Lost airway during anesthesia induction: alternatives for management

Pediatric and adult patients with upper airway obstruction pose several challenges to the anesthesiologist and otolaryngologist--head and neck surgeon. The initiation of general anesthesia and endotracheal intubation may progress to complete life-threatening respiratory decompensation with failure to achieve endotracheal intubation or mask ventilation. Hurried invasive maneuvers such as large-bore needle tracheal entry and cricothyrotomy are recognized salvage techniques, but other modes of extratracheal ventilation are now possible before surgical airway procedures are required. The laryngeal mask airway and esophagotracheal Combitube (Kendall Sheridan Health Care Products Co., Argyle, NY) are described, with examples of their clinical application. The combined technique of anterior commissure laryngoscopy and intubation with the gum elastic bougie is the preferred alternative for achieving tracheal entry when extratracheal ventilation cannot be accomplished. An algorithm for joint management of the problem airway by anesthesiologist and otolaryngologist--head and neck surgeon is illustrated.