Failed Intubation Protocol: Oxygenation Without Aspiration

SUMMARY

The stimulus for the development of ‘failed intubation drill’ was a maternal death. The mother died from the consequences of silent pulmonary acid aspiration associated with a difficult endotracheal intubation. It occurred at a time when regional anaesthesia was rarely used for caesarean section in the locality. The purpose of the drill (or protocol) was to outline a safe plan of action following failure to intubate the trachea in a mother anaesthetized for an obstetric operation. It was necessary to take steps to effect oxygenation without aspiration. The details for enabling a safe changeover to a general anaesthetic without an endotracheal tube were given. The plan recognized that oxygenation would be difficult in some patients. Such cases were to be allowed to wake up before a decision on an alternative anaesthesia could be made.

The maintenance of cricoid pressure and placing the patient in the left lateral head-down posture remains essential to the protocol.

This chapter deals with some causes of unexpected difficulty with visualization of the larynx. Methods of improving the chance of successful intubation in problem cases are given. The factors which make intermittent positive pressure ventilation by face-mask difficult, or impossible, are reviewed, and the ways of clearing an obstructed airway when intubation has failed are outlined. The authors attach importance to the use of the triple airway manoeuvre, and forward displacement of the larynx by endo-oesophageal intubation in some cases. Where there is complete inability to ventilate by face-mask following a failed intubation, transtracheal oxygenation via a catheter inserted through the cricothyroid membrane is effective and life-saving.

A failed intubation protocol is presented.