Airway disasters during volunteer medical missions to the Developing World contribute to a mortality rate higher than surgeries in hi-tech environments. Difficult airways tend to be much more severe than in hi-tech environments. Whereas congenital anomalies often receive initial repair in infancy, patients in developing nations may not be able to seek repair until adulthood, if at all. Burn scars and trauma may never receive acute care, resulting in severe scarring and contractures. In addition, lack of sophisticated airway equipment and support makes caring for such patients especially risky. As a veteran of volunteer missions to 5 continents, I am aware of a disturbing number of close calls and medical catastrophes.
Difficult Airway
Let’s start with an example of how things can quickly go awry in a developing world setting.
Case #1
The patient was a 13-year-old girl with severe keloid scars of chin and chest from an untreated burn as a toddler. We performed a difficult awake, minimally sedated intubation in preparation for scar release and grafting. The child struggled during the intubation, developing a nose bleed.
Anesthesia was halothane/oxygen via a Bain circuit, and using a free-standing vaporizer attached to an H cylinder. The only monitors were a manual blood pressure (BP) cuff, and a pulse oximeter brought from the United States. Electricity went off several times during the procedure. At the end of surgery the patient developed hypoxemia of 85%. No arterial blood gases were available.
We assumed blood aspiration caused the worsening hypoxemia after we suctioned blood from the endotracheal tube. However, we could not rule out pneumothorax because breath sounds were markedly unequal and the surgeons had extensively dissected the neck scar.
Off To Radiology
As no portable X-ray equipment existed, we took her to radiology, which was in a quonset hut behind the hospital. Off we went at 9 pm, across the pitch black, dirt covered compound, pushing her bed and an H cylinder on an industrial dolly. Once there, we discovered the bed would not fit through the door. A quick visit to the emergency department to borrow a hand carry stretcher solved this problem. Twenty minutes later, after hand developing the X-ray, we confirmed the diagnosis of probable aspiration. Hypoxia continued to worsen, saturation now 75% and dropping. Our self-inflating bag could not provide positive end-expiratory pressure (PEEP).
A quick dash back to the perioperative area, carrying the stretcher and pushing the dolly, found us facing locked doors. As we had been the last case, the cleaning crew assumed we were leaving for the night. After tracking down the key and now back with our Bain circuit, positive pressure improved the oxygenation — at least until the tank abruptly went dry. An RN rolled another H cylinder into the room and switched regulators while mouth-to-tube ventilation took place.
Time To Improvise
As long as she breathed against about 10 cm of water pressure PEEP, maintained by squeezing the manual bag, she remained oxygenated. The only available ventilator did not work. Therefore, we left her intubated and attached to the Bain Circuit overnight.
The Bain arm had no manometer. We manufactured PEEP by attaching a long length of suction tubing to the Bain exhalation bag port using an endotracheal tube adaptor. We submerged the free end into 10 cm of sterile water in an irrigation bottle. I taped the pop-off valve completely open to prevent accidental circuit obstruction. As her condition improved overnight, I suctioned 5 cm of water out of the bottle, reducing PEEP to 5.
We extubated the child the following morning. Unfortunately she lost a small part of her graft.
Analysis
This case illustrates some of the serious challenges of dealing with a difficult airway in the developing world. We desperately wanted to operate on this child because she was so crippled by her deformity. Fear that we were her last and only hope drove us to proceed.
Choosing light sedation to intubate her seemed prudent because we were afraid of losing the airway if we rendered her unconscious. In addition, her keloid would have prevented easy cricothyrotomy if we did lose the airway. Unfortunately, the uncooperative child struggled vigorously enough to cause trauma. A significant blood aspiration followed. That aspiration could easily have proven fatal had we not been clever enough, and to be brutally frank lucky enough, to figure out how to jury rig a successful management strategy.
Case #2
Local anesthesia with ketamine/versed sedation was used during a cleft lip repair in a 13-year-old girl with Pierre Robbin syndrome and a very difficult airway. The anesthesiologist chose sedation because he feared that he could lose the airway if he induced full general anesthesia. After receiving deep sedation the child obstructed her airway and the anesthesiologist was then unable to ventilate or intubate her. She died of hypoxic injury.
Always be prepared for potential airway obstruction before you start in order to avoid an airway disaster such as this one.
