French Society of Anesthesia and Resuscitation
In collaboration with:
Company resuscitation in French
Club ENT anesthesia
Club obstetrical anesthesia
Association of pediatric anesthetists
French-speaking
Samu de France
French Society of Emergency Medicine
Difficult intubation
Experts Conference
Short text
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Experts Conference - Sfar - 2006
• Chairman of the Conference of Experts
Anne-Marie Cros (Bordeaux)
• Experts
Bruno Bally (Grenoble), Jean-Louis Bourgain (Villejuif), Jean Chastre (Paris), Xavier Combes
(Créteil),Pierre Diemunsch (Strasbourg), Marc Fischler (Suresnes), Daniel Francon (Marseille),
Yann Hervé (Bordeaux), Samir Jaber (Montpellier), Ollivier Laccourreye (Paris), Olivier
Langeron (Paris), Annick Legras (Tours), François Lenfant (Dijon), Bruno Marciniak (Lille),
Gilles Orliaguet (Paris), Didier Pean (Nantes), Patrick Ravussin (Sion), Martine Richard
(Grenoble), François Sztark (Bordeaux).
Experts Conference - Sfar – 2006
This expert meeting is an update of the expert conference organized by the Society
French Anesthesia and Intensive Care (Sfar) in 1996. It was organized and took place
accordance with the methodology developed by Sfar. The president of the conference was
designated by the Committee and was the reference group of experts in collaboration with the
committee. The experts worked in sub-groups for each question. They developed the
recommendations after analysis and synthesis of the literature. References have been
analyzed with the grading scale established by the Committee repositories. Recommendations have
were discussed in plenary and approved by all the experts either unanimously or by a majority
two thirds.
FORCE RECOMMENDATIONS
The letters in brackets represent the levels of recommendations resulting from the analysis of
literature.
• Grade A: two studies (or more ...) Level I
• Grade B: a study level I
• Grade C: study (ies) Level II
• Grade D: a study (or more ...) Level III
• Grade E: Studies Level IV or V
Question 1
What are the predictors of difficult intubation
and mask ventilation difficult?
Definition
Intubation is difficult if it requires more than two laryngoscopy and / or implementation of an
alternative technique after optimization of the position of the head, with or without laryngeal
manipulation external.
Mask ventilation is difficult: 1) it is impossible to get a chest expansion sufficient or tidal volume greater
than the dead space (3 ml / kg), a plot capnography identifiable to maintain SpO2> 92% 2) it is necessary
to use oxygen more rapid times call another operator 3) if the insufflation pressure is greater than 25
cmH2O Screening for difficult intubation (DI) and difficult mask ventilation (DMV) must be systematic
and documented whenever intubation is planned or likely (consultation Anesthesia, ICU admission).
In emergency conditions, screening is more difficult but it should be done whenever possible.
Predictive criteria
Predictive criteria of DMV
Age greater than 55 years, a body mass index (BMI)> 26 kg/m2, lack of teeth, mandibular protrusion
limiting the presence of snoring and beard were found as predictors of DMV (grade C). The presence of
two of these factors is predictive a DMV. The risk of ID multiplied by 4 is difficult in patients with a DMV
(grade D).
Experts Conference - Sfar – 2006
Predictive criteria ventilation impossible
Thyromental a distance <6 cm and the presence of snoring are predictive criteria of ventilation
impossible (grade C).
Prediction criteria ID
The following criteria are predictive of ID, it is recommended to search: history of ID, Mallampati class>
2, thyromental distance (DTM) <6 cm mouth opening <35 mm (grade C). It is also advisable to seek the
mandibular mobility (lip bite test) mobility of the cervical spine (angle made by the head fully extended
on the neck and bending maxima above 90 °) (E grade).
Certain clinical situations increase the risk of ID: a BMI> 35 kg/m2, an apnea Obstructive sleep apnea
(OSA) with neck> 45.6 cm, cervicofacial disease (grade D) and pre-eclampsia (grade E).
