4 Tips on Difficult Airway Management

Thomas Wherry, MD, medical director for Health Inventures and principal for Total Anesthesia Solutions, discusses four best practices for managing a difficult airway.

1. Develop a difficult airway cart. Dr. Wherry recommends an ambulatory surgery center's first priority should be tasking anesthesiologists and nurse anesthetists with developing a difficult airway cart. This means researching each provider's preferred equipment and stocking the cart with those supplies. "I would highly recommend the center not buy anything [before checking with the anesthesiologist], because they wouldn't want to spend a lot of money on something only to find out the provider wants something else," he says.

He says the cart should include multiple sizes of LMAs, as well as some type of fiberoptic instrument. An ASA document, titled "Practice Guidelines for Management of the Difficult Airway" and available on the ASA website, suggests the cart carry rigid laryngoscope blades of alternate design and size, tracheal tubes of assorted sizes and fat least one device suitable for emergency noninvasive airway ventilation, among others.

2. Run annual drills. On an annual basis, Dr. Wherry recommends the anesthesia providers go over a difficult airway scenario with ASC staff. Every staff member should know where equipment for difficult airway management is located, as well as how to use it. "It's important to go through a drill ahead of time, so you know at what point you should cancel the procedure and wake the patient up," he says. "As long as you can ventilate the patient, there's really no reason to panic." He says going over the process regularly will decrease the likelihood of panic and medical error.

3. Pre-screen patients for risk factors. During the pre-op screening, Dr. Wherry says staff should identify patients at risk for a difficult airway. "You want to screen out patients with difficult airways, [which means they might have] obstructive sleep apnea, large BMI or morbid obesity, jaw owl issues, rheumatoid arthritis or history of having a difficult airway," he says. A potentially difficult airway doesn't necessarily mean the case should be moved to the hospital, but a thorough pre-op screening process allows anesthesia providers to make an informed decision about the appropriateness of the case before the day of service.

4. Follow ASA guidelines. The American Society of Anesthesiologists publishes guidelines on difficult airway management, including an algorithm that takes providers through airway management step-by-step. The algorithm recommends providers assess the likelihood and clinical impact of basic management problems, consider the relate merits and feasibility of basic management choices and develop primary and alternative strategies, among other recommendations.

"No one likes surprises," Dr. Wherry says. "That's why it's so important to follow the ASA algorithm and the decision tree about whether you can ventilate the patient safety," he says. "The [question] is whether you can do the case with an LMA. If you absolutely have to intubate, you certainly try the traditional way with the direct landoscopy and then the fiberoptic."

Learn more about Health Inventures.

Read more on anesthesia:

-Letter From ASA to Joint Commission Urges Action on Medication Management Concerns

-Anesthesiologist Warns Hospitals His Surgical Invention Could Spread Bacteria

-Perioperative Physicians More Likely to "Burn Out" Than Nurses, Nurse Anesthetists

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