My daughter is a fit 22-year-old with perfectly normal neck anatomy and mobility. She'd be easy to intubate, right? Wrong. Ask her to open her mouth and you'd see enormous tonsils that could make her susceptible to airway difficulties during surgery. Look at her in pre-op, however, and you'd never suspect she's a higher-risk patient. And that's crucial to understand: While airway emergencies are far from routine, having the necessary equipment at the ready and procedures in place should always be in the back of your mind, no matter how normal the anatomy seems or how easy the case appears.

Look for these red flags
The best defense against airway emergencies is being proactive in recognizing the potential for them to occur. That starts with pre-op patient assessments aimed at uncovering physical traits or lifestyle habits that could lead to problems during surgery.

• Are they overweight? Obesity is certainly a clear indication that airway problems might arise. Ask all patients — not just the obese or men — if they're heavy snorers or suffer from sleep apnea. Assess the size of the patient's tongue and mouth opening. In the obese and sleep apnea sufferers, added tissue mass around the neck and chin can make intubation a challenge and could cause the airway to collapse when sedated muscles relax. But also know that heavy patients carry their weight in different places. A morbidly obese patient could still have perfectly acceptable head and neck anatomies as they relate to safe intubation and ventilation.
• Do they smoke? Research presented at this year's American Society of Anesthesiologists meeting highlighted the effects of smoking on surgical complication risks. Researchers at the Cleveland Clinic in Ohio discovered that smokers — defined as patients who claimed to have smoked cigarettes in the year before surgery — were more likely to require unplanned intubation or mechanical ventilation. However, patients who quit smoking in the 2 to 3 weeks before surgery significantly decreased their complication risks.
• Do they have lung issues? Listen to the patient's lungs. Any wheezing should make you consider postponing the case. Patients with a history of emphysema, asthma or chronic obstructive pulmonary disease have reactive airways. Regional anesthesia, which takes airway manipulation out of the equation, may be a safer option when anesthetizing pulmonary cripples.
• Are they known problem cases? Ask patients if anesthesia providers have told them they're difficult to intubate at previous surgeries. Might seem like an obvious question to ask, but asking the obvious often leads to the information you need to make the best clinical decisions.

Expect the unexpected
Airway emergencies often occur when you least expect them, when no red flags were raised during the pre-op physical assessment and nothing about the patient looks out of the ordinary.

Hang laminated copies of the American Society of Anesthesiologists' Difficult Airway Algorithm (see page 61) on every anesthesia machine and difficult airway cart. They'll be great references for responders to work off of when helping the anesthesia provider solve airway issues.

In general, an oral or nasal airway will solve an anatomical obstruction (swollen tissues, big tongue, short neck, obesity, short thyro-mental distance). If these airways don't work, use laryngeal mask airways and endotracheal intubation, followed by more invasive measures. Positive pressure ventilation or drug interventions will relieve laryngospasms. Broncho-spasms usually respond to medication therapy.

Keep an easily accessible cart stocked with the supplies and devices needed to manage a difficult airway. It's also a good idea to include a laryngeal mask airway in the cart to secure initial ventilation in patients who can't be intubated.

When faced with a difficult intubation or ventilation, a variety of tools offer assistance, including laryngoscope blades (in various shapes and sizes) and laryngeal mask airways. If you have to intubate a patient with a difficult airway under regional or deep sedation, a laryngeal mask airway should be the first device you reach for, if not otherwise contraindicated. Video laryngoscopes are also extremely effective. The relatively affordable and easy-to-use devices have revolutionized airway management in the outpatient setting. They're incredibly effective as a primary intubating tool and are just as helpful for navigating difficult airways: Providers can watch the device's progress on a small screen, navigating around anatomical obstructions to place its tip near the vocal cords. Cost may be an obstacle to making video laryngoscopes standard tools in each of your anesthesia carts, but you should strongly consider having at least one in your facility for providers to use during atypical or emergency intubations.

When all else fails
If ventilation is inadequate and intubation is unsuccessful, you've got a full-fledged airway emergency on your hands. Attempt to ventilate the airway using a rigid bronchoscope, esophageal-tracheal combitude ventilation or transtracheal jet ventilation. If you can't establish an emergency airway, decide between awakening the patient and continuing the surgery using laryngeal mask airway or facemask ventilation. If an airway can't be achieved, you'll be forced to grab a cricothyroidotomy kit to perform a percutaneous tracheostomy.

The goal is to never reach that last resort. If you're dealing with a problem patient, don't hesitate to perform additional lab tests and take X-rays to get a clear understanding of the extent of the airway issues. And don't be afraid to make the tough call if a patient isn't suitable for surgery in your facility. When it comes to working on elective surgical patients with the potential for airway issues, always err on the side of caution.