Best Practice & Research Clinical Anaesthesiology Vol. 18, No. 4, pp.

531548, 2004
doi:10.1016/j.bpa.2004.05.006 available online at http://www.sciencedirect.com

1 Strategies for airway management

Lauren C. Berkow*
MD

Assistant Professor Department of Anesthesia, Johns Hopkins Medical Institution, 600 Wolfe Street Meyer 8-134, Baltimore, MD 21287, USA

Airway management is a critical part of anaesthesia practice. Management includes mask ventilation, laryngoscopy, endotracheal intubation and extubation of the patient. Difculty can be encountered at any of these stages, potentially resulting in signicant complications. Thorough preoperative assessment, as well as careful planning and preparation, can reduce the potential for complications. The American Association of Anesthesiologists (ASA) developed and recently revised guidelines for the management of the difcult airway. These guidelines focus on strategies for intubation as well as alternative airway techniques that can be used when a patient with a difcult airway is encountered. Key words: endotracheal; intubation; difcult; airway; mask ventilation; extubation; laryngoscopy; bre-optic scope; laryngeal mask airway.

Airway management is a critical part of the care provided to patients by the anaesthesiologist, regardless of the type of anaesthetic administered. The process of airway management can be divided into three phases: airway evaluation, actual management of the airway (i.e. mask ventilation, laryngoscopy and endotracheal intubation), and extubation of the airway. Difculty in airway management presents a continuing challenge to the anaesthesiologist. According to the American Association of Anesthesiologists (ASA) Committee on Professional Liability Closed Claims Project, although claims due to respiratory events (inadequate ventilation, oesophageal intubation, difcult intubation) have been decreasing over the past decade, they still represent 32% of all claims.1 These data also show that the reduction in claims is due mostly to a decrease in inadequate and oesophageal intubation, and not to a decrease in difcult intubation claims. The use of pulse oximetry and end-tidal carbon dioxide monitoring is the most likely explanation for this trend. Difcult intubation is still responsible for 6.4% of claims according to the closed claims database, of which brain damage or death was the outcome in 57%.2 In the most recent analysis of the closed claims database, 14% of
* Tel.: 1-410-955-2611; Fax: 1-410-614-7903. E-mail address: lberkow@jhmi.edu (L.C. Berkow). 1521-6896/$ - see front matter Q 2004 Elsevier Ltd. All rights reserved.

532 L. C. Berkow

difcult airway claims occurred in non-OR/PACU locations, and 95% of these claims resulted in death or brain damage.3 This analysis also found that severe outcomes were more likely if difcult mask ventilation or the cannot intubate/cannot ventilate scenario was encountered.3 The ASA formed a task force on management of the difcult airway that created and recently updated practice guidelines for management of the difcult airway.4 These guidelines provide recommendations for difcult airway management as well as analysis of the available literature to date. Again, the guidelines stress the importance of a thorough preoperative evaluation as well as management strategies. In developing strategies for airway management, it is important to dene what constitutes a difcult airway. There is currently no universally accepted denition of this term. Upon induction of anaesthesia, difcult (or impossible) mask ventilation, difcult laryngoscopy, or difcult intubation may occur. It is difcult to dene the true incidence of a difcult airway, since the denitions used vary from study to study. In addition, assessment of difculty does contain a subjective component that may vary among observers. According to the ASA practice guidelines, a difcult airway is dened as the clinical situation in which a conventionally trained anesthesiologist experiences difculty with face mask ventilation of the upper airway, difculty with tracheal intubation, or both.4 The task force further divides the difcult airway into four categories: difcult face mask ventilation, difcult laryngoscopy, difcult tracheal intubation, and failed intubation. Strategies for successful management of each of these categories based on the existing available data will be discussed.

AIRWAY EVALUATION The rst step in airway management should involve a thorough history and physical examination of the patient in order to predict potential difculty in both mask ventilation and intubation. Despite the lack of evidence in the literature linking patient history to prediction of difculty, there do exist certain disease states and congenital disorders that have been shown to be associated with potential difculty (Table 1). Pregnancy, in particular, has been associated with an increased likelihood of difcult intubation.5,6 Obstructive sleep apnoea has also been linked to difculty in mask
Table 1. Disease states associated with difcult airway management. Congenital PierrreRobin syndrome TreacherCollins syndrome Goldenhars syndrome Mucopolysaccharidoses Achondroplasia Micrognathia Downs syndrome Acquired Morbid obesity Acromegaly Infections involving the airway (Ludwigs angina) Rheumatoid arthritis Obstructive sleep apnoea Ankylosing spondylitis Tumours involving the airway Trauma (airway, cervical spine)

Adapted from Clinical Anesthesia (2001, Lippincott, Philadelphia), and Airway Management: Principles and Practice (1996, Mosby, St Louis) with permission.

