الفهرس 
Basic Clinical Considerations of Airway ManagementOnly 14 pages are availabe for public view
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Abstract
Appropriate airway management is an essential part of the anesthetist’s role. Difficult intubation should be anticipated whenever possible. A strategy needs to be developed in order to anticipate problems. The different factors that contribute to make intubation and/or ventilation difficult can be related to anesthetist, such as inadequate preoperative assessment, inadequate equipment preparation, inexperience and poor technique, or factors related to equipment such as malfunction and unavailability, or factors related to patient such as anatomical, congenital, traumatic, pathological and physiological factors.
The anatomy of the upper airway is of ultimate importance for successful mask ventilation, intubation, cricothyrotomy and regional anesthesia of the larynx.
The clinical history will usually help to identify the former problem, while physical examination of the airway is required to reveal either disproportion between the various structures of the airway (e.g. tongue, larynx) and/or difficulties in aligning the oral, pharyngeal, and laryngeal axes. The different techniques used to diagnose these problems are described. The algorithms used by the anesthetist when management of the airway is found difficult.
Three situations are considered:
(a) Anticipated difficult intubation, for which awake fiberoptic intubation would appear to be the technique of choice in the majority of cases.
(b) Unforeseen difficult intubation in a patient whose lungs can be ventilated: here, various techniques for control of the airway such as laryngeal mask, awaking the patient or tracheostomy will be briefly described.
(c) Both tracheal intubation and lung ventilation are impossible: this is a life-threatening emergency, for which three solutions are proposed, these include use of the laryngeal mask airway, the Combitube, or transtracheal ventilation.
These situations will be analyzed with the aim of proposing management strategies that always guarantee the safety of the patient.
The laryngeal mask airway (LMA) is single most important development in airway devices in the past 20 years. It was developed by British anesthesiologist Dr. Archie Brain. Since its introduction into clinical practice in 1988, it has been used in more than 100 million patients worldwide.
Esophageal-tracheal Combitube tubes are initially designed for prehospital care, these airways may provide adequate ventilation as a temporizing measure until a more secure airway can be obtained. These combination tubes are currently part of the ASA recommendation for a patient that cannot be intubated or ventilated.
The cuffed oropharyngeal airway (OPA) was invented by Greenberg in 1990. It consists of a Guedel type oropharyngeal airway with a cuff attached to the distal part. It is designed for use in anesthetized patients who are breathing spontaneously when facemask ventilation has proved to be difficult.
A flexible fiberoptic bronchoscope is the most useful general-purpose aid to awake intubation in the patient with a known difficult airway.
Choices for an awake intubation including rigid laryngoscopy, blind orotracheal or nasotracheal technique, fiberoptic/stylet technique, illuminating stylet and semirigid stylets were discussed.
The ASA Task Force on Management of the Difficult Airway encourages the use of a well-equipped, organized difficult-airway cart in every anesthetizing location.
The anesthesiologist should have a preformulated strategy for extubation of the difficult airway. This strategy will depend in upon the surgery, the condition of the patient, and the skills and preferences of the anesthesiologist.
The anesthesiologist should document the presence and nature of the airway difficulty in the medical record. The intent of this documentation is to guide and facilitate the delivery of future care.
Significant advances in the management of the difficult airway have occurred in recent years. However, there is much more to learn with regard to recognition of the difficult airway, preparation of the patient for an awake intubation, new techniques of endotracheal intubation, and establishment of gas exchange in patients cannot be intubated or ventilated by mask. As the anesthesiologist ability to manage the difficult airway improves, respiratory-related morbidity and mortality will decrease.