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Canadian Journal of Anaesthesia

, Volume 45, Issue 8, pp 757–776 | Cite as

The unanticipated difficult airway with recommendations for management

  • Edward T. Crosby
  • Richard M. Cooper
  • M. Joanne Douglas
  • D. John Doyle
  • Orlando R. Hung
  • Pascal Labrecque
  • Holly Muir
  • Michael F. Murphy
  • Roanne P. Preston
  • D. Keith Rose
  • Louise Roy
Special Article

Abstract

Purpose

To review the current literature and generate recommendations on the role of newer technology in the management of the unanticipated difficult airway.

Methods

A literature search using key words and filters of English language and English abstracted publications from 1990–96 contained in theMedline, Current Contents andBiological Abstracts databases was carried out. The literature was reviewed and condensed and a series of evidence-based recommendations were evolved.

Conclusions

The unanticipated difficult airway occurs with a low but consistent incidence in anaesthesia practice. Difficult direct laryngoscopy occurs in 1.5–8.5% of general anaesthetics and difficult intubation occurs with a similar incidence. Failed inubation occurs in 0.13–0.3% general anaesthetics. Current techniques for predicting difficulty with laryngoscopy and intubation are sensitive, non-specific and have a low positive predictive value. Assessment techniques which utilize multiple characteristics to derive a risk factor tend to be more accurate predictors. Devices such as the laryngeal mask, lighted stylet and rigid fibreoptic laryngoscopes, in the setting of unanticipated difficult airway, are effective in establishing a patent airway, may reduce morbidity and are occasionally lifesaving. Evidence supports their use in this setting as either alternatives to facemask and bag ventilation, when it is inadequate to support oxygenation, or to the direct laryngoscope, when trachéal intubation has failed. Specifically, the laryngeal mask and Combitube™ have proved to be effective in establishing and maintaining a patent airway in “cannot ventilate” situations. The lighted stylet and Bullard (rigid) fibreoptic scope are effective in many instances where the direct laryngoscope has failed to facilitate trachéal intubation. The data also support integration of these devices into strategies to manage difficult airway as the new standard of care. Training programmes should ensure graduate physicians are trained in the use of these alternatives. Continuing medical education courses should allow physicians in practice the opportunity to train with these alternative devices.

Keywords

Tracheal Intubation Airway Management Laryngeal Mask Airway Difficult Airway Direct Laryngoscopy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Résumé

Objectif

Passer en revue la documentation courante et fournir des recommandations sur le rôle de la nou velle technologie dans la conduite à tenir lors d’une intubation difficile.

Méthodes

On a procédé à une recherche documentaire selon des mots-clés et des filtres de langue anglaise et des publications de résumés anglais de 1990 à 1996, contenus dans les bases de données deMedline, Current Contents etBiological Abstracts. La littérature a été revue et résumée et une série de recommandations basées sur les faits ont été élaborées.

Conclusion

Les difficultés d’intubation non prévues surviennent selon une incidence faible, mais constante, dans la pratique de l’anesthésie. Des problèmes de laryngoscopie directe et des difficultés d’intubation ont lieu dans 1,5–8,5 % des anesthésies générales. Léchéc de l’intubation survient dans 0,13–0,3 % des anesthésies générales. Les techniques habituelles de prédiction des difficultés de laryngoscopie et d’intubation sont sensibles, mais non spécifiques et ont une faible valeur prédictive. Des techniques d’évaluation qui utilisent plusieurs caractéristiques pour en déduire un facteur de risque ont généralement de meilleures qualités prédictives. Lors d’une intubation difficile inattendue, des appareils comme le masque laryngé, le stylet lumineux et le laryngoscope fibroscopique rigide sont efficaces dans le rétablissement de la perméabilité des voies aériennes, ils peuvent réduire la morbidité et peuvent parfois sauver des vies. Lexpérience encourage leur emploi en remplacement du masque et de la ventilation manuelle quand la ventilation assistée est inappropriée, ou à la place du laryngoscope direct quand l’intubation endotrachéale a été un échec. Le masque laryngé et le Combitube® ont été spécialement efficaces dans le rétablissement et le maintien de la perméabilité des voies aériennes, dans les situations où l’on ne peut ventiler. Le stylet lumineux et le fibroscope rigide Bullard réussissent souvent à faciliter l’intubation endotrachéale quand le laryngoscope direct a échoué. Les données favorisent également l’intégration de ces dispositifs, considérée comme le nouveau standard de soins, dans la démarche à suivre lors de l’intubation difficile. Les programmes de formation devraient garantir que les médecins diplômés soient familiarisés avec l’usage de ces solutions de remplacement. L’éducation médicale continue devrait donner aux praticiens l’occasion d’apprendre à utiliser ces dispositifs.

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Copyright information

© Canadian Anesthesiologists 1998

Authors and Affiliations

  • Edward T. Crosby
    • 1
  • Richard M. Cooper
    • 1
    • 3
  • M. Joanne Douglas
    • 1
    • 4
  • D. John Doyle
    • 1
    • 2
  • Orlando R. Hung
    • 1
    • 5
  • Pascal Labrecque
    • 1
    • 6
  • Holly Muir
    • 1
    • 2
  • Michael F. Murphy
    • 1
    • 2
  • Roanne P. Preston
    • 1
  • D. Keith Rose
    • 1
    • 2
  • Louise Roy
    • 1
  1. 1.Department of AnaesthesiaUniversity of Ottawa, Ottawa General HospitalOttawa
  2. 2.Department of AnaesthesiaUniversity of TorontoCanada
  3. 3.Department of AnaesthesiaUniversity of British ColumbiaCanada
  4. 4.Department of AnaesthesiaDalhousic UniversityCanada
  5. 5.Department of AnaesthesiaLaval UniversityCanada
  6. 6.Department of AnaesthesiaUniversity of MontrealCanada

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