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Airway management is more difficult and stressful in obstetrics, and the consequences of difficulty are more serious than in many other areas. Most problems involve general anaesthesia although airway management may be required in regional anaesthesia. One advantage of regional anaesthesia, if not the main one, is the avoidance in most cases of the need for airway support. Apart from the possible contribution of reduced training in airway management and obstetric general anaesthesia, another factor that might lead to a higher reported incidence is that trainees are now taught to declare failure earlier rather than persist with attempts to intubate. The value of a drill in the management of difficult/failed intubation has long been recognised and a modern, simplified version is offered. Care must also be taken with tracheal extubation, especially if there is a risk of laryngeal oedema, perhaps exacerbated by intubation, for example in pre-eclampsia.
Nowadays, most patients tolerate short-term trans-laryngeal tracheal intubation with few, if any, complications. For those who require more prolonged intubation, a tracheostomy may provide a number of advantages. This chapter outlines indications, timing, complications and techniques of tracheostomy. Complications of tracheostomy can be classified into perioperative, early and late, with both the type and incidence of specific complications differing between surgical and percutaneous techniques. In some centres routine tracheostomy for ventilator-dependent patients is viewed as an ideal training opportunity, increasing both the duration of the procedure and the risk of surgical misadventure. Ultrasound imaging of the neck prior to tracheostomy allows the anatomy of the anterior neck structures to be identified, particularly the location of blood vessels and the depth and angulation of the trachea. This information may contribute to the risk to benefit analysis between surgical and percutaneous tracheostomy. The chapter also discusses the role of cricothyroidotomy or mini-tracheostomy.
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