Indian J.
PG
328 ISSUE2005;
Anaesth. : AIRWAY
49 (4) : MANAGEMENT
328 - 335
AIRWAY MANAGEMENT IN OBSTETRICS
Dr. Rudra A.
Introduction
Although the use of general anaesthesia has been
declining in obstetric patients, it may still be required in
some cases. Maintenance of the airway during obstetric
anaesthesia is difficult to estimate, still remains the single
most important cause of anaesthesia related maternal
morbidity and mortality.1-4 It has been recognized that the
physiologic and anatomic changes during pregnancy, and
emergency intervention in an inadequately prepared
patient make the problem more challenging. Deaths from
anaesthesia related cause are particularly lamentable because
many of these anaesthetics are elective, they are provided
to young pregnant women in the prime of life, and some
might be prevented if more experienced personnel were
provided. The two outstanding differences in the care of the
obstetric patient include (a) consideration of the needs of
the foetus and (b) dramatically reduced maternal oxygen
reserves in the presence of greater metabolic requirements.
The difficult airway is a clinical situation which
include either one or altogether the concepts of failed
intubation, difficult intubation, difficult laryngoscopy, and
difficult mask ventilation.
Failed intubation is the inability to place the
endotracheal tube. It occurs in approximately 0.13% to
0.35% or 1:750 to 1:280, of obstetric patients.5
Difficult intubation can be defined as, when “the
proper insertion of the endotracheal tube with conventional
laryngoscopy requires more than three attempts and/or more
than 10 minutes”.5
Difficult laryngoscopy can be defined when “it is
not possible to visualize any portion of the vocal cords with
conventional laryngoscope”.5
Difficult mask ventilation can be defined as “not
possible for the unassisted anaesthesiologist to maintain
oxygen saturation more than 90% using 100% oxygen and
positive pressure mask ventilation in a patient whose oxygen
saturation was more than 90% before anaesthetic
intervention, and/or it is not possible for the unassisted
anaesthesiologist to prevent or reverse signs of inadequate
ventilation during positive pressure mask ventilation”.5
M.D., FAMS
Prof. of Anaesthesiology
Calcutta National Medical College, Kolkata
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
328
Although, the American Society of Anaesthesiologists’
(ASA) difficult airway algorithm and several modifications
have been published, specific problems of the obstetric
patient, to date, have not been addressed.5-9 Therefore, the
spectrum of challenges presented by a parturient requiring
anaesthesia, make the role of anaesthesiologist both
challenging and rewarding.10
This review highlights some recent developments
in predicting airway difficulties, advances in airway
management and also strategies and techniques for
management of predicted and unpredicted difficult airway
in obstetric patients.
Differences in obstetric airways
Recognition and evaluation
The incidence of failed intubation in the parturients
has been estimated between 1.3 to 3 per thousand and difficult
endotracheal intubation of 64 per thousand.11,12 Therefore,
one of the most critical, if not the most crucial, part of the
physical examination is the assessment of airway to avoid
disaster associated with airway problems, particularly
for those at risk for operative delivery. There are numerous
methods for assessing the airway, which may help in
predicting a difficult airway. However, a simple three step
method of airway evaluation may be performed that includes
a assessment of (1) the mouth opening and the visibility of
the posterior pharyngeal structures (supine versus sitting),
(2) the mandibular length, and (3) the neck mobility.
Mallampati hypothesized that the degree to which
oropharyngeal structures could be visualized upon examination
should correlate with the structures that could be seen on
larygoscopy and develop a scoring system. However,
Mallampati classification used alone is imprecise. If
combined with other predictors of difficult airway criteria
(thyromental distances, neck extension, interincisor space,
submandibular compliance), the specificity and sensitivity
of the preoperative assessment are improved.13 Thyromental
distance, when the distance between the boney point of
the mentum and the upper border of the thyroid bone is less
than 6.5 cm, would correlate with difficult laryngoscopy.14,15
Neck extension (atlanto-occipital extension) importance lies
with alignment of the oral and pharyngeal axes during
laryngoscopy. Normal value is 35 degree. A decrease of
more than one-third correlates with difficult endotracheal
intubation.16 Neck extension may be affected by ankylosis,
RUDRA : AIRWAY MANAGEMENT IN OBSTETRICS
short/stocky neck and dwarfism. Interincisor space - is the
degree to which a patient can open her mouth. When the
interincisor gap is less than 5 centimetres, intubation
may be difficult.17 Submandibular Compliance-airway
difficulty may be encountered if the compliance of the
tissue in the submandibular space is compromised where,
the soft tissue is displaced during laryngoscopy. Tumor
infiltration, scarring from radiation, burns, surgery may
affect visualization of the larynx.18
No single test can be used to predict difficult airway
with certainty. Combining two or more tests improves the
positive predictive value (the percentage of difficult
laryngoscopies correctly predicted as difficult) and increase
the specificity (the ability to correctly identify normal
patients as normal), but decreases the sensitivity (to detect
true difficult intubations). If all the above tests are positive
the anaesthesiologist should have a high index of suspicion
that airway maintenance would be difficult in anaesthetised
parturient.
