Tracheal intubation is indicated in a variety of situations when illness or a medical procedure prevents a person from maintaining a clear airway, breathing, and oxygenating the blood. In these circumstances, oxygen supplementation using a simple face mask is inadequate. Actual or impending airway obstruction is a common indication for intubation of the trachea.Thus airway management is a vital skill that is relevant to the practice of all medical specialities, especially anaesthesiology, critical care, emergency medicine and surgery. Inappropriate airway management may result in adverse outcomes.
The All India Difficult Airway Association (AIDAA) have come up with the latest guidelines taking into account the recent developments and current practices in airway management. These were published in the Indian Journal of Anaesthesia, Volume 60,Issue 12, Dec 2016. Here are the following recommendations:
- The AIDAA recommends optimum pre‑oxygenation and nasal insufflation of 15 L/min oxygen during apnoea in all patients, and calling for help if the initial attempt at intubation is unsuccessful.
- Transnasal humidified rapid insufflations of oxygen at 70 L/min (transnasal humidified rapid insufflation ventilatory exchange) should be used when available.
- No more than three attempts at tracheal intubation and two attempts at supraglottic airway device (SAD) insertion if intubation fails, provided oxygen saturation remains ≥ 95% should be made.
- Intubation should be confirmed by capnography. Blind tracheal intubation through the SAD is not recommended.
- If SAD insertion fails, one final attempt at mask ventilation should be tried after ensuring neuromuscular blockade using the optimal technique for mask ventilation.
- Failure to intubate the trachea as well as an inability to ventilate the lungs by face mask and SAD constitutes ‘complete ventilation failure’, and emergency cricothyroidotomy should be performed.
- Patient counselling, documentation and standard reporting of the airway difficulty using a ‘difficult airway alert form’ must be done.
- In addition, the AIDAA provides suggestions for the contents of a difficult airway cart.
Following is the algorithm suggested by AIDAA for the management of Unanticipated difficult tracheal intubation :
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