The ASA first developed and published practice guidelines for management of the difficult airway in 1993.² These guidelines heightened practitioners’ awareness of the scope and magnitude of problems related to complex airway management and encouraged familiarity with a standardized clinical airway algorithm. At that same time, the Johns Hopkins Department of Anesthesiology and Critical Medicine initiated a collaborative effort with the Department of Otolaryngology—Head and Neck Surgery to develop and modify airway management techniques and clinical algorithms.¹¹

More recently, other organizations and countries have proposed and tested their own strategies and algorithms for managing difficult airway/intubation cases.¹²^–¹⁵ Some algorithms incorporate the use of new airway devices,¹⁶ whereas others are designed for use in settings other than the operating room.^8,¹⁷ A text on emergency department airway management has recommended a universal algorithm in addition to algorithms for specific circumstances.^18,¹⁹ Guidelines developed for anesthesiologists in the operating room cannot reasonably be applied to emergent intubation in the field, and the most successful algorithms have been developed at a local level by a multidisciplinary team.²⁰

The creation of these various algorithms is still in harmony with the purpose of the ASA practice guidelines: (1) the practice guidelines are not intended as standards or absolute requirements; (2) they are subject to revision as warranted by the evolution of medical knowledge, technology, and practice; and (3) their recommendations may be adopted, modified, or rejected according to clinical needs and constraints.¹ Considering all of these variables tends to move airway management farther away from one standardized difficult airway/intubation algorithm. This leads to the inevitable conclusion, as noted in an ASA editorial, that optimal or preferred tracheal intubation techniques and devices will be different for each individual patient and depend on the skill and experience of the practitioner in that particular clinical setting.²¹

C A Difficult Airway/Intubation Team

Strategies for improving the response to difficult airway/intubation during an emergency code situation can include the use of a difficult airway response team (DART) and a DART equipment cart such as the one developed in 2008 at the Johns Hopkins Medical Institutions. This multidepartmental educational and operational program involved anesthesiology, otolaryngology, trauma surgery, and the emergency department; clarified unclear roles of the various providers; and initiated facility-wide quality improvement of problems such as difficulty accessing specific equipment.²² A retrospective review at this institution of cases from 1992 through 2006 demonstrated an annual frequency of approximately 6.5 emergency surgical airways (cricothyrotomy or tracheostomy). Two years after initiation of a comprehensive DART program, the annual frequency was approximately 2.2, despite an increase in the number of patients reported to have difficult airway/intubation.²³ Implementation of the DART program also reduced the number of airway sentinel events from several in the preceding 2 years to none in the first 2 years of the DART program. In addition, no claims related to airway events were paid during this time.²⁴

D Consequences of Difficult Airway Management

The consequences of a difficult airway or difficult intubation can include minor or major adverse medical events or death, professional liability to the practitioner, and direct and indirect costs to the patient and the health care system. In 1988, the ASA Committee on Professional Liability closed claims study found that respiratory events were the most common cause of brain damage and death during anesthesia, with difficult intubation being the likeliest category for risk reduction. The median payment for respiratory claims was $200,000.²⁵ In a 1992 loss analysis study conducted by the Physicians Insurers Association of America, files from 43 physician-owned malpractice insurance companies (representing approximately 2000 anesthesiologists nationally) ranked “intubation problems” as the third most prevalent misadventure. The average paid indemnity for 175 of 339 files was $196,958.²⁶ In an analysis of approximately 5000 claims filed in Maryland over a 15-year period that named an anesthesiologist as a defendant, insertion of an endotracheal tube was the sixth most common medical procedure leading to a liability claim. One malpractice claim was filed for every 7.5 patient injuries that occurred from difficult airway events and adverse outcomes, and a single claim in 1994 resulted in a jury award of $5 million (Laura Morlick, Johns Hopkins Medical Institutions, Baltimore, MD, personal communication, July 17, 1994). A study of the ASA closed claims database from 1985 to 1999 revealed that 67% of claims of difficult airway liability were associated with intubation.²⁷

During airway management, repeated intubation attempts cause swelling and bleeding, with each attempt creating a greater likelihood of failed intubation and ventilation leading to potentially disastrous consequences, even brain damage or death.^18,^27,²⁸ Prolongation of the airway management process has been shown to increase the rate complications up to 70% with multiple tracheal intubation attempts.^8,²⁹

Most complaints initiated against physicians are unrelated to the physician’s technical skill but arise because of inadequate records or poor communication. More complete documentation and communication may be the practitioner’s best defense.³⁰ A 1994 survey of patients who were enrolled by Johns Hopkins in the MedicAlert National Difficult Airway/Intubation Registry found that, despite experiencing adverse outcomes (cancellation of surgery, dental trauma, soft tissue trauma, desaturation, cardiovascular compromise, and cricothyrotomy or tracheostomy), 100% felt that the enrollment gave them a sense of comfort in that future care providers would understand the significance of their difficult airway/intubation. Enrollment in the Registry and documentation of enrollment in the patient’s medical record is a positive reflection of the provider’s concern for the patient’s future safety.³¹ In a fall 2010 survey conducted by the MedicAlert Foundation of more than 700 members already enrolled in the National Difficult Airway/Intubation Registry, 69.6% of respondents said that a physician had recommended that they enroll, and 92.7% said that what they expected to gain from enrolling was peace of mind knowing that their difficult airway/intubation information would be available in an emergency (A. Wigglesworth, personal communication, September 23, 2010).

