Management of Unanticipated Difficult Intubation

Airway management, ensuring uninterrupted oxygenation and ventilation, is a fundamental part of the practice of anesthesia and of emergency and critical care medicine. Endotracheal intubation is an airway management technique indicated in a variety of clinical situations, most commonly for the maintenance of the upper airway during general anesthesia, but also in any situation involving the maintenance and protection of the upper airway when the airway may be compromised or positive pressure ventilation is necessary. A difficult intubation is defined by the American Society of Anesthesiologists as tracheal intubation requiring more than three attempts, in the presence or absence of tracheal pathology. Unanticipated difficulty with endotracheal intubation may result in catastrophic outcomes, including cerebral anoxia and death. Of the anesthesia events involving complications reported to the Pennsylvania Patient Safety Authority in 2009, 36 reports involved a difficult intubation. In 23 reports, difficult intubation was described as unanticipated. Even the most thorough assessment of the airway may not detect the possibility of a difficult intubation, and every anesthetist should have a predetermined strategy for dealing with this situation. Alternative methods of managing the airway should be initiated after two or three unsuccessful attempts at intubation. This article discusses assessment of the airway, identification of patients at risk for a difficult intubation, and risk reduction strategies, including plans for dealing with an unexpected difficult intubation. Recent advances in airway management techniques and devices will be summarized. (Pa Patient Saf Advis 2010 Dec;7[4]:113-22.) Management of Unanticipated Difficult Intubation