In the obstetric patient, it is also prudent to attempt
to estimate the severity of local oedema and friability of
mucosal tissues. Also, evaluation of the airway may need
to be repeated, since changes may occur throughout the
pregnancy as well as during the course of labour.19
The key to any approach is to realize that any and
all external assessments are at least estimates or educated
guesses as to what will actually be visualized on direct
laryngoscopy of the sedated and paralysed patient. Difficult
or impossible intubations will occur, and the only safe way
to manage them is to be well prepared. Vigilance is the
key, along with backup plans and the availability of any
necessary equipment in case of difficulty.
Pregnancy induced anatomical and
physiological changes
The anatomical and physiological factors place the
pregnant woman at greater risk of airway management
complications and difficult intubation than the nonpregnant
woman.6,20
Anatomical changes
Anatomical factors that place the pregnant woman
at increased risk for airway management complications
and difficult intubation include pregnancy-induced
generalised weight gain and particularly, increase in breast
size, respiratory mucosal oedema, and an increased risk of
pulmonary aspiration.21 In the supine position, the enlarged
breasts tends to fall back against the neck, which can
interfere with insertion of the laryngoscope and intubation.
Preexisting conditions that appear in the non-obstetric
329
population include full dentition, small mandible,
protruding incisors, limited mouth opening or neck extension,
short neck, high-arched palate, large breasts21 would act
additionally to cause airway more difficult. Several systemic
diseases such as rheumatoid arthritis, diabetes mellitus,
dwarfism, systemic sclerosis, sarcoidisms, ankylosing
spondylitis, and tumours of the neck may hinder mouth
opening or neck extension in the obstetric patient.21
Finally, increased abdominal contents raise the diaphragm
and alter the normal anatomical alignment of the upper
airway. Moreover, a badly placed hip wedge causing a
thoracic lift effect, as well as misapplied cricoid, inadequate
anaesthesia plus muscle relaxation because of propensity
to minimize doses and anxiety on the part of the
inexperienced anaesthesiologist during induction of
anaesthesia may also complicate airway management in the
obstetric population. Many of these changes can be overcome
with preparation and attention to details such as positioning.
Physiologic changes
Anatomic changes enhance the likelihood of difficulty
in airway management, it is the physiologic changes that
make the consequences much more severe. The obstetric
patient has a 20% to 30% higher oxygen consumption at
term due to increased work of breathing and foetal metabolic
requirements. In addition, total compliance of the chest is
reduced because of the upward displacement of the abdominal
contents by the uterus and the weight of the enlarged breasts.
This is particularly true in patients in the supine position.
The most important pregnancy-induced change the reduction
in the functional residual capacity (oxygen reserve or supply).
Closing capacity (CC) however remains unchanged. The
resulting decrease in the FRC/CC ratio causes faster small
airway closure when lung volume is reduced; thus parturient
can desaturate at a higher rate than non-pregnant woman
can.10 Moreover, airway closure at tidal volume in the
supine position increases the shunt fraction and furthers the
potential for hypoxaemia. Patient with preexisting
neuromuscular disease, or had received narcotics for pain
relief during labour, or magnesium sulphate for preterm
labour or pregnancy-induced hypertension are prone to
inadequate minute ventilation. The clinical effects of these
physiologic changes is rapid desaturation during apnoea on
induction of anaesthesia. During this time, apnoeic
oxygenation can be accomplished by ensuring a patent airway
and delivering 100% oxygen. This will increase the time
available before oxygen saturation falls. Furthermore,
induction of anaesthesia in the head up position may have
an advantage because of increased functional residual
capacity. Approximately in 12 to 15% of parturients at
term, the gravid uterus may compress the venacava and
330 PG ISSUE : AIRWAY MANAGEMENT
aorta in the supine position, causing decreased venous
return, decreased cardiac output, blood pressure, and uterine
blood flow. Therefore, pregnant women should not be allowed
to assume the supine position.
