Have you ever been in a code situation where there were multiple failed intubation attempts on a patient? If so, you aren’t likely to forget it. Managing a difficult airway is one of the most challenging circumstances for even the most seasoned medical professional. 

As a nurse, you will find that the more you can anticipate a problem before it happens and prepare for the next steps should the problem occur, you can avoid a potential crisis. The American Society of Anesthesiologists updated their “Practice Guidelines for Management of the Difficult Airway” in 2013. Though the literature is geared towards anesthesiologists,it is still relevant for any nurse who works with critical patients that could experience a respiratory emergency. Let’s take a look at some of the strategies that are discussed.


Perform an airway evaluation

Just as you would do a medical history and physical exam on any new patient, do a specific evaluation of the airway. If you have the time to peruse the patient’s chart, see if there are any indications of previous airway difficulties or any medical conditions that may predispose a difficult airway. In addition, assess the patient’s physical features. Characteristics such as a short, thick neck, a high-arched or narrow palate, limited range of head and neck motion, and long upper incisors are all considered non-reassuring findings that may lead to a difficult intubation (Apfelbaum et al., 2013).

Obviously, in an emergent situation this may not always be possible.


Keep specialized airway equipment easily accessible

A portable cart with equipment for difficult airways should be kept stocked and readily available.  Flexible fiberoptic bronchoscopes, video laryngoscopes, and surgical airway equipment are all examples of the types of equipment that some hospitals now maintain in a special airway emergency crash cart.


Administer oxygen to the patient prior to and during the airway management process

The guidelines recommend that a patient with a known or suspected difficult airway be preoxygenated via face mask before attempting intubation. It is also recommended that the patient be administered oxygen as possible during the airway management process. This can be via nasal cannula, face mask, or laryngeal mask airway (Apfelbaum et al., 2013).


Consider multiple intubation strategies

The guidelines suggest that traditional intubation should not alway be primary approach for patients with a difficult airway. Instead, the  anesthesiologist should consider the level of patient cooperation and the amount of difficulty with ventilation and airway access. Based on these factors, the proper method of intubation should be selected. 

Awake intubation is discussed as one option. Rather than waiting until the patient receives general anesthesia, observational studies show success in difficult airway intubation while the patient remains awake (Apfelbaum, 2013). An uncooperative or young patient may rule this out, however. 

Other options include video assisted laryngoscopy, the use of intubating stylets, and the use of a supraglottic airway. 

You may not be the one making the decisions about what method to use to intubate a patient or actually performing the airway management technique. Yet being able to recognize a patient with a potential difficult airway and understanding the best practice guidelines for handling such patients will greatly aid your delivery of safe patient care.


Editor's Note: This blog was originally published in March of 2016. It has been re-published with additional up to date content.


New Call-to-action