Skip to main content
SpringerLink
Log in

Difficult Intubation: How to Avoid a Tracheostomy

  • Chapter
  • First Online:
Tracheostomy

Abstract

Difficulty in airway management is a clinically important complication, which can lead to morbidity and mortality. An emergency surgical airway is necessary when noninvasive techniques fail and severe hypoxemia develops. To reduce this risk, knowledge, careful assessment, good planning, and judgment, as well as the use of a wide range of techniques and devices, are required. Airway assessment helps to anticipate the difficult airway, and a set of devices should be available for proper management in difficult cases. Maintenance of oxygenation is a priority, and preoxygenation should be performed before any attempt at airway management. Bag mask ventilation and direct laryngoscopy require careful positioning of the patient and an array of basic skills on the part of the operator. The laryngeal mask airway is an important rescue device in the “cannot intubate, cannot ventilate” situation. Recent advances have led to the development of videolaryngoscopes that facilitate the indirect visualization of the larynx, with minimal mouth opening and head extension. Difficult-airway algorithms have been developed to provide a structured response to this life-threatening situation.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

Similar content being viewed by others

Abbreviations

BURP:

Backward, upward, rightward pressure

CPAP:

Continuous positive airway pressure

LMA:

Laryngeal mask airway

References

  1. Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Intensive Care Med. 2008;34(2):222–8.

    Article  PubMed  Google Scholar 

  2. Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth. 2012;109(S1):i68–85.

    Article  PubMed  Google Scholar 

  3. Bannister FB, Macbeth RG. Direct laryngoscopy and tracheal intubation. Lancet. 1944;244:651–4.

    Article  Google Scholar 

  4. Burkle CM, Zepeda FA, Bacon DR, Rose SHA. historical perspective on use of the laryngoscope as a tool in anesthesiology. Anesthesiology. 2004;100(4):1003–6.

    Article  PubMed  Google Scholar 

  5. Gonzalez H, Minville V, Delanoue K, Mazerolles M, Concina D, Fourcade O. The importance of increased neck circumference to intubation difficulties in obese patients. Anesth Analg. 2008;106(4):1132–6.

    Article  PubMed  Google Scholar 

  6. Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987;42(5):487–90.

    Article  CAS  PubMed  Google Scholar 

  7. Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, Riou B. Prediction of difficult mask ventilation. Anesthesiology. 2000;92(5):1229–36.

    Article  CAS  PubMed  Google Scholar 

  8. Ketherpal S, Han R, Tremper KK, Shanks A, Tait AR, O’Reilly M, Ludwig TA. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105(5):885–91.

    Article  Google Scholar 

  9. Tanoubi I, Drolet P, Donati F. Optimizing preoxygenation in adults. Can J Anaesth. 2009;56(6):449–66.

    Article  PubMed  Google Scholar 

  10. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165–75.

    Article  PubMed  Google Scholar 

  11. Futier E, Constantin JM, Pelosi P, Chanques G, Massone A, Petit A, Kwiatkowski F, Bazin JE, Jaber S. Noninvasive ventilation and alveolar recruitment maneuver improve respiratory function during and after intubation of morbidly obese patients: a randomized controlled study. Anesthesiology. 2011;114(6):1354–63.

    Article  PubMed  Google Scholar 

  12. Adnet F, Borron SW, Dumas JL, Lapostolle F, Cupa M, Lapandry C. Study of the “sniffing position” by the magnetic resonance imaging. Anesthesiology. 2001;94(1):83–6.

    Article  CAS  PubMed  Google Scholar 

  13. Greenland KB, Edwards MJ, Hutton NJ, Challis VJ, Irwin MG, Sleigh JW. Changes in airway configuration with different head and neck positions using magnetic resonance imaging of normal airways: a new concept with possible clinical applications. Br J Anaesth. 2010;105(5):683–90.

    Article  CAS  PubMed  Google Scholar 

  14. Buis ML, Maissan IM, Hoeks SE, Klimek M, Stolker RJ. Defining the learning curve for endotracheal intubation using direct laryngoscopy: a systematic review. Resuscitation. 2016;99:63–71.

    Article  PubMed  Google Scholar 

  15. Collins SR. Direct and Indirect Laryngoscopy: Equipment and Techniques. Respir Care. 2014;59(6):850–64.

    Google Scholar 

  16. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39(11):1105–11.

    Article  CAS  PubMed  Google Scholar 

  17. Knill RL. Difficult laryngoscopy made easy with a “BURP”. Can J Anaesth. 1993;40(3):279–82.

    Article  CAS  PubMed  Google Scholar 

  18. Takahata O, Kubota M, Mamiya K, Akama Y, Nozaka T, Matsumoto H, Ogawa H. The efficacy of the “BURP” maneuver during a difficult laryngoscopy. Anesth Analg. 1997;84(2):419–21.

