Management of the difficult adult airway. With special emphasis on awake tracheal intubation

J L Benumof
Anesthesiology 1991, 75 (6): 1087-110
Difficulty in managing the airway is the single most important cause of major anesthesia-related morbidity and mortality. Successful management of a difficult airway begins with recognizing the potential problem. All patients should be examined for their ability to open their mouth widely and for the structures visible upon mouth opening, the size of the mandibular space, and ability to assume the sniff position. If there is a good possibility that intubation and/or ventilation by mask will be difficult, then the airway should be secured while the patient is still awake. In order for an awake intubation to be successful, it is absolutely essential that the patient be properly prepared; otherwise, the anesthesiologist will simply fulfill a self-defeating prophecy. Once the patient is properly prepared, it is likely that any one of a number of intubation techniques will be successful. If the patient is already anesthetized and/or paralyzed and intubation is found to be difficult, many repeated attempts at intubation should be avoided because progressive development of laryngeal edema and hemorrhage will develop and the ability to ventilate the lungs via mask consequently may be lost. After several attempts at intubation, it may be best to awaken the patient, do a semielective tracheostomy, or proceed with the case using mask ventilation. In the event that the ability to ventilate via mask is lost and the patient's lungs still cannot be ventilated, TTJV should be instituted immediately. Tracheal extubation of a patient with a difficult airway over a jet stylet permits a controlled, gradual, and reversible (in that ventilation and reintubation is possible at any time) withdrawal from the airway. Significant advances in the management of the difficult airway have occurred in recent years. Eighty percent of the 127 references in this article were published after 1985. However, there is much more to learn with regard to recognition of the difficult airway, preparation of the patient for an awake intubation, new techniques of endotracheal intubation, and establishment of gas exchange in patients who cannot be intubated or ventilated by mask. As the anesthesiologist's ability to manage the difficult airway significantly improves, respiratory-related morbidity and mortality will decrease.

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