Choose Elective Patients Wisely
In true emergencies, there may be no choice with respect to managing a difficult airway. However, on many volunteer overseas missions, the providers do have a choice regarding which patients they choose to operate on. When dealing with airways, choose wisely. For an in depth discussion of preparing for difficult airways as well as techniques to manage them please see my review:
10 Rules for Approaching Difficult Intubation: Always Prepare for Failure
Ask yourself some questions.
Will This Patient Be Difficult To Intubate?
Examine the patient. There are 3 requirements for successful laryngoscopy. You must be able to:
- Adequately open the mouth to insert the blade and look inside
- Align the 3 airway axes sufficiently to at least bring part of the larynx into view (e.g. tilt the head back and bring the jaw forward)
- Have enough room to shift the tongue forward, off of the glottis
If you think this patient will be difficult to intubate, stop, assess risk, and create a plan.
Will I Be Able to Ventilate This Patient?
Can’t intubate/can’t ventilate is often an avoidable airway disaster. Learn to recognize the patient who may be challenging to ventilate.
- Can you obtain a good mask seal?
- Can you generate sufficient airway pressure to overcome resistance?
- Do you have the optimal equipment (e.g. pediatric sized masks, oral/nasal airways)?
- Will you need a two-handed technique and, if so, do you have an assistant to squeeze the bag?
- Can you manage bleeding or other source of aspiration risk?
Stop and reconsider what you are about to do if you worry you may not be able to ventilate.
Does The Team Have Equipment or Skills That Mitigate The Risks?
Evaluate what equipment and techniques you have to assist intubation. Does your team have a portable video laryngoscope, for example? Could you use awake blind nasal intubation? Is someone else on your team more appropriate for this particular patient? Realistically assess your team’s collective skill level with the equipment and techniques at hand. If you lack sophisticated aids and/or expertise, think very carefully about proceeding.
Can The Hospital Safely Care For The Patient Postoperatively?
Finally, assess whether the site can provide an appropriate level of postoperative care.
Case #3
The surgeon created a pedicle flap in a 10 y.o. girl to close a facial defect caused by Noma. Noma is a type of gangrene that destroys mucous membranes of the mouth and other tissues occurring in malnourished children in areas where sanitation and cleanliness are lacking. The flap sealed half of the mouth closed.
One of the local nurses approached me in PACU. She told me that she overheard the surgeon giving postop instructions to the girl’s father. The surgeon’s planned to have the father use of pair of scissors to divide the pedicle from its base in 10 days time. The nurse was concerned because the parents were so poor that they did not own a pair of scissors.
When I questioned our surgeon, he stated that there “were no local plastic surgeons available”, cutting the graft would “unlikely cause significant bleeding”, “infection rarely occurs in facial wounds”, and “just give them a pair of scissors”. At that point I intervened and arranged for a local general surgeon to follow the girl . Our plastic surgeon gave the general surgeon instructions on how to divide the pedicle safely.
Assess Postoperative Care Needs
Scheduling high-risk cases despite hospital deficiencies puts the responsibility for safe care on your team. This should be planned long before the case comes to the OR. Use common sense. Assess:
- surgical follow-up
- airway support
- need for ICU type observation
- blood transfusion needs
- infection risk vs hospital cleanliness/wound care
- age range for pediatric patients (based on nursing skill set and equipment sized for children)
- home discharge environment
Are There Other Options?
Consider potential alternatives. For example, could you:
- reschedule the patient in a few years during a follow-up mission, allowing a child to grow older?
- bring along different equipment next time?
- make arrangements to transport the patient to a different venue/country for surgery?
- perform a more minor, less risky, but potentially still life improving procedure?
- improve the current situation in any way?
Good Communication Prevents Problems
Case #4
The anesthesiologist on my team discovered that his 3 y.o. patient for cleft lip repair also had a locked jaw that could not be opened at all due to a TMJ infection suffered as an infant. (Previously discussed in Ventilate and Intubate But Don’t Forget Communicate) Unfortunately he found this out after induction.
The goal to do 100 cases had put time pressure on all. I and the team’s physician assistant had between us done all the screening preops while on the advance team. The P.A. noted the jaw pathology in her note, but didn’t verbally alert me. I had been too preocupied with OR set up and other exams to fully read her note when I signed off on it. The surgeon had written in his note that he planned to also repair the TMJ. However, he felt he didn’t need to mention it or plan for it with the case anesthesiologist. The case anesthesiologist saw my sign off on the chart and felt he was good to go, without doing an exam himself.
