Despite development of anesthesiology and resuscitation, difficult respiratory tracts continue to remain a serious problem. Loss of respiratory tracts at the critical patient creates for the last potentially life-threatening situation. Development of technologies of ensuring passability of the upper airways and the systems of assessment reduces the probability of a lethal outcome at the patient, but there are always situations in which difficulties with respiratory tracts arise suddenly and difficult give in to control.
Difficulties with ensuring passability of the upper airways arise in intensive care unit and resuscitation usually at transfer of the patient to IVL or when holding resuscitation actions. Training of personnel, ability to work in team, following to accurate algorithms and existence near at hand of all necessary equipment is very important.
Assessment of respiratory tracts in an intensive care is often complicated because of serious condition of the patient and deficiency of time. Use of complex scales of assessment, for example, of LEMON scale is recommended. It is essentially important to estimate the patient also on existence of factors of difficult mask ventilation. According to one conducted research, factors of difficult mask ventilation are: male age, existence of a beard, existence of a sleepy apnoea, assessment on Mallampati's 3 or 4 scale, radiation therapy of the head and neck in the anamnesis. The risk of difficult mask ventilation considerably increases at a combination of these factors. It is also necessary to estimate the patient regarding existence at the last full stomach and to make a stomach decompression if necessary.
Tactics of actions of the resuscitator with signs of difficult respiratory tracts is chosen proceeding from a concrete clinical situation. If the patient is available to contact and the doctor has time, it is necessary to intubate the patient in consciousness, after local anesthesia of respiratory tracts, by means of a fibrobronkhoskop. If the unconscious patient, a situation demands immediate control of passability and protection of respiratory tracts, then set for performance of a konikotomiya prepares and the trachea intubation by means of the video laryngoscope is recommended. In difficult situations the decision on need of implementation of surgical access to respiratory tracts can be made at once.
After carrying out an intubation in consciousness, before introduction to the patient of sedative drugs, it is important to be convinced that the endorakhealny tube really is in a trachea. Instrumentally finding of an endotracheal tube in a trachea is confirmed by registration of a kapnogramma of the correct form.
Unexpectedly difficult intubation of a trachea when the resuscitator faces difficulties suddenly is more difficult situation. In this situation it is very important to work on certain algorithms, the developed authoritative societies on problems of difficult respiratory tracts. One of the most authoritative algorithms of actions at unexpectedly difficult intubation is the algorithm of the British society on problems of difficult respiratory tracts (DAS — Difficult Airway Society).
This algorithm represents the action plans which are called letters of the Latin alphabet — A, B, C and D. All operations are performed consistently, transition to the following plan is carried out at inefficiency of previous.
The plan And — the initial action plan at collision with difficulties. It is recommended to use the improved position of the head and patient's neck, to change the sizes and types of blades, to use buzh for an intubation. Three attempts of an intubation and one more are admissible if it is carried out by more skilled colleague. In breaks between attempts of the patient ventilate with a mask. It is recommended to use the video laryngoscope. At failure pass to plans In and Page.
The plan In represents installation of a laryngeal mask (it is desirable the second generation). It is recommended at unsuccessful first installation to change types and the sizes of laryngeal masks. The plan With — attempt of manual ventilation by a mask about use of an oropharyngeal or nasopharyngeal air duct. These plans alternate. If ventilation is successful, then there is time to wake the patient and to intubate in the subsequent in consciousness and also to provide alternative accesses to respiratory tracts if it is impossible to wake the patient, for example, to execute a tracheostomy. At failure pass to the plan of D.
The plan of D represents immediate performance of a konikotomiya. Time allowed for manipulation — 30 seconds. The konikotomiya technique "scalpel-buzh-tube No. 6" is recommended. After performance of a konikotomiya adjust ventilation of the patient. Further tactics of maintaining the patient depends on a clinical situation.