Published Guidelines and Strategies
The American Society of Anesthesiologists guidelines, first published in 1993 (1) as landmark publication and updated in 2003 (2), emphasize that in patients with an anticipated difficult airway (DA), basic decision-making should focus on airway management in the awake state or after induction of general anesthesia (GA), use of noninvasive or invasive techniques for primary access to the airway, and preservation or interruption of spontaneous ventilation. These principles are also emphasized by the Italian expert working group (20). When tracheal intubation is considered necessary, both expert groups highly recommend awake flexible-bronchoscopy assisted (FBA) tracheal intubation as primary option.
In a large prospective study at a tertiary care hospital, Heidegger and co-workers (11) demonstrated that FBA techniques of tracheal intubation performed by trained and experienced operators are highly successful in the elective and emergency management of the DA. In patients with an anticipated DA, including those with anatomic features predictive of difficult tracheal intubation, extreme obesity, and/or upper airway obstruction, they performed primary awake FBA nasotracheal intubation. In patients with a history of difficult tracheal intubation, primary FBA orotracheal intubation under GA was chosen. In a further evaluation of their data, they emphasized that FBA techniques may have some limitations (12). The main reasons for failed FBA tracheal intubation in two percent were inability to identifiy anatomical structures and to pass the tracheal tube through the nose past the laryngeal aperture. The overall high success rates of FBA tracheal intubation may not be applicable to less experienced operators.
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