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      Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults


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          These guidelines provide a strategy to manage unanticipated difficulty with tracheal intubation. They are founded on published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.

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              Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance.

              The objective of this study was to systematically determine the diagnostic accuracy of bedside tests for predicting difficult intubation in patients with no airway pathology. Thirty-five studies (50,760 patients) were selected from electronic databases. The overall incidence of difficult intubation was 5.8% (95% confidence interval, 4.5-7.5%). Screening tests included the Mallampati oropharyngeal classification, thyromental distance, sternomental distance, mouth opening, and Wilson risk score. Each test yielded poor to moderate sensitivity (20-62%) and moderate to fair specificity (82-97%). The most useful bedside test for prediction was found to be a combination of the Mallampati classification and thyromental distance (positive likelihood ratio, 9.9; 95% confidence interval, 3.1-31.9). Currently available screening tests for difficult intubation have only poor to moderate discriminative power when used alone. Combinations of tests add some incremental diagnostic value in comparison to the value of each test alone. The clinical value of bedside screening tests for predicting difficult intubation remains limited.

                Author and article information

                Role: Handling editor
                Br J Anaesth
                Br J Anaesth
                BJA: British Journal of Anaesthesia
                Oxford University Press
                December 2015
                10 November 2015
                10 November 2015
                : 115
                : 6
                : 827-848
                [1 ]Department of Anaesthesia, Northampton General Hospital , Billing Road, Northampton NN1 5BD, UK
                [2 ]Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust , 235 Euston Road, London NW1 2BU, UK
                [3 ]Department of Anaesthesia, NHS Lothian , Crewe Road South, Edinburgh EH4 2XU, UK
                [4 ]Department of Anaesthesia, University Hospitals Coventry & Warwickshire NHS Trust , Clifford Bridge Road, Coventry CV2 2DX, UK
                [5 ]Department of Anaesthesia, Barts Health , West Smithfield, London EC1A 7BE, UK
                [6 ]Department of Anaesthesia, The Royal National Throat Nose and Ear Hospital , 330 Grays Inn Road, London WC1X 8DA, UK
                [7 ]Department of Anaesthesia, St James's Hospital , PO Box 580, James's Street, Dublin 8, Ireland
                [8 ]Department of Anaesthesia, The Norfolk and Norwich University Hospitals NHS Foundation Trust , Colney Lane, Norwich NR4 7UY, UK
                [9 ]Department of Anaesthesia, Guy's and St Thomas’ NHS Foundation Trust , Great Maze Pond, London SE1 9RT, UK
                Author notes
                [* ]Corresponding author. E-mail: chris.frerk@ 123456ngh.nhs.uk

                [Related article:]This Article is accompanied by Editorials aev298 and [Related article:]aev404.

                © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

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