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secretions, and edema in the periglottic structures. This will further complicate subsequent intubation attempts and may render intubation impossible by completely
obstructing the airway, leaving an urgent surgical airway the only resort [1].
An ASA closed claims analysis of difcult airway management cases indicated
that when DTI was expected, almost 70% of anesthetists still decided to proceed
with routine general anesthesia and paralysis. Of those cases, more than 60%
evolved to CICV (cannot intubate, cannot ventilate) and poor outcomes were signicantly more common than in cases intubated differently. Very similar results
were found in other surveys in other countries for more than 20years [59, 60].
However, even with a careful assessment of these ndings, occasionally patients
will be surprisingly difcult. If one encounters a difcult airway case, one needs to
make an informed decision about how to proceed based on the availability of equipment, preferably before the onset of desaturation. The options for difcult airway
tools include the intubating laryngeal mask airway, ber-optic bronchoscope, intubating stylet, articulating laryngoscope, video laryngoscope (VL), and cricothyrotomy [3].
As for any procedure, the patient should be prepared adequately. The rst step is
to have the patient positioned ideally on the bed. The body should be located just at
the head of the bed so that the occiput is supported on the edge. The head is placed
in neutral alignment with the vertebral axis and, if the cervical spine is stable, the
head is slightly extended to achieve the so-called snifng position. The bed is then
raised or lowered to the proper height required by the person doing the procedure
[61–63]. All required equipment should be immediately available at the bedside,
and all necessary medications should be drawn up in syringes. A reliable intravenous access should be conrmed rst and foremost.
If the patient is breathing on his or her own, it would be prudent to hold off the
administration of neuromuscular blocking drugs. Often, in traumatic airways, the
only way to identify the tracheal opening is to watch the subglottic area for spontaneous respiration.
In elective intubations, the patient with a history of difcult intubation can be
intubated awake. The airway is prepped with nebulized viscous lidocaine 4% 5cc
to 10cc for 15 minutes to achieve topicalization of the buccal, subglottic structures and trachea. A ber-optic bronchoscope with a preloaded endotracheal tube
is introduced through the nares, which leads to a less acute angle on approaching
the vocal cords. The vocal cords are identied, and the scope is passed through the
true cords. After visualization of the tracheal rings, an endotracheal tube is passed
over the bronchoscope, and position is conrmed through direct visualization.
The bronchoscope is removed, and the patient is sedated and ventilated after
reconrmation of the right position of the endotracheal tube by capnography.
Fiber-optic bronchoscopy has the disadvantages of being operator dependent;
therefore, considerable experience is a prerequisite. It can also be difcult to visualize laryngeal structures when the airway is bloody or full of secretions, since the
aspiration port on the scope is small, and it can be difcult to suction large volumes or thick mucus.
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Expected DMV
Most of the studies conrm the opinion of Langeron that increased BMI, advanced
age, history of snoring, and presence of a beard are independent predictors of DMV
[30]. The presence of a beard is the only reversible risk factor for DMV, which is
why it is preferable that the patient shaves prior to the operation if he has associated
other risk factors for DMV. The mandibular protrusion test is a key predictor for
DMV.Takenaka etal. suggested that abnormalities in mandibular protrusion may be
a common indicator of both DI and DMV [64].
Most of the patients labeled as difcult to ventilate also have signs of a potential
DI and are candidates for awake ber-optic intubation [65]. On the other hand, some
patients with risk factors for DMV may have indicators of easy intubation
(Mallampati, thyromental distance, etc.) or a previous history of “easy” tracheal
intubation. In this category of patients, it is recommended to address preoperatively
the reversible factors of DMV [40].
