Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

Abstract

These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

Management of pediatric ‘cannot intubate, cannot oxygenate’

“…Because the distal anatomy may be more difficult to define than the proximal anatomy, the more distal attempts to obtain a clear airway along the trachea in pediatric patients may lower the success rates for both cannula and scalpel techniques 2. Moreover, we should select the scalpel–finger–bougie technique, which is recommended in the guideline for cricothyroidotomy in adults if the cricothyroid membrane is impalpable or if other techniques have failed 1. An emergent tracheostomy can also be carried out in pediatric patients2 as follows: a midline vertical incision is made with a scalpel from thyroid cartilage to the upper edge of sternum, soft tissue is dissected bluntly by finger.…”

“…“Cannot intubate, cannot oxygenate” (CICO) is a rare but life‐threatening situation 1. In pediatric CICO, the Difficult Airway Society (DAS) guideline suggests some airway rescue techniques 2, 3.…”

Difficult Airway Management of a Heart Transplantation Recepient with Ebstein Anomaly

“…Zor hava yolu ve entübasyon düşünülen hastalarda birçok farklı yöntem (larengeal maske yardımıyla, fleksibl fiberoptikbronkoskop (FOB) ile entübasyon, kör nazal entübasyon, retrograd entübasyon, spontan solunum korunarak inhalasyon yöntemiyle entübasyon, lokal anestezi ile uyanık entübasyon gibi) uyanık veya derin anestezi altında spontan solunum korunarak entübasyon denenebilir [5] . Önemli olan zor hava yolu öngörülen veya bilinen olguya önceden planlanmış bir strateji (algoritma) ile müdahale etmektir [6] . Algoritmalarda tercih yapılır-ken planlanan cerrahi girişim, hastanın genel durumu ve anestezistin deneyim ve becerileri göz önüne alınmalıdır.…”

Deneysel Rat Modeli: Anestezi İndüksiyonu Öncesi %100 O2 İle Preoksijenizasyon Uygun mu Değil mi?

“…Sensitivity and interest to hyperoxia is not satisfactory in anesthesia induction and perioperative period, although anesthesia is so closely related with intensive care. Preoxygenation with 100% before induction is still recommended in anesthesia textbooks [7,8] . These may be due to habits related to past airway concerns and healthy patients being able to eliminate the damage caused by the operation-induced hyperoxia.…”