How to Avoid These 10 Difficult Airway Pitfalls

Calling an ENT surgeon only as a last resort for a deteriorating patient with a difficult airway, underestimating the risks posed by pre-existing medical conditions that render airways a minefield, and picking the wrong-sized endotracheal tube that leads to serious long-term sequelae are a few of the pitfalls to heed when treating these patients, noted several ENT surgeons who lead skilled airway management teams. In interviews with ENTtoday, they offered some cautionary tales about these challenges, along with practical tips on how to overcome them.

1. Communication Breakdowns

With so many specialists working on a typical difficult airway team, preparation and communication are crucial, said Paul C. Bryson, MD, the director of the Cleveland Clinic Voice Center and section head of laryngology, in Ohio, where he primarily treats adult patients.

Failure to review a patient’s prior airway management event, such as a previously challenging intubation, and not sharing that information with anesthesia colleagues, is a lost opportunity for being better prepared if those challenges recur.

Not performing CT scans and video laryngoscopy to visualize key anatomical structures in the patient’s airway before a procedure is another miss. “These exams provide incredibly useful conversation points in terms of what the upper airway looks like before you initiate airway care,” Dr. Bryson said. “They don’t prevent or fix every difficulty. But you will be far better prepared when a routine case deteriorates, and emergency interventions are needed.”

Dr. Bryson also cautioned against not communicating with a full complement of airway specialists. At Cleveland Clinic, he works closely with interventional pulmonologists for their expertise in rigid bronchoscopy. “They’re highly skilled airway surgery partners.” When considering such collaborations, “remember that managing the difficult airway is a team sport,” he said. “You’re the ENT airway specialist, but you’re also the coach, and you’re responsible for having all the right players in place to ensure the best outcomes.”

Mathieu Bergeron, MD, FRCSC, a pediatric otolaryngologist at CHU Sainte-Justine Hospital in Montreal, said he routinely reviews key difficult airway case details with nursing, anesthesia, ENT, and OR technicians “to ensure we are all on the same page and to build trust and rapport.” Why take that approach? “I often say the best airway rescue is the one that you never have to use because you anticipated the problems before even starting the case.”

To foster better communication and planning, Taher Valika, MD, the medical director of the aerodigestive program at Ann & Robert H. Lurie Children’s Hospital of Chicago, and his team have daily focused ENT/anesthesia airway huddles. “We review which patients may be difficult to intubate, which are likely manageable with mask ventilation, what size equipment and airway devices should be available, and whether the safest plan involves spontaneous ventilation or paralysis,” he said. “We also discuss the intra-operative plan, backup options, and post-operative airway strategy.”

2. Don’t Underestimate the Fragility of Younger Patients

Dr. Valika warned that children with difficult airways “can appear stable until they suddenly are not.” When the margin for error is small, “a seemingly controlled airway situation can rapidly devolve into an emergency.” These patients’ very limited airway reserve is the main challenge that sometimes can be overlooked, he noted, recalling a recent patient at Lurie Children’s who initially sounded like he was humming in the exam room, but who was actually found to have biphasic stridor. “When we evaluated him, this child had a pinpoint airway,” Dr. Valika said. “At that point, he could not safely go home.” The case “was a reminder that severe airway obstruction can be deceptively subtle, and that some children are compensating right up until the moment they no longer have a functioning airway.”

3. Not Heeding the Importance of Pre-Existing Conditions

Cancer patients with airway fibrosis from previous radiation treatments are a particular challenge, noted Jonathan M. Bock, MD, FACS, a professor in the division of laryngology and professional voice department of otolaryngology and communication sciences, Froedtert & Medical College of Wisconsin, in Milwaukee. In such cases, Dr. Bock probes the airway with a large-bore IV catheter or needle with saline in the syringe, “pulling back until you get air,” he said. “By leaving the needle in place, you can dissect down to the airway to localize it even in a bed of scar tissue.”

Congenital disorders are another challenging pre-existing condition, particularly in children. Dr. Bergeron cited, as an example, children with complete tracheal rings (CTR), which are characterized by a rigid cylinder-type airway “that is very unforgiving,” he said. “If there is any swelling or secretion, the airway will rapidly obstruct, and you cannot intubate them safely.” (Int J Pediatr Otorhinolaryngol. doi:10.1016/j.ijporl.2020.109977).

Dr. Bergeron said he has seen teams without full knowledge of CTR try repeatedly to intubate the patient, causing even more edema and airway worsening.

The far more effective approach, he noted, is to place the patient on a high-flow nasal cannula and introduce heliox, a breathing gas mixture of helium and oxygen that is much lighter than oxygen alone and thus can move through narrowed airways with less turbulence and resistance. Another option in these cases is to use extracorporeal membrane oxygenation (ECMO). Although ECMO “may seem dramatic,” all possible interventions need to be on the table to ensure optimal outcomes, he stressed.

