1. Do you conduct pre-op airway exams?

Your anesthesia providers should conduct a pre-op evaluation of the patient's airway before each case. Although physical characteristics aren't always associated with intraoperative airway trouble, there are red flags that can be identified during exams, including relatively long upper incisors, a prominent overbite, a short, a thick neck and the inability to visualize the uvula when the patient's tongue is protruded.

2. Do you have a plan in place?

There are 5 categories of difficult airway management options to consider: mask ventilation, supraglottic airway, laryngoscopy, tracheal intubation and surgical airway. The key is to consider the patient-specific characteristics and comorbidities that could make maintaining the airway a challenge, decide which approach would be best and ensure the required tools are in the OR in the event they're needed.

For example, patients who don't have the ability to open their mouth fully could be candidates for mask ventilation, but would be less suited for placement of a supraglottic airway. A history of airway trouble is also a crucial consideration. When planning endotracheal intubations on patients who've been difficult intubations in the past, decide if there are enough warning signs that would call for awake intubation. If your facility does not have the tools and providers available to perform that technique, refer the patient to another facility that does.

3. Do you have the right equipment?

Being prepared to handle difficult airways requires having a fully stocked airway cart on hand. The American Society of Anesthesiologists suggests investing in rigid laryngoscope blades, video laryngoscopes, tracheal tubes, tracheal tube guides, supraglottic airways, flexible fiber-optic intubation equipment, equipment for emergency invasive airway access and an exhaled carbon dioxide detector.

Check airway carts routinely to ensure the devices and equipment are current and in good working order. Every member of your clinical team should take a turn reviewing the cart's contents. If nurses are the only ones routinely reviewing the items, your anesthesia providers might find themselves unsure of where they can access supraglottic airways or emergency intubation equipment when a crisis occurs and every second counts.

4. Have you considered new technologies?

There are several technologies available that can help rescue an airway or serve as a primary airway if you suspect a patient will be a difficult intubation.

"? Video laryngoscopes have revolutionized airway management. This technology makes it easier for the provider to visualize the vocal cords and related airway structures without a direct line of sight. The devices help eliminate difficult airways as a result of traditional challenges, such as patients with large incisors that hamper views of the glottis.

With the large and complete view of the airway afforded by the video technology, providers are also able to overcome or avoid common intubation obstacles they face when caring for obese patients. For example, providers can watch the advancement of the laryngoscope and alter its movement as needed for more precise placement and prevention of injuries or damage to airway structures. Video laryngoscopes also enable providers to establish airways with less movement of the patient's head and neck, a key to caring for obese individuals who have thicker and larger anatomy, which can make manipulation and intubation difficult.

"? Supraglottic airways can be inserted into the pharynx to allow ventilation, oxygenation and administration of anesthetic gases, without the need for endotracheal intubation. The latest options have received recent upgrades. They're easier to place, cause less airway trauma, improve seal pressure and provide better gastric access. A variety of sizes should be stocked in your emergency airway cart.

"? Disposable flexible intubation video scopes, which can facilitate tracheal intubation in patients with anticipated or unanticipated difficult airways, are a recent game-changing technology. Many facilities don't stock their emergency airway cart with traditional flexible intubation scopes because of cost concerns and, hopefully, because the devices aren't often needed. However, the latest disposable options can be bought for a fraction of what reusable scopes costs. The disposable scopes also don't have to be cleaned and disinfected between uses.

5. Do you conduct annual drills?

Conduct regular difficult airway drills with staff and anesthesia providers. There is no standard recommendation for how frequently these drills should be held. I host difficult airway workshops at our institution every 3 months and require my staff to complete it every 2 years. We go over standard information about how to handle difficult airway emergencies, review the equipment on the difficult airway cart and touch on other relevant guideline updates that are beneficial for them to know.

A difficult airway drill requires full participation from every member of the surgical team; nurses need to retrieve the difficult airway cart while the anesthesia provider focuses on the patient and other staff members assist as needed. Members of the care team should also feel empowered to speak up if they have a concern about the patient's airway. That's true of most safety initiatives, but it's especially important when airways could be compromised. Providers shouldn't repeat the same technique while trying to manage a difficult airway because repeated intubation attempts could create serious problems such as swelling or bleeding. That's why it's important for staff to feel comfortable stepping in to suggest switching to airway management plan B or C, which providers should have considered and discussed with the team before the procedure.

An important reminder: Extubation is a critical point of care, but anesthesia providers and surgical team members sometimes lose focus on securing the airway as they complete charting, clean the room and turn their attention to the next case. But be aware that airway complications, such as laryngospasms, can occur when airway devices are removed. The end of surgery is not the time to ignore the importance of proper airway management. OSM