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Complications of Managing the Airway

Key Points Serious complications of airway management result from not recognizing the degree of airway difficulty. To minimize injury to the patient, the airway practitioner should examine the patient’s airway carefully, identify potential problems, devise a plan that involves the least risk for injury, and have a backup plan immediately available. Common sense should prevail at all times. In the practice of airway management, errors of…

Extubation and Reintubation of the Difficult Airway

KEY POINTS Careful planning of tracheal extubation or tube exchange is as vital as the planning required for intubation. Airway complications are as common after tube removal as during insertion. Anticipating a successful extubation is an inexact science. Any emergent reintubation is likely to be more complex because of physiologic instability and contextual challenges. Reintubation may fail because of inadequate access to the airway (e.g., halo…

Monitoring the Airway and Pulmonary Function

KEY POINTS The most reliable method for determining the intratracheal location of an endotracheal tube (ETT) is direct visualization of the tube passing through the vocal cords; flexible scope assessment can define the specific location of the ETT in the airways. When using CO 2 detection in exhaled gas from an ETT to document whether it is within the trachea, CO 2 should be present for…

Mechanical Ventilation

Key Points The indications for mechanical ventilation include hypoxemic and hypercapnic respiratory failure, altered mentation with patient inability to protect the airway, hemodynamic instability, and maintenance of adequate oxygenation and ventilation during deep sedation, general anesthesia, or neuromuscular blockade. Positive end-expiratory pressure (PEEP) improves oxygenation in patients with hypoxemic respiratory failure, optimizes alveolar recruitment, and decreases cycles of recruitment and derecruitment of alveolar lung units. Assist-control…

The Endotracheal Tube and Respiratory Care

Key Points Polyurethane endotracheal tube (ETT) cuffs that have high-volume/low-pressure (HVLP) cuffs can conform to the irregular borders of the tracheal lumen and, therefore, are more effective at preventing microaspiration. ETT placement has mechanical and physiologic consequences. Vigilant surveillance of skin hygiene, airway patency, cuff integrity, and ventilatory support is necessary to minimize injury and maximize support. Evaluation of a cuff/air leak is a multifaceted endeavor…

Airway Management in Intensive Care Medicine

Key Points Intensive care unit (ICU) patients’ airways are extremely demanding; airway-related mortality and severe morbidity may be orders of magnitude higher than in general OR practice. Difficult airway (DI) is at least twice as common. Airway intervention must be prompt and smooth: The critically ill simply do not tolerate poor airway management. The ICU must have immediate access to a flexible intubation scope (at least…

Airway Management in Non-Operating Room Locations

KEY POINTS Specific training for non-operating room anesthesia (NORA) should be incorporated into anesthesia residency programs. Monitoring for both oxygenation and ventilation is required during sedation, including the use of capnography. Intubation of the patient with an anticipated difficult airway (DA) may be best managed in the operating suite with optimal equipment and familiar anesthesia staffing before transporting the patient to the NORA location. An anesthesia…

Regional Anesthesia and the Difficult Airway

Key Points Regional anesthesia can provide an alternative to general anesthesia for certain surgical procedures; these includes surgeries to the thoracic and abdominal cavities and wall, and surgery to the extremities. The surgeries should be of limited duration (i.e., not more than 90 to 120 minutes) with only minor blood loss and, preferably, with the patient in the supine position. Ultrasound assessment of the regional target…

Obesity, Sleep Apnea, the Airway, and Anesthesia

Key Points A high body mass index (BMI) is a weak but statistically significant predictor of difficult intubation (DI) and difficult mask ventilation (DMV). Body fat distribution, rather than the BMI value, may be a better predictor of difficult laryngoscopy. Measuring the neck circumference at the thyroid cartilage level is a useful addition to the normal daily practice of measuring weight or BMI during preoperative airway…

Airway Management in Neurosurgical Patients

Key Points In addition to airway assessment, neurologic examination and communication with the surgeon is invaluable before the induction of anesthesia for neurosurgical procedures. Patients with an unstable cervical spine may be unable to cooperate with an awake flexible scope intubation (FSI) because of intoxication, hypoxia, or head injury. The need for a cervical spine injury (CSI) patient’s airway to be secured is often urgent because…

