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The Physiologically Difficult Airway

March 8, 2021

Written by Sam Parnell

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The Society for Airway Management recently published consensus recommendations for the evaluation and management of the physiologically difficulty airway. You should read the entire article, but the key recommendations listed below focus on preoxygenation, apneic oxygenation, and peri-intubation hemodynamic optimization with fluid or vasopressor resuscitation.

Why does this matter?
Tracheal intubation is one of the most common procedures performed in the United States. We tend to focus on the anatomically difficult airway, as we should. However, even with normal anatomy, intubation is not without risk. Potential complications range from transient oxygen desaturation and hypotension to anoxic brain injury and death. Furthermore, critically ill patients with physiologic derangements are at significantly higher risk for intubation related complications. How should we manage intubation for these high-risk patients? Enter… Society for Airway Management, a.k.a. SAM. Coincidence? I think not. By way of review, we also covered the physiologically difficult airway in children recently.

Stop, preoxygenate, and listen. SAM is back with my brand new invention.
The SAM’s Special Projects Committee, representing Anesthesia, Critical Care Medicine, and Emergency Medicine, developed consensus recommendations for the evaluation and management of the physiologically difficulty airway, specifically relating to critically ill patients in the out-of-operating room setting. These recommendations were created after extensive literature review, use of a modified Delphi method, and completion of an anonymous survey to assess level of agreement for each recommendation. The top 10 recommendations from the article are listed in the table below. However, I recommend reading the entire article, as there are numerous additional high yield recommendations pertaining to patients with hypoxemia, hypotension, right ventricular dysfunction, severe metabolic acidosis, and neurologic injury.

Keep in mind that these recommendations lack a risk of bias assessment, and there is a paucity of high-quality data to support some of these guidelines. Still, these recommendations seem to make physiologic sense and have a high level of agreement from a diverse group of expert clinician-scientists. So, the next time you plan to “tube ‘em”, stop, preoxygenate, and listen to the SAM recommendations.

From cited article

Editor’s note: I cannot be held responsible for the Vanilla Ice throwback reference above. Will it ever stop? Yo, I don’t know. ~Clay

Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management. Anesth Analg. 2021 Feb 1;132(2):395-405. doi: 10.1213/ANE.0000000000005233.

What are your thoughts?