The Difficult Airway: Part 2. Preparing for Failure

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

Managing a patient's compromised airway involves preparing for the possibility of not being able to complete the intubation procedure in a timely manner. To avoid ongoing hypoxia and hypercapnea, management should include being ready to use alternative or "rescue" methods, including a surgical airway.

In this article, part two of a two-part series on airway management, alternative airway measures are discussed, as well as the liability involved when they are not used expediently and efficaciously. Several case examples are presented below that illustrate the importance of timely decision making, equipment familiarity, technical proficiency, and creating optimal conditions for success in the use of alternative airways.

Case Example: Timely Alternative Airway. Following an otherwise uncomplicated tonsillectomy, a 3-year-old male experienced recurrent episodes of bleeding from the pharynx over a period of days.1 On his third visit to the ED for bleeding, he was taken to the operating room (OR) in an attempt to locate and stop the bleeding. He was first examined in the OR by the anesthesiologist, who observed no active bleeding. About the time that rapid sequence intubation (RSI) was performed, the patient experienced rebleeding. At that time, the patient's airway was being managed by both a CRNA as well as the anesthesiologist. At least two attempts at oral intubation were unsuccessful. After some delay, which included a failed attempt at cricothyrotomy and after the patient arrested, a tracheostomy was begun. At the moment the scalpel entered the trachea, the anesthesiologist was able to orally intubate the patient. The patient later had a return of spontaneous circulation and survived, but with hypoxic brain injury. He is enrolled in a special needs program and requires physical, occupational, and speech therapies. According to the plaintiff's attorney, "The defense attorneys and claims representatives ... appreciated that this child's injuries were due to negligence, and it was their obligation to provide for his future."2 The case was settled for $5.335 million.

The value and critical importance of alternative techniques and devices for "rescue" of an otherwise uncontrolled airway and their timely application have been well established over the last decade and has become the expected standard of care. Consequently, practice guidelines for healthcare providers in the ED, OR, and out-of-hospital setting have been established and reflect these expectations.

Case Example: Familiarity with Alternative Airway Equipment.3 In this case, an anesthesiologist was required to spend a specified amount of time "on call" to the hospital's ED to maintain hospital privileges. He was contacted by an ED physician for help treating a patient who had suffered a head-injury and was comatose, but who was still breathing on her own. The ED physician had been unsuccessful securing the airway after several attempts, both using laryngoscopy and fiberoptic nasal intubation. The ED physician, and later a respiratory therapist, called the anesthesiologist and requested his assistance in managing the airway. The anesthesiologist never responded to the ED. In anticipation of the patient's need of a surgical airway, the ED physician also contacted an on-call surgeon, who came to the ED and secured the patient's airway by performing a tracheostomy.

The next day, the ED physician filed a complaint regarding the anesthesiologist's failure to respond. After a hospital investigation, his hospital privileges were revoked. He filed charges with the Illinois Department of Human Rights and with the Equal Opportunity Commission, alleging that his privileges were revoked because of his religion and national origin. Both entities found no evidence of discrimination. He then filed suit in federal court, claiming that revocation of his privileges was in violation of the Civil Rights Act.4 He was unsuccessful in his claim.

The litigation resulting from these events uncovered a factual dispute: whether the ED physician (and by proxy, the respiratory therapist as well) actually requested that the anesthesiologist come to the ED. The anesthesiologist contended that he informed the ED physician that "in light of the bleeding and swelling in the patient's throat caused by her failed intubation attempts, any further efforts to intubate could prove fatal." He also claimed that he told the ED physician that "the patient was in need of a tracheostomy, a procedure that, as an anesthesiologist, he was not qualified to perform."3

Also, the record is not clear as to whether the anesthesiologist was unfamiliar with the fiberoptic method in general, or more particularly, with the fiberoptic equipment available at the ED. The ED physician claimed that he "refused to assist her after apprising her that the hospital did not possess a suitable fiberoptic laryngoscope [sic] for nasal intubation. The respiratory therapist claimed that he told the anesthesiologist that "the patient was becoming increasingly unresponsive and that they had contacted [him] because of their inability to intubate, but that [he] claimed that he did not have experience with [the hospital's] flexible fiberoptic equipment."3

Had the litigation that resulted from this incident involved a claim of negligence, at issue would likely be the standard of care for anesthesiologists: 1) in attempting laryngoscopy despite another healthcare provider's failure with that method; 2) in being familiar with the equipment available in the hospital, more specifically with the fiberoptic equipment as that used by the ED physician; and 3) in being able to perform methods and use devices relating to the "rescue" of the failed airway, including performing a surgical airway (despite the anesthesiologist's claim that this procedure is not within his domain of practice).

