The problem of “difficult airways” — multicenter studies of Federation of anaesthesiologists and reanimatologists to analyze current clinical practice and review the training system in the Russian Federation. Review

A.A. Andreenko1, E.L. Dolbneva2, V.I. Stamov3

1 FGBVOU VO “Military Medical Academy named after S.M. Kirov” Ministry of Defence of Russia, St. Petersburg, Russia

2 FGBNU “RNCH named by acad. B.V. Petrovsky”, Moscow, Russia

3 UKB № 2 FGAOU VO “Moscow State Medical University named after I.M. Sechenov” Ministry of Health of Russia, Moscow, Russia

For correspondence: Aleksander A. Andreenko — Cand. Med. Sciences, Assistant Professor, Deputy Head of the Department of Anesthesiology and Resuscitation FGBVOU VO “Military Medical Academy named after S.M. Kirov” Ministry of Defence of Russia, St. Petersburg; e-mail:

For citation: Andreenko AA, Dolbneva EL, Stamov VI. The problem of “difficult airways” — multicenter studies of Federation of anaesthesiologists and reanimatologists  to analyze current clinical practice and review the training system in the Russian Federation. Review. Annals of Critical Care. 2019;3:34–41.

DOI: 10.21320/1818-474X-2019-3-34-41


“Difficult airways” situations continue to be one of the main causes of anesthetic mortality and morbidity. Current requirements of patient safety during anesthesia determine the need for the necessary equipment and compliance with existing clinical guidelines. The situation with the equipment of hospitals in the Russian Federation with different airway devices and medical equipment, as well as the approaches used by anesthesiologists are regularly reviewed by the FAR Committee of Difficult Airways by distributing a questionnaire. During the last 10 years there has been a positive trend in the level of hospital equipment with supraglottic airways, there has been an increase in the awareness of specialists about the existing clinical guidelines. An updated version of the survey was developed to examine the current situation in the Russian Federation, to analyze the effectiveness of the approaches used to solve the problem of “difficult airways” and to evaluate the role of the existing recommendations of the FAR.

The role of the human factor is decisive in the development of a significant part of critical situations during anesthesia. A modern training program for clinical residents in anesthesiology should include training in upper airways assessment, performing basic maneuvers of airways management, working out techniques for using various devices, as well as using existing algorithms of actions during “difficult airways” situations. The ability to apply theoretical knowledge and act requires training in a high-fidelity simulation and subsequent analysis of residentʹs performance. The newly developed survey is devoted to the analysis of the situation with airways management training in the clinical residency. Based on the results of the survey, it is planned to develop a draft national airways management training program for anesthesia residents.

Keywords: airways management, difficult airways, human factor, critical situations, airways management training, national survey of airways management.

