Guidelines and algorithms for managing the difficult airway | Revista Española de Anestesiología y Reanimación (English Edition)

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Gaitini, I. Matter, M. Somri" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.A." "apellidos" => "Gómez-Ríos" "email" => array:1 [ 0 => "magoris@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Gaitini" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Matter" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Somri" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Departamento de Anestesiología y Medicina Perioperativa, Complejo Hospitalario Universitario de A Coruña, La Coruña, Galicia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Grupo de Anestesiología y Tratamiento del Dolor, Instituto de Investigación Biomédica de A Coruña (INIBIC), La Coruña, Galicia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Anesthesiology, Bnai Zion Medical Center, Haifa, Israel" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Surgery, Bnai Zion Medical Center, Haifa, Israel" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Faculty of Medicine, Technion, Institute of Technology, Haifa, Israel" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guías y algoritmos para el manejo de la vía aérea difícil" ] ] "textoCompleto" => "IntroductionIn 1990, Dr. Robert Caplan and his colleagues published “Adverse Respiratory Events in Anesthesiology: A Closed Claims Analysis” in the journal Anesthesiology.<a class="elsevierStyleCrossRef" href="#bib0255">1</a> This article summarised a detailed retrospective analysis of medical-legal litigation over a period of 5 years in the United States. The main causes of most irreversible brain injuries and deaths associated with anaesthetic procedures were found to be difficult tracheal intubation (TI), oesophageal intubation and inadequate ventilation.In the same year, the American Society of Anesthesiologists (ASA) established an Expert Working Group on Difficult Airway Management. The outcome of this group was the “Practice Guidelines for Management of the Difficult Airway”, published in 1993, with subsequent updates in 2003 and 2013<a class="elsevierStyleCrossRef" href="#bib0260">2</a> (Supplementary Figure S1 available online). The UK's Difficult Airway Society (DAS) issued its own recommendations in 2003, which were revised in 2013<a class="elsevierStyleCrossRef" href="#bib0265">3</a> (Supplementary Figure S2 available online).The inability to successfully manage a difficult airway (DA) is responsible for 600 deaths annually and 30% of deaths attributable to anesthesia.<a class="elsevierStyleCrossRef" href="#bib0270">4</a> Evidence consistently indicates that successful DA management requires compliance with specific pre-established strategies. Thus, a number of anaesthesiology societies have developed their own country-specific guidelines and algorithms. All of these aim to simplify protocols and facilitate the management of DA, and to minimise the incidence of adverse outcomes. There are currently no universal algorithms or standards, so guidelines serve only as basic recommendations and not as standards of care or absolute requirements.<a class="elsevierStyleCrossRef" href="#bib0275">5</a> The updated versions of the ASA and DAS guidelines are the most widely used, and have served as a reference for the development of others. The recommendations are based on scientific evidence, rigorous bibliographic analysis and expert opinion.<a class="elsevierStyleCrossRef" href="#bib0280">6</a> All guidelines require periodic updates in light of ongoing technological advances and changes in medical knowledge.Despite the existence of relevant guidelines and algorithms, the National Audit Project 4 (NAP4), developed in 2011 by the Royal College of Anaesthetists and the DAS, showed that reliance on inadequate criteria, together with poor planning and training, were the main determinants of poor outcomes in DA management.<a class="elsevierStyleCrossRef" href="#bib0285">7</a> Cognitive processing and motor skills often deteriorate under situations of stress, such as an unpredicted DA.<a class="elsevierStyleCrossRef" href="#bib0290">8</a> In these scenarios, therefore, a clear pre-established strategy is necessary.<a class="elsevierStyleCrossRef" href="#bib0275">5</a> This article presents a synthesis of the ASA and DAS guidelines and algorithms, with the purpose of facilitating decision-making. The recommendations of these guidelines are complementary, since the limitations of one are supplemented by the other. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the main limitations of both guidelines and algorithms.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>DefinitionsAccording to Gil et al., 18% of patients are difficult to intubate, 5% are difficult to oxygenate and 0.004–0.008% cannot be intubated/oxygenated.<a class="elsevierStyleCrossRef" href="#bib0295">9</a> Determining and comparing the incidence of difficult airway is hampered by the use of varying definitions in the literature.The use of precise terminology is the key to any guideline and algorithm, and enables an adequate progression of strategies. Despite the absence of standard terminology, the ASA algorithms propose a series of definitions.Difficult airwayClinical situation in which an experienced anaesthesiologist with conventional training has difficulty ventilating the upper airway with a face mask (FM) or TI or both.Difficult insertion of a supraglottic airway (SGA)The placement of the SGA requires multiple attempts, in the presence or absence of tracheal pathology.Difficult ventilation with an FM or SGAAdequate ventilation cannot be provided due to one or more of the following problems: inadequate FM or SGA seal, excessive gas leak or excessive resistance to the ingress or egress of gas. Signs of inadequate ventilation include: absent or inadequate chest movement or breath sounds, auscultory signs of severe obstruction, cyanosis, gastric air entry or dilation, decreased or inadequate oxygen saturation, absent or inadequate exhaled carbon dioxide, absent or inadequate spirometric measures of exhaled gas flow, and haemodynamic changes associated with hypoxaemia and hypercapnia (e.g. hypertension, tachycardia, arrhythmias).Difficult laryngoscopyNo portion of the vocal cords is visible, after multiple attempts at conventional laryngoscopy.Difficult tracheal intubationTI requires multiple attempts, in the presence or absence of tracheal pathology.Failed intubationPlacement of the endotracheal tube fails after several attempts.These definitions have their limitations. For example, they do not include specific Cormack–Lehane grades to characterise the visualisation of laryngeal structures, they do not mention the use of adjuvants that can facilitate ventilation, laryngoscopy or TI, and they do not specify the maximum number of attempts. The latter is pivotal in decision-making and helps to avoid the “cannot intubate, cannot oxygenate” (CICO) scenario due to repeated attempts. Most of these deficiencies are addressed by the DAS, which includes descriptions of optimal conditions for ventilation and TI, as well as the definition of a laryngoscopy attempt.Pre-operative evaluation of the airwayBoth the ASA and the DAS guides emphasise the importance of preoperative airway assessment to anticipate potential problems and prepare strategies to reduce adverse outcomes.<a class="elsevierStyleCrossRef" href="#bib0275">5</a> Thus, preoperative airway assessment should be performed routinely to identify factors that could lead to difficulties in ventilation with FM, insertion of an SGA, laryngoscopy, TI, and surgical access.<a class="elsevierStyleCrossRef" href="#bib0300">10</a>While there are multiple predictors of DA (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), none is totally reliable since they all have low sensitivity, specificity and positive predictive value.<a class="elsevierStyleCrossRefs" href="#bib0305">11,12</a> Test combinations must therefore be used to increase reliability.<a class="elsevierStyleCrossRef" href="#bib0300">10</a> However, even in the absence of predictors, a pre-established plan is necessary to overcome any difficulties that may arise.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Another point that is essential in planning the management of DA is the assessment of aspiration risk. Pharmacological measures and preoperative fasting are important for reducing volume and raising the pH of gastric contents. In patients with an intestinal obstruction or with slow gastric emptying, a nasogastric tube should be inserted to minimise residual gastric volume.<a class="elsevierStyleCrossRefs" href="#bib0315">13,14</a>Pre-induction preparationOptimal patient positioning maximises the probability of success and minimises the number of attempts. The “sniffing” position (slight cervical flexion with head in hyperextension) is most frequently used. Ramping (horizontal alignment of the external auditory canal with the suprasternal fork) is necessary for obese patients. Both positions optimise airway patency, respiratory mechanics and passive oxygenation during apnea.<a class="elsevierStyleCrossRef" href="#bib0265">3</a>Adequate pre-oxygenation is imperative for all patients before proceeding to the induction of general anaesthesia (GA). Increasing oxygen reserve delays the onset of hypoxia, allowing more time for airway management. Apnoea time without desaturation is limited to 1–2min in a healthy adult breathing room air; whereas with correct pre-oxygenation, this is extended to 8min.<a class="elsevierStyleCrossRefs" href="#bib0325">15–17</a>Pre-oxygenation can be achieved with the administration of 100% oxygen through a well-sealed FM until the expired oxygen fraction is 0.87–0.90. Other methods include “apnoeic oxygenation”, which involves administering 15L/min of oxygen through a nasal cannula, and positioning the head at a 25° angle in the obese patient with continuous positive airway pressure, and prolonging the duration of apnoea without desaturation.<a class="elsevierStyleCrossRef" href="#bib0265">3</a>Anticipated difficult airway: awake tracheal intubationThis situation focuses on patients who present with characteristics that predict difficulty or with a previous history of DA, and is addressed in the ASA guide. In contrast, the DAS only considers the unanticipated DA.Awake TI is the technique of choice in anticipated DA, since preservation of muscle tone maintains airway patency and facilitates identification of anatomical structures. Moreover, spontaneous ventilation is preserved and prevents the larynx from adopting a more anterior position during anaesthesia induction, thus facilitating TI.The choice of technique (a non-invasive technique using fibreoptic bronchoscopy [FOB], video laryngoscopy [VL] or an SGA versus an invasive technique such as a surgical airway, percutaneous airway, jet ventilation, or retrograde intubation) will depend on the type of surgery, the patient's status and the anaesthesiologist's skills and preferences.Awake TI using FOB is successful in 88–100% of cases.<a class="elsevierStyleCrossRefs" href="#bib0340">18–20</a> To achieve such high success rates the patient must be fully informed about the technique and the risks and carefully prepared (e.g. administer antisialagogues, such as glycopyrrolate, atropine and scopolamine and nasal vasoconstrictors, such as 5% liquid cocaine and phenylephrine).<a class="elsevierStyleCrossRef" href="#bib0355">21</a> Other considerations, such as supplemental oxygen throughout the procedure (e.g. nasal cannula, endoscopic mask),<a class="elsevierStyleCrossRef" href="#bib0360">22</a> safe conscious sedation, maintenance of spontaneous ventilation and patient cooperation,<a class="elsevierStyleCrossRef" href="#bib0355">21</a> and suitable topical or regional anaesthesia that must include oral cavity, oropharynx, larynx and trachea,<a class="elsevierStyleCrossRefs" href="#bib0355">21,23</a> are all important to ensure patient comfort and avoid reflex airway responses, such as coughing or laryngospasm, or sympathetic cardiovascular responses.<a class="elsevierStyleCrossRef" href="#bib0365">23</a> If regional anaesthesia is chosen, the nerves to be blocked are the trigeminal (which innervates the upper airway mucosa), the glossopharyngeal nerve (innervates the oropharynx), and the pneumogastric nerve (innervates the tracheal mucosa).<a class="elsevierStyleCrossRef" href="#bib0355">21</a>Lack of patient cooperation, limited resources and unskilled operators are among the factors that cause a given technique to fail. In the case of failure of awake intubation, an alternative strategy should be selected. If the patient's condition allows, the surgery can be cancelled. This is appropriate in cases where the patient needs to be fully informed, when the airway mucosa presents oedema, bleeding or trauma, or different equipment or personnel are needed. If the surgery cannot be delayed, GA induction may be possible if ventilation with FM or SGA is adequate. Another alternative is to perform regional anaesthesia (neuroaxial or epidural anaesthesia, as appropriate), if feasible. None of these alternatives involve securing the airway, so a plan to deal with a difficult TI must be made. Surgical access of the airway may be the best option in patients with traumatic or obstructive upper airway lesions.Unanticipated difficult airway after induction of general anesthesia or in an unconscious or non-cooperative patientThis section includes cases of predicted DA in which awake TI is not possible (e.g. a paediatric, agitated or unconscious patient), and in which difficult TI is diagnosed after induction of GA (unanticipated DA). The latter is the most common situation and is often caused by poor airway assessment.<a class="elsevierStyleCrossRef" href="#bib0285">7</a> In both situations, the patient may have a full stomach, so the risk of bronchopulmonary aspiration is considerable.The decision-making process is influenced by the patient's characteristics, the urgency of the surgery, and the skills of the operator. The fundamental principle must always be maintaining airway patency, oxygenation, and minimising the risk of aspiration.If FM ventilation is adequate, emergency intubation will not be required. However, if FM ventilation is inadequate, an emergency non-invasive technique (insertion of an SGA) is indicated or, failing this, an invasive surgical technique (surgical, percutaneous airway or jet ventilation). In both cases, help should be summoned immediately, and the feasibility of restoring spontaneous ventilation and awakening the patient should be considered.The possibility of performing ventilation with FM is a key issue in decision-making. Therefore, early ventilation with FM using 100% oxygen after induction of GA is always recommended. This also enables the anaesthetist to assess the convenience of maintaining spontaneous ventilation before performing neuromuscular blockade (NMB). TI can be successfully achieved without NMB, so it is a valid alternative in a suspected DA.Each laryngoscopy and TI attempt can potentially cause airway trauma and worsen the situation further. Therefore, they must be performed under optimum conditions from the start, and the number and duration of attempts should be limited since the probability of success decreases with each attempt. Repeated attempts can cause oedema and bleeding, reduce the likelihood of effective rescue with an SGA, and increase the risk of progression to a CICO scenario. Therefore, the DAS recommends a maximum of 3 TI attempts; a fourth attempt can only be made by an experienced anaesthesiologist.<a class="elsevierStyleCrossRef" href="#bib0265">3</a> After a failed attempt, the same technique should not be repeated, and changes should be introduced in each additional attempt to improve the chances of success. This may include changing the position of the patient, the device or blade, or the depth of NMB, using adjuncts such as introducers and stylet, and calling in a more experienced operator. When all attempts fail, the TI must be declared unsuccessful and the next level of the algorithm should be attempted. Impaired ventilation should indicate the early use of an SGA and, if unsuccessful, the use of surgical access.Gas exchange during and between TI attempts (ventilation with FM) should be maintained using apnoeic oxygenation techniques<a class="elsevierStyleCrossRef" href="#bib0370">24</a> and positive pressure ventilation through an endoscopic mask<a class="elsevierStyleCrossRefs" href="#bib0375">25,26</a> or a laryngeal mask airway (LMA); the latter also serves as a conduit for the FOB.