Anesth Pain Med.  2023 Oct;18(4):331-339. 10.17085/apm.23123.

A comprehensive review of difficult airway management strategies for patient safety

• Jung H

• KMID: 2550912
• DOI: http://doi.org/10.17085/apm.23123

Abstract

Difficult airway management is critical to ensuring patient safety. It involves addressing the challenges and failures that can occur, even with skilled healthcare providers, during face mask ventilation, intubation, supraglottic airway placement, invasive airway procedures, or extubation. Although the incidence of the most critical situation in airway management, “cannot intubate, cannot oxygenate,” is low at 0.0019–0.04%, its occurrence can have severe consequences, including dental injury, airway injury, hypoxic brain damage, and even death. This study aimed to offer healthcare providers a comprehensive and evidence-based approach for difficult airway management by reviewing recent guidelines and incorporating the latest evidence-based practices to improve their preparedness and competence in difficult airway management, and thus ultimately contribute to improved patient safety.

Keyword

Airway management; Airway obstruction; Cricothyroidotomy; Face mask ventilation; Intubation; Supraglottic airway; Ventilation.

Figure

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  Fig. 1. Upper lip bite test. The upper lip bite test, which involves instructing patients to bite their upper lip with their lower incisors, offers a classification system based on the following criteria: Class 1, the lower incisors extend beyond the vermilion border of the upper lip; Class 2, the lower incisors can bite the lip but cannot extend above the vermilion border; Class 3, the lower incisors cannot bite the upper lip at all.

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  Fig. 2. American Society of Anesthesiologists difficult airway algorithm (2022) [1]. Low- or high-flow nasal cannula, elevated position of the head throughout the procedure, and noninvasive ventilation during preoxygenation [2]. Awake intubation techniques include flexible bronchoscope, video laryngoscopy, direct laryngoscopy, combined techniques, and retrograde wire-aided intubation [3]. Invasive airway techniques include surgical cricothyrotomy, needle cricothyrotomy with a pressure-regulated device, large-bore cannula cricothyrotomy, or surgical tracheostomy. Elective invasive airway techniques include above and retrograde wire-guided intubation and percutaneous tracheostomy. Moreover, consider rigid bronchoscopy and ECMO [4]. Other options include, but are not limited to, alternative awake technique, awake elective invasive airway, alternative anesthetic techniques, induction of anesthesia (if unstable or cannot be postponed) with preparation for emergency invasive airway, and postponing the case without attempting the above options [5]. Consideration of size, design, positioning, and first versus second-generation SGA may improve the ability to ventilate [6]. Includes postponing the case or postponing the intubation and returning with appropriate resources (e.g., personnel, equipment, patient preparation, awake intubation) [7]. Alternative difficult intubation approaches include, but are not limited to video-assisted laryngoscopy, alternative laryngoscope blades, combined techniques, intubating SGA (with or without flexible bronchoscopic guidance), flexible bronchoscopy, introducer, and lighted stylet or light wand. Adjuncts that may be used during intubation attempts include tracheal tube introducers, rigid stylets, intubating stylets, or tube changers and external laryngeal manipulation [8]. Other options include, but are not limited to, proceeding with the procedure using a face mask or SGA ventilation. The pursuit of these options usually implies that ventilation will not be problematic. SGA: supraglottic airway, CO2: carbon dioxide, CICV: cannot intubation, cannot ventilation.

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  Fig. 3. Malposition of the endotracheal tube where end-tidal carbon dioxide can be measured. The appropriate location of the endotracheal tube is within the trachea. However, in cases where the tip of the endotracheal tube is positioned in the oropharynx or nasopharynx, capnography can still be measured.

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  Fig. 4. Difficult Airway Society management of unanticipated difficult tracheal intubation (2015). SGA: supraglottic airway, SAD: supraglottic airway device, CICV: cannot intubation, cannot ventilation.

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