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  1. Tracheal intubation can be accomplished using several techniques, including direct visual (rigid) laryngoscopy, video laryngoscopy, indirect visual (fiberoptic) laryngoscopy, guided blind (retrograde), and complete blind (eg, intubation through supraglottic airway [SGA] or blind nasal) intubation. Each technique has its preferred indication, risks, and benefits.

  2. Soft tissue upper airway obstruction is common after induction of anesthesia. Insertion of an oropharyngeal airway or an SGA or application of a jaw thrust often is successful for overcoming soft tissue airway obstruction.

  3. General anesthesia and muscle relaxants facilitate tracheal intubation. A rapid-acting muscle relaxant is used during rapid-sequence induction and intubation.

  4. During general anesthesia, airway management without tracheal intubation has become well-accepted common practice since the introduction of SGA devices. As with any technique, it is incumbent upon the physician to determine what technique is most appropriate given the clinical scenario.

  5. Securing the airway under topical anesthesia with or without sedation (an "awake intubation") provides the optimal approach for a patient with a severely compromised or difficult airway.

  6. Awake intubation should be encouraged, taught, and practiced regularly to help maintain comfort and skill with the technique.

  7. The availability of a difficult airway cart should be assured for every anesthetizing location.

  8. Many major anesthetic complications are frequently associated with airway mismanagement, including inadequate ventilation or oxygenation and unrecognized esophageal intubation.

  9. Laryngospasm is common with airway stimulation during light anesthesia. Stridor indicates partial blockade of the airway. Lack of stridor may indicate complete closure of the larynx with no air exchange.

  10. For patients in whom the upper airway is obstructed, establishing emergency ventilation with a supraglottic device (eg, laryngeal mask airway), esophageal device (eg, Combitube), cricothyrotomy, or transtracheal jet ventilation is a must and should be applied as soon as possible to prevent brain injury and death.

  11. Trauma to laryngeal structures can leave patients with vocal cord paralysis and serious voice dysfunction.

  12. Many airway disasters have been reported after patient extubation. A well-planned and prepared extubation is a must for high-risk patients to minimize airway-related complications.

In the anesthetic environment, an artificial airway conducts gases between the anesthesia machine's breathing system and the alveoli. Effective management requires keeping the airway free of secretions, contamination, and obstruction while minimizing complications. Critical illness often causes weakness and obtundation sufficient to impair gas exchange. The sedative, narcotic, anesthetic, and relaxant drugs that facilitate surgery predictably compromise airway patency and protection. The Closed Claims Study of the American Society of Anesthesiologists Committee on Professional Liability has shown that tragic and costly complications of anesthesia frequently have resulted from problematic airway management.1 Some of the obligations of the anesthesiologist include ensuring that the patient is adequately oxygenated, the lungs are ventilated, and airway patency is maintained. Essential attributes of the expert airway manager include knowledge, sound judgment, skills for a range of techniques, and a plan for all conceivable contingencies.2,3

Mastery of the airway demands familiarity with normal and variant anatomy and the alterations caused by sedation, anesthesia, and ...

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