Organizational Aspects of Difficult Airway Management

Abstract

I N 1858, Eugène Bouchut, a pediatrician from Paris, published a series of seven cases of successful orotracheal in-tubation to bypass laryngeal obstruction resulting from diphtheria. 1 His presentation was reportedly not well received by the French Academy of Sciences because of safety concerns. Today, millions of tracheal intubation procedures are performed every year, and in emergent situations, the procedure still carries a high risk of complications of up to 30%. Accordingly , new information that could potentially lead to improved outcome of tracheal intubation is important. In this issue of ANESTHESIOLOGY, four groups of clinical researchers 2-5 present important new insight that might help improve the safety of patients undergoing emergency tra-cheal intubation. The work of Combes et al. 2 and Martin et al. 3 focused on emergent intubation, whereas Amathieu et al. 4 and Aziz et al. 5 report on their experiences with new devices to manage a difficult airway in the operating room. It is challenging to develop guidelines for tracheal intubation that are widely aphoristic because the clinical scenarios leading to tracheal intubation attempts, as well as the available equipment , are diverse. Although National Anesthesia Societies conclude that standards of practice and monitoring in a prehospital setting should be the same as an in-hospital tracheal intubation, 6 this does not reflect real-world reality, where the conditions under which a patient requires anesthesia for intubation vary widely. Tracheal intubations, even in the most affluent parts of the world, are being performed by healthcare providers with different training backgrounds, such as paramedics, emergency department nurses, respiratory therapists, and physicians of different specialties. In addition, the available equipment and peer support differ between a tertiary care hospital operating room and a preclinical intubation in the field. Finally, the acuity and nature of a patient's disease vary depending on the clinical scenario (preclinical, emergency department, intensive care unit, or operating room), which in turn affects the strategic planning of airway management. Accordingly, guidelines developed for an-esthesiologists in the operating room 7 cannot be reasonably applied to emergent intubation in the field. What Does the Work of Martin et al., Combes et al., Aziz et al., and Amathieu et al. Add to the Existing Literature? Emergency Intubation The two articles by Combes et al. and Martin et al. discussed in this editorial 23 show the benefits and limitations of a locally developed, standardized approach to airway management. Combes et al. 2 developed a very specific algorithm for unanticipated difficult airway management in the prehospi-tal emergency setting. The use of this algorithm was associated with a very high (more than 99%) success rate of emergent management of patients with difficult airways. The authors are to be commended for this accomplishment, which may help save the lives of future patients. We believe that all organizations responsible for prehospital resuscitations should develop a local algorithm for use by their specific providers. This suggestion is supported by a basic principle of performance improvement initiatives: these initiatives need to fit into local culture. The flip-side of this conclusion implies that any locally developed, specific algorithm 2 needs to be substantially modified to fit in any other clinical scenario. The algorithm of Combes et al. 2 may not work very well outside of the Service de Medecine d'Urgence et de Reanimation of the Henri-Modor University Hospital in Creteil, France, which reportedly consists of a skilled team of three people a senior physician, a nurse anesthetist, and an experienced medic/ambulance driver. This ideal skill set probably does not represent an average approach to preclinical emergency medicine outside of Paris. The highly trained preclinical airway team of Combes et al. and the sophisticated in-hospital airway emergency response team of Martin et al. reported a high success rate for tracheal intubation. In addition, Martin et al. reported a 2.3% complications rate in 2,400 intubations. We find the latter results impressive as well as far less than published data. The lower complication rate in the study by Martin et al. compared with the study of Combes et al. can possibly be explained by the different study design (retrospective vs. pro