Are you ready for difficult airways?

When a patient in the intensive care unit at St. John NorthEast Community Hospital in Detroit went into respiratory arrest, anesthesia personnel were unable to secure an airway after several attempts, so Robert Takla, MD, FACEP, medical director of emergency services at the hospital, was called in to help. "This patient had a very challenging airway and a short neck, which [we] were unable to extend because of a chronic flexion," he says.

After trying unsuccessfully to visualize the vocal cords, Takla asked for a central line kit. "I proceeded to do a percutaneous needle cricothyroidostomy and subsequently advanced the guide wire retrograde until I was able to grab it from the patient’s mouth," he says. Next, Takla advanced the endotracheal tube over the guide wire, confirming that it was in the trachea and not the esophagus. "Despite the flimsiness of the guide wire, it worked like a charm," he says.

The above scenario illustrates the fact that ED physicians must be prepared for all types of airways, says Takla. "This patient would have definitely died without a definitive airway, and if it took too long, the patient would have suffered an ischemic insult," he says. Difficult airways that require alternative skills and techniques are rarely encountered, says Takla. "That is precisely why they must be learned and practiced."

Preparing for rare catastrophic events is easily overlooked, adds Richard M. Levitan, MD, an attending ED physician at the Hospital of the University of Pennsylvania in Philadelphia. "Failed airways can quickly result in brain injured or dead patients," Levitan warns.

Here are ways to improve airway management in your ED:

Encourage physicians to attend a difficult airway course. 

ED physicians need specialized training in the management of the difficult airway, says Takla. "Most of the time we are able to intubate without difficulty, so we become proficient and good at intubating the typical’ patient," he says. He recommends having physicians take a "difficult airway" course. "These skills can be practiced and mastered in non-life-threatening situations, with the added benefit of experts on hand to assist in your technique," he says. "You also learn other ways, which you may not have thought of, to skin the cat." (See "Sources and Resource," at the end of this article, for list of courses.)

Use fiberoptic scopes routinely.

At Levitan’s tertiary care center, fiberoptic intubations number only about three per year. To become comfortable using fiberoptic scopes, ED personnel should use them for nasopharyngoscopy examination and not only for actual intubation, advises Levitan. "For example, they should be used for foreign body evaluation, angioedema, and smoke inhalation," he explains. Levitan recommends having two scopes: a short nasopharyngoscope for routine examination and a long scope for intubation. An alternative is to have a mid-length scope that is long enough for intubation if needed, but easier to use for a routine exam than a 60 cm standard intubating bronchoscope, says Levitan. Both the mid-length scope and the intubating bronchoscope have a working channel that must be wire brushed after each use, as well as cleansed using a dedicated sterilization process, he adds.

Obtain the best-quality laryngoscopes.

You can dramatically improve the performance of your staff at direct laryngoscopy by acquiring the best-quality laryngoscopes, Levitan says. (See "Case study: Use direct laryngoscopy," in this issue.) "No operating room in the country routinely uses plastic blades, and we shouldn’t either," he says. Stainless steel blades, preferably with a fiberoptic light source, are far superior in terms of feel, performance, and illumination, he adds. "My department’s performance dramatically improved when we made this transition," he reports. He notes that the cost of stainless steel laryngoscopes with a fiberoptic light are about $150-$250, as compared to $50 to $100 for stainless steel laryngoscopes with a standard light.  "The disposable systems cost far less, approximately $5 per blade or less, depending on quantity," he says. "But these are single use."

Assess your needs.

First, Levitan recommends reviewing your current practice and performance for airway management. He suggests asking the following questions:

  • How many failed airways occur in your setting?
  • Are there problems specific to certain individuals?
  • Is there a subpopulation of patients commonly seen with airway issues, such as head and neck cancers, major trauma, or angioedema?
  • What back-up services are available to help in these circumstances?

Use this information to decide whether the acquisition and use of complicated and expensive difficult airway devices, such as a flexible fiberoptic scope for intubation, is realistic, says Levitan. "You need to consider if such services could or should be provided by an in-house consultant," he says. The ED tracks intubation success through a standard airway form that includes number of attempts, complications, methods of intubation, and means of tube placement confirmation, he notes. (To see the form, click here.)

Become familiar with the laryngeal mask airway (LMA) and Combitube (manufactured by Mansfield, MA-based Tyco-Kendall USA).

No practitioner will master all of the alternative devices, and no ED needs to have all of them, advises Levitan. "For rescue ventilation, every ED should have the LMA and Combitube," he says. "Individuals can easily acquire LMA experience in the OR."

Sources and resources

For more information about airway management, contact:

Richard M. Levitan, MD, Department of Emergency Medicine, Ground Ravdin, Room 279, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104. Telephone: (215) 662-7260. Fax: (215) 662-3953. E-mail:

Robert Takla, MD, FACEP, Emergency Services, St John NorthEast Community Hospital, 4777 E. Outer Drive, Detroit, MI 48234-3281. Telephone: (313) 369-5689. Fax: (313) 369-5582. E-mail:

Here is a partial listing of training resources and courses in airway management:

The Airway Course is a three-day course that includes instruction in airway techniques, including intubating, Fasttrach LMA, Combitube, rigid fiberoptic laryngoscope, fiberoptic intubating bronchoscope, needle cricothyrotomy percutaneous cricothyrotomy, surgical cricothyrotomy, and pediatric airway skills. The cost is $995. Upcoming course dates for 2002 are Feb. 15-17 in Las Vegas; March 22-24 in Seattle; April 12-14 in Hilton Head, SC; May 18-20 in Philadelphia; May 31-June 2 in Montreal, Quebec, Canada; Sept. 20-22 in Seattle; Oct. 25-27 in Chicago; and Nov. 15-17 in Atlanta. To register, contact: The Airway Course, P.O. Box 14694, Gainesville, FL 32604. Telephone: (866) 924-7929 or (352) 251-4752. Fax: (352) 692-1002. Web:

Northwest Anesthesia Seminars offers an Emergency Airway Management Hands-On Workshop. Upcoming course dates are Nov. 14, 2001, in Key West, FL, and Nov. 26, 2001, in Las Vegas. For more information, contact: Northwest Anesthesia Seminars, P.O. Box 2797, Pasco, WA 99302. Telephone: (800) 222-6927 or (509) 547-7065. Fax: (509) 547-1265. E-mail:

The University of Texas — Houston Medical School will hold its Fourth Biennial Difficult Airway Management Conference Feb. 28 - March 3, 2002, in Lake Tahoe, CA. For more information, contact: The University of Texas — Houston Medical School. Telephone: (713) 500-5126. E-mail: Web:

Training videotapes from the AirwayCam series are available. Volume 1 provides an introductory overview to direct laryngoscopy and demonstrates techniques and different blades on a variety of adult and pediatric patients. Volume 2 covers pediatrics intubations, and Volume 3 focuses on advanced airway imaging and laryngoscopy techniques. The tapes cost $149.95 each plus $5 shipping and handling. For more information, contact: AirwayCam Technologies, P.O. Box 337, Wayne, PA 19087. Telephone: (610) 341-9560. Fax: (610) 341-1866. E-Mail: Web: