Tools and Techniques for Better Airway Management

Dr. Shapiro says airway assessments should include global attributes such as the patient’s height and weight and the thickness and range of motion of their neck. The assessment should also include a thorough examination of the oral pharynx, how far the patient can open their mouth and how well providers can visualize the oropharynx.

Identifying potentially difficult airways before surgery is one essential element of effective airway management. Having the tools on hand to maintain a patient’s ventilation when intubation proves challenging is the other. During difficult airway cases, as well as during anticipated routine cases that turn difficult, providers should have immediate access to laryngeal mask airways (LMA) and video laryngoscopes. “The success stories these tools have engendered have been told most dramatically during difficult intubations, because they enable anesthesia professionals to establish airways during emergent situations,” says Dr. Shapiro.

• LMAs. Sara Laws, a CRNA with NorthStar Anesthesia at Saint Francis Hospital in Wilmington, Del., points to several advantages of using an LMA. “They’re easy to insert and they can be used on a spontaneously breathing patient or with mechanical ventilation,” she says.

LMAs are also effective emergency airway rescue tools if patients prove to be a difficult intubation. When a provider is skilled in performing an intubation with an LMA, says Ms. Laws, the OR runs more efficiently, thus cutting down on case times. “The LMA has proven to be significantly less invasive to the patient than an endotracheal tube, and it is much easier for the anesthesia professional to position and place where it needs to be so they can maintain ventilation and keep the patient safe,” says Dr. Shapiro.

An LMA is most often used during cases that do not involve muscle paralysis. “They’re a great tool to have on hand during short-duration surgeries,” says Ms. Laws. “However, an LMA is generally not used in surgeries where there is a high risk of the patient aspirating stomach contents, which is particularly common during surgeries lasting longer than two hours.”

An LMA often uses low-inflation pressure, so the device might not be appropriate for use in patients with illnesses that cause low lung compliance such as pulmonary fibrosis, pneumonia and pulmonary edema.

The type of procedure also influences when these devices are used. “Intubating LMAs are typically larger and more obstructive than tracheal tubes and not generally used during mouth and throat surgeries because they don’t prevent laryngospasm, which is a transient and reversible spasm of the vocal cords that temporarily makes it difficult for the patient to breathe,” says Ms. Laws.

• Video Laryngoscopes. Video laryngoscopes incorporate an integrated camera and display monitor, which allows for easier airway management during difficult intubations such as those performed on neonates, obese individuals and patients whose anatomy restricts direct views of the laryngeal inlet. They’re versatile intubation tools that deliver exceptional first-attempt intubation success. “These devices are primarily used in difficult airway situations where intubation is hard to obtain with traditional laryngoscopy,” says Ms. Laws. “They come with special stylets that help the provider visualize the vocal cords and structures on a screen.”

Ms. Laws says video laryngoscopes come in handy when she intubates patients with decreased range of motion in the neck, which is common in individuals who underwent previous cervical spine fusion surgery and those with large tongues and anterior airways. Video laryngoscopes allow providers to place an endotracheal tube more easily, which is a more definitive method of providing ventilation and securing the airway, notes Dr. Shapiro.

The clear images captured by video laryngoscopes can be projected to standalone monitors, which create a more engaged OR, according to Ms. Laws. “That makes the airway visible to everyone in the room during difficult intubations,” she says. Instead of only the provider viewing the patient’s airway during direct laryngoscopy, the entire surgical team can watch the intubation as it unfolds and assist as needed.

Video laryngoscopes have also made providers feel more comfortable performing the aerosol-generating procedure during the pandemic. “We’re able to stand more upright while we view the airway on the device’s screen, which puts more distance between us and the patient, meaning there’s less risk of being exposed to airway droplets,” says Ms. Laws.

The tools also create more of a closed system during intubation, says Dr. Shapiro, but he cautions that any airway manipulation creates the potential of a highly concentrated exposure to the coronavirus for the anesthesia provider and members of the surgical team.

The highest and best use of video laryngoscopes, according to Dr. Shapiro, is during emergent situations. “It’s those events for which anesthesia professionals train so hard to manage,” he explains. “They must be familiar with the technology that’s available to assist them when they don’t have a lot of time to respond.”

It’s a good idea to have video laryngoscopes on hand even for expected routine cases, if for no other reason than anesthesia providers can familiarize themselves with the tool during low-risk intubations and develop skills that will prove invaluable when they need to secure emergency access to the airway. “That’s not when they should be trying to locate the device, making sure it’s in good working order and learning how to use it,” says Dr. Shapiro.