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Tracheal Intubation Awake Or Under Anesthesia for Potential Difficult Airway: Look Before You Leap Fu-Shan Xue Capital Medical University

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Tracheal Intubation Awake Or Under Anesthesia for Potential Difficult Airway: Look Before You Leap Fu-Shan Xue Capital Medical University Washington University School of Medicine Digital Commons@Becker Open Access Publications 2018 Tracheal intubation awake or under anesthesia for potential difficult airway: Look before you leap Fu-Shan Xue Capital Medical University Qian-Jin Liu Washington University School of Medicine in St. Louis Follow this and additional works at: https://digitalcommons.wustl.edu/open_access_pubs Recommended Citation Xue, Fu-Shan and Liu, Qian-Jin, ,"Tracheal intubation awake or under anesthesia for potential difficult airway: Look before you leap." Chinese Medical Journal.131,6. (2018). https://digitalcommons.wustl.edu/open_access_pubs/6692 This Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in Open Access Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact [email protected]. [Downloaded free from http://www.cmj.org on Monday, April 2, 2018, IP: 128.252.174.220] Comments Tracheal Intubation Awake or Under Anesthesia for Potential Difficult Airway: Look Before You Leap Fu‑Shan Xue1, Qian‑Jin Liu2 1Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China 2Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA Securing a patent airway remains a pivotal point in clinical and third most frequent causal and contributory factors anesthesia, while failure to establish airway in anesthetized (next to patient factors; 77%), respectively. Furthermore, patients can cause severe outcomes in a few minutes.[1] deficiencies in airway assessment, underutilization of awake According to the closed claims analysis conducted by the tracheal intubation, inappropriate use of supraglottic airway American Society of Anesthesiologists, a leading cause of devices, and evidence of poor airway management planning anesthesia‑related patient injury is the inability to intubate were also noted.[4] These findings indicate that current the trachea and secure the airway. As consequences, 85% strategies for airway management are not ideal and further of those are either death or brain damage.[2] In a review improvements are required. of litigation related to anesthesia in the National Health Awake tracheal intubation is often considered as one of the Service hospitals in the UK from 1995 to 2007, airway‑ and safest performants for patients with known or predicted respiratory‑related events account for 12% of all anesthesia difficult airways,[14] but the technique itself is a tremendous claims, 53% of deaths, and 27% of reparation, and are stimulating and uncomfortable procedure. Some patients involved in ten out of the fifty most expensive claims.[3] In even refuse awake tracheal intubation and thereafter abandon addition, about half of the incidents reported to the fourth surgical treatment because of anxiety and trepidation, National Audit Project of the Royal College of Anaesthetists especially for those who had this experience in the past. In and the Difficult Airway Society describe that airway addition, awake tracheal intubation is impossible to be carried complications are related to primary problems with tracheal out successfully in some cases, such as younger children and intubation, including failed intubation, delayed intubation, psychopathic patients with difficult airways due to their and “cannot intubate cannot oxygenate” situation.[4] These lack of cooperation.[15] For these cases, tracheal intubation facts have greatly facilitated the progress of clinical under general anesthesia becomes necessary. When the airway management and resulted in the development of tracheal intubation is performed under general anesthesia in new related strategies and techniques.[5] Furthermore, in patients with known or predicted difficult airways, the next numerous nations, practice guidelines have been developed thing that the anesthesiologists eager to know is whether to assist anesthesiologists for safe airway management in or not the facemask ventilation is difficult. If facemask perioperative period.[6‑12] Due to those tremendous efforts, ventilation is not difficult, the airway is manageable by using the incidence of serious complications related to airway the facemask ventilation even if the larynx proves difficult management has been significantly decreased.[1] to be visualized or tracheal intubation is a failure.