Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Dec 2005
ReviewEvaluation of the airway and preparation for difficulty.
Preoperative airway evaluation is essential to consider which is the best method of maintaining and protecting the airway during surgery and whether problems with airway management are likely. In general surgical patients, the prevalence of difficult intubation is low and tests have poor predictive power. ⋯ The absence of reliable prediction in general surgical patients means that airway strategy holds the key to successful management. Where there are obvious abnormalities in the history, examination or imaging the preoperative evaluation will allow choice of the most appropriate airway strategy which may include preparation of the patient, assembling of alternative airway equipment, advice and help from a more senior or skilled anaesthetist or aid from a surgical colleague or assistant.
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Best Pract Res Clin Anaesthesiol · Dec 2005
ReviewStrategies and algorithms for management of the difficult airway.
Management of the difficult airway is the most important patient safety issue in the practice of anaesthesia. Many national societies have developed algorithms and guidelines for management of the difficult airway. The key issues of this chapter are definition of terms, the advantages and disadvantages of the use of guidelines, and a comparison of different algorithms and guidelines for management of the most important clinical airway scenarios. Although there is no strong evidence of benefit for any specific strategy or algorithm for management of the difficult airway, there is strong agreement that a pre-planned strategy may lead to improved outcome.
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Supraglottic airway devices are developed with increasing frequency following the overwhelming success of the laryngeal mask airway (LMA). Currently, the LMA, the ProSeal laryngeal mask airway (PLMA), the laryngeal tube (LT), the laryngeal tube with integrated suctioning tube (LTS) and the oesophageal tracheal combitube (OTC) are the best evaluated and most widespread devices. ⋯ LT and LTS are primarily intended as emergency airway devices, but have also been successfully used during controlled ventilation in adults. The OTC, though advocated for emergency as well as routine use, is limited by high airway morbidity and possible serious complications.
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Anaesthesiologists, paediatricians, paediatric intensivists and emergency physicians are routinely challenged with airway management in children and infants. There are important differences from adult airway management as a result of specific features of paediatric anatomy and physiology, which are more relevant the younger the child. In addition, a number of inherited and acquired pathological syndromes have significant impact on airway management in this age group. ⋯ Important new studies have gathered evidence about risks and benefits of certain confounding variables for airway problems and specific techniques for solving them. Airway-related morbidity and mortality in children and infants during the perioperative period are still high, and only a thorough risk determination prior to and continuous attention during the procedure can reduce these risks. Appropriate preparation of the available equipment and frequent training in management algorithms for all personnel involved appear to be very important.
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Fiberoptic intubation of the spontaneously breathing patient is the gold standard and technique of choice for the elective management of a difficult airway. In the hands of the properly trained and experienced user, it is also an excellent 'plan B' alternative when direct laryngoscopy unexpectedly fails. ⋯ Portable fiberscopes can be used in remote settings, increasing patient safety. This review discusses current fiberoptic intubation techniques and their applications in the management of both the anticipated and unanticipated difficult airway.