    Article  CAS  PubMed  Google Scholar 

  19. Brazil V, Grobler C, Greenslade J, Burke J. Comparison of intubation performance by junior emergency department doctors using gum elastic bougie versus stylet reinforced endotracheal tube insertion techniques. Emerg Med Australas. 2012;24(2):194–200.

    Article  PubMed  Google Scholar 

  20. Cook TM, Kelly FE. Time to abandon the ‘vintage’ laryngeal mask airway and adopt second-generation supraglottic airway devices as first choice. Br J Anaesth. 2015;115(4):497–9.

    Article  CAS  PubMed  Google Scholar 

  21. Ramachandran SK, Kumar AM. Supraglottic airway devices. Respir Care. 2014;59(6):920–31.

    Article  PubMed  Google Scholar 

  22. Henderson J. Airway management in the adult. In: Miller RD, editor. Anesthesia. 7th ed. Philadelphia: Elsevier Churchill Livingstone; 2010. p. 1573–610.

    Google Scholar 

  23. Bein B, Scholz J. Supraglottic airway devices. Best Pract Res Clin Anaesthesiol. 2005;19(4):581–93.

    Article  CAS  PubMed  Google Scholar 

  24. Van Zundert A, Brimacombe J. The LMA Supreme—a pilot study. Anaesthesia. 2008;63(2):209–10.

    Article  PubMed  Google Scholar 

  25. Kleine-Brueggeney M, Greif R, Schoettker P, Savoldelli GL, Nabecker S, Theiler LG. Evaluation of six videolaryngoscopes in 720 patients with a simulated difficult airway: a multicentre randomized controlled trial. Br J Anaesth. 2016;116(5):670–9.

    Article  CAS  PubMed  Google Scholar 

  26. Kaplan MB, Ward D, Hagberg CA, Berci G, Hagiike M. Seeing is believing: the importance of video laryngoscopy in teaching and in managing the difficult airway. Surg Endosc. 2006;20(Suppl2):S479–83.

    Article  PubMed  Google Scholar 

  27. YC S, Chen CC, Lee YK, Lee JY, Lin KJ. Comparison of video laryngoscopes with direct laryngoscopy for tracheal intubation: a meta-analysis of randomised trials. Eur J Anaesthesiol. 2011;28(11):788–95.

    Article  Google Scholar 

  28. Niforopoulou P, Pantazopoulos I, Demestiha T, Koudouna E, Xanthos T. Video-laryngoscopes in the adult airway management: a topical review of the literature. Acta Anaesthesiol Scand. 2010;54(9):1050–61.

    Article  CAS  PubMed  Google Scholar 

  29. Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth. 2015;114(2):181–3.

    Article  CAS  PubMed  Google Scholar 

  30. Timanaykar RT, Anand LK, Palta S. A randomized controlled study to evaluate and compare Truview blade with Macintosh blade for laryngoscopy and intubation under general anesthesia. J Anaesthesiol Clin Pharmacol. 2011;27(2):199–204.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Lu Y, Jiang H, Zhu YS. Airtraq laryngoscope versus conventional Macintosh laryngoscope: a systematic review and meta-analysis. Anaesthesia. 2011;66(12):1160–7.

    Article  CAS  PubMed  Google Scholar 

  32. Berkow LC, Greenberg RS, Kan KH, Colantuoni E, Mark LJ, Flint PW, Corridore M, Bhatti N, Heitmiller ES. Need for emergency surgical airway reduced by a comprehensive difficult airway program. Anesth Analg. 2009;109(6):1860–9.

    Article  PubMed  Google Scholar 

  33. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O’Sullivan EP, Woodall NM, Ahmad I. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827–48.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Benumof JL, Berry FA, Bode RH, Cheney FW, Guildry OF, Ovassapian A. Practice guidelines for management of the difficult airway: an update report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251–70.

    Article  PubMed  Google Scholar 

  35. Combes X, Andriamifidy L, Dufresne E, Suen P, Sauvat S, Scherrer E, Feiss P, Marty J, Duvaldestin P. Comparison of two induction regimens using or not using muscle relaxant: impact on postoperative upper airway discomfort. Br J Anaesth. 2007;99(2):276–81.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. National Cancer Institute-INCA, Rio de Janeiro, RJ, Brazil

    Ronald Lima M.D., Ph.D., Leonardo Vianna Salomão M.D. & Pedro Rotava M.D., M.Sc.

Authors
  1. Ronald Lima M.D., Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Leonardo Vianna Salomão M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pedro Rotava M.D., M.Sc.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Leonardo Vianna Salomão M.D. .

Editor information

Editors and Affiliations

  1. National Cancer Institute INCA, Rio de Janeiro, Brazil

    Terence Pires de Farias

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Lima, R., Salomão, L.V., Rotava, P. (2018). Difficult Intubation: How to Avoid a Tracheostomy. In: de Farias, T. (eds) Tracheostomy. Springer, Cham. https://doi.org/10.1007/978-3-319-67867-2_20

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-67867-2_20

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-67866-5

  • Online ISBN: 978-3-319-67867-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation