Preventing Airway Emergencies

I’m in Egypt at the 35th International Conference Egyptian Anesthesia 2019. I was given the great honor of presenting my article on the 10 Rules For Approaching Difficult Intubation: Always Prepare For Failure. That article was the most read review article on the Anesthesia News site in 2018, another honor. Thank you readers. A link to that article can be found here. Please feel free to share it with your students.

I have attended many lectures at the Egyptian Conference, and the overarching emphasis on patient safety and continuously improving care is impressive.

It’s been estimated that there are at least 25 million intubations in the United States per year and 50 million worldwide. Even though the percent risk of failed airway is very small, when multiplied by large numbers of intubations the estimates of potential number of critical airway events is impressive.

During my presentation, I referred to 3 recurring themes.

  • Preparation is key
    • You can’t prevent every difficult airway situation – but you can prevent most of them
  • Your decisions, and how you make them are important
    • You can always make a bad situation worse
  • Teamwork and Communication are key
    • You cannot and should not do this alone

Let’s look at these more closely.

Preparation is Key To Avoiding Difficult Airway Situations

Patients can be difficult to intubate because of anatomy or the circumstances surrounding the intubation. For example, failed intubations are more common in emergency room settings, prehospital settings, and delivery rooms. Emergency procedures tend to have more severe outcomes than elective ones.

According to the American Society of Anesthesiologists Closed Claims review, airway complications are twice as likely to occur out of the OR. Inadequate oxygenation is 6 times as likely. This makes sense because those situations frequently are emergencies, in locations with minimal specialized airway equipment, personnel unfamiliar with your techniques, distractions, poor patient positioning, and often, poor lighting. But no matter the status of the patient and circumstances surrounding care, there are always things that can be done to optimize the situation.

Assess Your Patient

In an emergency you may not be able to perform a detailed exam, but you should perform as complete an airway exam as possible. Don’t just look at the physical characteristics without considering why those particular traits might make the intubation or the ventilation more difficult. Instead, use the criteria of why you expect difficulty to guide your planning and your actions.

Recognizing a patient with a potentially difficult airway is an opportunity that allows you to prepare ahead to have equipment, personnel, and a backup plan. It can help you decide between awake and asleep intubation, or to choose to use or not use muscle relaxants. It also can alert you to the fact that a patient may need to receive care in a different setting or with more experienced providers, if possible. It can help you prepare your team to assist you.

Take Stock of Your Resources

Intubation is a team effort. You need to have all of the right people and equipment. Sometimes that means moving a patient to a different and more optimal location, or asking for more expert help. Ask yourself the following questions:

  • What type of help do you need for this particular patient?
  • Should this patient be intubated here, or transferred to the OR or other setting?
  • Who should intubate this patient? The first attempt is often the best chance at success. For a particular patient, that may mean allowing someone with more experience to intubate.
  • What equipment do you need?
  • Do you have all the attachments?
  • Is there functioning suction?

Make sure your staff in the OR and on the ward is well trained ahead of time. If you ask for a rescue laryngeal mask airway in a can’t intubate/can’t ventilate event, you don’t want your nurse asking you what it looks like.

Use A Critical Event Check List

No one can remember everything in today’s complex medical world. Things get even worse in a crisis. It often feels as though epinephrine doubles your strength and halves your intelligence. Stress, distractions, and sometimes chaos associated with a critical event often cause highly skilled providers to forget crucial, potentially lifesaving steps and drug dosages.

Access to a critical event checklist can be lifesaving. The aviation industry has used checklists for decades. Use of such a resource in an emergency is a wise decision, not a sign of weakness.

My hospital uses the Crisis Event Checklist from Harvard, and Brigham and Woman’s Hospital.

Position Your Patient

We have all been guilt of not optimally positioning a patient for intubation only to then have difficulty visualizing the larynx. Things are worse outside of the OR where we don’t have all of the normal positioning devices.

Take any patient with an easy airway, place him on the floor in cardiac arrest, surround him with providers whom you don’t know offering help but not knowing what you need, and that intubation will be difficult.

