AANA journal course: update for nurse anesthetists--beyond the laryngoscope: advanced techniques for difficult airway management.

Airway catastrophes have been identified as the leading cause of injury and death during anesthesia. Proper management of a patient with a technically difficult airway commences with problem recognition. Physical limitations to mask ventilation and endotracheal intubation may be accurately identified by thorough observation. All patients should be examined for oral structure visibility, size of mandibular space, and ability to assume "sniffing" position. Patients with compromised airways should have patency secured while remaining awake by direct laryngoscopy, nasotracheal intubation, fiberoptic endoscopy, retrograde intubation, or possibly tracheostomy. Partial or complete airway obstruction requires immediate recognition and intervention. Repeated, unsuccessful attempts at endotracheal intubation should be avoided, as these may lead to laryngeal edema or hemorrhage which may critically compromise airway maintenance. Prudent options may include awakening the patient, proceeding with mask ventilation, or performing semi-elective tracheostomy. Emergency airway access may be achieved with a tracheoesophageal airway, esophageal tracheal combitube, laryngeal mask airway, digital intubation, or obtained surgically by transtracheal jet ventilation or tracheostomy. Reduction of airway-related morbidity and mortality is best achieved with an understanding of airway anatomy, common causes and prompt recognition of compromise, and alternative techniques of establishing patency and ventilation.