Anesthesiology clinics of North America
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Anesthesiol Clin North America · Dec 2002
ReviewObstructive sleep apnea in the adult obese patient: implications for airway management.
Adult obese patients with suspected or sleep test confirmed OSA present a formidable challenge throughout the perioperative period. Life-threatening problems can arise with respect to tracheal intubation, tracheal extubation, and providing satisfactory postoperative analgesia. ⋯ If opioids are used for the extubated postoperative patient, then one must keep in mind an increased risk of pharyngeal collapse and consider the need for continuous visual and electronic monitoring. The exact management of each sleep apnea patient with regard to intubation, extubation, and pain control requires judgment and is a function of many anesthesia, medical, and surgical considerations.
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The ProSeal LMA is a major advance over the Classic LMA because of the following reasons: it allows ventilation at much higher airway pressures; it protects the lungs from aspiration and the stomach from gastric insufflation; it facilitates passage of a gastric tube and monitoring devices into the esophagus; it can be inserted like the Classic or Intubating LMA; it has its own built-in bite block; malposition is detected more readily; and, through use of techniques such as gum elastic bougie-guided insertion, correct positioning is almost guaranteed. The ProSeal can be considered a replacement device for the Classic LMA, but the Flexible LMA is still preferable for most intraoral procedures, and the Intubating LMA is still preferable whenever intubation is required. Limitations are that it is slightly more difficult to insert and requires more careful thought to use optimally.
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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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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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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.