scholarly journals Management of Difficult Tracheal Intubation

2019 ◽  
Vol 131 (4) ◽  
pp. 818-829 ◽  
Author(s):  
Aaron M. Joffe ◽  
Michael F. Aziz ◽  
Karen L. Posner ◽  
Laura V. Duggan ◽  
Shawn L. Mincer ◽  
...  
Keyword(s):  
Tracheal Intubation ◽  
Airway Management ◽  
Difficult Intubation ◽  
Multiple Testing ◽  
Difficult Tracheal Intubation ◽  
Sufficient Information ◽  
Physical Status ◽  
Emergency Procedures ◽  
Malpractice Claims ◽  
Preoperative Predictors

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database. Methods Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management. Results Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A “can’t intubate, can’t oxygenate” emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80). Conclusions Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.

scholarly journals Comparison of Incidence of Difficult Intubation between Obese and Nonobese Patients, and Comparison of Three Predictors of Difficult Intubation in Obese Patients

2016 ◽  
Vol 1 (2) ◽  
pp. 41-44
Author(s):  
Johann Mathew
Keyword(s):  
Tracheal Intubation ◽  
Difficult Intubation ◽  
Mouth Opening ◽  
Difficult Tracheal Intubation ◽  
Neck Circumference ◽  
Obese Patients ◽  
Chi Square ◽  
Neck Extension ◽  
Difficulty Scale ◽  
Nonobese Patients

ABSTRACT Background Anticipating a difficult airway is of prime importance to an anesthesiologist. Data available are inconclusive to say that tracheal intubation is more difficult in the obese. The deficiency occurring with individual factors can be avoided by adopting multiple airway assessment factors. In this study, we aim to compare the incidence of difficult intubation between obese and nonobese patients and compare three predictors of difficult intubation. Study design Prospective observational study. Materials and methods About 250 patients were assigned to two groups, obese and nonobese based on their body mass index. Preoperatively, neck circumference (NC), mouth opening, thyromental distance (TMD), neck extension, NC/TM ratio, Mallampati classification (MPC), and Wilson score (WS) were calculated. Difficulty of intubation was assessed using the intubation difficulty scale (IDS). All tracheal intubations were performed by anesthetists with more than 2 years of experience. Statistical analysis used Data analysis was done with the help of Statistical Package for the Social Sciences (SPSS) version 15, MedCalc version 11, and Epi data software. Qualitative data are presented with the help of frequency and percentage table, and association among various study parameters is done with chi-square test. Results The incidence of difficult intubation determined by the IDS (≥5) was more frequent in the obese group (88.6% in obese vs 11.4% in nonobese). Of the three variables, WS was found to be statistically significant (p < 0.005). Neck circumference to thyromental ratio is a new predictor for difficult tracheal intubation (DTI). But an NC/TM ratio of ≥5 gives high false positive for our population. How to cite this article Mathew J, Gvalani SK. Comparison of Incidence of Difficult Intubation between Obese and Nonobese Patients, and Comparison of Three Predictors of Difficult Intubation in Obese Patients. Res Inno in Anesth 2016;1(2):41-44.

Airway Management in Children

2019 ◽  
Author(s):  
James Peyton ◽  
Raymond Park
Keyword(s):  
Tracheal Intubation ◽  
Airway Management ◽  
Fiberoptic Bronchoscopy ◽  
Difficult Tracheal Intubation ◽  
Airway Device ◽  
Successful Outcome ◽  
Supraglottic Airway ◽  
Supraglottic Airway Device ◽  
Factors Associated ◽  
Life Threatening

Airway management in children is usually very straightforward. Unfortunately, when it is not straightforward complications associated with problems encountered while managing the airway can be life-threatening. Airway management can be considered to consist of several different techniques for oxygenating and ventilating an anesthetized patient, namely mask ventilation, supraglottic airway device ventilation, and tracheal intubation. This chapter discusses these techniques and the factors associated with difficulty in performing them. There are anatomic features associated with difficulty in all of these techniques that are caused by syndromes or abnormal airway anatomy in children, although around 20% of difficult intubations are unanticipated. The majority of complications occur when attempting a difficult tracheal intubation. Morbidity and mortality relating to tracheal intubation correlate to the number of attempts at tracheal intubation. Severe hypoxia is estimated to occur in around 9% of children who are difficult to intubate and hypoxic cardiac arrest in nearly 2%, so the key to successful airway management is to focus on maintaining oxygenation and choosing a technique with the best chance of a successful outcome during the first attempt at airway management. This review contains 6 figures, 7 tables, and 41 references.  Keywords: cricothyrotomy, difficult airway, direct laryngoscopy, fiberoptic bronchoscopy, front of neck access, intubation, pediatric, videolaryngoscopy

Airway assessment and management

2021 ◽  
pp. 361-404
Author(s):  
Jules Cranshaw ◽  
Emira Kursumovic ◽  
Tim Cook
Keyword(s):  
Tracheal Intubation ◽  
Airway Management ◽  
Difficult Intubation ◽  
Rapid Sequence Induction ◽  
Respiratory Viruses ◽  
Airway Assessment ◽  
Rapid Sequence ◽  
Sequence Induction ◽  
Practical Information ◽  
Apnoeic Oxygenation

This chapter provides detailed, practical and up-to-date information on management of the airway. It demystifies airway terminology, outlines airway assessment, and describes the management of the unanticipated difficult airway in adults. It includes a new section on intubating critically ill patients using the vortex approach, and outlines the equipment and techniques used to aid airway management. It gives practical information on the emergency front of neck airway and strategies to approach the obstructed airway. It explains rapid sequence induction, inhalational induction, awake tracheal intubation, and extubation after difficult intubation. It contains new sections on apnoeic oxygenation and how to manage patients with airborne respiratory viruses.

scholarly journals Awake Fiberoptic or Awake Video Laryngoscopic Tracheal Intubation in Patients with Anticipated Difficult Airway Management

2012 ◽  
Vol 116 (6) ◽  
pp. 1210-1216 ◽  
Author(s):  
Charlotte V. Rosenstock ◽  
Bente Thøgersen ◽  
Arash Afshari ◽  
Anne-Lise Christensen ◽  
Claus Eriksen ◽  
...  
Keyword(s):  
Tracheal Intubation ◽  
Difficult Airway ◽  
Scale Score ◽  
Visual Analog Scale ◽  
Difficult Intubation ◽  
Visual Analog Scale Score ◽  
Difficult Tracheal Intubation ◽  
Fiberoptic Intubation ◽  
Analog Scale ◽  
Intubation Success

Background Awake flexible fiberoptic intubation (FFI) is the gold standard for management of anticipated difficult tracheal intubation. The purpose of this study was to compare awake FFI to awake McGrath® video laryngoscope, (MVL), (Aircraft Medical, Edinburgh, Scotland, United Kingdom) intubation in patients with an anticipated difficult intubation. The authors examined the hypothesis that MVL intubation would be faster than FFI. Methods Ninety-three adult patients with anticipated difficult intubation were randomly allocated to awake FFI or awake MVL, patients were given glycopyrrolate, nasal oxygen, topical lidocaine orally, and a transtracheal injection of 100 mg lidocaine. Remifentanil infusion was administered intravenously to a Ramsay sedation score of 2-4. Time to tracheal intubation was recorded by independent assessors. The authors also recorded intubation success on the first attempt, investigators' evaluation of ease of the technique, and patients reported intubation-discomfort evaluated on a visual analog scale. Results Eighty-four patients were eligible for analysis. Time to tracheal intubation was median [interquartile range, IQR] 80 s [IQR 58-117] with FFI and 62 s [IQR 55-109] with MVL (P = 0.17). Intubation success on the first attempt was 79% versus 71% for FFI and MVL, respectively. The median visual analog scale score for ease of intubation was 2 (IQR 1-4) versus 1 (IQR 1-6) for FFI and MVL, respectively. The median visual analog scale score for patients' assessment of discomfort for both techniques was 2, FFI (IQR 0-3), MVL (IQR 0-4). Conclusions The authors found no difference in time to tracheal intubation between awake FFI and awake MVL intubation performed by experienced anesthesiologists in patients with anticipated difficult airway.

scholarly journals A data review of airway management in patients with oral cavity or oropharyngeal cancer: A single-institution experiences

