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  • The Internet Journal of Anesthesiology
  • Volume 30
  • Number 3

Original Article

New Building Blocks for the Airway Algorithm

K Eichenbaum, A Bronstein, K Scope, D Feierman, K Tyagaraj

Citation

K Eichenbaum, A Bronstein, K Scope, D Feierman, K Tyagaraj. New Building Blocks for the Airway Algorithm. The Internet Journal of Anesthesiology. 2012 Volume 30 Number 3.

Abstract
 

To the Editor:

The introduction of modern optical airway devices permits a number of new options for safer management of the difficult airway. As the American Society of Anesthesiology Task Force endeavors to update the standardized Difficult Airway Algorithm of 2003 (1), we would like to offer a modular addition to the existing algorithm (Fig. 1). This module can prompt further discussion and provide an initiative for further review and update of the algorithm. In addition, there is opportunity to build on current concepts in the management of the difficult airway (2-5).

Traditionally the ASA Task Force defined ‘difficult airway’ to be when a conventionally trained anesthesiologist has difficulty with either mask ventilation, tracheal intubation, or both. The 2003 standardized algorithm encompasses a wide range of management techniques compiled from literature, expert opinion, commentary and feasibility data. An updated version could include a decision tree for both anticipated and unanticipated airway difficulties. In this way the use of techniques available for difficult intubation as stated in Table 3 (1), now inclusive of optical devices, can be integrated into the rescue sequence on an individualized level.

With the updated module, the modern devices can be utilized after the demonstration of successful ventilation, keeping in mind that practitioners should only attempt intubating techniques that are within their skill set and comfort level. For example, if nasal fiberoptic is attempted, the practitioner would need to be comfortable with management of bleeding complications that may arise. If the patient has a small mouth opening, i.e. less than two finger breadths, the fiberoptic devices would be a recommended next step. If the patient has an adequate mouth opening, video fiberoptic and/or the fiberoptic video stylet devices, or other techniques such as rigid bronchoscopy and intubating LMA may be attempted.

Figure 1
Proposed modular addition to the 2003 Difficult Airway Management Algorithm.

References

1. American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of difficult airway. Anesthesiology 2003;98:1269–77
2. Saxena S. The ASA difficult airway algorithm: is it time to include video laryngoscopy and discourage blind and multiple intubation attempts in the nonemergency pathway? Anesth Analg 2009;108:1052
3. Crosby, E. The unanticipated difficult airway — evolving strategies for successful salvage. Can J Anaesth. 2005 Jun-Jul;52(6):562-7
4. Amathieu, R et al. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrach™): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology. 2011 Jan;114(1):25-33
5. Hagberg, C.A. Current Concepts In the Management Of the Difficult Airway. Anesthesiology News Special Edition, Issue May 2012

Author Information

Kenneth D Eichenbaum, MD, M.S.Eng
Department of Anesthesiology, Maimonides Medical Center

Aden Bronstein, MD
Department of Anesthesiology, Maimonides Medical Center

Kenneth Scope, MD
Department of Anesthesiology, Johns Hopkins

Dennis Feierman, MD, Ph.D.
Vice Chairman, Department of Anesthesiology, Maimonides Medical Center

Kalpana Tyagaraj, MD
Program Director, Department of Anesthesiology, Maimonides Medical Center

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