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What Is the Challenge of Difficult and Failed Airway Management?

Competency with regard to airway management is fundamental to the practice of anesthesia, emergency medicine, emergency medical services (EMS), critical care medicine, hospital medicine, and other acute care specialties. The focus of this chapter is the management of the difficult and failed airway in an emergency or urgent situation. Management of the predicted difficult intubation is dealt with in Chapter 3 and in Section 2 of this book.

The airway practitioner in an urgent or emergency situation is faced with two particular challenges: to be able to accurately and expeditiously predict a difficult airway, and to be able to recognize when airway management has failed.1 No matter the situation, reliably and reproducibly ensuring timely and effective oxygenation and ventilation is imperative.

Appropriate planning, selection of the airway devices and techniques, clear communication of that plan and calm execution based on learned methods and experience enhances success even in these most difficult cases. The need for clearly communicated Plan A (first line or initial plan), B (backup or salvage plan), and C (failed airway plan) cannot be over emphasized.

How Reliably Can We Predict a Difficult Airway?

There are five means through which effective ventilation occurs:

  • Spontaneous patient driven

    And ventilation provided through:

  • Bag-mask (BMV)

  • Extraglottic device (EGD)

  • Endotracheal intubation

  • Surgical airway

The latter four of these are artificial or nonnatural interventions, or methods of active airway management. In the event that a patient is unable to sustain adequate spontaneous gas exchange, or if in the course of therapy, the patient's ability to maintain adequate gas exchange (e.g., due to the use of medications) is compromised or eliminated, one of these four methods must be employed successfully to assure survival. They constitute the four dimensions of airway management. Hence, the assessment for anticipated difficulty should focus on these four independent operations:

  • Difficult BMV

  • Difficult laryngoscopy and orotracheal intubation (direct laryngoscopy [DL] or video-laryngoscopy [VL])

  • Difficult EGD

  • Difficult surgical airway

Ordinarily mask-ventilation and orotracheal intubation are the usual methods employed in managing the airway of patients unable to adequately breathe for themselves. If a difficult airway is anticipated, and it is not to be managed “awake,” EGDs and surgical airway techniques are usually considered rescue options. Importantly, they ought not be considered “defacto” evidence of “failure” if they are “part of the plan,” a fundamental concept advanced in this text. Techniques under consideration as first line or back up depend in large part on the context of the situation such as the condition of the patient, the skill of the practitioner, the availability of skilled assistance, the location and equipment available, and the time of day (see Chapter 7: Context Sensitive Airway Management).

Acute care practitioners ought to be able to determine ...

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