Received: 22.07.2019

Accepted: 03.09.2019


  1. Mora J.C. , Kaye A.D., et al. Trends in Anesthesia-Related Liability and Lessons Learned. Advances in Anesthesia. 2018; 36: 231–249.
  2. Metzner J., Posner K.L., Lam M.S., Domino K.B. Closed claims’ analysis. Best. Pract. Res. Clin. Anaesthesiol. 2011; 25(2): 263–276. DOI: 10.1016/j.bpa.2011.02.007
  3. Peterson G.N., Domino K.B., Caplan R.A., et al. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005; 103(1): 33–39.
  4. Schroeder R.A., Pollard R., Dhakal I., et al. Temporal Trends in Difficult and Failed Tracheal Intubation in a Regional Community Anesthetic Practice. Anesthesiology. 2018; 128(3): 502–510. DOI: 10.1097/ALN.0000000000001974
  5. Cook T.M., Woodall N., Frerk C. Fourth National Audit Project. 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. Br. J. Anaesth. 2011; 106(5): 617–631. DOI: 10.1093/bja/aer058
  6. Долбнева Е., Стамов В., Андреенко А., Бунятян А. Анализ проблемы «трудных дыхательных путей» в России: особенности и перспективы. Часть 1. Медицинский алфавит. 2016; 20(283): 9–13.[Dolbneva E.L., Stamov V.I., Andreenko A.A., Bunatyan A.A. Analysis of the problem of “difficult airways” in Russia: features and prospects. Part 1. Medicinsky Alphavit. 2016; 20(283): 9–13. (In Russ)]
  7. Приговор № 1-10/20151-382/2014 от 3 марта 2015 г. по делу № 1-10/2015 [электронный документ]. Доступно по: Ссылка активна на 22.07.2019. [Prigovor № 1-10/20151-382/2014 ot 3 marta 2015 g. po delu № 1-10/2015 [Internet]. Available from: (accessed 22.07.2019). (In Russ)]
  8. Приговор от 28 ноября 2013 г. по делу № 1-335/2013 [электронный документ]. Доступно по: Ссылка активна на 22.07.2019. [Prigovor ot 28 noyabrya 2013 g. po delu № 1-335/2013 [Internet]. Available from: (accessed 22.07.2019). (In Russ)]
  9. Гаврилова Е.Г. Дефекты анестезиолого-реанимационной помощи (по материалам комиссионных судебно-медицинских экспертиз). Анестезиология и реаниматология. 2014; 2: 70–75. [Gavrilova E.G. Defects of anesthesiology and resuscitation care (based on materials of forensic medical examinations). Anestesiologia I reanimatologia. 2014; 2: 70–75. (In Russ)]
  10. Долбнева Е., Стамов В., Андреенко А., Бунятян А. Анализ проблемы «трудных дыхательных путей» в России: особенности и перспективы. Часть 2. Медицинский алфавит. 2016; 33 (296): 34–39.[Dolbneva E.L., Stamov V.I., Andreenko A.A., Bunatyan A.A. Analysis of the problem of “difficult airways” in Russia: features and prospects. Part 2. Medicinsky Alphavit. 2016; 33(296): 34–39. (In Russ)].
  11. Андреенко А.А., Долбнева Е.Л., Стамов В.И. Обеспечение проходимости верхних дыхательных путей в стационаре. Клинические рекомендации Федерации анестезиологов-реаниматологов России (второй пересмотр, 2018 г.). Вестник интенсивной терапии им. А.И. Салтанова. 2019; 2: 7–31. DOI: 10.21320/1818-474X-2019-2-7-7-31 [Andreenko A.A., Dolbneva E.L., Stamov V.I. Airway management in hospital. Russian Federation of anesthesiologists and reanimatologists guidelines (second edition, 2018). Alexander Saltanov Intensive Care Herald. 2019; 2: 7–31. (In Russ)]
  12. Rajesh M.C., Suvarna K., Indu S., et al. Current practice of difficult airway management: A survey. Indian J Anaesth. 2015; 59(12): 801–806. DOI: 10.4103/0019–5049.171571
  13. Gómez-Prieto M.G., Míguez-Crespo M.R., Jiménez-del-Valle J.R., et al. National survey on airway and difficult airway management in intensive care units. Med Intensiva. 2018; 42(9): 519–526. DOI: 10.1016/j.medin.2018.01.001
  14. Astin J., King E.C., Bradley T., et al. Survey of airway management strategies and experience of non-consultant doctors in intensive care units in the UK. Br J Anaesth. 2012; 109: 821–825.
  15. Cook T.M., Kelly F.E. A national survey of videolaryngoscopy in the United Kingdom. British Journal of Anaesthesia. 2017; 4 (118): 593–600. DOI: 10.1093/bja/aex052
  16. Bjurström M.F., Persson K., Sturesson L.W. Availability and Organization of Difficult Airway Equipment in Swedish Hospitals: A National Survey of Anaesthesiologists. Acta Anaesthesiol Scand. 2019; 8. DOI: 10.1111/aas.13448
  17. Wong D.T., Mehta A., Tam A.D., et al. A survey of Canadian anesthesiologistsʼ preferences in difficult intubation and “cannot intubate, cannot ventilate” situations. Can J Anaesth. 2014; 61(8): 717–726. DOI: 10.1007/s12630-014-0183-0
  18. Gleeson S., Groom P., Mercer S. Human factors in complex airway management. BJA Education. 2016; 16: 191–197. DOI:
  19. Jones C.P.L., Fawker-Corbett J., Groom P., et al. Human factors in preventing complications in anaesthesia: a systematic review. Anaesthesia. 2018; 73(Suppl. 1): 12–24. DOI: 10.1111/anae.14136
  20. Frerk C., Mitchell V.S., McNarry A.F., et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia 2015; 115: 827–848.
  21. Lindkær Jensen N.H., Cook T.M., Kelly F.E. A national survey of practical airway training in UK anaesthetic departments. Time for a national policy? Anaesthesia. 2016; 71: 1273–1279. DOI: 10.1111/anae.13567
  22. Dunn S., Connelly N.R., Robbins L. Resident training in advanced airway management. J Clin Anesth. 2004; 16(6): 472–476.
  23. Spaliaras J., Streiff A., Mann G., Straker T. Teaching and training in airway management: Time to evaluate the current model? Airway. 2019; 2: 28–35.
  24. Ono Y., Tanigawa K., Shinohara K., et al. Human and equipment resources for difficult airway management, airway education programs, and capnometry use in Japanese emergency departments: a nationwide cross-sectional studyю Int J Emerg Med. 2017; 10: 28. DOI: 10.1186/s12245-017-0155-6
  25. Joffe A.M., Liew E.C., Olivar H., et al. A National Survey of Airway Management Training in United States Internal Medicine-Based Critical Care Fellowship Programs. Respiratory Care July. 2012; 57 (7): 1084–1088. DOI:
  26. Pott L.M., Randel G.I., Straker T., et al. A survey of airway training among U.S. And Canadian anesthesiology residency programs. J Clin Anesth 2011; 23: 15–26.
  27. Hagberg C.A. Combined fellowship training in head and neck anesthesia and advanced airway management. J Head Neck Anesth. 2019; 3: e9.
  28. Society for Head and Neck Anesthesia Consensus Statement. Available from: [Last accessed on 2019 Mar 10]
  29. Straker T. Airway management: Isn’t that what anesthesiologists do? J Head Neck Anesth. 2019; 3: e11.
  30. Sun Y., Pan C., Li T., Gan T.J. Airway management education: Simulation based training versus non simulation based training. A systematic review and meta-analyses. BMC Anesthesiol. 2017; 17: 17.
  31. Зайцев А., Дубровин К., Светлов В. Роль методов визуализации для обеспечения безопасности пациента в анестезиологической практике (обзор). Общая реаниматология. 2018; 14(6): 80–94.[Zaitsev A.Y., Dubrovin K.V., Svetlov V.A. Сontribution of Imaging Techniques for Patientʼs Safety in Anesthesiology Practice (Review). General Reanimatology. 2018; 14(6): 80–94. (In Russ.)] DOI: 10.15360/1813-9779-2018-6-80-94

Airway management in hospital. Russian Federation of anesthesiologists and reanimatologists guidelines (second edition, 2018)

A.A. Andreenko1, E.L. Dolbneva2, V.I. Stamov3

1 FGBVOU VO “Military Medical Academy named after S.M. Kirov” Ministry of Defence of Russia, Saint-Petersburg

2 FGBNU RNCH named by acad. B.V. Petrovsky, Moscow

3 UKB № 2 FGAOU VO “Moscow State Medical University named after I.M. Sechenov” Ministry of Health of Russia, Moscow

For correspondence: Aleksander A. Andreenko — Cand. Med. Sciences, Assistant Professor, Deputy Head of the Department of Anesthesiology and Resuscitation, FGBVOU VO “Military Medical Academy named after S.M. Kirov” Ministry of Defence of Russia, Saint-Petersburg; e-mail:

For citation: Andreenko AA, Dolbneva EL, Stamov VI. Airway management in hospital. Russian Federation of anesthesiologists and reanimatologists guidelines (second edition, 2018). Alexander Saltanov Intensive Care Herald. 2019;2:7-31.