<a class="elsevierStyleCrossRef" href="#bib0385">27</a>All the TI techniques available for an awake patient can also be used for the unconscious or anesthetised patient. However, under such conditions, TI with direct laryngoscopy and FOB is likely to be more difficult, for the reasons discussed above. The choice of technique determines the probability of success. VL offers better glottic vision than conventional direct laryngoscopy, and is currently the first choice for some anesthesiologists.<a class="elsevierStyleCrossRefs" href="#bib0270">4,28</a> FOB or optical stylet may be the preferred technique for skilled operators. The use of FOB should be avoided in an emergency due to technical problems (ventilation, secretions and bleeding), unless used by an experienced operator. In general, any blind technique should be avoided due to the high failure rate and the potential for airway trauma, which can result in further deterioration of ventilation. The first and second choice of laryngoscope will be determined by the experience and training of the anaesthesiologist.Besides poor vision of the laryngeal structures, difficulty in TI may be due to the impossibility of advancing the ETT through the glottis. Small diameter ETTs are easier to insert because they enable better visualisation of the passage between the vocal cords, and cause less trauma. The advance of the ETT can be impeded by arytenoids, especially when guided by an introducer or FOB. This problem can be overcome by counter clockwise rotation of the ETT, by reducing the gauge difference between the FOB or introducer and the ETT, and by using flexible ETTs with a silicone distal end and centre hole. A preconfigured stylet can facilitate TI in grade 2 or grade 3 Cormack–Lehane view. Blind insertion in grades 3b and 4 is not recommended because of the high risk of airway trauma. The use of a stylet is necessary when using a VL with an angled blade without a guide channel.Once TI has been achieved, correct placement should be ascertained by visual confirmation of ETT between the vocal cords, bilateral and symmetrical thoracic expansion, auscultation, and capnography. Availability of the latter is necessary, since this is the gold standard for confirmation of pulmonary ventilation. The utility of ultrasound has also been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0395">29</a>If all TI attempts are unsuccessful, the following should be considered: (1) Awakening the patient. This is the safest option if the intervention can be deferred, and requires complete reversal of NMB. In the case of NMB with rocuronium or vecuronium, reversal is reliably achieved with the administration of sugammadex.<a class="elsevierStyleCrossRefs" href="#bib0400">30,31</a> Surgery may be postponed or performed using awake TI or regional anaesthesia; (2) Attempting TI with FOB via an SGA. This is an option if the clinical condition is stable, oxygenation is possible through an SGA, and the anaesthesiologist is experienced in the technique. As a basic principle, the number of airway interventions should be minimised; thus, repeated attempts are inappropriate. Blind techniques are discouraged because of the frequent need for repeated attempts and the potential complications; (3) Proceeding with surgery using an FM or SGA. If awakening the patient is not an option, for example, in the case of emergent surgery (e.g. caesarean section). This is a high-risk technique and therefore may only be used in life-threatening situations. Ventilation through these devices may be impaired by device malpositioning, regurgitation, airway oedema, or surgical factors; (4) Securing the airway by surgical access (tracheotomy or cricothyroidotomy) before losing ventilation capacity with FM or SGA.Failure of TI and ventilation with FM, without life-threatening hypoxaemia, require insertion of an SGA to maintain oxygenation. The LMA, the Combitube and the laryngeal tube have demonstrated effectiveness in emergency airway rescue in this scenario.<a class="elsevierStyleCrossRef" href="#bib0260">2</a> An observational study found that LMA provided effective rescue ventilation in 94.1% of patients who could not be ventilated with FM or intubated.<a class="elsevierStyleCrossRef" href="#bib0410">32</a> The DAS algorithm includes this step after failure of TI, regardless of whether FM ventilation is feasible. After insertion, correct ventilation should be confirmed by means of clinical examination and capnography, and the surgical team should stop and think in order to decide how best to proceed.Although the guidelines do not clarify a particular order of selection, the type of rescue SGA must be selected before anaesthesia induction. Factors to consider are the clinical situation, availability of the device, its risks and benefits, and operator experience. The ideal features of an SGA for airway rescue are: easy insertion at the first attempt, high oropharyngeal sealing pressure, isolation of the gastrointestinal and the respiratory tract, and FOB-guided TI compatibility. Second-generation SGAs are more effective and safer than first-generation ones, as they provide better sealing and offer greater protection against aspiration; therefore, they should be available in all centers.<a class="elsevierStyleCrossRef" href="#bib0265">3</a>Cricoid pressure reduces the hypopharyngeal space, and can prevent insertion of the SGA. If cricoid pressure is used during fast sequence induction, it must be released during insertion of the device. Importantly, SGAs are not useful in patients with glottic or subglottic obstruction. In such cases, the use of the rigid bronchoscope enables ventilation by establishing a permeable airway beyond the obstruction.The Combitube, when correctly placed, enables ventilation with a higher sealing pressure than the traditional LMA, protects against regurgitation, and allows TI with FOB, while the oesophageal cuff protects the airway.<a class="elsevierStyleCrossRef" href="#bib0415">33</a>Repeated attempts at SGA insertion increase the risks of airway injury, decrease the likelihood of success, and delay the decision to accept failure and to switch to an alternative technique to maintain oxygenation. The DAS recommends a maximum of 3 SGA insertion attempts: 2 with the preferred second generation device, and the third with an alternative SGA. Changing the size of the device is considered a new attempt.<a class="elsevierStyleCrossRef" href="#bib0265">3</a>“Can’t intubate, can’t oxygenate” (CICO) scenarioIf ventilation through FM and SGA is not achieved, or becomes inadequate, invasive airway access should be performed promptly (surgical, percutaneous airway, or transtracheal jet ventilation). Incidence of CICO, a potentially fatal situation that requires immediate action, will vary depending on the setting, patient characteristics and the experience of the physician. Thus, the number of cases increases from 0.002% at the intrahospital level<a class="elsevierStyleCrossRef" href="#bib0265">3</a> to 2% in emergency services.<a class="elsevierStyleCrossRef" href="#bib0420">34</a>In this scenario, the risks associated with an invasive rescue technique should be weighed against the risks of hypoxic brain injury or death. Various surgical techniques and devices have been described, but the evidence does not confirm the superiority of any particular approach.<a class="elsevierStyleCrossRefs" href="#bib0425">35,36</a> In an emergency setting in which cognitive processes and psychomotor coordination are limited, the ideal rescue technique should entail a simple and familiar procedure.<a class="elsevierStyleCrossRef" href="#bib0435">37</a> DAS recommends cricothyroidotomy with a scalpel as the method of choice,<a class="elsevierStyleCrossRef" href="#bib0265">3</a> since this is the fastest and most reliable instrument to secure the airway, and the necessary equipment is available in any location. The technique involves the following: neck extension, identification of the cricothyroid membrane with the index finger, previous stabilisation of the larynx with the non-dominant hand, transverse incision with a number 10 blade scalpel through the skin and the cricothyroid membrane (make a transverse incision with the cutting edge of the blade facing towards you and turn it 90° so that the sharp edge points caudally), gentle insertion of up 10–15cm of an elastic bougie with angled tip through the incision before withdrawing the scalpel blade and railroading a lubricated size 6.0mm cuffed tracheal tube over the bougie into the trachea. The procedure should only be attempted with complete neuromuscular blockade and oxygen (100%) delivered to the upper airway using an SGA, well-adjusted FM, or nasal insufflation. In cases where the cricothyroid membrane is not palpable (e.g. an obese patient), a previous caudocephalic central incision of 8–10cm and a digital dissection of the adipose tissue are recommended to identify laryngeal structures.<a class="elsevierStyleCrossRef" href="#bib0265">3</a>The foregoing technique has several advantages: it protects the airway from aspiration, and enables normal minute ventilation with low pressure and end-tidal CO2 monitoring. However, most anaesthesiologists do not feel competent to perform it.<a class="elsevierStyleCrossRef" href="#bib0285">7</a> In the case of an unexpected DA, a properly trained surgeon may not be immediately available. Anesthesiologists must therefore learn to perform a cricothyroidotomy with a scalpel and maintain their competence in the technique with periodic refresher training.Transtracheal jet ventilation is another relatively easy-to-perform invasive technique that can save lives and provide the time needed to secure a definitive airway. However, this approach has significant limitations, since it involves inserting a small-calibre cannula (<4mm) into the cricothyroid membrane using the Seldinger technique (the cannula can become kinked or displaced) and requires a high-pressure oxygen source of 20–50psi. Transtracheal jet ventilation is associated with significant morbidity and a high risk of complications, such as subcutaneous emphysema and barotrauma.<a class="elsevierStyleCrossRefs" href="#bib0440">38,39</a> Moreover, it cannot be used in patients with upper airway obstruction, because it could produce tension pneumothorax. Ravussin® cannulas (VBM, Sulz, Germany) and various types of devices for jet ventilation are available on the market, the Manujet® (VBM, Sulz, Germany) being the most popular.Extubation and postoperative careApproximately one-third of complications occur during extubation or in the postoperative period.<a class="elsevierStyleCrossRef" href="#bib0450">40</a>Current evidence does not provide sufficient basis for assessing the benefits of any specific DA extubation strategy. Nonetheless, a safe, carefully considered strategy should be followed, taking into account the type of surgery, the patient's condition, and the clinician's abilities and preferences. The ideal method of extubation is gradual, step by step, and reversible at any time. The ASA recommends weighing up the relative merits of awake extubation versus extubation before the return of consciousness, assessing the presence of clinical factors that may impair ventilation after extubation (e.g. altered mental status, abnormal gas exchange, airway oedema, an inability to eliminate secretions, and inadequate return of neuromuscular function), putting in place a pre-established airway management plan in the event that spontaneous ventilation is ineffective after extubation (for example, the equipment necessary to deal with a DA), and considering the short-term use of an ETT exchanger or a jet stylet that serves as a ventilation and guidance device for TI.Postoperative surveillance is essential for diagnosing and treating possible adverse effects which could otherwise go unnoticed. Any instrumentation and manipulation of a DA can cause trauma or complications, such as oedema, haemorrhage, oesophageal or tracheal perforation, pneumothorax or pulmonary aspiration. Airway complications have been reported after the use of VL, second generation SGAs, and FOB.<a class="elsevierStyleCrossRefs" href="#bib0455">41–43</a>Pharyngeal and oesophageal lesions are the most frequent complications after difficult TI. They usually manifest clinically in the postoperative period; however, they are difficult to diagnose. Pneumothorax, pneumomediastinum, and emphysema are only present in 50% of cases. Post-perforation mediastinitis of the airway has a high mortality risk, therefore, the patient should be closely monitored in order to rule out the clinical triad of pain (deep cervical pain, chest pain, and dysphagia), fever, and crepitation. Likewise, patients should also be warned of possible signs and symptoms associated with complications that result from the treatment of DA. If late symptoms appear, they should seek medical attention immediately.<a class="elsevierStyleCrossRef" href="#bib0470">44</a>In the postoperative period, it is essential to document in detail the difficulty encountered in ventilation and TI, and to describe the techniques used, indicating their success or failure.<a class="elsevierStyleCrossRef" href="#bib0475">45</a> Informing the patient and adding notifications, medical alerts, or registering the event in a DA database is useful.<a class="elsevierStyleCrossRef" href="#bib0475">45</a>Algorithms developed by other anesthesiological societiesSeveral countries have published their own algorithms through their respective anaesthesiology societies. Following the first algorithm published by the ASA, France (in 1996), Canada<a class="elsevierStyleCrossRefs" href="#bib0480">46,47</a> (in 2013), Italy<a class="elsevierStyleCrossRef" href="#bib0490">48</a> (in 2005) and Germany<a class="elsevierStyleCrossRef" href="#bib0495">49</a> (in 2015) developed their own.All these algorithms, like the ASA and DAS, emphasise the importance of predicting a difficult airway and the need for a pre-formulated strategy to increase safety, limit trauma, and prioritise oxygenation/ventilation, the use of various devices and techniques, and the need to develop skills and maintain competence.<a class="elsevierStyleCrossRef" href="#bib0500">50</a> They also they indicate that all airway material should be correctly classified, transportable, and immediately and easily accessible in order to facilitate quick resolution of difficult cases. Most of the relevant documents currently available present recommendations based on systematic reviews, with levels of evidence regarding the prediction of DA, the treatment of anticipated an unexpected DA, CICO scenario and extubation of DA. Like the ASA algorithm, the Italian, German and French guidelines incorporate all the scenarios into a single document. In contrast, the Canadian Society developed separate guidelines for each situation, comparable to the DAS. Likewise, the guidelines consider awake TI as the strategy of choice for predicted DA; the FOB as the gold standard for DA in the awake, sedated, or anesthetised patient, and for controlling ETT positioning; VL as a superior alternative to direct laryngoscopy for the primary management of DA, and as an excellent rescue device after DA failure; and the SGA as a non-invasive rescue method when FM ventilation is not possible.The guidelines differ mainly in specific details, such as algorithm organisation, the number of suggested TI attempts, alternative devices, and recommended surgical access techniques. Thus, unlike the ASA and DAS, which focus on cricothyroidotomy, the German and Canadian guidelines recommend the transtracheal airway approach, and the French and Italian guidelines recommend the percutaneous approach, which is guided by the Seldinger technique. Nonetheless, there is no clear evidence of the superiority of any particular technique. Interestingly, the ASA remains the only guideline that takes into account emergency tracheotomy, which other guidelines consider too risky and time-consuming, especially when compared to surgical cricothyroidotomy.ConclusionThe first algorithm, the “Practice Guidelines for Management of the Difficult Airway”, issued by the ASA in 1993, together with later versions issued in 2003 and 2013, marked a turning point in airway management. Since then, numerous anaesthesiology societies have developed their own algorithms, one of the most important being the DAS, which was updated in 2015.All guidelines and algorithms on this subject are important insofar as they have changed clinical practice by encouraging professionals to plan specific strategies to address DA. However, in the absence of a universally accepted protocol, available guidelines are intended only as basic recommendations and not as standards of care or absolute requirements, and thus should not replace local institutional policies. Guidelines should be adapted to the specific skills and individual judgement of anaesthesiologists, to the availability of devices in each centre, and to patient characteristics. Practitioners should develop their own individual strategies, based on their knowledge and clinical experience. Techniques selected should be routinely applied prior to their application in a real-life DA. This assures the best means of facing the challenges of DA management.Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres978758" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec947849" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres978757" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec947848" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Definitions" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Difficult airway" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Difficult insertion of a supraglottic airway (SGA)" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Difficult ventilation with an FM or SGA" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Difficult laryngoscopy" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Difficult tracheal intubation" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Failed intubation" ] ] ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Pre-operative evaluation of the airway" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Pre-induction preparation" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Anticipated difficult airway: awake tracheal intubation" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Unanticipated difficult airway after induction of general anesthesia or in an unconscious or non-cooperative patient" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "“Can’t intubate, can’t oxygenate” (CICO) scenario" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Extubation and postoperative care" ] 12 => array:2 [ "identificador" => "sec0075" "titulo" => "Algorithms developed by other anesthesiological societies" ] 13 => array:2 [ "identificador" => "sec0080" "titulo" => "Conclusion" ] 14 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of interest" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-07-01" "fechaAceptado" => "2017-07-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec947849" "palabras" => array:5 [ 0 => "Guidelines" 1 => "Algorithms" 2 => "Airway" 3 => "Difficult airway" 4 => "Anaesthesia" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec947848" "palabras" => array:5 [ 0 => "Guías" 1 => "Algoritmos" 2 => "Vía aérea" 3 => "Vía aérea difícil" 4 => "Anestesia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The difficult airway constitutes a continuous challenge for anesthesiologists. Guidelines and algorithms are key to preserving patient safety, by recommending specific plans and strategies that address predicted or unexpected difficult airway. However, there are currently no “gold standard” algorithms or universally accepted standards. The aim of this article is to present a synthesis of the recommendations of the main guidelines and difficult airway algorithms." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La vía aérea difícil constituye un continuo desafío para el anestesiólogo y su tratamiento es una de las tareas de mayor exigencia al representar un riesgo vital. Las guías y algoritmos juegan un papel clave en la preservación de la seguridad del paciente al recomendar planes y estrategias específicos para abordar la vía aérea difícil prevista o inesperada. Sin embargo, no existen actualmente algoritmos «de referencia», ni estándares universalmente aceptados. El objetivo de este artículo es presentar una síntesis de las recomendaciones de las principales guías y algoritmos de la vía aérea difícil." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Gómez-Ríos MA, Gaitini L, Matter I, Somri M. Guías y algoritmos para el manejo de la vía aérea difícil. Rev Esp Anestesiol Reanim. 2018;65:41–48." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "TThis article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page:" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0095" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">American Society of Anesthesiologists (ASA) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No specific considerations for paediatric and obstetric patients, patients with a full stomach, and patients with glottic or subglottic obstruction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Poorly defined terminology with no definition of attempt, optimal ventilation attempt with a face mask, and optimal attempt by conventional laryngoscopy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No discussion of the implications of neuromuscular relaxants or the role of regional anaesthesia in patients with difficult airway \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No discrimination between an obstructed or unobstructed airway \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The clinical endpoint is successful tracheal intubation (TI), but this may not be necessary if ventilation is adequate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The algorithm begins with TI failure, but difficulty ventilating with an FM or a supraglottic device may have been the initial problem. Thus, the algorithm can direct the clinician to interventions that have already proven ineffective \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Does not follow a linear decision tree; this limits its usefulness in an emergency situation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Does not present a flow chart for extubation \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1658231.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Difficult Airway Society (DAS) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Only addresses the management of unexpected DA \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Does not list individual techniques in relation to levels of evidence \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1658232.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Limitations of the guidelines and algorithms of the American Society of Anesthesiologists and the Difficult Airway Society." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Predictors \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Normal \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Interincisor distance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>4cm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mallampati-Samsoon classification \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Grade I–II \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neck \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Elastic and flexible \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thyromental distance (Patil's test) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>6cm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mandibular protrusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ability to protrude the lower jaw beyond the upper incisors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atlanto-occipital joint \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cervical extension of 35° \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sterno-mental distance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>12cm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">History of previous intubation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No difficulty or sequelae \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1658233.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Predictors of difficult airways." ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 90422 ] ] 3 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc2.pdf" "ficheroTamanyo" => 83023 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:50 [ 0 => array:3 [ "identificador" => "bib0255" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse respiratory events in anesthesia: a closed claims analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "R.A. Caplan" 1 => "K.L. Posner" 2 => "R.J. Ward" 3 => "F.W. Cheney" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "1990" "volumen" => "72" "paginaInicial" => "828" "paginaFinal" => "833" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2339799" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0260" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "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" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.L. Apfelbaum" 1 => "C.A. Hagberg" 2 => "R.A. Caplan" 3 => "C.D. Blitt" 4 => "R.T. Connis" 5 => "D.G. Nickinovich" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e31827773b2" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2013" "volumen" => "118" "paginaInicial" => "251" "paginaFinal" => "270" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23364566" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0265" "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" => "bib0270" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Can fiberoptic bronchoscopy be replaced by video laryngoscopy in the management of difficult airway?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.A. Gómez-Ríos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2015.11.008" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2016" "volumen" => "63" "paginaInicial" => "189" "paginaFinal" => "191" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26778672" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0275" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is there a gold standard for management of the difficult airway?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.A. Artime" 1 => "C.A. Hagberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anclin.2015.02.011" "Revista" => array:6 [ "tituloSerie" => "Anesthesiol Clin" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "233" "paginaFinal" => "240" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25998999" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0280" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An evidence-based approach to airway management: is there a role for clinical practice guidelines?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E.T. Crosby" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2044.2011.06940.x" "Revista" => array:7 [ "tituloSerie" => "Anaesthesia" "fecha" => "2011" "volumen" => "66" "numero" => "Suppl. 2" "paginaInicial" => "112" "paginaFinal" => "118" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22074085" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0285" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.M. Cook" 1 => "N. Woodall" 2 => "C. Frerk" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aer058" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2011" "volumen" => "106" "paginaInicial" => "617" "paginaFinal" => "631" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21447488" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0290" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cognitive errors detected in anaesthesiology: a literature review and pilot study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.P. Stiegler" 1 => "J.P. Neelankavil" 2 => "C. Canales" 3 => "A. Dhillon" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aer387" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2012" "volumen" => "108" "paginaInicial" => "229" "paginaFinal" => "235" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22157846" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0295" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[Chapter 13]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fiberoptic and flexible endoscopic-aided techniques. Benumof and Hagberg's Airway Management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K.S.L. Gil" 1 => "P.A. Diemunsch" 2 => "C.A. Hagberg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:6 [ "edicion" => "3rd ed." "fecha" => "2013" "paginaInicial" => "365" "paginaFinal" => "411" "editorial" => "W.B. Saunders" "editorialLocalizacion" => "Philadelphia" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0300" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessment before airway management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. Baker" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anclin.2015.02.001" "Revista" => array:6 [ "tituloSerie" => "Anesthesiol Clin" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "257" "paginaFinal" => "278" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25999001" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0305" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Shiga" 1 => "Z. Wajima" 2 => "T. Inoue" 3 => "A. Sakamoto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2005" "volumen" => "103" "paginaInicial" => "429" "paginaFinal" => "437" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16052126" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0310" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188064 patients registered in the Danish Anaesthesia Database" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.K. Norskov" 1 => "C.V. Rosenstock" 2 => "J. Wetterslev" 3 => "G. Astrup" 4 => "A. Afshari" 5 => "L.H. Lundstrom" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/anae.12955" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "2015" "volumen" => "70" "paginaInicial" => "272" "paginaFinal" => "281" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25511370" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0315" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary aspiration during procedural sedation: a comprehensive systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.M. Green" 1 => "K.P. Mason" 2 => "B.S. Krauss" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aex004" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2017" "volumen" => "118" "paginaInicial" => "344" "paginaFinal" => "354" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28186265" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0320" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute intraoperative pulmonary aspiration" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "K.S. Nason" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.thorsurg.2015.04.011" "Revista" => array:6 [ "tituloSerie" => "Thorac Surg Clin" "fecha" => "2015" "volumen" => "25" "paginaInicial" => "301" "paginaFinal" => "307" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26210926" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0325" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preoxygenation: physiologic basis. Benefits, and potential risks" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "U. Nimmagadda" 1 => "M.R. Salem" 2 => "G.J. Crystal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0000000000001589" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2017" "volumen" => "124" "paginaInicial" => "507" "paginaFinal" => "517" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28099321" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0330" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preoxygenation and prevention of desaturation during emergency airway management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.D. Weingart" 1 => "R.M. Levitan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.annemergmed.2011.10.002" "Revista" => array:6 [ "tituloSerie" => "Ann Emerg Med" "fecha" => "2012" "volumen" => "59" "paginaInicial" => "165" "paginaFinal" => "175.e1" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22050948" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0335" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.K. Ramachandran" 1 => "A. Cosnowski" 2 => "A. Shanks" 3 => "C.R. Turner" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jclinane.2009.05.006" "Revista" => array:6 [ "tituloSerie" => "J Clin Anesth" "fecha" => "2010" "volumen" => "22" "paginaInicial" => "164" "paginaFinal" => "168" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20400000" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0340" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Awake