Difficult Airway Management

By: Bereket Habtamu

Advisor: Leulayehu Akalu

April 24/2014
• Acknowledgement
• Objective
• Introduction
–Airway Anatomy
–Comparative Anatomy of pediatric vs. Adult Airway
• Definition of difficult airway
• Prevalence
• Causes of difficult airway
• Airway Assessment
–History
–Physical examination
• Predictive tests of difficult airway
–Investigation
• Management approach to difficult airway
–Basic preparation for difficult airway management
–Strategies For Intubation of Anticipated difficult airway
–Un anticipated Difficult Airway
–Difficult intubation with difficult mask ventilation
–ASA Algorithm of difficult airway
–Cant intubate…cant ventilate and
• Emergency cricothyrodotomy
»Cannula/needle cricothyrodotomy
»Surgical cricothyroidotomy
–Awake fibroptic intubation technique
–Rapid Sequence Induction
• Extubation after difficult intubation
• Follow up care
• Summery
• References
• 
 OBJECTIVE
• To inculcate the importance of difficult
airway management and there by to
bring changes in clinical practice and
patient safety
 INTRODUCTION
. The primary focus of this paper is the management
of the difficult airway encountered during
administration of anesthesia and tracheal
intubation. It is also used to facilitate the
management of the difficult airway and to reduce
the likelihood of adverse outcomes. The principal
adverse outcomes associated with the difficult
airway include (but are not limited to) death, brain
injury, cardiopulmonary arrest, unnecessary surgical
airway, airway trauma, and damage to the teeth
 Cont. ….
• Literature report that greater than 30% of
anesthesia related morbidity and mortality is
due to inadequate airway management.
Generally this paper will help us to``
vigorously evaluate and manage the air way
peri-operatively, so that we can bring changes
in airway management and patient safety.
Anatomy of Airway
Anatomy /cont. …
Comparative Anatomy of Pediatric VS Adult
airway
Knowing the differences between the airway of a
child and that of an adult is essential for
anesthetists in order for them to safely administer
anesthesia.
• A child’s nostrils, oropharynx and trachea are
relatively narrow;
• The trachea is short;-4cm from the larynx to the
carina and has a narrow diameter of 6 mm.
• The tongue is relatively large and tends to fall
backwards under anesthesia.
 Cont. …
• The salivary secretions of children are more
pronounced than those of adults.
• The larynx of a child is more ventrally located.
Until the age of 8 to 10 years, the most narrow
point is larynx cartilage and not, as is the case
with adults, with the glottis.
• The epiglottis is relatively large and shaped like
a U.
• The size of the tonsils and the adenoid in
children can complicate the intubation process.
 DEFFINITION OF DIFFICULT AIR WAY

American society of Anesthesiologist (ASA)

suggested that when sign of inadequate
ventilation could not be reversed by mask
ventilation or oxygen saturation could not be
maintained above 90% or
if a trained Anesthetist using conventional
laryngoscope take’s more than 3 attempts or
more than 10 minute are required to complete
tracheal intubation
 Definition Cont’d. ...

The difficult airway represents a complex

interaction between patient factors, the clinical
setting, and the skills of the practitioner.
Clinicians and investigators use explicit
descriptions of the difficult airway.
Suggested descriptions include (but are
not limited to):
 Cont’d...
1.Difficult face mask ventilation: - It is
not possible for the anesthesiologist to provide adequate
face mask ventilation due to one or more of the following
problems: inadequate mask seal, excessive gas leak, or
excessive resistance to the ingress or egress of gas.
- Signs of inadequate face mask ventilation include
(but are not limited to) absent or inadequate chest
movement, absent or inadequate breath sounds,
auscultatory signs of severe obstruction, cyanosis, gastric
air entry or dilatation, decreasing or inadequate oxygen
saturation (SpO2), absent or inadequate exhaled carbon
dioxide,
 Cont’d …
absent or inadequate spirometric measures of
exhaled gas flow, and hemodynamic changes
associated with hypoxemia or hypercarbia (e.g.,
hypertension, tachycardia, arrhythmia).
2. Difficulté SGA placement: SGA placement requiers
multiple attempts, in the presence or absence of
tracheal pathology.
3. Difficult laryngoscopy:
It is not possible to visualize any portion of the
vocal cords after multiple attempts at conventional
laryngoscopy.
 Cont’d….
3. Difficult tracheal intubation:
Tracheal intubation requires multiple attempts,
in the presence or absence of tracheal pathology.
Or Tracheal intubation requires more than three
attempts or greater than 10 minutes.
4. Failed intubation:
Placement of the endotracheal tube fails after
multiple intubation attempts.