DOI: 10.21320/1818-474X-2019-2-7-31


The review presents the clinical guidelines of the Federation of Anaesthesiology and Resuscitation specialists of Russia, revised in 2018. The recommendations are based on a review of publications and modern international guidelines of the Difficult Airway Society (DAS, 2015), American Society of Anesthesiologists (ASA, 2013), the European Society of Anesthesiologists (ESA, 2018).

“Difficult airways” are encountered relatively infrequently in modern anesthesia practice, but if it is impossible to ensure adequate oxygenation of patients, they lead to post-hypoxic brain damage or circulatory arrest. Current requirements for patient safety during anesthesia determine the need for a thorough assessment of patients before surgery, identification of prognostic signs of difficult ventilation through a face mask or supraglottic airway device, difficult laryngoscopy and tracheal intubation, difficult cricothyrotomy. As a result of the examination, the anesthesiologist is obliged to formulate the main and reserve action plan, prepare the necessary equipment, and involve specialists if necessary.

The recommendations provide evidence of the effectiveness of modern devices for ventilation and tracheal intubation. Algorithms for making decisions and actions in various situations with predictable and unpredictable “difficult airways” in patients with different risks of aspiration are proposed. An algorithm for preparing, predicting possible complications and performing extubation of the trachea is also proposed. The recommendations presented in the review are aimed at achieving the goal of increasing patient safety during general anesthesia by reducing the risk of developing critical disorders of gas exchange due to airway management problems.

Keywords: tracheal intubation, difficult airways, difficult mask ventilation, difficult laryngoscopy, difficult intubation, supraglottic airway devices, cricothyrotomy, failed intubation

Received: 25.02.2019

Accepted: 26.03.2019


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. Anesthesiology. 2013; 118: 251–270. DOI: 10.1097/ALN.0b013e31827773b2

Cheney F.W., Posner K.L., Lee L.A., et al. Trends in anesthesia-related death and brain damage: a closed claims analysis. Anesthesiology. 2006; 105: 1081–1086.

Domino K.B., Posner K.L., Caplan R.A., Cheney F.W. Airway injury during anesthesia: A closed claims analysis. Anesthesiology. 1999; 91: 1703–1711.

Metzner J., Posner K.L., Lam M.S., Domino K.B. Closed claims’ analysis. Best. Pract. Res. Clin. Anaesthesiol. 2011; 25(2): 263–276. DOI: 10.1016/j.bpa.2011.02.007

Miller C.G. Management of the Difficult Intubation in Closed Malpractice Claims. ASA Newsletter. 2000; 64(6): 13–16 & 19.

Cook T.M., MacDougall-Davis S.R. Complications and failure of airway management. Br. J. Anaesth. 2012 Dec;109 Suppl 1:i68-i85. DOI: 10.1093/bja/aes393.

Cook T.M., Woodall N., Frerk C.; Fourth National Audit Project. 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. Br. J. Anaesth. 2011; 106(5): 617–631. DOI: 10.1093/bja/aer058

Долбнева Е.Л., Стамов В.И., Мизиков В.М., Бунятян А.А. «“Трудные дыхательные пути” — частота встречаемости в РФ и пути решения». Тезисы XIV Съезда Федерации анестезиологов и реаниматологов. С. 116–117. [Dolbneva E.L., Stamov V.I., Mizikov V.M., Bunyatyan A.A. «Difficult airways» is the frequency of occurrence in the Russian Federation and solutions. Tezisy XIV Sezda Federacii anesteziologov i reanimatologov. P. 116–117. (In Russ)]

Millerʼs Anesthesia, 7th Ed. By Ronald D. Miller, Lars I. Eriksson, Lee A. Fleisher, et al. Philadelphia, PA: Elsevier/Saunders, 2012.

Алгоритмы действий при критических ситуациях в анестезиологии. Рекомендации Всемирной федерации обществ анестезиологов. Под ред. Брюса Маккормика (Bruce McCormick). Русское издание под ред. Э.В. Недашковского. Архангельск: СГМА. Главы: «План интубации трахеи», «Непредвиденно сложная интубация», «Сценарий “не могу интубировать — не могу вентилировать”». [Algoritmy dejstvij pri kriticheskih situaciyah v anesteziologii. Rekomendacii vsemirnoj federacii obshchestv anesteziologov. (Algorithms for action in critical situations in anesthesiology. Recommendations of the World Federation of Anesthesiology Societies). Pod redakciej Bryusa Makkormika (Bruce McCormick). Russkoe izdanie pod red. E.V. Nedashkovskogo. Arhangelʼsk: SGMA. Glavy: “Plan intubacii trahei”, “Nepredvidenno slozhnaya intubaciya”, “Scenarij ‘ne mogu intubirovatʼ — ne mogu ventilirovatʼ”. (In Russ)]

Анестезиология: национальное руководство. Под ред. А.А. Бунятяна, В.М. Мизикова. М.: ГЭОТАР-Медиа, 2013. Серия «Национальные руководства». Мизиков В.М., Долбнева Е.Л. Глава 11. «Поддержание проходимости дыхательных путей и проблема “трудной интубации трахеи”». [Anesteziologiya: nacionalʼnoe rukovodstvo (Anesthesiology: national guidelines) Pod red. A.A. Bunyatyana, V.M. Mizikova. M.: GEOTAR-Media, 2013. (Seriya “Nacionalʼnye rukovodstva”). Mizikov V.M., Dolbneva E.L. Glava 11. “Podderzhanie prohodimosti dyhatelʼnyh putej i problema ‘trudnoj intubacii trahei’”. (In Russ)]

