Abstract
Difficulty with airway management in obstetric patients occurs infrequently and failure to secure an airway is rare. A failed airway may result in severe physical and emotional morbidity and possibly death to the mother and baby. Additionally, the family, along with the medical and nursing staff, may face emotional and financial trauma. With the increase in the number of cesarean sections performed under regional anesthesia, the experience and training in performing endotracheal intubations in obstetric anesthesia has decreased. This article reviews the management of the difficult and failed airway in obstetric anesthesia. Underpinning this important topic is the difference between the nonpregnant and pregnant state. Obstetric anatomy and physiology, endotracheal intubation in the obstetric patient, and modifications to the difficult airway algorithms required for obstetric patients will be discussed. We emphasize that decisions regarding airway management must consider the urgency of delivery of the baby. Finally, the need for specific equipment in the obstetric difficult and failed airway is discussed. Worldwide maternal mortality reflects the health of a nation. However, one could also claim that, particularly in Western countries, maternal mortality may reflect the health of the specialty of anesthesia.
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References
Caton D (2000) John Snow’s practice of obstetric anesthesia. Anesthesiology 92:247–252
Mendelson CL (1946) The aspiration of stomach contents into the lungs during obstetric anaesthesia. Am J Obstet Gynecol 52: 191–205
Tomkinson J, Turnbull A, Robson G, Cloake E, Adelstein AM, Weatherall J (1979) Report on confidential enquiries into maternal deaths in England and Wales 1973–1975. Rep Health Soc Subj (Lond) 14:1–166
Tunstall ME (1976) Failed intubation drill. Anaesthesia 31: 850
Albright GA (1979) Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology 51:285–287
Ghosh MK (2001) Maternal mortality. A global perspective. J Reprod Med 46:427–433
Hawkins JL, Koonin LM, Palmer SK, Gibbs CP (1997) Anesthesia-related deaths during obstetric delivery in the United States, 1979–1990. Anesthesiology 86:277–284
Clyburn PA (2004) Early thoughts on “Why Mothers Die 2000–2002”. Anaesthesia 59:1157–1159
Confidential Enquiry into Maternal and Child Health (2004) Why mothers die 2000–2002—the sixth report of confidential enquiries into maternal deaths in the United Kingdom. RCOG Press, London
Ross BK (2003) ASA closed claims in obstetrics: lessons learned. Anesthesiol Clin North America 21:183–197
Benumof JL (1991) Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology 75:1087–1110
Cormack RS, Lehane J (1984) Difficult tracheal intubation in obstetrics. Anaesthesia 39:1105–1111
Lyons G (1985) Failed intubation. Six years’ experience in a teaching maternity unit. Anaesthesia 40:759–762
Rocke DA, Murray WB, Rout CC, Gouws E (1992) Relative risk analysis of factors associated with difficult intubation in obstetric anesthesia. Anesthesiology 77:67–73
Samsoon GL, Young JR (1987) Difficult tracheal intubation: a retrospective study. Anaesthesia 42:487–490
Yeo SW, Chong JL, Thomas E (1992) Difficult intubation: a prospective study. Singapore Med J 33:362–364
Crapo RO (1996) Normal cardiopulmonary physiology during pregnancy. Clin Obstet Gynecol 39:3–16
Brimacombe J (1992) Acute pharyngolaryngeal oedema and pre-eclamptic toxaemia. Anaesth Intensive Care 20:97–98
Brock-Utne JG, Downing JW, Seedat F (1977) Laryngeal oedema associated with pre-eclamptic toxaemia. Anaesthesia 32:556–558
