BACKGROUND Difficult airway management (DAM) is a challenging aspect of anesthetic care. Although nearly all DAM episodes result in successful intubation, complications are common and clinical decision-making may be complex. In adults with anticipated DAM scheduled for nonemergent surgery, we prospectively observed clinical decisions made during DAM such as awake/sedated versus anesthetized, choice of initial and subsequent devices, case cancellation/postponement, conversions between awake and anesthetized approaches, and process complications such as multiple intubation/supraglottic airway (SGA) insertion attempts, difficult bag-mask ventilation (BMV), hypoxemia, and cardiovascular destabilization. METHODS From 2009 to 2014, we prospectively observed 1295 episodes of anticipated DAM in a convenience sample of 1245 adults scheduled for nonemergent surgery. Trained observers recorded airway management decisions and process complications during DAM. We described clinical decisions made during DAM and outcomes including number of attempts, need for BMV, hypoxemia, and cardiovascular destabilization. RESULTS No cases were canceled/postponed for airway management failure and all intubations were eventually successful. Of the 1295 episodes of airway management in our study cohort, 166 (13%) were intubated awake. Patients intubated awake had more difficult airway indicators than those intubated anesthetized, their first-pass success rate was 49%, 30% required ≥3 attempts, 4% required a device change, 50% experienced hypoxemia, and 29% experienced cardiovascular destabilization. Among the 1129 patients intubated while anesthetized, first-pass success rate was 64% and 20% required ≥3 attempts, 11% required a device change, hypoxemia occurred in 30%, and cardiovascular destabilization in 20%. One patient (0.08%) was converted from an anesthetized to an awake approach. Patients with a failed anesthetized intubation attempt and difficult BMV between attempts were at high risk for multiple attempts (67%) and hypoxemia (100%). CONCLUSIONS Airway management was successful in all patients and the incidence of process complications was higher than in routine airway management. Despite a high risk of DAM, 87% of patients were intubated anesthetized and conversions between awake and anesthetized approaches were rare. That patients intubated awake had more difficult airway indicators implies that clinicians reserve awake intubation for particularly difficult airways. The high incidence of multiple attempts, hypoxemia, and cardiovascular destabilization in patients intubated awake suggests that awake airway management remains challenging. We found no clear pattern in device choices after a first failed attempt. Patients with a first failed anesthetized intubation attempt and difficult BMV were at particularly high risk for hypoxemia.

中文翻译：

---

择期手术预期困难气道管理期间的临床决策和过程并发症。


背景 困难的气道管理 （DAM） 是麻醉护理的一个具有挑战性的方面。尽管几乎所有的 DAM 发作都会导致插管成功，但并发症很常见，临床决策可能很复杂。在预期 DAM 计划进行非紧急手术的成人中，我们前瞻性地观察了 DAM 期间做出的临床决策，例如清醒/镇静与麻醉、初始和后续设备的选择、病例取消/推迟、清醒和麻醉方法之间的转换，以及过程并发症，例如多次插管/声门上气道 （SGA） 插入尝试、气囊面罩通气困难 （BMV）、低氧血症和心血管不稳定。方法 从 2009 年到 2014 年，我们在 1295 名计划进行非紧急手术的成年人的便利样本中前瞻性地观察了 1245 次预期 DAM 发作。训练有素的观察者记录了 DAM 期间的气道管理决策和过程并发症。我们描述了 DAM 期间做出的临床决策和结局，包括尝试次数、对 BMV 的需求、低氧血症和心血管不稳定。结果 没有病例因气道管理失败而取消/推迟，所有插管最终均成功。在我们的研究队列的 1295 次气道管理发作中，166 例 （13%） 是清醒插管的。清醒插管患者的气道指标比插管麻醉患者更难，他们的首次通过成功率为 49%，30% 需要 ≥3 次尝试，4% 需要更换设备，50% 出现低氧血症，29% 出现心血管不稳定。 在 1129 名麻醉时插管的患者中，首次通过成功率为 64%，其中 20% 需要 ≥3 次尝试，11% 需要更换设备，30% 发生低氧血症，20% 发生心血管不稳定。1 例患者 （0.08%） 从麻醉转为清醒方法。麻醉插管尝试失败且两次尝试之间 BMV 困难的患者多次尝试 （67%） 和低氧血症 （100%） 的风险较高。结论 所有患者气道管理均成功，过程并发症的发生率高于常规气道管理。尽管 DAM 风险很高，但 87% 的患者接受了插管麻醉，并且清醒和麻醉方法之间的转换很少见。清醒插管患者的气道指标更困难，这意味着临床医生将清醒插管保留给特别困难的气道。清醒插管患者多次尝试、低氧血症和心血管不稳定的高发生率表明清醒气道管理仍然具有挑战性。在第一次尝试失败后，我们发现设备选择没有明确的模式。首次麻醉插管尝试失败且 BMV 困难的患者发生低氧血症的风险特别高。