Needless to say this spectacular failure to communicate had placed our patient in a potentially dangerous situation. The patient was easy to ventilate. Fortunately I was skilled at blind nasal intubation in anesthetized children. During intubation, we maintained anesthesia using spontaneous ventilation of halothane via a nasal airway attached to the breathing circuit with an endotracheal tube adapter.
For further description of this nasal ventilation technique, as well as other airway tricks, see the review article:
10 Common Pediatric Airway Problems—And Their Solutions
Follow common sense communication rules regardless of where you are.
- Communicate. Never assume your teammates, no matter how talented or highly educated, know what you consider important — or that they will remember to tell you.
- Never skip a safety step, regardless of how “easy” or “safe” the case seems. No intubation is easy, and all involve some risk. My Dad was a commercial airline pilot. He always tells me that the more difficult approaches are often also the safest. In a difficult approach, everyone in the cockpit is intently focused, and distractions are not tolerated, because the crew knows the landing is not easy. In contrast, an easy landing approach invites overconfidence and distraction, which can lead to disaster.
- Always have a plan B and the necessary equipment to carry it out.
We are all skilled at our jobs and attentive to our patients. Sometimes it’s the communication that trips us up.
Learn To Say No
When you volunteer to work in the Developing World, you clearly need to expect the unexpected and be able to do everything with nothing. However, you need to be especially cautious when approaching the difficult airway to avoid an airway disaster.
It is emotionally traumatic to deny health care to people in need. Volunteer missions often screen hundreds of patients before choosing the few they can care for.
Saying no is painful. Cancelling the cleft lip repair in a wheezing baby with high fever and severe bronchitis, after the father had walked 250 miles to bring his baby to the hospital, was one of the hardest things I’ve ever done. The father cried. I cried. I’m still haunted by the concern that the baby may never have gotten another chance. However patient safety must always come first.
The following photos are patients with difficult airways screened for surgery in various developing countries. We chose not to operate on any of them because we felt the risks were too high. The group was able to arrange for some to be brought to the U.S. for surgery.
Iatrogenic Airway Disasters
Sometimes we cause our own difficult airways.
Airway Obstruction: Forgotten Packs
Case #5
Eight-year-old boy: difficult palate, prolonged bleeding using multiple packs, last case of the day, last case of the trip. The child developed severe and worsening obstruction in the recovery room. The surgeons were adamant that all packs had been removed. The child was rushed back to the OR for re-induction and intubation. There, while treating cyanosis and multifocal PVCs, a pack was found and removed. The child did well. Apparently the first pack used had been shoved down the esophagus during the attempts at hemostasis and coughed up when the child became agitated. It was not visible during the final 10 minutes of observation in the OR or during extubation.
Case #6
Fifteen-month-old girl: routine cleft palate. The patient developed an intraoperative fever of 101°F (39°C) probably due to hot OR temperatures and atropine. Concerned, the surgeons admitted they rushed through the case. The patient obstructed following extubation and a pack was removed. These surgeons had discussed the need for care in the use of packs at the beginning of the case, but became distracted by the fever.
Be compulsive about airway packs. List whether they are in or out prominently in your record. Our surgeons routinely began to tie the end of any packs to the mouth gag so they couldn’t forget them. Verify all packs are out at the end.
Airway Obstruction in Recovery Room
My missions were predominantly plastic surgery related, concentrating on cleft lip, cleft palates, and burn scars. The local PACU and ward nurses who worked with our team nurses were not always expert with pediatric airways. Our surgeons, therefore, placed heavy gauge silk sutures in the tongues of every child less than 5 y.o. after airway surgery. The sutures were taped to the child’s cheek. This loop gave any RN, regardless of skill level, a helpful string to pull the tongue forward in case a child obstructed. The sutures were removed the following day on rounds.
Make sure that the appropriate airway equipment for rescue is immediately available to the nursing staff and that they know how to use it.
Be Vigilant
You can prevent airway disasters in the developing world by carefully assessing your patients and choosing surgical candidates wisely, when possible. Always prepare for the worst and communicate closely as a team.
For a downloadable copy of my full review article on providing anesthesia in the developing world see:
“Anesthesia in Distant Places: Prevention of Anesthesia Mishaps”