[16] When As airway management specialists in a hospital, the tracheal intubation under general anesthesia is planned anesthesiologists successfully manage airway relying on a wide range of knowledge, including the ability to Address for correspondence: Prof. Fu‑Shan Xue, predict difficult airway, to formulate plans for airway Department of Anesthesiology, Beijing Friendship Hospital, Capital management, and to possess the skills for using all kinds Medical University, NO.95 Yong‑An Road, Xi‑Cheng District, of airway devices.[13] The expert panel that reviewed Beijing100050, China E‑Mail: [email protected] 184 cases of major airway complications in the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society concludes that poor This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, judgment (59%) and education/training (49%) are the second tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. Access this article online For reprints contact: [email protected] Quick Response Code: Website: © 2018 Chinese Medical Journal ¦ Produced by Wolters Kluwer ‑ Medknow www.cmj.org Received: 25‑01‑2018 Edited by: Ning‑Ning Wang DOI: How to cite this article: Xue FS, Liu QJ. Tracheal Intubation Awake or 10.4103/0366‑6999.226891 Under Anesthesia for Potential Difficult Airway: Look Before You Leap. Chin Med J 2018;131:753‑6. Chinese Medical Journal ¦ March 20, 2018 ¦ Volume 131 ¦ Issue 6 753 [Downloaded free from http://www.cmj.org on Monday, April 2, 2018, IP: 128.252.174.220] on patients with known or predicted difficult airways, it is sevoflurane inhalation and cannot be relieved by routine imperative to know whether adequate facemask ventilation airway maneuvers, sevoflurane is turned off and the patient can be obtained after anesthetic induction. is woken up for awake tracheal intubation. Third, for patients with adequate facemask ventilation under sevoflurane As far, many preoperative approaches and tests in predicting anesthesia, direct laryngoscopy attempt is allowed and difficult facemask ventilation after anesthetic induction then second decision‑marking point of the FDAE approach have been proposed.[17] Ideally, a screening test for difficult depends on whether or not laryngoscopic view is adequate. If facemask ventilation should allow diagnosis of all problem cases (sensitivity = 100%), without false positives in patients the laryngoscopic view is good, and the chances of achieving who are easy to ventilate (specificity = 100%). As difficult successful tracheal intubation are high, intravenous muscle facemask ventilation is a low incidence and high‑risk event relaxants are allowed before tracheal intubation. If the by many reasons, such a guaranteed test does not exist, and laryngoscopic view is bad, video‑assisted intubation is it seems unlikely that one will be developed in the future. performed. These features of the FDAE approach provide The currently available evidence indicates that most of the high yield of securing the airway. the preoperative airway assessment tests only have a low It must be emphasized that the final goal of airway predictive performance for difficult facemask ventilation after management is oxygenation, rather than successful tracheal anesthetic induction.[1] Thus, the new tests and evidences for intubation. Failure of tracheal intubation does not directly prediction of difficult facemask ventilation are still needed. lead to adverse outcomes, such as death or brain injury as In this issue of CMJ, Wang et al.[18] reported their findings a result of oxygenation failure, if facemask ventilation is [19] from a multicentric prospective randomized study adequate. Importantly to point out that nearly one‑third which had tested a new approach, fast difficult airway of difficult facemask ventilation is actually accompanied by evaluation (FDAE), for difficult facemask ventilation difficult or impossible tracheal intubation. Difficult facemask after anesthetic induction. The authors randomly assigned ventilation is, therefore, a more critical situation to be avoided 302 patients with potential difficult facemask ventilation and resolved in anesthetized patients than tracheal intubation [20] and difficult intubation undergoing elective surgeries into failure. Most of the current guidelines for difficult the FDAE and control groups. In the FDAE group, patients airway management during anesthetic induction begin with [7‑10] were gradually induced with sevoflurane, and adequacy of unsuccessful intubation attempts. These guidelines aim facemask ventilation during spontaneous breathing was to solve the intubation problems and to prevent adverse assessed at various anesthetic levels. If facemask ventilation outcomes. This FDAE approach significantly differs from was adequate, tracheal intubation was performed using those of practice guidelines. The investigators mainly focus
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