Our actions, or lack thereof, can make intubation more difficult. Anesthesia providers are not perfect. External influences can sabotage our intubation attempts by tempting us to skip steps — steps that could make the technique safer for the patient. Common intubation pitfalls include:

• Distraction
• Crisis Situation
• Time Pressure
• Lack of Experience
• Lack of Equipment
• False Sense of Security

For example, positioning a patient for intubation is an extremely important step. Yet it’s common for providers to fail to optimally position a patient for intubation. Let’s look at a case to see how external influences might keep us from positioning.

Case

My colleague was struggling with a difficult intubation in the ICU. The patient was profoundly hypotensive and ventilation was difficult. The patient was flat on the bed, sinking into the mattress without any head positioning. Direct laryngoscopy was difficult. He tried 3 times with the MAC 4 without visualizing the larynx.

The intubator then switched to the GlideScope (Verathon). Use of the GlideScope Video Laryngoscope (GVL) in our hospital was relatively new at the time, and our providers were still gaining experience. The endotracheal tube was loaded on the GVL specific rigid stylet. The anesthesiologist had a great view of the larynx but he could not get the endotracheal tube (ETT) lined up to pass through the cords. Removing and reinserting the ETT multiple times, he later admitted that he was looking solely at the monitor, and never asked for help or made any changes. He finally succeeded. Oxygen saturation rose to 94%.

An hour later, as the patient’s blood pressure responded to vasopressors and volume, my colleague was called back to the ICU to investigate the source of significant bleeding from the posterior pharynx. Examination revealed that the endotracheal tube had perforated and was passing through the right posterior tonsillar pillar on its path into the trachea. The patient was brought to the operating room for controlled reintubation and repair of the injury.

Discussion

Let me start by saying my colleague is excellent and has many years of experience. But we are all human and susceptible to intubation pitfalls. Although he was incautious with the GVL, his first error was failing to optimally position the patient. What factors led our anesthesiologist to fail to position the patient for intubation?

Common Intubation Pitfalls Preventing Positioning

• Distraction: I forgot to position the patient
• Crisis: I don’t have time to waste
• Time Pressure: I must hurry up and finish
• Lack of Experience: I’m still learning to master that technique
• Lack of Equipment: I don’t have anything to put under the head
• False Sense of Security: I’ve skipped positioning before and it worked fine

Distraction

When faced with an emergency, or when in a rush, it’s easy to forget the basics. Operating rooms and ICUs are busy, noisy places with lots of distractions. Life literally hangs in the balance. It’s easy to forget the basics, like putting a pillow under the head before you intubate, when you’re distracted.

Avoiding Distractions

• Be aware of your own mental state
• Focus on the patient and be vigilant
• Speak up if others are distracting
• Prepare the equipment ahead of time when possible
• Practice for emergencies
• Follow consistent safety routines so that they become second nature

Crisis Situations

People don’t think as clearly when placed in stressful situations. Studies have shown that one’s ability to think (frequently called executive function) degrades rapidly and profoundly with stress. [1,2]

The anesthesiologist initially used direct laryngoscopy 3 times without changing anything. He then performed intubation with the GVL multiple times without changing approach or asking for help. He finally succeeded but with grave complications.

Insanity has been defined as doing the same thing over and over and expecting a different outcome. A crisis can force your brain into that type of repetitive holding pattern if you aren’t careful. It also makes time stand still — meaning the intubator often is unaware of how much time is passing.

The more experience we have, the better we manage the stress of emergencies. But one factor that can always help is using a team approach to crisis management and problem solving. Lead, communicate, keep everyone in the loop, ask for help, tell people how to help. I always remind my students that intubation is a team “sport”.

I encourage you to check out the program TeamSTEPPS, an excellent educational approach to clinical team building to promote communication and shared problem solving. It helps train critical thinking in an emergency. A complete review of TeamSTEPPS principles is too complicated to include here, but the key skill sets are improving communication, leadership, situation monitoring, and mutual support. 

Time Pressure: The Ultimate Intubation Pitfall

The anesthesiologist felt he couldn’t waste time stopping to improve the patient’s awkward positioning. Once he began video laryngoscopy, the anesthesiologist felt he couldn’t stop to correct the positioning, because intubation had already been delayed.

However, in this case pausing, quickly repositioning, and perhaps getting assistance with cricoid pressure would likely have sped up the intubation and perhaps voided the trauma.

More generally, in today’s operating rooms, time often seems like the major driving force. The surgeon is looking over your shoulder, wanting to start, finish and get on to the next case. The OR wants to minimize in room time to keep the surgeon happy and to minimize costs. The anesthesia provider needs to be efficient, otherwise they might never get a chance to eat at all during the day between cases.

Time pressure encourages skipping steps and is a dangerous force to be reckoned with. People will always want you to move faster. Learning to combat time pressure is a required and essential skill in anesthesia.