5. Difficult Tracheostomy :
 PREVALENCE/1-4%/
Fact of the matter is even with proper evaluation only
15 to 50 % were picked up while difficult face mask
ventilation in general is about 1:10,000 out of which
again 15% proved to be the difficult intubation,
while incidence of extreme difficult or abandons
intubation in general surgery patients are 1:2000
but in obstetrics is 1:300 and of course most critical
incidence is Hypoxia
 CAUSES OF DIFFICULT AIRWAY CAUSES
OF DIFFICULT INTUBATION
Causes of difficult airway can be seen in three dimensions;
Anesthetist, equipment and patient factors.
1. Anesthetist:
Inadequate preoperative assessment
Inadequate equipment preparation
Inexperienced or poor technique
2. Equipment:
Malfunctions
Unavailability
No trained assistance
 CONTINUES…………..
3. Patient:
a. Congenital ; Syndromes /Downs, Pierre Robbins, Martans, Anchondroplegia/
b. Acquired; Reduced Jaw movement Reduced neck movement
Truisms Rheumatoid arthritis
Fibroses Ankylosing spondylitis
Rheumatoid arthritis Cervical fracture
Tumors Compression/goiter, surgical
Ankylosing Spondylitis hemorrhage/ Tumors
Jaw wiring Edema/abscess
Morbid obesity
Pregnancy
Acromegally
Steroid therapy
Diabetes
Pediatrics
 Anatomical factors associated with Difficult
Laryngoscopy;
• Short muscular neck
• Protruding incisors
• Long, high arched palate
• Receding lower jaw
• Poor mobility of the jaw
• Increased anterior depth of the mandible/decreased
jaw opening, requires x-ray/
• Decreased atlanto-occipital distance/decreased
neck extension, requires x-ray/
 Causes of difficult/failed mask ventilation
Laryngospasm Body Mass Index > 26 Kg/m2
Laryngeal pathology History of snoring

Lower airway pathology Absence of teeth

Inadequate mask seal Beards

Excessive gas leak Facial abnormality

Age greater than 55 yrs. Obstructive sleep apnea

 AIRWAY ASSESSMENT
• Basic airway assessment requires three components: History,
Physical examination and
Investigations
1. History;
2. Physical Examination;
3. Investigations’
1.History;
-Congenital airway difficulties e.g. pierre Robin,
klippel-Feil, Downs Syndromes.
-Acquired airway difficulties e.g. rheumatoid arthritis, ankylosing
spodylitis, pregnancy, diabetes.
-Iatrogenic e.g. TMJ surgery, cervical fusion, oral/pharyngeal
radiotherapy, laryngeal/tracheal surgery
-Reported previous anesthetic e.g. sore throat. Check anesthetic notes.
2. Physical Examination :
 Should be conducted, whenever feasible, prior to the
initiation of anesthetic care and airway management in all
patients.
 Detect physical characteristics that may indicate the
presence of a difficult airway.
3. Investigations :
Indicated to characterize the likelihood or nature of the
anticipated airway difficulty. The findings of the airway
history and physical examination may be useful in guiding
the selection of specific diagnostic tests /like X-ray, MRI and
CT Scan/ and consultation.
 Components of the Preoperative Airway
Physical Examination
Airway Examination Component Nonreassuring Findings
1. Length of upper incisors Relatively long
2. Relation of maxillary and Prominent “overbite”
mandibular incisors during (maxillary incisors normal
jaw closure anterior to mandibular
incisors
3. Relation of maxillary and Patient mandibular
mandibularincisors during incisors anterior to
voluntary protrusion (in mandible front of)
maxillary incisors
 Cont’d. …
4. Interincisor distance Less than 3 cm
5.Visibility of uvula Not visible when tongue
is protruded with patient in
sitting position (e.g., Mallampati class
greater than II)
6. Shape of palate Highly arched or very
narrow
7. Compliance of Stiff, indurated, occupied
mandibular space by mass, or nonresilient
 Cont’d. …
8. Thyromental distance Less than three ordinary
finger breadths
9. Length of neck Short
10. Thickness of neck Thick
11. Range of motion of Patient cannot touch tip of head
and neck chin to chest or cannot
extend neck
 Predictive tests of difficult airway