When anesthesia induction is planned, the team should be prepared for any possible scenario [66]. Preparation should include the readiness of the difcult airway
cart and jet ventilation in the room, availability of an experienced assistant in case
help is needed, and rapid reversal (sugammadex) of neuromuscular blockade in the
need to resume spontaneous breathing. Some anesthesiologists may elect to induce
with a short-acting neuromuscular blocking agent like succinylcholine. Adequate
preoxygenation with 100% oxygen before loss of consciousness is crucial. Apneic
oxygenation affords the anesthesiologist several minutes to manage the airway
before oxygen desaturation [67].
Unexpected DTI
If problems in intubating the trachea are encountered, bag-mask ventilation can
provide a bridge to the patient while equipment is being prepared or more skilled
hands arrive for intubation. A quick decision, whether to awaken the patient or to
proceed with alternative intubation techniques, should be made (e.g., different
laryngoscope blades, exible ber-optic scope or other ber-optic techniques,
lighted wand, retrograde intubation, or surgical airway). In the potentially lifethreatening “cannot intubate, cannot ventilate” situation, either transtracheal jet
ventilation, laryngeal mask airway, esophageal-tracheal Combitube, or a surgical
airway must be performed/inserted immediately. Anesthesiologists should train
under routine conditions on these alternative techniques in order to be comfortable
with these critical situations [1].
Denitrogenation of the lungs should be performed routinely before anesthesia
induction. This is accomplished with giving the patient 100% oxygen via a face
mask for 5min before administration of any induction dose of apneic drug. This
will oxygenate the patient by diffusion, allowing some apneic time during a potentially prolonged intubation attempt. Patients who are obtunded should be mask ventilated with 100% oxygen before any intubation attempt to achieve the same
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denitrogenation. In the obtunded patient, the mouth and posterior pharynx should be
explored and suctioned before mask ventilation, as aspiration events and inability to
protect the airway are likely in altered mental states.
When intubation is difcult, publications showed that anesthetists may tend to
repeat the same technique at intubation several times, most of the time followed by
another anesthetist doing the same. This was shown by the fourth National Audit
Project of the Royal College of Anaesthetists and Difcult Airway Society (NAP4)
to increase the risk of progression to CICV leading to an increase in death and brain
damage [59]. According to Mort, there is a dramatic increase in airway complications when more than two direct laryngoscopies were attempted [68]. All national
unanticipated DTI guidelines stress that alternative techniques should be attempted
when direct laryngoscopy fails, and to limit the number of trials [69, 70]. Further
trials of laryngoscopy have a close to 80% failure rate, but alternative techniques
(SAD, indirect laryngoscopy) might be more successful. In a UK study of failed
obstetric intubation, 50% of failures were followed by management that deviated
from known recommendations [60].
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Unexpected DMV
According to the ASA algorithm, once DMV is encountered, the patient’s head
position should be optimized. In most situations, it is advisable to avoid the development of the difculty, e.g., by applying continuous positive airway pressure
(CPAP) ventilation to stent the airway open, as it may collapse after loss of consciousness. Partial obstruction may result in negative pressure efforts that lead to
further collapse and complete airway obstruction, creating a vicious cycle that is
difcult to break [33].
DMV andDTI
In some instances, unanticipated difcult laryngeal visualization may be faced after
an “easy” MV.When MV is difcult in some cases, a grade 1 view may be obtained
with direct laryngoscopy [30]. Difculty in one of these techniques does not necessarily mean that the other will also be difcult. Studies have shown that a relationship
exists between DMV and incidence of DI.Langeron etal. demonstrated that patients
with DMV have a higher incidence of DI than those with easy MV.They found the
incidence of DI to be 8% in easy-to-ventilate patients, and 30% in those who had
DMV, a fourfold increase [50]. Also, the incidence of impossible intubation increased
12-fold (0.5% vs. 6%) in patients who had DMV.Although the average of DI is probably around 8%, most of those patients should be suspected to have DMV.Kheterpal
etal. identied many factors that predispose to DMV and also to DI [30]. Obstructive
sleep apnea, history of snoring, obese neck anatomy, limited mandibular protrusion,
and BMI of 30kg/m2 or more are shared predictors for both DMV and DI.However,
despite this association, a large percentage of patients who experienced DMV in that
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study eventually had successful tracheal intubation. On the other hand, minimal data
were found in the literature about the relationship between invasive mechanical ventilation (IMV) and DI.Of 37 patients (0.16%) who experienced IMV, 26 were easily
intubated, 10 had DI but were eventually intubated, and only 1 patient required emergency cricothyrotomy [30]. Although this is the largest reported group of patients
with IMV, the number is still too small to draw any conclusions.
