title: Unanticipated difficult airway in anesthetized patients: prospective validation of a management algorithm.
abstract: BACKGROUND
  Management strategies conceived to improve patient safety in anesthesia have rarely been assessed prospectively. The authors undertook a prospective evaluation of a predefined algorithm for unanticipated difficult airway management.
  
  
  METHODS
  After a 2-month period of training in airway management, 41 anesthesiologists were asked to follow a predefined algorithm for management in the case of an unanticipated difficult airway. Two different scenarios were distinguished: "cannot intubate" and "cannot ventilate." The gum elastic bougie and the Intubating Laryngeal Mask Airway (ILMA) were proposed as the first and second steps in the case of impossible laryngoscope-assisted tracheal intubation, respectively. In the case of impossible ventilation or difficult ventilation, the IMLA was recommended, followed by percutaneous transtracheal jet ventilation. The patient's details, adherence rate to the algorithm, efficacy, and complications of airway management processes were recorded.
  
  
  RESULTS
  Impossible ventilation never occurred during the 18-month study. One hundred cases of unexpected difficult airway were recorded (0.9%) among 11,257 intubations. Deviation from the algorithm was recorded in three cases, and two patients were wakened before any alternative intubation technique attempt. All remaining patients were successfully ventilated with either the facemask (89 of 95) or the ILMA (6 of 95). Six difficult-ventilation patients required the ILMA before completion of the first intubation step. Eighty patients were intubated with the gum elastic bougie, and 13 required a blind intubation through the ILMA. Two patients ventilated with the ILMA were never intubated.
  
  
  CONCLUSIONS
  When applied in accordance with a predefined algorithm, the gum elastic bougie and the ILMA are effective to solve most problems occurring during unexpected difficult airway management.
authors.affiliation: Service d' Anesthésie Réanimation, Hôpital Henri-Mondor, 51 Avenue du Maréchal de Lattre-de-Tassigny, 94100 Créteil Cedex, France. xavier.combes@hmn.ap-hopparis.fr
authors.forename: Xavier
authors.initials: X
authors.lastname: Combes
authors.forename: Bertrand
authors.initials: B
authors.lastname: Le Roux
authors.forename: Powen
authors.initials: P
authors.lastname: Suen
authors.forename: Marc
authors.initials: M
authors.lastname: Dumerat
authors.forename: Cyrus
authors.initials: C
authors.lastname: Motamed
authors.forename: Stéphane
authors.initials: S
authors.lastname: Sauvat
authors.forename: Philippe
authors.initials: P
authors.lastname: Duvaldestin
authors.forename: Gilles
authors.initials: G
authors.lastname: Dhonneur
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000758:Anesthesia / Q000009:adverse effects / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods / Q000706:statistics & numerical data*