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
- 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