endotracheal intubation in patients with cervical spine disease: a comparison of the Bullard laryngoscope and the fiberoptic bronchoscope" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.I. Cohn" 1 => "M.H. Zornow" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "1995" "volumen" => "81" "paginaInicial" => "1283" "paginaFinal" => "1286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7486117" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0345" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Awake fibreoptic intubation in the patient at high risk of aspiration" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Ovassapian" 1 => "T.C. Krejcie" 2 => "S.J. Yelich" 3 => "M.H. Dykes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "1989" "volumen" => "62" "paginaInicial" => "13" "paginaFinal" => "16" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2917109" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0350" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A comparison of anesthetic techniques for awake intubation in neurosurgical patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D.K. Reasoner" 1 => "D.S. Warner" 2 => "M.M. Todd" 3 => "S.W. Hunt" 4 => "J. Kirchner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Neurosurg Anesthesiol" "fecha" => "1995" "volumen" => "7" "paginaInicial" => "94" "paginaFinal" => "99" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7772974" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0355" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preparing to perform an awake fiberoptic intubation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.E. Walsh" 1 => "G.D. Shorten" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Yale J Biol Med" "fecha" => "1998" "volumen" => "71" "paginaInicial" => "537" "paginaFinal" => "549" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10604785" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0360" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Optimizing oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Badiger" 1 => "M. John" 2 => "R.A. Fearnley" 3 => "I. Ahmad" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aev262" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2015" "volumen" => "115" "paginaInicial" => "629" "paginaFinal" => "632" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26253608" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0365" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Airway anesthesia: theory and practice" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.J. Doyle" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anclin.2015.02.013" "Revista" => array:6 [ "tituloSerie" => "Anesthesiol Clin" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "291" "paginaFinal" => "304" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25999003" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0370" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings: a narrative review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D.T. Wong" 1 => "A.J. Yee" 2 => "S.M. Leong" 3 => "F. Chung" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12630-016-0802-z" "Revista" => array:6 [ "tituloSerie" => "Can J Anaesth" "fecha" => "2017" "volumen" => "64" "paginaInicial" => "416" "paginaFinal" => "427" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28050802" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0375" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A novel non-invasive ventilation mask to prevent and manage respiratory failure during fiberoptic bronchoscopy, gastroscopy and transesophageal echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L. Cabrini" 1 => "G. Landoni" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Heart Lung Vessel" "fecha" => "2015" "volumen" => "7" "paginaInicial" => "297" "paginaFinal" => "303" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26811835" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0380" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical application of a novel endoscopic mask: a randomized controlled trial in aged patients undergoing painless gastroscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Cai" 1 => "Z. Huang" 2 => "T. Zou" 3 => "M. He" 4 => "S. Wang" 5 => "P. Huang" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.7150/ijms.16919" "Revista" => array:6 [ "tituloSerie" => "Int J Med Sci" "fecha" => "2017" "volumen" => "14" "paginaInicial" => "167" "paginaFinal" => "172" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28260993" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0385" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aids for facilitation of difficult tracheal intubation review and recent advances" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Muallem" 1 => "A. Baraka" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Middle East J Anaesthesiol" "fecha" => "2012" "volumen" => "21" "paginaInicial" => "785" "paginaFinal" => "791" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23634559" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0390" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Videolaryngoscopy as a new standard of care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Zaouter" 1 => "J. Calderon" 2 => "T.M. Hemmerling" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aeu266" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2015" "volumen" => "114" "paginaInicial" => "181" "paginaFinal" => "183" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25150988" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0395" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasonography for endotracheal tube position in infants and children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Jaeel" 1 => "M. Sheth" 2 => "J. Nguyen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00431-017-2848-5" "Revista" => array:6 [ "tituloSerie" => "Eur J Pediatr" "fecha" => "2017" "volumen" => "176" "paginaInicial" => "293" "paginaFinal" => "300" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28091777" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0400" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sugammadex: a revolutionary approach to neuromuscular antagonism" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A.F. Kopman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2006" "volumen" => "104" "paginaInicial" => "631" "paginaFinal" => "633" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16571954" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0405" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reversal of rocuronium-induced neuromuscular block by the selective relaxant binding agent sugammadex: a dose-finding and safety study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I.F. Sorgenfrei" 1 => "K. Norrild" 2 => "P.B. Larsen" 3 => "J. Stensballe" 4 => "D. Ostergaard" 5 => "M.E. Prins" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2006" "volumen" => "104" "paginaInicial" => "667" "paginaFinal" => "674" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16571960" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0410" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated difficult tracheal intubation along with difficult mask ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.L. Parmet" 1 => "P. Colonna-Romano" 2 => "J.C. Horrow" 3 => "F. Miller" 4 => "J. Gonzales" 5 => "H. Rosenberg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "1998" "volumen" => "87" "paginaInicial" => "661" "paginaFinal" => "665" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9728849" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0415" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fiberoptic-guided airway exchange of the esophageal-tracheal Combitube in spontaneously breathing versus mechanically ventilated patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L.A. Gaitini" 1 => "S.J. Vaida" 2 => "M. Somri" 3 => "M. Fradis" 4 => "B. Ben-David" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "1999" "volumen" => "88" "paginaInicial" => "193" "paginaFinal" => "196" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9895091" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0420" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Variation in the type, rate, and selection of patients for out-of-hospital airway procedures among injured children and adults" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.D. Newgard" 1 => "K. Koprowicz" 2 => "H. Wang" 3 => "A. Monnig" 4 => "J.D. Kerby" 5 => "G.K. Sears" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1553-2712.2009.00604.x" "Revista" => array:6 [ "tituloSerie" => "Acad Emerg Med" "fecha" => "2009" "volumen" => "16" "paginaInicial" => "1269" "paginaFinal" => "1276" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20053248" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0425" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Emergency cricothyrotomy – a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Langvad" 1 => "P.K. Hyldmo" 2 => "A.R. Nakstad" 3 => "G.E. Vist" 4 => "M. Sandberg" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1757-7241-21-43" "Revista" => array:5 [ "tituloSerie" => "Scand J Trauma Resusc Emerg Med" "fecha" => "2013" "volumen" => "21" "paginaInicial" => "43" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23725520" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0430" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of cricothyrotomy, tracheostomy, and percutaneous tracheostomy in airway management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.A. Akulian" 1 => "L. Yarmus" 2 => "D. Feller-Kopman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anclin.2015.02.009" "Revista" => array:6 [ "tituloSerie" => "Anesthesiol Clin" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "357" "paginaFinal" => "367" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25999008" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0435" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous emergency airway access; prevention, preparation, technique and training" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.S. Kristensen" 1 => "W.H. Teoh" 2 => "P.A. Baker" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aev029" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2015" "volumen" => "114" "paginaInicial" => "357" "paginaFinal" => "361" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25694555" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0440" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transtracheal jet ventilation in 50 patients with severe airway compromise and stridor" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D.J. Ross-Anderson" 1 => "C. Ferguson" 2 => "A. Patel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aeq278" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2011" "volumen" => "106" "paginaInicial" => "140" "paginaFinal" => "144" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20952426" "web" => "Medline" ] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0445" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pneumo-thorax/mediastinum/(retro)peritoneum/scrotum – a full house of complications following JET ventilation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "T.F. Pezier" 1 => "G.M. Widmer" 2 => "G.F. Huber" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.14639/0392-100X-726" "Revista" => array:6 [ "tituloSerie" => "Acta Otorhinolaryngol Ital" "fecha" => "2017" "volumen" => "37" "paginaInicial" => "72" "paginaFinal" => "75" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27070540" "web" => "Medline" ] ] ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0450" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Difficult Airway Society guidelines for the management of tracheal extubation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Popat" 1 => "V. Mitchell" 2 => "R. Dravid" 3 => "A. Patel" 4 => "C. Swampillai" 5 => "A. Higgs" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2044.2012.07075.x" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "2012" "volumen" => "67" "paginaInicial" => "318" "paginaFinal" => "340" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22321104" "web" => "Medline" ] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0455" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications associated with the use of the GlideScope videolaryngoscope" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.M. Cooper" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Can J Anaesth" "fecha" => "2007" "volumen" => "54" "paginaInicial" => "54" "paginaFinal" => "57" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17197469" "web" => "Medline" ] ] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0460" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence of and risk factors for difficult ventilation via a supraglottic airway device in a population of 14,480 patients from South-East Asia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T. Saito" 1 => "W. Liu" 2 => "S.T. Chew" 3 => "L.K. Ti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/anae.13153" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "2015" "volumen" => "70" "paginaInicial" => "1079" "paginaFinal" => "1083" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26052860" "web" => "Medline" ] ] ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0465" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fiberoptic intubation: an overview and update" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.R. Collins" 1 => "R.S. Blank" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4187/respcare.03012" "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2014" "volumen" => "59" "paginaInicial" => "865" "paginaFinal" => "878" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24891196" "web" => "Medline" ] ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0470" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of laryngeal mask airway vs. tracheal intubation: a systematic review on airway complications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.F. Van Esch" 1 => "I. Stegeman" 2 => "A.L. Smit" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jclinane.2016.10.004" "Revista" => array:6 [ "tituloSerie" => "J Clin Anesth" "fecha" => "2017" "volumen" => "36" "paginaInicial" => "142" "paginaFinal" => "150" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28183554" "web" => "Medline" ] ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0475" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "What we all should know about our patient's airway: difficult airway communications. Database registries, and reporting systems registries" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Feinleib" 1 => "L. Foley" 2 => "L. Mark" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anclin.2015.02.010" "Revista" => array:6 [ "tituloSerie" => "Anesthesiol Clin" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "397" "paginaFinal" => "413" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25999011" "web" => "Medline" ] ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0480" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The difficult airway with recommendations for management – Part 1. Difficult tracheal intubation encountered in an unconscious/induced patient" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Law" 1 => "N. Broemling" 2 => "R.M. Cooper" 3 => "P. Drolet" 4 => "L.V. Duggan" 5 => "D.E. Griesdale" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s12630-013-0019-3" "Revista" => array:6 [ "tituloSerie" => "Can J Anaesth" "fecha" => "2013" "volumen" => "60" "paginaInicial" => "1089" "paginaFinal" => "1118" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24132407" "web" => "Medline" ] ] ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0485" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The difficult airway with recommendations for management– Part 2. The anticipated difficult airway" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.A. Law" 1 => "N. Broemling" 2 => "R.M. Cooper" 3 => "P. Drolet" 4 => "L.V. Duggan" 5 => "D.E. 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Continuing education

Guidelines and algorithms for managing the difficult airway

Guías y algoritmos para el manejo de la vía aérea difícil

M.A. Gómez-Ríosa,b,

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magoris@hotmail.com

Corresponding author.