Inter incisor gap/II gap/;

• The distance between the incisors with the
mouth opens maximally.
• Affected by temporo-mandibular joint and upper
cervical spine mobility
• <3cm makes intubation difficulty more likely.
• <2.5cm makes LMA insertion difficult.
• <2cm makes LMA insertion impossible.
 Patient protrusion of the mandible;

• Class A…-able to protrude the lower mandible

anterior to the upper incisors
• Class B…-lower incisor can just reach the
margin of upper incisor
• Class C…-lower incisor cannot protrude to the
upper incisor
• N.B. classes B and C are associated with
difficult laryngoscopy
 Mallampati test/with samsoon and young’s modification/;
Examine patient’s oropharynx while the patient opens their mouth
maximally and protrude their tongue without phonating /a/.

 Class 1---faucial pillars, soft palate, and uvula visible

 Class 2---faucial pillars, and soft palate visible but tip of uvula
masked by base of tongue
 Class 3---only soft palate visible
 Class 4---soft palate not visible
N.B. Class 3 and Class 4 are associated with risk of laryngoscopy.
This test is prone to inter observer variation.
Predicts about 50% of difficult laryngoscopies.
Cont’d…
 Cormack Lehane’s Grading

• Grade I – most of the glottis is seen no difficulty

• Grade II – only the posterior part of glottis is visible
pressure on the laynx may improve the view slight
difficulty
• Grade III – the epiglottis is visible but none of the
glottis can be seen. abougie may be used there may be
severe difficulty
• Grade IV – not even the epiglottis is visible the
situation usually arises with obvious pathology
intubation may be impossible with out special
techniques
Cont’d…
 Thyromental distance/patil test/
The distance from tip of thyroid cartilage to the
tip of mandible neck fully extended;
• Normal>7cm, <6cm predicts 75% of difficult
laryngoscopy
• Combined patil and mallampati /<7cm&>Class
3/increases specificity/>97%/
 Sternomental distance/savva test/;
The distance from the upper border of manubrium to
the tip of mandible, neck fully extended and mouth
closed.
• <12.5cm is associated with difficulty/positive
predictive is 82%/
Extension of upper cervical spine;
• When limited /<90 degree/ risk of difficult
laryngoscopy is increased.
• Movement is assessed by;
 Flexing the head on the neck, immobilizing the
lower cervical spine with one hand on the neck
then fully extending the head.
 Cont’d. …
• Placing a pointer on the vertex or forehead allows
the angle of movement to be estimated.
• Placing one finger on patients chin and one finger
on occipital protrudence and extending head
maximally.
• With normal cervical spine mobility the finger on
the chin is higher than the one on the occiput.
• Level finger shows moderate limitation.
• If the finger on chin is lower than one on the
occiput, indicates sever limitation.
 Wilson score;
 

• Has five factors –weight, upper cervical spine

mobility, jaw movement, receding mandible,
buck teeth, each scored from 0-2. /from normal
to abnormal/
• N.B A total score of >/= 2 predicts 75% of
difficult intubation; 12% false positive.
 
 MANAGEMENT APPROACH TO DIFFICULT
AIRWAY
BASIC PREPARATION FOR ANTICEPATED
DIFFICULT AIRWAY MANAGEMENT
1. Inform the patient.
2. Prepare at least one portable storage unit.
3. Senior help backup.
4. Definite initial plan (A) for ventilation and
intubation.
5. Discussion with colleagues in advance.
6. Definite plan (B) than option of awake intubation.
7. Ideal situation surgery team standby.
 Suggested Contents of the Portable Storage
Unit for Difficult Airway Management
1. Rigid laryngoscope blades of alternate design
and size from those routinely used; this may
include a rigid fiberoptic laryngoscope
2. Tracheal tubes of assorted sizes
3. Tracheal tube guides. Examples include (but are
not limited to semi rigid stylets, ventilating tube
changer, light wands, and forceps designed to
manipulate the distal portion of the tracheal tube
 Cont’d. …
4. Laryngeal mask airways of assorted sizes; this
may include the intubating laryngeal mask
airway and the LMA-Proseal.
5. Flexible fiberoptic intubation equipment
6. Retrograde intubation equipment
 Cont’d. …
7. At least one device suitable for emergency
noninvasive airway ventilation. Examples include
(but are not limited to) an esophageal tracheal
Combitube, a hollow jet ventilation stylet, and a
transtracheal jet ventilator.
8. Equipment suitable for emergency invasive airway
access (e.g., cricothyrotomy)
9. An exhaled CO2 detector
 Strategies for Intubation of
anticipated Difficult Airway
• Awake Intubation; awake fiberoptic intubation is
successful in 88–100% of difficult airway patients.
Complications; poor compliance/coughing, bleeding in
airway, excess secretion, laryngospasm, vomiting,
aspiration, airway obstruction, etc…
• Video-assisted Laryngoscopy; improved laryngeal
views, a higher frequency of successful intubations,
and a higher frequency of first attempt intubations
with video-assisted laryngoscopy than direct
laryngoscopy.
 Cont’d …
• Intubating Stylets or Tube-Changers; successful
intubation in 78–100% of difficult airway patients when
intubating stylets were used.
complications; include mild mucosal bleeding, sore throat,
lung laceration and gastric perforation.

• SGAs for Ventilation; use of the LMA can maintain

ventilation for adult difficult airway but
desaturation (SpO2 < 90%) frequencies of 0–6% occur
when the LMA is used for pediatric difficult airway
 Cont’d …
• ILMA; successful intubation in 71.4–100% of difficult
airway patients when an ILMA was used.
Complications; include sore throat, hoarseness, and
pharyngeal edema.

• Rigid Laryngoscopic Blades of Alternative Design

and Size; improve glottic visualization and facilitate
successful intubation for difficult airway patients
 continues…
• Fiberoptic-guided Intubation; successful in 87–
100% of difficult airway patients.
Comparing rigid fiberscopes with rigid direct
laryngoscopy report equivocal findings for
successful intubation and time to intubate.
• Lighted Stylets or Light Wands. successful
intubation in 96.8–100% of difficult airway patients
when lighted stylets or light wands were used.
Equivocal findings when comparing lighted stylets
with direct laryngoscopy.
 Cont’d. …
Confirmation of Tracheal Intubation.
• Capnography is the gold standard for
confirmation of tracheal intubation.
• it confirms tracheal intubation in 88.5–100% of
difficult airway patients.
Other methods include; .
- Esophageal detectors or self-inflating bulbs and
-Fiberoptic confirmation of tracheal intubation
-detecting breath sounds on axillary area
bilaterally by auscultation
- movement of breathing bag
 UNEXPECTED DIFFICULT AIRWAY
Despite careful assessment, approximately 50% of airway difficulties

arise unexpectedly. Problems;

1. Unexpected encounter with difficult airway is mostly gone worse

because mainly GA is already given including (NMB,S).
2. Equipment may not be in hand.
3. Senior and back up plan not available so delay occur in active
resuscitation.
TECHNIQUE OF MANAGEMENT
1. Manipulation of the patients airway./BURP/
2. Laryngeal pressure.
3. Nasal or oral airway.
4. Different blades of laryngoscope
5. Bougies and stylet
6. LMA. and
7. Combitube.
 Cont’d…
1 1
alt Manipulation of airway
er different blade, bugie, stylet
na
tiv 2
e LMA, ILMA, Combitube
2
alternative 3
Trantracheal Jet Ventilation

3
alternative 4
Cricothyroidotomy, Tracheostomy

4
alternative
 MANAGEMENT OF DIFFICULT INTUBATION
Management of intubation difficulties can be
considered as four step processes:-
A . Primary intubation attempt;-
-optimal anesthesia -optimal position
-optimal blade
-optimal laryngeal manipulation
-bougies or stylet
B. Secondary intubation attempt;-
-intubation with LMA,ILMA
-fiber optic intubation/rigid or flexible/
-light wands or
-retrograde intubation
 Cont’d…
C. Oxygenation/ventilation via face mask /but
includes use of supraglotic adjuncts
D. Invasive tracheal techniques;
- needle cricothyroidotomy
- cannula cricothyroidotomy
- surgical airways
In most cases senior help should be called
when plan A fails.
Plan D should be reserved for cannot ventilate
cannot intubate conditions with progressive
desaturation despite adequate oxygenation
attempt.
 Difficult intubation with
difficult/impossible mask ventilation
1
-An emergency life threatening if not well managed.
-Insertion of LMA can rescue the airway in greater than
90% of cases.
Where oxygenation is not possible, plan D is life saving
technique and all anesthetists should be equipped and
prepared to perform plan D when ever required.
N.B But in case of Rapid sequence Induction after two
attempts of intubation, proceed directly to plan C/omit
plan B/ and wake the patient up.
ASA DIFFICULT AIRWAY ALGORITHM
Cont’d ...
Cont’d…
 Can’t intubate …. Can’t ventilate/CICV
 It is always a life-threatening condition.
 It occurs in 1:5000 routine anesthetics.
 It is more common in;
Emergency anesthesia
Intubation in the emergency department
After multiple attempts at intubation and
Inexperienced anesthetists
Immediate management;
• Call for help
• Attempt oxygenation by airway.
• Emergency oxygen flush
• Two man ventilation…CPAP
 Cont’d…
• Rescue air way with insertion of LMA. Effective in
greater than 90% of cases
• If the patient is making spontaneous effort and
respiratory noise, maintain CPAP and 100%
oxygen until they awake.
• But if there is progressive desaturation with
above techniques consider emergency surgical air
way.
.
 
