Progress in management of the obstructed airway

There is no consensus as to the ideal approach for the anaesthetic management of the adult obstructed airway and there are advocates of awake fibreoptic intubation, inhalational induction and intravenous induction techniques. This review considers the different options available for obstruction at different anatomical levels. Decisions must also be made on the urgency of the required intervention. Particular controversies revolve around the role of inhalational vs intravenous induction of anaesthesia, the use or avoidance of neuromuscular blockade and the employment of cannula cricothyroidotomy vs surgical tracheostomy.     

Anesthetic management of the patient undergoing head and neck cancer surgery

The head and neck cancer patient should be in the best possible medical condition before facing surgery, bearing in mind the status of the tumor and the urgency of the procedure. Careful assessment of the patient's upper airway will enable the anesthesiologist to select an appropriate course of action to secure the airway before the operation begins. In many cases, the patient can be safely intubated after the induction of general anesthesia. In other situations, the patient may require an examination of the airway while awake with the aid of sedation and topical analgesia to determine the safest intubation technique. If the patient has evidence of a difficult airway, a flexible fiberoptic-guided intubation may be indicated to secure the airway in the awake patient patient before general anesthesia is induced. Some patients with severe airway obstruction or large, bulky supraglottic tumors usually undergo an initial tracheostomy with local anesthesia to secure the airway. Following surgery, extubation of the patient's trachea requires careful attention and may have to be performed over a jet-ventilating stylet.     

Endotracheal intubation following thyroidectomy

Thirty-five patients requiring tracheostomy or endotracheal intubation, following thyroidectomy are reviewed. Conditions included 30 patients with multinodular goitre, three patients with Graves's disease and two patients with carcinoma of the thyroid. Early in the series, emergency tracheostomy was performed in three patients with airway obstruction following thyroidectomy. Ten patients were deemed at extremely high risk of developing airway obstruction and underwent prophylactic tracheostomy. Endotracheal intubation has been used in preference to tracheostomy in the latter part of the series. Emergency endoctracheal intubation was performed on one patient and prophylactic intubation was carried out in 20 patients. The morbidity and length of hospital stay in this latter group was considerably less than those requiring tracheostomy. It is concluded that patients with potential airway obstruction following thyroidectomy should have prophylactic endotracheal intubation, in preference to tracheostomy.     

Anaesthesia for facial trauma

Facial trauma is common and can produce both physical and psychological problems for patients. Managing patients in both the emergency setting and elective theatre environment can be extremely challenging, so airway interventions should be carefully planned so the safest and most effective technique can be chosen. This may mean that direct laryngoscopy may not be the safest or most straightforward option and awake tracheal intubation, videolaryngoscopy, submental intubation or awake tracheostomy may be a better choice in a given set of circumstances. An understanding of common mechanisms of injury and pathologies and the likely difficulties that will be present are essential. Senior anaesthetic input and effective teamwork is required to provide excellent levels of care for these patients.     

Anaesthesia for maxillofacial trauma

Facial trauma is common and can produce both physical and psycho-logical problems for patients. Managing patients in both the emer-gency setting and elective theatre environment can be extremely challenging, so airway interventions should be carefully planned so the safest and most effective technique can be chosen. This may mean that direct laryngoscopy may not be the safest or most straight-forward option and awake tracheal intubation, videolaryngoscopy, submental intubation or awake tracheostomy may be a better choice in a given set of circumstances. An understanding of common mechanisms of injury and pathologies and the likely difficulties that will be present are essential. Senior anaesthetic input and effective teamwork are required to provide excellent levels of care for these patients.     

Anaesthesia for facial trauma

Facial trauma is common and can produce both physical and psychological problems for patients. Managing patients in both the emergency setting and elective theatre environment can be extremely challenging, so airway interventions should be carefully planned so the safest and most effective technique can be chosen. This may mean that direct laryngoscopy may not be the safest or most straightforward option and awake fibreoptic intubation, videolaryngoscopy, submental intubation or awake tracheostomy may be a better choice in a given set of circumstances. An understanding of common mechanisms of injury and pathologies and the likely difficulties that will be present are essential. Senior anaesthetic input and effective teamwork are required to provide excellent levels of care for these patients.     

Awake tracheal intubation through the laryngeal mask in neonates with upper airway obstruction

Neonates with Pierre Robin or Treacher-Collins syndrome are at risk of upper airway obstruction and may require surgical fixation of the tongue to the mandible. Such neonates are at high risk of hypoxia during induction of anesthesia and thus awake fiberoptic intubation would be required. We experienced neonates in whom awake fiberoptic intubation could not be carried out, because of severe hypoxia. Awake insertion of the laryngeal mask solved this problem. A 1-month-old neonate with Pierre Robin syndrome and another with Treacher-Collins syndrome were scheduled for surgical fixation of the tongue to the mandible, for constant upper airway obstruction. In both patients, awake fiberoptic intubation was attempted but abandoned, because SpO(2) rapidly decreased during the attempts. Awake insertion of the laryngeal mask relieved upper airway obstruction and facilitated oxygenation. Fiberoptic intubation through the laryngeal mask was easily achieved. Anesthesia was then induced. No hypoxia occurred after insertion of the laryngeal mask. In a further two neonates with Treacher-Collins syndrome and in one neonate with Pierre Robin syndrome, awake fiberoptic intubation through the laryngeal mask was also successful. We believe that in neonates with predicted difficult intubation, who are at risk of upper airway obstruction and awake fiberoptic intubation could aggregate hypoxia, awake insertion of the laryngeal mask can be useful in facilitating oxygenation (by relieving upper airway obstruction) and in facilitating fiberoptic intubation.     

Anaesthetic anagement of Miller’s syndrome

Miller's syndrome is a rare congenital disorder with facial features similar to that of Treacher-Collins syndrome. This report details the anaesthetic management of an infant during multiple surgical procedures, beginning with pylormyotomy at one month of age. Airway management was difficult because of severe micrognathia and was accomplished using an awake intubation with a conventional straight blade modified for continuous administration of oxygen ("oxyscope"). Due to recurrent upper airway obstruction and the anticipated need for multiple surgical procedures in the first years of life, a tracheostomy was placed. Because of the multiple airway, orthopaedic, and nutritional difficulties, it is important that a prospective, multidisciplinary approach be used in these patients' care. Consideration should be given to early tracheostomy for airway maintenance.     

A feasibility study of awake videolaryngoscope‐assisted intubation in patients with periglottic tumour using the channelled King Vision® videolaryngoscope

Airway management in patients with periglottic tumour is a high‐risk procedure with potentially serious consequences. There is no consensus on how best to secure the airway in this group of patients. We conducted a feasibility study of awake tracheal intubation using a King Vision^® videolaryngoscope with a channelled blade in a cohort of 25 patients, with a periglottic tumour requiring diagnostic or radical surgery. We used 10% and 4% lidocaine to topicalise the airway and midazolam and remifentanil for sedation. We recorded the success rate, number of attempts, time to obtain glottic view, time to intubation and complications. Twenty‐three of the 25 patients (92%, 95%CI 75–98%) were intubated with the awake videolaryngoscope‐assisted technique, with 17/23 (74%, 95%CI 54–87%) intubations achieved at the first attempt. Five patients required two and one patient, three attempts at intubation. Two patients (8%, 95%CI 2–25%) could not tolerate the procedure due to inadequate topical anaesthesia. Median (IQR [range]) times to obtain glottic view and to intubate were 19 (17–22 [10–30]) s and 49 (42–71 [33–107]) s, respectively. Traces of blood in the airway were observed in 4/25 (16%, 95%CI 6–35%) patients. Although airway management in this group of patients was expected to be difficult, successful awake intubation with the King Vision videolaryngoscope was achieved in the majority of patients within less than a minute. This study highlights a number of potential advantages of awake videolaryngoscope‐assisted intubation over other awake methods of securing the airway in patients with upper airway obstruction due to periglottic mass.     

Management of the difficult adult airway. With special emphasis on awake tracheal intubation.