Pregnant women are more prone to aspiration of
gastric contents after induction of general anaesthesia than
nonpregnant patients. Heartburn caused by reflux of gastric
contents occurs in upto 80% of parturients at term. These
effects are due to an elevated gastric acid content, with
decreased pH, and reduced function of the gastroesophageal
sphincter secondary to the mechanical and hormonal
effects that occur early in pregnancy. Elevated levels of
progesterone cause gastric emptying to be delayed and
lower oesophageal sphincter pressure to be decreased, and
placental gastrin causes gastric acid production to increase.
The changes are clinically significant by 10 to 12 weeks of
gestation. By 20 weeks of gestation, the gravid uterus exerts
physical pressure on the stomach causing its upward
displacement and rotation, which alters the angle of the
gastroesophageal junction and increases pressure.
Furthermore, intragastric pressure is increased in patients
with polyhydramnios, multiple gestations, and by the
lithotomy position. In addition, fundal pressure at delivery
either vaginally or by caesarean section increases the
intragastric pressure. Hence, all obstetric patients are at
increased risk of pulmonary aspiration and should receive
aspiration pharmacoprophylaxis and mechanoprophylaxis
before any manipulation of the airway. Pharmacoprophylaxis
would include preoperative administration of nonparticulate
antacid such as 0.3 M sodium citrate, 30 millilitres. This
has a duration of action of 40 to 60 minutes. Thus, problems
of aspiration may occur however during emergence from
anaesthesia, when the effect of sodium citrate is much less
predictable. Intravenous administration of histamine
receptor (H2) blocking agent 40 minutes before airway
managements, are useful adjuncts. Ranitidine is preferred
than cimetidine because the latter may cause haemodynamic
instability when given parenterally and has been associated
with changes in liver function. In an event of an extreme
emergency, it is still useful to administer intravenous
ranitidine at induction because it would be effective by
the time the mother emerges from anaesthesia, when
sodium citrate is unreliable. Omeprazole, an proton pump
inhibitor and antisecretory agent require 40 minutes to reduce
gastric acidity.22-24 Administration of metoclopramide
decreases gastric volume as a prokinetic agent within
30-60 minutes. It crosses the placenta but has not been
shown to have any lasting adverse neurobehavioural effects
on the newborn.23 It should be noted that none of these
combinations are fully effective, particularly after large
meal had recently been eaten.
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
The use of a nasogastric or orogastric tube prior to
induction of anaesthesia, to enable physical emptying of the
stomach has been suggested, particularly a parturient has
had opiates in labour and is therefore most likely to have
a full stomach. Physical removal of gastric contents would
reduce the volume by a greater degree than pharmacological
methods, but the remaining volume may still make the
pregnant woman vulnerable to aspiration. In a parturient at
high risk of aspiration, it may be more practical to insert
a nasogastric or orogastric tube after induction of anaesthesia,
once the airway is secured. As the risk of aspiration continues
into the recovery period, this may be a logical approach
and one that is more acceptable to the mother.
During the induction of anaesthesia, cricoid pressure
is applied which supplies the necessary barrier to
regurgitation of gastric contents during the induction of
anaesthesia and prevents inflation of the stomach during
positive pressure ventilation.25 The cricoid cartilage is the
only tracheal cartilage with a ring structure. The thumb
and middle finger are placed on either side of the cricoid
to prevent lateral movement of the cartilagenous ring which
could make intubation difficult. The backward pressure
compress the oesophagus on the vertebral column and
causes it to be occluded, while the airway remains patent
because the cricoid is a complete ring of cartilage. If
active vomiting occurs, cricoid pressure should be
abandoned to prevent rupture of oesophagus. The present
recommendation is to use a constant backward force of 30
Newtons to the cricoid (equivalent to a force of 3 kg on a
weighing scale). However, recent debate has centred
around 20 Newtons would be an adequate force to occlude
the oesopagus with less distortion of airway than a greater
force.26
It has been well established that total body water
significantly increases in pregnancy, that also has important
effect in respect of airway. Increase in the body water is
due to the effect of increased progesterone levels.21 An
increase in the total body water leads to mucosal oedema
of the larynx, nasopharynx, and vocal cords. This
engorgement may be further worsened by pregnancy-induced
hypertension or strenuous labour, and concurrent respiratory
tract infection.11,19,27 Moreover, the patients who are
receiving oxytocin may be more prone to fluid overload due
to its antidiuretic side effect. This results in decreased
space (partial obstruction) and increased risk of bleeding
with standard airway management techniques.28 Therefore,
it is recommended for them to have smaller sized
endotracheal tube and vasoconstrictor agents with minimal
effect on uteroplacental blood flow. Enlargement of tongue
may make it difficult to retract onto the mandibular space
during direct laryngoscopy.