A more detailed discussion on positioning can be found here.

Consider Awake Intubation If You Expect Difficulty

When I was training, we didn’t have video-laryngoscopy or LMAs. Awake intubation for anticipated difficult airway was routine. If any patient looked remotely difficult we would do an awake intubation.  This made us very comfortable with the technique for emergency situations.  Blind nasal intubation and fiberoptic intubation were common procedures.

Today we don’t intubate awaken nearly as often. A main reason is that video-laryngoscopy and LMAs have revolutionized our ability to manage the majority of the challenging intubations another way. It’s fair to say that awake intubation requires more advanced skills and takes more time.

However some patients need to be intubated awake, especially if there is concern about the ability to ventilate the patient. Begin the preparation early when awake intubation is a possibility. Nasal vasoconstriction and oral drying agents take at least 20 minutes to work well. Numbing the airway must be effective. Explain to the patient what to expect and what they must do to help.

How much sedation should you give? It depends on how scary your patient is. If the first 4 steps are done well, you won’t need a lot of sedation. Use sedation cautiously. Over sedation can quickly produce apnea or make your patient uncooperative.

And remember that awake intubation doesn’t just mean fiberoptic. You can perform awake intubation with:

  • Blind nasal intubation
  • Standard laryngoscopy
  • Video-laryngoscopy
  • Via intubating or standard LMA
  • Combined techniques (e.g. Fiberoptic/LMA)

Your Decisions, And How You Make Them, Are Important

Things happen quickly during an intubation, especially in an emergency setting. It’s important to avoid unforced errors.

Call For Help Early

Oxygen desaturation once it begins will cause rapid deterioration. Don’t wait until it begins to call for help, it takes time for help to arrive and equipment to be brought.

Change Plans If Something’s Not Working.

We’re all human. Once we begin a task it is a common failing to just keep repeating the same steps over and over again, expecting that eventually it will work. This is the definition of insanity. If something doesn’t work the first time, change something.

Be Aware: Time Stands Still In A Crisis.

What seems like 1 to 2 minutes can really be 10 to 15. Force yourself to keep track of the clock. Especially pay attention to the duration of apneic periods. Lack of ventilation harms patients, not the lack of an endotracheal tube.

Know When To Stop

There are many times when we can stop and wake the patient up to do an awake intubation, or to cancel surgery and bring the patient back another day when more optimal preparations can be made — and any edema or airway trauma can have a chance to resolve.

Teamwork And Communication Are Key

You cannot and should not do this alone. I teach my students that intubation is a team effort, which means it’s a coordinated effort by a small group of people with a common goal. To succeed, everyone needs to know the problem and the plan, especially when you are expecting difficulty. If your helpers don’t know the plan, then they either could fail to do what you need them to do or could even accidentally sabotage your efforts.

Function As A Team.

Anesthesiologists really good at talking to each other and not so good at keeping the team informed. Your team can’t read your mind.

Your team also needs to be empowered to give suggestions. Everyone needs to know that if they see something, they should say something.

We need the leaders in a critical event to be open to feedback and suggestions. We need to foster a clinical environment in which all of our staff feels empowered enough to speak up when they see something.

TeamSTEPPS is an educational program whose goal is to create highly functioning crisis management teams. In TeamSTEPPS, there is something called the Two-Challenge Rule for when you feel there has been a potential breach of safety. The Two-Challenge Rule states that if your first verbal observation of a problem is not acknowledged or acted upon, then you should challenge again. If the safety issue persists, then becoming more assertive is recommended. Don’t curse, but use “CUS” words, that is:

  • I am Concerned about …
  • I am Uncomfortable because …
  • This is a Safety issue …

It’s very difficult to challenge anyone in authority. The airline industry recognized this prior to initiating industry-wide retraining in teamwork and communication. There were accident reports of airplanes crashing, flying into mountains and running out of fuel, because copilots and other flight personnel did not feel empowered to point out mistakes they had recognized. The airlines realized they had a culture that showed:

  • excessive deference to a leader;
  • hesitation of subordinates to speak up; and
  • reluctance to immediately question a clearly unusual or suspect event.

