Difficult Airway for Intubation by Bronchoscopy : Importance of the Functional Anatomy of the Upper Airway

AbstractIn children with mandibular hypoplasia, airway management is challenging. However, detailed cephalometric assessment data for this population are sparse. The aim of this study was to find risk factors for predicting difficult airways in children with mandibular hypoplasia, and compare upper airway anatomical differences using three-dimensional computed tomography (3D CT) between children with mandibular hypoplasia and demographically matched healthy controls. There were significant discrepancies in relative tongue position (P < 0.01) and anterior distance of the hyoid bone (P < 0.01) between patients with mandibular hypoplasia and healthy controls. All mandibular measures were significantly different between the two groups, except for the height of the ramus of the mandible. After adjusting for age and sex, the anterior distance of hyoid bone and inferior pogonial angle were significantly associated with a difficult airway (P = 0.01 and P = 0.02). Quantitative analysis of upper airway structures revealed significant discrepancies, including relative tongue position, hyoid distance, and mandible measures between patients with mandibular hypoplasia and healthy controls. The anterior distance of the hyoid bone and inferior pogonial angle may be risk factors for a difficult airway in patients with mandibular hypoplasia.

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Basics of Airway and Oxygen Delivery Devices

Mayo Clinic Critical and Neurocritical Care Board Review ◽

10.1093/med/9780190862923.003.0114 ◽

2019 ◽

pp. 835-839

Author(s):

Andrew W. Murray

Keyword(s):

Tracheal Intubation ◽

Brain Death ◽

Difficult Airway ◽

Brain Damage ◽

Oxygen Delivery ◽

Upper Airway ◽

Patent Airway ◽

Definition Of ◽

Facemask Ventilation

One of the greatest responsibilities in managing an airway is to maintain a continuously patent airway. Any loss of patency of the patient’s airway is critical, and if the ability to provide ventilatation is lost, brain damage can rapidly develop potentially lead to brain death. The definition of difficult airway is not standardized in the anesthesiology literature, but it has been described as the situation when “a conventionally trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both”

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Recurrent Acute Upper Airway Obstruction after Anterior Cervical Fusion

Anaesthesia and Intensive Care ◽

10.1177/0310057x9802600314 ◽

1998 ◽

Vol 26 (3) ◽

pp. 305-307 ◽

Cited By ~ 20

Author(s):

A. Penberthy ◽

N. Roberts

Keyword(s):

Airway Obstruction ◽

Difficult Airway ◽

Endotracheal Intubation ◽

Cervical Myelopathy ◽

Surgical Repair ◽

Upper Airway ◽

Upper Airway Obstruction ◽

Anterior Fusion ◽

Dural Tear ◽

Cervical Fusion

A 67-year-old man presented with cervical myelopathy for which a C3/4 discectomy and anterior fusion was performed. Recurrent episodes of acute upper airway obstruction necessitated laryngoscopy and endotracheal intubation. Drainage of a prevertebral collection of CSF and surgical repair of a dural tear corrected the obstructive symptoms. Management of the difficult airway is discussed.

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A new self-designed “tongue root holder” device to aid fiberoptic intubation

Clinical Oral Investigations ◽

10.1007/s00784-020-03297-2 ◽

2020 ◽

Vol 24 (12) ◽

pp. 4335-4342

Author(s):

Xiaofei Cao ◽

Junbei Wu ◽

Yin Fang ◽

Zhengnian Ding ◽

Tao Qi

Keyword(s):

Risk Factors ◽

Difficult Airway ◽

Soft Palate ◽

Elective Surgery ◽

Upper Airway ◽

Orotracheal Intubation ◽

Fiberoptic Intubation ◽

Fiberoptic Bronchoscope ◽

Airway Clearance ◽

Jaw Thrust Maneuver

Abstract Objective In this study, we aimed to assess the feasibility of fiberoptic intubation (FOI), using a new, self-designed, “tongue root holder” device, in combination with the jaw thrust maneuver. Methods Three hundred patients undergoing elective surgery requiring orotracheal intubation were enrolled. Patients presented at least one or more risk factors for difficult airway. The patients were randomly allocated at a 1:1 ratio to one of two groups: group L, FOI with tongue root holder, or group C, standard FOI. Orotracheal FOI was performed after commencement of anesthesia. The jaw thrust maneuver was applied in both groups to facilitate advancement of the fiberoptic bronchoscope. The primary endpoint was the feasibility of FOI. The secondary endpoints were number of attempts, time to intubation, and airway clearance at the soft palate and epiglottis levels. Results The FOI was achieved in all 150 patients in group L, significantly higher than that in group C (100% vs 95.3%; P = 0.015). Less attempts of intubation were made in group L (P = 0.039). Mean time to successful intubation on the first attempt was shorter in group L (P < 0.001). The mean times to view the vocal cord and carina were also shorter in group L (P = 0.011 and P < 0.001, respectively). Airway clearance was better in group L at both the soft palate and the glottis levels (P = 0.010 and P = 0.038, respectively). Conclusions This study shows that FOI is feasible with the newly introduced, self-designed, “tongue root holder” device, when combined with the jaw thrust maneuver in patients with risk factors for difficult airway. The device also provides better airway clearance, less intubation attempts, and shorter time to intubation at first attempt. Clinical relevance Fiberoptic bronchoscope has been the gold standard for routine management of difficult airway. A technique to open the airway is introduced to reduce the incidence rate of upper airway obstruction.

