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7/27/2019 Difficult-Tracheal-Intubation-Prediction-and-Management.pdf
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Dr I H Wilson, Department of Anaesthesia,
Royal Devon and Exeter Hospital, Exeter,
EX2 5DW
Dr Andreas Kopf, Department of Anaesthesia,
Benjamin Franklin Medical Centre, Free
University of Berlin, Hindenburgdamm 30
12200 Berlin-Lichterfelde, Germany
INTRODUCTION
PREDICTION AND MANAGEMEN
TRACHEAL INTUBATION
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anaesthetic is administered so there is a reco
future use.
PREDICTING DIFFICULT INTUBATIO
Tracheal intubation is best achieved in the c
sniffing the morning air position in whic
neck is flexed and there is extension at the cr
cervical (atlanto-axial) junction. This align
structures of the upper airway in the opti
position for laryngoscopy and permits the
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raise their face up testing for extension of th
atlanto-axial joint. Laryngoscopy is optimally
performed with the neck flexed and extension at thatlanto-axial joint. Reduction of movement at thi
joint is associated with difficulty.
Protrusion of the mandible is an indication of th
mobility of the mandible. If the patient is able t
protrude the lower teeth beyond the upper incisor
intubation is usually straightforward [6] If th
Update in Anaesthesia
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operative patient, and some experience on th
of the anaesthetist.
This technique may be performed using eifibreoptic flexible bronchoscope or other fibre
or using direct laryngoscopy. The patient is car
prepared with a full explanation of why they a
to have awake intubation. Atropine 500m
glycopyrrolate 200mcg should be g
intramuscularly half an hour before intubati
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smooth as possible (figure 3). The tube may ge
obstructed at the level of the epiglottis or the voca
cords. There are a number of techniques to overcomthis. The transtracheal wire may be used to guid
a fibreoptic bronchoscope into the trachea and the
the endotracheal tube placed over the scope. A
larger hollow catheter may be placed over the wir
into the trachea and the tube passed over the catheter
A disposable ureteric dilator which is hollow an
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surgery altogether. In situations where surgery i
of an urgent nature it may be prudent to carry on th
general anaesthetic under face mask anaesthesia ithe airway is easy to maintain. If the airway i
impossible to maintain and the patient is becomin
hypoxic, an emergency cricothyroidotomy i
required. If time allows an emergency tracheostom
can be considered.
Failure of face mask ventilation occurs when th
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Case History 3
A three year old girl was admitted to hospita
increasingly severe upper airway obstructionpresumed diagnosis of epiglottis. She was
straight to the operating theatre and anaes
was induced using oxygen and halothane.
anaesthetist maintained a degree of conti
airway pressure via the T-piece and after a prol
induction he laryngoscoped the child to re
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difficult intubation. Journal of Cardiothoracic Anaesthesi
1987;1:565-8
14. King TA, Adams AP. Failed tracheal intubation. BritisJournal of Anaesthesia 1990;65:400-414
15. Cobley M, Vaughan RS. Recognition and managemen
of difficult airway problems. British Journal of Anaesthesi
1992;68:90-7
Update in Anaesthesia