Буров Н.Е., Волков О.И. Тактика и техника врача-анестезиолога при трудной интубации. Клин. анестезиол. и реаниматол. 2004; 1(2): 68–74. [Burov N.E., Volkov O.I. Tactics and technique of the anesthesiologist with difficult intubation. Klinicheskaya Anesteziologiya i Reanimatologiya. 2004; 1(2): 68–74. (In Russ)]

Буров Н.Е. Протокол обеспечения проходимости дыхательных путей. (Обзор литературы и материалов совещания главн. анестезиологов МЗСР РФ. 2005). Клин. анестезиол. и реаниматол. 2005; 2(3): 2–12. [Burov N.E. Airway management (literature review). Klinicheskaya Anesteziologiya i Reanimatologiya. 2005; 2(3): 2–12. (In Russ)]

Молчанов И.В., Буров Н.Е., Пулина Н.Н., Черкавский О.Н. Алгоритм действия врача при трудной интубации. Клиническая практика. 2012; 2: 51–57. [Molchanov I.V., Burov N.E., Pulina N.N., Cherkavskij O.N. Algorithm for difficult tracheal intubation. Klinicheskaya praktika. 2012; 2: 51–57. (In Russ)]

Молчанов И.В., Заболотских И.Б., Магомедов М.А. Трудный дыхательный путь с позиции анестезиолога-реаниматолога: пособие для врачей. Петрозаводск: ИнтелТек, 2006. [Molchanov I.V., Zabolotskih I.B., Magomedov M.A. Trudnyj dyhatelʼnyj putʼ s pozicii anesteziologa-reanimatologa posobie dlya vrachej (Difficult airway from the perspective of an anesthesiologist: manual for doctors). Petrozavodsk: IntelTek, 2006. (In Russ)]

De Hert S., Staender S., Fritsch G., et al. Pre-operative evaluation of adults undergoing elective noncardiac surgery Updated guideline from the European Society of Anaesthesiology. Eur. J. Anaesthesiol. 2018; 35: 407–465. DOI: 10.1097/EJA.0000000000000817

Roth D., Pace N.L., Lee A., et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst. Rev. 2018; 5: CD008874. DOI: 10.1002/14651858.CD008874.pub2

Ferrari L.R., Bedford R.F. General anesthesia prior to treatment of anterior mediastinal masses in pediatric cancer patients.Anesthesiology. 1990; 72: 991–995.

Siyam M.A., Benhamou D. Difficult endotracheal intubation in patients with sleep apnea syndrome. Anesth. Analg. 2002; 95: 1098–1102.

Khan Z.H., Mohammadi M., Rasouli M.R., et al. The diagnostic value of the upper lip bite test combined with sternomental distance, thyromental distance, and interincisor distance for prediction of easy laryngoscopy and intubation: a prospective study. Anesth. Analg. 2009; 109: 822–824. DOI: 10.1213/ane.0b013e3181af7f0d

Tremblay M.H., Williams S., Robitaille A., Drolet P. Poor visualization during direct laryngoscopy and high upper lip bite test score are predictors of difficult intubation with the GlideScope1 videolaryngoscope. Anesth. Analg. 2008; 106: 1495–1500.

Roth D., Pace N.L., Lee A., Hovhannisyan K., et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database of Systematic Reviews. 2018, Issue 5. Art. No.: CD008874. DOI: 10.1002/14651858.CD008874.pub2

El-Ganzouri A.R., McCarthy R.J., Tuman K.J., et al. Preoperative airway assessment: predictive value of a multivariate risk index. Anesth. Analg. 1996; 82: 1197–1204.

Wilson M.E., Spiegelhalter D., Robertson J.A., Lesser P. Predicting difficult intubation. Br. J. Anaesth. 1988; 61: 211–216.

Nørskov A.K., Rosenstock C.V., Wetterslev J., et al. Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015; 70: 272–281. DOI: 10.1111/anae.12955

Mallin M., Curtis K., Dawson M., Ockerse P., Ahern M. Accuracy of ultrasound-guided marking of the cricothyroid membrane before simulated failed intubation. Am. J. Emerg. Med. 2014; 32: 61–63.

Gambee A.M., Hertzka R.E., Fisher D.M. Preoxygenation techniques: Comparison of three minutes and four breaths. Anesth. Analg. 1987; 66: 468–470.

Goldberg M.E., Norris M.C., Larijani G.E., et al. Preoxygenation in the morbidly obese: A comparison of two techniques. Anesth. Analg. 1989; 68: 520–522.

Dixon B.J., Dixon J.B., Carden J.R., et al. Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005; 102: 1110–1115.

Altermatt F.R., Munoz H.R., Delfino A.E., Cortinez L.I. Preoxygenation in the obese patient: effects of position on tolerance to apnoea. Br. J. Anaesth. 2005; 95: 706–709. DOI: 10.1093/bja/aei231

Harbut P., Gozdzik W., Stjernfält E., et al. Continuous positive airway pressure/pressure support pre-oxygenation of morbidly obese patients. Acta Anesthesiol. Scand. 2014; 58(6): 675–680. DOI: 10.1111/aas.12317

Heinrich S., Horbach T., Stubner B., et al. Benefits of Heated and Humidified High Flow Nasal Oxygen for Preoxygenation in Morbidly Obese Patients Undergoing Bariatric Surgery: A Randomized Controlled Study. J. Obes. Bariatrics. 2014; 1(1): 7.

Patel A., Nouraei S.A.R. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015; 70: 323–329. DOI: 10.1111/anae.12923

Badiger S., John M., Fearnley R.A., Ahmad I. Optimizing oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system. Br. J. Anaesth. 2015; 115: 629–632. DOI: 10.1093/bja/aev262

Tanoubi I., Drolet P., Donati F. Optimizing preoxygenation in adults. Can. J. Anaesth. 2009; 56: 449–466. DOI: 10.1007/s12630-009-9084-z

Ramachandran S.K., Cosnowski A., Shanks A., Turner C.R. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J. Clin. Anesth. 2010; 22: 164–168. DOI: 10.1016/j.jclinane.2009.05.006

Cohn A.I., Zornow M.H. Awake endotracheal intubation in patients with cervical spine disease: A comparison of the Bullard laryngoscope and the fiberoptic bronchoscope. Anesth. Analg. 1995; 81: 1283–1286.