Airway management 533

ventilation and intubation.7,8 In addition, a history of difcult ventilation and/or intubation in the past may be helpful in guiding airway management. Similarly, there is insufcient evidence to date to link any single aspect of the physical examination of the airway to difculty with intubation. No single factor or group of factors has been shown to have high specicity, sensitivity, or positive predictive value for predicting the presence of a difcult intubation. However, there are aspects of the airway examination that may suggest the presence of a difcult airway. The recently updated ASA guidelines for management of the difcult airway recommend assessment of several airway features, many of which are listed in Table 2.4 Mallampati initially described his classication of airway assessment in 1983.9,10 He hypothesized that a large tongue would cause difculty in exposing the larynx, leading to difcult laryngoscopy. Since a large tongue also obscures the view of the uvula and tonsillar pillars, he created three classes that he demonstrated to be correlated with degree of difculty experienced at laryngoscopy. With the patient sitting up and maximally protruding his/her tongue, visibility of the faucial pillars, soft palate and uvula were noted. Class I described full visualization of all three structures, Class II allowed visualization of only the faucial pillars and soft palate, and in Class III patients only the soft palate was visible (Figure 1). Samsoon and Young modied the original classication to add a fourth class where not even the soft palate is visible (Figure 1).11 Ezri et al recently described a class zero, where any part of the epiglottis is visible on mouth opening and tongue protrusion, which was associated with grade I laryngoscopy and uneventful intubation.12

Table 2. Components of the preoperative airway physical examination. Airway examination component 1. Length of upper incisors 2. Relation of maxillary and mandibular incisors during normal jaw closure 3. Relation of maxillary and mandibular incisors during voluntary protrusion 4. Inter-incisor distance 5. Visibility of uvula 6. Shape of palate 7. Compliance of mandibular space 8. Thyromental distance 9. Length of neck 10. Thickness of neck 11. Range of motion of head and neck Non-reassuring ndings Relatively long Prominent overbite (maxillary incisors anterior to mandibular incisors) Patient mandibular incisors anterior to (in mandible front of) maxillary incisors Less than 3 cm Not visible when tongue is protruded with patient in sitting position (e.g. Mallampati class .II) Highly arched or very narrow Stiff, indurated, occupied by mass, or non-resilient Less than three ordinary nger breadths Short Thick Patient cannot touch tip of chin to chest or cannot extend neck

This table displays some ndings of the airway physical examination that may suggest the presence of a difcult intubation. The decision to examine some or all of the airway components shown in this table depends on the clinical context and judgement of the practitioner. The table is not intended as a mandatory or exhaustive list of the components of an airway examination. The order of presentation in this table follows the line of sight that occurs during conventional oral laryngoscopy. Reprinted from Practice Guidelines for Management of the Difcult Airway; an updated report by the American Society of Anesthesiologists Task Force on management of the difcult airway (2003, Anesthesiology 98: 12691277) with permission. Q Lippincott Williams & Wilkins Publishers.

534 L. C. Berkow

Class I

Class II

Class III

Class IV

Figure 1. Modied Mallampati classication. From Samsoon GLT and Young JRB, Difcult tracheal intubation: a retrospective study (1987, Anaesthesia 42: 487490) with permission. Q Blackwell Publishing.

