From variance to guidance for awake tracheal intubation

Aziz, Michael F.; Kristensen, Michael Seltz

doi:10.1111/anae.14947

Cited by 13 publications

(39 citation statements)

References 20 publications

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“…Nevertheless, it is important for the airway manager to appreciate that for many difficult airway situations, ATI can proceed with a variety of devices. 75 …”

Section: Implementation Of the Planned Strategy When Difficult Tracheal Intubation Is Predictedmentioning

confidence: 99%

“…Nevertheless, it is important for the airway manager to appreciate that for many difficult airway situations, ATI can proceed with a variety of devices. 75 Other options to facilitate ATI include optical stylets, the concurrent use of VL and the FB, or awake placement of an SGA under topical anesthesia to provide a conduit for FB-aided intubation. 77 The latter is particularly effective in the setting of redundant upper airway tissue, as seen with significant obesity, patients with obstructive sleep apnea, and some children with predicted difficult airways.…”

Section: Choice Of Device To Facilitate Awake Tracheal Intubationmentioning

confidence: 99%

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Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

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Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. Findings and key recommendations Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient’s tolerance for withdrawal of airway support and whether re-intubation might be difficult.

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“…Nevertheless, it is important for the airway manager to appreciate that for many difficult airway situations, ATI can proceed with a variety of devices. 75 …”

Section: Implementation Of the Planned Strategy When Difficult Tracheal Intubation Is Predictedmentioning

confidence: 99%

Section: Choice Of Device To Facilitate Awake Tracheal Intubationmentioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

View full text Add to dashboard Cite

show abstract

“…Some patients cannot be intubated with a hyperangulated videolaryngoscope [4,8,20], and in case of failed (or impossible) neuraxial anesthesia, awake tracheal intubation with a FB is the primary choice if rescue invasive techniques are to be avoided [4,8]. e advantages of an awake patient are that a patent airway is preserved (with the largest possible airway diameter due to preserved intrinsic airway muscle tone), spontaneous breathing is preserved (hence oxygenation), the glottic opening is easier to localize (air bubbles) and easier to intubate (naturally aligned oropharyngeal axis), the patient can be sitting (thus avoiding aortocaval compression), and there is some protection against aspiration [4,5]. Since the introduction of videolaryngoscopes in 2001, awake tracheal intubation with a FB may have become an underutilized technique [5,6].…”

Section: Discussionmentioning

confidence: 99%

“…is may be due to lack of confidence in skills, reluctance due to concerns regarding patient discomfort, and time consumption. Most patients, however, do not perceive this as uncomfortable [4,25,26], and the median time to perform awake tracheal intubation with a FB is only 8 minutes longer than for tracheal intubation after induction [5,26,27].…”

Section: Discussionmentioning

confidence: 99%

“…Some common features among nonpregnant and pregnant patients in general, where airway management can be predicted to be very difficult and for whom awake tracheal intubation should be considered, are (1) previous difficult airway, (2) significant neck pathology, (3) severely reduced mouth opening, and (4) severely reduced neck movements. Neck pathology from tumor, previous surgery, or radiation increases the risk of failure in every aspect of airway management [4][5][6][7][8]. Mouth opening is normally 40−60 mm depending on gender, height/weight, age, and ethnicity [9].…”

Section: Introductionmentioning

confidence: 99%

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Managing Known Difficult Airways in Obstetric Patients Using a Flexible Bronchoscope and IRRIS: A Case-Illustrated Guide for Nonexpert Anesthesiologists, without Surgical Backup

Hannig

Hauritz

Jessen

et al. 2021

Case Reports in Anesthesiology

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Pregnancy is associated with anatomical and physiological changes leading to potential difficult airway management. Some pregnant women have known difficult airways and cannot be intubated even with a hyperangulated videolaryngoscope. If neuraxial techniques are also impossible, awake tracheal intubation with a flexible bronchoscope may be one of the few available options to avoid more invasive techniques. The Infrared Red Intubation System (IRRIS) may help nonexpert anesthesiologists in such situations and may enhance the chance of successful intubation increasing safety for the mother and the fetus, especially in hospitals without the ear, nose, and throat surgical backup.

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Infrared flashing light through the cricothyroid membrane to guide flexible bronchoscopic tracheal intubation

Jauho

Johannsen

Hesselfeldt

et al. 2021

Anaesthesia Reports

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Flexible bronchoscopic tracheal intubation is a fundamental technique in the management of the difficult airway but requires specific skills which may be both difficult to achieve and maintain. Therefore, techniques to improve its success should be developed. We present two cases, one where the ear, nose and throat surgeon could not view the glottis due to laryngeal pathology, and one where pathology in the oropharynx obscured access to the trachea during attempts at flexible bronchoscopic and videolaryngoscopic tracheal intubation. In both cases, tracheal intubation was subsequently successful due to the use of the Infrared Red Intubation System. This is an infrared light source that is secured to the anterior neck. It emits a flashing infrared light that is captured by the flexible bronchoscope, thus guiding the way to the trachea. These are the first reports of this technology being used for flexible bronchoscopic tracheal intubation in patients with severe airway pathology where conventional approaches had failed. Both cases emphasise that this technique can be of benefit in avoiding a surgical airway.

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From variance to guidance for awake tracheal intubation

Cited by 13 publications

References 20 publications

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Managing Known Difficult Airways in Obstetric Patients Using a Flexible Bronchoscope and IRRIS: A Case-Illustrated Guide for Nonexpert Anesthesiologists, without Surgical Backup

Infrared flashing light through the cricothyroid membrane to guide flexible bronchoscopic tracheal intubation

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