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Toronto Notes 2019
Appendices
Anesthesia A31
Difficult Tracheal Intubation
Airway exam or history predicts difficult tracheal intubation
If general anesthesia is induced . . .
1. Is tracheal intubation predicted to success in no more than 3 attempts? 2. If tracheal intubation fails, will face mask or SGD ventilation succeed?
. . . and are other patient and contextual issues favourable?
1. Rapid oxygen desaturation unlikely with onset of apnea? 2. Little risk of aspiration once unconcsious?
3. No obstructing airway pathology?
4. Additional skilled help available?
5. Clinician skilled in planned technique(s) and equipment available?
Is local or regional anesthesia feasbile for surgical case?
NO
Low risk of failed oxygenation if induced
Consider intubation after induction of general anesthesia
• e.g. IV induction (e.g. RSI) • e.g. inhalational induction
YES NO
Significant risk of failed oxygenation if induced
Is awake intubation feasible?
• Patient can cooperate • Situation acuity permits
Figure 18. Anticipated difficult tracheal intubation
Consider awake intubation/tehniques
• e.g. awake oral/nasal
• e.g. awake tracheotomy
YES NO
Other options
IV = intravenous; RSI = rapid sequence induction/intubation; SGD = supraglottic device
Reprinted with permission: Law JA, et al. The difficult airway with recommendations for management – Part 2 – The anticipated difficult airway. Can J Anesth 2013;60:1119-1138.
• e.g. induction with “double set-up” preparation for immediate cricothyrotomy or tracheotomy