RESUMEN
OBJECTIVE: To review alternative airway management techniques and their suitability to the intensive care setting. DATA SOURCES: A review of publications reported from 1975-2002 and identified in both the Medline and Pubmed databases on the products used in the management of a difficult airway. In addition new airway devices were identified by accessing the product catalogues of major manufacturers and third-party vendors. The publications were assessed for their relevance to the intensive care setting. SUMMARY OF REVIEW: Many devices to manage the difficult airway have been designed for use in the controlled environment of an anaesthetic room rather than the intensive care unit. In addition, there is very little opportunity to evaluate and train with alternative techniques in real-life situations in the critical care setting. We review products that are considered as alternative airway devices to the standard endotracheal tube and include alternative intubating devices to the standard laryngoscope and devices to achieve a trans-tracheal airway. We also consider their suitability to the intensive care setting. CONCLUSIONS: There is a wide range of techniques available to manage the difficult airway. Due to the limited opportunity to train in the use of alternative airway techniques, such techniques should ideally involve an extension of those skills commonly practised by intensivists (e.g. bronchoscopy). Ultimately, the most important features when choosing a technique to manage a difficult airway are the training, knowledge and experience of the practitioner.
RESUMEN
OBJECTIVE: To review the management of the difficult airway in the intensive care unit patient. DATA SOURCES: A review of publications reported from 1975-2002 and identified in both the Medline and Pubmed databases on the management of the difficult airway. The publications were also assessed for their relevance to the intensive care setting. SUMMARY OF REVIEW: Endotracheal intubation is performed infrequently in the intensive care unit and usually in patients who have a higher than average rate of difficulty. The consequences of inadequate airway management can be devastating not only for the patient, but psychologically for the staff involved in whom airway management should be a core skill. Most of the reports reviewing the management of patients with a difficult airway are found in the field of anaesthesia and to a lesser extent in the field of emergency medicine. This review looks at the application of all the reported literature for difficult airway management in the intensive care setting. We propose guidelines that may assist both the trainee in intensive care medicine and the experienced intensivist in the management of the airway in the intensive care patient. CONCLUSIONS: The principles of difficult airway management, including a back-up plan and calling for assistance early, hold true in the intensive care setting as much as in any other clinical setting. It is vital that clinicians develop their own difficult airway algorithm based on their training and experience.