Anesthesiology clinics of North America
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Management of the difficult airway remains one of the most challenging tasks for anesthesia care providers. Most airway problems can be solved with relatively simple devices and techniques, but clinical judgment borne of experience is crucial to their application. ⋯ Each airway device has unique properties that may be advantageous in certain situations, yet limiting in others. Specific airway management techniques are greatly influenced by individual disease and anatomy, and successful management may require combinations of devices and techniques.
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Anesthesiologists traditionally approach airway management and maintenance of a patent airway through translaryngeal techniques. Most of the techniques and devices routinely used in clinical practice (orotracheal intubation, nasotracheal intubation, laryngeal mask airway, Combitube, fiberoptic intubation, and so forth) maintain airway patency by way of manipulation of components of the upper airway. Successful maintenance of a patient airway involves a detailed understanding of the interaction of each device or technique with the structures of the upper airway. The goals of this article are to review the skills commensurate with successful recognition of airway problems and management of the patient with a known or suspected difficult airway.
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Despite many recent innovations in equipment for difficult airway management, it remains the leading cause of the most devastating adverse outcomes in anesthesia. Fiberoptic airway management is among the most versatile of techniques for difficult airway management. ⋯ It is most frequently used when difficult airway management is predicted but also may be appropriate when unforeseen difficulty arises. It cannot be too strongly emphasized, however, that this technique takes time and should be entertained only if the anesthesia care provider is able to maintain adequate oxygenation and ventilation until the airway is secured.
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Although this article merely glances the surface of some of the more fundamental aspects of managing the simple airway, one can see that an exhaustive discussion would require much more space than allotted herein. Although the author has attempted to reflect in a more clinically relevant tone in text, the best and most effective way to learn and remember such techniques is to perform them together with an experienced clinician. Attention to detail, subtleties, and nuances of the basic airway techniques, along with a willingness to refine this lost art of airway management, will re-solidify the foundation of excellent anesthesia and airway management.
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The ETC is an easily inserted, double-lumen/double-balloon supraglottic airway device. The major indication of the ETC is as a back-up device for airway management. It is an excellent option for rescue ventilation in both in- and out-of-the-hospital environments and in situations of difficult ventilation and intubation. ⋯ Continued airway management with an ETC that has been placed is a reasonable option in many cases. Having thus secured the airway, it may not be necessary to abort the anesthetic or to continue with further airway management efforts. In order to avoid serious trauma to the esophagus or airway, redesigning the ETC using a softer material for the tube is advisable.