Many studies have used this classication, as well as other anatomical factors, to try to predict difculty with intubation. Table 3 lists a number of these studies. The Mallampati classication system has been criticized for its signicant inter-observer variation as well as low sensitivity, but is still widely used in airway assessment. Oates et al compared Mallampati class and the Wilson risk sum in predicting difcult intubation.13 Wilsons risk sum was based on a prospective study of 633 patients and found ve risk factors associated with difcult intubation that could be totalled to give a risk sum: weight, head and neck movement, jaw movement, receding mandible, and degree of buck teeth.14 Oates et al found both tests to have poor sensitivity in predicting a difcult intubation. Tham et al studied the effects of posture, phonation and observer on Mallampati classication and found an improvement in Mallampati class with phonation as well as signicant inter-observer variation in classication.15 Butler and Dhara evaluated Mallampati class and thyromental distance in predicting difcult intubation and found both tests to be low in sensitivity, specicity and positive predictive value.16 Several other studies have found that the assessment of multiple factors appears to have higher predictive value than single factors used alone.18,19 Some studies have used radiological assessment of the head and neck in order to identify features that may be associated with difcult intubation.19 21 Many of the studies performed to date and their results are listed in Table 3. Karkouti et al tested the inter-observer reliability of 10 tests used to predict difcult intubation and found only mouth opening and chin protrusion to have good interobserver reliability.22 It is of note that, of all the tests studied, seven showed only moderate reliability, and Mallampati class had poor reliability. On the basis of the existing evidence to date, it is difcult to recommend which airway characteristics are most predictive of difcult laryngoscopy or intubation. The low incidence of difcult laryngoscopy and intubation make large prospective studies difcult to perform. However, since a wide variety of testsincluding Mallampati class, thyromental distance, oral excursion, neck extension as well as other factorsmay be associated with difculty, a thorough preoperative evaluation of these characteristics should still be undertaken. On the basis of the evaluation, if difculty is suspected, extra preparation should be undertaken, especially if there has been a history of difcult intubation in the past. This may result in some false positives, i.e. easy intubation despite suspicion of difculty, but this would be preferable to an unanticipated difcult intubation.

Airway management 535

Table 3. Studies attempting to predict difcult intubation. Number of patients 26 (13 difcult, 13 control) Factors associated with difcult intubation " Anterior and posterior depth of mandible # Distance between C1 and occiput # Mobility of mandible # Range of extension of atlantooccipital joint Mallampati Class III associated with difcult laryngoscopy Mallampati Class IV " Weight, # head and neck movement, # jaw movement, receding mandible, buck teeth # Atlanto-occipital extension, # chin protrusion, " tongue size Mallampati class III or IV and TM distance .7 cm Mallampati Class III or IV, short neck, obesity, receding mandible, protruding, missing, or single maxillary incisor Neither Mallampati class nor TM distance found to be good predictors Longer mandiblohyoid distance Short mandibular ramus # Mouth opening, # TM distance, # visualization of hypopharynx # Sternomental distance (Mallampati class, TM distance associated but with low sensitivity and specicity) None of the factors studied showed high sensitivity or high predictive value No signicant difference in X-ray or MRI studies between difcult intubation patients and controls Risk index using: Mallampati class, TM distance, mouth opening, neck movement, weight, inability to prognath, history of difculty Mallampati class, atlanto-occipital angle (continued on next page)

Author White and Kander72

Year

Type of study

1975 Retrospective X-ray evaluation

Nichol and Zuck19 1983 X-ray evaluation Mallampati et al10 Samsoon and Young11 Wilson et al14 1985 Prospective 1987 Retrospective 1988 Prospective

Unclear 210 13 633

Bellhouse and Dore73 Frerk74 Rocke et al6

1988 Retrospective X-ray evaluation 1991 Prospective and retrospective 1992 Prospective

33 244, 23 1606 (obstetrical patients) 250

Butler Dhara16

and

1992 Prospective

Chou and Wu20

1993 Retrospective Xray evaluation

Rose and Cohen23 1994 Prospective

111 (11 difcult 100 control) 29 000

Savva75

1994 Prospective

350

Tse et al76

1995 Prospective

471

Samra et al77

El-Ganzouri et al17

1995 Prospective X-ray and MRI evaluation 1996 Prospective

40

10 507

Jacobsen et al78

1996 Prospective

100

536 L. C. Berkow

Table 3 (continued) Author Nath and Sekar79 Year Type of study Number of patients 298 Factors associated with difcult intubation Scoring system using: TM distance ,7 cm, Mallampati class III/IV, # head extension, protruding teeth, mouth opening ,4 cm, neck length ,7.5 cm, neck circumference .33 cm Multivariate risk index using: Mallampati class, head and neck ROM, TM distance, inter-incisor gap and mandible luxation, clinical symptoms of airway pathology, history of difculty Mallampati class, TM distance, thyrosternal distance, neck circumference, depth of spine C2, angle A Mouth opening, chin protrusion, atlanto-occipital extension Ratio of height to TM distance better predictor than TM distance alone " Age, male sex, TMJ pathology, OSA, Mallampati class 3 or 4, abnormal upper teeth Class III upper lip bite test (inability to bite upper lip with lower incisors)

