The difficult airway: Part I

Initial intubation methods

By Mark J. Greenwood, DO, JD, FAAEM, FCLM, Flight Physician, Aero Med Spectrum Health, Grand Rapids, Michigan.

Airway management that results in a negligence claim usually involves a "difficult airway." Airways classified as difficult typically are compromised by an anatomical or other condition that makes intubation by the oral, nasal, or surgical routes difficult or impossible. Difficult airway management requires making sophisticated and timely decisions, as well as technical proficiency on the part of the healthcare provider. Claims of negligent management of the difficult airway often are heavily litigated because patient injuries resulting from failures in airway management may be severe, including, most notably, brain damage and death.

Whether from the perspective of a healthcare provider faced with managing a patient's airway, or from hindsight (i.e., after claims of negligent management arise), two issues should be kept in mind: 1) the appropriateness of the method selected for the initial or first attempt at intubation; and 2) given the possibility of failure, the selection of the most timely and effective alternative airway measures to "rescue" the airway and to ensure adequate oxygenation and ventilation of the patient. The first of these issues and the difficulties it can present in medical scenarios is discussed this month in part one of a two-part series. Part two of this series will discuss the liability that may occur when alternative measures are not used in a timely and effective manner.

Medical Decision Making. Managing the difficult airway first requires determining the extent to which the airway is, or has the potential to become, compromised. Second, it requires choosing an intubation method that considers the limitations of the intubation methods themselves.

Choosing which intubation method to use for the initial attempt requires considering the risks and limitations of each of them. Most notably, with the use of rapid sequence intubation (RSI), the use of neuromuscular blocking (NMB) agents is necessitated to cause paralysis of the patient's muscles, including those responsible for spontaneous breathing. With RSI, the extent of the benefit of improved visualization must outweigh the risks of both the inability to complete the intubation procedure and the inability to provide oxygenation and ventilation by secondary methods.

Several case examples will be offered that illustrate the extent to which healthcare providers who manage patient airways must demonstrate sophisticated and timely decision making, as well as technical proficiency.

Case Example: Should we intubate? In this case, the plaintiff, a 52-year-old male, experienced tracheal swelling after developing an allergic reaction to prescribed pain medication following minor goiter surgery.1 He drove to the ED of the same hospital from which he was discharged 36 hours earlier and was examined by a board-certified emergency physician. She determined that the patient's airway was becoming obstructed and that he needed to be intubated. She called the hospital's anesthesia services to perform the intubation, and notified surgical services that one of their patients had returned with complications. Within minutes, anesthesia and the on-duty surgery resident responded to the ED.

The dictated medical records indicate that the ED physician and the surgery resident "fought" over whether to intubate the plaintiff. Ultimately, the resident ordered anesthesia to leave, and the patient received a respiratory (inhalation) treatment (albuterol). Forty minutes later, while still in the ED, the patient's airway completely obstructed and he arrested. A tracheotomy was performed but not in time to prevent severe brain damage. Married and a father of two, he survived for eight months in a comatose state before dying from his injuries.

This case highlights, among many obvious risk management errors, how the extent of airway compromise may entail a dynamic process. An airway that is increasingly compromised also is becoming increasingly "difficult." Its management requires rapid and appropriate medical decision making that occurs within the associated time constraints. Given that less than one hour after walking into the ED on his own the plaintiff was comatose with severe brain damage and that the conflict between the ED physician and the resident was memorialized in the medical record, it is no surprise that this case was settled pre-suit for $1.667 million.1

Case Example: RSI or Blind Nasotracheal Intubation (BNTI)? The plaintiff in this case was severely burned when he used a cutting torch on a barrel containing flammable liquid.2 Following an explosion, he was engulfed in flames for 30 seconds and suffered extensive and deep burns on his body that included his face and neck. While en route to the hospital via ambulance, he maintained spontaneous breathing and received high-flow oxygen. In the ED, he had an increased respiratory rate and decreased levels of blood oxygen. Based on the patient's hypoxia and respiratory distress, a decision was made to intubate. The ED physician called a certified registered nurse anesthetist (CRNA) to accomplish this task.