If a copilot facing personal death in an airplane crash can’t question the pilot, how easy is it for a nurse, for example, to challenge a doctor?

We Have The Power To Decrease The Incidence Of Bad Outcomes

In closed claims analyses, human error has been implicated in 80% of critical events. Human error is unavoidable and therefore we need to work hard to avoid it.

We need to carefully assess, develop a strategy for Plans A, B and C and gather our resources before we start.

We need to think carefully and reassess how our plan is going as our care proceeds. You can always make a bad situation worse.

We need to improve our skills in teamwork, leadership, and communication.

Pay attention to those three principals. If we do, then we can help make errors much less likely to occur, and much less damaging when they do.


May The Force Be With You

Christine Whitten MD, author

Anyone Can Intubate: A Step By Step Guide
Pediatric Airway Management: A Step by Step Guide


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Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon    Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten

PostObstructive Pulmonary Edema

Patients with postobstructive pulmonary edema (or P.O.P.E.) develop sudden, unexpected and potentially life-threatening pulmonary edema after relief of airway obstruction.  It can be mild or severe. My first experience with it was in 1983.

The Case

In 1983, we didn’t have pulse oximetry, end-tidal carbon dioxide monitoring or even automated blood pressure cuffs. The patient was a healthy 6’3” tall and 250 lbs , 20 year old man. All muscle and clearly in great shape. He had just had knee surgery under general anesthesia and was on the verge of waking up.

He was coughing vigorously on the endotracheal tube. Four people held him down. My resident, fearful he night hurt himself or the team, extubated him while he was still coughing and before he was following commands. Unfortunately the patient was still in stage 2, when the airway reflexes are hyperdynamic.

Within seconds the patient went into laryngospasm, intense spasmodic closure of the vocal cords and other laryngeal muscles. There followed several minutes of struggling to re-establish an open airway. Finally the spasm broke with the use of positive pressure and the patient awoke.

However the mood in the room quickly turned from relief to concern. Our patient started to panic, claiming that he couldn’t breathe. His color was poor. He was wheezing badly, with pink frothy sputum bubbling out of his mouth. He was awake enough to communicate with us but so panicked that he started to fight the team of caregivers. Continue reading

Difficult Intubation In A Newborn

Difficult neonatal intubation can occur unexpectedly. We’re ready to perform neonatal resuscitation in the delivery room. We may be less ready to have to deal with a difficult neonatal airway at the same time. Recently I, and my colleagues, had to manage an unanticipated difficult neonatal intubation in labor and delivery.

The Case

The baby was born extremely edematous, and in respiratory distress. Although it was easy to ventilate the baby using the NeoPuff, airway swelling prevented the neonatologist  from identifying the epiglottis and vocal cords. The anatomy was too distorted. Following protocol when faced with a difficult intubation, the neonatologist called a “Code White”, an overhead page that in my hospital summons help from anesthesia, nursing, respiratory care and pharmacy to assist with either a emergency pediatric cardiac arrest or emergency intubation.

As a responding anesthesiologist, I too was unable to see landmarks during laryngoscopy. Continue reading

Announcing My New Book: Pediatric Airway Management: A Step-by-Step Guide

At long last, after two years of writing (and rewriting),  illustrating, and  filming  on-line videos, I’m excited to announce the publication of my new book Pediatric Airway Management: A Step-by-Step Guide, by Christine E. Whitten MD.

Anyone who rarely cares for children tends to be anxious when faced with a small child’s airway. This is true even if they are comfortable with adult airway management.

My goal for this book is to demystify basic pediatric airway management. I want to give you the skills you need to recognize when a child is in trouble and act quickly to safeguard that child, including helping them breathe if necessary. Continue reading

Intubation During Cardiac Resuscitation

Intubation during cardiac resuscitation is often challenging because of the circumstances surrounding the intubation. Excitement and apprehension accompany this life saving effort. If you don’t intubate often, you’re likely to be nervous. Even experienced intubators get excited in emergency situations, but we control our excitement and let the adrenaline work for us, rather than against us.

