difficulty of mask ventilation; difficulty of SGA placement; difficulty of laryngoscopy;
difficulty of intubation; and difficulty of surgical access. Then, opportunities to deliver supplemental oxygen throughout the difficult airway process should be pursued.
Finally, the provider should consider the relative merits and feasibility of basic management choices:
• awake intubation versus intubation after induction of general anesthesia;
• non-invasive techniques versus invasive techniques for the initial approach to
intubation;
• video-assisted laryngoscopy as an initial approach to intubation; and
• preservation versus ablation of spontaneous ventilation.
Techniques for managing difficult intubation include awake intubation, blind intubation (oral or nasal), fiber-optic intubation, intubation with a stylet or tube changer,
SGA as an intubating conduit, use of laryngoscope blades of varying design and size,
use of a light wand, retrograde intubation and video laryngoscopy. In the event of difficult ventilation, consider the following techniques: use of an intratracheal jet stylet,
invasive airway access, SGA, use of oral and nasopharyngeal airways, and use of a
rigid ventilating bronchoscope.
Safe, not sorry
The best safety measure is preparation. That means having the necessary equipment
and supplies, having the training and expertise for all staff to work as a team when
presented with a difficult airway, evaluating all patients before surgery, and having —
and using — a difficult airway algorithm. Thanks to better tools and more widespread
use of algorithms, care of our patients is getting safer: An analysis of closed claims
found that incidence of negative claims and severity of outcomes related to difficult
airways have demonstrably improved since the ASA guidelines were first released in
1993.1
Always keep in mind that, when the clinical risks of proceeding with airway manageJ A N U A R Y 2013 | S U P P L E M E N T
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