RUDRA : AIRWAY MANAGEMENT IN OBSTETRICS
The weight gain that accompanies pregnancy is
frequently 20 kg or more. Obesity has been reported to
further increase the risk of anaesthetic complications in
parturients.5,6 A high body mass index (BMI) has been
associated with an increased risk of airway management
problems including difficult intubation.21,29 [BMI is the
bodyweight in kilograms over height in metres squared.
The normal BMI is 20-25; a BMI of 25-30 is overweight,
a BMI of 30-40 is obese, and a BMI more than 40 is
morbidly obese. In other words, an overweight patient
weighs less than 20% more than the predicted IBW, obese
patient weighs more than of IBW, and morbidly obese
patient weighs more than twice of IBW (IBW = Ideal Body
Weight)].29 The breast enlargement that accompanies
pregnancy is more pronounced in the presence of excessive
weight gain. Intubation of this patient with enlarged breasts
is facilitated by the use of a short handled lanyrgoscope
and breast retraction during laryngoscopy. Proper positioning
of the patient facilitates intubation attempts and increases
the likelihood of success. Regional anaesthesia may also be
more difficult to perform, and extra long needles (spinal or
epidural) should be available. Associated changes in
respiratory parameters in addition to the changes due to
pregnancy include, reduction or decrease in functional
residual capacity (FRC), vital capacity (VC), total lung
capacity (TLC), and chest wall compliance. Moreover, there
would be increase in the work of breathing as the abdominal
contents press against the diaphragm and make respiratory
excursion of the diaphragm difficult.28 Furthermore, morbidly
obese patients have a higher incidence of other complicating
medical conditions such as diabetes mellitus, chronic
hypertension, and pregnancy induced hypertension.
Morbid obesity has been implicated as a contributing
factor in up to 80% of anaesthesia related maternal deaths.
Therefore, evaluation of the airway is most important.
Measurement of oxygen saturation in the sitting and supine
positions provides an early way to assess the degree of
airway closure and the potential for deterioration with
further decrease in functional residual capacity. If general
anaesthesia is “inevitable” and a difficult airway is
anticipated, proper positioning of the patient with elevated
shoulders by folded towels below the occiput and place the
head in sniffing position so that, the enlarged breasts could
be fallen from the neck and chin. These manoeuvres would
open up the area that is often lost in rolls of fat, allowing
easy insertion of the laryngoscope blade.28 In these patients,
some of the airway “gadgets” and alternative methods of
securing the airway become important.29,30
Management options and plans
Although the use of general anaesthesia has been
declining in obstetric patients, it may still be required in
331
selected cases. Difficult endotracheal intubation can be
expected due to the anatomic and physiologic changes
associated with pregnancy. As 50% of difficult intubations
in obstetric practice occur unexpectedly, protocols dealing
with the management of difficult airway should be at
anaesthesia locations.31 Moreover, it is essential for the
anaesthesiologists to perform a proper pre-anaesthetic
evaluation and identify the factors predictive of difficult
intubation.
The recognized difficult airway
Early recognition and Planning
The key to proper management of any airway is
anticipation of difficulty, adequate preparation (patient
and equipment), and a detailed plan of action should
problems arise. Management of the obstetric patient must
also take into account the condition of the foetus and the
urgency of the operative procedure. A difficult airway
may be either recognized or unrecognized before
intubation, and airway management varies accordingly.
There is strong agreement among experts in airway
management that specific strategies lead to improved
outcome.
All patients in the obstetric unit should have
assessments of their airway. Because preparation is important
to avoid disaster associated with airway problems, a careful
assessment of the parturient airway is necessary, particularly
for those at risk for operative delivery. Their evaluation
should include a record of prior surgeries and anaesthesia.
