Difficult Airway Injuries Are on the Rise

Make sure these tips, tools and technologies are in your arsenal to keep patients safe.

Difficult airway scenarios in the ASC present life-threatening events that continue to be significant factors in patient injury, death and subsequent malpractice claims, especially with patients who are obese and/or have sleep apnea.

Such high stakes make regularly reviewing proper airway management tools for responding if a patient presents with a difficult airway a must.

Video laryngoscopes, reusable and single-use, are the most common devices anesthesia providers use to combat difficult airways, but there are plenty of other tools and technologies providers should have in their toolkits to keep patients safe, according to Craig Atkins, DNP, CRNA, CRNA program administrator at Rocky Vista University School of Nurse Anesthesia Practice in Englewood, Colo. But having the tools is only part of it, and as Dr. Atkins reminds leaders, “advance planning and team preparedness is key.” That’s true whether you’re planning to handle an expected challenging airway or acting fast when an unexpected difficult airway occurs.

Know the latest risk assessment best practices

Prevention starts with knowing your patient is at risk before surgery, says Dr. Atkins, adding that ASC providers should be aware of two trends “upping the chance” of encountering a difficult airway:

• The rising obesity crisis because extra body tissue can obstruct the airway and create challenges during direct laryngoscopy.

• Obstructive sleep apnea, which can be related to obesity and is a growing health concern associated with difficult intubation.

The 2022 American Society of Anesthesiologists (ASA) Practice Guidelines for Management of the Difficult Airway outlines specific practices for pre-anesthesia assessment for difficult airways. For example, a preprocedural airway risk assessment should be performed by the person(s) responsible for airway management. This assessment should include a review of patient history. Then, a physical examination of facial features and anatomical measurements can identify physical characteristics that may indicate the potential for a difficult airway. Bedside endoscopy, virtual laryngoscopy/bronchoscopy or 3D printing may also be employed for this risk assessment.

PROVIDER TOOLS

Two Resources to Boost Confidence in Managing Difficult Airways

OPEN TO SUGGESTION Many of the safety initiatives at CHRISTUS Spohn Alice Hospital are the direct result of suggestions staff made to leadership.  |  CHRISTUS Spohn Alice Hospital

Outpatient surgery team members should be familiar with the latest update to the ASA Practice Guidelines for Management of the Difficult Airway, which published in January 2022. “This resource provides an excellent place to review the management of the difficult airway and can provide insight into why airway providers do what they do,” says Robert Matthews, PhD, CRNA, practicing clinician in the department of Anesthesia at the University of North Carolina in Chapel Hill.

Review the open access guideline here.

Regular education is also key to maintaining proficiency for a confident response if a difficult airway does present. Dr. Matthews provides online education throughout the year through The Difficult Airway Course curriculum. Online and in-person training content includes presentations, faculty discussions, Q&A, “how-to” videos and case reviews.

—Carina Stanton

Expect the unexpected

While presurgical assessment for a difficult airway is the cornerstone of safe anesthesia care, it’s not foolproof. “Our ability to predict which patients will present with the difficult airway is currently imperfect, making the possibility of an unanticipated difficult airway a likelihood in any setting where airway management is provided,” cautions Robert Matthews, PhD, CRNA, practicing clinician in the Department of Anesthesia at the University of North Carolina in Chapel Hill.

A difficult airway is defined by the ASA as: The clinical situation in which anticipated or unanticipated difficulty or failure is experienced by a physician trained in anesthesia care, including but not limited to one or more of the following: facemask ventilation, laryngoscopy, ventilation using a supraglottic airway, tracheal intubation, extubation, or invasive airway.

“Difficult airway management requires our utmost attention to effectively supply and maintain oxygen in sufficient amounts to patients,” says Dr. Matthews. To make this happen, your team should anticipate airway difficulty with every patient and prepare accordingly with three key tools: the right equipment, knowledgeable personnel prepared to act fast for the patient and an established plan for a coordinated response.

• Have the right tools on hand. Your difficult airway cart should contain a variety of masks, oral and nasal airways, laryngoscopes and blades, potentially a jet ventilator and a cricothyrotomy set. Additional items include video laryngoscopy with various blades, flexible fiberoptic scopes and supraglottic airways, where the device sits on top of the larynx and pushes the extra tissue away, opening the airway.

Dr. Atkins believes video laryngoscopy is the future. “If COVID taught us anything, it’s that we do not need to put our face right on top of another’s to intubate—video laryngoscopy provides a method to limit exposure to airborne diseases and has been a godsend for difficult airway management,” he says. At the rural hospital in Richmond, Ky., where he practiced before entering teaching, providers performed one to three fiberoptic intubations a month before purchasing video laryngoscopes. “Once we got it, we seldom used the fiberoptic — maybe only one to three times a year.”

Research cited in the 2022 ASA guidelines includes meta-analyses of randomized controlled trial comparisons of video-assisted laryngoscopy and direct laryngoscopy in patients with predicted difficult airways. These findings showed that using video-assisted laryngoscopy improved laryngeal views and produced a higher frequency of successful intubations, including first-attempt intubations and fewer intubation maneuvers.

Besides the video laryngoscope, Dr. Matthews talks about several other types of tools commonly used as part of a smart management plan for difficult airways, the first being supraglottic airway devices. These are used to establish a patent’s airway and can be used as a rescue tool when difficulty with mask ventilation is encountered. According to the 2022 ASA guidelines, data findings from randomized controlled trials comparing flexible intubation through supraglottic airways or flexible intubation scopes alone produced a higher frequency of first-attempt intubation success with the supraglottic airway.

However, Dr. Matthews says a flexible fiberoptic scope can be a valuable tool because it enables the visualization of a patient’s vocal cords, allowing for the placement of an endotracheal tube. A randomized controlled trial cited in the 2022 ASA guideline showed that using a flexible illuminated stylet (i.e., a lightwand) in patients with anticipated difficult airways produced a significantly higher frequency of successful intubations and shorter intubation times as compared to blind intubation.

• Build an action plan around your difficult airway cart. Perhaps the most important “tool” Dr. Matthews suggests is having “prepared personnel ready to respond quickly when a surgical airway is in a crisis.” This includes making sure the difficult airway cart is stocked with appropriate equipment to adequately respond to a difficult airway situation. The 2022 ASA guidelines make recommendations regarding the availability of equipment for airway management, as well as preparedness to use items on difficult airway cart in concert as a team. The guidelines describe important factors such as informing the patient with a known or suspected difficult airway, preoxygenation, patient positioning, sedative administration, local anesthesia, supplemental oxygen used during difficult airway management, patient monitoring and human factors. Some of these human factors involve making sure that a skilled individual is present or immediately available to assist with airway management when feasible. Also, the guidelines emphasize the importance of monitoring the patient according to ASA Standards before, during and after airway management for all patients.

Dr. Matthews recommends the anesthesia care provider as well as nurse, surgeon and other team members review the contents of their difficult airway cart together on a monthly basis and discuss the plan for action if it’s needed. “This allows for familiarity in a calm and controlled setting, rather than during the high-stress moments when the team is actually managing a difficult airway,” he says. OSM