Context and Definition

Context

CAVEAT: While the theory contained in this session provides useful knowledge about airway management, putting this knowledge into practice requires extensive supervised practical experience. Such experience can be reinforced and developed by courses such as the UK TEAM course upon which this session draws extensively.

Airway management in an elective situation is usually straightforward. Any difficulties in airway maintenance and ventilation prior to endotracheal intubation are usually dealt with by simple repositioning manoeuvres and the use of adjuncts. [1] Laryngoscopy usually provides a clear view of the cords and intubation itself is easy.

In the time critical environment of the emergency department, the scenario is complicated by

• Limited scope for prior assessment
• The often poor physiological reserve of the patient
• The potential for a range of pathologies which may still be rapidly evolving

The failure rate for rapid sequence intubation in the emergency department is about 1%, with a cricothyroidotomy rate varying from 0.5% (medical patients) to 2.3% (trauma). [1]

Awareness of indicators of difficulty and techniques to deal with problems can reduce the complication rate. [2]

Definition

For the purposes of this session the following definitions are used:

Difficult airway is being used to describe:

• Problems with bag-valve mask ventilation (BVM) despite repositioning and use of adjuncts, as covered in the session Basic Airway Management in the Adult
• Difficulties in intubation when attempted by a competent airway practitioner

Failed intubation is the inability to successfully place an endotracheal tube after three attempts by a competent airway practitioner. [3]

Can’t intubate, can’t oxygenate (CICO) is when a failed intubation is compounded by an inability to maintain adequate oxygen saturation with BVM.