, L. Gaitinic,e, I. Matterd,e, M. Somric,d

a Departamento de Anestesiología y Medicina Perioperativa, Complejo Hospitalario Universitario de A Coruña, La Coruña, Galicia, Spain

b Grupo de Anestesiología y Tratamiento del Dolor, Instituto de Investigación Biomédica de A Coruña (INIBIC), La Coruña, Galicia, Spain

c Department of Anesthesiology, Bnai Zion Medical Center, Haifa, Israel

d Department of Surgery, Bnai Zion Medical Center, Haifa, Israel

e Faculty of Medicine, Technion, Institute of Technology, Haifa, Israel

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            "entidad" => "Department of Surgery&#44; Bnai Zion Medical Center&#44; Haifa&#44; Israel"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Faculty of Medicine&#44; Technion&#44; Institute of Technology&#44; Haifa&#44; Israel"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Gu&#237;as y algoritmos para el manejo de la v&#237;a a&#233;rea dif&#237;cil"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In 1990&#44; Dr&#46; Robert Caplan and his colleagues published &#8220;<span class="elsevierStyleItalic">Adverse Respiratory Events in Anesthesiology&#58; A Closed Claims Analysis</span>&#8221; in the journal <span class="elsevierStyleItalic">Anesthesiology</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">1</span></a> This article summarised a detailed retrospective analysis of medical-legal litigation over a period of 5 years in the United States&#46; The main causes of most irreversible brain injuries and deaths associated with anaesthetic procedures were found to be difficult tracheal intubation &#40;TI&#41;&#44; oesophageal intubation and inadequate ventilation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the same year&#44; the American Society of Anesthesiologists &#40;ASA&#41; established an Expert Working Group on Difficult Airway Management&#46; The outcome of this group was the &#8220;<span class="elsevierStyleItalic">Practice Guidelines for Management of the Difficult Airway</span>&#8221;&#44; published in 1993&#44; with subsequent updates in 2003 and 2013<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">2</span></a> &#40;Supplementary Figure S1 available online&#41;&#46; The UK&#39;s Difficult Airway Society &#40;DAS&#41; issued its own recommendations in 2003&#44; which were revised in 2013<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a> &#40;Supplementary Figure S2 available online&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The inability to successfully manage a difficult airway &#40;DA&#41; is responsible for 600 deaths annually and 30&#37; of deaths attributable to anesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">4</span></a> Evidence consistently indicates that successful DA management requires compliance with specific pre-established strategies&#46; Thus&#44; a number of anaesthesiology societies have developed their own country-specific guidelines and algorithms&#46; All of these aim to simplify protocols and facilitate the management of DA&#44; and to minimise the incidence of adverse outcomes&#46; There are currently no universal algorithms or standards&#44; so guidelines serve only as basic recommendations and not as standards of care or absolute requirements&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">5</span></a> The updated versions of the ASA and DAS guidelines are the most widely used&#44; and have served as a reference for the development of others&#46; The recommendations are based on scientific evidence&#44; rigorous bibliographic analysis and expert opinion&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">6</span></a> All guidelines require periodic updates in light of ongoing technological advances and changes in medical knowledge&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the existence of relevant guidelines and algorithms&#44; the National Audit Project 4 &#40;NAP4&#41;&#44; developed in 2011 by the Royal College of Anaesthetists and the DAS&#44; showed that reliance on inadequate criteria&#44; together with poor planning and training&#44; were the main determinants of poor outcomes in DA management&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">7</span></a> Cognitive processing and motor skills often deteriorate under situations of stress&#44; such as an unpredicted DA&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">8</span></a> In these scenarios&#44; therefore&#44; a clear pre-established strategy is necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">5</span></a> This article presents a synthesis of the ASA and DAS guidelines and algorithms&#44; with the purpose of facilitating decision-making&#46; The recommendations of these guidelines are complementary&#44; since the limitations of one are supplemented by the other&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the main limitations of both guidelines and algorithms&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definitions</span><p id="par0025" class="elsevierStylePara elsevierViewall">According to Gil et al&#46;&#44; 18&#37; of patients are difficult to intubate&#44; 5&#37; are difficult to oxygenate and 0&#46;004&#8211;0&#46;008&#37; cannot be intubated&#47;oxygenated&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">9</span></a> Determining and comparing the incidence of difficult airway is hampered by the use of varying definitions in the literature&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The use of precise terminology is the key to any guideline and algorithm&#44; and enables an adequate progression of strategies&#46; Despite the absence of standard terminology&#44; the ASA algorithms propose a series of definitions&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Difficult airway</span><p id="par0035" class="elsevierStylePara elsevierViewall">Clinical situation in which an experienced anaesthesiologist with conventional training has difficulty ventilating the upper airway with a face mask &#40;FM&#41; or TI or both&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Difficult insertion of a supraglottic airway &#40;SGA&#41;</span><p id="par0040" class="elsevierStylePara elsevierViewall">The placement of the SGA requires multiple attempts&#44; in the presence or absence of tracheal pathology&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Difficult ventilation with an FM or SGA</span><p id="par0045" class="elsevierStylePara elsevierViewall">Adequate ventilation cannot be provided due to one or more of the following problems&#58; inadequate FM or SGA seal&#44; excessive gas leak or excessive resistance to the ingress or egress of gas&#46; Signs of inadequate ventilation include&#58; absent or inadequate chest movement or breath sounds&#44; auscultory signs of severe obstruction&#44; cyanosis&#44; gastric air entry or dilation&#44; decreased or inadequate oxygen saturation&#44; absent or inadequate exhaled carbon dioxide&#44; absent or inadequate spirometric measures of exhaled gas flow&#44; and haemodynamic changes associated with hypoxaemia and hypercapnia &#40;e&#46;g&#46; hypertension&#44; tachycardia&#44; arrhythmias&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Difficult laryngoscopy</span><p id="par0050" class="elsevierStylePara elsevierViewall">No portion of the vocal cords is visible&#44; after multiple attempts at conventional laryngoscopy&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Difficult tracheal intubation</span><p id="par0055" class="elsevierStylePara elsevierViewall">TI requires multiple attempts&#44; in the presence or absence of tracheal pathology&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Failed intubation</span><p id="par0060" class="elsevierStylePara elsevierViewall">Placement of the endotracheal tube fails after several attempts&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">These definitions have their limitations&#46; For example&#44; they do not include specific Cormack&#8211;Lehane grades to characterise the visualisation of laryngeal structures&#44; they do not mention the use of adjuvants that can facilitate ventilation&#44; laryngoscopy or TI&#44; and they do not specify the maximum number of attempts&#46; The latter is pivotal in decision-making and helps to avoid the &#8220;cannot intubate&#44; cannot oxygenate&#8221; &#40;CICO&#41; scenario due to repeated attempts&#46; Most of these deficiencies are addressed by the DAS&#44; which includes descriptions of optimal conditions for ventilation and TI&#44; as well as the definition of a laryngoscopy attempt&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pre-operative evaluation of the airway</span><p id="par0070" class="elsevierStylePara elsevierViewall">Both the ASA and the DAS guides emphasise the importance of preoperative airway assessment to anticipate potential problems and prepare strategies to reduce adverse outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">5</span></a> Thus&#44; preoperative airway assessment should be performed routinely to identify factors that could lead to difficulties in ventilation with FM&#44; insertion of an SGA&#44; laryngoscopy&#44; TI&#44; and surgical access&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">While there are multiple predictors of DA &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; none is totally reliable since they all have low sensitivity&#44; specificity and positive predictive value&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">11&#44;12</span></a> Test combinations must therefore be used to increase reliability&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">10</span></a> However&#44; even in the absence of predictors&#44; a pre-established plan is necessary to overcome any difficulties that may arise&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Another point that is essential in planning the management of DA is the assessment of aspiration risk&#46; Pharmacological measures and preoperative fasting are important for reducing volume and raising the pH of gastric contents&#46; In patients with an intestinal obstruction or with slow gastric emptying&#44; a nasogastric tube should be inserted to minimise residual gastric volume&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">13&#44;14</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Pre-induction preparation</span><p id="par0085" class="elsevierStylePara elsevierViewall">Optimal patient positioning maximises the probability of success and minimises the number of attempts&#46; The &#8220;sniffing&#8221; position &#40;slight cervical flexion with head in hyperextension&#41; is most frequently used&#46; Ramping &#40;horizontal alignment of the external auditory canal with the suprasternal fork&#41; is necessary for obese patients&#46; Both positions optimise airway patency&#44; respiratory mechanics and passive oxygenation during apnea&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Adequate pre-oxygenation is imperative for all patients before proceeding to the induction of general anaesthesia &#40;GA&#41;&#46; Increasing oxygen reserve delays the onset of hypoxia&#44; allowing more time for airway management&#46; Apnoea time without desaturation is limited to 1&#8211;2<span class="elsevierStyleHsp" style=""></span>min in a healthy adult breathing room air&#59; whereas with correct pre-oxygenation&#44; this is extended to 8<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">15&#8211;17</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Pre-oxygenation can be achieved with the administration of 100&#37; oxygen through a well-sealed FM until the expired oxygen fraction is 0&#46;87&#8211;0&#46;90&#46; Other methods include &#8220;apnoeic oxygenation&#8221;&#44; which involves administering 15<span class="elsevierStyleHsp" style=""></span>L&#47;min of oxygen through a nasal cannula&#44; and positioning the head at a 25&#176; angle in the obese patient with continuous positive airway pressure&#44; and prolonging the duration of apnoea without desaturation&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Anticipated difficult airway&#58; awake tracheal intubation</span><p id="par0100" class="elsevierStylePara elsevierViewall">This situation focuses on patients who present with characteristics that predict difficulty or with a previous history of DA&#44; and is addressed in the ASA guide&#46; In contrast&#44; the DAS only considers the unanticipated DA&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Awake TI is the technique of choice in anticipated DA&#44; since preservation of muscle tone maintains airway patency and facilitates identification of anatomical structures&#46; Moreover&#44; spontaneous ventilation is preserved and prevents the larynx from adopting a more anterior position during anaesthesia induction&#44; thus facilitating TI&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The choice of technique &#40;a non-invasive technique using fibreoptic bronchoscopy &#91;FOB&#93;&#44; video laryngoscopy &#91;VL&#93; or an SGA versus an invasive technique such as a surgical airway&#44; percutaneous airway&#44; jet ventilation&#44; or retrograde intubation&#41; will depend on the type of surgery&#44; the patient&#39;s status and the anaesthesiologist&#39;s skills and preferences&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Awake TI using FOB is successful in 88&#8211;100&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">18&#8211;20</span></a> To achieve such high success rates the patient must be fully informed about the technique and the risks and carefully prepared &#40;e&#46;g&#46; administer antisialagogues&#44; such as glycopyrrolate&#44; atropine and scopolamine and nasal vasoconstrictors&#44; such as 5&#37; liquid cocaine and phenylephrine&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">21</span></a> Other considerations&#44; such as supplemental oxygen throughout the procedure &#40;e&#46;g&#46; nasal cannula&#44; endoscopic mask&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">22</span></a> safe conscious sedation&#44; maintenance of spontaneous ventilation and patient cooperation&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">21</span></a> and suitable topical or regional anaesthesia that must include oral cavity&#44; oropharynx&#44; larynx and trachea&#44;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">21&#44;23</span></a> are all important to ensure patient comfort and avoid reflex airway responses&#44; such as coughing or laryngospasm&#44; or sympathetic cardiovascular responses&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">23</span></a> If regional anaesthesia is chosen&#44; the nerves to be blocked are the trigeminal &#40;which innervates the upper airway mucosa&#41;&#44; the glossopharyngeal nerve &#40;innervates the oropharynx&#41;&#44; and the pneumogastric nerve &#40;innervates the tracheal mucosa&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">21</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Lack of patient cooperation&#44; limited resources and unskilled operators are among the factors that cause a given technique to fail&#46; In the case of failure of awake intubation&#44; an alternative strategy should be selected&#46; If the patient&#39;s condition allows&#44; the surgery can be cancelled&#46; This is appropriate in cases where the patient needs to be fully informed&#44; when the airway mucosa presents oedema&#44; bleeding or trauma&#44; or different equipment or personnel are needed&#46; If the surgery cannot be delayed&#44; GA induction may be possible if ventilation with FM or SGA is adequate&#46; Another alternative is to perform regional anaesthesia &#40;neuroaxial or epidural anaesthesia&#44; as appropriate&#41;&#44; if feasible&#46; None of these alternatives involve securing the airway&#44; so a plan to deal with a difficult TI must be made&#46; Surgical access of the airway may be the best option in patients with traumatic or obstructive upper airway lesions&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Unanticipated difficult airway after induction of general anesthesia or in an unconscious or non-cooperative patient</span><p id="par0125" class="elsevierStylePara elsevierViewall">This section includes cases of predicted DA in which awake TI is not possible &#40;e&#46;g&#46; a paediatric&#44; agitated or unconscious patient&#41;&#44; and in which difficult TI is diagnosed after induction of GA &#40;unanticipated DA&#41;&#46; The latter is the most common