Basic Anesthesia Management

Airway Management
Airway Management:
• Difficult and failed airway management account for 2.3% to 16.6% of
anesthetic deaths
• Management of the airway is paramount to safe perioperative care
(1) Thorough airway history and physical examination;
(2) Consideration of the ease of rapid tracheal intubation by direct or indirect
laryngoscopy;
(3) Preinduction formation of a management plan, which includes the use of
supraglottic ventilation (e.g., facemask supraglottic airway [SGA]);
(4) Aspiration risk assessment;
(5) Estimation of the relative risk of failed airway maneuvers.
Review of Airway Anatomy
Airway Anatomy:
• Refers to the upper airway
• Nasal and Oral cavities
• Pharynx
• Larynx
• Trachea
• Principal Bronchi
Airway Anatomy:
• The anatomically complex airway undergoes significant changes in its
size, shape, and relationship to the cervical spine from infancy into
childhood

Infant larynx is proportionately smaller than adults

Vertical Location: C3-C5 in Infants; C4-C6 in adults
Pliable (Flexible) Laryngeal cartilage in the infant / child
Vocal Folds: Anterior Angle (with respect to perpendicular axis of larynx in infant / child)
Aryepiglottic folds closer to midline in infant / child
Epiglottis: Relatively longer, narrower and stiffer in infant
Mucosa more vulnerable to trauma in infant
Airway Anatomy:
Pharynx
• It is in the pharynx that the air and food pathways cross.
• The soft palate serves as a flap valve
• This flap shuts off the mouth from the oropharynx, for example, during the
process of chewing food so that breathing may continue unaffected
• Completely raised soft palate can shut off the nasopharynx from the
oropharynx, thus preventing food entering the nasopharynx in swallowing
Airway Anatomy:
Larynx (9)
• Epiglottis
• Thyroid Cartillage
• Cricoid Cartillage
• Arytenoid Cartillage (2)
• Cuneiform Cartillage (2)
• Corniculate Cartillage (2)
Airway Anatomy:
Trachea
• The trachea is a mobile cartilaginous and membranous tube.
• Approximately 15 cm in adults and is circumferentially supported by 17 to 18 C-
shaped cartilages
• It begins in the neck as a continuation of the larynx at the lower border of the
cricoid cartilage at the level of the 6th cervical vertebra
• It ends at the carina where the bronchi divides into a left and right principal
bronchi at the level of the sternal angle (opposite the disc between the 4th and
5th thoracic vertebrae).
• During expiration, the bifurcation rises by about one vertebral level
• During deep inspiration may be lowered as far as the 6th thoracic vertebra
Airway Anatomy:
Principal Bronchi
• The right principal (main) bronchus is wider, shorter, and more
vertical than the left
• The left principal (main) bronchus is narrower, longer, and more
horizontal than the right. It passes to the left below the arch of the
aorta and in front of the esophagus.
Airway Management
Airway Management
Airway management always begins with a thorough airway-relevant
history and physical examination
Airway Management: Asssessment
• Mouth Opening: incisor distance of 3 cm or greater (Adult)
• Mallampati Classification: Examine the of the tongue in relation to the oral
cavity
• Class I: Entire Palatal Arch, including bilateral faucial pillars in visible down to the base
• Class II: Upper part of faucial pillars and most of the uvula are visible
• Class III: Only soft and hard palates are visible
• Class IV: Only hard palate is visible
• Thyromental Distance: Distance between mentum (chin) and superior
thyroid notch (3 fingerbreadths); < 4cm associated with difficult DL
• Neck Circumference: A neck circumference of >17 inches is associated with
difficulties in visualization
Mikhail and Morgan
Barash
Mallampati Classification:
Airway Management: Asssessment
Cormack and Lehane
• Grade 1: includes visualization of the entire glottic aperture
• Grade 2: includes visualization of only the posterior aspects of the
glottic aperture
• Grade 3: is visualization of the tip of the epiglottis
• Grade 4: is visualization of no more than the soft palate
Cormack-Lehane:
Airway Management: Preoxygenation
Preoxygenation should be practiced in all cases when time allows.
• This procedure entails the replacement of the nitrogen volume of the
lung (as much as 95% of the functional residual capacity) with oxygen
in order to provide an apneic oxygen reservoir
