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      Difficult airway and difficult intubation in postintubation tracheal stenosis: a case report and literature review

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          Abstract

          Management of a “difficult airway” remains one of the most relevant and challenging tasks for anesthesiologists and pulmonary physicians. Several conditions, such as inflammation, trauma, tumor, and immunologic and metabolic diseases, are considered responsible for the difficult intubation of a critically ill patient. In this case report we present the case of a 46-year-old male with postintubation tracheal stenosis. We will focus on the method of intubation used, since the patient had a “difficult airway” and had to be intubated immediately because he was in a life-threatening situation. Although technology is of utter importance, clinical examination and history-taking remain invaluable for the appropriate evaluation of the critically ill patient in everyday medical life. Every physician who will be required to perform intubation has to be familiar with the evaluation of the difficult airway and, in the event of the unanticipated difficult airway, to be able to use a wide variety of tools and techniques to avoid complications and fatality.

          Most cited references35

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          Difficult tracheal intubation in obstetrics.

          Difficult intubation has been classified into four grades, according to the view obtainable at laryngoscopy. Frequency analysis suggests that, in obstetrics, the main cause of trouble is grade 3, in which the epiglottis can be seen, but not the cords. This group is fairly rare so that a proportion of anaesthetists will not meet the problem in their first few years and may thus be unprepared for it in obstetrics. However the problem can be simulated in routine anaesthesia, so that a drill for managing it can be practised. Laryngoscopy is carried out as usual, then the blade is lowered so that the epiglottis descends and hides the cords. Intubation has to be done blind, using the Macintosh method. This can be helpful as part of the training before starting in the maternity department, supplementing the Aberdeen drill.
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            Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.

            (2003)
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              Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance.

              The objective of this study was to systematically determine the diagnostic accuracy of bedside tests for predicting difficult intubation in patients with no airway pathology. Thirty-five studies (50,760 patients) were selected from electronic databases. The overall incidence of difficult intubation was 5.8% (95% confidence interval, 4.5-7.5%). Screening tests included the Mallampati oropharyngeal classification, thyromental distance, sternomental distance, mouth opening, and Wilson risk score. Each test yielded poor to moderate sensitivity (20-62%) and moderate to fair specificity (82-97%). The most useful bedside test for prediction was found to be a combination of the Mallampati classification and thyromental distance (positive likelihood ratio, 9.9; 95% confidence interval, 3.1-31.9). Currently available screening tests for difficult intubation have only poor to moderate discriminative power when used alone. Combinations of tests add some incremental diagnostic value in comparison to the value of each test alone. The clinical value of bedside screening tests for predicting difficult intubation remains limited.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                Therapeutics and Clinical Risk Management
                Therapeutics and Clinical Risk Management
                Dove Medical Press
                1176-6336
                1178-203X
                2012
                2012
                27 June 2012
                : 8
                : 279-286
                Affiliations
                [1 ]Pulmonary Department, “G Papanikolaou” General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
                [2 ]Cardiothoracic Department, Saint Luke Private Hospital, Thessaloniki, Greece
                [3 ]1st University Surgery Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
                [4 ]Cardiothoracic Department, University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
                [5 ]1st Pulmonary Department, “G Papanikolaou” General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
                [6 ]Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
                [7 ]Neurology Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
                Author notes
                Correspondence: Paul Zarogoulidis, Pulmonary Department, “G Papanikolaou” General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece, Tel +30 697 727 1974, Fax +30 231 099 2433, Email pzarog@ 123456hotmail.com
                Article
                tcrm-8-279
                10.2147/TCRM.S31684
                3395408
                22802693
                0bc10b9a-3d0d-41a7-9090-3e1de7d28e6a
                © 2012 Zarogoulidis et al, publisher and licensee Dove Medical Press Ltd

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                History
                Categories
                Review

                Medicine
                difficult airway,bronchoscopic intubation,predictive factors,predictive scales
                Medicine
                difficult airway, bronchoscopic intubation, predictive factors, predictive scales

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