Tyler Crosby, MD, an assistant professor in the department of otolaryngology, head and neck surgery at the University of California, San Francisco School of Medicine, cautioned against assuming that congenital conditions are only the purview of pediatric ENTs. Some of these patients survive into adulthood, he noted, and the attendant airway anomalies such as micrognathia and macroglossia can make both mask ventilation and tracheal intubation a challenge. “They tend to be more hypotonic, and they don’t emerge from anesthesia as well,” he said. “They’re not easy cases.” (AANA J. 2015;83:35-41).

4. Being Too Reluctant to Recommend and Manage Tracheostomies

Over the years, “I’ve become more willing to suggest a tracheostomy for my patients with difficult airways, to ensure safety,” Dr. Bryson said.  “Then we work backwards on a plan for removing it safely.” This approach is well-suited to the aforementioned cancer patient with airway scarring, as well as patients with bilateral vocal cord paralysis and multi-level airway obstruction. “We can still meet their functional needs—they can still work and live with the tracheostomy,” he said. “Plus, if they live far away from our center and they experience an emergency at or near home, having that surgical airway in place can be lifesaving.”

Dr. Bock highlighted a related pitfall: not being involved in the long-term care of tracheostomy patients. “As otolaryngologists, we are masters of the upper airway,” he said. “We have more experience managing these structures and sequelae than almost anyone else in the hospital.” With that expertise, he argued, comes responsibility. Some ENT physicians bristle at being asked to help manage the long-term care of tracheostomy patients, “but we shouldn’t be annoyed that we’re asked—we should be grateful,” he said. “They’re asking because we are the experts.”

5. Overlooking the Benefits of Awake Intubation

One effective but sometimes under-used strategy for managing patients with difficult airways is to do an awake intubation with very little sedation, Dr. Bock noted. This should not be an overlooked strategy, “because sometimes the only thing that is keeping a patient from rapidly declining is their own respiratory drive,” he said. Those benefits are underscored in Difficult Airway Society guidelines for awake tracheal intubation in adults, including preserving spontaneous ventilation and airway tone while maintaining patient cooperation and protective reflexes (Anaesthesia. doi:10.1111/anae.14904).

Dr. Bryson agreed that awake intubation can be an effective management strategy, citing patients who present with an upper airway tumor or obstruction, or post-radiation changes “that make their airway incredibly challenging,” he said. “In the awake setting, you can navigate around that anatomy, while avoiding the complications that can occur during anesthesia, such as excessive relaxation of the upper airway resulting in obstruction.”

6. Delays in Bringing an ENT Surgeon onto a Case

Handing over the airway reins to ENT team members is not always a smooth process. “Sometimes, we get called into a case as the surgical airway team of last resort, when a patient is already in grave trouble,” Dr. Bryson said. A better approach: “Bring us in early so we can help with a more thorough assessment and anticipate and avoid problems before they occur.”

Dr. Crosby has also encountered delayed ENT consults, to the detriment of the patient. He cited one recent case where his team got a call about a cancer patient who was about to be sedated for an interventional radiology procedure. “They said they just wanted to give us a ‘heads-up’ in case there were issues. Well, we took a look at the patient’s neck, and it was hard as a rock from previous radiation, with no palpable landmarks. We told the radiology team that if an emergent surgical airway developed, it would have been highly challenging to manage, even in an ideal care setting and with prior knowledge of, and planning for, the patient.”

The disconnect in this case is “the idea that our ENT team is ‘just down the hall’—we can come and save the day in case anything happens,” Dr. Crosby said. “That’s not a viable management plan. We need to be consulted far earlier to ensure optimal outcomes.”

7. Not Trusting Your Residents

Dr. Bock said he has experienced a related handoff issue when doing awake intubations. “Our anesthesiology staff may only do six or eight of these procedures a year, whereas when I am in the clinic, I’m scoping 20 larynges a day, and our residents are scoping dozens of awake patients a week,” he said. “Yet I’ve been in way too many situations where a resident at the bedside offers help during an airway emergency and is sidelined. Then I walk in and say, ‘Hey, let them try,’ and the resident successfully secures the airway with the fiberoptic bronchoscopy scope, and the patient is stabilized.” Making sure your residents are respected and relied upon is thus key, he stressed.

8. Poor Equipment Planning

Dr. Crosby said he sees a lot of long-term sequelae from patients intubated with the wrong-sized endotracheal tube. “I tell my critical care colleagues to be really thoughtful about the size tube you’re using, how long you’re leaving it in, and the damage it could cause while still in place.” That potential damage, he noted, includes severe laryngeal injuries and stenosis leading to patients needing lifelong tracheostomies. “Nobody wants to see these patients suffer from multiple surgeries and attempts to get the trach out,” he said. “That can set up a patient for a lot of misery, even if they recover from their acute reason for being in the ICU, whether for heart failure exacerbations, COPD, etc.”

Several management fallacies can lead to improper tube selection, such as the assumption that a large tube is needed in patients who are morbidly obese to provide enough positive air pressure to maintain the airway, Dr. Crosby noted. “The problem is that a patient’s height determines how big their airway is, not their weight,” he explained, adding that he has treated very short patients with high body weight who were intubated with tubes two sizes too large, resulting in significant airway complications that required ongoing management.

Dr. Valika echoed the importance of having the right equipment at hand, particularly for emergency cases. At Lurie Children’s, Dr. Valika and his colleagues have developed a Rapid Difficult Airway Response team (RaDAR) supported by a dedicated instrument cart that brings both specialized personnel and essential pediatric airway equipment immediately to the bedside. Many institutions use such carts, which give responders the devices they need to intervene based on a sequence outlined in Krishna et al: optimize oxygenation, deploy supraglottic rescue, default to video laryngoscopy, escalate to fiberoptic techniques, and prepare for front-of-neck access (J Pediatr Intensive Care. doi:10.1055/s-0038-1624576).

“We have dedicated RaDAR carts located in each ICU,” Dr. Valika said. “The cart brings critical pediatric airway equipment to the bedside, including a flexible bronchoscope, supraglottic airway rescue devices, and a pediatric tracheostomy tray.”

Just as important, however, is the composition of the team responding to an airway emergency. The RaDAR team at Lurie Children’s includes anesthesia for comanaging ventilation; ENT for endoscopic intubation or surgical airway intervention; and a technician who ensures the equipment is ready and functioning, Dr. Valika noted. “The goal is to have expertise and tools arrive together, which allows us to respond quickly, safely, and effectively when a difficult airway becomes an emergency.”

Dr. Bergeron said he learned the lesson of poor equipment planning the hard way via a pediatric case where he assumed the right-sized tracheostomy tube was stocked in the OR and ready for use. “What I wanted was a size three, but the nurse handed me a size five, which actually is about four times too large,” he said. “That was the last time I took difficult airway equipment and planning for granted.”

As for other crucial pediatric airway equipment that should be at hand, Dr. Bergeron recommended video laryngoscopes or intubation with a rigid endoscope such as a Hopkins rod, which he said can be “lifesavers.” The devices allow everyone on the airway team to directly visualize when the tube is properly placed in the infant’s airway. If the patient fails to respond, as evidenced by no CO₂ return or chest rise, “you cannot blame the intubation,” he said. Rather, it is time to move on to other interventions, such as adjusting medications and anesthesia.

Dr. Crosby agreed that without proper planning, equipment issues can be a huge pitfall. “It’s something we can take for granted, but it’s important to be familiar with the airway equipment your hospital has, where it is, and how to set it up,” he said. “I advise mentally going through the surgical plan and contingencies step by step and ensuring the equipment needed for each step is in the room and functional before the patient even rolls into the OR.”

The last thing a team wants “is to reach a time-critical portion of a case and find you cannot expose a patient’s airway because of a broken light source or disconnected suction, or you need to dilate an airway quickly and find the balloon is not in the room.”

He added a related pitfall: At many centers, “airway cases can be high acuity, low frequency. So, you may have little choice but to perform these cases with a team that does not have extensive experience with the surgery or your equipment needs.” Thus, “minimizing chance and guesswork is critical.”

9. Transferring a Patient Without an Adequate ENT Workup

Dr. Crosby said his team often receives calls about patients who are being transferred to ENT management without anyone having actually assessed the airway. There can be a sense that if a patient appears relatively stable—if they’re not in obvious distress and their oxygen saturation is acceptable—they’re safe to transfer. “I would caution against that assumption,” he said. “We need to perform at least a foundational airway assessment before sending a patient elsewhere. Even a simple bedside flexible scope can provide valuable information.”

10. Poor Patient Positioning

This is a common pitfall even among experienced airway teams, Dr. Bock noted. During emergency intubation attempts, he’s often seen anesthesiologists trying to perform the procedure with the patient lying down. “I’ll suggest, ‘Why don’t we try moving this patient forward to a different position so that we can better visualize their airway. When we scope people in the clinic, for example, we have them sitting forward, and that makes a huge difference when viewing the airway.”

In fact, “this is the first thing we teach our students and residents in the clinic when they’re trying to get a good view of the larynx with the scope through the nose; just have the patient sit forward. It’s so much easier and effective.”  

 

David Bronstein is a freelance medical writer based in New Jersey.