• Healthy patient breathing room air (FIO2 = 0.21) will experience
oxyhemoglobin desaturation to a level of less than 90% after
approximately 1 to 2 minutes of apnea
• BUT preoxygenation with 100% O2 via a tight-fitting facemask may support at
least 8 minutes of apnea before desaturation occurs
Airway Management: Preoxygenation
Time-sparing Methods
• A series of four vital capacity breaths of 100% O2 over a 30-second
period, a high arterial PaO2 (339 mmHg) can be achieved, but the
time to desaturation remains shorter than with traditional techniques
• A modified vital capacity technique, wherein the patient is asked to
take eight deep breaths in a 60- second period, shows promise in
terms of prolonging the time to desaturation
• The authors of the current chapter prefer the technique of applying a
tight-fitting mask for 5 minutes or more of tidal volume breathing
100% oxygen at flows of 10 to 12 L/min
Airway Management: Preoxygenation
In OBESE patients
• Bilevel Positive Airway Pressure
• Reverse Trendelenburg Position
• Pharyngeal insufflation of Oxygen
• Oxygen is insufflated at a rate of 3 to 15 L/min via a nasal cannula or nasal-
only facemask upon induction of anesthesia
• Relies on the phenomenon of apneic oxygenation, a process by which gases
are entrained into the alveolar space during apnea
Airway Management: Preoxygenation
In OBESE patients
• Transnasal Humidified Rapid-Insufflation Ventilatory Exchange
(THRIVE)
• May also be used during periods of unplanned or intentional apnea (e.g.,
failed tracheal intubation or suspension laryngoscopy, respectively)
• Oxygen flows of 30 to 70 L/min of oxygen are delivered via specialized nasal
cannulae (OptiFlow™, Fisher and Paykel Healthcare Limited, Panmure,
Aukland, New Zealand)
• Apneic durations of 55 minutes have been reported with this technique
• Hypercapnia occurs to a limited degree as compared to traditional apnea,
which is attributed to turbulent flow at the glottic opening
Airway Management: Support of Airway
The Anesthesia Facemask
• Device most commonly used to deliver anesthetic gases and ventilate
an apneic patient
• Highly effective, minimally invasive, and requires the least
sophisticated equipment
• A two handed jaw-thrust technique has been shown to be superior
to the classic onehanded grip for this maneuver
• Gas leaks
• the most common reason for suboptimal preoxygenation
Airway Management: Support of Airway
The Anesthesia Facemask
• Expiratory chin drop
• When positive-pressure inspiration is successful, but is not followed by
passive gas escape during expiration, allowing phasic head flexion and
reducing chin/jaw lifting will often improve gas egress
• When positive-pressure inspiration is successful, but is not followed
by passive gas escape during expiration, allowing phasic head flexion
and reducing chin/jaw lifting will often improve gas egress
• A patient with normal lung compliance should require no more than
20 to 25 cm H2O pressure for lung inflation
Airway Management: Support of Airway
The Anesthesia Facemask
• IF there are no contraindications (e.g., increased aspiration risk), mask
ventilation can be the primary ventilatory technique for anesthetic
maintenance
• OTHERWISE, administer anesthetic gases and oxygen and to facilitate
ventilation until the anesthetic state is adequate for use of another
means of airway support (SGA or ETT)
• Decision should be made after careful consideration of the patient’s
coexisting diseases and surgical requirements.
Airway Management: Support of Airway
The Nasal Airway
• Long enough to reach from the nare to the thyroid notch
• Inserted along the floor of the nose, in an anterior–posterior direction,
and should always be prepared with water-soluble lubricant to reduce
trauma to the highly vascular nasal mucosa
• A vasoconstrictor agent (e.g., oxymetazoline or phenylephrine) may be
applied before insertion of the nasal airway to decrease this risk.
• Resistance to insertion should prompt repositioning of the airway
bevel, reassessment of the direction of insertion, or change to a
smaller airway or the contralateral nare
Airway Management: Support of Airway
The Nasal Airway
• The typical rounded oral airway is placed with its longitudinal
concavity rotated in a rostrad direction
• Once the distal end of the airway has been inserted to the level of the
oropharynx, the device is rotated 180 degrees and insertion is