In children the Mallampati classification is not validated (grade E). The prediction criteria IDs are facial
dysmorphism, a DTM <15 mm in the newborn infant 25 mm and <35 mm in children less than 10 years,
a mouth opening less than three fingerbreadths Child and snoring at night with or without OSA (gradeE).
ID prediction criteria in the context of emergency
Recommended criteria should be sought wherever possible, but they are not adapted to the context of
the emergency. Some situations should alert the operator: trauma cervicofacial (spine trauma, facial
trauma), ENT pathology (cervicofacial or oropharyngolaryngée) and the presence of facial burns (grade
E).
Question 2
Arterial oxygen desaturation and maintaining oxygenation
during intubation.
All patients should be préoxygénés, especially when an ID and / or VMD planned (grade C) and when
patients are at risk of desaturation during intubation. The risk factors desaturation during intubation
are: emergency intubation with induction rapid sequence (SRI), a VMD predictable, predictable ID,
obesity and pregnancy, infant and newborn child ASA class 3 or 4, the child and the child with buzzer
tract infection upper airways (VAS). Finally, the elderly and chronic bronchopathe are also at risk
desaturation (grade D).
The obese, pregnant women, infants, children with upper airway infection and insufficient
breathing preoxygenation may desaturate despite good conduct (grade A).
In obese patients, children and pregnant women, due to the decrease in FRC, denitrogenation
is faster but the apnea time is shorter (Grade B).
Preoxygenation maneuvers must be performed with a mask sealed gas flow sufficient and appropriate
size ball (grade D). FEO2 monitoring is recommended, anesthesia, as well as monitoring of SpO2 (grade
E).
It is recommended that preoxygenation with FiO2 three minutes to 1 adult (grade B) and two minutes in
children (grade C), or by asking the patient to achieve eight deep breaths with a flow rate of 10 l / min of
oxygen for one minute (grade C).
Experts Conference - Sfar – 2006
Pregnant women, the technique of four vital capacity is for 30 seconds alternative to the standard
preoxygenation (grade D).
In obese patients, the half-sitting position is recommended during oxygenation (grade D).
In respiratory failure it is recommended to extend the preoxygenation under control
FEO2 (grade D).
After induction, the cannulation oropharyngeal is recommended because it facilitates ventilation
mask (grade C).
Use the main circuit is recommended because it allows monitoring of exhaled gases, the
spirometry and insufflation pressures (grade D).
Mask ventilation in pressure or volume controlled using the main circuit respirator is a practice
to be encouraged (grade D).
It is recommended to ventilate a patient whose SpO2 falls below 95%, even if it is
full stomach (grade D).
Question 3
What local anesthetic techniques, locoregional and general anesthesia?
Place in the context
Sedation and local anesthesia with intubation fiberscope
Sedation or analgesia associated with ALR or AL enhance patient comfort and hemodynamic parameters
(grade E).
Maintaining spontaneous ventilation is a must, especially if mask ventilation is expected difficult (grade
E).
Sedation or analgesia bad behavior can make airway management more difficult (Grade E). Propofol and
remifentanil administered continuously are the agents of choice (grade C). They should be titrated and
administration to target concentration is recommended (grade C). The initial concentration is low and
gradually increased in increments until the effect sought (grade C). Target concentrations are based
pharmacokinetic models used. For propofol target concentration at the site of action of 2 mg / ml may
be recommended with the Schnider model, it is 1.5 ng / ml for remifentanil with the Minto modelSchnider (grade D). The joint administration of these two agents is not recommended due to the
increased risk of apnea (grade C).
The inhalation anesthesia with sevoflurane is the reference method in children. It is also an alternative
in adults (grade D), the Fesevo should be titrated according to the desired effect (grade E). The risk of
this technique is the loss of freedom that VAS affect the administration of sevoflurane (grade E).
Local anesthesia can be performed either with layered techniques, or with an aerosol of lidocaine
to 5% with an oxygen flow rate of 5 l / min (Grade D). The maximum dose is 4 to 6 mg / kg in adults
and 3 mg / kg in children. Topical anesthesia of the nose must be associated with a vasoconstrictor.