The interview allows the initial establishment of rapport
between the anaesthesia providers and the patient during
the time of invasive procedures, such as awake intubation.
Certain anatomical features indicate that endotracheal
intubation via conventional means is very likely to be
difficult, if not impossible. Very large breasts and heavy
chest wall, large tongue, no teeth and shrunken cheeks,
fixed head or neck flexion, massive jaw may also render
mask ventilation difficult or impossible. Any doubt regarding
the ability to maintain airway patency would lead to the
consideration of alternative methods of anaesthesia. Options
include the use of regional anaesthesia, awake intubation
followed by general anaesthesia, or local infiltration
anaesthesia.
Regional anaesthesia
Aspiration pharmacoprophylaxis minimizes the
potential for aspiration. Regional anaesthesia is a
controversial solution in the presence of a recognized
potentially difficult airway. Still, spinal or epidural
anaesthesia is acceptable if there is no contraindication.
332 PG ISSUE : AIRWAY MANAGEMENT
However, the anaesthesiologist should anticipate the
possibility of failed anaesthesia, development of seizures,
high block or total spinal anaesthesia resulting in respiratory
arrest. Therefore, the anaesthesiologist should be fully
prepared (both mentally and technically) to administer
general anaesthesia.6,21
Epidural anaesthesia provide the advantage of
slow titration of the level of anaesthesia (graded epidural),
which could avoid major haemodynamic shifts or
respiratory compromise. However, disadvantage of epidural
anaesthesia include inadvertent intravascular injection,
injection of local anaesthetic into an unintended space
(subarachnoid space), compared with spinal anaesthesia.
Awake intubation followed by general anaesthesia
A very safe option to secure the airway with an
endotracheal tube while the patient remains awake.2,3,6,20
The reasons for awake intubation in a patient with recognized
difficult airway are : (a) the natural airway is better
maintained, (b) the presence of normal muscle tone helps
to maintain the natural separation of the upper airway
structures, which facilitate identification of anatomical
landmarks and (c) induction of general anaesthesia and
muscle paralysis result in anterior movement of larynx,
which impede visualization of the larynx during
laryngoscopy.32
Because of foetal concerns, the use of routine sedation
is not recommended in the parturient. An anticholinergic,
such as glycopyrrolate that does not cross the placenta
easily due to quaternary in nature is a useful adjunct to
decrease secretion and allows better application of local
anaesthetic spray to airway mucosa, improves visualization,
and inhibits vagal reflexes.21 Supplemental oxygen via nasal
prongs should be provided during the procedure. Minimal
monitoring should include the use of an automated blood
pressure cuff, pulse oxymeter, and an ECG.
If the nasal route is chosen, the nasal mucosa should
be sprayed with a vasoconstrictor. An awake look may be
undertaken with topical spray applied to the oropharynx
or a glossopharyngeal nerve block, or both, in order to
facilitate tolerance of the laryngoscope in the oropharynx.
The glossopharyngeal nerve provides innervation to the
posterior third of the tongue, vallecula, anterior surface of
the epiglottis, posterior and lateral walls of the pharynx,
and tonsiller pillars. Blocking this nerve, especially if this
is combined with topicalization of the oral cavity, may
allow the patient to tolerate attempts at awake visualization
of the oropharynx.32-36 Before intubation, topicalization of
vocal cords should be performed. Laryngeal reflexes should
be maintained by avoiding injections of lignocaine into the
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
trachea, as obstetric patients are prone for aspiration of
stomach contents.
The choice of technique regarding tracheal intubation
depends on several factors, including skill, experience of
the laryngoscopist and the urgency of caesarean section.
Awake intubation is usually accomplished by the use of a
flexible fibreoptic bronchoscope. Otherwise, it may also be
performed with the aid of intubating laryngeal mask
airway, a light wand, or a rigid fibreoptic laryngoscope
(Bullard, Upsher, Wu).
Local infiltration for caesarean delivery
If a patient with a difficult airway requires urgent
caesarean delivery, local infiltration and field block could
be provided. Moreover, it should be considered as last
resort when spinal/epidural/general techniques of anaesthesia
are not viable or have failed.37,38 However, this technique
may not be the most pleasant option for either the obstetrician
or the patient. Local anaesthetic infiltration is a technique
rarely used today for caesarean delivery.
