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How to Make the Difficult Airway Less Difficult

Training, experience and planning can turn a difficult airway into just another day at the office. Photo Verathon Medical

We were on a tactical-EMS (TEMS) operation in February in the mountains of western Maryland. Several of us lamented, whined actually, about the cold, wet weather. Our TEMS team leader, Mark Gibbons, set us straight, “There’s no such thing as bad weather, just those ill prepared for current conditions.”

My friend’s statement easily applies to most difficulties we encounter in life. Tasks that we find troublesome are usually hard to manage because we are unprepared or conditions are unexpected. The same applies to airways we label as difficult.

In previous articles on airway anatomy, I discussed how understanding the anatomy helps us make better decisions and improves our level of success. The same paradigm applies to a “difficult airway.” As medical practitioners, the more clearly we understand why an airway is difficult, the less difficult it becomes to manage.

From Difficult to Everyday
Although there’s little you can do about your patient’s anatomy and physiologic condition, you still have to deal with it. I used to believe that I chose the laryngoscope blade for my patient. I was wrong; the patient picks the blade. I had to learn to perform a good patient assessment and really understand my patient’s needs. A good assessment only takes about a minute or so, but it’s a lot more than just glancing at the patient’s face. How far can you open the patient’s mouth? What’s the length of the jaw? Is the neck mobile? A short neck, short jaw and receding mandible calls for a straight blade, not a 3 Mac just because I like a curved blade. If you don’t listen to your patient, you’ll create a difficult airway.

Another thing we can’t change is our working environment. How many times have you used the “belly flop” intubation position on the floor? Sure, you can always move the patient from the bathroom to the living room, but it’s still a tough place to work. If you want to turn a tough position into a difficult airway, then never prepare yourself to work in that environment. The Maryland State Police Department runs a program called the Airway Rodeo. The final session is a scenario-based competition between teams. We place manikins in every position you can imagine: secured to a backboard, sitting up, even duct-taped to the underside of a table. The idea is to challenge our students to intubate in the most awkward, absurd positions we can envision so when they’re faced with something similar in the field, the patient position doesn’t make the situation a difficult airway.

Training and experience are two factors that can turn a difficult airway into just another day at the office. Of course, it works the other way too. The great part is that you have complete control over both of these factors. There’s always time to train. Commit just 30 minutes a day to your profession. Read an article. Listen to a podcast. Review a peer’s patient care report. Talk to someone who’s been there, done that. Case reviews and scenario-based training are the best way to become experienced before you’re faced with a real patient. Don’t let a lack of training and experience create a difficult airway situation.

For the past 10 years, Dr. Richard Dutton, trauma anesthesiologist at the R Adams Cowley Shock Trauma Center, has been a mentor and friend. His view on equipment has made a huge impression on me. Our equipment should be simple, we have to know how to use our tools, and our equipment must be readily at hand. Now, I’m a big widget guy. But we all know the chances of something actually working in an emergency is inversely proportional to the number of moving parts. It’s OK to have an airway gadget with a lot of parts as long as you’re prepared for them to fail and you’re prepared to deal with it. Know your equipment and have it with you. As Dr. Dutton is fond of saying, “If it’s not within three feet of you, it may as well be on Mars.” You’re a professional; don’t allow equipment issues to create a difficult airway situation.

Failing to have a plan, failing to understand a plan and failing to follow a plan have led many a good medical professional down long, torturous roads. My gosh, folks! We’ve got more algorithms than I can count, so I know you’ve got one for managing a patient’s airway. Know it and use it. Airway management, and especially endotracheal intubation, is a high-consequence therapy. Your plan should be simple to follow, flexible and well practiced. At a minimum, it should provide strategies based on patient assessment, environmental conditions, distance to a hospital and available equipment. A task force of the American Society of Anesthesiologists recognized this in 1992 and said it best in their 2002 update, “ … the use of specific strategies facilitates the intubation of the difficult airway.”(1) Don’t create a difficult airway by failing to plan.

Situational awareness is the proper alignment of your perception of reality with reality.(2) In one study, the U.S. Coast Guard found the lack of situational awareness accounted for 54% of medium- and high-severity towing vessel incidents.(3) Every profession has a book full of examples of adverse incidents that occurred because of poor situational awareness. Airway management is no different.

I arrived as the second paramedic at motor vehicle crash. The patient was in the ambulance, so I hopped in the side door. I saw a used endotracheal tube on the floor, a bloody laryngoscope blade and the crew bagging the patient. I heard them say, “He’s clinched. You need to RSI him.” I started my assessment and found the patient’s “clinched jaw” was held securely in place with a tight-fitting cervical collar. Nonchalantly, I opened the front of the cervical collar and found a non-clinched, highly mobile jaw. What was a difficult airway turned out to be a case of poor situational awareness.

Those of you who have sat in on my lectures know I don’t think difficult airways are as common or as bad as we’re sometimes led to believe. I think that, for the most part, we control our destiny. Although you can’t control a patient’s anatomy or some of the situations in which we work, you’re at the helm in regards to training, experience, equipment, strategies and situational awareness. If I may be so bold as to modify Mark Gibbons’ quote, I would say, “there are no difficult airways, only providers ill prepared for current conditions.”

Be safe my friends.

1. American Society of Anethesiologists. Practice guidelines for management of the difficult airway: An updated report by the american society of anesthesiologists task force on management of the difficult airway. Anesthesiology. 2003; 98:1269–1277.
2. Personal communication with Commander Curtis Ott, USCG (ret). June 2008.
3. Crew Endurance Management, USCG, 2008, p 1

One comment

  1. Could not agree with you more. Here in Jacksonville there has been a large push by myself and a few others over just this topic. Cpt. Billy Cockman, with our training division, has even hammered home the team concept with airway maintenance. Something he is teaching, and our department is seeing a lot of success with, is a two person version of the old sky-hook method. If there is one person controlling the blade in a “pull towards” fashion, the provider with the tube’s job and visualization just got much easier. We hope to see an article from Cpt. Cockman about this adjustment very soon. Thanks Charlie! Great article!

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