The CRNA apparently performed an awake laryngoscopy to better predict the degree of visualization that would be obtained after administering the NMB agent. Given her lack of adequate visualization of airway structures, she was not comfortable performing the RSI procedure. Because the plaintiff was awake, and breathing, she recommended BNTI. However, despite her reservations and upon the recommendation of the ED physician, she performed RSI. Visualization by laryngoscopy remained poor because of burns, swelling, and a short mandible — despite administration of the NMB agents. She inserted the ET tube but was not certain of a tracheal placement; the tube was left in place despite this uncertainty. A carbon dioxide device was attached to the ET tube that did not confirm the presence of carbon dioxide and there was no increase in the plaintiff's blood oxygen level. These all indicated lack of adequate ventilation and suggested esophageal tube placement. Unfortunately, concerns about proper placement were temporarily alleviated by the ED physician's reported auscultation of breath sounds over the lung fields and the absence of sounds over the stomach. The plaintiff then received a narcotic pain medication, which was followed within minutes by the loss of his pulse. Resuscitation efforts were unsuccessful. At autopsy, the medical examiner found the ET tube in the esophagus.

The plaintiff's emergency medicine expert testified that the ED physician's failure to detect an esophageal intubation when listening for breath sounds amounted to an honest error in judgment, but that failure to check for placement using laryngoscopy and failure to notice that the patient's oxygen saturation levels were not rising was evidence of reckless disregard. The jury apparently agreed, finding reckless disregard on the part of the ED physician. The contracting anesthesia group was liable for the CRNA's negligence. On appeal, the court found that the county hospital and the ED physician as its agent were immune under the state's Good Samaritan Act.

This result was despite the reasoning (as articulated in the dissenting opinion) that it is "illogical to infer the legislature intended application of a different standard to medical professionals working as part of the same team, affording greater protection to the person in charge than to those carrying out the orders ... "3

This case highlights the level of sophistication required in choosing between various methods of airway management. Although RSI offers important advantages over other forms of airway management (primarily in its improving laryngoscopy), its use does not guarantee success. Consequently, despite the widespread use of RSI, other methods of airway management must remain available to and part of the armamentarium of healthcare providers in the management of ED patients.

Rescue devices often include those inserted into a supraglottic position (e.g., laryngeal mask airway or LMA) and double lumen devices (e.g., Combitube).

Case Example: Patient-Specific Airway Challenges. This case involves a patient who was scheduled to have a hysterectomy.4 She had a history of temporomandibular joint (TMJ) disease, which caused pain and limitation in jaw opening. Because of this, her pain management physician and her oral surgeon advised her to have nasotracheal intubation for the hysterectomy, rather than oral intubation. On the day of her surgery, the plaintiff told at least two hospital employees that she would need nasal intubation. Just before surgery, she gave a copy of her x-rays to her anesthesiologist. According to the plaintiff, his response was "to cast the x-rays aside and tell her that he would decide what type of intubation she would receive."4 She was then intubated orally for anesthesia. In a negligence action, she asserted that as a result of the oral intubation, the anesthesiologist caused severe injury to her lower teeth, an increase in her facial pain, and damage to the tissue and bone structure of the TMJ.

The legal issue was whether the plaintiff could proceed in a cause of action under a theory of lack of informed consent (medical battery). If so, her "knowledge and awareness" of facts related to intubation would be dispositive and she would not require expert medical testimony. The trial court found that "the patient knew that the anesthesiologist might use oral intubation and that she authorized the procedure both by signing a consent form prior to the surgery and by not stopping the procedure when she became aware that [the anesthesiologist] might use oral intubation." The appellate court reversed the decision, finding that "a genuine issue of material fact existed as to whether she authorized [the anesthesiologist's] use of oral intubation."4

Decisions made in the context of elective procedures generally require the informed consent of the patient. This ensures that the patient is reasonably aware of the risks and benefits of the proposed procedure and of alternative procedures; and is also aware that another healthcare provider, more experienced, or experienced in other methods, may be available to perform the procedure. In this latter case, it would be important to determine whether the fiberoptic device was available and the extent of the healthcare provider's expertise and comfort in performing fiberoptic nasal intubation.5

Summary. Choosing the appropriate method for intubation in any patient is of paramount importance; this decision is made more challenging in those with difficult airways. Timely and sophisticated determinations may keep liability in these situations at bay.


1. Patient has allergic reaction to painkiller. Michigan Medical Law Report. Dolan Media Company; Farmington Hills, Michigan: 2008;4:15.

2. Jackson County Hospital v. Aldrich 835 So. 2d 318 (Fla. App. 2002). This case was discussed in a prior publication: Greenwood MJ. Nasal intubation or rapid sequence intubation. Am J Emerg Med 2005;23:921-922.

3. Jackson County Hospital v. Aldrich, at 332 (Miner J, dissenting).

4. Hensley v. Scokin 148 S.W.3d 352 (Tenn. 2003).

5. Liang BA, Lagasse RS. Listening to the patient: potential medical battery in oral intubation. J Clin Anesth 2005;17:75-77.