2019 ◽  
Author(s):  
Gang Zheng ◽  
Lei Feng ◽  
Carol M Lewis
Keyword(s):  
Body Mass Index ◽  
Tracheal Intubation ◽  
Oral Cavity ◽  
Airway Management ◽  
Range Of Motion ◽  
Body Mass ◽  
Oropharyngeal Cancer ◽  
Difficult Tracheal Intubation ◽  
Mallampati Score ◽  
History Of

Abstract Background: Oral cavity and oropharyngeal cancer impose significant threat to airway management. Head and neck radiotherapy (HNRT) may further increase the difficulty of tracheal intubation. We hypothesized that a history of HNRT would be associated with a high rate of difficult tracheal intubation. Methods: Adult patients with a history of HNRT were identified. Non-HNRT controls were case-matched by age, sex and body mass index. The tracheal intubation status between the two patient groups (treated vs. untreated with HNRT) was compared. The t test was used to evaluate differences in continuous variables between the 2 groups. Fisher’s exact test or a chi-square test was used to test for associations between radiation status and patient characteristics that may be associated with difficult tracheal intubation. Odds ratio and its confidence interval were used to assess the effect of radiation status on intubation status. Results: The final cohort of 472 matched patients in age, sex and body mass index consisted of 236 patients who had HNRT before surgery and 236 who had upfront surgery without HNRT. The percentage of patients who had restricted neck range of motion in the HNRT group was significantly higher than in the control group (22.3% vs. 11.0%; P = 0.001). The proportion of patients with trismus (P = 0.11) or difficult tracheal intubation (p = 0.73) did not differ significantly between the 2 groups. 12.7% patients in the study had difficult tracheal intubation. Patients who had mallampati scores of 3 or 4 had significantly higher rate of difficult tracheal intubation than did patients with mallampati scores of 1 or 2 (17.8% vs. 8.7%; p = 0.004). Multivariate logistic regression model showed no difference between HNRT and intubation status after adjusting neck range of motion and mallampati score (OR=0.91, 95% CI: 0.510 to1.612) Conclusions: Previous treatment with HNRT was not associated with additional risk of difficult tracheal intubation. Mallampati score may be a sensitive measurement for difficult tracheal intubation in this patient population.

scholarly journals Predictors of Difficult Tracheal Intubation on Adult Elective Patients in a Teaching Hospital

2016 ◽  
Vol 10 (1) ◽  
pp. 34-39
Author(s):  
Dawit Tafesse ◽  
Getu Ataro
Keyword(s):  
Tracheal Intubation ◽  
Difficult Intubation ◽  
Prospective Observational Study ◽  
Preoperative Evaluation ◽  
Preoperative Assessment ◽  
Difficult Tracheal Intubation ◽  
Adult Patients ◽  
Chi Square ◽  
Chi Square Test ◽  
Sensitivity Specificity

Background: During routine preoperative assessment of patients one of the commonest practices is predicting difficulty of tracheal intubation from various factors detected. Whether the factors reliably predict the difficulty is subject of argument. This study was conducted to assess the predictors of difficult tracheal intubation in adult patients. Methods: In this prospective observational study, we studied 120 consecutive elective adult patients admitted for general, gynecologic and orthopedic surgeries. Socio-demographic parameters and test variables such as BMI, TMD, SMD, IIG and Mallampati class were collected during preoperative evaluation. CL grade and difficulty of intubation were observed while the anesthetist in duty performs the laryngoscopy. While the former obtained from the preoperative anesthesia note, the latter were filled to questionnaire based on what the anesthetist reports during or after laryngoscopy. The prevalence of difficult intubation and the sensitivity, specificity, PPV and NPV of the tests were analyzed. SPSS-20 and different formulas were used during analysis. Chi square test was used and P<0.05 was considered as statistically significant. Result: The overall prevalence of difficult tracheal intubation was 2.5%. The sensitivity, specificity, PPV & NPV of the tests were 0%, 98.3%, 0% & 97.46% for BMI; 0%, 97.5%, 0% & 100% for SMD; 100%, 96.64%, 20% & 100% for TMD; 0%, 99.17%, 0%, & 100% for IIG; and 100%, 99.14%, 75% & 100% for Mallampati test. Conclusion: The incidence is not quite small that anesthetists should use necessary tests to predict the difficult intubation. Probably combining the tests being the best option, Mallampati test alone can predict the difficult intubation in adult patients.

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