1997 Prospective and retrospective

Arne et al18

1998 Prospective

3290

Naguib et al21

1999 Retrospective and prospective

56

Karkouti et al22 Schmitt et al80

2000 Prospective and retrospective 2002 Prospective

461 270

Ezri et al81

2003 Prospective

1472

Khan et al82

2003

300

ROM, range of movement; OSA, obstructive sleep apnoea; TM, thyromental; TMJ, temporoman dibular joint.

AIRWAY MANAGEMENT Airway management, inside or outside of the operating room, consists of mask ventilation, laryngoscopy and endotracheal intubation. Difculty can be encountered during any or all of these procedures. Alternative and adjunctive devices have been developed to assist in difcult ventilation as well as laryngoscopy and intubation. There are no denitive variables to date to accurately predict difculty in airway management. There are, however, data to suggest that the availability of alternate airway devices and airway adjuncts may decrease the incidence of complications associated with difcult laryngoscopy and intubation. Mask ventilation The ASA task force denes face mask ventilation as inadequate if it is not possible for the anesthesiologist to provide adequate face mask ventilation due to one or more of

Airway management 537

the following problems: inadequate mask seal, excessive gas leak, or excessive resistance to ingress or egress of gas.4 Inadequate mask ventilation may lead to hypoxaemia, hypercarbia, and decreases in oxygen saturation, all of which may lead to haemodynamic changes such as hypertension, hypotension and arrhythmias. The rst step recommended by the ASA task force in the difcult airway algorithm is assessment of the likelihood of difcult ventilation (Figure 2). In addition, the division between the emergent and non-emergent pathways in the algorithm is determined by the ability to provide adequate face mask ventilation. The incidence of difcult mask ventilation (DMV) varies in the literature from 0.07 to 15%.17,23 25 Many studies of difcult intubation do not address difcult mask ventilation. This may be due to the fact that the denition of DMV remains imprecise. Langeron et al conducted a study of 1502 patients to specically assess difcult mask ventilation.24 Langerons study found a DMV incidence of 5%, and identied ve criteria as independent risk factors for DMV: age . 55, body mass index . 26 kg/m2, beard, lack of teeth, and history of snoring. Chou and Wu also reported that a large hypopharyngeal tongue often present in patients with obstructive sleep apnoea may be associated with difcult mask ventilation as well as difcult intubation.8 Lingual tonsil hyperplasia has also been associated with difcult mask ventilation.26 Certain manoeuvres can assist in the management of difcult mask ventilation, such as jaw thrust, placement of an oral airway, and two-person mask ventilation. This can potentially overcome the upper airway obstruction that may be the cause of difcult ventilation. If these manoeuvres fail, options include waking the patient, attempting laryngoscopy, or placement of a supraglottic airway device. A variety of supraglottic devices have been developed both for primary use as an airway device during anaesthesia and as a rescue device after failed ventilation or failed laryngoscopy/intubation. Some of the supraglottic devices currently available are listed in Table 4. All of these devices are currently available in single-use, disposable forms. If the obstruction is glottic or subglottic, however, these devices will not alleviate the problem. These devices can be used as a sole airway device during anaesthesia or as a bridge to intubation, since they will accommodate placement of a bre-optic bronchoscope. These devices are also becoming more widely used outside the operating room and by pre-hospital providers. Although several supraglottic devices now exist, the majority of clinical studies have been performed on the laryngeal mask airway (LMA), which was introduced in 1988 in the UK and in 1991 in the USA. It has gained widespread use as an alternative to endotracheal intubation in outpatient anaesthesia as well as an airway adjunct during management of the difcult airway.27,28 Although the device is most commonly used in the USA with spontaneous ventilation, the LMA has been widely used in the UK with positive pressure ventilation with few complications.29 The use of the LMA with positive pressure ventilation remains controversial because of the concerns about gastric aspiration.30 Its efcacy and safety have also been reported for use during gynaecological, laparoscopic, and even prone procedures.31,32 It has also been incorporated into the revised ASA difcult airway algorithm as a rescue device during inadequate face mask ventilation.4 Other, newer supraglottic devices have been studied and found to have safety and efcacy proles similar to the LMA device.33,34 A newer LMA proseal device contains an additional channel to allow gastric tube placement, and the intubating LMA device was adapted from the original LMA to facilitate endotracheal intubation.

