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Editorial

Anesthesiology and the Difficult AirwayWhere Do We Currently Stand?


Anesthesiology has made a significant advance in airway either attached to the handle of the laryngoscope itself
care since the introduction of the facemask and then or is freestanding. Currently, there are several video
followed by endotracheal tubes for assisted ventilation.[1] laryngoscopes commercially available with different
The need for assisted ventilation for the advancement of designs of the laryngoscope bladestraight, curved, as well
anesthesia care has resulted in significant improvements in as hyperangulated.[6] Some of the blades are channeled for
health care for patients needing surgical, diagnostic, and guided endotracheal tube advancement. In case there is no
intensive care. Practitioners involved in the care of patients channel on the blade, most video laryngoscopes require the
requiring sedation and general anesthesia have recognized endotracheal tube to be preshaped with a stylet. There are
that jawlift, proper neck positioning, use of continuous many reports of their successful use during difficult airway
positive airway pressure, recognizing the difficult upper care.[11,12] A recent Cochrane review reports that video
airway before sedation, and meeting as a group of experts laryngoscopes improve the glottis view and may reduce
to establish the difficult airway algorithm have led to the number of failed intubations, particularly in patients
significant progress in successfully establishing an airway presenting with a difficult airway. Despite this, there is no
and decreasing airwayrelated morbidity.[2,3] For decades, current evidence that use of a video laryngoscope reduces
the facemask, an oral airway, curved and straightbladed the number of intubation attempts or the incidence of
laryngoscopes for performing endotracheal intubation, hypoxia or respiratory complications.[13] It has not been
along with proper training for their use, were the mainstay shown that any video laryngoscope is superior when
of upper airway care. This then led to the introduction of the compared to another and the choice is based on the
gumelastic bougie for accessing minimally visible laryngeal preference and familiarity of the person managing the
inlets even after applying significant externally applied upper airway.
downward and upward laryngeal pressure. The bougie In a cannot intubate cannot ventilate scenario, the
is then serving as a guide for advancing the endotracheal American Society of Anesthesiologist difficult airway
tube. Until the availability of bedside capnography became algorithm suggests the use of a supraglottic airway
available for confirming successful endotracheal intubation, device (SAD). There are the firstgeneration SADs and
practitioners relied on clinical signs that included observing more modern secondgeneration SADs. The firstgeneration
chest expansion, auscultating for bilateral breath sounds, SADs include the classic and flexible LMA as well as
and the use of an esophageal detector device.[4] Currently, the laryngeal tube and Cobra perilaryngeal airway. These
bedside capnography is a requirement for documenting devices have been further developed with the ultimate
successful endotracheal intubation. Dr. Archie Brain from goal of improving patient safety mainly to reduce the
the United Kingdom realized that facemask ventilation risk of pulmonary aspiration of gastric contents and
requires significant expertise and skill to prevent stomach have resulted in the introduction of the following second
distension and often required not only jawlift but also generation SADs: LMA ProSeal and LMA Supreme, IGel
an oral airway for effective lung ventilation. After several supraglottic airway, and laryngeal tube suction II. All these
prototypes, he successfully introduced the laryngeal mask secondgeneration SADs have a separate lumen to access
airway (LMA).[5] This was a significant contribution of the stomach and aspirate gastric contents. In addition,
the 20th century to upper airway care. Along with the use some of the SADs can be used as a conduit for intubation,
of fiberscope devices, practitioners became increasingly which makes them a very useful tool in the unanticipated
comfortable in providing care for patients with a difficult difficult airway.[14,15] Overall, secondgeneration SADs are
upper airway. recommended in the setting of a difficult airway.[3] Table 1
The video laryngoscopes, a recent addition, have received summarizes the currently available SADs.
uniform reception by anesthesia providers, intensivists, Almost all advanced anesthesia practice sites currently
E.R. physicians, pulmonologists, neonatologists, and keep prepared a difficult airway cart equipped with items
paramedics.[610] They not only serve as a great teaching to support practitioners during the care of a patient with an
tool but also have allowed smooth and safe introduction expected and unexpected difficult airway. These carts are
of either an endotracheal tube, an endotracheal tube equipped with gum elastic bougies, SADs, cricothyrotomy
introducer, or fiberscopes in the care of both anatomically kits, esophageal obturator airways, endotracheal
normal upper airways and also those with a difficult tubechangers, and support items to perform fiberscope
upper airway in newborns, infants, children, adolescents, and video laryngoscopy. Furthermore, present is a system
and adults. A video laryngoscope is any laryngoscope to perform jetventilation. Kept next to the cart are video
with a builtin video camera that allows the process of laryngoscopes and a fiberscope tower. The setup used at
airway management to be watched on a screen that is the University of Minnesota is displayed in Figure1.