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A predictive formula for difficult endotracheal intubation in the emergency department

10.21203/rs.3.rs-49018/v1 ◽

2020 ◽

Author(s):

En-Chih Liao ◽

Wen-Han Chang ◽

Ching-Hsiang Yu ◽

Cheng-Ying Shen ◽

Fang-Ju Sun ◽

...

Keyword(s):

Emergency Department ◽

Airway Obstruction ◽

Difficult Airway ◽

Endotracheal Intubation ◽

Difficult Intubation ◽

Upper Airway ◽

High Body Mass Index ◽

Upper Airway Obstruction ◽

Binary Logistic Regression Model ◽

Difficult Endotracheal Intubation

Abstract Background Current predictors for evaluating difficult endotracheal intubation had poor accessibility or sensitivity at the emergency department, so we evaluated the incidence and predictive factors, then built an easy-to-use predictive formula. Methods This was a 17-month prospective observational study. For the 110 patients, difficult airway was defined as Cormack & Lehane classification grade III and IV at first attempt of intubation. The univariate associations between patient characteristics and difficult endotracheal intubation were then analyzed, and the significantly associated factors were included in a multivariate binary logistic regression model then a predictive formula was generated. Generalized association plot (GAP) was used to show the relationship between each variable. Results The incidence of difficult intubation in our study was 35.5%. In the difficult airway group, significantly higher rates (p < 0.05) of high body mass index (BMI); double chin; thick, short neck; Mallampati difficulty; smaller inter-incisors distance; smaller thyromental distance; and upper airway obstruction were noted. Finally, a predictive formula for difficult intubation was successfully established by the combination of four predictors: BMI (odds ratio [OR] = 1.270), thyromental distance (OR = 0.614), upper airway obstruction (OR = 4.038), and Mallampati difficulty (OR = 5.163). A cut-off score of 4 provided the best sensitivity (79.5%) and specificity (81.7%)(95% CI: 0.794 to 0.938). Conclusions Our predictive formula could be used by emergency physicians to quickly identify and carefully manage patients with potentially difficult intubation. Early expert consultation could be sought when necessary.

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Functional Anatomy of the Upper Airway

Emergency Medicine Clinics of North America ◽

10.1016/s0733-8627(20)30518-6 ◽

1988 ◽

Vol 6 (4) ◽

pp. 639-669 ◽

Cited By ~ 3

Author(s):

Ian R. Morris

Keyword(s):

Functional Anatomy ◽

Upper Airway

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The Percutaneous Transtracheal Jet Ventilation in a Patient with Partial Upper Airway Obstruction

Hong Kong Journal of Emergency Medicine ◽

10.1177/102490790100800406 ◽

2001 ◽

Vol 8 (4) ◽

pp. 223-226 ◽

Cited By ~ 1

Author(s):

KY Fung ◽

MC Yuen ◽

WK Tung

Keyword(s):

Airway Obstruction ◽

Difficult Airway ◽

Upper Airway ◽

Upper Airway Obstruction ◽

Emergency Physicians ◽

Jet Ventilation ◽

Partial Upper Airway Obstruction ◽

Set Up

Difficult airway is a challenging emergency problem for emergency physicians. We reported a patient with partial upper airway obstruction managed by percutaneous transtracheal jet ventilation (PTJV) before definite airway was secured. The development, the set up, the advantages, and the precautions of using PTJV are briefly described.

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Changes in the upper airway following induction of anaesthesia: a prospective observational study protocol to determine the use of ultrasound in the assessment of a difficult airway in China

BMJ Open ◽

10.1136/bmjopen-2019-029782 ◽

2019 ◽

Vol 9 (7) ◽

pp. e029782

Author(s):

Fang Dong ◽

Yong Wang ◽

Xia Wang ◽

Huanyi Zhao ◽

Wuhua Ma

Keyword(s):