538 L. C. Berkow

Figure 2. Reprinted from Practice Guidelines for Management of the Difcult Airway; an updated report by the American Society of Anesthesiologists Task Force on management of the difcult airway (2003, Anesthesiology 98: 12691277) with permission. Q Lippincott Williams & Wilkins Publishers.

Airway management 539

Table 4. Supraglottic devices. Laryngeal mask airway (LMA) Combitube Portex soft seal laryngeal mask CobraPLA perilaryngeal airway PAXpress (vital signs) Laryngeal tube Streamlined liner of the pharynx airway (SLIPAe)

Laryngoscopy The denition of difcult laryngoscopy is dened by the ASA taskforce as the inability to visualize any part of the vocal cords despite multiple attempts at conventional laryngoscopy.4 The incidence of difcult laryngoscopy varies from study to study, but has been reported to be 1 5% (Table 5). The view at laryngoscopy was divided into four grades by Cormack and Lehane in 1984 on the basis of a study of obstetric patients.35 The entire glottis is visible in a grade 1 view, while in a grade 2 view only the posterior portion of the glottis can be seen; in a grade 3 view only the epiglottis can be seen, and in a grade 4 view not even the epiglottis can be seen (Figure 3). The authors classied a grade 3 or 4 view as difcult, and this classication has been widely accepted. The variety in the incidence of difcult laryngoscopy and intubation in the reported literature may be attributed to the fact that some investigators dene difcult laryngoscopy as a grade 4 view while others use either grade 3 or 4 view as their denition. The ASA task force denition incorporates both grade 3 and grade 4 views. Calder et al reported an increased incidence of difcult laryngoscopy based on the Cormack Lehane view in patients with cervical spine disease, especially in patients with rheumatoid arthritis.36 Cohen et al surveyed 120 anaesthetists in Great Britain and found signicant inconsistency with the use of the Cormack Lehane grading system, as well as lack of familiarity, and suggested the use of a non-numerical system of grading laryngoscopy.37 Yentis and Lee described a modied Cormack Lehane grading system, dividing the grade 2 classication into 2a and 2b.38 In a grade 2a view, a part of the vocal cords can be observed, while in a grade 2b view only the arytenoids can be seen. They found a grade
Table 5. Incidence of difcult laryngoscopy/intubation. Author Wilson et al14 Frerk74 Oates et al13 Rocke et al6 Butler and Dhara16 Rose and Cohen23 Savva75 El-Ganzouri et al17 Arne et al18 Incidence (%) 1.5 4.5 1.8 2.1 1.6 1.8 4.9 1.0 4.2

540 L. C. Berkow

Grade I

Grade II

Grade III

Grade IV

Figure 3. CormackLehane grades of laryngoscopy. From Samsoon GLT and Young JRB, Difcult tracheal intubation: a retrospective study (1987, Anaesthesia 42: 487490) with permission. Q Blackwell Publishing.

2b but not a grade 2a view to be associated with difcult laryngoscopy. A study by Koh et al in the Asian population supports the use of this modied system.39 Cook further modied the original Cormack Lehane system to create a non-numerical system.40 Grade 1 and 2a views are redened as easy, grade 2b and 3a (epiglottis can be seen and lifted) as restricted, and grade 3b (epiglottis cannot be lifted) and grade 4 as difcult. This system may have better practical use as well as continuity between evaluators than a numerical system, as suggested by Cohen et al (Table 6). The presence of lingual tonsillar hyperplasia has also been associated with difcult laryngoscopy.41,42 Ovassapian et al reported 33 patients who presented with unanticipated difcult intubation, all of whom were found to have lingual tonsil hyperplasia by bre-optic examination.42 This condition, if asymptomatic, cannot be detected on routine airway examination. Difcult intubation has been dened by the ASA task force as well as by other authors as the need for multiple attempts at intubation, which may be due to difcult laryngoscopy or other factors. Other investigators have dened difcult intubation as requiring the use of a gum elastic bougie or special equipment. Since the denitions of difcult intubation are more varied than difcult laryngoscopy it may make more sense to use difcult laryngoscopy as the tool with which to identify a patient with a difcult airway. However, despite difcult laryngoscopy, intubation may still be uncomplicated, so it is still unclear which terminology is best and remains the subject of much debate. Several manoeuvres have been described that may improve the view at laryngoscopy using conventional techniques (i.e. laryngoscopy blades such as the Macintosh and Miller blades). Knill described the BURP technique in 1992, consisting of backward, upward, and rightward pressure on the thyroid cartilage to improve visualization of the larynx.43 Benemof and Cooper recommended performing optimal external laryngeal manipulation (OELM) to obtain the best view, and demonstrated a consistent improvement in laryngeal grade with this manoeuvre in 181 patients, especially with
Table 6. Cooks classication of laryngoscopic view. Cormack and Lehane 1 2 2 3 3 4 Method of intubation Direct Direct Indirect Indirect Specialist Specialist New grading Easy Easy Restricted Restricted Difcult Difcult

