Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4586_Библиотеки_им_академика_М_И_Перельмана

5. Airway management strategy (awake beroptic intubation [AFOI], video laryn-

Studies have demonstrated that inadequate assessment and planning contrib­ute to airway complications and that current airway assessment strategies have poor diagnostic accuracy in predicting DI in the general population [18]. Virtual endoscopy (VE) can simulate endoscopic intraluminal views like those obtained by the conventional fiberoptic bronchoscopy (FOB). It is non-inva­sive and easily obtained by postprocessing a routinely acquired high-resolu­tion computed tomography (CT) data set using simple computer software. Multi-plane CT scanning is often performed for patients with head and neck disease [18, 19]. Compared with FOB, which is limited for the evaluation of intraluminal pathologies, VE in a single examination which can depict intra­luminal manifestations of different diseases, along with a bird-eye-like dem­onstration of surrounding anatomy, giving a more holistic view of the airway. Preprocedural VE information with precise mapping of location and extent of airway pathologies helps in proper planning of anesthesia [20]. Evidence indi­cates that multi-slice detector CT imaging with a 3D reconstruction of the images can significantly increase the diagnostic accuracy of the procedure up to 94–100% [21]. VE can be very helpful in detecting epiglottis pathologies. Though not able to detect dynamic pathologies, it can detect other pathologies like morphological anomalies or misplaced epiglottis. This would save the patient discomfort of naso-endoscopy in some instances. For example, one can find the epiglottitis in adult patient with VE after CT-3D reconstruction (Fig.26.3a) and with the bronchoscopic exam in the same patient (Fig.26.3b). There are now some trials to get 3D images from MRI scans to better visualize the soft tissue [22, 23].

Some experts argue that there is really no difcult airway but rather unplanned con­duct of anesthesia. Evaluation and planning of anesthesia during preoperative assessment, with a strategy that includes multiple exit routes if needed, for patients with OSA, ensures a safe anesthesia with minimum unnecessary risks. El-Ganzouri etal. [33] developed a multivariate risk index, El-Ganzouri Risk Index (EGRI), that

involves the analysis of six parameters commonly performed during the preopera­tive evaluation. Each variable is assigned a score (0 or 1). A score≥4 has a high sensitivity for predicting DI (Table26.1). In a study by Corso etal. [34], EGRI has proven to predict DI and DMV.This would enable the operator to identify difcult cases with a single bedside test to formulate a tailored airway management plan that mitigates the potential risks. Cortellazzi etal. [35] showed that predicted difcult airway by EGRI; using video laryngoscopy (VL) had better outcomes compared to those who were managed with DL.A protocol for patients undergoing general anes­thesia and scored 7in EGRI was developed by Cortellazzi etal., and they advocated routine intubation with GlideScope® video laryngoscope (Verathon Inc., WA, USA). For patients scoring eight or more, awake FOI (AFOI) is advised with a backup Supraglottic Airway Device (SAD). In case of a score, less than seven but more than four, both DL and VL, can be implemented based on operator preference and expe­rience, with a backup SAD.Awake intubation is frequently described in the litera­ture as the preferred method for securing the airway in adult patients with epiglottitis, whereas children are usually intubated following an inhalational induction.