continued to its ultimate position
• Avoids displacement of the tongue into the hypopharynx
• Can be aided by caudad displacement of the tongue with a tongue depressor
• A small oral aperture, intrapharyngeal mass or foreign body, intact gag
reflex or otherwise light anesthesia may prevent oral airway placement
Airway Management: Support of Airway
Laryngospasm
• A local reflex closure of the vocal folds
• Can be caused by saliva, blood, or vomitus touching the glottis / pain
or visceral stimulation
• Mechanism: Lateral cricoarytenoids, the thyroarytenoid, and the
cricothyroid muscles in response to stimulation of the vagus nerve
• Continued spontaneous ventilation against closed vocal cords results in:
• Hypoxia
• Noncardiogenic (negative pressure) pulmonary edema continued spontaneous
ventilation against closed vocal cords
Airway Management: Support of Airway
Laryngospasm Management:
• Removing the offending stimulus (if identified)
• Administering oxygen with continuous positive airway pressure (CPAP)
• Deepening the plane of the anesthesia
• Administering a rapid-acting muscle relaxant (IF other maneuvers are
unsuccessful!!!)
Airway Management: Support of Airway
Supraglottic Airways (SGA)
• Devices that isolate the airway above the vocal cords
• Associated with lower incidence of:
• sore throat, coughing, and laryngospasm on emergence, decreased reversible
bronchospasm
Airway Management: Support of Airway
The LMA Classic (Laryngeal Mask Airway)
• Composed of a perilaryngeal mask and an airway barrel
• Device is designed to sit in the hypopharynx with an anterior surface
aperture overlying the laryngeal inlet
• Inflatable cuff fills the hypopharyngeal space, creating a seal that allows
positive-pressure ventilation with up to 20 cm H2O pressure
• Adequacy of the seal depends on correct placement, appropriate size, and
patient anatomy, and is less dependent on the cuff-filling pressure or volume
• Recommended usage: 2 to 3 hours but reports of more than 24 hours usage
exist
Airway Management: Support of Airway
• SGAs produce significantly less reversible bronchospasm than ETTs
• Well suited to the patient with a history of bronchospasm
• Because the halogenated inhaled anesthetics are potent
bronchodilators, bronchospasm is more likely to occur at the times of
induction and emergence
• When tracheal intubation is mandatory for the surgical procedure and
bronchospasm concerns exists: BAILEY Maneuver
• Deflated LMA is placed behind the in situ ETT
• ETT is removed, the LMA is inflated
• Patient is emerged on the LMA
Airway Management: Support of Airway
SGA Removal
• An SGA should be removed either when the patient is deeply
anesthetized or after protective airway reflexes have returned and
the patient is able to open the mouth on command
• Removal during excitation stages of emergence can be accompanied
by coughing and/or laryngospasm
• Many clinicians remove the LMA fully inflated so that it acts as a
“scoop” for secretions above the mask, bringing them out of the
airway
Airway Management: Support of Airway
Contraindications to SGA Use
• Clinical scenarios with an increased risk of regurgitation (e.g., full
stomach, hiatus hernia with significant gastroesophageal reflux,
intestinal obstruction, delayed gastric emptying, unclear history
• High airway resistance
• Glottic or subglottic obstruction
• Limited mouth opening (<1.5cm)
Airway Management: Support of Airway
Complications of SGA Use
• Aspiration
• Laryngospasm, coughing, gagging, and other events characteristic of airway
manipulation
• Postoperative sore throat varies from 4
• Rare reports exist of nerve injury including damage to the hypoglossal, lingual, and
recurrent laryngeal nerves.
• Manifest within 48 hours postoperatively
• Resolve spontaneously in 1 hour to 18 months.
• Predisposing factors: use of small masks, lidocaine lubrication, and nitrous oxide, cuff
overinflation, difficult or alternate insertion techniques, nonsupine positioning, and
cervical bone or joint disease.
Airway Management: Support of Airway
Other SGAs
• LMA Flexible
• The King Laryngeal Tube
• Cookgas air-Q
• Second-Generation Supraglottic Airways (LMA ProSeal)
Airway Management: Tracheal Intubation
Direct Laryngoscopy
• GOAL: Produce a direct line of sight from the operator’s eye to the
larynx
• The GOLD STANDARD for verification of tracheal intubation is