Laryngeal views Most of cords visible Posterior cord visible Only arytenoids visible Epiglottis visible and liftable Epiglottis adherent to pharynx No laryngeal structures seen

Modication 1 2a 2b 3a 3b 4

From Cook TM, A new practical classication of laryngeal view (2000, Anaesthesia 55: 274 279) with permission. Q Blackwell Publishing.

Airway management 541

higher laryngoscopic grades.44 Other authors have also found external laryngeal manipulation to be helpful.14,45 It is important to clarify that both of these manoeuvres differ from cricoid pressure used during rapid sequence intubation in patients at risk of aspiration, and the need for cricoid pressure during induction of anaesthesia may preclude the use of these manoeuvres. In addition to specic manoeuvres as well as cricoid pressure (which may improve or worsen the view at laryngoscopy), achieving optimal head and neck positioning is an important factor. The optimal head position during laryngoscopy has also been debated. Despite the wide acceptance of the snifng position to supposedly align the three axes for laryngoscopy, the role of this position has recently been questioned.46 48 A study by Adnet et al suggests that the snifng position may not offer any additional advantage to laryngoscopy over simple head extension except in obese patients and patients with limited head extension, while another study by Schmitt and Mang suggests that head and neck elevation beyond the snifng position may improve laryngoscopic view.48,49 These authors do agree that some degree of extension and positioning does offer an advantage over a neutral head position. Intubation Intubation, or the placement of an endotracheal tube through the vocal cords, can be performed using a variety of techniques, some direct and some indirect. While the majority of routine intubations are performed after direct laryngoscopy and visualization of the vocal cords, many other devices exist that do not require direct visualization. In fact, intubation using a gum elastic bougie or bre-optic bronchoscope is in fact an indirect procedure; the endotracheal tube is actually not placed through the vocal cords under direct vision. Other techniques that do not require vocal cord visualization include light wand intubation, retrograde intubation, intubation through an intubating LMA, and the Combitube. Intubation may be difcult despite the presence of a grade 1 or grade 2 view at laryngoscopy if anatomical factors exist that make passage of an endotracheal tube difcult. Subglottic stenosis, tumours compressing the trachea, or an anterior larynx may contribute to difculty at intubation. Vocal cord pathology such as the presence of polyps or tumour may prevent passage of an endotracheal tube. There is no single device that is the best device for use in a suspected or unsuspected difcult intubation. The ASA difcult airway algorithm outlines several pathways for use when a difcult intubation is encountered, and advocates the use of alternative approaches to intubation.4 These recommended alternative approaches are listed in Table 7. Many of these devicessuch as the Combitubee, Trachlighte (a lightwand), and the intubating LMAhave been shown to be effective in the management of the difcult intubation.50 52 Previous experience with many of these alternative devices and familiarity with their techniques may improve the success rate during their use in management of the difcult airway. Intubation using the exible bre-optic bronchoscope is probably the oldest and best described technique for managing the difcult airway.53,54 This technique can be performed in either the awake or the anaesthetized patient, via either the oral or nasal route. It does not require the use of a laryngoscope blade, and the scope can be used to navigate around a variety of airway pathologies that may be contributing to difculty. Awake intubation has been considered by many to be the best technique when intubation is expected to be difcult, and comprises an entire section of the ASA difcult airway algorithm.4,53,55 In the awake patient, airway patency as well as airway

