DIFFICULT INTUBATION

Always have skilled assistance, preferably another anaesthetist, when difficulty is expected or the patient's cardio-respiratory reserve is low.

LOOK FOR

* History of difficult intubation
* Anatomical hallmarks at pre-operative assessment
* Patho-physiological states involving head and neck region
* Syndromes known to be associated with difficult intubation

Call for skilled assistance
Call for the difficult intubation trolley
Maintain ventilation with oxygen at all times
Have someone feel the pulse and call out the SpO2.
If you cannot ventilate the lungs Airway Obstruction

If you can ventilate by face mask, consider
     waking the patient up OR
     maintaining anaesthesia and trying to intubate (1)

If the latter choice is made, try basic manoeuvres first:
     Optimise the head and neck position (2)
     Try laryngeal manipulations such as "BURP" (3)
     Try a well-lubricated gum elastic bougie or stylet (4)
     Try different laryngoscope blades
If these fail:
     Consider:inserting an LMA (5)
     Consider other techniques:   Blind nasal
                                                Retrograde
                                                Lighted stylet
If an LMA is in place consider whether to proceed and whether steps should be taken to secure endotracheal intubation
Confirm correct placement of endotracheal tube.

Review the situation
Exclude other complications (6)
There is a risk of awareness:
     Go and see the patient in the ward
     Explain the full circumstances and reassure them (7)
Advise them to warn future anaesthesiologists (7)
See  - After the Crisis

The figures reported here are based on an analysis of 160 reports of difficult intubation in the first 4000 AIMS anaesthesia incidents.

(1) Techniques will vary with the experience and familiarity with the techniques of the individual anaesthesiologist.
      Avoid multiple attempts at laryngoscopy/intubation, as this may cause bleeding and laryngeal oedema, worsening the
      situation.
(2) This may require 2 assistants:
      The first to apply pressure to the larynx and/or the back of the neck, the second to lift the head up.
(3) BURP refers to Backward Upward Rightward Pressure, as described by Knill (see Knill, RL. Difficult laryngoscopy
      made easy with a "BURP" Can J Anaesth 1993; 40: 279-282).
(4) The most common aid to facilitate successful intubation in the AIMS series was the bougie (46%), followed by a
      stylet (23%).
(5) The LMA is easy to insert and works well in 95% cases. It does not provide airway protection.
(6) Airway trauma
     Pulmonary oedema
     Post-obstructive pulmonary oedema
     Cardiovascular signs and symptoms
(7) Document the problem in the case notes and give the patient a letter to warn future anaesthetists. If a particular
     precipitating event was significant, or a particular action was useful in resolving the crisis, this should be clearly
     explained and documented.