Airway Management in Head and Neck Surgery

Key Points Airway problems in head and neck (H&N) patients are common, and so are the airway failures. The anesthesia provider must develop and maintain excellent dexterity with a wide range of airway management devices and techniques. The preoperative endoscopic airway examination (PEAE) should become an integral part of the H&N anesthesia provider’s armamentarium. In patients with compromised airway, awake or asleep flexible scope intubation (FSI)…

Airway Management in Obstetric Patients

Key Points Anesthesia is a leading cause of maternal mortality and ranks seventh in the United States and eleventh in the United Kingdom. Airway-related complications during general anesthesia (GA) for cesarean delivery (CD) feature as a predominant cause of anesthesia-related maternal morbidity and mortality and are preventable. Pregnancy-related anatomic and physiologic changes are not the sole reason for difficulty with intubation, ventilation, and extubation. Other reasons…

Airway Management in Pediatric Patients

Key Points The first attempt at the pediatric airway should be the best attempt and includes proper preparation of equipment and positioning. The pediatric airway anatomy is different in children, whose larynx is located higher in the neck with a relatively larger tongue. Children have a differently shaped epiglottis, and their vocal cords are angled. The newborn rib cage is oriented parallel, and the intercostal muscles…

Airway Management in Burn Patients

Key Points The priorities and approaches to airway management in the burn patient are different in the acute, subacute, and chronic phases of burn injury. Airway edema results from thermal and inhalation injury, and rapidly increases with fluid resuscitation. Induction drugs that cause vasodilation or decreased cardiac output can result in hemodynamic instability in burn patients, even though the dose requirements may be augmented. Succinylcholine is…

Airway Management in Trauma

Key Points Although many trauma patients may initially appear to maintain and protect their airway, they remain at risk of progressive airway obstruction or multisystem traumatic comorbidities necessitating frequent reevaluation. Intubating a trauma patient should be part of an overall team-based approach to resuscitation. Although intubation may not be necessary to maintain airway patency, the patient’s expected clinical course or need for emergent surgical intervention may…

Austere Environment and Disaster Preparedness

Key Points Mass casualty events and the practice of anesthesia in austere environments are situations for which anesthesiologists should be prepared. Proper triage techniques can help prevent misallocation of resources and also can help alleviate psychic trauma on healthcare professionals. Anesthesiologists are willing to respond to disasters but desire further education and training in preparation for them. A mass casualty event resulting from communicable disease, whether…

Cardiopulmonary Resuscitation and Airway Management

Key Points Cardiac arrest is a leading cause of mortality. Current AHA Guidelines recommend chest compressions before initial airway management. Ventilation and oxygenation during CPR can be performed via bag mask ventilation or an advanced airway device (either an endotracheal tube or a supraglottic airway). Interruptions in chest compressions should be minimized during airway management. Hyperventilation should be avoided during CPR. Ventilation plays a larger role…

Prehospital Airway Management

Key Points Noninvasive ventilation (NIV) is widely used in the prehospital setting and may be considered in patients with altered mental status when closely attended. Supine patients undergoing medication-facilitated airway management (MFAM) should be moved off the ground (e.g., to the stretcher) before intubation whenever possible. Patients being intubated on the ground should have their positioning optimized, and video-assisted laryngoscopy (VAL) used whenever possible. Strong consideration…

Confirmation of Tracheal Intubation

Key Points Clinical signs to determine proper endotracheal tube (ETT) placement and positioning have limitations. Secondary confirmatory methods must be used in routine and emergent settings to minimize the chances of ETT misplacement or improper ETT depth. Exhaled CO 2 detection, especially by waveform capnography, is the most sensitive method to detect proper ETT placement in the respiratory tract. Exhaled CO 2 determines tracheal placement of…

Surgical Airway in Emergent and Nonemergent Contexts

Key Points For anatomic reasons, emergency surgical airway in the hands of advanced airway managers will usually be a cricothyrotomy. The critical step in cricothyrotomy is recognizing when it is required. Decision-making should not be left solely to the airway manager—those not directly involved in airway management may better recognize an emerging cannot ventilate/cannot oxygenate (CVCO) situation. We have chosen CVCO in this chapter to reflect…