sustained detection of exhaled carbon dioxide
ASA Difficult Airway Practice Guidelines:
• No one measure may be adequate to determine difficulty of DL and
multiple measures must be integrated in order to make sensible
airway management decisions
Airway Management: Tracheal Intubation
Three-axis model by Bannister and MacBeth (1944)
• Alignment of the laryngeal, pharyngeal, and oral axes would result in
adequate glottic view
• Rationale of the intubation sniffing position (SP)
• Neck is flexed by 35 degrees
• Head extended by 15 degrees
• Placing a support (around 7 cm in the adult) under the patient’s occiput
Airway Management: Tracheal Intubation
Two-axes/tongue-displacement model by Chou and Wu
• Maximizes the spaces between the alveolar ridge and laryngeal
aperture through oropharyngeal alignment and tongue displacement
• Explain difficulties with DL as well as why common methods of airway
assessment lack predictive power
Airway Management: Tracheal Intubation
Direct Laryngoscopy Blades
• Macintosh (Curved) Blade:
• Used to displace the epiglottis out of the line of sight by placement of the
distal tip in the vallecula and tensing of the glossoepiglottic ligament
• Advantageous whenever there is little room to pass an ETT
• Miller (Straight) Blade:
• Reveals the glottis by compressing the epiglottis against the base of the
tongue
• Better in the patient who has a small mandibular space, large incisors, or a
large epiglottis
Airway Management: Tracheal Intubation
Special Considerations: Direct Laryngoscopy
• Infant and Child
• Larger occiput in children: elevation of the head is NOT required to achieve a sniffing
position
• Hyperextension at the atlanto-occipital joint may cause airway obstruction from the relative pliability
of the trachea and should be avoided
Cricoid cartilage is the most rigid portion of the airway until 6 to 8 years of age
• Intubator must be sensitive to resistance to advancement of an ETT that has
easily passed the vocal folds
• Short length of the trachea: High risk of endobronchial intubation or
accidental extubation with head movement
Airway Management: Tracheal Intubation
Special Considerations: Direct Laryngoscopy
• Laryngeal view is NOT achieved: Backward–upward– rightward
pressure (BURP) maneuver may be applied
• Larynx is displaced backward (B) against the cervical vertebrae, upward (U,
superiorly) and to the patient’s right (R), using pressure (P) over the thyroid
cartilage
• “Optimal external laryngeal manipulation”
• Pressing posteriorly and cephalad over the thyroid, hyoid, and cricoid
cartilages
• Cricoid pressure is applied (Sellick maneuver)
Airway Management: Tracheal Intubation
Other Tracheal Intubations:
• Image-guided laryngoscopy
• Optical Stylets
• The Shikani Seeing Optical Stylet (SOS)
• The Levitan First Pass Success Scope
• BIF
• Videolaryngoscopy
• C-MAC system
• McGrath Mac
• Channeled scopes
• Airtraq optical laryngoscope
Airway Management:
NPO Status and Rapid-Sequence Induction:
• Induction of anesthesia profoundly depresses intrinsic reflexes that
protect the airway from the entrance of foreign bodies, including
regurgitated material
• Manipulation of the upper esophageal inlet reduces the closing
pressure of the lower esophageal sphincter
• Control of Gastric Contents:
• Minimizing intake
• Increasing gastric emptying
• Reducing gastric volume and acidity
Airway Management: Control of Gastric Contents
Reduction of gastric acidity
• Famotidine given a few hours before surgery effectively reduces gastric
volume and increases gastric pH better than ranitidine
• Rabeprazole, lansoprazole, and omeprazole (PPI) are most effective
when given in two successive doses (one the evening before and one
the morning of anesthesia)
• Single-dose therapy with omeprazole, which is most effective when
administered the night before
• Sodium citrate oral solution: increases gastric pH and is best
administered within 1 hour preoperatively in a dose of 15 to 30 mL
Airway Management: Rapid Sequence Induction
• Indicated when there is increased risk of gastric content aspiration
• Gain control of the airway in the shortest amount of time after the
ablation of protective airway reflexes with the induction of
anesthesia
• Intravenous anesthetic induction agent is administered and
immediately followed by a rapidly acting neuromuscular blocking
drug
Airway Management: Rapid Sequence Induction