542 L. C. Berkow

Table 7. Alternative approaches to intubation. Use of different laryngoscope blades Laryngeal mask airway (with or without bre-optic guidance) Fibre-optic intubation Light wand intubation Tube changer or intubating stylet Retrograde intubation Blind intubation (nasal or oral) Modied from the American Society of Anesthesiologists Task Force (2003, Anesthesiology 98: 1269 1277) with permission.

reexes are maintained, reducing the potential risk of aspiration. The patients respiratory and neurological status can also be evaluated during intubation, which can be benecial in patients with cervical spine pathology or obstructive sleep apnoea. Awake intubation can be successfully performed using a variety of techniques, including bre-optic intubation, direct laryngoscopy, retrograde intubation, or intubation through a supraglottic device or via surgical airway access.53,55 Many of these techniques require careful topicalization and preparation of the airway. Adnet et al proposed an intubation difculty scale (IDS) to describe total intubation difculty based on seven parameters known to be linked to difcult intubation.56 The scorebased on number of supplementary intubation attempts, supplementary operators, and alternative techniques used, as well as glottic exposure, vocal cord position, use of external laryngeal pressure, and lifting force needed during laryngoscopyis calculated after intubation is completed. This scale could potentially be used to predict future intubation difculty as well as to delineate the specic factors that lead to difculty. ASA algorithm The most recent revision of the ASA difcult airway algorithm provides guidelines for the management of a difcult airway (Figure 2). These guidelines were not intended as standards but as recommendations for anaesthesiologists based on the available literature and a survey of a panel of experts. The algorithm recommends assessment of the patient in four areas: difcult ventilation, difcult intubation, difculty with patient cooperation or consent, and difcult tracheostomy. Then, while delivering supplemental oxygen to the patient and applying appropriate monitoring, three basic management choices are described: awake intubation versus intubation after induction of anaesthesia, non-invasive versus invasive initial intubation techniques, and preservation versus ablation of spontaneous ventilation. The preservation of spontaneous ventilation in either an awake or sedated patient offers some advantages. Airway reexes and airway tone are preserved, which may prevent aspiration as well as collapse of airway structures. By considering non-invasive versus invasive techniques, the anaesthesiologist also considers what special equipment may be needed during intubation attempts. The next step described in the algorithm is the development of primary and alternative strategies for intubation, and the guidelines provide several pathways based on the previous management choices. It is crucial that alternative strategies be

Airway management 543

considered and preparations made in advance so that additional devices and support are available if needed. Strategy A involves awake intubation, either by non-invasive or invasive approaches. Strategy B involves intubation after induction of general anaesthesia. If initial intubation attempts fail, the algorithm suggests calling for help as well as awakening the patient or returning to spontaneous ventilation. The algorithm then divides into two pathways, determined by the presence or absence of adequate face mask ventilation. If face mask ventilation is possible, the nonemergent pathway is entered. If face mask ventilation is not adequate and an LMA cannot be successfully placed, the emergent pathway is entered. Placement of an LMA device as a rescue technique was not part of the original ASA algorithm released in 1993; it was added to the revised algorithm based on evidence in the literature supporting its role in airway management.28,57 The algorithm also emphasizes the role of invasive airway access such as cricothyroidotomy or tracheostomy if multiple intubation attempts fail, as well as awakening the patient if possible. The algorithm does not specically endorse any single technique but emphasizes the creation of a preformulated strategy as well as alternative approaches to intubation. Extubation While the majority of procedures that begin with routine, uneventful intubation conclude with successful extubation, the extubation of the difcult airway may warrant special consideration. Difculty with laryngoscopy and intubation may result in airway oedema that may preclude safe extubation. In addition, an initially difcult intubation may prove to be an even more challenging re-intubation, especially if respiratory compromise occurs. If extubation complications are a signicant concern, continued endotracheal intubation during the immediate postoperative period should be considered. Patients who underwent uncomplicated intubation may also develop respiratory complications after extubation requiring some level of airway management. Asai et al reported a higher incidence of respiratory complications associated with extubation than with intubation.58 Benemof initially described the technique of extubation over an exchange catheter in the patient with a difcult airway, allowing re-intubation over the catheter if needed.53 This method has been reported with success by numerous other authors, using a variety of airway exchange catheters now available.59 61

TRACKING OF PATIENTS AND THE ROLE OF DATABASES Since many patients identied as having a difcult airway may return to the operating room in the future for airway management, tracking of these patients and the creation of databases to disseminate information can be very important. Currently, no international database exists, although many societies and individual hospitals maintain databases.62 64 The Difcult Airway Society has created a national difcult airway database linked to the Medic Alert system in the UK. The Medic Alert registry in the USA also keeps track of patients and issues Medic Alert bracelets that can be labelled difcult airway. Some centres post airway alerts and send letters to patients advising them of airway difculty.62,64 Certainly the tracking and education of patients could potentially avoid future difculties with airway management as well as guide advance preparation.

