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 Table of Contents  
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 9-12

Strategic airway management in an independent anaesthetic practice – Hurdles and possible solutions

1 Department of Anaesthesiology, Kanachur Institute of Medical Sciences, Mangaluru, Karnataka, India
2 Department of Anaesthesiology, KS Hegde Medical Academy, Mangaluru, Karnataka, India

Date of Submission19-Sep-2021
Date of Acceptance01-Nov-2021
Date of Web Publication11-Feb-2022

Correspondence Address:
Dr. Sathyajith Karanth Airody
Flat No. 301, Saraswathi Residency, Bejai-Kapikad 4th Cross, Mangaluru - 575 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_54_21

Rights and Permissions

Airway management in an independent anaesthetic practice, often with limited resources, is always challenging. Comprehensive situational awareness, detailed airway evaluation, strategic planning and efficient execution of the plan are essential components of care. Equally important is the willingness to back out if the situation demands. Although the placement of a definitive airway device is necessary for the safe conduct of anaesthesia, prevention of hypoxia and secondary insults takes priority at times of crisis and all attempts should be channelled to achieve this at all costs. The practicing anaesthesiologist must always be prepared with an airway kit for dealing with emergencies and also train support staff in managing a difficult or failed airway.

Keywords: Difficult airway, hypoxia, intubation, reoxygenate, supraglottic airway device

How to cite this article:
Airody SK, Bangera A. Strategic airway management in an independent anaesthetic practice – Hurdles and possible solutions. Airway 2022;5:9-12

How to cite this URL:
Airody SK, Bangera A. Strategic airway management in an independent anaesthetic practice – Hurdles and possible solutions. Airway [serial online] 2022 [cited 2023 Sep 21];5:9-12. Available from: https://www.arwy.org/text.asp?2022/5/1/9/337582

“Hypoxia, or lack of oxygen in the tissues, is the fundamental cause for all degenerative disease. Oxygen is the source of life to all cells.”

-Stephen Levine

It is this thought that sweeps through the mind of every practicing anaesthesiologist each time he or she induces anaesthesia. The worry that haunts most anaesthesiologists is failure to access the airway resulting in hypoxia, more so in a resource-limited setting. This fear can, on one hand, be quelled by sheer arrogance that “it will not happen to me” which can not only be life-threatening for the patient but also career-threatening to the anaesthesiologist. On the other hand, meticulous preparation and execution of airway care is not only appropriate but also immensely rewarding. We all would like to be in the second category of anaesthesiologists though there can be surprises that can spring up during a long professional career. Such airway emergencies can only be addressed by a well-rehearsed and protocolised airway management plan that is executed with rational resource allocation in a given healthcare setting.

Almost every anaesthetic society has designed or adopted airway guidelines to fall back upon at the time of need, either elective or emergent. Resource-limited or constrained settings pose a special set of problems that an anaesthesiologist will face either due to the lack of resources, technical expertise of the professional or nonavailability of additional help in the healthcare setting that one practices in. Standard guidelines cannot be adopted in their entirety in these settings. A workable plan of action with a ready-pack of emergency airway equipment and a periodically rehearsed 'dry run' can save the day for such practicing anaesthesiologists.

A systematic approach for the management of airway should include:

  1. A set of quickly reproducible airway assessment tests and scoring systems
  2. A protocol-based approach to a relatively straightforward airway
  3. A specific approach to an anticipated difficult airway depending on the anticipated difficulty which is discussed and prepared for beforehand
  4. A preplanned approach to an unanticipated difficult airway depending on the point at which the problem is faced. This should be a flexible plan in accordance with the setup that one practices in
  5. An equipment kit for an anticipated/unanticipated difficult airway kept in readiness by the anaesthesia professional
  6. A regular 'mock airway management drill' to check the readiness of the system for training of the entire team.