The only recommended blocks are block bilateral laryngeal nerves and block tracheal injection
lidocaine through the membrane thyroid intercrico-thyoid (E grade).
Experts Conference - Sfar – 2006
Predictable anesthesia ID (excluding fibro optic)
General anesthesia may be considered depending on the context (grade D). Choice or not maintaining
spontaneous ventilation must consider the possibility of mask ventilation and use oxygenation
techniques recommended (grade E). The depth of anesthesia and relaxation muscle must be sufficient
to optimize intubating conditions (grade D). Anesthesia should be rapidly reversible (grade E).
Propofol and sevoflurane are the agents of choice in the absence of airway obstruction may (grade C).
The addition of an opioid optimizes intubation conditions but with a higher risk respiratory depression
and apnea (grade C). The administration of agents to target concentration is recommended (grade C).
If neuromuscular blockade is required, only succinylcholine may be recommended in the absence of
contra-indication (grade C).
In the case of a difficult intubation unplanned
Depth of anesthesia and muscle relaxation sufficient time must be maintained that continued intubation
maneuvers (grade E).
In children,
The inhalation anesthesia with sevoflurane is the reference technique against a predictable ID
(grade D). The establishment of an intravenous line before induction is recommended (grade E). the
depth of anesthesia and muscle relaxation must be sufficient to prevent the risk laryngospasm (grade E).
Emergency medicine and resuscitation
Apart from cardio-respiratory arrest, intubation should be performed after general anesthesia (grade E).
The persistence of laryngeal reactivity degrades intubation conditions and increases the risk of serious
complications (grade E).
The anesthesia must be performed using a rapid sequence induction (grade B). Etomidate and
Ketamine is recommended (grade D). Curare of choice is in the absence of succinylcholine contraindication (grade E).
The anesthesia must be maintained and deepened if the patient shows signs of revival. A new injection
of succinylcholine may be performed if the patient shows signs of reversal compromising intubation
(grade E).
Question 4
What equipment for intubation and ventilation?
Composition of difficult intubation trolley.
The choice of devices constituting a trolley ID must consider algorithms Team anesthesia and must cope
with all situations. Training of all operators likely to use is mandatory (grade E).
A metal blade must be preferred to a plastic blade disposable if laryngoscopy under difficult or
emergency intubation (grade C).
Experts Conference - Sfar – 2006
To perform a transtracheal oxygenation, it is recommended to use only equipment designed and
validated for this purpose (grade E).
The use of disposable equipment should be privileged level of technical performance and safety in use
equivalent to that of the reusable devices.
Material support an ID must be grouped in a cart or in a suitcase easily identifiable and can be used at
any time of the day and night (grade E). The composition of trolley ID recommended by the panel is
attached.
In pediatrics, the material must be adapted to the size of the child, the infant straight blade Miller
may be useful. The laryngeal mask intubation (PWM Fastrach types) can be used from 30 kg.
Oxygenation transtracheal and cricothyrotomy are not recommended in very young children (grade E).
A set of cricothyroidotomy is recommended in case of medical emergency ID (grade E).
Question 5
Strategies and algorithms
Strategy management can anticipate a critical situation. This management strategy
load is centered on maintaining oxygenation of the patient. Faced with an ID provided must
anticipate possible difficulties with oxygenation and ensure the availability of resources to
maintain during intubation maneuvers: mask ventilation and / or technical assistance. Of
decision algorithms intubation and oxygenation were developed. They allow taking
responsible for these different clinical situations: planned or unplanned ID and VMD. They are
presented in the appendix.