544 L. C. Berkow

TRAINING AND EDUCATION The management of the patient with an anticipated or unanticipated difcult airway is an important aspect of anaesthesiology training. Preoperative evaluation as well as the use of alternative airway techniques should be part of all anaesthesiology residency curriculums. Practice of alternative airway techniques during elective cases and routine intubations can improve familiarity with these devices. Hagberg et al conducted a recent survey of 132 anaesthesiology residency programmes and found that 33% of the programmes that responded had a difcult airway rotation.65 A previous survey conducted by Koppel and Reed in 1995 found similar results.66 Use of the bre-optic bronchoscope and the LMA were the most frequently taught alternative techniques among those programmes. As of 1996, the Accreditation Council for Graduate Medical Education (ACGME) requires that all anaesthesiology residents obtain signicant experience in specialized airway techniques such as bre-optic intubation and LMA placement.67 Surveys of practising anaesthesiologists in both the USA and Canada showed that, despite the availability of a variety of new airway devices and techniques, direct laryngoscopy and bre-optic intubation remain the most common techniques used for intubation.68,69 In addition, these surveys found that equipment and alternative devices for management of the difcult airway were not always immediately available. A large number of airway courses and workshops currently exist in the USA and Europe that provide education and practice on mannequins and simulators of both the updated ASA algorithm and newer alternative airway devices. A study by Naik et al showed that anaesthesia residents who had received bre-optic intubation training on a model performed better in the operating room, suggesting that training outside the operating room might be benecial.70 Increased availability of models and simulators may allow for improved training outside the operating room. The practice of anaesthesiology has often been compared to aviation, where the use of simulators has improved performance and safety.71 Increased practice of both difcult airway scenarios and alternative airway devices outside the operating room could have a signicant impact on the successful management of the patient with the difcult airway.

SUMMARY Airway management remains an integral part of anaesthetic management. Despite the fact that no single airway characteristic has consistently predicted the presence of a difcult airway, a thorough preoperative history and airway assessment can identify potential risk factors. Advance preparation and planning, including the availability of alternative airway devices and supraglottic devices, may help successfully manage an anticipated or unanticipated difcult airway. No one single technique or device has been proven to be the best. The guidelines developed by the American Society of Anesthesiologists can be used to guide airway management. Difculty in mask ventilation, laryngoscopy or intubation may be encountered during the course of airway management. Specic considerations should also be taken during the extubation of a patient after difculty with initial airway management. Tracking of patients, and continued education and training of anaesthetists, can potentially decrease the number of unanticipated difcult intubations as well as airway complications. Models and simulators may play a greater role in the future in the practice and training of difcult airway management.

Airway management 545

Practice points a thorough history and physical examination pertaining to the airway, as well as a history of difcult intubation, are important parts of the preoperative evaluation no single airway characteristic has been shown to accurately predict difculty in airway management a patient may be labelled as having a difcult airway if difculty is encountered during mask ventilation, laryngoscopy, or intubation (or a combination of the three) a variety of new supraglottic and intubation devices now exist to assist in difcult airway management the ASA Task Force on management of the difcult airway has published and recently revised guidelines to assist the anaesthesiologist in successfully managing a patient with a difcult airway familiarity with newer devices, as well as training in workshops with models and simulators, may play a role in decreasing complications associated with difcult airway management

Research agenda larger, multicentre clinical studies of preoperative airway evaluation may identify factors or groups of factors that can accurately predict difcult mask ventilation, laryngoscopy or intubation further studies supporting the value of simulators and airway models should be performed guidelines for the use of supraglottic devices need to be developed, especially in relation to their role outside the operating room very little research still currently exists on difcult mask ventilation and extubation of the difcult airway

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