Step one, therefore, is to remain in control of your own sense of alarm. The leaders, which includes the person in control of the airway, must stay calm. If you appear panicked, the rest of your team will follow your lead.

Step two is to quickly assess the situation. Is the patient being ventilated? Ventilation takes priority over intubation. Is there suction available? Without suction you many not be able to see the glottis, and you won’t be able to manage emesis. What help do you have? The intubator almost always needs some assistance in having someone hand equipment, or assist with cricoid pressure, among other tasks. As I tell my students, intubation is a team sport.

Finally you need to assess what position the patient is in, and how can you optimize that position. The patient is often in a less than optimal position while chest compressions are in progress. You usually find the patient in one of two awkward positions: on the ground or in a bed. This article discusses techniques to better manage intubation during cardiac resuscitation, especially with the patient in an awkward position. Illustrations are copyright from Anyone Can Intubate, 5th Edition.  Continue reading

Not All Airway Emergencies Need Intubation

An emergency department physician I met the other day shared with me an experience from her hospital  that offers a good example of the fact that there are many different ways of managing an airway emergency in a child that don’t involve intubation. Medical management can sometimes avoid some of the risks of losing the airway that intubation might impose.

The Case

The child was an 18 month old girl whose older brother had been playing with laundry detergent pods. He had offered a pod to his little sister, who promptly put it in her mouth and chewed it, releasing the liquid. Her mother had brought her to the emergency room with respiratory distress. The child had severe stridor and was breathing at 40 times a minute. Oxygen saturation was 92%. She was awake and alert but anxious.

The ED doctor recognized significant airway obstruction and was concerned that the obstruction could worsen if the edema got worse. She immediately called for an anesthesiologist and a Head and Neck surgeon to come to the Emergency Department to evaluate the child. While waiting, she gave 10 mg of IM decadron and treated the child with nebulized racemic epinephrine. She attached a pulse oximeter and left the child sitting on her mother’s lap and otherwise did not disturb the child, trying to avoid making her cry. By the time the anesthesiologist and surgeon arrived the stridor, although still present, sounded better.

The question was what to do now? Continue reading

Remember That Respiratory Failure Is Not Always Due to Lung Failure

There are many causes of respiratory failure. Some causes of respiratory failure result from disease or damage to the respiratory system. However disease or injury to other organ systems such as the central nervous system, the musculoskeletal system, or the presence of cardiac or septic shock can also cause respiratory dysfunction.

While final diagnosis will certainly affect treatment, assessing and managing the patient’s ability to breathe will not change with diagnosis.  However, once the airway is secure, you then have to diagnose and treat the real problem in order to resolve the respiratory failure.

The Case

In this case, I was an anesthesia resident doing my pediatric rotation at a children’s hospital. It was my turn to be on call for the weekend. At this particular hospital back in 1982, the anesthesia department managed the airway emergencies in the Emergency Department so when I got the page to go to the ED, I ran.

Inside the triage cubicle a 6 year-old girl was clearly unresponsive. She had been sick with fever, nausea, vomiting and diarrhea for several days according to her mother, who was crying in the corner. She hadn’t been able to hold down any food or fluids for over 24 hours. Her temperature was 102F. She was breathing rapidly but very shallowly. We did not as yet have pulse oximetry, but her color was dusky blue. Her blood pressure was 60/40 and her pulse was 150. She looked septic.

I placed an oral airway and assisted her breathing. She didn’t react at all to the oral airway — no gag reflex. We decided to intubate.

My colleagues quickly placed an IV and I decided to intubate without induction agent or muscle relaxant. If she didn’t need those agents then I didn’t want to potentially compromise her status by giving them. Had she reacted at all when I started to perform direct laryngoscopy I would have aborted and changed the plan.

She didn’t respond at all as I slid the endotracheal tube into the trachea.

We gave her two boluses of 20ml/kg of normal saline. Her color improved, her pulse came down to 110 and her blood pressure rose to 80/50, appropriate for her age. But she still hadn’t woken up.

