Management of the difficult airway

J L Benumof
Annals of the Academy of Medicine, Singapore 1994, 23 (4): 589-91
Respiratory catastrophes are the most common cause of anaesthesia-related brain deaths and death. If an airway is recognised to be difficult, endotracheal tube (ETT) intubation should be performed awake. Awake intubation demands proper preparation of the patient. When the patient is properly prepared any one of a number of ETT intubation techniques can be successful. Once in a great while a surgical airway may be the best first choice. If the patient refuses to be intubated awake, or a difficult airway is not recognised, and anaesthesia is induced, then the airway will ordinarily be first controlled by mask ventilation prior to conventional laryngoscopy. If conventional laryngoscopy should fail, a call for help should be initiated and the airway should be controlled by mask ventilation. If ETT intubation by conventional laryngoscopy is still unsuccessful after a few attempts (perhaps using a different blade or head position) and special alternative techniques fail, the patient should either be awakened, the case done by mask, or a semi-elective surgical airway cricothyroidotomy performed. If at any point mask ventilation becomes impossible and the patient still cannot be intubated, then transtracheal jet ventilation (TTJV) through a percutaneous IV catheter should be instituted. Once life-sustaining gas exchange is again effected by TTJV, then the patient should either be awakened, a semi-elective tracheostomy or cricothyroidotomy performed or the patient intubated with a special ETT intubation technique. An intubated patient with a known difficult airway should be extubated over a jet stylet.

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