General anaesthesia
When general anaesthesia is to be used in obstetric,
the method of airway management would depend on the
urgency of the procedure and the anticipated ease of difficulty
of intubation and ventilation. Before the administration of
general anaesthetic, all patients should be thoroughly
evaluated, receive aspiration pharmacoprophylaxis and
cricoid pressure, and be positioned in the optimal position
for intubation. All equipments for routine and emergency
airway management should be immediately available.
If tracheal intubation is unsuccessful with initial
attempt, the anaesthesiologist must make a judgement
whether to attempt a second laryngoscopy directly, or attempt
mask ventilation. An immediate second laryngoscopy is
acceptable if oxygen desaturation has not occurred. The
second laryngoscopy may be successful by molar approach.39
The laryngoscope is inserted directly down the left side of
the mouth to access the larynx. Improved view of the larynx
could be achieved because the tongue does not need to be
compressed. The technique should be practised on an
intubation dummy and on elective cases before being used
in the obstetric situation. At whatever time intubation is
successful, the caesarean section may proceed. If intubation
is not successful after second laryngoscopy, oxygenation is
most likely to be successful by two handed jaw thrust and
bag ventilation by a third party. This manoeuvre may open
the airway and allow adequate oxygenation bypassing three
primary areas of airway obstruction (tongue, epiglottis, and
soft palate). It is important to ensure that the jaw thrust is
applied to the posterior border of the ramus of the mandible
RUDRA : AIRWAY MANAGEMENT IN OBSTETRICS
with the thrust being applied towards the ceiling. With
adequate jaw thrust and a proper mask seal, oxygenation
should be possible in most of the cases, but cricoid pressure
may need to be removed or adjusted to improve the airway.
The unrecognized difficult intubation
Emergency airway management in the unprepared
and unfamiliar patient is often challenging. Occasionally,
in spite of careful assessment of the airway, general
anaesthesia may be induced and then endotracheal intubation
of the parturient may prove to be impossible. Although,
many predictions of a difficult laryngoscopic intubation
have been developed, they all have low positive predictive
values, and thus the unanticipated difficult laryngoscopic
intubation would continue to occur in our day to day practice
for the foreseeable future. However, it cannot be
overemphasized that a plan of action should be detailed
before hand and followed once the situation occurs and
supplies should be immediately available to implement that
plan to mitigate the associated morbidity and mortality.6,21
Once it has been determined that it is not possible to
visualize the larynx, maternal oxygenation must be
accomplished with gentle mask ventilation while maintaining
cricoid pressure. If ventilation is unsuccessful, correct
positioning of the head, remove misapplied cricoid pressure,
and request for more experienced or different anaesthesia
practitioner.2,3,6,20 The key is to not keep trying the same
thing over and over and to not panic. Multiple laryngoscopies
lead to a catecholamine response that may reduce uterine
blood flow in the foetus who may already be subjected to
maternal hypoxaemia. Moreover, continued laryngoscopy
may also increase the likelihood of aspiration. Numerous,
repeated attempts at laryngoscopies should not be done to
avoid pharyngeal trauma which would make ventilation
progressively more difficult if not impossible.40
Mask ventilation
Failure to intubate the obstetric patient is often
followed by difficulty with mask ventilation and possible by
pulmonary aspiration. Either of these conditions rapidly
leads to hypoxaemia for both the mother and the foetus.
The adequacy of mask ventilation and the presence or
absence of foetal distress are extremely important factors
that must be taken into account in these situations.
The patient who cannot be intubated but can be
adequately ventilated by mask with no foetal distress
When the anaesthesiologist is unable to intubate the
trachea of an anaesthetized patient, it is essential to try to
maintain gas exchange by mask ventilation. During
positive pressure mask ventilation, maintenance of cricoid
pressure is mandatory until the patient is fully able to
333
protect her airway. After awakening the patient, option
include awake intubation, regional anaesthesia, and local
infiltration anaesthesia. Continuation of general anaesthesia
without significant foetal distress by face mask would be
dangerous in obstetric patient as they are very much prone
to aspirate gastric contents.
The patient who cannot be intubated but who can be
adequately ventilated by mask with foetal distress
This is a situation where welfare of both the mother
and child depend. Therefore, a delicate balance should be
achieved to manage the situation. The initial step is to
evaluate the adequacy of mask ventilation. Ventilation and
oxygenation should be easy to maintain, rather than marginal,
or tenuous upon which the following options depend.