OLD Beliefs NEW studies

[1] Mask ventilation is omitted for [1] Little evidence that omission of
fear of gastric insufflation mask ventilation provides any
clinical benefit, especially in patients
with poor pulmonary reserve

IF oxyhemoglobin desaturation
occurs, gentle positive-pressure
ventilation (<25cm H20) is
recommended
Airway Management: Rapid Sequence Induction

OLD Beliefs NEW studies

[2] Cricoid pressure is applied (Sellick [2] MRI studies have suggested that the
maneuver) esophagus is laterally displaced in a majority of
normal patients

Adequacy of esophageal ablation has been

questioned

May worsen the laryngoscopic view

P.S. Correctly applied cricoid pressure was
effective in preventing gastric fluids from Contraindicated during active vomiting and
leaking into the pharynx cervical spine or laryngeal fracture
 Airway Management: The Airway Approach
Algorithm
Based on five fundamental questions.
1. Is airway control necessary?
2. Could tracheal intubation be (at all) difficult?
3. Can supraglottic ventilation be used if needed?
4. Is there an aspiration risk?
5. Will the patient tolerate an apneic period? Can hypoxia be rapidly
corrected through other means?
Airway Management: Extubation
 Airway Management: The Airway Approach
Algorithm
• Exception to the AAA is a patient who is unable to cooperate owing to
mental disability, language barriers, intoxication, anxiety, depressed
level of consciousness, or young age
• May still be approached by Box A but awake intubation may need to
be forgone in favor of techniques that maintain spontaneous
ventilation
 Airway Management: The Airway Approach
Algorithm
When awake intubation fails, the clinician has a number of options:
(1) Canceling the surgical case and arranging specialized equipment or
personnel for a return to the operating room;
(2) Changing to a regional anesthetic technique; or
(3) If clinically indicated, calling for a surgical airway (e.g. cricothyrotomy)