Jensen D, Wolfe LA, Slatkovska L, Webb KA, Davies GA, O’Donnell DE (2005) Effects of human pregnancy on the ventilatory chemoreflex response to carbon dioxide. Am J Physiol Regul Integr Comp Physiol 288:R1369–1375
Chang AB (2004) Physiology changes of pregnancy. In: Chestnut DH (ed) Obstetric anesthesia principles and practice. Elsevier Mosby, Philadelphia, pp 23–24
Zavala DC, Printen KJ (1984) Basal and exercise tests on morbidly obese patients before and after gastric bypass. Surgery 95:221–229
D’Alessio JG, Ramanathan J (1998) Effects of maternal anesthesia in the neonate. Semin Perinatol 22:350–362
Afolabi BB, Lesi FE, Merah NA (2006) Regional versus general anaesthesia for caesarean section. Cochrane Database Syst Rev: CD004350
Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, Liu PL (1985) A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 32:429–434
(1992) Anesthesia for emergency deliveries. ACOG committee opinion: committee on obstetrics: maternal and fetal medicine. Number 104-March 1992. Int J Gynaecol Obstet 39:148
Gillett GB, Watson JD, Langford RM (1984) Ranitidine and single-dose antacid therapy as prophylaxis against acid aspiration syndrome in obstetric practice. Anaesthesia 39:638–644
Hey VM, Ostick DG (1978) Metoclopramide and the gastrooesophageal sphincter. A study in pregnant women with heartburn. Anaesthesia 33:462–465
Murphy DF, Nally B, Gardiner J, Unwin A (1984) Effect of metoclopramide on gastric emptying before elective and emergency caesarean section. Br J Anaesth 56:1113–1116
Davies JM, Weeks S, Crone LA, Pavlin E (1989) Difficult intubation in the parturient. Can J Anaesth 36:668–674
Baraka AS, Taha SK, Aouad MT, El-Khatib MF, Kawkabani NI (1999) Preoxygenation: comparison of maximal breathing and tidal volume breathing techniques. Anesthesiology 91:612–616
Norris MC, Dewan DM (1985) Preoxygenation for cesarean section: a comparison of two techniques. Anesthesiology 62: 827–829
Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA (2005) Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology 103:645–653
(1993) Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 78:597–602
Johnson MD, Luppi CJ, Over D (1998) Cardiopulmonary resuscitation in pregnancy. In: Gambling DR, Douglas MJ (eds) Obstetric anesthesia and uncommon disorders. WB Saunders, Philadelphia, pp 51–74
Ezri T, Szmuk P, Evron S, Geva D, Hagay Z, Katz J (2001) Difficult airway in obstetric anesthesia: a review. Obstet Gynecol Surv 56:631–641
Suresh MS, Wali A (1998) Failed intubation in obstetrics airway management strategies. Anesthesiol Clin North America 16:477–498
Hawthorne L, Wilson R, Lyons G, Dresner M (1996) Failed intubation revisited: 17-year experience in a teaching maternity unit. Br J Anaesth 76:680–684
Callander CC, Thomas JS (1988) The ethics of difficult tracheal intubation. Anaesthesia 43:703–704
Fuhrman TM, Farina RA (1995) Elective tracheostomy for a patient with a history of difficult intubation. J Clin Anesth 7:250–252
Hawksworth CR, Purdie J (1998) Failed combined spinal epidural then failed intubation at an elective caesarean section. Hosp Med 59:173
Popitz-Bergez FA, Leeson S, Thalhammer JG, Strichartz GR (1997) Intraneural lidocaine uptake compared with analgesic differences between pregnant and nonpregnant rats. Reg Anesth 22:363–371
Taddio A, Stevens B, Craig K, Rastogi P, Ben-David S, Shennan A, Mulligan P, Koren G (1997) Efficacy and safety of lidocaineprilocaine cream for pain during circumcision. N Engl J Med 336:1197–1201
Degler SM, Dowling RD, Sucherman DR, Leighton BL (2005) Awake intubation using an intubating laryngeal mask airway in a parturient with spina bifida. Int J Obstet Anesth 14:77–78
