tools to manage the difficult airway and prevent avoidable trauma? It's your
responsibility to ensure that they do.
L ooking for trouble
A thorough pre-op airway assessment is paramount, but I'm afraid some
providers have gotten away from the practice. A good exam includes checking
anatomy of the airway and throat, tests — like assessing the Mallampati score
— and ensuring dentition is in place and healthy. Providers must document
what they see (and what they can't see, for that matter).
Mallampati scores of 3 or 4 indicate the potential of a challenging airway, but
providers must always assume an airway is suspect until proven otherwise.
They must always have a way to rescue the patient; anything they do should be
able to be backed up and, if possible, reversed. Do not burn bridges. A well-
stocked airway cart contains various types and sizes of laryngoscope blades, air-
ways, Magill's forceps for manipulating the endotracheal tube into the glottis, a
video laryngoscope and tools for fiber-optic awake intubation.
Best practice for airway management involves having plans B and C at your
fingertips in the event plan A — conventional intubation — fails. Plan B could
involve the use of a video laryngoscope, the airway device that's pushing awake
fiber-optic intubation for the gold standard label of difficult airway management.
Video laryngoscopy transmits clear images of the glottic inlet, giving providers
the confidence they need to secure challenging airways caused by anatomical
abnormalities, obesity and past trauma. Plan C might involve the use of a supra-
glottic airway device, the preferred rescue device in the American Society of
Anesthesiologists' difficult airway algorithm.
Providers who suspect a difficult airway before the first attempt at intubation
can administer light sedation and perform a precursory exam of airway anato-
my. If they identify and can access familiar anatomical landmarks, intubation
can proceed as planned and the patient can be fully anesthetized for surgery. If
the suspicion of a difficult airway is realized, the provider can use a video laryn-
2 6 S U P P L E M E N T T O O U T PAT I E N T S U R G E R Y M A G A Z I N E January 2015
