Indian Journal of Anaesthesia

: 2012  |  Volume : 56  |  Issue : 2  |  Page : 210--211

Management of difficult airway. Awake and under anaesthesia

Ashish Bangaari, Trevor Nair 
 Department of Anaesthesiology, MIOT Hospitals, Manapakkam, Chennai, Tamil Nadu, India

Correspondence Address:
Ashish Bangaari
Department of Anaesthesiology, MIOT Hospitals, 4/112, Mount Poonamallee Road, Manapakkam, Chennai, Tamil Nadu-600089

How to cite this article:
Bangaari A, Nair T. Management of difficult airway. Awake and under anaesthesia.Indian J Anaesth 2012;56:210-211

How to cite this URL:
Bangaari A, Nair T. Management of difficult airway. Awake and under anaesthesia. Indian J Anaesth [serial online] 2012 [cited 2020 Nov 29 ];56:210-211
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We read with great interest the review article by Dr. Ramkumar on airway for awake intubation [1] and had few additions and suggestions to be made on the content published.

The title of the article is about awake intubation for difficult airway (DA); however, the author mentions in great detail about intubation under anaesthesia, pre-oxygenation with 100% oxygen and muscle relaxants. The title could probably have been, "Management of DA: Awake and under anaesthesia". The author seems preoccupied with fibreoptic intubation (FOI) for management of DA. FOI no doubt is the best available modality for awake DA, but not a panacea for DA management. [2] Retrograde intubation, blind nasal intubation, laryngeal mask and direct laryngoscopy under airway blocks can be performed under expert hands to secure awake DA, and could have been mentioned in detail in the article. We would have liked to read on DA in an emergency situation too. Psychological preparation of the patient mentions that consent for surgical airway or cricothyridotomy is always preferred. A surgical patent and secure airway still remains as the last resort in DA management in spite of latest airway "gadgets", and remains the ultimate rescue measure in emergency DA.

We would like to add on ketamine as an alternate drug for sedation for FOI. Low-dose ketamine is frequently used for paediatric bronchoscopies as well as for conscious sedation DA intubations, either alone or in combination with hypnotics, opiods and sedatives. [3]

The author mentions about fibreoptic bronchoscopy (FOB) under general anaesthesia with muscle relaxants. We feel that if it is easy to mask ventilate the patient, it is preferable to use a non-depolarizing relaxant rather than succinylcholine. It gives enough time for the endoscopist for controlled laryngoscopy and fibrescopy as well as for training students. Moreover, we usually perform a check direct laryngoscopy after FOB to visualize the Cormack Lehane grade. It gives us confidence during extubation of the DA and determines whether reintubation is possible with or without fibreoscopy.

The discussion on airway blocks does not mention the complications of the techniques. They are either common (haematoma, inadvertent arterial injection) or specific to a block, e.g. vascular, posterior tracheal wall and vocal cords damage, subcutaneous emphysema with trans-tracheal block and upper airway obstruction due to relaxation of musculature around the base of the tongue following glossopharyngeal nerve block.


1Ramkumar V. Preparation of the patient and the airway for awake intubation. Indian J Anaesth 2011;55:442-7.
2Ng A, Vas L, Goel S. Difficult paediatric intuabation when fibreoptic laryngoscopy fails. Paediatr Anesth 2002;12:801-5.
3Javid MJ. Subcutaneous dissociative conscious sedation (sDCS) an alternative method for airway regional blocks; A new approach. BMC Anesthesiology 2011;11;19.