AIRWAY ASSESSMENT IN OUTPATIENT DENTAL PRACTICE
The aim of this paper was to represent up-to-date data about airway assessment in outpatient dental practice. The application of sedation and general anesthesia create favorable conditions for dental treatment performing and therefore more frequent claim in outpatient practice. Broad introduction of sedation and general anesthesia in dental office practice apparently will be accompanied by anesthesia related complication risks.
At present there are no universal or officially approved criterions for prognosis of complexity or inefficiency of supraglottic devices insertion, in spite of they are the major part of airways patency restoration algorithm. Airway examination begins from detail medical history, which concern previous attempts of airways management during sedation and general anesthesia. Local examination should include assessment of mouth opening and neck extension ability, examination of pharynx soft tissues and determining of thyromental distance. Also detects neck circumference, movement restriction in neck part of the spine and temporomandibular anchylosis, presence of lacking or forward teeth. Large neck circumference, which often associates with obstructive sleep apnea, is the risk factor of difficult intubation in obese patients. Cricothyroid membrane palpation performs for determining of possible access to airways in cases of urgent cricothyroidotomy necessity.
In difficult intubation risk group patients with pathological obese it is important not in fact excessive body mass, but location of excessive fat deposits. Their location in lower abdomen and hips less substantially than in upper part of the body. Short and thick neck and excess of fatty tissues in upper part of the back area is essential obstacle for rigid laryngoscopy. Moreover, soft tissues excess in the area of pharynx and epiglottis may complicate both tracheal intubation and mask ventilation. Mask ventilation with high positive pressure in obese patients increase inflow of air in the stomach. Lungs functional residual capacity in obese patients’ decreased and rapid decrease of oxygen saturation accelerate hypoxemia development and reduce the time for achievement of adequate ventilation both by mask and endotracheal tube.
Some diseases promote difficult tracheal intubation for example in patients with progressive rheumatoid arthritis and spondylosis. With rheumatoid arthritis may be limited movement in any kind of joint including neck part of the spine, temporomandibular and cricoarytenoid joints. Voice changes, dysphagy, dysarthria, or globus sensation may indicate to larynx lesion. For enhancement of the mask ventilation efficiency and oxygenation traditionally used chin lift and jaw thrust maneuvers. But it is very difficult to perform in patients with the limited joint movement.
In patients with severe congenital anomalies, which influence on the airways patency, outpatient sedation and general anesthesia should consider as contraindication.
The airway assessment before induction of deep sedation or general anesthesia is very important for detection of potential problems which related to mask or laryngeal mask ventilation (or other supraglottic devices) and/or endotracheal intubation.
In spite of introduction of new supraglottic devices and video laryngoscopy, detail preoperative examination of patient airway allow to detect cases which require application of emergency airways patency restoration algorithm. The optimal approach is combination of the precise medical history investigation, physical examination and prognostic tests performing.
The decisions, which capable ensure for patient safety and favorable outcome, should be accept only after that as physician estimate patients airway and own ability to mask ventilation, endotracheal intubation and algorithms application.
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