Distinguishing difcult intubation from difcult ventilation is important. If the
patient is difcult to intubate, adequacy of bag-mask ventilation becomes paramount, especially if the patient is already paralyzed or not breathing on their own.
The incidence of difcult and impossible MV determined by the four-point grading
scale is reported to be 1.4–5% and 0.15%, respectively [30, 50, 71]. DMV combined
with DI occurs in 0.14% of adult patients undergoing general anesthesia [72].
Following initially unsuccessful attempts at intubation, no single subsequent
technique is superior to others in all circumstances. For example, in one series of
698 patients with both difcult mask ventilation and difcult laryngoscopy, intubation was eventually successful with direct laryngoscopy in 177, direct laryngoscopy
with bougie introducer in 284, VL in 163, and other techniques in 73; one patient
required emergent cricothyrotomy [72]. After failed intubation in the AIMS study,
1in 7 patients also exhibited DMV, and in an obstetric failed intubation setting,
DMV occurred in 30% and IMV in 10% of cases [73, 74].
The ASA practice guideline on difcult airway management urges anesthetists to
routinely examine patients to identify predictors of airway technique failure [70].
When such features are elicited, we should optimize our intubation option, knowing
that the best shot is the rst attempt. If it fails, the feasibility of rescue techniques
should be planned ahead of time.
Regarding laryngeal masks, failure of laryngeal mask airway (LMA) placement
was associated with a threefold increase in the likelihood of DMV from 1.9 to 5.6%
[75]. In the ASACCP dataset, it was suggested that “LMA rescue ability may be
hindered by effects of multiple preceding intubation attempts” [59]. Finally, as
emphasized previously, multiple attempts at direct laryngoscopy are associated with
the development of both DMV and CICV [30].
Based on the review of large datasets, expert groups have recommended that VL
should be the rst rescue technique when direct laryngoscopy and/or mask or SGA
ventilation have failed, because of its high success rates. In a large, multicenter
retrospective study of failed DL utilizing the Multicenter Perioperative Outcomes
Database, in 1619 rescue attempts, VL resulted in the highest success rate (92%),
compared with FSI (78%), use of an SGA as a conduit for intubation (78%), or use
of a lighted stylet (77%) [76].
M. S. Rizk et al.
Management ofDifficult Airway
After induction of anesthesia, management of DMV is a dynamic process in which
close observation of the efcacy of oxygenation should be accompanied simultaneously by adjustments of the maneuvers, use of adjuncts, and call for help as soon as
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difculty is encountered. The most commonly used maneuvers to open the airway
are head tilt, chin lift, and jaw thrust. The placement of an oropharyngeal or nasopharyngeal airway can also facilitate ventilation. Operator change or two-person
MV technique might be successful.
Figure 18.1 shows the failure progression of DMV and the management steps
that can be followed to establish adequate ventilation. The gure is based on the
ASA difcult airway algorithm and other evidence from the literature [40, 66,
70, 77–82].