situation and is often caused by poor airway assessment&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">7</span></a> In both situations&#44; the patient may have a full stomach&#44; so the risk of bronchopulmonary aspiration is considerable&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The decision-making process is influenced by the patient&#39;s characteristics&#44; the urgency of the surgery&#44; and the skills of the operator&#46; The fundamental principle must always be maintaining airway patency&#44; oxygenation&#44; and minimising the risk of aspiration&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">If FM ventilation is adequate&#44; emergency intubation will not be required&#46; However&#44; if FM ventilation is inadequate&#44; an emergency non-invasive technique &#40;insertion of an SGA&#41; is indicated or&#44; failing this&#44; an invasive surgical technique &#40;surgical&#44; percutaneous airway or jet ventilation&#41;&#46; In both cases&#44; help should be summoned immediately&#44; and the feasibility of restoring spontaneous ventilation and awakening the patient should be considered&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The possibility of performing ventilation with FM is a key issue in decision-making&#46; Therefore&#44; early ventilation with FM using 100&#37; oxygen after induction of GA is always recommended&#46; This also enables the anaesthetist to assess the convenience of maintaining spontaneous ventilation before performing neuromuscular blockade &#40;NMB&#41;&#46; TI can be successfully achieved without NMB&#44; so it is a valid alternative in a suspected DA&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Each laryngoscopy and TI attempt can potentially cause airway trauma and worsen the situation further&#46; Therefore&#44; they must be performed under optimum conditions from the start&#44; and the number and duration of attempts should be limited since the probability of success decreases with each attempt&#46; Repeated attempts can cause oedema and bleeding&#44; reduce the likelihood of effective rescue with an SGA&#44; and increase the risk of progression to a CICO scenario&#46; Therefore&#44; the DAS recommends a maximum of 3 TI attempts&#59; a fourth attempt can only be made by an experienced anaesthesiologist&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a> After a failed attempt&#44; the same technique should not be repeated&#44; and changes should be introduced in each additional attempt to improve the chances of success&#46; This may include changing the position of the patient&#44; the device or blade&#44; or the depth of NMB&#44; using adjuncts such as introducers and stylet&#44; and calling in a more experienced operator&#46; When all attempts fail&#44; the TI must be declared unsuccessful and the next level of the algorithm should be attempted&#46; Impaired ventilation should indicate the early use of an SGA and&#44; if unsuccessful&#44; the use of surgical access&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Gas exchange during and between TI attempts &#40;ventilation with FM&#41; should be maintained using apnoeic oxygenation techniques<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">24</span></a> and positive pressure ventilation through an endoscopic mask<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">25&#44;26</span></a> or a laryngeal mask airway &#40;LMA&#41;&#59; the latter also serves as a conduit for the FOB&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">27</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">All the TI techniques available for an awake patient can also be used for the unconscious or anesthetised patient&#46; However&#44; under such conditions&#44; TI with direct laryngoscopy and FOB is likely to be more difficult&#44; for the reasons discussed above&#46; The choice of technique determines the probability of success&#46; VL offers better glottic vision than conventional direct laryngoscopy&#44; and is currently the first choice for some anesthesiologists&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">4&#44;28</span></a> FOB or optical stylet may be the preferred technique for skilled operators&#46; The use of FOB should be avoided in an emergency due to technical problems &#40;ventilation&#44; secretions and bleeding&#41;&#44; unless used by an experienced operator&#46; In general&#44; any blind technique should be avoided due to the high failure rate and the potential for airway trauma&#44; which can result in further deterioration of ventilation&#46; The first and second choice of laryngoscope will be determined by the experience and training of the anaesthesiologist&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Besides poor vision of the laryngeal structures&#44; difficulty in TI may be due to the impossibility of advancing the ETT through the glottis&#46; Small diameter ETTs are easier to insert because they enable better visualisation of the passage between the vocal cords&#44; and cause less trauma&#46; The advance of the ETT can be impeded by arytenoids&#44; especially when guided by an introducer or FOB&#46; This problem can be overcome by counter clockwise rotation of the ETT&#44; by reducing the gauge difference between the FOB or introducer and the ETT&#44; and by using flexible ETTs with a silicone distal end and centre hole&#46; A preconfigured stylet can facilitate TI in grade 2 or grade 3 Cormack&#8211;Lehane view&#46; Blind insertion in grades 3b and 4 is not recommended because of the high risk of airway trauma&#46; The use of a stylet is necessary when using a VL with an angled blade without a guide channel&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Once TI has been achieved&#44; correct placement should be ascertained by visual confirmation of ETT between the vocal cords&#44; bilateral and symmetrical thoracic expansion&#44; auscultation&#44; and capnography&#46; Availability of the latter is necessary&#44; since this is the gold standard for confirmation of pulmonary ventilation&#46; The utility of ultrasound has also been demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">29</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">If all TI attempts are unsuccessful&#44; the following should be considered&#58; &#40;1&#41; Awakening the patient&#46; This is the safest option if the intervention can be deferred&#44; and requires complete reversal of NMB&#46; In the case of NMB with rocuronium or vecuronium&#44; reversal is reliably achieved with the administration of sugammadex&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">30&#44;31</span></a> Surgery may be postponed or performed using awake TI or regional anaesthesia&#59; &#40;2&#41; Attempting TI with FOB via an SGA&#46; This is an option if the clinical condition is stable&#44; oxygenation is possible through an SGA&#44; and the anaesthesiologist is experienced in the technique&#46; As a basic principle&#44; the number of airway interventions should be minimised&#59; thus&#44; repeated attempts are inappropriate&#46; Blind techniques are discouraged because of the frequent need for repeated attempts and the potential complications&#59; &#40;3&#41; Proceeding with surgery using an FM or SGA&#46; If awakening the patient is not an option&#44; for example&#44; in the case of emergent surgery &#40;e&#46;g&#46; caesarean section&#41;&#46; This is a high-risk technique and therefore may only be used in life-threatening situations&#46; Ventilation through these devices may be impaired by device malpositioning&#44; regurgitation&#44; airway oedema&#44; or surgical factors&#59; &#40;4&#41; Securing the airway by surgical access &#40;tracheotomy or cricothyroidotomy&#41; before losing ventilation capacity with FM or SGA&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Failure of TI and ventilation with FM&#44; without life-threatening hypoxaemia&#44; require insertion of an SGA to maintain oxygenation&#46; The LMA&#44; the Combitube and the laryngeal tube have demonstrated effectiveness in emergency airway rescue in this scenario&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">2</span></a> An observational study found that LMA provided effective rescue ventilation in 94&#46;1&#37; of patients who could not be ventilated with FM or intubated&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">32</span></a> The DAS algorithm includes this step after failure of TI&#44; regardless of whether FM ventilation is feasible&#46; After insertion&#44; correct ventilation should be confirmed by means of clinical examination and capnography&#44; and the surgical team should stop and think in order to decide how best to proceed&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Although the guidelines do not clarify a particular order of selection&#44; the type of rescue SGA must be selected before anaesthesia induction&#46; Factors to consider are the clinical situation&#44; availability of the device&#44; its risks and benefits&#44; and operator experience&#46; The ideal features of an SGA for airway rescue are&#58; easy insertion at the first attempt&#44; high oropharyngeal sealing pressure&#44; isolation of the gastrointestinal and the respiratory tract&#44; and FOB-guided TI compatibility&#46; Second-generation SGAs are more effective and safer than first-generation ones&#44; as they provide better sealing and offer greater protection against aspiration&#59; therefore&#44; they should be available in all centers&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Cricoid pressure reduces the hypopharyngeal space&#44; and can prevent insertion of the SGA&#46; If cricoid pressure is used during fast sequence induction&#44; it must be released during insertion of the device&#46; Importantly&#44; SGAs are not useful in patients with glottic or subglottic obstruction&#46; In such cases&#44; the use of the rigid bronchoscope enables ventilation by establishing a permeable airway beyond the obstruction&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The Combitube&#44; when correctly placed&#44; enables ventilation with a higher sealing pressure than the traditional LMA&#44; protects against regurgitation&#44; and allows TI with FOB&#44; while the oesophageal cuff protects the airway&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">33</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Repeated attempts at SGA insertion increase the risks of airway injury&#44; decrease the likelihood of success&#44; and delay the decision to accept failure and to switch to an alternative technique to maintain oxygenation&#46; The DAS recommends a maximum of 3 SGA insertion attempts&#58; 2 with the preferred second generation device&#44; and the third with an alternative SGA&#46; Changing the size of the device is considered a new attempt&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">&#8220;Can&#8217;t intubate&#44; can&#8217;t oxygenate&#8221; &#40;CICO&#41; scenario</span><p id="par0200" class="elsevierStylePara elsevierViewall">If ventilation through FM and SGA is not achieved&#44; or becomes inadequate&#44; invasive airway access should be performed promptly &#40;surgical&#44; percutaneous airway&#44; or transtracheal jet ventilation&#41;&#46; Incidence of CICO&#44; a potentially fatal situation that requires immediate action&#44; will vary depending on the setting&#44; patient characteristics and the experience of the physician&#46; Thus&#44; the number of cases increases from 0&#46;002&#37; at the intrahospital level<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a> to 2&#37; in emergency services&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">34</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">In this scenario&#44; the risks associated with an invasive rescue technique should be weighed against the risks of hypoxic brain injury or death&#46; Various surgical techniques and devices have been described&#44; but the evidence does not confirm the superiority of any particular approach&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">35&#44;36</span></a> In an emergency setting in which cognitive processes and psychomotor coordination are limited&#44; the ideal rescue technique should entail a simple and familiar procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">37</span></a> DAS recommends cricothyroidotomy with a scalpel as the method of choice&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a> since this is the fastest and most reliable instrument to secure the airway&#44; and the necessary equipment is available in any location&#46; The technique involves the following&#58; neck extension&#44; identification of the cricothyroid membrane with the index finger&#44; previous stabilisation of the larynx with the non-dominant hand&#44; transverse incision with a number 10 blade scalpel through the skin and the cricothyroid membrane &#40;make a transverse incision with the cutting edge of the blade facing towards you and turn it 90&#176; so that the sharp edge points caudally&#41;&#44; gentle insertion of up 10&#8211;15<span class="elsevierStyleHsp" style=""></span>cm of an elastic bougie with angled tip through the incision before withdrawing the scalpel blade and railroading a lubricated size 6&#46;0<span class="elsevierStyleHsp" style=""></span>mm cuffed tracheal tube over the bougie into the trachea&#46; The procedure should only be attempted with complete neuromuscular blockade and oxygen &#40;100&#37;&#41; delivered to the upper airway using an SGA&#44; well-adjusted FM&#44; or nasal insufflation&#46; In cases where the cricothyroid membrane is not palpable &#40;e&#46;g&#46; an obese patient&#41;&#44; a previous caudocephalic central incision of 8&#8211;10<span class="elsevierStyleHsp" style=""></span>cm and a digital dissection of the adipose tissue are recommended to identify laryngeal structures&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">3</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">The foregoing technique has several advantages&#58; it protects the airway from aspiration&#44; and enables normal minute ventilation with low pressure and end-tidal CO<span class="elsevierStyleInf">2</span> monitoring&#46; However&#44; most anaesthesiologists do not feel competent to perform it&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">7</span></a> In the case of an unexpected DA&#44; a properly trained surgeon may not be immediately available&#46; Anesthesiologists must therefore learn to perform a cricothyroidotomy with a scalpel and maintain their competence in the technique with periodic refresher training&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Transtracheal jet ventilation is another relatively easy-to-perform invasive technique that can save lives and provide the time needed to secure a definitive airway&#46; However&#44; this approach has significant limitations&#44; since it involves inserting a small-calibre cannula &#40;&#60;4<span class="elsevierStyleHsp" style=""></span>mm&#41; into the cricothyroid membrane using the Seldinger technique &#40;the cannula can become kinked or displaced&#41; and requires a high-pressure oxygen source of 20&#8211;50<span class="elsevierStyleHsp" style=""></span>psi&#46; Transtracheal jet ventilation is associated with significant morbidity and a high risk of complications&#44; such as subcutaneous emphysema and barotrauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">38&#44;39</span></a> Moreover&#44; it cannot be used in patients with upper airway obstruction&#44; because it could produce tension pneumothorax&#46; Ravussin<span class="elsevierStyleSup">&#174;</span> cannulas &#40;VBM&#44; Sulz&#44; Germany&#41; and various types of devices for jet ventilation are available on the market&#44; the Manujet<span class="elsevierStyleSup">&#174;</span> &#40;VBM&#44; Sulz&#44; Germany&#41; being the most popular&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Extubation and postoperative care</span><p id="par0220" class="elsevierStylePara elsevierViewall">Approximately one-third of complications occur during extubation or in the postoperative period&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">40</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Current evidence does not provide sufficient basis for assessing the benefits of any specific DA extubation strategy&#46; Nonetheless&#44; a safe&#44; carefully considered strategy should be followed&#44; taking into account the type