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Der Anaesthesist

, Volume 67, Issue 10, pp 725–737 | Cite as

Management des schwierigen Atemwegs

Übersicht über die aktuellen Leitlinien
  • J. C. Schäuble
  • T. Heidegger
Leitthema

Zusammenfassung

Die aktuellen Atemwegsleitlinien empfehlen im Fall von erwarteten und unerwarteten Atemwegsproblemen ein algorithmusbasiertes Vorgehen. Der Schwerpunkt der Handlungsempfehlungen liegt nicht länger auf „tools and devices“, sondern zunehmend auf guter Planung, Vorbereitung und Kommunikation. Beim erwartet schwierigen Atemweg soll der Atemweg im „Wachzustand“ unter Erhalt der Spontanatmung gesichert werden. Die Intubation mittels flexibler Intubationsendoskopie („Fiberoptik“) ist dabei die Methode der Wahl. Die Aufrechterhaltung der Oxygenation hat oberste Priorität. Beim unerwartet schwierigen Atemweg kommen neben der Maskenbeatmung supraglottische Atemwegshilfen zum Einsatz. Die frühzeitige Gabe von Muskelrelaxanzien kann zur Optimierung der Maskenbeatmung beitragen. Einige Leitlinien empfehlen zur Reduktion des Zeitdrucks bei Entscheidungsprozessen apnoische Oxygenationstechniken, und bei respiratorischen Hochrisikopatienten im nichtnüchternen Zustand den Einsatz einer vorsichtigen Maskenbeatmung. Bei Intubationsproblemen soll frühzeitig ein Einsatz der Videolaryngoskopie erfolgen. Die Frage nach der optimalen Technik zur transtrachealen Oxygenierung ist derzeit nicht abschließend geklärt. Ist eine Rückkehr zur Spontanatmung nicht rechtzeitig zu gewährleisten, muss der Atemwegsalgorithmus bei nichtbeherrschbaren Oxygenationsproblemen – ohne Zeitverlust durch Verharren auf erfolglosen Maßnahmen – konsequent abgearbeitet werden („Vorwärtsstrategie“). Wichtiger als die Frage, welcher Algorithmus zur Anwendung kommt, ist, dass jede Anästhesieabteilung über einen solchen verfügt und ihn anwendet. Er soll sich an lokalen Gegebenheiten und Präferenzen orientieren, möglichst einfach aufgebaut und die Anzahl der Hilfsmittel limitiert sein. Der Ausbildung im Atemwegsmanagement sowie dem kontinuierlichen Training werden ein hoher Stellenwert beigemessen.

Schlüsselwörter

Schwieriger Atemweg Intubation Atemwegsmanagement Algorithmus Leitlinie 

Management of the difficult airway

Overview of the current guidelines

Abstract

Several national airway task forces have recently updated their recommendations for the management of the difficult airway in adults. Routinely responding to airway difficulties with an algorithm-based strategy is consistently supported. The focus is increasingly not on tools and devices but more on good planning, preparation and communication. In the case of anticipated airway difficulties the airway should be secured when the patient is awake with maintenance of spontaneous ventilation. Unaltered a flexible bronchoscopic intubation technique is advised as a standard of care in such patients. The importance of maintenance of oxygenation is emphasized. Face mask ventilation and the use of supraglottic devices are recommended if unexpected airway difficulties occur. Face mask ventilation may be facilitated and optimised by early administration of neuromuscular blocking agents. If required, in not fastened patients threatened by acute hypoxia, carefully applied and pressure-controlled ventilation may ensure sufficient oxygenation until the airway is secured. Apnoeic oxygen techniques are recommended in high-risk patients and to relieve the time pressure of falling oxygen saturation during decision-making processes. The early use of video laryngoscopy is advised for endotracheal intubation in the case of failed direct laryngoscopy or if intubation is expected to be difficult. For the coverage of cannot intubate-cannot oxygenate scenarios, second generation supraglottic devices and invasive airway access are advocated. The discussion regarding the optimal technique for emergency invasive airway access is still in progress. In the case of uncontrollable respiratory deterioration and progressive hypoxia, the algorithm must be consistently executed and without delay due to ineffective activities (straightforward strategy). Although there is no evidence to support the selection of a particular approach, the importance and the need for a defined airway concept/algorithm in any anesthesia department is fostered. Simplicity and clarity are essential for recall under stressful and time-sensitive conditions. The algorithm should be adapted to local conditions and preferences and devices should be limited to a definite number. The acquisition and maintenance of expertise by education and training is demanded.

Keywords

Difficult airway Intubation Airway management Algorithm Guideline 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

J.C. Schäuble und T. Heidegger geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.Institut für AnästhesiologieKantonsspital WinterthurWinterthurSchweiz
  2. 2.Departement für Anästhesie, Intensivmedizin und ReanimationSpitalregion RheintalWerdenbergSchweiz
  3. 3.Universität BernBernSchweiz

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