| Abstract: |
A thorough knowledge of airway-related physiology and anatomy is vital for the acute-care clinician. Physiologic considerations dictate the need for preoxygenation and suggest when the patient will be less likely to tolerate difficulty, if encountered, with airway management. Familiarity with airway anatomy is vital for successful direct laryngoscopy, where landmark recognition is instrumental in leading the clinician to the laryngeal inlet. Equally, to be successful with the use of alternative intubation devices, the clinician must maintain a “mental image” of the airway anatomy through which they pass.Most intubations in emergencies are performed using direct laryngoscopy (DL) which retains the advantage of direct visualization of the laryngeal inlet, with immediate confirmation of tube passage through the cords in many cases, and the ability to evaluate the oropharynx for foreign material in the same setting. DL is a core skill to the acute-care clinician. Done properly, with a knowledgeable appreciation of the anatomy, it will be successful most of the time. However, as with BMV, having a good approach to difficult laryngoscopy, predicted or not, is also needed.Even though its utility may be limited in the emergency setting, an airway exam looking for predictors of difficult laryngoscopic intubation is still warranted to help determine the best approach to the intubation, and to anticipate the need for help and preparation of additional equipment.Many alternative intubation devices are available. They differ in their degree of history, published evidence of their effectiveness, cost, and whether they are blind techniques or allow indirect vision. Most are probably similar in their learning curve and success rates in difficult situations. Unfortunately, many clinical trials of these devices have been performed in comparison to conventional DL, leaving unanswered the question of how they compare to best look DL (i.e., using head lift, ELM, and adjuncts such as the bougie). However, case reports, case series, and studies of patients with actual difficult airways do suggest their utility in difficult situations (although often, in the hands of expert users). Certainly, moving on to an alternative intubation device after a best look laryngoscopy has failed is preferable to multiple futile attempts at direct laryngoscopic intubation. Which alternative intubation device or devices the clinician chooses to become familiar with will depend on individual or institutional preference. However, no matter which device, the clinician must make the effort to gain experience by using it in lower-acuity or routine situations until competence and confidence in its use are attained.With application of a consistent approach to difficult bag-mask ventilation and difficult laryngoscopy, failed intubation or failed oxygenation scenarios will be only infrequently encountered. However, when the need arises, extraglottic device use has transformed the airway management landscape away from the old “can’t intubate — cut the neck” directive. That being said, every clinician with a practice mandate that includes airway management should be familiar with indications for, and knowledge of how to rapidly perform a cricothyrotomy.
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