Ovassapian A., Krejcie T.C., Yelich S.J., Dykes M.H. Awake fibreoptic intubation in the patient at high risk of aspiration. Br. J. Anaesth. 1989; 62: 13–16.

Smith C.E., Pinchak A.B., Sidhu T.S., et al. Evaluation of tracheal intubation difficulty in patients with cervical spine immobilization: Fiberoptic (WuScope) versus conventional laryngoscopy. Anesthesiology. 1999; 91: 1253–1259.

Asai T., Eguchi Y., Murao K., et al. Intubating laryngeal mask for fibreoptic intubation–particularly useful during neck stabilization. Can. J. Anaesth. 2000; 47: 843–848.

Asai T., Matsumoto H., Shingu K. Awake tracheal intubation through the intubating laryngeal mask. Can. J. Anaesth. 1999; 46: 182–184.

Frappier J., Guenoun T., et al. Airway management using the intubating laryngeal mask airway for the morbidly obese patient. Anesth. Analg. 2003; 96: 1510–1515.

Fukutome T., Amaha K., et al. Tracheal intubation through the LMA-Fastrach in patients with difficult airways. Anaesth. Intensive Care. 1998; 26: 387–391.

Nakazawa K., Tanaka N., Ishikawa S., et al. Using the intubating laryngeal mask airway (LMA-Fastrach) for blind endotracheal intubation in patients undergoing cervical spine operation. Anesth. Analg. 1999; 89: 1319–1321.

Palmer J.H., Ball D.R. Awake tracheal intubation with the intubating laryngeal mask in a patient with diffuse idiopathic skeletal hyperostosis. Anaesthesia. 2000; 55: 70–74.

Dimitriou V.K., Zogogiannis I.D., Liotiri D.G. Awake tracheal intubation using the Airtraq laryngoscope: A case series. Acta Anesthesiol. Scand. 2009; 53: 964–967. DOI: 10.1111/j.1399-6576.2009.02012.x

Suzuki A., Toyama Y., Iwasaki H., Henderson J. Airtraq for awake tracheal intubation. Anaesthesia. 2007; 62: 746–747.

Thong S.-Y., Gar-Ling Wong T. Clinical Uses of the Bonfils Retromolar Intubation Fiberscope. Anesth. Analg. 2012; 115(4): 855–866.

Takahata O., Kubota M., Mamiya K., et al. The efficacy of the ‘‘BURP’’ maneuver during a difficult laryngoscopy. Anesth. Analg. 1997; 84: 419–421.

Levitan R.M., Mechem C.C., Ochroch E.A., et al. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann. Emerg. Med. 2003; 41: 322–330.

Hasegawa K., Shigemitsu K., Hagiwara Y., et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann. Emerg. Med. 2012; 60: 749–754. DOI: 10.1016/j.annemergmed.2012.04.005

Lewis S.R., Butler A.R., Parker J., et al. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br. J. Anaesth. 2017; 119(3): 369–383. DOI: 10.1093/bja/aex228

Marouf H.M., Khalil N. A Randomized Prospective Study Comparing C-Mac D-Blade, Airtraq, and Fiberoptic Bronchoscope for Intubating Patients with Anticipated Difficult Airway. J. Anesth. Clin. Res. 2017; 8: 766. DOI: 10.4172/2155–6148.1000766

Pieters B.M., Maas E.H., Knape J.T., van Zundert A.A. Videolaryngoscopy vs. direct laryngoscopy use by experienced anaesthetists in patients with known difficult airways: a systematic review and meta-analysis. Anaesthesia. 2017; 72(12): 1532–1541. DOI: 10.1111/anae.14057

Koh J.C., Lee J.S., Lee Y.W., Chang C.H. Comparison of the laryngeal view during intubation using Airtraq and Macintosh laryngoscopes in patients with cervical spine immobilization and mouth opening limitation. Korean J. Anesthesiol. 2010; 59: 314–318. DOI: 10.4097/kjae.2010.59.5.314

Lim Y., Yeo S.W. A comparison of the GlideScope with the Macintosh laryngoscope for tracheal intubation in patients with simulated difficult airway. Anaesth. Intensive Care. 2005; 33: 243–247.

Malik M.A., Subramaniam R., et al. Randomized controlled trial of the Pentax AWS, Glidescope, and Macintosh laryngoscopes in predicted difficult intubation. Br. J. Anaesth. 2009; 103: 761–768. DOI: 10.1093/bja/aep266

Serocki G., Bein B., Scholz J., Dörges V. Management of the predicted difficult airway: A comparison of conventional blade laryngoscopy with video-assisted blade laryngoscopy and the GlideScope. Eur. J. Anesthesiol. 2010; 27: 24–30. DOI: 10.1097/EJA.0b013e32832d328d

Aziz M.F., Dillman D., Fu R., Brambrink A.M. Comparative effectiveness of the C–MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology. 2012; 116: 629–636. DOI: 10.1097/ALN.0b013e318246ea34

Enomoto Y., Asai T., Arai T., et al. Pentax-AWS, a new videolaryngoscope, is more effective than the Macintosh laryngoscope for tracheal intubation in patients with restricted neck movements: A randomized comparative study. Br. J. Anaesth. 2008; 100: 544–548. DOI: 10.1093/bja/aen002

Jungbauer A., Schumann M., Brunkhorst V., et al. Expected difficult tracheal intubation: A prospective comparison of direct laryngoscopy and video laryngoscopy in 200 patients. Br. J. Anaesth. 2009; 102: 546–550. DOI: 10.1093/bja/aep013

Jabre P., Combes X., Leroux B., et al. Use of gum elastic bougie for prehospital difficult intubation.Am.J. Emerg. Med. 2005; 23: 552–555.

