What is the point of doing this?
You perform an airway assessment on patients about to have an anaesthetic in order to identify patients who may be difficult to intubate or oxygenate. The point of identifying this early is to avoid an unanticipated difficult intubation or oxygenation after the patient is asleep and paralysed – which can be a lethal situation.
As a junior trainee on the team, you may be sent to ‘pre-op’ some patients by your registrar or consultant. It is an important job, and they are relying on you to make an appropriate assessment and communicate your findings with them to keep your patient safe. The more assessments you make, the better your ‘radar’ will be for people who may be difficult.
The NAP 4 audit found that failure to assess for and identify potential difficulty, or the application of poor judgement in management planning, may contribute to a poor outcome. Here is a snapshot of a case study mentioned in the full report:
There were 133 anaesthesia reports in NAP 4. Difficulty with airway management was anticipated in 66 and not anticipated in 67. 16 of these patients died, 5 had severe morbidity associated (eg. permanent brain injury), and 103 had moderate morbidity (significant but not permanent harm or moderate increase in treatment). A quarter to 1/3 of the 133 patients had no recorded airway assessment (!) There are a number of learning points in their full report, which is well worth a read.
What do I need to find out from the airway assessment?
Crawley and Dalton’s excellent BJA education article on predicting the difficult airway lists these questions that are super useful in helping you work out the information you need when performing an assessment:
- Will I be able to mask ventilate?
- Will I be able to perform laryngoscopy, directly or indirectly?
- Will I be able to intubate this patient?
- Is there a significant aspiration risk?
- If I predict difficulty, should I secure the airway awake?
- Can I access the cricothyroid membrane if needed?
- How will the airway behave at extubation?
How to look at an airway and know what you’re talking about
How to make an airway strategy
- The Life in the fast lane page for airway assessment can be found here.
- NAP 4 full report
- BJA Education article on predicting the difficult airway
- DAS guidelines for unanticipated difficult intubation
- DAS guidelines for ICU intubations
- Paediatric difficult intubation guidelines (DAS + APA)
- DAS guidelines for difficult intubation in obstetrics