The first option, awake the patient.2,21 This difficult
decision would probably preserve the life of the mother, but
it may result in the demise of the foetus.
The second option is to continue anaesthesia via
mask ventilation, while an assistant maintains cricoid
pressure. When the lungs can be ventilated easily with a
face mask after a failed intubation, it is better to use either
a laryngeal mask airway (LMA) or an oesophageal tracheal
combitube (ETC) in order to rescue airway.41,42 However,
the laryngeal mask airway (LMA) offers little advantage.
The LMA may promote gastric regurgitation and may
prevent escape of regurgitated stomach contents from the
pharynx which “provokes” pulmonary aspiration. Application
of cricoid pressure should be maintained unless it interferes
with the maintenance of a clear airway. The proseal LMA
(PLMA) may provide better protection against aspiration
than LMA. Surgery can start when the patient is well
anaesthetized using a volatile agent in 100% oxygen.
Traditionally, halothane has been the agent of choice in this
situation, however sevoflurane could be used due to its
advantages over halothane. Sevoflurane is probably a more
logical agent to use because of the ease of induction without
breath holding and coughing, if available. It has similar
properties of halothane in the spontaneously breathing
patient, depth of anaesthesia is easier to control because of
its low blood gas solubility and it is less cardio depressant.
Fundal pressure and uterine exteriorization should be avoided
to prevent regurgitation of stomach contents.
Failed intubation drill
Following induction of anaesthesia, if the
anaesthesiologist fails to intubate the trachea, then a failed
intubation drill should be initiated. There exist a multiplicity
of failed intubation drills, some more complicated than
others, but the essential requirement of all of them is to
maintain oxygenation. If necessary, cricoid pressure
334 PG ISSUE : AIRWAY MANAGEMENT
should be altered or released, since oxygenation takes
precedence over protection from aspiration. Oxygenation is
most likely to be successful by a two handed jaw thrust
and bag ventilation by a third party. Sometimes, cricoid
pressure may need to be removed or adjusted to improve
the airway. A simple failed intubation drill is illustrated
below.
In the original failed intubation drill proposed by
Tunstall,43 the recommendation included, turning the patient
to their side, passing an orogastric tube to empty the
stomach, and providing inhalational anaesthesia by mask.
Inadequate mask ventilation
The last resort is to perform a tracheostomy or
cricothyrotomy before the ability to ventilate with the mask
is lost. Transtracheal jet ventilation via a catheter placed
through the cricothyroid membrane is probably the fastest
route to oxygenation in a patient who is desaturating. When
performing jet ventilation, it is extremely important to
ensure adequate exhalation in order to prevent excessive
barotrauma.
Extubation
If the patient was difficult to intubate, extreme
care should be taken at extubation. Extubation to be done
in sitting upright position which allow free excursion
of diaphragm and decrease the risk of reflux.26 After full
recovery, patient should be informed and counselled
regarding problems encountered and its relevance to
further anaesthetics. Clear description regarding the
problem and subsequent management should be kept in
the hospital notes.
INDIAN JOURNAL OF ANAESTHESIA, AUGUST 2005
Fig. : Algorithm for failed intubation in obstetric patient17
Summary
Failed tracheal intubation in obstetric anaesthesia is
every anaesthesiologist’s nightmare. Because of the physiologic
and anatomic changes associated with pregnancy, the difficult
airway must be anticipated. The true incidence of difficult
intubation and ventilation is difficult to estimate.44 There is
no universal method to predict the problem, nor the
technology to overcome it. Airway catastrophies are leading
contributory factor to anaesthesia related maternal morbidity
and mortality.45 Patients die from hypoxia and acid aspiration,
if the failed intubation is unrecognized or the corrective
measures are inadequate. Careful and timely evaluation of
all parturient should identify the majority of parturients
with difficult airway. However, management of the patient
with a difficult airway is a crisis situation that anaesthesiologists
must be most able to handle successfully.46 Thus, the
problem could only be managed successfully by increasing
knowledge and awareness. Each anaesthesiologist must
develop a plan, consistent with his or her expertise, to deal
with the unexpected difficult airway. Anaesthesiologists
should familiarize themselves with various airway devices/
gadgets in the event of a difficult airway. Caesarean section
should wait until the patient is stabilized.
RUDRA : AIRWAY MANAGEMENT IN OBSTETRICS
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CORRIGENDUM
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missing. Error is regretted.
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