4 2017 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow


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Richtsfeld and Belani: Anesthesiology and the difficult airway

When a difficult airway is encountered, it is of utmost In conclusion, the practice of airway care during anesthesia
importance that the management of the airway is accurately and critical care of patients has advanced significantly since
documented in the patients medical record to guide and the introduction of open drop ether. The facemask and oral
facilitate future airway management. This information airway played a major role in the beginning and this was
should be shared with the patient as well. Currently, this followed by the introduction of the endotracheal tube. Uses
is done most of the time by orally informing the patient of lowpressure, high volume cuffed endotracheal tubes are
and relatives or with a letter to the patient to provide to currently the standard of care during anesthesia. However,
future practitioners. It is not hard to imagine that with there will always be patients with a difficult upper airway.
this way of communication quite frequently important Experienced practitioners are skilled in detecting these
information in regards to airway care is lost. To overcome patients preinduction and taking appropriate measures
this communication gap, Shanahan etal. developed a to establish successful endotracheal intubation with the
website which allows the practitioner to enter information devices that are currently available. The availability of the
about a patients difficult airway, create a printed letter to difficult airway cart along with the video laryngoscopes
the patient, and access the patients information online with and fiberscopes has improved airway management in
the help of an accompanying smartphone application.[16] patients with an unexpected difficult upper airway. At
our institution, all practitioners and trainees participate
Table 1: Currently available supraglottic airway devices in a periodic airway simulation drill [Figure 2].[17] This
SAD Access to Conduit for Integrated reinforces everyones knowledge about the contents of
stomach intubation bite block the difficult airway cart and provides an opportunity to
LMA Classic do a handson practice in both cadavers and mannequins
LMA Supreme + + to increase familiarity and the steps that one needs to use
LMA ProSeal + + to successfully encounter the unexpected difficult upper
LMA Fastrach +
airway. This editorial provides a brief prelude to several
igel supraglottic + + +
articles in this journal related to the care of patients with a
airway
difficult upper airway.
AirQ Masked + +
Laryngeal Airways Martina Richtsfeld, Kumar G Belani1
Laryngeal tube From the Department of Anesthesiology, University of Minnesota Masonic
Laryngeal tube suction + Childrens Hospital, 1Department of Anesthesiology, University of
LMA: Laryngeal mask airway, SAD: Supraglottic airway device Minnesota, Minneapolis, MN 55455, USA

Figure1: Aphotographic display of the difficult airway cart, supraglottic airway devices, video laryngoscopes, and fiberscope with TV tower that are in
use at the University of Minnesota. The difficult airway cart includes items such as the gumelastic bougie, endotracheal tubechangers, cricothyrotomy
and jetventilation kits, supraglottic airway devices, and support items such as antifog and lubricant for the fiberscope, localanesthetic atomizers, and
oral airways to support fiberscope introduction. All practitioners at the institution make up these carts with a joint discussion, and so, the contents will
vary from institution to institution

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Richtsfeld and Belani: Anesthesiology and the difficult airway

Figure2: Different stations of the difficult airway workshop as taught at the University of Minnesota. The workshop detailed in the figure is for those interested
in advanced airway care. Intensivists, pulmonologists, emergency medicine physicians also participate to learn and teach different aspects of airway care

Address for correspondence: Dr.Kumar G Belani, University of management. Br J Anaesth 1983;55:8015.


Minnesota, Minneapolis, MN 55455, USA. 6. Yumul R, ElvirLazo OL, White PF, Sloninsky A, Kaplan M,
Email:kumarbelani@gmail.com Kariger R, etal. Comparison of three video laryngoscopy
devices to direct laryngoscopy for intubating obese patients: A
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