Difficult respiratory tracts – one of the most serious problems of anesthesiology since the moment of its origin. The invalidism and death of patients owing to impossibility of ensuring passability of respiratory tracts, though significantly decreased recently, still figures prominently among anesthesia complications. It is important that the anesthesiologist from the very beginning of the activity raised gravity of this problem and did not ignore it.
As difficult respiratory tracts in anesthesiology it is understood situations when takes place not only a difficult intubation, but also difficult mask ventilation complicated removal of a glottis (laringoskopiya) and difficult surgical access (a konikotomiya or a tracheostomy).
Huge value in prevention of the difficult situations connected with respiratory tracts preliminary assessment and planning of tactics of the anesthesiologist in this or that situation has them. For assessment of a condition of respiratory tracts a number of researchers offered the whole set of tests (the Mallampati test, a tiromentalny and stenomentalny distance, opening of a mouth, promotion of a mandible, etc.), but as practice shows, any of them is not reliable in itself. Now for assessment of probability of a difficult intubation use of complex tests is recommended. For example, the LEMON system abroad was widely adopted, the scale MOSCOW-TD is widespread among us. The essence of complex systems of assessment consists that instead of one sign (Mallampati's scale, for example) which in itself can have rather low predictive value, can be used several signs united in the uniform system of assessment. Are most often used: Mallampati test, opening of a mouth, extension of the head, promotion of a mandible, existence of obesity, existence of a difficult intubation in the past. On the termination of assessment the doctor has a certain number of points depending on which number the plan of its actions can be under construction.
If to speak about forecasting of difficult mask ventilation, then risk factors of such state are also established. According to one research it: radiotheraphy concerning oncological diseases of the head and neck in the anamnesis, a male, a syndrome of a sleepy apnoea in the anamnesis, existence of a beard (it can also be a predictor of a difficult intubation), assessment on Mallampati's scale 3–4 and the expressed morbid obesity
Having estimated a condition of respiratory tracts, the anesthesiologist has to draw a conclusion — whether with high probability problems at this patient will take place? In spite of the fact that the problem of unexpectedly difficult intubation is relevant, at the vast majority of patients of complexity in ensuring passability of respiratory tracts it is possible to predict. Having defined that at this patient of a problem with an intubation (± ventilation) will take place, it is necessary to make the plan of action for a case of development of this or that situation.
The main question which it is required to answer the anesthesiologist when planning providing respiratory tracts at such patient: in consciousness or in a dream it is going to carry out a trachea intubation? Absolute indications for decision-making in favor of an intubation in consciousness under local anesthesia: full stomach and expected difficulties with mask ventilation. In other situations performance of an intubation is possible under anesthetic.
The patient's intubation in an anesthesia at expected difficulties is carried out with use of a fibrobronkhoskop or the video laryngoscope. The patient's intubation in consciousness under local anesthesia is carried out with use of a fibrobronkhoskop. In the latter case it is extremely important to pay attention to careful anesthesia of respiratory tracts.
Despite careful assessment of respiratory tracts before operation, in some cases unexpectedly difficult intubation can take place. Actions of the anesthesiologist in this situation come down to consecutive performance of an accurate algorithm of actions (transition to the following item is carried out at inefficiency of previous):
Help call, repeated attempts of an intubation with change of conditions (change of position of the head, a blade, an ispolzoaniye of the buzha-conductor, etc.), no more than four attempts;
Installation of a laryngeal mask for ensuring ventilation and oxygenation of the patient (no more than two attempts, devices of the second generation are recommended);
At inefficiency – the last attempt of ventilation in four hands, with use of an air duct and change of position of the head of the patient if necessary;
At inefficiency – performance of a surgical or puncture konikotomiya.
The patient at whom difficulties with respiratory tracts took place has to be carefully informed after operation on what difficulties were and as they managed to be solved. Delivery to the patient of a special instruction for anesthesiologists who will carry out grants at this patient in the future is optimum.