Management of Time Pressure

• Prioritize tasks
• Work as a team
• Use effective team communication
• Maintain a calm demeanor
• Ask for help

Lack of Experience

This anesthesiologist was inexperienced with using the GVL and was struggling to use the device. The unique injuries with video laryngoscopy are typically associated with focusing on the beautiful image of the larynx on the monitor rather than looking at the patient. In this case, the anesthesiologist was using the useful but very rigid GVL stylet. The most likely cause of injury was blind insertion of the styletted endotracheal tube (ETT) into a taut tonsillar pillar. The anesthesiologist concentrated on the monitor, not the patient, while inserting the ETT into the pharynx. Injury to the tonsillar pillars and soft palates has previously been reported in the literature. [3,4]

Anesthesia is constantly changing. When I first started, for example, we didn’t have video laryngoscopy. Every few years I and my colleagues have had to learn new skills, new drugs, and new techniques.

But that means you and I will always be inexperienced with something. When concentrating on new steps, it’s easy to overlook the old ones. For example, learning video laryngoscopy with a GlideScope requires an entirely different skill set: inserting an ETT while looking at a monitor instead of directly at the patient. It’s easy to forget that the steps that help with direct laryngoscopy, also help with video laryngoscopy.

Managing Lack of Experience

• Recognize that you will always be learning and therefore inexperienced with new things.
• Practice new equipment and techniques electively to be comfortable in the emergency.
• Build on your old skills — and keep using them while you incorporate new ones.
• Leave your ego at the door, ask for advise and help from those more experienced than you.

Check out “Avoiding Difficult Intubation of The Easy Airway”, describing how to avoid the most common direct laryngoscopy errors — factors that can also help with video laryngoscopy.

For more advice on using a GlideScope see:

• GlideScope: Tricks For Successful Intubation
• GlideScope Technique For Intubation In Small Mouths

Lack of Equipment: Risk vs Benefit

Sometimes you don’t have the exact tool, or drug, you need. For example, in this case the pillow under the patient’s head to properly position it for intubation was missing.

You will often be missing equipment in your career. Does your anesthesia cart only have a curved blade because the straight one is still being cleaned? You don’t have the right size nasal or oral airway in your cart? Should you assume that you won’t need them and go ahead anyway? Or it’s the end of the day and you have just enough propofol in the room for one routine induction. Should you ask for more in case a second dose is needed? Missing the ambu bag? What about an extra IV bag? The list goes on. You will constantly be asking yourself “Should I forge ahead or fix the situation?”

It’s risk vs benefit. Not having a straight blade in the room, if intubation with a curved blade proves difficult, could easily lead to loss of the airway. That’s really bad, so you’d want to get one before you start. Not having an extra IV bag is not so urgent and you could proceed, since your RN could go get you one later.

If the risk of not having the item is great in the vent that you do end up needing it, then stop and ask someone to bring it to you. If it feels like you’re rushing or skipping a step, you probably are.

Avoid Missing Equipment

• Keep your equipment/word space organized
• Identify missing equipment before you start
• Assess the risk of proceeding without the missing item in terms of potential harm to the patient in the event that you need the item
• Ask for help from team members in acquiring missing items

False Sense of Security

Ultimately, we often skip steps because we believe we can get away with it. We’ve skipped those steps before, and it worked fine. This leads to a false sense of security. Injury prevention depends upon realizing that we can potentially cause harm while administering our anesthetic.

False sense of security isn’t just an intubation pitfall. It can sabotage just about any anesthetic activity if you’re not careful. If we don’t recognize the areas of risk, we can’t mitigate that risk. It is the failure to consider risk that tempts us to skip steps, rush, take short cuts or fail to prepare for the unexpected.

This case illustrates common pitfalls in intubation, emphasizing the significance of proper patient positioning, especially under stressful circumstances. It highlights a case where distractions, time pressure, and inexperience led to complications. The incident underscores the importance of following consistent procedures and utilizing team support to ensure patient safety and effective outcomes during intubation. Let’s keep our patients safe out there.

May The Force Be With You

Christine E. Whitten MD, author:

Anyone Can Intubate: A Step-by-Step Guide, 5th Edition
Pediatric Airway Management: A Step-by-Step Guide
Basic Airway Management: A Step-by-Step Guide

References

1. Luethi, M., Meier, B., & Sandi, C. (2009). Stress effects on working memory, explicit memory, and implicit memory for neutral and emotional stimuli inhealthy men. Frontiers in Behavioral Neuroscience, 1-9.
2. Schmader, T., Johns, M., & Forbes, C. (2008). An Integrated Process Model of Stereotype Threat Effects on Performance. Psychological Review, 336-356.
3. Thorley DS, Simons AR, Mirza O, et al. Palatal and retropharyngeal injury secondary to intubation using the GlideScope video laryngoscope. Ann R Coll Surg Engl. 2015;97(4): e67-e69.
4. Leong WL, Lim Y, Sia AT. Palatopharyngeal wall perforation during GlideScope intubation. Anaesth Intensive Care. 2008;36(6):870-874.