Nolan J.P., Wilson M.E. Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum elastic bougie. Anaesthesia. 1993; 48: 630–633.

Bhatnagar S., Mishra S., Jha R.R., et al. The LMA Fastrach facilitates fibreoptic intubation in oral cancer patients. Can. J. Anaesth. 2005; 52: 641–645.

Shung J., Avidan M.S., Ing R., et al. Awake intubation of the difficult airway with the intubating laryngeal mask airway. Anaesthesia. 1998; 53: 645–649.

Parnell J.D., Mills J. Awake intubation using fast-track laryngeal mask airway as an alternative to fiberoptic bronchoscopy: A case report. AANA J. 2006; 74: 429–431.

Xu M., Li X.-X., Guo X.-Y., Wang J. Shikani Optical Stylet versus Macintosh Laryngoscope for Intubation in Patients Undergoing Surgery for Cervical Spondylosis: A Randomized Controlled Trial. Chin. Med. J. Engl. 2017; 130(3): 297–302. DOI: 10.4103/0366–6999.198926

Ainsworth Q.P., Howells T.H. Transilluminated tracheal intubation. Br. J. Anaesth. 1989; 62: 494–497.

Hung O.R., Pytka S., et al. Lightwand intubation: II-Clinical trial of a new lightwand for tracheal intubation in patients with difficult airways. Can. J. Anaesth. 1995; 42: 826–830.

Kuo Y.W., Yen M.K., Cheng K.I., Tang C.S. Lightwand-guided endotracheal intubation performed by the nondominant hand is feasible.Kaohsiung J. Med. Sci. 2007; 23(10): 504–510.

Weis F.R., Hatton M.N. Intubation by use of the light wand: Experience in 253 patients. J. Oral. Maxillofac Surg. 1989; 47: 577–580; discussion 581.

Wilson W.M., Smith A.F. The emerging role of awake videolaryngoscopy in airway management. Anaesthesia. 2018; 73(9): 1058–1061. DOI: 10.1111/anae.14324

Alhomary M., Ramadan E., Curran E., Walsh S.R. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta-analysis. Anaesthesia. 2018; 73(9): 1151–1161. DOI: 10.1111/anae.14299

Moore A.R., Schricker T., Court O. Awake videolaryngoscopy-assisted tracheal intubation of the morbidly obese. Anaesthesia. 2012; 67(3): 232–235. DOI: 10.1111/j.1365-2044.2011.06979.x

Mahrous R.S., Ahmed A.M. The Shikani Optical Stylet as an Alternative to Awake Fiberoptic Intubation in Patients at Risk of Secondary Cervical Spine Injury: A Randomized Controlled Trial. J. Neurosurg. Anesthesiol. 2018; 30(4): 354–358. DOI: 10.1097/ANA.0000000000000454

Vinayagam S., Dhanger S., Tilak P., Gnanasekar R. C-MAC® video laryngoscope with D-BLADE™ and Frova introducer for awake intubation in a patient with parapharyngeal mass. Saudi J. Anaesth. 2016; 10(4): 471–473.

Hegazy A.A., Kawally H., Ismail E.F., et al. Comparison between fiberoptic bronchoscope versus C–MAC video-laryngoscope for awake intubation in obese patients with predicted difficult airway. Res. Opin. Anesth. Intensive Care. 2018; 5: 134–140. DOI: 10.4103/roaic.roaic_28_17

Frerk C., Mitchell V.S., McNarry A.F., et al. Difficult Airway Society intubation guidelines working group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br. J. Anaesth. 2015; 115(6): 827–848. DOI: 10.1093/bja/aev371

Ferson D.Z., Rosenblatt W.H., Johansen M.J., et al. Use of the intubating LMA-Fastrach in 254 patients with difficult-to-manage airways. Anesthesiology. 2001; 95: 1175–1181.

Jeon H.K., So Y.K., Yang J.H., Jeong H.S. Extracorporeal oxygenation support for curative surgery in a patient with papillary thyroid carcinoma invading the trachea. J. Laryngol. Otol. 2009; 123: 807–810. DOI: 10.1017/S0022215108003216

Sendasgupta C., Sengupta G., Ghosh K., et al. Femoro-femoral cardiopulmonary bypass for the resection of an anterior mediastinal mass. Indian. J. Anaesth. 2010; 54: 565–568. DOI: 10.4103/0019–5049.72649

Neelakanta G. Cricoid pressure is effective in preventing esophageal regurgitation. Anesthesiology. 2003; 99: 242.

Difficult Airway Society Extubation Guidelines Group, Popat M., Mitchell V., Dravid R., Patel A., Swampillai C., Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012; 67(3): 318–340. DOI: 10.1111/j.1365-2044.2012.07075.x

Schnell D., Planquette B., Berger A., et al. Cuff Leak Test for the Diagnosis of Post-Extubation Stridor. J. Intensive Care Med. 2017: 885066617700095. DOI: 10.1177/0885066617700095. [Epub ahead of print] PubMed PMID: 28343416.

Keeratichananont W., Limthong T., Keeratichananont S. Cuff leak volume as a clinical predictor for identifying post-extubation stridor. J. Med. Assoc. Thai. 2012; 95(6): 752–755.