of surgery&#44; the patient&#39;s condition&#44; and the clinician&#39;s abilities and preferences&#46; The ideal method of extubation is gradual&#44; step by step&#44; and reversible at any time&#46; The ASA recommends weighing up the relative merits of awake extubation versus extubation before the return of consciousness&#44; assessing the presence of clinical factors that may impair ventilation after extubation &#40;e&#46;g&#46; altered mental status&#44; abnormal gas exchange&#44; airway oedema&#44; an inability to eliminate secretions&#44; and inadequate return of neuromuscular function&#41;&#44; putting in place a pre-established airway management plan in the event that spontaneous ventilation is ineffective after extubation &#40;for example&#44; the equipment necessary to deal with a DA&#41;&#44; and considering the short-term use of an ETT exchanger or a jet stylet that serves as a ventilation and guidance device for TI&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Postoperative surveillance is essential for diagnosing and treating possible adverse effects which could otherwise go unnoticed&#46; Any instrumentation and manipulation of a DA can cause trauma or complications&#44; such as oedema&#44; haemorrhage&#44; oesophageal or tracheal perforation&#44; pneumothorax or pulmonary aspiration&#46; Airway complications have been reported after the use of VL&#44; second generation SGAs&#44; and FOB&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">41&#8211;43</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Pharyngeal and oesophageal lesions are the most frequent complications after difficult TI&#46; They usually manifest clinically in the postoperative period&#59; however&#44; they are difficult to diagnose&#46; Pneumothorax&#44; pneumomediastinum&#44; and emphysema are only present in 50&#37; of cases&#46; Post-perforation mediastinitis of the airway has a high mortality risk&#44; therefore&#44; the patient should be closely monitored in order to rule out the clinical triad of pain &#40;deep cervical pain&#44; chest pain&#44; and dysphagia&#41;&#44; fever&#44; and crepitation&#46; Likewise&#44; patients should also be warned of possible signs and symptoms associated with complications that result from the treatment of DA&#46; If late symptoms appear&#44; they should seek medical attention immediately&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">44</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">In the postoperative period&#44; it is essential to document in detail the difficulty encountered in ventilation and TI&#44; and to describe the techniques used&#44; indicating their success or failure&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">45</span></a> Informing the patient and adding notifications&#44; medical alerts&#44; or registering the event in a DA database is useful&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Algorithms developed by other anesthesiological societies</span><p id="par0245" class="elsevierStylePara elsevierViewall">Several countries have published their own algorithms through their respective anaesthesiology societies&#46; Following the first algorithm published by the ASA&#44; France &#40;in 1996&#41;&#44; Canada<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">46&#44;47</span></a> &#40;in 2013&#41;&#44; Italy<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">48</span></a> &#40;in 2005&#41; and Germany<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">49</span></a> &#40;in 2015&#41; developed their own&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">All these algorithms&#44; like the ASA and DAS&#44; emphasise the importance of predicting a difficult airway and the need for a pre-formulated strategy to increase safety&#44; limit trauma&#44; and prioritise oxygenation&#47;ventilation&#44; the use of various devices and techniques&#44; and the need to develop skills and maintain competence&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">50</span></a> They also they indicate that all airway material should be correctly classified&#44; transportable&#44; and immediately and easily accessible in order to facilitate quick resolution of difficult cases&#46; Most of the relevant documents currently available present recommendations based on systematic reviews&#44; with levels of evidence regarding the prediction of DA&#44; the treatment of anticipated an unexpected DA&#44; CICO scenario and extubation of DA&#46; Like the ASA algorithm&#44; the Italian&#44; German and French guidelines incorporate all the scenarios into a single document&#46; In contrast&#44; the Canadian Society developed separate guidelines for each situation&#44; comparable to the DAS&#46; Likewise&#44; the guidelines consider awake TI as the strategy of choice for predicted DA&#59; the FOB as the gold standard for DA in the awake&#44; sedated&#44; or anesthetised patient&#44; and for controlling ETT positioning&#59; VL as a superior alternative to direct laryngoscopy for the primary management of DA&#44; and as an excellent rescue device after DA failure&#59; and the SGA as a non-invasive rescue method when FM ventilation is not possible&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The guidelines differ mainly in specific details&#44; such as algorithm organisation&#44; the number of suggested TI attempts&#44; alternative devices&#44; and recommended surgical access techniques&#46; Thus&#44; unlike the ASA and DAS&#44; which focus on cricothyroidotomy&#44; the German and Canadian guidelines recommend the transtracheal airway approach&#44; and the French and Italian guidelines recommend the percutaneous approach&#44; which is guided by the Seldinger technique&#46; Nonetheless&#44; there is no clear evidence of the superiority of any particular technique&#46; Interestingly&#44; the ASA remains the only guideline that takes into account emergency tracheotomy&#44; which other guidelines consider too risky and time-consuming&#44; especially when compared to surgical cricothyroidotomy&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusion</span><p id="par0260" class="elsevierStylePara elsevierViewall">The first algorithm&#44; the &#8220;<span class="elsevierStyleItalic">Practice Guidelines for Management of the Difficult Airway</span>&#8221;&#44; issued by the ASA in 1993&#44; together with later versions issued in 2003 and 2013&#44; marked a turning point in airway management&#46; Since then&#44; numerous anaesthesiology societies have developed their own algorithms&#44; one of the most important being the DAS&#44; which was updated in 2015&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">All guidelines and algorithms on this subject are important insofar as they have changed clinical practice by encouraging professionals to plan specific strategies to address DA&#46; However&#44; in the absence of a universally accepted protocol&#44; available guidelines are intended only as basic recommendations and not as standards of care or absolute requirements&#44; and thus should not replace local institutional policies&#46; Guidelines should be adapted to the specific skills and individual judgement of anaesthesiologists&#44; to the availability of devices in each centre&#44; and to patient characteristics&#46; Practitioners should develop their own individual strategies&#44; based on their knowledge and clinical experience&#46; Techniques selected should be routinely applied prior to their application in a real-life DA&#46; This assures the best means of facing the challenges of DA management&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0270" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The difficult airway constitutes a continuous challenge for anesthesiologists&#46; Guidelines and algorithms are key to preserving patient safety&#44; by recommending specific plans and strategies that address predicted or unexpected difficult airway&#46; However&#44; there are currently no &#8220;gold standard&#8221; algorithms or universally accepted standards&#46; The aim of this article is to present a synthesis of the recommendations of the main guidelines and difficult airway algorithms&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La v&#237;a a&#233;rea dif&#237;cil constituye un continuo desaf&#237;o para el anestesi&#243;logo y su tratamiento es una de las tareas de mayor exigencia al representar un riesgo vital&#46; Las gu&#237;as y algoritmos juegan un papel clave en la preservaci&#243;n de la seguridad del paciente al recomendar planes y estrategias espec&#237;ficos para abordar la v&#237;a a&#233;rea dif&#237;cil prevista o inesperada&#46; Sin embargo&#44; no existen actualmente algoritmos &#171;de referencia&#187;&#44; ni est&#225;ndares universalmente aceptados&#46; El objetivo de este art&#237;culo es presentar una s&#237;ntesis de las recomendaciones de las principales gu&#237;as y algoritmos de la v&#237;a a&#233;rea dif&#237;cil&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez-R&#237;os MA&#44; Gaitini L&#44; Matter I&#44; Somri M&#46; Gu&#237;as y algoritmos para el manejo de la v&#237;a a&#233;rea dif&#237;cil&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;41&#8211;48&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">TThis article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program&#46; An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page&#58;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">American Society of Anesthesiologists &#40;ASA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No specific considerations for paediatric and obstetric patients&#44; patients with a full stomach&#44; and patients with glottic or subglottic obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Poorly defined terminology with no definition of attempt&#44; optimal ventilation attempt with a face mask&#44; and optimal attempt by conventional laryngoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No discussion of the implications of neuromuscular relaxants or the role of regional anaesthesia in patients with difficult airway&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No discrimination between an obstructed or unobstructed airway&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The clinical endpoint is successful tracheal intubation &#40;TI&#41;&#44; but this may not be necessary if ventilation is adequate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">The algorithm begins with TI failure&#44; but difficulty ventilating with an FM or a supraglottic device may have been the initial problem&#46; Thus&#44; the algorithm can direct the clinician to interventions that have already proven ineffective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Does not follow a linear decision tree&#59; this limits its usefulness in an emergency situation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Does not present a flow chart for extubation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Difficult Airway Society &#40;DAS&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Only addresses the management of unexpected DA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Does not list individual techniques in relation to levels of evidence&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Adverse respiratory events in anesthesia&#58; a closed claims analysis"
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                          "autores" => array:4 [
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                            3 => "F&#46;W&#46; Cheney"
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                        "paginaFinal" => "833"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Practice guidelines for management of the difficult airway&#58; an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway"
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                      "titulo" => "Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults"
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                            5 => "A&#46; Patel"
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                      "doi" => "10.1093/bja/aev371"
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                      "titulo" => "Can fiberoptic bronchoscopy be replaced by video laryngoscopy in the management of difficult airway&#63;"
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                          "autores" => array:1 [
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                    0 => array:2 [
                      "doi" => "10.1016/j.redar.2015.11.008"
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                        "tituloSerie" => "Rev Esp Anestesiol Reanim"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.anclin.2015.02.011"
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                        "tituloSerie" => "Anesthesiol Clin"
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                    0 => array:2 [
                      "titulo" => "An evidence-based approach to airway management&#58; is there a role for clinical practice guidelines&#63;"
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                          "autores" => array:1 [
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                        "link" => array:1 [
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                        "paginaInicial" => "507"
                        "paginaFinal" => "517"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28099321"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Preoxygenation and prevention of desaturation during emergency airway management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "S&#46;D&#46; Weingart"
                            1 => "R&#46;M&#46; Levitan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.annemergmed.2011.10.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Emerg Med"
                        "fecha" => "2012"
                        "volumen" => "59"
                        "paginaInicial" => "165"
                        "paginaFinal" => "175&#46;e1"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22050948"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0335"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Apneic oxygenation during prolonged laryngoscopy in obese patients&#58; a randomized&#44; controlled trial of nasal oxygen administration"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46;K&#46; Ramachandran"
                            1 => "A&#46; Cosnowski"
                            2 => "A&#46; Shanks"
                            3 => "C&#46;R&#46; Turner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jclinane.2009.05.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Anesth"
                        "fecha" => "2010"
                        "volumen" => "22"
                        "paginaInicial" => "164"
                        "paginaFinal" => "168"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20400000"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0340"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Awake endotracheal intubation in patients with cervical spine disease&#58; a comparison of the Bullard laryngoscope and the fiberoptic bronchoscope"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;I&#46; Cohn"
                            1 => "M&#46;H&#46; Zornow"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "1995"
                        "volumen" => "81"
                        "paginaInicial" => "1283"
                        "paginaFinal" => "1286"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7486117"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0345"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Awake fibreoptic intubation in the patient at high risk of aspiration"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Ovassapian"
                            1 => "T&#46;C&#46; Krejcie"
                            2 => "S&#46;J&#46; Yelich"
                            3 => "M&#46;H&#46; Dykes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "1989"
                        "volumen" => "62"
                        "paginaInicial" => "13"
                        "paginaFinal" => "16"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2917109"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0350"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A comparison of anesthetic techniques for awake intubation in neurosurgical patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "D&#46;K&#46; Reasoner"
