Best Practices in Airway Management

An inside look at the importance of a critical clinical area and providers’ best defenses against problems.

Airway management is a crucial component of modern medicine and enabling the safe and effective administration of anesthesia during surgery is paramount to patient safety. In recent years, an aging population with a higher rate of obesity and sleep apnea has made patients with difficult airways more common than in the past. While it is possible to address a difficult airway by using external maneuvers, this creates risk for the patient and limits the medical staff. It is far better to have airway devices on hand that are specifically designed to address the problem of distal pharyngeal collapse.

A storied past

The history of airway devices dates back to the 19th century when the first oral airway was introduced to facilitate air passage during anesthesia. Many devices have been developed since then, including face masks, endotracheal tubes, video laryngoscopes and supraglottic airway devices. Each advancement aimed to improve patient safety and ease of use for healthcare providers.

Maintaining a patent airway during anesthesia is essential to ensure adequate oxygenation and ventilation. It prevents hypoxia and its associated complications, which can lead to brain damage, organ failure or even death. A patent airway also allows for the delivery of anesthetic gases and efficient removal of carbon dioxide, which is crucial for maintaining a stable and safe anesthetic depth.

Difficult airways arise when an anesthesiologist trained in conventional methods encounters challenges in opening the airway, providing facemask ventilation to the upper airway or performing tracheal intubation. Anatomical, physiological or pathological factors contribute to this difficulty, heightening the risk of airway compromise and potentially resulting in insufficient oxygenation, ventilation or both.

The importance of maintaining a patent airway during anesthesia cannot be overstated.

Frequently, airway obstruction triggers this issue, manifesting as the patient’s inability to breathe or be ventilated, which significantly elevates the likelihood of negative outcomes. Swift intervention is crucial to avert hypoxia, hypoxic brain injury or death. In the perioperative setting, it can lead to increased morbidity, longer hospital stays and higher healthcare costs.

A changing landscape

Long-term demographic changes have made difficult airways both more common and harder to treat. The increasing prevalence of obesity, obstructive sleep apnea (OSA) and an aging population have contributed to a rise in the condition. Obesity can alter the upper airway anatomy and function, making intubation and mask ventilation more challenging. OSA patients often have airway collapsibility and increased pharyngeal tissue, making airway management difficult. The aging population presents challenges due to reduced muscle tone, decreased respiratory function and comorbidities that can complicate airway management.

The condition can be challenging to manage in outpatient and non-operating room anesthesia (NORA) settings. These facilities often have limited resources, equipment and personnel compared to traditional operating rooms. Outpatient procedures have become longer and more complex, increasing the need for personnel to be adept at knowing how to swiftly manage difficult airways.

The growth of outpatient surgery and office-based procedures has also led to the increased use of deeper sedation and light general anesthesia, which can increase the risk of airway compromise and make airway management more challenging for anesthesia providers to keep the patient spontaneously breathing and comfortable.

Not surprisingly, ASCs and NORA settings have seen an increase in respiratory-related complications during surgery, which are five times higher outside of the traditional OR. A recent study of liability claims found that respiratory depression was responsible for 21% of adverse events, with more than half of these events being preventable with better monitoring and ventilation. Careful monitoring for apnea allows for early recognition and facilitates quick intervention, if necessary, with the proper tools. Left untreated, apnea can result in hypoxia, respiratory function decline, asystole or death, with a mortality rate of almost 40%.

Tackling trouble spots

Anesthesia personnel must be aware of the possibility of difficult airways. This requires a thorough preoperative assessment, including a detailed medical history, physical examination and identification of risk factors such as obesity, OSA or anatomic abnormalities.

Continuous monitoring of vital signs, including oxygen saturation, heart rate, blood pressure and end-tidal carbon dioxide is crucial to detect early signs of airway compromise. Providing oxygen with an adequate delivery source is also important to maximize appropriate FiO2 levels. Anesthesia personnel should be vigilant in recognizing any changes in these parameters, as they may indicate the need for a quick intervention to maintain a patent airway.

The chin lift jaw thrust (CLJT) maneuver is one such initial intervention for managing difficult airways. It involves lifting the chin and pushing the jaw forward to open the airway, allowing for improved oxygenation and ventilation. The CLJT maneuver should be performed promptly when signs of airway compromise are detected.

While the CLJT maneuver can be effective in managing difficult airways, it also carries several drawbacks. It may cause discomfort, bruising or injury to the patient, especially if performed forcefully or for an extended period. Performing it may distract anesthesia personnel from other tasks, such as monitoring vital signs or administering medications. The maneuver can contribute to crowding around the patient, limiting access for other healthcare providers. CLJT may also be time-consuming, delaying other aspects of patient care and prolonging the overall procedure.

If a mask is used, certain factors can make positive-pressure mask ventilation more challenging. These include facial hair, which can interfere with the seal between the mask and the face, leading to inadequate ventilation. A lack of teeth can cause difficulty in maintaining a proper mask seal, resulting in poor ventilation. A high STOP-BANG score indicating a greater risk of OSA can make mask ventilation more difficult due to increased pharyngeal tissue and airway collapsibility.

It is important to weigh risk factors before deciding on an airway strategy. A difficult airway is more likely for individuals with obesity, OSA or challenging head, oral and neck anatomy. Patients with pre-existing respiratory conditions such as asthma, COPD or a history of smoking may have limited respiratory reserve and are more susceptible to rapid desaturation. Obesity can lead to reduced functional residual capacity and increased oxygen consumption, making these patients more prone to desaturation. A history of smoking can impair pulmonary function and increase the risk of desaturation during intubation. In these cases, apneic oxygenation techniques such as distal pharyngeal airway (DPA), nasal high-flow oxygen or continuous positive airway pressure (CPAP), can help maintain oxygenation during intubation attempts.

Vigilance and monitoring

The importance of maintaining a patent airway during anesthesia cannot be overstated. This requires vigilance in identifying at-risk patients, close monitoring of vital signs and having a variety of airway management techniques on-hand.

While the basic airway management techniques such as the CLJT maneuver, OPA and NPA can be useful in managing difficult airways, they do also have several limitations. As a result, relying solely on CLJT, OPA, and NPA is not a sustainable solution for handling difficult airways. Anesthesia providers should have access to a range of airway devices, such as distal pharyngeal airways, nasal high-flow oxygen, nasal CPAP, and supraglottic airways.

Familiarity with the pros, cons and indications for each device will enable providers to recommend the most appropriate tool for a given situation, ultimately improving patient outcomes and ensuring a safe and efficient anesthesia experience. Is it time to add new tools to your airway kit? OSM