Clinics in Medical Education

The Concept of the Physiologically Difficult Airway

Published October 1, 2024 | Clinics in Medical Education 

Issue 3 | Volume 1 | September 2024

In critical care settings, airway management presents unique challenges, especially when patients exhibit physiological derangements that exacerbate complications during intubation. The term “physiologically difficult airway” refers to patients whose underlying medical conditions make intubation riskier, potentially leading to life-threatening outcomes such as hypoxemia, hypotension, or cardiac arrest. Traditional guidelines for difficult airway management primarily focus on anatomical challenges, but they often overlook these significant physiological considerations.

Physiological Factors Affecting Airway Management:

  1. Hypoxemia: Patients with poor oxygen reserves, such as those with acute respiratory distress syndrome (ARDS) or chronic lung disease, are at heightened risk of rapid oxygen desaturation during intubation. Preoxygenation techniques become crucial for extending safe apnea time, reducing the likelihood of severe oxygen depletion.
  2. Hypotension: Intubation can precipitate hypotension, especially in patients already experiencing shock or heart failure. Peri-intubation hypotension increases the risk of mortality and organ failure, making preemptive hemodynamic management essential.
  3. Right Ventricular Dysfunction: Positive pressure ventilation can exacerbate right ventricular failure, increasing the likelihood of hemodynamic collapse.
  4. Severe Acidosis: Patients with severe metabolic acidosis, such as those in diabetic ketoacidosis, are highly vulnerable to respiratory collapse when ventilatory requirements exceed mechanical support capabilities.

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REFERENCES

1.  Kornas RL, Owyang CG, Sakles JC, Foley LJ, Mosier JM; Society for Airway Management’s Special Projects Committee. Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management. Anesth Analg. PMID: 33060492

2.  Kornas, Rebecca L. MD*; Owyang, Clark G. MD†; Sakles, John C. MD‡; Foley, Lorraine J. MD, MBA§; Mosier, Jarrod M. MD‡,‖; on behalf of the Society for Airway Management’s Special Projects Committee. Evaluation and Management of the Physiologically Difficult Airway: Consensus Recommendations From Society for Airway Management. Anesthesia & Analgesia PMID: 33060492