If MV is still impossible, the anesthesiologist should seriously consider discontinuing the anesthetic and awaken the patient. When recovery from anesthesia
induction is possible and spontaneous breathing is resumed, the case can be rescheduled, or an awake tracheal intubation technique performed. Recovery time is critical, and waiting for the patient to spontaneously breathe is not always a safe option
and might lead to fatal outcome. Reversal of neuromuscular blockade can consume
time. Bisschops etal. observed that the total time to prepare and administer sugammadex turned out to be 8.9min [83]. Makris etal. pointed out that a readily available syringe preloaded with sugammadex placed in the difcult airway trolley
would reduce this time [84]. Naquib etal. showed that recovery of neuromuscular
function only took 4.5min with 1.2mgkg−1 rocuronium at induction of anesthesia,
followed 3min later by 16mgkg−1 sugammadex [85]. Despite these results, the
Fig. 18.1 Failure progression of DMV, and steps to take to establish ventilation
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duration of apnea after sugammadex reversal may last as long as 15min, mainly in
obese patients. During this rescue, if ventilation is unsuccessful, oxygen desaturation will occur despite full reversal of neuromuscular blockade. Therefore, in a
CICV scenario, the clinical maneuvers such as restoration of a patent airway and
oxygenation are vital and should come before any pharmacological tools [86].
Meanwhile, the operator may either proceed with tracheal intubation or use an
alternative ventilatory device. Crosby etal. [77] considered an attempt at tracheal
intubation a prudent rst intervention in cases of IMV. As previously noted,
Kheterpal etal. [30] reported successful tracheal intubation in 36 of 37 patients who
had IMV, and only 1 patient required cricothyrotomy. Based on these results
(because this was the largest group of IMV patients studied), limited trials of direct
laryngoscopy and tracheal intubation should be considered.
The decision to proceed with either technique will be dictated by its availability,
urgency to establish ventilation, and the patient’s oxygen saturation. The laryngeal
mask airway (LMA) is considered by many to be the rst-choice rescue ventilation
device [59]. Because of its success rate, ease of insertion, and increased familiarity
with its use, the LMA was included in the ASA difcult airway algorithm as an
early option to be considered whenever it is difcult or impossible to ventilate [70].
Success with supraglottic airway ventilation relies on the clinician’s skill and experience with specic devices. The Combitube or other supraglottic airway devices
may be tried if both face mask and LMA fail to establish adequate ventilation [70,
79, 80]. Two relatively new supraglottic devices deserve mention because of the
reported success in their use to rescue ventilation. These are the laryngeal tube (LT)
and the LMA CTrach. The LT (King Systems, Noblesville, IN) is a silicone tube
with a proximal (pharyngeal) cuff and a distal (esophageal) cuff and ventilatory
apertures in between [87]. This device is easily inserted even by inexperienced personnel [88]. Its ventilatory efciency has been demonstrated with both controlled
and spontaneous ventilation [89, 90]. There are many reports of the LT used as a
rescue ventilation device in difcult airway situations [80, 91]. Placement, however,
may sometimes be difcult or impossible in patients with upper airway masses. The
LT cannot prevent or treat airway obstruction at or beyond the glottis [92]. The
LMA CTrach (LMA North America, San Diego, CA) is another device that was
successfully used in patients with difcult airways [93]. It is a modication of the
intubating LMA that incorporates a built-in ber-optic system to transmit images to
a small screen. The device can be used to rescue ventilation while simultaneously
performing tracheal intubation under visualization [94]. More time is required,
however, for its accurate placement [95]. More clinical trials are currently needed
on the use of these two promising devices and their role in difcult airway
management.
Several other devices have also been introduced. The choice of the proper device
should be based on the etiology of the problem, limitations of the device, experienced clinical judgment, and familiarity with its use, which can be crucial to its
successful application.