  Airway Assessment Top

The airway assessment plan must be clinically applicable at the bedside of the patient. This should include but not be limited to relevant airway history such as past anaesthetic records, airway alerts/bracelets, airway trauma, unexpected intensive care unit (ICU) admissions, obstructive sleep apnoea, stridor and risk of regurgitation or aspiration. Though many tests and scoring systems are available, they lack high sensitivity or specificity as a predictor of a difficult airway [Table 1].[1]
Table 1: Sensitivity, specificity and positive predictive value of commonly used airway tests and scoring systems

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Despite this, it is still worth doing a quick survey of the airway which assesses interincisor gap, temporomandibular joint mobility, modified Mallampati class, neck movement, thyromental distance, upper lip bite test and neck circumference. On the basis of these airway parameters, an experienced anaesthesiologist will be able to form a reasonably confident opinion regarding difficult mask ventilation, insertion of supraglottic and infraglottic airway devices.

  Conventional Approach to Airway Management Top

A well-rehearsed conventional airway management approach helps operating room personnel to be prepared at all times for a 'no-surprise airway'.[2] During every airway intervention, it is mandatory to preoxygenate adequately. It will be prudent to continue oxygen supplementation even during the process of intubation using free flow oxygen through a nasal canula. This step buys extra time for additional airway manoeuvres and delays onset of desaturation. It is equally important to reoxygenate the patient in between intubation attempts. This mandatory break provides an opportunity for the intubator to rethink the strategy, summon additional help and equipment that may be needed, and to explain the further plan of action to the team. These steps are worthwhile considering in every situation. If a nonconventional airway access is planned in a straight-forward airway, it needs to be discussed with the personnel involved beforehand and a 'dry run' needs to be done. This helps operating room personnel to be psychologically prepared and trained for any eventuality during an emergency, translating into safer patient outcome. These exercises also help in training the support team whenever a new member is added to the team.

  Airway Management in an Anticipated Difficult Airway Top

When a difficult airway is anticipated, one should explain the exact nature of the problem and encourage the patient/relations to get the procedure done at an advanced centre where the required facilities are available. Should there be a need to perform the surgery in the present setup itself, the anaesthetic options and possible risks must be clearly explained to the patient. The anaesthesiologist should then proceed with either local, regional or central neuraxial anaesthesia. A cautious approach to general anaesthesia is acceptable provided the team formulates a clear plan of action regarding when to back out without compromising the patient safety. Surgeries in patients with an anticipated difficult airway can be planned depending on the problem anticipated, surgery planned, the patient's level of understanding and the resources available. All these paths of action need to be discussed with all team members involved and the patient or his/her responsible attendant and should be documented in the patient record. In all cases, the emergent surgical airway or cricothyroidotomy facility should be available to prevent a hypoxic event that may arise any time during the conduct of anaesthesia.[3]

  Airway Management in an Unanticipated Difficult Airway Top

When a conventional approach to airway fails, the problems may arise at any point of anaesthetic induction beginning with difficulty in bag and mask ventilation, or maybe difficulty in placement of a definitive infraglottic airway device. The best option for such scenarios also starts at the very beginning. Every airway access intervention should begin with optimal preoxygenation using a ramped-up position and continuous positive airway pressure of 5–10 cm H2O for 3 min. This should be followed by adequate muscle relaxation with a depolarising muscle relaxant such as suxamethonium provided there is no contraindication for its use. The All India Difficult Airway Association guidelines may be the best option to fall back on at the time of need.[4],[5] Surgical cricothyroidotomy using either a ready kit or a locally assembled cricothyrotomy kit with BP handle and a 4.0 mm or 5.0 mm ID endotracheal tube railroaded on a paediatric tube exchanger, a surgical tracheostomy or percutaneous dilatational tracheostomy[6] with definitive airway if expertise is available should always be the first choice for emergency airway access. All through these interventions, prevention of hypoxia should be of foremost concern. There may be some additional considerations such as release of cricoid pressure that needs to be borne in mind in patients at risk of aspiration where rapid sequence induction is being performed.[5] In these unanticipated difficult airway scenarios when the operator is faced with problems in airway interventions, one should always remember to “Call for help” early. A quick review of the equipment that is available and reformulation of a fresh airway strategy is appropriate. A critical review of the steps is made with the idea of detecting any step that might have been missed. Finally, the best decision in a given situation may be to back off while the opportunity still exists and to re-group another day. Remember that airway-related catastrophes are often due to failure to oxygenate; not failure to intubate.

