The evolution of airway management – new concepts and conflicts with traditional practice

Abstract

In the last 25 yr, there have been several advances in the safe management of the airway. Videolaryngoscopes and supraglottic airways, now in routine use by new trainees in anaesthesia, have had their genesis in the recent past. The 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society published in 2011 a seminal report that has influenced airway management worldwide . Understanding how the report's recommendations were constructed and how clinical guidelines compliment rather than contradict them is important in understanding the tenets of safe airway management. Over the last 25 yr there has been an increasing understanding of the effects of human factors in anaesthesiology: we may not perform in a predictable or optimal manner when faced with unusual and threatening challenges. The place of cricoid pressure in anaesthetic practice has also evolved. Current recommendations are that it be applied, but it should be released rapidly should airway difficulty be encountered. The need to prevent hypoxaemia by preoxygenation has long been recognized, but the role of high-flow nasal oxygen in anaesthesia is now being realized and developed. Clinicians must decide how novel therapies and long-standing practices are adapted to best meet the needs of our patients and prevent harm during airway management.

Cognitive re-engineering after a 15-year experience with routine videolaryngoscopy

“…2,3 These problems were exacerbated by the lack of a reliable assessment process that could reliably predict difficult intubation. 4 In 2003, only two videolaryngoscopes were available: the Storz system which provided an improved view using a Macintosh blade or the Glidescope system which in addition to the improved view used a hyperangulated blade that we believed would reduce muscle fatigue. We chose to use the Glidescope and also mandated the use of an enhanced airway assessment protocol, the El Ganzouri Score or Simplified Airway Risk index.…”

The midline approach for endotracheal intubation using GlideScope video laryngoscopy could provide better glottis exposure in adults： A randomized controlled trial

“…In the past decade, video laryngoscopy-assisted tracheal intubation has been extensively applied in airway management because of better visualization of the laryngeal structures on a high-resolution video screen [1][2][3] . Common teaching in direct laryngoscopy advocates that the device is inserted into the right side of the mouth, the tongue is moved to the left by the blade flange, the blade tip is advanced into the epiglottic vallecula, and then the device is raised to obtain the laryngeal view (right-sided approach) [4] .…”

Feasibility of forced oscillatory assessment of respiratory mechanics across a laryngeal mask airway in rabbits

“…Feasibility of forced oscillatory assessment of respiratory mechanics across a laryngeal mask airway in rabbits 2 A Dos Santos Rocha et al The use of the laryngeal mask airway (LMA) is widely considered as an alternative to the endotracheal tube (ETT) for securing the airways during sedation and/or general anesthesia, both in experimental research (Bateman et al 2005, Toman et al 2015 and in the clinical environment (von Ungern-Sternberg et al 2007, Park et al 2016, McNarry and Patel 2017, Mihara et al 2017. The ease of insertion and minimal adverse respiratory consequences (Park et al 2016, Xu et al 2016, Drake-Brockman et al 2017 have contributed to the generalized use of LMA for patients of all ages (von Ungern-Sternberg et al 2007) for elective and urgent situations and, more recently, for animal models, particularly if follow-up measurements are planned.…”