Several important points should be noted. The awakening of the patient or the deferral of
intervention must be considered at each stage (grade E). The call for help in the early stages of
the algorithm is recommended (grade E). It is recommended not to intubate persist and move to
the next step after two failures and do not forget to maintain oxygenation between attempts
(grade E)
It is not recommended to consider the practice of laryngoscopy to assess the real difficulty
ID of a scheduled without a strategy planned care (grade E). So it is not recommended to
consider the creation of a ALR without providing an alternative in case of failure, the
airway control in case of difficulty oxygenation and delaying surgery if the requirements to
achieve a sedation are not met.
It is recommended to inform the patient of the occurrence of difficult intubation or ventilation
mask and mention in the medical record.
As part of the emergency, the SRI with Sellick maneuver is the reference technique (grade C).
Cricothyroidotomy is preferred transtracheal oxygenation (grade D). The intubation Obstetrics
posed by the dual problem of inhalation risk and the risk of fetal distress. Oxygenation should be
preferred (grade D).
Resuscitation, oxygenation should be encouraged even at the expense of inhalation risk (grade
E).
The fiberscope is recommended in the presence of a foreseeable difficulty of intubation (grade
E). In this context, noninvasive ventilation may be interesting (Grade D).
Experts Conference - Sfar – 2006
Question 6
Extubation: Extubation criteria. Management of risk situations
Respiratory complications are the most frequent cause of postoperative reintubations (grade C).
The complications of extubation are most often related to obstruction mechanical airway or
respiratory dysfunction (grade D).
After an ID, extubation should be performed in the presence of a senior physician (grade E).
Conventional extubation criteria must be met and especially a complete block reversal confirmed
by a T4/T1 ratio higher than 90% (grade D).
The leak test is not predictive of extubation anesthesia risk (grade D).
The implementation of a preventive guide exchanger is not justified unless the track access
Air is made difficult by the surgical procedure (grade E).
Question 7
What education and training what?
All practitioners who may perform intubation should be trained in technical recommended algorithms
supported (grade E).
Training by simple companionship should not start on the patient. The training must include a learning
model and then learning about patient (grade E). The maintenance of knowledge may involve training
mannequin.
Teaching techniques such as the use of LMA or intubation with a ILMA can be in the operating room
after learning model (grade E). Other techniques such as oxygenation transtracheal endoscopy and
clinical indications were limited. It can be done involve collaboration with other specialists such as
pulmonologists and ENT (grade E).
IN CONCLUSION
The conference of experts answers most of the problems and situations that may arise in daily practice.
It is nevertheless certain situations where clinical judgment must prevail and where the choice of
strategy management is in terms of risk / benefit. The evolution of technology has simplified the
management of ID. The development of algorithms a team is the cornerstone of care provided
techniques are known all achievable at any time. Support an ID through the development of a
strategy beforehand.
Experts Conference - Sfar – 2006
ANNEXES
Algorithms difficult intubation planned
(1 general "umbrella" algorithm intubation
and that of the oxygen).
Experts Conference - Sfar – 2006
Algorithm unanticipated difficult intubation
Experts Conference - Sfar – 2006
Chariots d’intubation
Recommended composition of a difficult intubation trolley anesthesia or resuscitation
• Magill forceps
• Probes for intubation of different sizes
• Macintosh blades metal of all sizes
• Chucks long legs
• LMA-Fastrach different sizes
• A first tracheal direct: set cricothyroidotomy
• Transtracheal oxygenation device enabled (manual injector)
• Guide exchanger hollow extubation
• Fiberscope
• Mask adapted (type Fibroxy) and cannulae aid fiberoptic
• For the fiberscope, it may be available on a trolley individualized
difficult intubation trolley where will the light source, and all the fiberscope accessories necessary for
the realization of endoscopy (the location of the carriage shall be known to all).
Pediatric features: available material must be adapted to the size and weight of children in care.
• Straight blades Miller
• LMA-Fastrach size 3 for children over 30 kg
• Laryngeal masks of different sizes for children less than 30 kg
Composition of a truck or in case of difficult intubation Emergency Medicine
• Magill forceps
• Probes of different sizes
• Macintosh blades metal of all sizes
• Chucks long legs
• LMA-Fastrach
• Set cricothyroidotomy
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