title: The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient.
abstract: BACKGROUND
  Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group's mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered.
  
  
  METHODS
  Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria.
  
  
  CONCLUSIONS
  The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative "Plan B" technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, "cannot intubate, cannot oxygenate" situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.
authors.affiliation: Department of Anesthesia, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada, jlaw@dal.ca.
authors.forename: J Adam
authors.initials: JA
authors.lastname: Law
authors.forename: Natasha
authors.initials: N
authors.lastname: Broemling
authors.forename: Richard M
authors.initials: RM
authors.lastname: Cooper
authors.forename: Pierre
authors.initials: P
authors.lastname: Drolet
authors.forename: Laura V
authors.initials: LV
authors.lastname: Duggan
authors.forename: Donald E
authors.initials: DE
authors.lastname: Griesdale
authors.forename: Orlando R
authors.initials: OR
authors.lastname: Hung
authors.forename: Philip M
authors.initials: PM
authors.lastname: Jones
authors.forename: George
authors.initials: G
authors.lastname: Kovacs
authors.forename: Simon
authors.initials: S
authors.lastname: Massey
authors.forename: Ian R
authors.initials: IR
authors.lastname: Morris
authors.forename: Timothy
authors.initials: T
authors.lastname: Mullen
authors.forename: Michael F
authors.initials: MF
authors.lastname: Murphy
authors.forename: Roanne
authors.initials: R
authors.lastname: Preston
authors.forename: Viren N
authors.initials: VN
authors.lastname: Naik
authors.forename: Jeanette
authors.initials: J
authors.lastname: Scott
authors.forename: Shean
authors.initials: S
authors.lastname: Stacey
authors.forename: Timothy P
authors.initials: TP
authors.lastname: Turkstra
authors.forename: David T
authors.initials: DT
authors.lastname: Wong
mesh_terms: D058109:Airway Management / Q000379:methods*; D000758:Anesthesia / Q000379:methods; D002170:Canada; D003413:Cricoid Cartilage / Q000601:surgery; D006801:Humans; D007442:Intubation, Intratracheal / Q000379:methods*; D017214:Laryngeal Masks; D014474:Unconsciousness