Confront Difficult Conversations Head On
Transitioning from a perioperative nurse to a leadership role in an Ambulatory Surgery Center (ASC) presented me with numerous challenges, but none were as daunting...
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By: Anthony Chipas
Published: 3/31/2015
Instead of visualizing the vocal cords, all I could see was pink and froth. Now what? That easy intubation just got a lot more interesting and a lot more challenging on the young male patient with the facial tumor. Thankfully, over my 42-year career in the OR, I had taken the time and effort to master the tools of difficult airway management. I set aside my laryngoscope and blade and reached into my difficult airway cart for my fiberoptic bronchoscope (this was before the advent of video laryngoscopes). Crisis averted. But only because I had learned this critical lesson about difficult airways: Better to prepare for challenging intubations than to (try to) predict them or, worse yet, foolishly think that one won't happen to you.
Our worst nightmare
The unanticipated difficult airway is an anesthesia provider's worst nightmare. It shows up without warning, rarely announcing itself in the form of an obese patient with limited head extension and obvious airway pathology. What if you can't visualize vocal cords? What if the patient starts desaturating?
We're fortunate that we can stock our airway carts with such new and advanced (and affordable!) tools as video laryngoscopes and disposable fiber-optic bronchoscopes. The ideal airway device is simple to set up and use, effective and reliable. But without the skills and competence you can only acquire through training and practice, the ideal airway device is pretty much useless. It is every anesthesia provider's personal and professional responsibility to acquire and maintain the necessary skills to use airway devices. Awake intubation is the cornerstone of the difficult airway algorithm. All anesthetists should be skilled in at least one alternative technique of tracheal intubation under vision.
Even with all of today's modern devices, you can't neglect such skills as cricothyrotomy. Yes, you might go your entire career without needing to perform an emergency airway puncture, but if the time ever comes, you'll be glad you went to that difficult airway hands-on workshop and worked on that pig trachea.
Practice makes
In airway management as in life, proper planning prevents poor performance. You can't predict challenging intubations, but you can certainly prepare for them. The confidence and requisite skills required for successful management of the difficult airway come with continual practice. And you can't keep the difficult airway cart locked up gathering dust until you need it (see "What's in Your Difficult Airway Cart?" on page 26).
At least once a month, all anesthesia providers should set aside a day to master the tools of difficult airway management on routine, healthy patients who have normal airways (you don't want to practice using the equipment when the patient's oxygen saturation is 60!). Pull out a piece of equipment from the airway cart you haven't used in while — or that you've never used — and learn how to use it. Pick any piece of equipment you use above the vocal cords. Maybe it's the fiberoptic bronchoscope, maybe an intubating LMA.
The tools of the trade
Over the years, we've seen a continual improvement in the tools for managing difficult intubations. Clearly, the future of difficult airway management is in the innovative use of video-assisted laryngoscopes and video stylets. This short guide will help you determine which equipment best fits you and your facility.
The most essential tool
With the ever-advancing technology and decreasing cost of difficult airway video laryngoscopes and stylets, there are few excuses for not having some type of video technology in your difficult airway cart, no matter how small the center may be. But we need to remember that the constant, ever-changing faces of difficult airway management are anesthesia providers. If their skills and confidence are not consistent with the technology available, then it doesn't matter what's in the difficult airway cart.
Nothing can be more frightening, more adrenaline-rushing, more potentially devastating than being faced with an emergency airway management case. This patient requires a competent anesthesia provider who has the skill and confidence to establish a patent airway in a hurry. The chance of this happening in any of our facilities has continued to increase over the past several years for a number of reasons, the greatest of which is obesity. That competent provider — that valuable tool — must be you.
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