READILY AVAILABLE Do a thorough airway exam and always have your rescue equipment nearby and ready.

The 3 Golden Rules of difficult airways: 1. Prepare as if every airway could be difficult. 2. Know that a thorough airway assessment can predict a potentially difficult airway. 3. Have a go-to plan and a couple of backup plans to manage difficult airways.

"Some airway difficulties can be anticipated and some can not," says Mike Morel, CRNA, of Martin (Tenn.) Anesthesia Group. "Always have Plans B and C ready."

That means keeping your airway cart well-stocked with rescue tools. "Have multiple back-up options immediately available, so if one thing doesn't work there is another quickly available," says Jeff Cryder, CRNA, of Scott & White Hospital in Temple, Texas. It's a good idea to laminate and tether to the cart the ASA's Difficult Airway Algorithm (tinyurl.com/lwhjddp) and a list of the cart's contents.

At the UAB Callahan Eye Hospital in Birmingham, Ala., the airway cart holds a long list of difficult airway equipment, including a variety of LMAs, laryngoscope blades, fiber-optic scopes, a bougie for endotracheal intubation, video-assisted laryngoscopes and Ambu bags with a well-fitting mask and PEEP (positive end expiratory pressure) valves, says chief CRNA Carol Craig.

At the ProMedica Wildwood Orthopaedic & Spine Hospital in Toledo, Ohio, the airway cart has supplies such as a handheld portable video laryngoscope, fiber-optic scope, a video laryngoscope and all necessary supplies available in the sterile core as well as routine airway supplies located in each OR, says Kendra Ondrus, CRNA, MA.

It's not enough to simply have the rescue tools on hand. Have trained personnel who know how to use this equipment — experienced CRNAs and anesthesiologists who can recognize the early signs of an emergency and have the available tools to handle the situation, several providers say.

Anesthesiologist Amber Jandik, MD, of Lee Memorial Outpatient Surgery Center in Fort Myers, Fla., adds that when a difficult airway strikes, there's no time to waste hunting down needed tools and supplies. "Have several sizes of LMAs available in each procedure room. Keep your [video laryngoscope] fully charged and easily accessible. Be sure each staff member knows what it is, where it is, and that when you ask for it, they are to bring it to you in a hurry."

Uninvited guest
The difficult airway is an uninvited guest to the OR. It can loudly announce its presence during the airway exam on a patient with a short, thick neck, or it can be a surprise intruder in a slender, healthy patient whose vocal cords are impossible to visualize. "Elicit from the patient any previous history of airway difficulties," says anesthesiologist Charles A. DeFrancesco, MD, of Delmont Surgery Center in Greensburg, Pa.

Regardless of whether the difficult airway barges in or tiptoes in, you've always got to be ready and able to give it the old heave-ho.

"Have your go-to rescue device," says anesthesiologist Carrie L. Frederick, MD, of Cumberland, Maine. "Use what you know how to use. This is not the time to learn something new. No single tool works in all patients. If you've done your airway assessment properly, you will know which airway management modalities might be difficult, and will have a variety of tools ready to overcome or bypass the areas you predicted to be challenging."

Learn an indirect intubation technique you're comfortable with and master it with "practice, practice, practice," says Todd A. Erickson, CRNA, of Island Anesthesia in Bainbridge Island, Wash.

Dr. DeFrancesco warns that it's impossible for a provider to be an expert at all airway rescue techniques. "It's wise for us to pick one technique and become comfortable with it," he says.

Losing the airway is a real and constant threat to every anesthesia provider. During anesthesia care, all protocols are secondary to airway concerns. "In anesthesia, our main concern is the airway," says Jason Espada, MSN, CRNA, chief nurse anesthetist at Gateway Surgery Center in Concord, N.C. "That's the very first assessment for every patient. You're always wondering, 'What if I have a difficult airway?'"

A pre-operative assessment to identify at-risk patients is always the best frontline defense. "If you don't do a thorough airway exam before you put someone to sleep, you're just asking for trouble," says Mr. Espada. "Don't just roll them out because they look healthy — especially if you're practicing by yourself and you don't have 2 sets of hands."

You'll discover most difficult airways during induction when you can't intubate or ventilate by other means, says anesthesiologist Charles Beck, DO, of McKinney, Texas. "An anticipated difficult airway will always be better than a surprise," says Michael Karren, CRNA, MS, of Madison Anesthesia Services in Rexburg, Idaho. Will the presence of a fiberscope or video LMA make you feel secure anesthetizing a patient with a known difficult airway? Mr. Karren's advice: Practice with video scopes and a variety of other advanced techniques on easy and routine cases to build confidence for when you need them for real. "And call for backup early," he adds.

Know your limitations
Have a plan in place for the surgical airway and hope you never need it, says anesthesiologist Joseph Bernstein, MD, of Saint Nicholas Surgery Center in Sheboygan, Wis.

The obesity sniffing position is a great aid to intubations, says anesthesiologist John Hsu, MD, director of anesthesia at Presbyterian Whittier (Calif.) Hospital. Intubating from the left side aligns the three axes so that intubation is easier, he adds.

Finally, check your ego at the door. Realize your limitations with regards to your expertise and comfort, the limitations imposed by the availability of specialized airway equipment and the amount of skilled help available to assist in attempting to rescue a difficult airway, says Dr. DeFrancesco. "Don't become overzealous in persistent attempts at intubation and risk losing the airway completely," he adds. "We all tend to fall into the trap of being macho, not wanting to admit defeat in these situations. It is far better to realize the difficulty and wake the patient up if necessary."