Instead of visualizing the vocal cords, all I could see was pink and froth. Now what? That easy intubation just got a lot more interesting and a lot more challenging on the young male patient with the facial tumor. Thankfully, over my 42-year career in the OR, I had taken the time and effort to master the tools of difficult airway management. I set aside my laryngoscope and blade and reached into my difficult airway cart for my fiberoptic bronchoscope (this was before the advent of video laryngoscopes). Crisis averted. But only because I had learned this critical lesson about difficult airways: Better to prepare for challenging intubations than to (try to) predict them or, worse yet, foolishly think that one won't happen to you.

Our worst nightmare
The unanticipated difficult airway is an anesthesia provider's worst nightmare. It shows up without warning, rarely announcing itself in the form of an obese patient with limited head extension and obvious airway pathology. What if you can't visualize vocal cords? What if the patient starts desaturating?

We're fortunate that we can stock our airway carts with such new and advanced (and affordable!) tools as video laryngoscopes and disposable fiber-optic bronchoscopes. The ideal airway device is simple to set up and use, effective and reliable. But without the skills and competence you can only acquire through training and practice, the ideal airway device is pretty much useless. It is every anesthesia provider's personal and professional responsibility to acquire and maintain the necessary skills to use airway devices. Awake intubation is the cornerstone of the difficult airway algorithm. All anesthetists should be skilled in at least one alternative technique of tracheal intubation under vision.

Even with all of today's modern devices, you can't neglect such skills as cricothyrotomy. Yes, you might go your entire career without needing to perform an emergency airway puncture, but if the time ever comes, you'll be glad you went to that difficult airway hands-on workshop and worked on that pig trachea.

Once a month, set aside a day to master the tools of difficult airway management on routine, healthy patients who have normal airways.

Practice makes
In airway management as in life, proper planning prevents poor performance. You can't predict challenging intubations, but you can certainly prepare for them. The confidence and requisite skills required for successful management of the difficult airway come with continual practice. And you can't keep the difficult airway cart locked up gathering dust until you need it (see "What's in Your Difficult Airway Cart?" on page 26).

At least once a month, all anesthesia providers should set aside a day to master the tools of difficult airway management on routine, healthy patients who have normal airways (you don't want to practice using the equipment when the patient's oxygen saturation is 60!). Pull out a piece of equipment from the airway cart you haven't used in while — or that you've never used — and learn how to use it. Pick any piece of equipment you use above the vocal cords. Maybe it's the fiberoptic bronchoscope, maybe an intubating LMA.

SECURE THE AIRWAY You can't always differentiate the difficult from the routine airway.

The tools of the trade
Over the years, we've seen a continual improvement in the tools for managing difficult intubations. Clearly, the future of difficult airway management is in the innovative use of video-assisted laryngoscopes and video stylets. This short guide will help you determine which equipment best fits you and your facility.

• Video stylets. Video stylets, glass video bundles that conduct light and a video image, are similar to bronchoscopes, but they're semi-rigid and malleable only outside the airway. You can fit a standard laparoscopic or bronchoscopy camera on a stylet's eyepiece. Video stylets include the Clarus Shikani and Levitan, and the Storz Bonfils. These scopes have a video eyepiece, but no built-in video monitor. The Clarus Vscope is similar to the other stylets, but has a built-in 1-inch monitor. Video stylets typically cost slightly less than video laryngoscopes. You must clean and sterilize these scopes between uses.
• Video-assisted laryngoscopes. The technology of video-assisted laryngoscopes has come a long way from early video scopes such as the Bullard and Upsher scopes. The newer devices have become more compact, user-friendly and cost-effective ($300 to $400). Many are self-contained with built-in video monitors. The new video laryngoscopes provide excellent laryngeal exposure in patients whom multiple experienced anesthesia providers have repeatedly found to be difficult or impossible to intubate using direct laryngoscopy. Video laryngoscopes are mandatory additions to all of our difficult airway carts and have a big place in the difficult airway algorithm. Their biggest advantage is in the lack of cross-contamination, because video laryngoscopes have disposable blades.
• Video laryngoscopes. These are the most advanced pieces of difficult airway equipment. Video laryngoscopes tend to be more complex than the stylets and therefore more expensive (about $18,000). The advantages of these scopes include built-in cameras and optical viewing systems. They require fewer specialized skills than first-generation technology and disposable blade covers decrease the chances of cross-contamination. Most of these scopes have short learning curves — they resemble and are used like the MacIntosh laryngoscope blades. These scopes come in 2 types, those with built-in video monitors and those with external monitors. Those with external monitors are slightly less portable but have a larger viewing area. These scopes include Verathon's Glidescope and the Storz C-MAC. The more portable scopes have small built-in video monitors and can be carried in your jacket pocket. Portable video laryngoscopes include the C-MAC Pocket Monitor, Covidien's McGrath, Pentax's Airway Scope and the King Vision. There's also the Airtraq, a completely disposable scope that costs about $90.
• Bronchoscopes. Traditional intubating bronchoscopes are very expensive, but are the gold standard for difficult airway management. The difficulty comes in proper cleaning of the suction ports, which if done incorrectly can lead to patient cross-contamination. An alternative for a center that does few bronchoscopic cases is the Ambu aScope3 single-use bronchoscope (about $400).

The most essential tool
With the ever-advancing technology and decreasing cost of difficult airway video laryngoscopes and stylets, there are few excuses for not having some type of video technology in your difficult airway cart, no matter how small the center may be. But we need to remember that the constant, ever-changing faces of difficult airway management are anesthesia providers. If their skills and confidence are not consistent with the technology available, then it doesn't matter what's in the difficult airway cart.

Nothing can be more frightening, more adrenaline-rushing, more potentially devastating than being faced with an emergency airway management case. This patient requires a competent anesthesia provider who has the skill and confidence to establish a patent airway in a hurry. The chance of this happening in any of our facilities has continued to increase over the past several years for a number of reasons, the greatest of which is obesity. That competent provider — that valuable tool — must be you.

SUGGESTED CONTENTS
What's in Your Difficult Airway Cart?

When a difficult airway strikes, there's no time to waste hunting down needed tools and supplies. A well-stocked airway cart should contain:

• Rigid laryngoscope blades of alternate design and size from those routinely used.
• Endotracheal tubes of assorted size.
• Endotracheal tube guides. Examples include (but are not limited to) semi-rigid stylets with or without a hollow core for jet ventilation, light wands and forceps designed to manipulate the distal portion of the endotracheal tube.
• Fiberoptic intubation equipment.
• Retrograde intubation equipment.
• At least one device suitable for emergency non-surgical airway ventilation. Examples include (but are not limited to) a transtracheal jet ventilator, a hollow jet ventilation stylet, the laryngeal mask and the esophageal tracheal combitube.
• Equipment suitable for emergency surgical airway access such as a cricothyrotomy.
• An exhaled CO2 detector.

— Anthony J. Chipas, PhD, CRNA