Surgery begins with airway management. While pre-surgical exams can red-flag difficult airways and mask ventilation is nearly always possible, failed intubation — defined as three or four unsuccessful attempts at direct laryngoscopy — demands immediate action. Here are six types of tools with which your anesthesia providers might handle difficult airways.

1. Laryngoscope blades. Used to displace the patient's tongue while the neck is extended for airway visualization and tracheal tube placement. Available in two types — Miller, a straight blade, and Macintosh, a curved blade — and four sizes of each type, at about $70 to $100 each. Consider stocking two of each type and size for different user preferences and needs, says Marty Resnik, CRNA, BSN, staff anesthetist at Case Medical Center and president of CRNA Anesthesia Associates in Cleveland.

2. Tracheal tubes and guides. The flexible-tipped tubes, available in multiple sizes at about $4 each, channel oxygen to the airway. Guides are often used to assist in placing tubes, says Mr. Resnik. Semi-rigid stylets, which slide into tubes to shape them for easier access; gum elastic bougies, the long, thin, semi-rigid tubes that can introduce tracheal tubes into the airway; and ventilating tube changers, which are inserted through the tracheal tube before it's removed to enable easy post-op reintubation if necessary, cost less than $10 each. Light wands, flexible lighted stylets that illuminate the airway, are more expensive at about $50. A disposable double-lumen tube called a combitube (about $80) can be installed without visualizing the larynx and can provide emergency ventilation even if it's placed down the esophagus.

3. Laryngeal mask airways. Placed above the larynx, LMAs can assist in ventilation and provide a conduit for intubation. "LMAs have taken a place as the first line of defense against airway difficulties," says Donald G. Ganim II, MD, anesthesiologist at Beverly Hospital and partner with Beverly Anesthesia Associates in Beverly, Mass. "They've revolutionized the difficult airway algorithm with their consistency and success. In most cases, the LMA is the first thing we reach for." LMAs are available in five sizes to fit pediatric and adult patients, with single-use models costing less than $10 and reusable models good for about 40 uses costing about $200.

4. Visualization instruments. Video laryngoscopes are similar to conventional laryngoscopes, but feature cameras on their blades that deliver images to external monitors or small screens on the scope. San Diego-based anesthesiologist and author Adam Dorin, MD, MBA, describes the "much improved lighting offered by the newer scopes [as] essentially a fiberoptic type of brightness in a short laryngoscope." They range from $8,000 to $15,000. Fiberoptic bronchoscopes, which range from $20,000 to $30,000, are essentially flexible tubes with light at one end and a view at the other. If a patient's mouth can't accommodate a video laryngoscope, a bronchoscope can access the airway through a nostril. Dr. Dorin notes, however, that these instruments' use as adjuncts for establishing airways "is only as good as the training and familiarity of the clinician when they reach for it in an emergency situation." Further, many smaller facilities doing elective procedures may find it difficult to cost-justify their purchase just for rare emergencies.

5. Invasive access. A retrograde intubation set, which employs a needle and catheter to externally thread a wire up the trachea and out the mouth to establish an airway, and a cricothyrotomy kit, which enables external tracheal intubation, are "last resort" options for cannot-ventilate, cannot-intubate emergencies. Pre-made, single-use kits can cost as much as $120, although facilities can assemble the components on their own. "A pack we put together has sterile towels, a scalpel handle, an 11 blade and hemostats," says Paul S. Patane, MD, MBA, medical director of Olive Surgery Center in Creve Coeur, Mo., and member of Ballas Anesthesia, which practices in suburban St. Louis.

6. Exhaled CO2 detector. Monitoring end tidal CO2 confirms that the tracheal tube is in the trachea, not the esophagus, ensuring the patient is properly oxygenated. During surgery, your anesthesia provider is already doing this; as a standard of care, end tidal CO2 is already measured by patient monitors. But a handheld detector can assist in post-op airway emergencies to confirm intubation when an end tidal CO2 monitor is unavailable, says Mr. Resnik.

Store airway supplies in a portable unit so equipment is nearby for any procedure. Make sure the cart remains nearby until patients are awake and transferred, says Dr. Ganim. The cart may even follow patients to post-op if difficulties are anticipated, but don't let busy techs wheel it away for cleaning and restocking before the case has concluded.

Know your options
The supplies your anesthesia staff needs depend on the cases your ORs host. Not every provider will use every device. "The choice of airway device is guided by a practitioner's experience," says Mr. Resnik. "They've all got a couple of tricks in their bags to use when an emergency happens."

While a well-stocked emergency airway cart may insure your staff against the risk of a lost airway, that confidence shouldn't necessarily lead your facility to schedule more potentially difficult cases. "Patient safety is first and foremost," says Dr. Ganim. "With every case, consult with anesthesia on where the most resources can be brought to bear on the patient. [These supplies] should not be seen as a means by which you can push the envelope."

At Dr. Patane's standalone ASC, a line drawn on cases has influenced the supplies on hand. "Any patient who on my pre-op assessment I feel we can't intubate with direct laryngoscopy, or who in their medical history needed anything besides direct laryngoscopy is not a candidate to be taken care of here," he says. "The feeling was, we don't want to get into situations with limited skilled hands and no access to other help." Since the only failed airways he expects to see are unexpected ones, his emergency supplies include just LMAs and an as-yet-unused cricothyrotomy kit.

Whatever supplies you choose, it's important that your anesthesia staff has a plan in place. "The ultimate question is, what's the worst road you can go down?" says Dr. Ganim. "And do you have the capability to resolve that situation?"