Ten minutes later the first blood test results returned. Her blood glucose was 10, extremely low. We gave her 2 ml/kg of D25W. Within two minutes she woke up and started fighting the endotracheal tube. As her other vital signs looked much improved and she was now awake and protecting her airway, we elected to extubate her.

The child was admitted to the pediatric ward, was treated for gastroenterits and she did well.

Learnings: Hypovolemia and Hypoglycemia Can Cause Respiratory Failure

This was the first experience that I remember seeing in my career that demonstrated that hypovolemic shock and hypoglycemia can cause profound respiratory failure without lung pathology.  It’s important to remember that respiratory failure can result from a variety of other systemic problems, not just dysfunction of the respiratory system.

Table showing the difference multi-system causes of respiratory distress and respiratory failure

Respiratory distress or respiratory failure can come from many causes.

While assisting ventilation and protecting the airway are first priorities to stabilize a patient, treating the cause of the respiratory failure may require more than just ventilation and/or intubation. In fact, treating the cause can sometimes help you avoid the progression of respiratory distress to respiratory failure. If you don’t consider a potential problem or cause, you’re not going to be able to diagnosis it.

May The Force Be With You

Christine Whitten MD
Author of Anyone Can Intubate: a Step by Step Guide, 5th Edition
Pediatric Airway Management: a Step by Step Guide

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten    Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon

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Communication In A Crisis: A Case of Respiratory Depression In A Child:

When I’m teaching communication in a crisis to my Perioperative/OR nurses, I often recount the story of what happened during one particular child’s recovery years ago. This case, involving a 2 year old child who developed respiratory depression in the recovery room, demonstrates how good communication in a crisis, including the ability to challenge an authority figure, can improve patient safety and allow collaborative teamwork in a crisis management situation. Continue reading

Airway Emergency: Start With The Basics of Airway Management

We have just finished another round of Critical Event Training for my hospital’s Anesthesia and OR staff. One of the scenarios we ran was how to manage a failed airway emergency: the dreaded “can’t intubate-can’t ventilate” airway emergency scenario.

As an instructor, it’s important for me to set the stage realistically. The more real the scenario, the more the providers will learn and be able to apply the information should they ever find themselves in a comparable situation. I must observe as the trainees respond to the emergency, and then help the trainees self-analyze what went well — or not so well — during the scenario. Of course, discussion of how things went during a training scenario always leads to sharing of examples from past real life scenarios. And after 37 years of practice I’ve had a lot of sharable experiences.

One past case we discussed is particularly appropriate for those students around the country who are just beginning to learn airway management because the solution rested in basic airway management techniques. This case, involving an intubation in an ICU patient that turned into a “can’t intubate/can’t ventilate” emergency demonstrates how returning to the basics of airway management can sometimes be the way to save your patient from harm. All illustrations from Anyone Can Intubate 5th Edition. Continue reading

Intubation With Airway Bleeding and Massive Emesis

During intubation, any liquid in the mouth that obscures the view of larynx not only hinders visualization, it risks aspiration. We’re used to being able to rapidly suction the mouth clear or secretions, blood, or vomit and then have a clear view of the larynx. But sometimes, either because of continued profuse airway bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate? Here I describe two cases, one involving blood and the other massive emesis, that required intubation through a large puddle of fluid. I offer tips and tricks to assist you in your future emergency management. Continue reading

Anticipated Difficult Intubation: Should I Intubate The Patient Awake?

When I was training, awake intubation for anticipated difficult airway was routine. Blind nasal intubation and fiberoptic intubation were common events. The advent of video laryngospcopy  has made the need for awake intubation much less common. Instruments like the Glidescope and the McGrath video laryngoscope have revolutionized intubation, and made the difficult intubation scenario fortunately much more uncommon.

However, awake intubation with the patient breathing spontaneously is still sometimes optimal for patient safety.  Awake intubation can be performed using standard laryngoscopy techniques, but it is more commonly done using specialty intubation techniques such as blind nasal or fiberoptic intubation.