Godley M, Reddy AR (1996) Use of LMA for awake intubation for caesarean section. Can J Anaesth 43:299–302
Shung J, Avidan MS, Ing R, Klein DC, Pott L (1998) Awake intubation of the difficult airway with the intubating laryngeal mask airway. Anaesthesia 53:645–649
Cohn AI, Hart RT, McGraw SR, Blass NH (1995) The Bullard laryngoscope for emergency airway management in a morbidly obese parturient. Anesth Analg 81:872–873
Broomhead CJ, Davies W, Higgins D (1995) Awake oral fibreoptic intubation for caesarean section. Int J Obstet Anesth 4:172–174
Edwards RM (1994) Fibreoptic intubation: a solution to failed intubation in a parturient? Anaesth Intensive Care 22:718–719
McLure HA, Yentis SM (1996) General anaesthesia for caesarean section in a parturient with Noonan’s syndrome. Br J Anaesth 77:665–668
Reid AW, Warmington AD, Wilkinson LM (1999) Management of a pregnant patient with airway obstruction secondary to goitre. Anaesth Intensive Care 27:415–417
Rezig K, Diar N, Benabidallah D, Dardel A (2001) Goiter and pregnancy: a cause of predictable difficult intubation. Ann Fr Anesth Reanim 20:639–642
Wong SY, Wong KM, Chao AS, Liang CC, Hsu JC (2003) Awake fiberoptic intubation for cesarean section in a parturient with odontoid fracture and atlantoaxial subluxation. Chang Gung Med J 26:352–356
Trevisan P (2002) Fibre-optic awake intubation for caesarean section in a parturient with predicted difficult airway. Minerva Anestesiol 68:775–781
Weksler N, Klein M, Weksler D, Sidelnick C, Chorni I, Rozentsveig V, Brill S, Gurman GM, Ovadia L (2004) Retrograde tracheal intubation: beyond fibreoptic endotracheal intubation. Acta Anaesthesiol Scand 48:412–416
Tunstall ME (1989) Failed intubation in the parturient. Can J Anaesth 36:611–613
Minville V, N’Guyen L, Coustet B, Fourcade O, Samii K (2004) Difficult airway in obstetric using Ilma-Fastrach. Anesth Analg 99:1873
Vaida SJ, Gaitini LA (2004) Another case of use of the ProSeal laryngeal mask airway in a difficult obstetric airway. Br J Anaesth 92:905
Han TH, Brimacombe J, Lee EJ, Yang HS (2001) The laryngeal mask airway is effective (and probably safe) in selected healthy parturients for elective Cesarean section: a prospective study of 1067 cases. Can J Anaesth 48:1117–1121
Anderson KJ, Quinlan MJ, Popat M, Russell R (2000) Failed intubation in a parturient with spina bifida. Int J Obstet Anesth 9:64–68
Awan R, Nolan JP, Cook TM (2004) Use of a ProSeal laryngeal mask airway for airway maintenance during emergency Caesarean section after failed tracheal intubation. Br J Anaesth 92:144–146
Chadwick IS, Vohra A (1989) Anaesthesia for emergency caesarean section using the Brain laryngeal airway. Anaesthesia 44:261–262
Keller C, Brimacombe J, Lirk P, Puhringer F (2004) Failed obstetric tracheal intubation and postoperative respiratory support with the ProSeal laryngeal mask airway. Anesth Analg 98:1467–1470
McClune S, Regan M, Moore J (1990) Laryngeal mask airway for caesarean section. Anaesthesia 45:227–228
Gataure PS, Hughes JA (1995) The laryngeal mask airway in obstetrical anaesthesia. Can J Anaesth 42:130–133
Baraka A, Salem R (1993) The Combitube oesophageal-tracheal double lumen airway for difficult intubation. Can J Anaesth 40:1222–1223
Klein H, Williamson M, Sue-Ling HM, Vucevic M, Quinn AC (1997) Esophageal rupture associated with the use of the Combitube. Anesth Analg 85:937–939
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Vasdev, G.M., Harrison, B.A., Keegan, M.T. et al. Management of the difficult and failed airway in obstetric anesthesia. J Anesth 22, 38–48 (2008). https://doi.org/10.1007/s00540-007-0577-z
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DOI: https://doi.org/10.1007/s00540-007-0577-z