Decision to awaken the patient should be considered based on the

adequacy of ventilation, the risk of aspiration, and the risk of proceeding
with intubation attempts or the surgical procedure.
Consideration of Regional Anesthesia:
The VORTEX approach:
• Assumes that there are three
categories of noninvasive
techniques available during an
airway “code”: mask ventilation,
SGA ventilation, and tracheal
intubation.
• Up to three attempts with
devices from each of these
categories may be attempted
prior to pursuing invasive
(surgical) airway access
AWAKE Airway Management:
• Provide maintenance of spontaneous ventilation in the event that the
airway cannot be secured rapidly
• Other benefits include increased size and patency of the pharynx,
relative forward placement of the base of the tongue, posterior
placement of the larynx, and the ability of the patient to cooperate
with procedures
• Confers some maintenance of upper and lower esophageal sphincter
tone, thus reducing the risk of regurgitation
AWAKE Airway Management:
Any sedative agent can be used
• GENERAL RULES:
• Dose judiciously
• Avoid polypharmacy (try to use no more than two agents)
• Have reversal agents at hand
• Small doses of Benzodiazepines:
• Alleviate anxiety without respiratory depression
• diazepam, midazolam, lorazepam
• Opioid receptor agonists:
• Used in small, titrated doses for their sedative and antitussive effects
• fentanyl, alfentanil, remifentanil
AWAKE Airway Management:
• Highly selective centrally acting α2- adrenergic agonist
(Dexmedetomidine)
• When combined with topical anesthesia, sedation with dexmedetomidine
provides for a smooth intubation without significant respiratory depression
• Ketamine
• Droperidol
AWAKE Airway Management:
Administration of an antisialagogue is important to the success of
awake intubation techniques
• Atropine (0.5–1 mg intramuscularly or intravenously)
• Glycopyrrolate (0.5–1 mg intramuscularly or intravenously)
• Often administered in the preoperative waiting area as the drying
effects of these medications may take some time (approximately 15
minutes)
AWAKE Airway Management:
Vasoconstriction of the Nasal Passages
• Required if there is to be instrumentation of this part of the airway
• Oxymetazoline
Local anesthetics are a cornerstone of awake airway management
• Topical anesthesia and injected nerve block techniques have been
developed to blunt the protective reflexes and provide airway analgesia
• Both effective and potentially dangerous drugs
• used within the tracheal–bronchial tree, there is potential for significant
intravascular absorption
AWAKE Airway Management: Local Anesthetics
Lidocaine
• Amide local anesthetic
• Topically applied, peak analgesia occurs within 15 minutes
• Common choice for airway topicalization
Benzocaine
• Ester local anesthetic
• very rapid onset (<1 minute) and short duration (~ 10 minutes)
• combined with Tetracaine in some preparations to prolong the
duration of action
AWAKE Airway Management: Local Anesthetics
Tetracaine
• Ester local anesthetic
• Longer duration of action than lidocaine or benzocaine
• Absorption of this drug from the respiratory and gastrointestinal
tracts is rapid
Cocaine
• Highly effective local anesthetic
• Also the only local anesthetic that is a potent vasoconstrictor
AWAKE Airway Management: Nasal Cavity
Nasal passages should always be included in the preparation for awake
intubation
• For sudden change in plan from Oral to Nasal
• Much of the preparation of the nose with local anesthesia will also
affect the pharyngeal airway
The Nasal Cavity
The nasal cavity is innervated by the greater and lesser palatine nerves
(innervating the nasal turbinates and most of the nasal septum) and
the anterior ethmoidal nerve (innervating the nares and anterior third
of the nasal septum), which are distal branches of the trigeminal nerve
(CN V)
The palatine nerves arise from the sphenopalatine ganglion located
posterior to the middle turbinate
AWAKE Airway Management: Nasal Cavity
PALATINE NERVE BLOCK
Noninvasive nasal approach:
• Cotton-tipped applicators soaked in local anesthetic are passed along
the lower border of the middle turbinate until the posterior wall of
the nasopharynx is reached and left there for 5 to 10 minutes
Invasive oral approach
• Needle is introduced into the greater palatine foramen
AWAKE Airway Management: Nasal Cavity
ANTERIOR ETHMOIDAL NERVE
• Cotton tipped applicators soaked in local anesthetic and placed along
the dorsal surface of the nose until the anterior cribriform plate is
reached. The applicators are left in place for 5 to 10 minutes.
AWAKE Airway Management: Oropharynx
Innervated by the vagus, facial, and glossopharyngeal nerves
• Simplest techniques involve aerosolized local anesthetic solution, or a
voluntary local anesthetic “swish and swallow.”
The GLOSSOPHARNYGEAL NERVE (CN IX)
• Supplies the afferent limb for the pharyngeal (gag) reflex
• Anesthesia of the glossopharyngeal nerve is key to comfortable awake
airway management
AWAKE Airway Management: Oropharynx
The GLOSSOPHARNYGEAL NERVE (CN IX)
Noninvasive technique:
• Anesthetic-soaked cotton-tipped applicators held gently against the inferior most
aspect of the contralateral folds that extend from the posterior aspect of the soft
palate to the base of the tongue bilaterally for 5 to 10 minutes
Invasive technique:
• Operator displaces the extended tongue and a 25-gauge spinal needle is inserted
into the fold near the floor of the mouth and an aspiration test is performed.
• If air is aspirated, the needle has passed through-and-through the membrane and is
withdrawn slightly prior to injection.
• If blood is aspirated, the needle tip is redirected more medially
AWAKE Airway Management: Oropharynx
SUPERIOR LARYNGEAL NERVE (branch of the vagus nerve)
• Sensory innervation to the base of the tongue, posterior surface of
the epiglottis, aryepiglottic folds, and arytenoids
Noninvasive technique
• Right-angled forceps with anesthetic-soaked cotton swabs are slid
over the lateral tongue and into the pyriform sinuses bilaterally, held
in place for 5 mins
Airway Management: Extubation
Criteria for AWAKE Postsurgical Extubation:
SUBJECTIVE (B-F-F MAIA)
• Breathing Spontaneously
• Following Commands
• Five-second sustained head lift
• Minimal end-expiratory concentration of inhaled anesthetics
• Airway clear of debris
• Intact Gag-reflex
• Adequate Pain CONTROL
Airway Management: Extubation
Criteria for AWAKE Postsurgical Extubation:
OBJECTIVE (DATS PVT)
• Dead space to tidal volume ratio of <0.6
• Alveolar-arterial PaO2 gradient <350 mmHg (on FIO2 of 1)
• T1/T4 ratio >0.7-0.8
• Sustained tetanic contractions (5 seconds)
• Peak voluntary negative inspiratory pressure > 20cmH20
• Vital Capacity > 10ml/kg
• Tidal Volume > 6mg/kg
Airway Management: Extubation
Clinical Situations Presenting Increased Risk for Complications at Time of Extubation:
Airway Management: Extubation
• The difficult airway represents a complex interaction between patient
factors, the clinical setting, and the skills of the practitioner