General Recommendations

1. Preoxygenate all patients (including children) to whatever extent possible. This provides a buffer to tolerate an inability to ventilate or intubate for several additional minutes.
2. Evaluate every airway carefully from the standpoint of history, physical examination, and other indicated investigations. Keep in mind that several small abnormalities may add up to a difficult airway.
3. Approach every patient with the possibility that mask ventilation or endotracheal intubation may not be possible. Have a backup plan formulated before the problem occurs. A TTJV system cannot be assembled from scratch when the oxygen saturation is falling. Make sure that whatever may be needed is available.
4. Whenever possible, provide mask ventilation before administering any muscle relaxant, especially nondepolarizers. Unless succinylcholine is contraindicated, consider its use when the airway looks potentially difficult and anesthetized intubation is selected. The short action (compared with any nondepolarizing relaxant) of succinylcholine can be a lifesaving and brain-saving approach in the “cannot mask/cannot intubate” situation. However, the duration of a dose of succinylcholine may be longer than the duration of a brain tissue oxygen level compatible with full recovery.^[71]
5. Gain confidence and skill with a variety of approaches to conscious intubation so that it can be applied properly when needed. Do not let less cognizant individuals (e.g., surgeons, nurses) unduly influence your decision to employ conscious intubation. The airway is your responsibility, and you, the patient, and the patients' loved ones suffer the consequences of misjudgments.