Difficulty in managing the airway is the single most important cause of major anesthesia-related morbidity and mortality. Successful management of a difficult airway begins with recognizing the potential problem. All patients should be examined for their ability to open their mouth widely and for the structures visible upon mouth opening, the size of the mandibular space, and ability to assume the sniff position. If there is a good possibility that intubation and/or ventilation by mask will be difficult, then the airway should be secured while the patient is still awake. In order for an awake intubation to be successful, it is absolutely essential that the patient be properly prepared; otherwise, the anesthesiologist will simply fulfill a self-defeating prophecy. Once the patient is properly prepared, it is likely that any one of a number of intubation techniques will be successful. If the patient is already anesthetized and/or paralyzed and intubation is found to be difficult, many repeated attempts at intubation should be avoided because progressive development of laryngeal edema and hemorrhage will develop and the ability to ventilate the lungs via mask consequently may be lost. After several attempts at intubation, it may be best to awaken the patient, do a semielective tracheostomy, or proceed with the case using mask ventilation. In the event that the ability to ventilate via mask is lost and the patient's lungs still cannot be ventilated, TTJV should be instituted immediately. Tracheal extubation of a patient with a difficult airway over a jet stylet permits a controlled, gradual, and reversible (in that ventilation and reintubation is possible at any time) withdrawal from the airway. Significant advances in the management of the difficult airway have occurred in recent years. Eighty percent of the 127 references in this article were published after 1985. 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 who cannot be intubated or ventilated by mask. As the anesthesiologist's ability to manage the difficult airway significantly improves, respiratory-related morbidity and mortality will decrease.     

Complete upper airway obstruction during awake fibreoptic intubation in patients with unstable cervical spine fractures

PURPOSE: To describe the presentation and management of complete upper airway obstruction with life threatening arterial oxygen desaturation that occurred during attempted awake fibreoptic intubation in two patients presenting with unstable C-spine injury. CLINICAL FEATURE: Complete upper airway obstruction occurred during awake fibreoptic intubation of two men (ASA II; 68 & 55 yr old) presenting with unstable C-spine fractures. In both cases, bag and mask ventilation with CPAP failed to relieve the progressive hypoxemia. A surgical airway was established urgently to oxygenate the two patients who were suffering progressive life-threatening oxygen desaturation. One patient had trans-cricothyroid jet ventilation performed through a 16G intravenous cannula prior to an urgent tracheostomy. In the other patient, an emergency tracheostomy was inserted. Interestingly, both patients had been sedated in the Neurosurgical Intensive Care Unit with morphine and benzodiazepines before their scheduled surgeries. The most likely etiology for the complete upper airway obstruction was laryngospasm due to inadequate topicalization of the airway and additional sedation given in the operating room. Neither patients suffered any new neurological deficits following these events. They went on to have uneventful surgeries. CONCLUSION: This case report suggest that prior to awake fibreoptic intubation, oxygenation, adequate topicalization with testing to verify the lack of pharyngeal and laryngeal responses and careful assessment of sedation levels in the operating room are prudent for a safe endoscopic intubation.     

Tongue swelling in the recovery room: a case report and discussion of postoperative angioedema

We present a case of potentially life-threatening postoperative swelling of the tongue and oropharynx that developed in the postanesthesia care unit in a patient taking lisinopril. The principal treatment of angioedema is the discontinuation of the precipitating agent and airway management. Patients with swelling limited to the face and oral cavity may only require monitoring. However, those with swelling in the floor of the mouth, tongue, and supraglottic or glottic areas should have their airway secured by tracheal intubation immediately. Early intubation in patients displaying these characteristics may decrease the incidence of emergent surgical airways. Angioedema is self-limiting, and the swelling usually resolves spontaneously in two to 3 days. Proper identification of angiotensin-converting enzyme inhibitor-associated angioedema requiring a timely airway intervention may reduce mortality, and recognition of its self-limiting course can prevent unnecessary tracheostomy.     

Acute epiglottitis in the adult: is intubation mandatory?

Acute epiglottitis (AE) in the adult results in inflammation of the supraglottic structures and carries the potential for complete airway obstruction. There is disagreement in the medical literature as to the appropriate management of the airway in the adult with AE. Some authors advocate intubation in all patients while others propose more selective intervention, intubating the trachea only in those patients presenting with airway compromise. We reviewed our institutional experience with 21 patients over the last seven years admitted with a proven diagnosis of AE. Six patients presented with respiratory distress, three in severe distress with symptoms and signs of upper airway obstruction. The three patients in severe distress were taken to the operating room, in two the tracheas were intubated and one underwent tracheostomy after failed intubation. All other patients were monitored but their tracheas were not intubated. The majority of the patients were monitored for 24 hr in the ICU before transfer to wards. No patient initially monitored required tracheal intubation for progression of disease. There were no deaths. Recommendations for the care of the airway in the adult with AE based on our experience and a review of approximately 1000 cases reported in the last ten years are presented. It is our opinion that adults presenting without respiratory symptoms may be safely monitored in an intensive care setting given that provision is made for tracheal intubation or tracheostomy should respiratory distress become evident.     

Airway management of patients undergoing oral cancer surgery: a retrospective study

OBJECTIVE: This retrospective study aims to describe the airway management and benefits of nasotracheal intubation over tracheostomy in 260 patients with oral cancer undergoing surgery. METHODS AND RESULTS: The medical records of 260 patients undergoing surgery for oral cancer were reviewed for airway management during the perioperative period. Eighteen patients had previous surgery for oral cancer and were scheduled for flap reconstruction, recurrence or other complications. In 28 cases neck movement was restricted and decreased mouth opening was found in 50% of all patients because of a large growth or fixation of tissues of head and neck, oral cavity, pharynx or larynx by tumour, or radiation fibrosis. In 53 patients intubation was undertaken under spontaneous ventilation. In 20 cases the trachea was extubated in the immediate postoperative period. In 220 cases patients were extubated next morning in the intensive care unit. In none of the cases was elective tracheostomy under local anaesthesia performed before surgery for the maintenance of the airway for anaesthesia. Elective tracheostomies were done in 17 cases. Three patients remained intubated for 24-48 h because of a high suspicion of airway obstruction following extubation due to a large pectoralis major flap. These three patients received a tracheostomy because of increased oropharyngeal and laryngeal oedema. In three cases emergency tracheostomies were performed due to upper airway obstruction after extubation and in one case prolonged elective ventilation was required due to severe chest infection. CONCLUSION: Oral cancer patients have a potentially difficult airway but, if managed properly during perioperative period, morbidity and mortality can be reduced or avoided. Oral cancer patients can be managed safely without the routine use of a tracheostomy. Nasotracheal intubation is a safe alternative to tracheostomy in oral cancer patients except in some selected patients.     

Management of airway in patients with laryngeal tumors

STUDY OBJECTIVE: To describe our systematic approach to securing the airway in patients with laryngeal tumors, developed over a 10-year period. DESIGN: Retrospective analysis. SETTING: University-affiliated veterans administration medical center. PATIENTS: Eight hundred one patients presenting for laryngeal tumor surgery in a 10-year period, 285 of whom underwent tracheostomy (25 with local anesthesia and 260 with general anesthesia). INTERVENTIONS: Preoperative examination, including history, physical examination, computed axial tomography and/or magnetic resonance imaging, and ear, nose, and throat surgeons' evaluation via indirect laryngoscopy or fiberoptic bronchoscopy were performed before the anesthesiologist's interventions. Local (topical) anesthesia and mild sedation were used for laryngeal evaluation with fiberoptic bronchoscopy. Tumor grade was then established, which determined how the airway would be secured: general anesthesia induction, receive topical anesthesia for awake, direct laryngoscopy, and tracheal intubation, or undergo tracheostomy with local anesthesia. MEASUREMENTS AND MAIN RESULTS: When the airway was secured, surgeons performed the biopsy, (any) tumor debulking, laser excision, or tracheostomy to establish both the airway and the diagnosis. Pulmonary function, including flow-volume loops and blood gas analysis were also useful in evaluating the degree of obstruction and gas exchange. In the event of respiratory distress, tracheostomy was performed after tracheal intubation or with local anesthesia, followed by direct laryngoscopy and biopsy. Depending on the diagnosis, further surgery and radiation treatment were planned next. CONCLUSIONS: With these guidelines, we have reduced the frequency of emergencies because of a lost airway, bleeding, or dislodging of tumor.     

