Difficult airway management and neuromuscular blockade

Gómez-Ríos, M.Á.

doi:10.1016/j.redare.2018.04.011

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Gómez-Ríos" "autores" => array:1 [ 0 => array:3 [ "nombre" => "M.Á." "apellidos" => "Gómez-Ríos" "email" => array:1 [ 0 => "magoris@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departmento de Anestesiología y Medicina Perioperatoria, Complejo Hospitalario Universitario de A Coruña; Hospital HM Modelo, A Coruña, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de la vía aérea difícil y bloqueo neuromuscular" ] ] "textoCompleto" => "We read the letter submitted by Pérez Fernández-Escandon et al.<a class="elsevierStyleCrossRef" href="#bib0040">1</a> in which they present a descriptive study to evaluate the influence of neuromuscular blockade (NMB) on difficult airway management. We would like to add a series of comments that might be of interest.NMB overrides the muscle tone of the upper airway and inhibits oropharyngeal reflexes. In doing so, it reduces the incidence of phenomena such as laryngospasm, optimises chest wall distensibility, and reduces the number of intubation attempts and complications by improving the conditions for intubation, and for this reason it is widely used in airway management. However, there is no unanimous consensus regarding its use in a potentially difficult airway, and its role in the progression to “cannot intubate, cannot oxygenate” (CICO) status. Therefore, we need to consider the evidence currently available. A recent systematic review evaluated the effect of using NMB vs. not using NMB on intubation conditions.<a class="elsevierStyleCrossRef" href="#bib0045">2</a> Avoiding NMB can increase the risk of difficult intubation (RR=P13.27, P<0.00001), difficult laryngoscopy (RR=2.54; P=0.0003), and upper airway discomfort or injury (RR=1.37; P=0.008).<a class="elsevierStyleCrossRef" href="#bib0045">2</a> For this reason, NMB is now becoming standard practice to facilitate face mask ventilation, intubation, or extraglottic device placement in unanticipated difficult airway,<a class="elsevierStyleCrossRefs" href="#bib0050">3,4</a> and is mandatory if front of neck access (FONA) is needed in a CICO situation.<a class="elsevierStyleCrossRefs" href="#bib0050">3,4</a> In this context, rocuronium is a rapid-onset relaxant that can be immediately reversed with sugammadex. The latter, in a CICO situation, is only useful when NMB is contributing or causing the airway obstruction, which is infrequent. It is important to bear in mind sugammadex does not reverse the effect of the other anaesthetic drugs used nor the mechanical obstruction of the airway. It can also cause laryngospasm, and if CICO persists it will be necessary to re-paralyse the patient with a non-aminosteroid NMB before progressing to emergency FONA.<a class="elsevierStyleCrossRef" href="#bib0060">5</a>In general terms, the current recommendation is that NMB should only be avoided in the presence of an anticipated difficult airway, where the technique of choice is awake intubation with awake patient, and when neuromuscular relaxants are contraindicated.<a class="elsevierStyleCrossRef" href="#bib0065">6</a> In any event, it must be borne in mind that all recommendations must be personalised; in other words, each case must be judged individually based on the specific characteristics of each patient.<a class="elsevierStyleCrossRef" href="#bib0070">7</a>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez-Ríos M. Tratamiento de la vía aérea difícil y bloqueo neuromuscular. Rev Esp Anestesiol Reanimac. 2018;65:477–478." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuromuscular blockade in the management of the difficult airway" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Pérez Fernández-Escandon" 1 => "A.I. Fernández Díez" 2 => "R. Pérez Blanco" 3 => "N. Guadalupe Fernández" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2017.07.010" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2018" "volumen" => "65" "paginaInicial" => "176" "paginaFinal" => "178" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28947268" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Avoidance versus use of neuromuscular blocking agents for improving conditions during tracheal intubation or direct laryngoscopy in adults and adolescents" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.H. Lundstrom" 1 => "C.H. Duez" 2 => "A.K. Norskov" 3 => "C.V. Rosenstock" 4 => "J.L. Thomsen" 5 => "A.M. Moller" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/14651858.CD009237.pub2" "Revista" => array:5 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2017" "volumen" => "5" "paginaInicial" => "Cd009237" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28513831" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0050" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Frerk" 1 => "V.S. Mitchell" 2 => "A.F. McNarry" 3 => "C. Mendonca" 4 => "R. Bhagrath" 5 => "A. Patel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aev371" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2015" "volumen" => "115" "paginaInicial" => "827" "paginaFinal" => "848" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26556848" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the management of tracheal intubation in critically ill adults" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Higgs" 1 => "B.A. McGrath" 2 => "C. Goddard" 3 => "J. Rangasami" 4 => "G. Suntharalingam" 5 => "R. Gale" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bja.2017.10.021" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2018" "volumen" => "120" "paginaInicial" => "323" "paginaFinal" => "352" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29406182" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0060" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Strategies for the prevention of airway complications - a narrative review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T.M. 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Allam" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aei006" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2005" "volumen" => "94" "paginaInicial" => "150" "paginaFinal" => "158" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15516354" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0070" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines and algorithms for managing the difficult airway" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.A. Gómez-Ríos" 1 => "L. Gaitini" 2 => "I. Matter" 3 => "M. Somri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2017.07.009" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2018" "volumen" => "65" "paginaInicial" => "41" "paginaFinal" => "48" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29031661" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000008/v1_201810100615/S2341192918301306/v1_201810100615/en/main.assets" "Apartado" => array:4 [ "identificador" => "70434" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Director" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000008/v1_201810100615/S2341192918301306/v1_201810100615/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918301306?idApp=UINPBA00004N"]

ISSN: 2341-1929

Revista Española de Anestesiología y Reanimación (REDAR) -the Spanish Journal of Anesthesiology and Resuscitation- is the scientific body of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy. This is a monthly journal (10 issues) that publishes scientific articles of all areas within its specialty: clinical anesthesia, resuscitation-intensive medicine and critical care, diagnosis and treatment of acute and chronic pain, urgent care and emergencies and studies on basic science and related fields. The journal accepts work in both Spanish and English.

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Vol. 65. Issue 8.