SummaryProblems with tracheal intubation are infrequent but are the most common cause of anaesthetic death or brain damage. The clinical situation is not always managed well. The Difficult Airway Society (DAS) has developed guidelines for management of the unanticipated difficult tracheal intubation in the non-obstetric adult patient without upper airway obstruction. These guidelines have been developed by consensus and are based on evidence and experience. We have produced flow-charts for three scenarios: routine induction; rapid sequence induction; and failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised patient. The flowcharts are simple, clear and definitive. They can be fully implemented only when the necessary equipment and training are available. The guidelines received overwhelming support from the membership of the DAS. Disclaimer: It is not intended that these guidelines should constitute a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement.

No abstract

SummaryData were collected prospectively on the use of the gum elastic bougie in 200 patients. The bougie was successfully inserted into the trachea and tracheal intubation was accomplished in 199 cases. The bougie was inserted into the trachea at the ®rst attempt in 178 cases. In nine cases (4.5%) a second, more experienced, clinician was required. In 173 cases, the grades of view were recorded before and after the application of laryngeal pressure; pressure improved the view in 80 cases (46%), had no effect in 89 (51%) and worsened the view in four cases (2%). Various recommendations for optimal external laryngeal pressure and use of the bougie were not followed on 15±64% of occasions. There is a need for better education in these techniques.

SummaryIn a randomised cross-over study, 48 anaesthetists attempted to place a Frova single-use introducer, an Eschmann multiple-use introducer and a Portex single-use introducer in the trachea of a manikin set up to simulate a grade 3 laryngoscopic view. The anaesthetists were blinded to success (tracheal placement) or failure (oesophageal placement). Successful placement (proportion, 95% confidence interval) of either the Frova introducer (65%, 50-77%) or the Eschmann introducer (60%, 46-73%) was significantly more likely than with the Portex introducer (8%, 3-20%). There were no significant differences between the success rates for the Frova and the Eschmann introducers. A separate experiment revealed that the peak force exerted by the Frova and Portex introducers was two to three times greater than that which could be exerted by the Eschmann introducer, p < 0.0001, indicating that the single-use introducers are more likely to cause tissue trauma during placement.