They say anesthesia is 99% boredom and 1% sheer terror. "When confronted with a difficult airway, things can get hairy and scary fast," says Melanie Susi, CRNA, of Cape Regional Medical Center in Cape May Court House, N.J. Here are 12 practical pearls to help you manage difficult airways so that near-catastrophes stay just that.
1. They're difficult to predict. A 2015 PubMed study revealed that 93% of 3,391 difficult intubations were unanticipated. And when difficult intubations were predicted? They happened only in 25% of cases. "It's possible that everything looks good upon examination, but as soon as you get in, problems arise," says Ms. Susi. "It's important to remember that even the most unlikely patient can be the victim of an airway emergency."
This highlights the importance of planning for crisis situations, even for patients that present no red flags (like an overbite, short neck or high BMI) during a pre-anesthesia exam. Keep difficult airway equipment readily on hand in "standardized equipment carts, so that they're all the same and everyone knows what's in them," says anesthesiologist Paul Patane, MD, MBA, CPE, with Ballas Anesthesia in Creve Coeur, Mo. "The trouble comes when you keep the bronchoscope in closet 4 because you don't want to buy the right size cart to fit it in."
2. There's more than one way to assess. Because this is the way they were trained, many anesthesia providers depend entirely on a patient's Mallampati classification for predicting the ease of intubation. Incorporate other methods, including the upper bite lip test (which assesses mandibular mobility), the thyromental distance (which estimates mandibular space) or the 11-point airway assessment scale put forth by Jonathan Benumof, MD, a professor of anesthesia in the School of Medicine at the University of California, San Diego.
Tony Chipas, PhD, CRNA, regional director for clinical services at Medstream Anesthesia Solutions, suggests adding a twelfth point to Dr. Benumof's system: locating the cricothyroid membrane during the pre-anesthesia exam instead of waiting until it's needed in the OR as an emergency access point. "Often, we don't take the time to test the patient," says Dr. Chipas, "to feel for crevices of the jaw, or to feel the submandibular tissues that can cause problems."