Checking expertise in anticipated difficult airway situations
Published Date: 12th March 2019
Publication Authors: Angus W, Miller S
Awake fibreoptic intubation of a patient with an obstructed upper airway is among the more challenging of airway procedures 1. A multidisciplinary approach to safe management is essential 2, with an experienced Ear, Nose and Throat (ENT) surgeon immediately available to perform emergency surgical tracheostomy should awake fibreoptic intubation performed by an experienced anaesthetist fail to secure the airway.
A recent case of airway deterioration re‐emphasised to us the importance of checking each clinician's experience before proceeding with any advanced airway management plan. A breathless, stridulous patient with a newly diagnosed laryngeal tumour was unable to lie flat, and needed awake fibreoptic intubation in the ‘tripod’ position (sitting, leaning forwards, hands braced on knees). The ENT surgeon on call had been a consultant for 20 years, but did not routinely undertake head and neck cancer surgery and had no experience of performing awake tracheostomy on a sitting patient, so was unwilling to rescue the airway surgically after two failed attempts at awake fibreoptic intubation. Further deterioration was eventually rescued by a 5th year anaesthetic registrar undertaking a surgical cricothyroidotomy (his first in vivo), passing a size 6.0 cuffed tracheostomy tube without complication. The patient was administered general anaesthesia, and a surgical tracheostomy was performed in the supine position by the same ENT surgeon. The patient was transferred to a regional hospital for definitive treatment.
This case illustrates two points. Firstly, clinicians should feel confident in declaring their experience of undertaking the procedures that might be demanded of them in these situations, and such declarations should be built into the airway management plans for such cases. Secondly, performing awake tracheostomy in a compromised, sitting patient is technically difficult – anaesthetists should be capable of performing surgical cricothyroidotomy in the sitting position as part of their difficult airway management plan, without assuming surgical rescue is always available
Angus, W. and Miller, S. (2018). Checking expertise in anticipated difficult airway situations . Anaesthesia. 73 (3), p398