Any anesthesiologist to OR 3, stat!" sounds over the hospital OR intercom and decades of experience and skill appear, specialized equipment at hand. Airway disaster averted.

But few of us practicing in freestanding surgical centers have the luxury of unlimited personnel and equipment. "Any anesthesiologist'" can be a very lonely call, especially if, like me, you're working in an ASC in the center of an office park. We do, however, have the ability and responsibility to select our patients, the airway challenges we're willing to manage and the procedures that we can safely perform.

While the ASA Practice Guidelines for Management of the Difficult Airway[1] provide detailed and comprehensive protocols for the management of patients with challenging airways, careful patient selection ' the cornerstone of ambulatory anesthesia ' should be the basis for adapting them to your practice. With that in mind, here are five questions to consider while developing your protocol:

1 What are your personnel resources? How many other anesthesiologists, CRNAs and ENT surgeons do you work with? Let's say you practice in a two-room surgery center where the only people skilled in airway management are you and two CRNAs. You can't hit a code button and call for an ENT surgeon or another anesthesiologist to help. On the other hand, if you're practicing in a 16-room surgery center, you've got a safety net of equipment and people to help in the case of an emergency.

2 What are your equipment resources and what is reasonable to have? If you're in a hospital, chances are you're going to have everything from rigid bronchoscopes to flexible bronchoscopes, maybe even video-assisted equipment, costing tens of thousands of dollars. That's a lot to spend for a device you're only going to use in case of an emergency. Ask yourself if more is always better. Let's go back to that stand-alone center in an office park: Do you even want the temptation to care for a patient with a challenging airway? If you lose the airway, you're going to be in big trouble. My advice is don't invest in tertiary equipment if the patient's not appropriate for your setting.

3 What is your ability to identify the patients who are at risk for an airway emergency? You should know which patients are appropriate for your facility before the day of surgery. Careful pre-operative screenings, histories and physical exams can help identify patients with potentially difficult airways before they even step foot in your center.

4 What types of previously identified difficult airways are you willing to manage in your center? Carefully and honestly consider the chances you're willing to take. Will the presence of a fiberscope or video LMA make you feel secure anesthetizing a patient with a known difficult airway or a "Could Not Intubate" Medic Alert bracelet? Should it? Will you be performing awake intubations? Should you?

5 What emergency procedures are you capable of performing? When was the last time you performed a retrograde intubation or cricothyroidotomy or used jet ventilation in an emergency? When intubation is indicated, and you can ventilate but not intubate, should you proceed with a spontaneous ventilating fiberscope intubation or a fast-track LMA intubation? Or should you reschedule in the main OR?

Your most important tool: Careful patient selection
Consider your unique abilities and resources and develop your airway management protocols relevant to these. While the ASA Guidelines were designed for all airway management situations, it's unreasonable to expect that all possible airway management procedures are available in all surgical centers. The limited personnel and resources in most ASCs require that you carefully select your patients. In fact, proper patient selection is the most important factor in avoiding airway emergencies.

Reference
1. Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2003; 98(5): 1269-1277.