. Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications. Br J Anaesth. 2010; 105(5):683-90.
Practice Guidelines for Management of the Difficult AirwayAn Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003; 98(5):1269-77.
Bourgain J, Camboulives J, Crinquette V, Cros A, Dubreuil M, Eurin B, et al., editors. Intubation difficile: Société française d'anesthésie et de réanimation Expertise collective. Annales Francaises d'anesthesie et de Reanimation; 1996: Elsevier.
Crosby ET, Cooper RM, Douglas MJ, Doyle DJ, Hung OR, Labrecque P, et al. The unanticipated difficult airway with recommendations for management. Can J Anaesthesia. 1998; 45(8):757-76.
SIAAR T. Task force on difficult airway management. L’intubazione difficile e la difficolta di controllo delle vie aeree nel’adulto (SIAARTI). Minerva Anesthesiologica. 1998; 64:361-71.
Voyagis G, Kyriakis K, Dimitriou V, Vrettou I. Value of oropharyngeal Mallampati classification in predicting difficult laryngoscopy among obese patients. Eur J Anaesthesiol. 1998;15(3):330-4.
Khan ZH, Kashfi A, Ebrahimkhani E. A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study. Anesth Analg. 2003; 96(2):595-9.
Tung A, Cook T. Upper airway anatomy. Obstructive Sleep Apnea: Pathophysiology, Comorbidities and Consequences: Pathophysiology, Comorbidities, and Consequences Br J Anaesth. 2007:81.
Cook T, MacDougall-Davis S. Complications and failure of airway management. Br J Anaesth. 2012;109(suppl_1):i68-i85.
Cook T, Woodall N, Frerk C, Project FNA. 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(5):617-31.
Haynes SR, Allsop JR, Gillies GWA. Arterial oxygen saturation during induction of anaesthesia and laryngeal mask insertion: prospective evaluation of four techniques: Br J Anaesth. 1992;68(5):519-22.