Recent Updates for Management of the Difficult Airway

Abstract

Airway management is safest when potential problems are identified before surgery, enabling the adoption of a strategy or a series of plans, aimed at reducing the risk of complications.Preoperative airway assessment should be performed routinely in order to identify factors that might lead to difficulty with face-mask ventilation, tracheal intubation, or front-of-neck access. The Difficult airway society (DAS) has developped many algorithms and guidelines to help in management of the difficult airway in different situations. These guidelines provide a sequential series of plans to be used when tracheal intubation fails and are designed to prioritize oxygenation while limiting the number of airway interventions in order to minimize trauma and complications. The anaesthetists should have back-up plans in place before performing primary techniques. If the difficult airway was unanticipated, the sequential plans of management should be as follows: Plan A: The essence ofPlan Ais to maximize the likelihood of successful intubation at the first attempt or, failing that, to limit the number and duration of attempts at laryngoscopy in order to prevent airway trauma and progression to a “can’t intubate can’t oxygenate” CICO situation.It is achieved by: optimizing head and neck position, preoxygenation, adequate neuromuscular blockade, direct or video laryngoscopy (maximum 3 attemps), external laryngeal manipulation, use of bougie and maintaining oxygenation and anaesthesia.If failed for intubation proceed to Plan B. Plan B: the emphasis of Plan B is on maintaining oxygenation using an SAD which creates the opportunity to stop and think about whether to wake the patient up, make a further attempt at intubation via the SAD, continue anaesthesia without a tracheal tube, or rarely, to proceed directly to a tracheostomy or cricothyroidotomy. If failed proceed to Plan C. Plan C:aiming at final attemps of facemask ventilation and waking up the patient. If failed declare CICO situation and proceed to Plan D. Plan D: aiming at applying a surgical airway by cricothyroidotomy. For the anticipated difficult airway, obeststrics and pediatrics, DAS has developped different algorithms which emphasize on maintaining oxygenation, and help the anesthetist in making a proper decision, whether to wake up the patient or proceed with surgery. There are many complications for the difficult airway management procedures as laryngospasm, laryngeal oedema , aspirationofgastric contents and traumatic injuries. The anesthetist should know how to manage these complications.