Difficult Airway ◽

General Anaesthesia ◽

Upper Airway ◽

Screening Tests ◽

Rank Test ◽

Correct Prediction ◽

Tertiary Teaching ◽

Lehane Grade ◽

Before And After ◽

Difficult Airways

IntroductionDifficult airway management is closely related to the safety and quality of medical care. However, the low incidence of correct prediction of difficult airway in clinical screening tests presents physicians with a dilemma. Depressed airway neuromuscular tension during sleep and anaesthesia tends to cause collapse of fragile parts of the upper airway. Although previous studies have confirmed that anterior cervical tissue thickness is associated with difficult airways, there is no evidence to support a correlation between a difficult airway and specific patterns or findings of anaesthesia-induced airway collapse. Thus, this study aims to examine changes in airway dimensions before and after induction of general anaesthesia to explore whether it could provide useful information regarding the specific anatomic changes occurring which may cause difficult airways.Methods and analysisThis will be a single-centre prospective observational single-blinded study, conducted in a tertiary teaching hospital in Guangzhou, China. Subjects will be recruited from patients (aged 18–65 years) scheduled for elective surgery under general anaesthesia. Sonographic measurement will be performed to detect changes in the thickness of the anterior cervical soft tissue before and after anaesthetic induction. Based on the resulting data distribution, analyses will initially compare these changes using a paired t-test or the Wilcoxon signed-rank test. The correlation of sonographic changes and Cormack–Lehane grade will be evaluated by using receiver-operating characteristic curves to detect the sensitivity and specificity of a measurement for detecting difficulties. Linear stepwise regression analysis will be used to assess the correlation between airway changes and demographic variables as well as clinical tests.Ethics and disseminationEthical approval has been obtained from the Ethics Committee of the First Affiliated Hospital of Guangzhou University of Chinese Medicine (ZYYECK (2018) 041). The results will be disseminated through conference presentations, professional journals and peer-reviewed publications.Trial registration numberChiCTR1900021123; Pre-results.

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Anaesthesia for Reconstruction Surgery Post Mandibulectomy in a Patient with a Predicted Difficult Airway: A Case Report

Integrative Journal of Medical Sciences ◽

10.15342/ijms.2021.426 ◽

2021 ◽

Vol 8 ◽

Author(s):

Omolola Adunni Fagbohun ◽

Ibifuro Dennar ◽

Olugbusi Sope ◽

Oresanwo Theressa

Keyword(s):

Difficult Airway ◽

Endotracheal Tube ◽

Mouth Opening ◽

Upper Airway ◽

Index Patient ◽

Anaesthetic Management ◽

Neck Mass ◽

Team Work ◽

Intubating Laryngeal Mask Airway ◽

Edentulous Mandible

Introduction: Mandibular surgeries, edentulous mandible, use of dentures, and aging all predispose to residual mandibular ridge resorption and thinning. The edentulous state of the mandible makes the tongue occlude the upper airway. All these, contribute to difficulty in managing the airway. An adequate pre-operative review helped classify this index patient as high risk for difficult airway and adequate steps were taken to facilitate optimal airway management.Case report: We present a 53 years old woman with mandibular deformity, anterior neck mass and inadequate mouth opening who has had a segmental mandibulectomy and a soft tissue closure of reconstruction plate. She was scheduled for mandibular reconstruction.She was successfully intubated using a size 4.5 Intubating Laryngeal Mask Airway (ILMA) through which a size 6.0 ID classic endotracheal tube was introduced for ventilation. A gum elastic bougie was then inserted through the endotracheal tube, both the ILMA and classic endotracheal tube were withdrawn. An armored tube size 6.5 ID was then rail roaded.Conclusion: The successful anaesthetic management of this difficult airway patient was facilitated by a thorough pre-anaesthetic plan, concise and skilled anaesthetic management strategy with a well organized team work.

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Extubation of the Difficult Airway: An Algorithmic Approach

The Open Anesthesiology Journal ◽

10.2174/1874321801206010001 ◽

2012 ◽

Vol 6 (1) ◽

pp. 1-8

Author(s):

C. Voscopoulos ◽

L. Jalota ◽

F. L. Kirk ◽

A. Saxena ◽

M. Lema ◽

...

Keyword(s):

Tracheal Intubation ◽

Difficult Airway ◽

Operating Room ◽

Upper Airway ◽

Clinical Situation ◽

Mask Ventilation ◽

Algorithmic Approach ◽

Intubate Patient ◽

Recovery Unit ◽

American Society

The difficult airway has been defined as a “clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation of the upper airway, tracheal intubation, or both.” Given the potentially lifethreatening consequences, the American Society of Anesthesiology has developed an airway algorithm that focuses on establishing an airway, generally for the induction of anesthesia. However, there is no algorithm on how to safely transition from an established airway back to the normal, natural airway. Up to 0.19 percent of patients can require reintubation in the post anesthesia recovery unit, with the known difficult airway at greater risk in these settings for failed reintubation. Because of this, there has been recognition of the need for guidelines in the form of an algorithm to deal with extubation in these patients. To fill this current need, we propose the following difficult to intubate patient extubation algorithm for use in the operating room setting.

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