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INTRODUCTION

Throughout the medical community, otolaryngologists are relied upon as experts of the airway. In this role we manage patients with a variety of airway-related conditions and are often called upon to evaluate and secure the airway in challenging scenarios. Our ability to function effectively stems from detailed anatomic knowledge, the ability to comprehensively assess the airway, expertise in the various procedural and technical aspects of securing an airway, and cooperation with our anesthesia colleagues. This chapter will first review how to evaluate the airway in a variety of patient scenarios. Physical exam components and key points in preparation for airway consults will be discussed. Next, steps and techniques in securing an airway along with the various instruments and equipment that one must be well-versed in will be reviewed in depth. Both surgical and nonsurgical airway techniques are included.

APPROACH TO AIRWAY MANAGEMENT

INITIAL EVALUATION

Patient Factors

Successful airway management must begin with a careful, thorough, and rapid evaluation of the airway. Obtaining a focused history allows for accurate anticipation of the “difficult airway” patient, and will help the otolaryngologist determine the best approach to securing the airway. Factors known to correlate with difficult airways are obesity, obstructive sleep apnea, history of head and neck cancer, prior surgery or radiation to the head and neck, and/or prior history of difficult intubation. Timing of last meal, as well as factors known to increase delay in gastric emptying (eg, gastroesophageal reflux disease [GERD], diabetes mellitus, opioid use), can help predict the risk of aspiration. An accurate history is also critical in evaluating the airway and formulating the best management plan. The physician should determine whether the obstruction occurred acutely or chronically. The age of the patient also helps in distinguishing the cause of the obstruction. Congenital airway anomalies (eg, laryngomalacia, choanal atresia, hemangioma, tracheomalacia) and acute inflammatory causes (ie, croup and epiglottitis) are more common in children. In adults, tumors are more likely. Trauma can cause rapid airway obstruction, and is essential to diagnose via early endoscopic evaluation. It is important to carefully ascertain the mechanism and type of injury. Suspicion of laryngeal trauma may make conventional endotracheal intubation perilous, as it can potentially result in worsening airway compromise due to laryngotracheal separation. In these circumstances, the physician should consider performing a tracheotomy while the patient is awake. Similarly, massive maxillofacial trauma may preclude normal translaryngeal intubation; a flexible fiber optic intubation or an awake tracheotomy should be considered in these situations.

Physical examination is a key element in deciding which patients may proceed with standard translaryngeal endotracheal intubation versus those at risk for upper airway obstruction, in which cases other strategies are best employed. The otolaryngologist must first determine the potential location of airway obstruction. Assessments of the general state of the patient, determining quality of respiration including voice, and examination of the head and neck ...

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