Management of the anticipated and unanticipated difficult airway in anesthesia outside the operating room.

PURPOSE OF REVIEW: The number of diagnostic and interventional procedures outside the operating room has dramatically increased over the last years. However, providing well tolerated anesthesia with the same standard of care in these locations is often challenging to the anesthesiologist. The remote locations include different organizational aspects and hazards. Airway management in general is still confronted with scenarios of difficult intubation and ventilation and often leads to significant morbidity and mortality. Continuous awareness of the potential complications is urged when providing anesthesia for remote procedures.

RECENT FINDINGS: Recent studies have poorly addressed the issue of airway management by trained anesthesiologists outside the operating room. The majority of evidence is provided in the field of emergency medicine and intensive care settings. However, when dealing with difficult airway management in the remote setting, careful assessment and preparation is even more important than in the operating room. New evidence concerning prediction of ventilation and intubation must be incorporated in algorithms of airway management. Different anesthetic regimens using remifentanil and avoiding the use of neuromuscular blockers have to be carefully considered since they might change the scenario of intubation conditions. The new era of video laryngoscopes offers important potential to increase the tools for airway management. These new devices have the perfect design to be incorporated in remote settings. However, studies mainly focus on the emergency department and ICU. Also, there is currently a lack of consensus among professionals about their use and the large number of different devices seems to avoid careful comparisons.

SUMMARY: Airway management outside the operating room is challenging and needs the implementation of algorithms including the new airway devices. The recent update of the practice guidelines about difficult airway management of the American Society of Anesthesiologists remains the standard reference guide.