  Personalised Difficult Airway Kit Top

This may include, but may not necessarily be limited to, assorted endotracheal tubes, videolaryngoscope, supraglottic airways, surgical cricothyrotomy kit (commercial or locally prepared) and a percutaneous dilatation tracheostomy set (if one is familiar with its use). This list may extend to include a flexible fibreoptic bronchoscope depending on the setup in which one practices.[7]

  Training/Preparation for Evaluation of a Catastrophic Airway Event Top

It is often quoted that the 'more one sweats in peace, the less one bleeds in war'. This is very true where airway management is concerned. The important steps include:

  1. Regular check of an “airway cart”
  2. Skill training of operating room personnel[8]
  3. Crucial aspects of airway skills/interventions for oneself as well as for one's team includes airway interventions such as 2-person bag and mask ventilation, bougie-assisted intubation, intubation using a supraglottic airway device as a conduit, intubation using videolaryngoscope, surgical cricothyrotomy, surgical/percutaneous tracheostomy.[5]

These tenets can be achieved by a simulated drill of an airway catastrophe and its management in a patient with an uncomplicated airway. Execution of the scenario under controlled conditions followed by debriefing will help the team to be prepared for an airway catastrophe when one actually strikes. Regular skill training for the practicing anaesthesiologist in surgical cricothyrotomy on animal tracheas/manikin will go a long way in managing such crises with ease and confidence.

An airway management plan displayed prominently in the operation theatre outlining steps to be taken during difficult mask ventilation, difficult laryngoscopy and difficult intubation will prepare the system to respond, react and assist the anaesthesiologist in getting a positive outcome during times of crisis.

In summary, a thorough airway assessment, prompt recognition of a difficult airway, good communication with the patient and the operating room personnel to formalise an appropriate airway management strategy including a proper backup plan, and a willingness to accept when things do not go as planned are all important links in the safe management of the airway. Backing off when it is still safe and referring a patient in whom one has faced airway difficulty to an advanced facility signifies good anaesthetic practice. Remember, dogged persistence when the situation is spiralling into a crisis is purely egotistic and is NOT to be commended. Airway managers must bear in mind that there is still a significant percentage of patients in whom we may fail to recognise the difficulty and end up with an unanticipated difficult airway. These situations can be safely dealt with through rational decision-making by a skilled specialist backed by a good support system. The golden rule to be remembered is that prevention of hypoxia at all stages of airway management is a primary goal and every attempt to maintain adequate oxygenation throughout is the cornerstone of safe airway management. The overriding need at any phase of airway management is to oxygenate. It is worth reiterating that the first step in airway management is to preoxygenate. Furthermore, one should never lose the opportunity to oxygenate during airway intervention and reoxygenate in-between attempts to secure the airway. While failure to maintain adequate oxygenation can be catastrophic; failure to intubate may still be clinically 'pardonable'. In an emergency, use a technique that one is familiar with as the first alternative. Remember not to burn bridges as we are not waging a war.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Bradley P, Chapman G, Crooke B, Greenland K. Airway assessment. Aust NZ College Anaesth (August) 2016:1-63.  Back to cited text no. 1
Drolet P. Management of the anticipated difficult airway – A systematic approach: Continuing professional development. Can J Anaesth 2009;56:683-701.  Back to cited text no. 2
Nickson C. Surgical cricothyroidotomy. In Life in the Fastlane;Nov 3, 2020.  Back to cited text no. 3
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of the unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.  Back to cited text no. 4
[PUBMED]  [Full text]  
Ramkumar V, Dinesh E, Shetty SR, Shah A, Kundra P, Das S, et al. All India Difficult Airway Association 2016 guidelines for the management of the unanticipated difficult tracheal intubation in obstetrics. Indian J Anaesth 2016;60:899-905.  Back to cited text no. 5
[PUBMED]  [Full text]  
Davidson SB, Blostein PA, Walsh J, Maltz SB, VandenBerg SL. Percutaneous tracheostomy: A new approach to the emergency airway. J Trauma Acute Care Surg 2012;73:S83-8.  Back to cited text no. 6
Bjurstrom MF, Bodelsson M, Sturesson LW. The difficult airway trolley: A narrative review and practical guide. Anesth Res Pract (January) 2019.  Back to cited text no. 7
Ouellette D. Basic Airway Management for Non-Anesthesia Operating Room Personnel: Education Implementation. University of New England: DUNE; DigitalUNE;2020 (Summer).  Back to cited text no. 8


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