Guidelines of difficult airway :
what’s new ?
Olivier Langeron, MD,
PhD
Department of Anesthesiology and Intensive Care
Pitié-Salpêtrière Hospital
Paris, France
Disclosures
BAXTER
COOK medical
COVIDIEN
Difficult airway management guidelines
SFAR difficult intubation : a collective expertise
Ann Fr Anesth Réanim 1996, 2007 (2014)
ASA practice guidelines for management of the difficult airway
Anesthesiology 1993, 2003, 2013
Canada the anticipated difficult airway with recommendations
for management
Can J Anaesth 1998
UK difficult airway society guidelines for management of
unanticipated difficult intubation
Anaesthesia 2004
Difficult airway issues
Anticipate it, to manage it !
How ?
difficult airway risk factors
difficult airway algorithms
DefinitionS of DMV
El-Orbany M and Woehlck HJ Anesth Analg 2009
1993
No universal definition
Simplification over time
2 main criteria despite
lack of objectivity:
2000
-Difficulties to maintain
oxygenation
-Necessity of additional
support to perform MV
2003
2005
2006
Definition of difficult intubation (DI)
ASA 2003 : DI if conventionnal laryngoscopy
> 3 attempts or > 10 minutes
multiples attempts
SFAR 1996 : DI if conventionnal laryngoscopy > 2
attempts or > 10 minutes
and/or alternative technique required after
optimization of head position, with or without external
laryngeal maneuver
2013
2006
Anticipated DMV
Impossible :
- lingual tonsill hyperplasia (LTH) +++
Ovassapian A et al. Anesthesiology 2002
- increased risk after tracheal intubation failures
(≥3) Mort T. Anesth Analg 2004
- laryngospasm / bronchospasm
Possible : prediction of DMV
Langeron O et al. Anesthesiology 2000
Kheterpal S et al. Anesthesiology 2006
Hypertrophied
Lingual Tonsil
From Jones DH et
al. Anesth Analg
1993
Sagittal Section
of normal
Tongue
and Larynx
Comparison of DMV prediction studies
Langeron
2000
Kheterpal
2006
DMV risk factors
http://www.sfar.org/cexpintubdifficile.html
Increasing risk if at least 2 of these factors:
•
•
•
•
•
•
Age >55 yr
BMI >26kg/m2
Jaw protrusion severely limited
Lack of teeth
Snoring
Beard
X 4 risk of difficult intubation with a DMV
Definition of a difficult airway
Mask ventilation
0
easy
Interaction
impossible
Cerebral damage
Death
0
Laryngoscopy - Intubation
DMV could be a dynamic process
Benumof JL Anesthesiology 1991
Multiple TI attempts
DMV prediction and number of risk factors
Kheterpal et al Anesthesiology 2006
DMV risk factor and clinical relevance
Patient information +++
Ask to shave the beard ?
Johnson JO et al Anesthesiology 1999
Optimization of mask ventilation
Better mask seal : appropriate face mask size,
mask ventilation achieved by two persons with a
two-handed mask ventilation technique
Use of large oral-pharyngeal / nasal-pharyngeal
airways
One person assigned to O2 administration (flush
valve…) and patient monitoring (SpO2 …)
DMV risk factor and clinical relevance
standard face mask ventilation
lower lip placement
DMV risk factor and clinical relevance
Expired tidal
volume (ml)
median value 0 ml (0–50ml)
400 ml (365–485 ml)
P < 0.001
standard face mask ventilation
lower lip placement
DI risk factors
http://www.sfar.org/cexpintubdifficile.html
History of a DI ++++
Recommended criteria (mandatory +++) :
Mallampati class >II
TMD <65mm
MO <35mm
Supplementary criteria
Limited jaw protrusion
Limited cervical spine mobility
Criteria dependent on context
BMI > 35kg/m2
OSA with neck circumference > 45.6cm
Neck and/or facial pathology
Pre-eclampsia
Strategy
Algorithms
Techniques
Strategy = Algorithms
Oygenation maintenance
Altenative techniques to control the airway
Rationale to use algorithms
To Analyze the difficult airway situation
To elaborate (local) solutions
To broadcast information
90 % ID solved with GEB
98 % patients intubated
100 % patients oxygenated
SFAR
2006
ANTICIPATED DIFFICULT INTUBATION
2006
Strategic Options
DMV prediction
Oxygenation Maintenance
( LMA or ILMA usable ? Invasive tracheal approach ? )
Choice of the anesthestic technique :
apnea or spontaneaous ventilation ?
SFAR
SFAR
2006
2006
INTUBATION
Mask ventilation efficient
2006
Spontaneous Ventilation
Apnea possible
Laryngoscopy 2 trials –
Anticipated
support
FAILURE
Gum elastic bougie
Videoloaryngoscope
ILMA
FAILURE
LMA <30 kg
FIBERSCOPE
Recovery
Recovery
FAILURE
Recovery
Intubation
Intubation
± fiberscope
Intubation
Tracheal access
If impossible
OXYGENATION
Mask ventilation and/or intubation failures
2006
Intubation
ILMA
LMA <30 kg
= SUPPORT
IN ANY
CASES
Recovery
Transtracheal O2
FAILURE
Contre Indication
Success
Failure
Others intubation
techniques
Recovery
Intubation
FAILURE
Recovery
CRICOTHYROIDOTOMY
TRACHEOTOMY
SFAR
2006
UNANTICIPATED DIFFICULT
INTUBATION
2006
= SUPPORT
and DI trolley
and Anesthesia
maintenance +++
Mask Ventilation
inefficient
efficient
Laryngoscopy 2 trials Gum elastic bougie
Videoloaryngoscope
Failure
ILMA
LMA <30 kg
Ventilation ILMA
efficient
Intubation
INTUBATION
ALGORITHM
inefficient
OXYGENATION
ALGORITHM
ASA
DIFFICULT AIRWAY ALGORITHM
Anesthesiology 1993 / 2003 /
Consider attempt LMA
ASA
DIFFICULT AIRWAY ALGORITHM
Anesthesiology 2013
Videolaryngoscopes
added
Algorithm Basic Rules
At each step : consider awaken patient option
Never go a “bridge too far”, never try the “last” option
Algorithm fitting with the patient case, local means and
operator abilities
Logistics (material, human resources and task
organization) are mandatory
Strategy to manage a difficult airway :
what remains !!!
Algorithm (ASA /SFAR) :
Mask ventilation adequate or not ?
The good question
Intubation algorithm or oxygenation
algorithm
The good option
Basic airway management
Preoxygenation, SpO2 monitoring
Chin lift and Jaw thrust
Oral / nasopharyngeal airway devices
Limited tracheal intubation attempts (<3)
Conclusion
DMV prediction is mandatory (SFAR guidelines for ex),
and the patient should be informed about the risk and the
solutions to decrease it
The main goal of airway management is patient
oxygenation and not necessary endotracheal intubation
A strategy (including DMV prediction and anesthesia
techniques) arising from guidelines and algorithms is
always the first step in a difficult airway management
DI
Oxygenation
maintenance
DMV
http://www.sfar.org/cexpintubdifficile.html