The Difficult Airway in Adult Critical Care

Gavin G. Lavery, MD, FCARSCI, MB, BCh, BAO; Brian V. McCloskey, MB, BCh, FRCA, FFARCSI, MRCP


Crit Care Med. 2008;36(7):2163-2173. 

In This Article

Intubation Under Anesthesia

Despite the safety advantage of awake intubation in these patients, anesthesia before attempted orotracheal intubation may be viewed as more appropriate. This strategy should only be used by those skilled and experienced in airway management. Preparation of the patient, equipment, and staff is paramount ( Table 2 ). Adjuncts (see subsequently) should be available, either to improve the chances of intubation or to provide a safe alternative airway if intubation cannot be achieved. The central principle is the induction of deep anesthesia, sufficient to allow direct laryngoscopy and tracheal intubation without the use of a muscle relaxant, with maintenance of spontaneous respiration. This involves an inhalational induction using a volatile agent (for example, sevoflurane) or the slow administration of an intravenous induction agent (for example, propofol) followed by an inhalational technique. The latter, although quicker, may cause apnea and (if manual ventilation cannot be achieved) a life-threatening situation.

Orotracheal intubation without neuromuscular blocking drugs may be facilitated by the use of lignocaine spray to the mucosa of the larynx and pharynx before intubation. Intubating conditions may not be as favorable as under the influence of neuromuscular block and, if passage of the tube into the trachea is not achieved relatively quickly, the patient (now breathing room air) will become less deeply anesthetized, making intubating conditions even more difficult. Kabrhel and colleagues[89] have recently published a detailed description of the procedure of orotracheal intubation using direct laryngoscopy.


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