Albert H. Santora

Evaluation of the Airway

The safety of anesthesia is predicated on anticipating difficulties in advance instead of reacting to them when they occur. Of course, we do not always have the luxury of time when dealing with unconscious patients. The manner in which we handle the airway is central to the safety of anesthesia because most of the serious problems we encounter in anesthesia usually have an airway component.

Mechanical Ventilation and Respiratory Care

Mechanical ventilation (MV) and respiratory care provide support to the patient who cannot maintain viable oxygenation, ventilation, and/or protective airway reflexes. Support is initiated when the patient cannot maintain a safe level of homeostasis. Support is withdrawn when the patient is able to breathe without artificial assistance. The level and duration of support depend on the cause of the respiratory system’s failure and the patient’s response to therapy.

Techniques of Intubation

This chapter provides the necessary information to successfully perform tracheal intubation. Individuals who are proficient at intubation can usually complete the procedure in less than 30 s.

Complications of Airway Management

The routine use of endotracheal tubes in anesthesia occurred following the introduction of the neuromuscular blocking drugs by Griffith and Johnson 1 Few will dispute the importance of endotracheal anesthesia; however, the technique is associated with a myriad of complications, ranging from minor injuries to lips and teeth to permanent brain damage and death. The process of endotracheal intubation involves bag/valve/mask ventilation, insertion of airways, the use of various aids, laryngoscopy, and endotracheal intubation. Complications can occur at any stage of the process, but the majority of serious complications occur in association with the insertion or failure to insert an endotracheal tube. Therefore, most of the emphasis is placed on complications arising from endotracheal intubation. Complications related to LMA insertion have been addressed in Chapter 6.

The Difficult Airway

The key tenet in the practice of medicine is that physicians must not perform procedures on patients unless they are capable of dealing with the complications. Every clinician must be prepared to establish a surgical airway if conventional means fail. When airway problems occur and the oxygen supply is removed, every second counts. There is only a limited amount of time before substantial injury occurs while waiting for the arrival of a surgeon to perform a tracheostomy. Clinicians must be prepared to deal with this problem themselves. Residents in training should, therefore, be exposed to the necessary equipment and should practice the techniques needed to establish a surgical airway. Ideally, they should be allowed to perform these procedures on animals during their training. A difficult intubation needs to be managed in an organized fashion as it is a true medical emergency. Most clinicians respond robotically to a cardiac arrest and quickly move through the ABCs of resuscitation without even thinking – a similar attitude must be adopted when dealing with difficult intubations.

Pediatric Airway Management

Pediatric airway problems are among the most difficult challenges clinicians may face in their medical careers. Those unaccustomed to dealing with children tend to approach pediatric airway problems with a disproportionate amount of fear – which, often engendered by inexperience, can interfere with performance. This chapter provides the knowledge necessary to deal with common airway problems occurring in children, as well as some advanced devices and their applications.

Advanced Airway Devices

As anesthesia and technology advance, more powerful techniques and more complicated equipment are utilized for airway management. Although early equipment was quite rudimentary, tremendous advances have been made during the past 50 years, and now modern-day equipment provides clinicians with sophisticated and versatile methods of ventilation and intubation. The aim of this chapter is to provide a brief description and information about a wide variety of commonly available advanced airway devices beyond the basic oxygen supplies, standard mask, conventional laryngoscope, and endotracheal tubes discussed in Chap. 4.

Surgical Options in Airway Management

The airway manager faces no challenge greater than that of dealing with an apneic patient whom he “cannot intubate, [and] cannot ventilate.” 1 Before the patient suffers irreversible hypoxic injury, the airway manager must be prepared to establish a surgical airway. The purpose of this chapter is to describe surgical airway management options for those not trained to perform a surgical tracheostomy.

The Laryngeal Mask Airway (LMA™) and Other Extraglottic (Supraglottic) Airway Devices

The LMA™ was invented by Dr. Archie Brain in 1981.1 Commercial products were introduced in England in 1988 and approved for use in the United States in 1991.2 Over the past 21 years, the LMA™ (Laryngeal Mask Airway) has been modified to offer more clinical options as well as to enhance patient safety. As of 2009, LMA™ products had been used in over 200 million surgical procedures.3 Articles on the LMA™ peaked in the mid-1990s2; however, research interest in the LMA™ remains keen. An analysis of the literature documented that the LMA ProSeal™ had the highest “immediacy index” in 2003.4 The index was designed to reflect the topic’s rank as a nidus for scientific inquiry. The LMA™ has established itself as a revolutionary airway management device that is a mainstay in the armamentarium of airway managers.

Extubation Strategies: The Extubation Algorithm

The American Society of Anesthesiologists’ difficult airway algorithm was introduced in 1993 and revised in 2003 1. Hagberg, 2 Wilson, 3 and others have published thoughtful critiques of the algorithm, offering numerous modifications to expand its application. The algorithm has achieved “Gold Standard” status in its current form (see Chap. 9 ). It represents the definitive schematic approach to “front-end” difficult airway management.