If all previously described techniques fail, the patient could not be ventilated or
intubated—an emergency surgical airway (ESA) is needed. As soon as the airway is
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labeled as potentially difcult, a surgeon should be consulted. Transtracheal jet ventilation may be considered when supraglottic ventilation devices fail, but the operator must be familiar with its use [81]. If all other measures fail to establish ventilation,
cricothyrotomy may be the only lifesaving alternative [70, 82]. There are also kits
available using a Seldinger technique, with a needle inserted through the cricothyroid membrane. On successful aspiration of air, a wire is passed into the trachea,
and the needle removed. A small incision is made in the skin, and a dilator is passed
over the wire. This should produce a large air leak on positive ventilation, conrming the placement. Then, a cricothyrotomy tube is passed through the opening and
the patient ventilated. Proper placement of an airway device should always be conrmed with an end-tidal carbon dioxide (CO2) device immediately and radiographically later to document the placement of the tube tip proximal to the carina.
ESA is a rescue technique and is performed in 1in 50,000 general anesthesia
cases where CICV occurs and increases 15-fold the risk of a poor outcome. However,
failure of ESA puts the patient at a signicant risk of death, and it accounts for more
than 25% of all anesthesia-related deaths [60, 71, 72].
The rarity, invasiveness, and emergency nature of ESA make its study difcult,
and much of the evidence is derived from models and simulations whose delity is
uncertain. NAP4 included a cohort of 80 cases of ESA (43% of all reports), perhaps
the largest in-hospital series. Thirteen of these patients died (16%), and seven suffered permanent harm (25% permanent harm or death). Despite high rates of failure
of ESA in this series, most patients made a full recovery. Failed initial ESA was
rescued variously by intubation, supraglottic airway device (SAD) placement,
patient awakening, or an alternative ESA technique.
CICV and attempted ESA occurred in several cases where NMBA was intentionally avoided and an airway rescue by a SGA was not attempted [60]. The NAP4
report recommended the use of NMBA and SGA whenever CICV is encountered
and before it progresses to ESA.The ASA closed claim reported that the use of
narrow-bore cricothyroidotomy in CICV cases was associated with high rates of
failed ventilation and of barotrauma [59]. It was also reported in NAP4 that needle
cricothyroidotomy performed by anesthetists had a high failure rate (63%) compared to surgical tracheostomy/cricothyroidotomy with 100% success rate.
However, it is worth mentioning that the former procedure was performed by an
anesthesiologist in extreme emergency situations, but the open technique was performed by a surgeon on a relatively stabilized patient where the anesthesiologist
was maintaining his oxygenation. Consequently, no conclusion could be drawn on
which technique is safer.
Evidence from a large series of various ESA techniques in sheep in a “wet lab”
suggests that well-trained anesthetists have a high success rate with needle cricothyroidotomy in lifelike situations [96].
Delay in performance of ESA is as important as equipment choice. In the
ASACCP analysis of difcult airway management, 79 (42%) cases progressed from
intubation difculty to CICV, and in two-thirds, a surgical airway was performed,
but too late to prevent an adverse outcome [59]. ESA was often performed when the
patient was either moribund or in fact dead. Similarly, in NAP4, there was clear
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evidence of delay in performing ESA and even cases where ESA was not performed
at all despite clear need [72]. There is a natural reluctance to perform such techniques, but the evidence is clear: when ESA is required, it is not the procedure that
kills patients, but delaying or not doing it that causes harm [97]. Training programs
could usefully emphasize behavioral aspects of cricothyroidotomy as equally
important as technical training.
When CICV occurs after general anesthesia, it is important to remember that the
primary task is to oxygenate the patient, and not to intubate the trachea: the patient
may need to be awakened, surgical airway obtained, or cardiopulmonary bypass
established. To make a right decision, it is necessary to know the advantages and
disadvantages of each option, as well as of each airway device, and to be acquainted
with these devices during routine anesthesia.
Conclusion
In summary, many airway devices exist to assist in the successful management of
the difcult airway. Proper identication is paramount to avoiding an airway disaster and the feared “cannot intubate, cannot ventilate” scenario. Any difcult airway
should be left to the best trained personnel available. When a difcult airway is
encountered, healthcare workers should refrain from repeating the same attempts at
intubation. Each practitioner should have a number of intubation techniques and
tools with which they are most comfortable and should know when to call for help.
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