DELICATE TOUCH Successful airway management is equal parts science and art. The science is straightforward. Mastering the art is what distinguishes skilled anesthetists from the rest.

Try explaining broken teeth, lacerated lips or damaged airways to patients who didn't know intubation mishaps could leave them hurting more than the surgery itself. Are your anesthetists doing all they can to plan for potential airway trouble? Do they have the tools to manage the difficult airway and prevent avoidable trauma? It's your responsibility to ensure that they do.

Looking for trouble
A thorough pre-op airway assessment is paramount, but I'm afraid some providers have gotten away from the practice. A good exam includes checking anatomy of the airway and throat, tests — like assessing the Mallampati score — and ensuring dentition is in place and healthy. Providers must document what they see (and what they can't see, for that matter).

Mallampati scores of 3 or 4 indicate the potential of a challenging airway, but providers must always assume an airway is suspect until proven otherwise. They must always have a way to rescue the patient; anything they do should be able to be backed up and, if possible, reversed. Do not burn bridges. A well-stocked airway cart contains various types and sizes of laryngoscope blades, airways, Magill's forceps for manipulating the endotracheal tube into the glottis, a video laryngoscope and tools for fiber-optic awake intubation.

Best practice for airway management involves having plans B and C at your fingertips in the event plan A — conventional intubation — fails. Plan B could involve the use of a video laryngoscope, the airway device that's pushing awake fiber-optic intubation for the gold standard label of difficult airway management. Video laryngoscopy transmits clear images of the glottic inlet, giving providers the confidence they need to secure challenging airways caused by anatomical abnormalities, obesity and past trauma. Plan C might involve the use of a supraglottic airway device, the preferred rescue device in the American Society of Anesthesiologists' difficult airway algorithm.

Providers who suspect a difficult airway before the first attempt at intubation can administer light sedation and perform a precursory exam of airway anatomy. If they identify and can access familiar anatomical landmarks, intubation can proceed as planned and the patient can be fully anesthetized for surgery. If the suspicion of a difficult airway is realized, the provider can use a video laryngoscope to secure the airway. They can also perform a transtracheal and superior laryngeal block before performing an awake intubation.

AIRWAY ISSUES
5 Potential Intubation Injuries

CLOSE WATCH Intubation-related trauma is rare, but occurs often enough to demand your attention.

Although intubation-related trauma is rare, it occurs often enough to demand your attention, according to a study published in Best Practice & Research Clinical Anaesthesiology. Here's what the study says about some common damage caused by heavy-handed intubation.

• Lip injuries — lacerations, hematomas, edema and teeth abrasions — are typically caused by inattentive or inexperienced providers. The injuries are more nuisance than serious problem, and typically resolve on their own.
• Dental injuries that occur during laryngoscopy account for half of dental trauma during surgery. The injuries are most common in pediatric patients with periodontal disease or fixed dental work and in any patient when intubation proves difficult. Advise high-risk patients of potential dental damage, and consider the use of tooth guards, even though they might obstruct views of the airway.
  Save a tooth that's been knocked out in moist gauze or normal saline. An oral surgeon or dentist may be able to save it if they act within an hour of the trauma.
• Tongue swelling can occur if the patient's neck is flexed significantly while a bite block is in place. A patient might also lose sensation in his tongue due to nerve injury caused by forceful laryngoscopy or if a supraglottic airway device is improperly placed or placed with an over-inflated cuff.
• Damage to the uvula can cause sore throat, odynophagia, painful swallowing, coughing, foreign body sensation and serious life-threatening airway obstruction. Sore throat occurs after approximately 40% of intubations. Notably, applying topical anesthesia to the end of the endotracheal tube does not lower the risk, and may in fact increase it.
• Trauma to the larynx and vocal cords is largely dependent on the intubation skills of providers and the difficulty of the airway. Patients typically respond to conservative therapy, although those with persistent hoarseness should consult with an ENT physician.

— Daniel Cook

Expecting the unexpected
Are patients with difficult airways susceptible to intubation-related injuries? A provider's abilities make a difference in reducing the risks, but the patient's body habitus, dentition and airway anatomy mark the line between problematic and traumatic intubations.

Whenever a provider places a laryngoscope blade in the mouth, his wrist is fixed. He pushes up and away to lift the jaw and reveal the glottis. When he can't initially see the glottis, he manipulates the blade, sometimes forcefully, to find the view, which can cause inadvertent injuries. Additionally, multiple attempts to access the glottis can cause airway edema, which might compromise the airway.

You can break or loosen teeth and cut lips trying to establish an airway when conventional intubation techniques aren't working and you're forced to ad lib and manipulate the blade, prying back the jaw to gain access to the glottis. Bleeding is the most common problem during nasal intubation. It obstructs your view, and if you fracture the turbinate, you can create a whole host of problems. Traumatic retropharyngeal dissection creates a false passage. Pushing through that "pouch" would cause dramatic bleeding, impossible conditions for intubation and infection risks. This type of injury is rare but dangerous, requiring the skills of an ENT specialist.

Broken teeth are much more dramatic and problematic for patients than a post-op sore throat, which is a relatively common side effect of repeated attempts at airway intubation. Dental events are often the result of provider error, but a patient's poor dentition could also contribute to the injury. Who or what's to blame is often traced to the documentation of dentition during the pre-op assessment.

Notify patients of the risks before surgery during routine pre-op phone calls. The more education you provide up front, the more understanding patients might be in PACU. Immediately alert patients of intubation trouble. Send them for immediate consults with a dental clinic for broken teeth or an ENT specialist for airway edema. The sooner you act to resolve intubation-related issues, the more likely the patient is to accept your treatment offers and move on. In the end, paying for the repairs might be less costly than defending your facility and anesthesia providers against a malpractice lawsuit and rebuilding your reputation in the community.

Have a boilerplate letter on file that's customizable with information about a patient's specific airway troubles. Include your contact information, so future caregivers can reach out for insights about why your providers ran into trouble and how they attempted to solve it. Give copies to patients and their families, and tell them to make the forms a part of their medical records. Any time they undergo surgery, they should present the letter to the anesthesia providers, who'll know to slow down, approach the airway with caution and assess which alternative intubation method is best in order to avoid trouble.

Common concern
Every provider has encountered patients with anatomy that makes intubation impossible, regardless of their skill level or chosen technique. Increased obesity, sleep apnea, post-surgical conditions and airway disease have made difficult airway management commonplace in both urban hospitals and rural surgery centers.