Schäuble J C, Heidegger T
Institut für Anästhesiologie, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Schweiz.
Departement für Anästhesie, Intensivmedizin und Reanimation, Spitalregion Rheintal, Werdenberg, Sarganserland, Schweiz.
Anaesthesist. 2018 Oct;67(10):725-737. doi: 10.1007/s00101-018-0492-8.
Several national airway task forces have recently updated their recommendations for the management of the difficult airway in adults. Routinely responding to airway difficulties with an algorithm-based strategy is consistently supported. The focus is increasingly not on tools and devices but more on good planning, preparation and communication. In the case of anticipated airway difficulties the airway should be secured when the patient is awake with maintenance of spontaneous ventilation. Unaltered a flexible bronchoscopic intubation technique is advised as a standard of care in such patients. The importance of maintenance of oxygenation is emphasized. Face mask ventilation and the use of supraglottic devices are recommended if unexpected airway difficulties occur. Face mask ventilation may be facilitated and optimised by early administration of neuromuscular blocking agents. If required, in not fastened patients threatened by acute hypoxia, carefully applied and pressure-controlled ventilation may ensure sufficient oxygenation until the airway is secured. Apnoeic oxygen techniques are recommended in high-risk patients and to relieve the time pressure of falling oxygen saturation during decision-making processes. The early use of video laryngoscopy is advised for endotracheal intubation in the case of failed direct laryngoscopy or if intubation is expected to be difficult. For the coverage of cannot intubate-cannot oxygenate scenarios, second generation supraglottic devices and invasive airway access are advocated. The discussion regarding the optimal technique for emergency invasive airway access is still in progress. In the case of uncontrollable respiratory deterioration and progressive hypoxia, the algorithm must be consistently executed and without delay due to ineffective activities (straightforward strategy). Although there is no evidence to support the selection of a particular approach, the importance and the need for a defined airway concept/algorithm in any anesthesia department is fostered. Simplicity and clarity are essential for recall under stressful and time-sensitive conditions. The algorithm should be adapted to local conditions and preferences and devices should be limited to a definite number. The acquisition and maintenance of expertise by education and training is demanded.
最近，几个国家气道工作组更新了成人困难气道管理的建议。持续支持采用基于算法的策略来应对气道困难。现在越来越关注的不是工具和设备，而是良好的规划、准备和沟通。对于预期的气道困难，应在患者清醒且自主通气维持的情况下确保气道安全。对于此类患者，建议采用改良的可弯曲支气管镜插管技术作为标准治疗方法。强调了维持氧合的重要性。如果出现意外气道困难，建议进行面罩通气并使用声门上气道装置。早期给予神经肌肉阻滞剂可能有助于并优化面罩通气。如果需要，对于受到急性缺氧威胁的未固定患者，谨慎应用并进行压力控制通气可确保足够的氧合，直至气道安全。对于高危患者以及在决策过程中缓解氧饱和度下降的时间压力，建议采用无呼吸氧合技术。如果直接喉镜检查失败或预计插管困难，建议早期使用视频喉镜进行气管插管。对于无法插管-无法氧合的情况，提倡使用第二代声门上气道装置和有创气道通路。关于紧急有创气道通路的最佳技术的讨论仍在进行中。在出现无法控制的呼吸恶化和进行性缺氧的情况下，必须始终如一地执行该算法，且不得因无效操作而延迟（直接策略）。尽管没有证据支持选择特定方法，但任何麻醉科都需要有明确的气道概念/算法，这一点很重要且很有必要。在压力大且时间紧迫的情况下，简单明了对于记忆至关重要。该算法应根据当地情况和偏好进行调整，设备数量应限定。需要通过教育和培训来获取和保持专业知识。