Many providers are uncomfortable with performing awake intubations and leave it as a last resort. There are a variety of reasons for this discomfort, including lack of experience and/or the fear that the patient will remember the intubation and think poorly of their care. However, awake intubation can be a safe and comfortable strategy in many clinical situations and all providers should develop expertise with one or more techniques of choice — before an emergency forces them to use one.

This article will discuss how to decide when to do an awake intubation. Future articles will discuss how to do them. Continue reading

Apneic Oxygenation: Increase Your Patient’s Margin Of Safety During Intubation

While breathing room air, oxygen saturation drops precipitously to below 90% within about a minute of the start of apnea in the average healthy adult. As we saw in a previous blog post, preoxygenation is one of the most important safety measures we can use prior to induction of anesthesia and in preparation for intubation. Adequate preoxygenation can more than double the time to hypoxia during open airway apnea, allowing more time for intubation to occur. However, increasing the time to critical hypoxia from 1 minute to 2 or 3 minutes with preoxygeation, as important as that is, can still be too short if the intubation turns out to be truly challenging. Apneic oxygenation is an easy technique to increase the time to desaturation significantly. However you have to know how to optimally provide it in order to safeguard your patient  Continue reading

Assisting Ventilation With Bag-Valve-Mask

As an anesthesiologist, I often run to emergencies where the patient is not breathing adequately and requires intubation. However, before any intubation, a patient in respiratory distress/failure needs ventilation. Providers who have passed ACLS are often able to ventilate an apneic patient well because they have practiced on the manikin. However, I often see that providers have more difficulty trying to assist ventilation of a patient who is still breathing spontaneously.

The typical inexperienced provider will try to provide large, slow breaths just as they were taught in ACLS. Unfortunately these breaths are often out of synch with the patient’s own breathing. Squeezing the bag while the patient is exhaling means that your inflation pressure must not only overcome the diaphragm, but also reverse the passive outflow of air, the elastic recoil of the lungs, and the rebound of the chest wall combined. The vocal cords may be closed. Ventilating out of synch with the patient won’t be as effective. The breath you deliver will take the path of least resistance to enter the stomach or escape from the mask. It often makes the patient cough.

Even worse,  providers will occasionally hesitate to try to assist a patient’s breathing while waiting for the intubation team because they feel they don’t know how. Delay in improving ventilation can place your patient at higher risk of complication. This is unfortunate because in many ways assisting ventilation is even easier than manually ventilating an apneic patient. Let’s see why. Continue reading

Don’t Be Afraid To Use Percutaneous Jet Ventilation In An Emergency

Needle cricothyrotomy or percutaneous jet ventilation (PCJV) can truly be a life saving procedure. It is a fast, effective way of providing oxygen to a patient with an obstructed airway who does not respond to more conventional means of opening the airway. The “can’t intubate-can’t ventilate” scenario is a good example. PCJV is faster to perform than a surgical airway. It will buy you time to establish a more permanent airway such as an intubation or surgical airway if the patient is hypoxic.

However, percutaneous transtracheal jet ventilation carries some rare though potentially serious risks of worsening airway obstruction and cardiovascular collapse if the catheter is not correctly positioned within the trachea. Fear may prevent us from using it. In addition, most of us have never had to use PCJV in an emergency or even seen it used. Lack of familiarity with the equipment and simple lack of comfort may make us hesitate to try. We may not even think about it in the moment of crisis. So let’s look at some of the ways we can use PCJV safely. Continue reading

Laryngospasm is a Life-Threatening Emergency

Laryngospasm is one of the more frightening events in anesthesia: the protective, reflex, spasmodic closure of the vocal cords that occurs when the vocal cords are stimulated.  When laryngospasm occurs, vocal cord closure can be so forceful that it can prevent all ventilation or even the passage of the endotracheal tube. Life-threatening hypoxia can quickly follow. Other potential complications include post obstructive pulmonary edema, and possibly even cardiac arrest.

Photo of laryngospasm demonstrating closure of the vocal cords and false cords Continue reading