Cook T.M., MacDougall-Davis S.R. Complications and failure of airway management, BJA: British Journal of Anaesthesia. 2012; 109(suppl. 1): i68–i85. DOI: 10.1093/bja/aes393

Hubble M.W., Wilfong D.A., Brown L.H., et al. A meta-analysis of prehospital airway control techniques part II: alternative airway devices and cricothyrotomy success rates. Prehosp. Emerg. Care. 2010; 14: 515–530. DOI: 10.3109/10903127.2010.497903

Hubert V., Duwat A., Deransy R., et al. Effect of simulation training on compliance with difficult airway management algorithms, technical ability, and skills retention for emergency cricothyrotomy. Anesthesiology. 2014; 120: 999–1008. DOI: 10.1097/ALN.0000000000000138

Cook T.M., Woodall N., Frerk C. Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1 Anaesthesia, Br. J. Anaesth. 2011; 106: 617–631). DOI: 10.1093/bja/aer058

Takayesu J.K., Peak D., Stearns D. Cadaver-based training is superior to simulation training for cricothyrotomy and tube thoracostomy. Intern. Emerg. Med. 2017; 12: 99–102. DOI: 10.1007/s11739-016-1439-1

Cooper R.M., Khan S.M. Extubation and reintubation of the difficult airway. In: Hagberg C.A., editor. Benumof and Hagberg’s Airway Management. 3rd ed. Philadelphia: Elsevier-Saunders, 2012: 1018–1046.

Cooper R.M. The use of an endotracheal ventilation catheter in the management of difficult extubations. Can. J. Anaesth. 1996; 43: 90–93.

Duggan L.V., Law J.A., Murphy M.F. Brief review: Supplementing oxygen through an airway exchange catheter: efficacy, complications, and recommendations. Can. J. Anesth. 2011; 58: 560–568. DOI: 10.1007/s12630-011-9488-4

Higgs A., Swampillai C., Dravid R., et al. Re-intubation over airway exchange catheters — mind the gap (letter). Anaesthesia. 2010; 65: 859–860. DOI: 10.1111/j.1365-2044.2010.06433.x

Bergold M.N., Kahle S., Schultzik T., et al. Intubating laryngeal tube suction disposable: Initial clinical experiences with a novel device for endotracheal intubation. Anaesthesist. 2016; 65(1): 30–35. DOI: 10.1007/s00101-015-0100-0

Singh M., Kapoor D., Anand L., Sharma A. Intubating laryngeal tube suction device (iLTS-D) requires ‘Mandheeral 1 and Mandheeral 2’ manoeuvres for optimum ventilation, Southern African Journal of Anaesthesia and Analgesia. 2018; 24(2): 63–64. DOI: 10.1080/22201181.2018.1436031

Ott T., Fischer M., Limbach T., et al. The novel intubating laryngeal tube (iLTS-D) is comparable to the intubating laryngeal mask (Fastrach) — a prospective randomised manikin study. Emergency Medicine. 2015; 23: 44. DOI: 10.1186/s13049-015-0126-y

Cook T.M., Kelly F.E. Time to abandon the ‘vintage’ laryngeal mask airway and adopt second-generation supraglottic airway devices as first choice. Br. J. Anaesth. 2015; 115: 497–499. DOI: 10.1093/bja/aev156

Guo Y., Feng Y., Liang H., et al. Role of flexible fiberoptic laryngoscopy in predicting difficult intubation. Minerva Anestesiologica. 2018;84(3): 337–345. DOI: 10.23736/S0375–9393.17.12144-9

Rosenblatt W., Ianus A.I., Sukhupragarn W., et al. Preoperative endoscopic airway examination (PEAE) provides superior airway information and may reduce the use of unnecessary awake intubation. Anesth. Analg. 2011; 112: 602–607. DOI: 10.1213/ANE.0b013e3181fdfc1c

Gätke M.R., Wetterslev J. Danish Anaesthesia Database. A documented previous difficult tracheal intubation as a prognostic test for a subsequent difficult tracheal intubation in adults. Anaesthesia. 2009; 64: 1081–1088. DOI: 10.1111/j.1365-2044.2009.06057.x

Kanaya N., Kawana S., Watanabe H., et al. The utility of three-dimensional computed tomography in unanticipated difficult endotracheal intubation. Anesth. Analg. 2000; 91: 752–754.

The features of anesthesia in bariatric surgery

E.Y. Garbuzov, G.A. Ovsyannikov, S.G. Sherbak

City Hospital № 40, Saint-Petersburg

For correspondence: Evgenii Garbuzov — MD, head of Department of anesthesiology and intensive care of Saint-Petersburg clinical hospital № 40, Saint-Petersburg; e-mail:

For citation: Garbuzov EY, Ovsyannikov GA, Shcherbak SG. The features of anesthesia in bariatric surgery. Alexander Saltanov Intensive Care Herald. 2018;2:31–5.

DOI: 10.21320/1818-474X-2018-2-31-35

Nowadays obesity is a worldwide problem. Changes associated with the obesity commonly increase risks of perioperative complications that could be fatal. The increasing of fat tissue influences significantly on pharmacokinetic of intravenous drugs, nevertheless effects of inhaled anesthetics remain more predictable. Structural changes of upper airways, sleep apnea obstructive syndrome, cervical osteochondrosis reduce visualization in direct laryngoscopy. Frequency of difficult tracheal intubation in patients with body weight index more than 40 kg/m2 reaches 13–24 %. In some cases awake tracheal intubation is necessary, that changes a traditional induction plan. Morbid obesity patients have often cardiovascular diseases, respiratory system disorders and increased intra-abdominal pressure, therefore they need a differentiated approach for ventilation strategy for safe anesthesia. Knowledge of the pathophysiology of these changes allows to take measures to prevent serious complications. Nowadays in the general surgery department of the Saint-Petersburg City Hospital № 40 we perform two types of bariatric operations: sleeve — resection and gastric-bypass. In this article we have presented our experience of perioperative management of morbid obese patient for bariatric surgery.