                            1 => "D&#46;S&#46; Warner"
                            2 => "M&#46;M&#46; Todd"
                            3 => "S&#46;W&#46; Hunt"
                            4 => "J&#46; Kirchner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg Anesthesiol"
                        "fecha" => "1995"
                        "volumen" => "7"
                        "paginaInicial" => "94"
                        "paginaFinal" => "99"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7772974"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0355"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Preparing to perform an awake fiberoptic intubation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46;E&#46; Walsh"
                            1 => "G&#46;D&#46; Shorten"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Yale J Biol Med"
                        "fecha" => "1998"
                        "volumen" => "71"
                        "paginaInicial" => "537"
                        "paginaFinal" => "549"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10604785"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0360"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Optimizing oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46; Badiger"
                            1 => "M&#46; John"
                            2 => "R&#46;A&#46; Fearnley"
                            3 => "I&#46; Ahmad"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aev262"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2015"
                        "volumen" => "115"
                        "paginaInicial" => "629"
                        "paginaFinal" => "632"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26253608"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0365"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Airway anesthesia&#58; theory and practice"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46;J&#46; Doyle"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.anclin.2015.02.013"
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiol Clin"
                        "fecha" => "2015"
                        "volumen" => "33"
                        "paginaInicial" => "291"
                        "paginaFinal" => "304"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25999003"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0370"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The effectiveness of apneic oxygenation during tracheal intubation in various clinical settings&#58; a narrative review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46;T&#46; Wong"
                            1 => "A&#46;J&#46; Yee"
                            2 => "S&#46;M&#46; Leong"
                            3 => "F&#46; Chung"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s12630-016-0802-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Can J Anaesth"
                        "fecha" => "2017"
                        "volumen" => "64"
                        "paginaInicial" => "416"
                        "paginaFinal" => "427"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28050802"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0375"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A novel non-invasive ventilation mask to prevent and manage respiratory failure during fiberoptic bronchoscopy&#44; gastroscopy and transesophageal echocardiography"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "L&#46; Cabrini"
                            1 => "G&#46; Landoni"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Heart Lung Vessel"
                        "fecha" => "2015"
                        "volumen" => "7"
                        "paginaInicial" => "297"
                        "paginaFinal" => "303"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26811835"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0380"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical application of a novel endoscopic mask&#58; a randomized controlled trial in aged patients undergoing painless gastroscopy"
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                          "etal" => true
                          "autores" => array:6 [
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                            2 => "T&#46; Zou"
                            3 => "M&#46; He"
                            4 => "S&#46; Wang"
                            5 => "P&#46; Huang"
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                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.7150/ijms.16919"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Med Sci"
                        "fecha" => "2017"
                        "volumen" => "14"
                        "paginaInicial" => "167"
                        "paginaFinal" => "172"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28260993"
                            "web" => "Medline"
                          ]
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                      ]
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                  ]
                ]
              ]
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              "identificador" => "bib0385"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Aids for facilitation of difficult tracheal intubation review and recent advances"
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                          "etal" => false
                          "autores" => array:2 [
                            0 => "M&#46; Muallem"
                            1 => "A&#46; Baraka"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Middle East J Anaesthesiol"
                        "fecha" => "2012"
                        "volumen" => "21"
                        "paginaInicial" => "785"
                        "paginaFinal" => "791"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23634559"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0390"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Videolaryngoscopy as a new standard of care"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46; Zaouter"
                            1 => "J&#46; Calderon"
                            2 => "T&#46;M&#46; Hemmerling"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/bja/aeu266"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2015"
                        "volumen" => "114"
                        "paginaInicial" => "181"
                        "paginaFinal" => "183"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25150988"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Ultrasonography for endotracheal tube position in infants and children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46; Jaeel"
                            1 => "M&#46; Sheth"
                            2 => "J&#46; Nguyen"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00431-017-2848-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Pediatr"
                        "fecha" => "2017"
                        "volumen" => "176"
                        "paginaInicial" => "293"
                        "paginaFinal" => "300"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28091777"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0400"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sugammadex&#58; a revolutionary approach to neuromuscular antagonism"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46;F&#46; Kopman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2006"
                        "volumen" => "104"
                        "paginaInicial" => "631"
                        "paginaFinal" => "633"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16571954"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0405"
              "etiqueta" => "31"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reversal of rocuronium-induced neuromuscular block by the selective relaxant binding agent sugammadex&#58; a dose-finding and safety study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "I&#46;F&#46; Sorgenfrei"
                            1 => "K&#46; Norrild"
                            2 => "P&#46;B&#46; Larsen"
                            3 => "J&#46; Stensballe"
                            4 => "D&#46; Ostergaard"
                            5 => "M&#46;E&#46; Prins"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesthesiology"
                        "fecha" => "2006"
                        "volumen" => "104"
                        "paginaInicial" => "667"
                        "paginaFinal" => "674"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16571960"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0410"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The laryngeal mask airway reliably provides rescue ventilation in cases of unanticipated difficult tracheal intubation along with difficult mask ventilation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
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                            1 => "P&#46; Colonna-Romano"
                            2 => "J&#46;C&#46; Horrow"
                            3 => "F&#46; Miller"
                            4 => "J&#46; Gonzales"
                            5 => "H&#46; Rosenberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "1998"
                        "volumen" => "87"
                        "paginaInicial" => "661"
                        "paginaFinal" => "665"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9728849"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0415"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fiberoptic-guided airway exchange of the esophageal-tracheal Combitube in spontaneously breathing versus mechanically ventilated patients"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "L&#46;A&#46; Gaitini"
                            1 => "S&#46;J&#46; Vaida"
                            2 => "M&#46; Somri"
                            3 => "M&#46; Fradis"
                            4 => "B&#46; Ben-David"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Anesth Analg"
                        "fecha" => "1999"
                        "volumen" => "88"
                        "paginaInicial" => "193"
                        "paginaFinal" => "196"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9895091"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib0420"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Variation in the type&#44; rate&#44; and selection of patients for out-of-hospital airway procedures among injured children and adults"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "K&#46; Koprowicz"
                            2 => "H&#46; Wang"
                            3 => "A&#46; Monnig"
                            4 => "J&#46;D&#46; Kerby"
                            5 => "G&#46;K&#46; Sears"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1553-2712.2009.00604.x"
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                        "tituloSerie" => "Acad Emerg Med"
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                        "paginaInicial" => "1269"
                        "paginaFinal" => "1276"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20053248"
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                      "titulo" => "Emergency cricothyrotomy &#8211; a systematic review"
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                            3 => "G&#46;E&#46; Vist"
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                        "tituloSerie" => "Scand J Trauma Resusc Emerg Med"
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                        "volumen" => "21"
                        "paginaInicial" => "43"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23725520"
                            "web" => "Medline"
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                    0 => array:2 [
                      "titulo" => "The role of cricothyrotomy&#44; tracheostomy&#44; and percutaneous tracheostomy in airway management"
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                      ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.anclin.2015.02.009"
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                        "tituloSerie" => "Anesthesiol Clin"
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                        "volumen" => "33"
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                        "paginaFinal" => "367"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25999008"
                            "web" => "Medline"
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                        "tituloSerie" => "Br J Anaesth"
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                        "paginaInicial" => "357"
                        "paginaFinal" => "361"
                        "link" => array:1 [
                          0 => array:2 [
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                            "web" => "Medline"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Transtracheal jet ventilation in 50 patients with severe airway compromise and stridor"
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                            0 => "D&#46;J&#46; Ross-Anderson"
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                        "tituloSerie" => "Br J Anaesth"
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                        "paginaInicial" => "140"
                        "paginaFinal" => "144"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20952426"
                            "web" => "Medline"
                          ]
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              "identificador" => "bib0445"
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                        "tituloSerie" => "Acta Otorhinolaryngol Ital"
                        "fecha" => "2017"
                        "volumen" => "37"
                        "paginaInicial" => "72"
                        "paginaFinal" => "75"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27070540"
                            "web" => "Medline"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Difficult Airway Society guidelines for the management of tracheal extubation"
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                          "autores" => array:6 [
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                            5 => "A&#46; Higgs"
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                        "tituloSerie" => "Anaesthesia"
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                        "paginaInicial" => "318"
                        "paginaFinal" => "340"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22321104"
                            "web" => "Medline"
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                    0 => array:2 [
                      "titulo" => "Complications associated with the use of the GlideScope videolaryngoscope"
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                        "tituloSerie" => "Can J Anaesth"
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                        "paginaInicial" => "54"
                        "paginaFinal" => "57"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17197469"
                            "web" => "Medline"
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              "identificador" => "bib0460"
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                0 => array:2 [
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                      "titulo" => "Incidence of and risk factors for difficult ventilation via a supraglottic airway device in a population of 14&#44;480 patients from South-East Asia"
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                        "tituloSerie" => "Respir Care"
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                        "paginaFinal" => "878"
                        "link" => array:1 [
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