Case Example: Optimal Conditions for Success. This case notes a plaintiff who was injured in a motor vehicle collision and suffered multiple traumatic injuries, including a closed head injury.5 The plaintiff was immobilized by EMS personnel, who used a cervical collar, and was transported to the ED. Given the severity of his closed head injury, an anesthesiologist was called to perform intubation. Five attempts at intubation using the blind nasotracheal intubation (BNTI) method were unsuccessful. Standard oral intubation was then attempted. The first attempt was made with the cervical collar in place; the second attempt was made after the front portion of the collar was removed to improve visualization. Both attempts failed. The plaintiff was then given a neuromuscular blocking (NMB) agent and underwent three more intubations attempts. During each attempt, a different size of laryngoscope blade was used. As these attempts also were unsuccessful, a surgical method was then used for intubation. The plaintiff subsequently was found to have a spinal cord injury that resulted in quadriplegia. He later died from complications of the spinal cord injury.

The issue in the legal case that resulted was whether the standard of care was violated by the physicians' making multiple attempts at oral intubation, and whether these attempts — given that the plaintiff had limited movement of his upper extremities and movement of his lower extremities when he arrived to the ED — were the proximate cause of his quadriplegia and death. There was evidence that he developed neurogenic shock during the intubation attempts. Radiographs obtained after the intubation attempts, when compared with films taken when he first arrived to the ED, also showed a greater displacement between the second and third cervical vertebrae.

Intubation procedures are associated with a number of complications and adverse events. Although the risk of hypoxia is ever- present, and may result from prolonged or repeated unsuccessful attempts or from unrecognized esophageal intubation, this case demonstrates that other serious injury can occur. It also demonstrates the value of "a best attempt" at intubation.6 This term describes creating optimal conditions for intubation so that on the first attempt there is a maximum chance of success. This is in contrast to what occurred in this case: The patient was harmed because efforts to optimize conditions were taken in stepwise fashion and resulted in several unsuccessful attempts at intubation that ultimately caused injury.

Preparing for the Failed Intubation. Managing a patient's compromised involves preparing for the possibility of not being able to complete the intubation procedure in a timely manner. This is especially critical when rapid sequence intubation is used and the patient is rendered apneic by NMB agents. The emergency healthcare provider must be prepared to use alternative or "rescue" measures to provide timely and adequate oxygenation and ventilatory support. Some measures may be temporizing or used as a "bridge" to intubation itself and include simply using bag-valve-mask (BVM) ventilations. They also may include using blindly inserted nonsurgical, supraglottic airway devices such as a laryngeal mask airway (LMA) or the Combitube (esophageal-tracheal double-lumen airway). Supraglottic devices can be rapidly and appropriately placed by airway practitioners with limited advanced skills. However, compared to standard endotracheal intubation, they provide less protection against aspiration of stomach contents or other fluids such as blood into the lungs (the LMA); and may be associated with a higher incidence of trauma to airway and esophageal structures (the Combitube). Because the extent of damage to the brain from hypoxia is measured in intervals of minutes or less, preparation for use of rescue airway materials must be made before beginning the intubation procedure.

Among alternative airways, the surgical route both is used only infrequently and carries significant risk.

Nevertheless, there are times when the surgical airway is the best or only alternative airway option. The cricothyroid membrane, because it is closer to the surface of the skin than are the tracheal rings, allows easier and quicker access to the trachea through cricothyrotomy than through tracheostomy. There are two techniques used to perform cricothyrotomy (open and percutaneous). Familiarity with both techniques is valuable.

Factors that drive the decision to choose one technique for cricothyrotomy over the other are prior experience and equipment availability. However, the open technique may be preferred for a number of reasons. First, the equipment required for this technique (primarily a scalpel) is widely available and its use is more familiar. Second, the open technique better exposes the structures overlying the airway to visual or palpatory inspection; in patient's whose neck anatomy has been compromised, it may both allow for fewer complications and provide greater chances for immediate success. Third, unlike the percutaneous technique, the open technique may not require extending the patient's neck; therefore, it is safer in trauma patients who may have an injury to the cervical spine.7

Summary. In the management of any patient's airway, preparation for failure has become a standard of care. Timely decision making, equipment familiarity, technical proficiency and creating optimal conditions for success in the use of alternative airways are critical elements in alternative airway management.


1. Child suffers brain damage during surgery. Michigan Medical Law Report. Dolan Media Company: Farmington Hills, Michigan; 2008;4(1):14.

2. Tricks of the trade. Michigan Medical Law Report. Dolan Media Company: Farmington Hills, Michigan; 2008;4(1):7.

3. Alexander v. Rush North Shore Medical Center 101 F.3d 487 (Ill. App.1996).

4. Civil Rights Act of 1986, Title VII (42 U.S.C. sect. 2000e).

5. Ellis v. David Oliver, M.D 473 S.E.2d 793 (S.C. 1996)

6. Schneider RE, Murphy MF. Bag mask ventilation and endotracheal intubation. In: Manual of Emergency Airway Management, 2nd Edition. Walls RM, ed. Lippincott Williams and Wilkins: Philadelphia; 2004:52, 82-83.

7. Advanced Trauma Life Support (ATLS), Program for Doctors, Seventh Edition. The American College of Surgeons, 2004.