Progress in management of the obstructed airway

Abstract

SummaryThere is no consensus as to the ideal approach for the anaesthetic management of the adult obstructed airway and there are advocates of awake fibreoptic intubation, inhalational induction and intravenous induction techniques. This review considers the different options available for obstruction at different anatomical levels. Decisions must also be made on the urgency of the required intervention. Particular controversies revolve around the role of inhalational vs intravenous induction of anaesthesia, the use or avoidance of neuromuscular blockade and the employment of cannula cricothyroidotomy vs surgical tracheostomy.

Sugammadex to rescue a ‘can't ventilate’ scenario in an anticipated difficult intubation: is it the answer?

“…When unexpected difficulty progresses to an inability to ventilate, patient safety may be compromised unless immediate oxygenation is achieved using a surgical airway. Patients with obstructing lesions at the tongue base and supraglottic region may be in danger of airway obstruction on induction of general anaesthesia due to loss of skeletal muscle tone [21]. Attempts at laryngoscopy, insertion of a SAD or airway adjuncts and any forceful airway manoeuvres may cause bleeding and oedema, leading to complete airway obstruction.…”

Conscious sedation for awake fibreoptic intubation: a review of the literature

“…While no one would argue that this recommendation applies to any agent that acts by modulating the GABA A receptor, there is little evidence that sedation with an agent that depresses ventilation but not level of consciousness (remifentanil) or vice versa (dexmedetomidine) is more dangerous than conducting AFOI with LA alone. Topical anesthesia in patients with critical airway obstruction can be difficult to achieve, 62 and though a rarity, inadequate anesthesia of the larynx or even the application of topical anesthesia itself can precipitate total airway obstruction [63][64][65] Although there has been a recent description of the use of dexmedetomidine with no use of LA at all, 57 there is generally more evidence supporting the safe use of remifentanil in this fashion, at least in the context of patients without critical airway obstruction.…”

Successful intubation of a difficult airway due to a large obstructive vocal cord polyp augmented by the delivery of a transtracheal injection of local anaesthetic

“…It is noted that introducing this form of spray is difficult to achieve in patients with critical obstruction 9. Transtracheal injection of local anaesthesia carries risks as the anatomy can be difficult to identify.…”