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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

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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