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Airway management after failure to intubate by direct laryngoscopy: outcomes in a large teaching hospital

[Le contrôle des voies aériennes après l’échec de l’intubation par laryngoscopie directe : résultats obtenus dans un grand hôpital universitaire]

From the Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.

Address correspondence to: Dr. Christopher M. Burkle, Department of Anesthesiology, Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905, USA. Phone: 507-284-9695; Fax: 507-284-0120; E-mail: burkle.christopher{at}mayo.edu

Purpose: The purpose of this single-centre database review was to establish the incidence of failure to intubate by direct laryngoscopy, to measure morbidity and mortality associated with this event, and to examine the use and efficacy of alternative airway devices.

Methods: Difficult intubation via direct laryngoscopy at Mayo Clinic Rochester is recorded in an electronic database using a functional classification: 0 = no difficulty; 1 = mild to moderate difficulty; and 2 = severe difficulty often requiring a change in intubation technique. Using this database, the total number of intubations was determined for a selected review period and the incidence of failure to intubate by direct laryngoscopy was established. Abstraction of chart data allowed for determination of associated morbidity and mortality, success of alternative airway devices, and case cancellation rate.

Results: During the period from August 1, 2001 through December 31, 2002, 37,482 patients underwent general anesthesia with attempted direct laryngoscopy. One hundred sixty-one patients (0.43%) could not be intubated by direct laryngoscopy alone. Morbidity associated with difficult intubation included soft tissue/dental damage (n = 8), intraoperative cardiac arrest (n = 1), and possible aspiration (n = 1). Three patients required intensive care unit admission. There was no associated mortality. The most commonly used alternative airway device was the flexible fibreoptic scope. Five case cancellations resulted from failure to intubate with alternative devices.

Conclusion: The rate of unexpected failure to intubate by direct laryngoscopy is essentially unchanged from earlier studies. While morbidity was low, continued education and early use of alternative difficult airway devices may further limit complications associated with this event.

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