Two cases of negative pressure pulmonary edema after induction of anesthesia and extubation

Two cases of negative pressure pulmonary edema are described. In one case, tracheal intubation was not successful and airway obstruction occurred after induction of anesthesia. Spontaneous breathing was restored by reversal of neuromuscular blocking action, but airway obstruction persisted. Urgent tracheostomy was therefore performed. A chest x-ray and clinical features indicated pulmonary edema immediately after tracheostomy. Treatment with mechanical ventilation and positive end-expiratory pressure improved pulmonary edema. In the other case, airway obstruction occurred after extubation. Removal of secretion in the oral cavity and assisted ventilation improved airway obstruction, but pulmonary edema was found by chest x-ray. Forced diuresis using furosemide and oxygen inhalation resulted in the improvement of pulmonary edema. Fortunatetly, in both cases, significant complications associated with pulmonary edema did not occur. Care should be taken of the risk of pulmonary edema when the airway was obstructed after induction of anesthesia or extubation under spontaneous breathing.     

Failed intubation in obstetrics

Failed intubation in obstetrics is rare. However, if the situation is not managed appropriately the consequences for the mother and newborn may be catastrophic. The skill of managing the airway seems to be decreasing, primarily because the skills are not being practised in general or obstetric anaesthesia. Solutions for this decrease in skills may include improved training and the use of manikins, both for role play and for practising skills. The priority of management is to provide oxygen to the mother and to call for assistance. Oxygen can be provided using basic airway, intubation, and, if necessary, surgical airway skills. Such skills need to be practised on manikins and non-obstetric patients. The decreasing incidence of general anaesthetics means that planning and preparation should be meticulous before and during caesarean section. Ideally, the first intubation attempt should be the best. If a failed intubation occurs, initially techniques such as the use of a bougie, McCoy blade or the left molar approach may be considered, provided hypoxia is avoided. If intubation is unsuccessful the mother should be woken and a regional technique or awake fibreoptic intubation from a suitably experienced practitioner should be considered. A simple protocol shown in this article can be used as a training tool to assess skills, decision-making and teamwork in the event of a failed intubation. Extubation after a difficult intubation should be done with care, and the patient warned of the difficulty in case of further anaesthetics.     

Anasthesia and mediastinal masses A case report and review of the literature

A case in which a mediastinal tumour caused complications including airway obstruction unrelieved by intubation during inhalational induction is described. Other case reports are reviewed and the anaesthetic management of patients with mediastinal tumours is discussed.     

Fiberoptic nasopharyngoscopy for evaluating a potentially difficult airway in a patient with elevated intracranial pressure

A 62-year-old man with a left temporal lobe tumor was scheduled for a semiurgent craniotomy for tumor excision. Previously, the patient had a laryngeal carcinoma that was resected and treated with chemotherapy and radiotherapy and a history of laryngeal biopsy with awake fiberoptic intubation. Because a difficult airway was anticipated, awake fiberoptic nasopharyngoscopy of the airway was performed under topical anesthesia in the operating room. This revealed a narrow glottic opening with no supraglottic pathology or friable tissue. Based on these airway observations, we proceeded safely with intravenous induction and secured the airway in a controlled fashion, thereby minimizing the risk of increased intracranial pressure and catastrophic complications. Nasopharyngoscopy can be used safely to evaluate the upper airway to stratify airway management in patients with a history of head and neck cancer presenting for neurosurgical procedures in the setting of elevated intracranial pressure.     

Treatment of the patient with upper airway obstruction caused by cancer of the larynx.

The treatment of a patient with imminent airway obstruction caused by a malignant tumor of the larynx is an uncommon clinical problem. These cases need to be evaluated, diagnosed, and managed with care, skill, speed, and above all, appropriateness of intervention. Three methods are available to control the airway: tracheostomy, emergency laryngectomy, and controlled tracheal intubation with or without tumor debulking. Two groups of patients had their airways managed either by tracheostomy and delayed elective surgery or by emergency laryngectomy. There was no survival advantage between the groups, and no increased risk of stomal recurrence was demonstrated. If time permits, the patient is considered suitable, and adequate anesthetic and surgical instrumentation is available, it is currently recommended that the obstructing laryngeal tumor be debulked by cold-steel or, preferably, CO2 laser and that the emergency situation be stabilized and the definitive treatment of the patient be converted to an elective procedure without the need to create a tracheostomy.