 Cont’d…
Subsequent management
Emergency cricothyroidotomy
Speed is essential to prevent hypoxic cardiac arrest or brain
damage.
Extend the neck and simultaneously apply slight traction
bilaterally to neck tissues.
Find cricothyroid membrane b/n thyroid cartilage and cricoid
cartilage/.
Options are surgical and needle/cannula cricothyroidotomy.
Cannulla of less than 2.0 mm ID require jet ventilation
Catheters of greater than 4.0 mm ID allows conventional
ventilation
 Special considerations;

• Avoid multiple intubation attempts by avoiding more

than two attempts for a single technique. So if one
technique has failed twice try something new!
• There is high risk of aspiration. So empty the
stomach.
• After prolonged obstruction anticipate possible post
obstructive pulmonary edema.
• Check that your theatre has a well-stocked difficult
intubation trolley always.
 AWAKE INTUBATION

Can be; Awake fiberoptic intubation

Blind tracheal intubation and
Intubation through supraglotic devices, etc…
• Awake Fiberoptic intubation;
successful in 88–100% of difficult airway patients.
Indications;- Anticipated difficult intubation,
laryngoscopy and/or mask ventilation
-Cervical spine instability or cord injury and
-To avoid hemodynamic instability during
intubation
 Preparation;

• Decongestant: phenylephrine 1% nasal spray orXylometazoline 0.1%

• Local anesthetics
• Drugs: Midazolam, fentanyl, propofol
Induction agents and NMBs
• Equipment’s: 6.0/6.5 mm ID nasal ETT
6/7 mm nasopharyngeal airways, nasal oxygen catheter
Safety pin, Fresstor spray, warm water in container
• Full clinical assessment of airway, assess nasal passages for patency and
history of epistaxis
• Explanation and consent co-operation
• Premedication
• IV access
• Nasal catheter
 Technique;

• Use mild sedation alfentyl/1-2mg/ and fentanyl/50-100

microgram/ or small doses Propofol/10-20mg/
• Verbal contact must be maintained at all times
• Determine most patent nostril and spray with 1ml 5% cocaine
solution
• Dilate nasal way by warmed 6mm then 7 mm nasopharyngeal
airway lubricated with cocaine or lidocaine and insert safety
pin to aid grip during manipulation of scope.
• Spray oropharynx with lidocaine 10% and use forrester spray
to topically anesthetize pharynx using lidocaine 2% as far as
possible
 Cont’d…
• Instill oxygen /2 litre/min/ via scope to oxygenate patient
• Clear secretions from tip and aid atomization of injected
local anesthetics.
• Pass lubricated fiberscope via nasopharyngeal airway and
having visualized vocal cords spray 1.5 ml 2% lidocaine onto
cords. Pass through cord and repeat for tracheal inlet.
• Load warmed, lubricated ETT onto scope and reinsert
through nasal airway to trachea.
• Remove the nasopharyngeal 7mm airway and advance ETT
over the scope
 Cont’d
• Turn ETT 90 degree anticlock wise to assist insertion
through cord.
• After visualizing correct placement remove scope
and advance ETT.
• Confirm with capnography, bag movement,
• Induce anesthesia, inflate cuff, and fix tube securely.
• Complication; coughing, bleeding in airway, excess
secretions, laryngospasm, vomiting, aspiration,
airway obstruction.
 RAPID SEQUENCE INDUCTION

Rapid IV induction and muscle relaxation to aid tracheal

intubation, combined with application of cricoid pressure to
reduce pulmonary aspiration.
Mask ventilation is relatively contraindicated before intubation.
If difficulty is anticipated consider a local/regional technique,
awake fiberoptic intubation.
Check;-anesthesia machine, vaporizers, breathing system,
ventilator, suction
-Two functioning laryngoscopes, cuffed ETT
-head in sniffing position
-Wide bore IV cannula
 Cont’d…
-anesthetic drugs and muscle relaxants
-emergency drugs
-plans for failed intubation and failed ventilation.
N.B Difficult intubation occurs 1in 20 cases and failed in 1
in 200.
Procedure;-
-switch on suction
-pre-oxygenation with 100% oxygen for 3 minutes or four
vital capacity breaths in extreme emergency.
-administer induction agent followed by suxamethonium.
 Cont’d…
• cricoid pressure is increased to 30N after loss of
consciousness.
• Attempt intubation as breathing stops.
• inflate cuff and check correct placement ETT then remove
cricoid pressure.
Problems with CP;
• correct application is a trained, practiced skill.
• the cricoid cartilage is held between the thumb and middle
finger and pressure is exerted by index finger posteriorly.
• some patients like distressed children tolerate CP after
induction.
 Cont’d…
Failed intubation;-
• In this event Gentle manual ventilation is part of failed intubation
protocol.
• If ventilation is difficult CP should be reduced or released and go to
CICV protocol.
• LMA is option of rescuing airway.
Pediatric consideration;
• Light CP pressure is required.
• Young children are unlikely to co-operate for pre-oxygenation and CP.
• RSI should be modified with gentle mask ventilation after induction,
before or during laryngoscopy.
• difficult laryngoscopy is much less common in children than adults.
 EXTUBATION AFTER DIFFICULT
INTUBATION
• Following difficult intubation the airway may
occlude when the tracheal tube is removed.
• Reintubation may more difficult due to;-
- Airway bruising and swelling
- Airway contamination with clot, pus or
regurgitated material
- Laryngospasm due to laryngeal or
recurrent laryngeal nerve injury
- New impairments/e.g. cervical fusion,
external fixators, dental wiring/.
 Cont’d…
The preformulated extubation strategy should include;-
• Prepare the same equipment and personnel as
difficult intubation.
• Have a plan and a backup plan.
• If an emergency surgical airway could still be
required consider;-
• delaying extubation and ventilating on
ICU.
• corticosteroid therapy to reduce edema
for 24 hours
• An elective tracheostomy
• Positioning hollow jet ventilation stylet
for apoenic oxygenation
 Cont’d…
• Before extubating;-
- Clear upper airway and trachea
- Ensure good haemostasis e.g. evacuation of
hematoma
- Empty stomach if required
- Ensure reversal of NMBs
- Remove any surgical packs
- Place patient in sitting position
- Pre-oxygenate, wake patient and extubate when
obeying commands
- Provide high oxygen after extubation and
- Monitoring closely in recovery room as needed.
 Summery of Techniques for Difficult
Airway Management
Techniques for Difficult Intubation;
- Awake intubation
- Blind intubation (oral or nasal)
- Fiberoptic intubation
- Intubating stylet or tube-changer
- Supraglottic airway as an intubating conduit
- Laryngoscope blades of varying design and size
- Light wand
- Videolaryngoscope
Techniques for Difficult Ventilation;

- Intratracheal jet stylet

- Invasive airway access
- Supraglottic airway
- Oral and nasopharyngeal airways
- Rigid ventilating bronchoscope
- Two-person mask ventilation
 Follow-up Care

Documenting the presence and nature of the airway

difficulty in the medical record.
The intent is to guide and facilitate the delivery of
future care. Aspects of
documentation that may prove helpful include (but
are not limited to);
• Description of the airway difficulties
• Description techniques used.
• The extent to which each of the techniques served
 Cont’d…
The anesthesiologist/anesthetist should inform the patient of
the airway difficulty that was encountered.
◦ The intent of this communication is to provide the
patient with a role in guiding and facilitating the delivery
of future care.
◦ It includes;- the presence of a difficult airway, - the
apparent reasons for difficulty, - how the intubation was
accomplished, and - the implications for future care.
◦ Notification systems;
written report to the patient,
written report in the chart,
communication with surgeon or,
a notification bracelet may be considered.