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Airway management for patients with airway disruption

Airway management for patients with airway disruption
  • Perform awake intubation if major laryngeal or tracheal/bronchial tear, provided the patient is awake, cooperative, hemodynamically stable, and able to maintain adequate O2 saturation.
  • If patient is uncooperative and DA is not otherwise suspected, consider rapid sequence intubation (RSI) using VAL and FIS.
  • Consider intubation and airway evaluation with VAL if a supralaryngeal defect is present. VAL has the added benefit of allowing multiple viewers, aiding in examination and surgical planning.
  • For infralaryngeal and tracheal injury, consider RSI followed by DL and insertion of an FIS (with appropriately sized endotracheal tube [ETT] already loaded over it) through the larynx to rapidly evaluate for possible airway injury. The ETT is then introduced over the FIS and the cuff positioned below the level of injury.[1,2]
  • Avoid positive pressure ventilation and transtracheal jet ventilation proximal to tear.
  • If bronchial disruption is suspected, consider lung separation via placement of a double lumen tube or bronchial blocker.
  • Consider cardiopulmonary bypass.*

DA: difficult airway; DL: direct laryngoscopy; ECMO: extracorporeal membrane oxygenation; FIS: flexible intubation scope; O2: oxygen; VAL: video-assisted laryngoscopy.

* UpToDate also suggests ECMO as an alternative.
References:
  1. Diez C, Varon AJ. Airway management. In: Essentials of Trauma Anesthesia, Varon AJ, Smith CE (Eds), Cambridge University Press 2012.
  2. Desjardins G, Varon AJ. Airway management for penetrating neck injuries. The Miami experience. Resuscitation 2001; 48:71.

Reproduced with permission from: Hagberg CA, Kaslow O. Difficult airway management algorithm in trauma: Updated by COTEP. ASA Monitor 2014; 78:56. Copyright © 2014 American Society of Anesthesiologists. Excerpted from ASA Monitor (2014) of the American Society of Anesthesiologists. A copy of the full text can be obtained from ASA, 1061 American Lane, Schaumburg, IL, 60173-4973 or online at www.asahq.org.

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