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Avoid Intubation Trouble
You shouldn't be surprised by a difficult airway.
Jeff Cryder
Publish Date: June 18, 2014   |  Tags:   Anesthesia
efficient intubation THIS WAY IN Understanding an airway's potential difficulty can enable a more efficient intubation.

Preparation goes a long way in handling potentially difficult airway situations, whether it is preventing emergencies from occurring or resolving the risks before they arise. Here's how the people at the head of the table anticipate, avoid and address airway complications.

Check the record
Can difficult airway situations be anticipated? In many cases, they can. Perhaps the primary source of such insights is the patients' own charts. Good, thorough documentation often notes if and when the patient has undergone a previous procedure in your facility, and possibly even procedures performed at other local facilities. If difficulties arose during these cases, it will list the details.

Review the documentation for all accounts of earlier anesthesia interactions, especially for any related complications. It might be recorded, for instance, that the patient underwent anesthesia the preceding year and presented a difficult airway, for which 4 attempts and ultimately a video laryngoscope were required before intubation was successful. Reading this, you can take note of which provider attended the case and, considering their level of experience, prepare yourself accordingly.

If documenting difficult airways in a patient's chart is not common at your facility, it's definitely time to institute the practice for safety's sake. I've even seen the inclusion of warning pages in charts, explaining the circumstances of the difficulty. The patient can be given a copy of this page as well, to present to surgeons and anesthesia providers in advance of any future procedures.

Anatomical indicators
If the patient's documentation doesn't signal airway difficulties, their anatomy can frequently be relied upon to tell the tale. Any anesthesia provider should be able to detect difficult airways through pre-surgical evaluations.

  • Mouth opening. Establishing an airway is contingent on the range of motion of the mandible since the maxilla is immobile. I ask patients to bite their upper lip with their lower teeth. If they can't articulate their lower jaw, due to temporomandibular joint disorder or other conditions, and if they have a hard time opening up for an examination of the anatomy inside, that's a clear sign to expect a difficult airway.
laryngeal mask airways AIRWAY ARSENAL Laryngeal mask airways, both traditional and intubating, should be part of an anesthesia provider's toolkit.
  • Neck injuries. Sometimes an airway difficulty is the result of a neck injury or a previous surgery to repair it. Patients suffering from cervical radiculopathy or herniated disks, for instance, might not be able to extend their necks, and anesthesia providers should be wary of causing further damage. Cervical fusion surgery implants rods, plates, screws or other hardware to join the vertebrae and immobilize the joints, which doesn't leave the patient with good prospects for extending the neck.
  • Excess weight. Overweight and obese patients are another group that is likely to present difficulties. The weight of the tissue in a thick neck or large breasts can easily threaten to collapse the airway, especially when a patient is positioned on her back. It also makes lifting and supporting the patient's head a strain for the anesthesia provider seeking to place an endotracheal tube.
  • Risky situations. Other patients who might present with airway difficulties — although perhaps less likely to be seen in outpatient surgery settings — include patients with congenital anomalies that affect the structure of the face, such as Down syndrome, Pierre Robin syndrome or Treacher Collins syndrome; oral or head and neck cancer patients whose airways may be obstructed by a tissue mass; trauma patients who have blood in their mouth; or patients who are coding, when intubation must be conducted while chest compressions are given.

If your anesthesia staffing involves an anesthesiologist who performs the pre-operative evaluations 30 minutes or so before surgery, and CRNAs attending the cases, placing the airways and providing anesthesia services in the OR, make sure the CRNAs conduct their own independent pre-op exams in the minutes before surgery. It is incumbent upon them to know what to expect and what is required in terms of patient positioning, intubation technique and assistive technology.

SUCCESSFUL STARTS
Pain-Free Airway Access

— EASY DOES IT LMAs should be well lubricated, so they slide in easily.

Intubation traumas are usually mild, with cut or bruised lips following sore throats as the most prevalent. How common are such incidents overall? Estimates vary widely, from as low as 17% to as high as 50%. One reason: If you ask post-op patients how they feel, they often say their knees or bellies hurt, but they don't mention that their throats are sore, unless you ask.

But more severe traumas, such as mucosal tears or dislocation of the arytenoid, while rare, aren't nonexistent. The same with dental damage, one of the more common catalysts causing patients to come looking for compensation. (Most practitioners tell them: Go to the dentist and send me the bill. Implants are expensive, but less expensive than legal hassles.)

Experienced providers know which patients are more vulnerable: Those with prominent teeth; with thick, short necks; and the grossly obese. When you anticipate a difficult airway, there are ways to make it easier, such as using video laryngoscopes. The disposable costs are considerable, so they're not practical for every patient, but they're also wonderful for getting yourself out of an unexpected jam. Fortunately, there just isn't the need with most patients.

The trauma rate is higher with women, because most have smaller tracheas. When you use a smaller tube, the size of the cuff relative to the airway tends to be bigger. You can use high-volume, low-pressure cuffs, but they, too, add considerable expense.

Diligence pays. Spend time in your ORs, watching to see how carefully your anesthesia providers secure airways. Are they gentle? Are they skilled with laryngoscopes? Do they use lubricating jelly on LMAs so they slide in more gently? In short, are they treating each patient the way you'd like to be treated?

— Robin J. Elwood, MD, FAAP

Dr. Elwood ([email protected]) is the vice chairman for clinical affairs and a professor in the anesthesia department at the University of Oklahoma in Norman, Okla.

video laryngoscope technology SIGHT LINES Video laryngoscope technology allows providers to see around the airway's curve.

'Invaluable' airway assists
Traditional devices such as bougies, Eschmann stylets and intubating laryngeal mask airways are essential basics for manipulating endotracheal tubes around the airway's angle and sliding them down the trachea. Light wands and fiber-optic bronchoscopes offer visualization to facilitate the tube's insertion. But video laryngoscope technology has quickly become the go-to device for any difficult or assumed-to-be difficult airway.

There are a number of reasons why. Video laryngoscopes have narrowed the gap in airway management proficiency. The learning curve for the devices isn't particularly steep. With a little bit of experience, and depending on the model, they can be easier to use than a fiber-optic scope. As a result, even providers with mediocre skills can generally obtain an airway with ease.

Users with more substantial experience often find that video laryngoscopes can be more reliable in comparison to other options, especially if they're designed to accommodate different sizes and styles of laryngoscope blades. Even the American Society of Anesthesiologists' difficult airway algorithm agrees: Its recent revision allows providers to go straight to video laryngoscopy for placing the tube.

In outpatient surgery, speed and efficiency are important, but so is economy. Video laryngoscopes can be pricey, especially the most advanced and reliable technologies, but the ability to safely and effectively intubate a patient or rescue a lost airway in fewer attempts and with little trauma to the airway makes them invaluable.

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