Keywords: anesthesia, morbid obesity, bariatric surgery, laparoscopic surgery, difficult airways, inhaled anesthetics, monitoring of neuromuscular block

Received: 20.12.2017


  1. Ершова Е.В., Трошина Е.А., Федорова О.С. Морбидное ожирение — возможности консервативной терапии. Ожирение иметаболизм. 2010; 4: 40–43. [Ershova E.V., Troshina E.A., Fyodorova O.S. Morbid obesity — capabilities of conservative treatment. Ozhirenie i metabolism. 2010; 4: 40–43. (In Russ)]
  2. Catenacci V.A., Hill J.O., Wyatt H.R. The obesity epidemic. Clinics in Chest Medicine. 2009; 30: 415–444.
  3. КляритскаяИ.Л., Стилиди Е.И., Максимова Е.В. Морбидное ожирение и ассоциированная патология: алгоритм ведения больных. Крымский терапевтический журнал. 2015; 1: 43–48 [Klyaritskaya I.L., Stilidi E.I., Maksimova E.V. Morbid obesity and concomitant diseases: the algorithm of treatment. Krymskii terapevticheskii zhurnal. 2015; 1: 43–48. (In Russ)]
  4. Virdis A., Neves M.F., Duranti E., et al. Microvascular endothelial dysfunction in obesity and hypertension. Current Pharmaceutical Design. 2013; 19: 2382–2389.
  5. Nejat E.J., Polotsky A.J., Pal L. Predictors of chronic disease at midlife and beyond — the health risks of obesity. Maturitas. 2010; 65: 106–111.
  6. Hushak G., Busch T., Kaisers U.X. Obesity in anesthesia and intensive care. Clinical endocrinology and metabolism. 2013; 27(2): 247–260.
  7. van Kralingen S., Diepstraten J., van de Garde E.M., et al. Comparative evaluation of propofol 350 and 200 mg for induction of anesthesia in morbidity obese patients: a randomized double-blind pilot study. European Journal of Anesthesiology. 2010; 27: 572–574.
  8. Pelosi P., Croci M., Ravagnan I., et al. The effects of body mass on lung volumes, respiratory mechanics, and gas exchange during general anesthesia. Anesthesia and Analgesia. 1998; 87: 654–660.
  9. Strollo P.J., Rogers R.M. Obstructive sleep apnea. Current concepts. New England Journal of Medicine. 1996; 334: 99–104.
  10. Lebuffe G., Andrieu G., Wierre F., et al. Anesthesia in the obese. Journal of visceral surgery. 2010; 147(Suppl.5); e11–e19.
  11. Эпштейн С.Л. Периоперационное анестезиологическое обеспечение больных с морбидным ожирением. Медицинский совет. 2013; 5–6: 17–27. [Epstein S.L. Perioperative anesthetic management in morbidly obese patients. Medicinskii sovet. 2013; 5–6: 17–27. (In Russ)]
  12. ЗаболотскихИ.Б., Лебединский К.М., Анисимов М.А. и др. Клинические рекомендации. Периоперационное ведение больных с сопутствующим ожирением (второй пересмотр) 2016: 1–24. [Zabolotskikh I.B., Lebedinskii K.M., Anisimov M.A., et al. Perioperative management in morbid obesity patients (second edition) 2016: 1–24. (In Russ)]
  13. Ozdogan H.K., Cetinkunar S., Karateke F., et al. The effects of sevoflurane and desflurane on the hemodynamics and respiratory functions in laparoscopic sleeve gastrectomy. Journal of Clinical Anesthesia. 2016; 35: 441–445.
  14. Singh P., Borle A., McGawin J., et al. Comparison of the Recovery Profile between Desflurane and Sevoflurane in Patients Undergoing Bariatric Surgery — a Meta-Analysis of Randomized Controlled Trials. Obesity surgery. 2017; 27: 3031–3039.
  15. Strum E.M., Szenohradszki J., Kaufman W.A., et al. Emergence and recovery characteristics of desflurane versus sevoflurane in morbidly obese adult surgical patients: a prospective, randomized study. Anesth.Analg. 2004; 99: 1848–1853.
  16. Николаенко Э.М., Куренков Д.А., Кирсанов И.И. идр. Эффективность миорелаксации с точки зрения оперирующего хирурга при лапароскопических вмешательствах. Вестник интенсивной терапии. 2015; 2: 39–44. [Nikolaenko E.M., Kurenkov D.A., Kirsanov I.I., et al. Efficiency of mioplegia by surgeon’s point of view during laparoscopic interventions. Vestnik intensivnoi tepapii. 2015; 2: 39–44. (In Russ)]
  17. Meyhoff C.S., Lund J., Jenstrup M.T., et al. Should dosing of rocuronium in obese patients be based on ideal or corrected body weight? Anesthesia and analgesia. 2009; 109: 787–792.
  18. Van Lancker P., Dillemans B., Bogaert T., et al. Ideal versus corrected body weight for dosage suggamadex in morbidity obese patients. Anesthesia. 2011; 66: 721–725.
  19. Adams J.P., Murphy P.G. Obesity in anesthesia and intensive care. British journal of anesthesiology. 2000; 85(1): 91–108.
  20. Benumof J.L. Obstructive sleep apnea in the adult obese patient: implications for airway management. Journal of clinical anesthesia. 2001; 13: 144–156.
  21. Ogunnaike B., Joshi G.P. Obesity, sleep apnea, the airway and anesthesia. In: Miller’s anesthesia. Ed. R.D. Miller. Сhapter 43. New York: Churchill Livingstone, 2015: 892–901.
  22. De Baerdemaeker L.E., Van der Herten C., Gillardin J.M., et al. Comparison of volume-controlled and pressure-controlled ventilation during laparoscopic gastric banding in morbidity obese patients. Obesity surgery. 2008; 18: 680–685.
  23. Неймарк М.И., Киселев Р.В., Булганин А.А. Особенности анестезиологического обеспечения оперативных вмешательств по поводу различных видов ожирения. Вестник интенсивной терапии. 2010; 5: 122–125. [Neimark M.I., Kiselev R.V., Bulganin A.A. Features of anaesthetic management in bariatric surgery. Vestnik intensivnoi terapii. 2010; 5: 122–125. (In Russ)]