III Difficult Airway/Intubation: Documentation of Critical Information

The communication of successful and unsuccessful airway management techniques consists of two parts: (1) documentation at the time of the event (preanesthesia, anesthesia, postanesthesia) for concurrent care providers during that episode of care, and (2) dissemination of that information to future care providers during subsequent episodes of care. This section deals with documentation to concurrent care providers during an episode of care.

A Documentation in Medical Records

In the past, no standardized, uniform, readily available document existed to precisely record airway events. Traditionally, difficult airway/intubation information was recorded in the paper anesthesia record as a nonstandardized, handwritten, free text entry. This information was not included in the operative report or on the face sheet of the medical record; it was hidden and seldom accessed by physicians and nurses caring for the patient in the intensive care unit or nursing unit. In addition, this information was department specific in that it was not shared with other departments (emergency; ear, nose, and throat) within the institution that also encountered patients with difficult airway or difficult intubation.

In 1987, Martin L. Norton and colleagues at the University of Michigan pioneered efforts to more fully evaluate patients with complex airway problems by establishing the University of Michigan Airway Clinic. This is believed to be the first formally established clinic specifically for patients with difficult airway/intubation. Clinical documentation consisted of a handwritten airway clinic record sheet and photodocumentation.³² Since that time, the standard of care for documentation of difficult airway/intubation information has been steadily evolving. In 1992, Lynette Mark and colleagues in the Johns Hopkins Anesthesiology and Critical Care Medicine Department developed the Anesthesiology Consultant Report. This two-page report fully described the preoperative evaluation of a difficult airway/intubation, including intraoperative airway techniques and management and a narrative description of the events. The Anesthesiology Consultant Report raised the standard of documentation during a patient’s initial episode of care in that its detailed airway management documentation was a more accessible part of the patient’s medical record. Care providers were also alerted by a highly visible wristband.¹¹

In 1993 and 2003, the ASA practice guidelines recommended that anesthesiologists document more fully in the medical record and include a description of the nature of the airway difficulties, the various airway management techniques that were employed, and the extent to which each of these techniques was beneficial or detrimental in managing the difficult airway.^1,²

B Documentation in In-House Electronic Medical Records

At the Johns Hopkins Medical Institutions, the 1992 Anesthesia Consultant Report evolved into an Anesthesia Consult form that contained a template and free-text entry as part of the in-house Johns Hopkins computerized medical record. In 1995, at Beth Israel Deaconess Medical Center in Boston, patients’ difficult airway/intubation information was entered into the nurse’s assessment section, and a “difficult airway/intubation” notice was placed in the computerized patient record.³³

At present, the electronic medical record (EMR) is, by definition, limited to a single health system. The University of Michigan Department of Anesthesiology and many other facilities use a perioperative clinical information software system such as Centricity (General Electric Healthcare, Waukesha, WI) to collect difficult airway/intubation information in an airway management record that contains required fields, a drop-down menu, and a comment section for free text. This information is available at bedside workstations throughout the facility, including the floor and intensive care units, as part of the EMR.⁹ Other institutions have developed their own EMR systems for in-house use, with multiple terminals that allow access throughout the hospital.

Recording in the EMR that the patient has a difficult airway or difficult intubation triggers the use of a difficult airway/intubation wristband and an alert on the facesheet similar to that for allergies. A commercially developed or in-house EMR system can ensure that a patient with difficult airway/intubation is recognized as such during the remainder of the hospital stay and subsequent hospital stays.

IV Difficult Airway/Intubation: Dissemination of Critical Information

The communication of successful and unsuccessful airway management techniques consists of documentation at the time of the event and dissemination of that information to future care providers. This section deals with dissemination of that critical information.

A ASA Recommendations for Dissemination of Information

Before the creation of the ASA practice guidelines, there was little or no literature discussing the benefits of patient notification of difficult airway management.⁷ The 1993 ASA practice guidelines recommended that the anesthesiologist inform the patient (or responsible person) of the airway difficulty that was encountered and that notification systems, such as a written report or letter to the patient or communication with the patient’s surgeon or primary caregiver, could be considered.² The 2003 ASA practice guidelines added a recommendation for a bracelet or equivalent identification device that could be kept with the patient at all times.¹

B Dissemination of Information via Paper Medical Records

Traditionally, difficult airway/intubation information was housed in the patient’s paper medical record. Even when this written documentation was adequate, it usually could not be disseminated to care providers during subsequent episodes of care because it was difficult or impossible to retrieve paper-based records from storage, particularly in the event of an emergency.

C Verbal Dissemination of Information

Most anesthesiologists inform the patient of a difficult airway/intubation in the postanesthesia care unit. However, this verbal communication of difficult airway information to the patient is unreliable. Communication can be hindered by the patient’s intubation or by postoperative pain or sedation. Family members present are usually more concerned about the patient’s surgical findings and recovery from anesthesia and surgery.⁷ One study found that 50% of patients informed verbally did not recall or were unsure about ever having had a postoperative conversation with their anesthesiologist.³⁴

Difficult airway/intubation information relayed verbally can be miscommunicated because of patients’ lack of understanding of medical words or because anxiety related to their medical condition prevents them from assimilating this information. In addition, providers may underrepresent the severity of the difficult airway/intubation to allay patients’ anxiety or because of fear of liability exposure. When these patients reenter the health care system, the previous verbal communication about difficult airway/intubation may not be remembered, and they may deny any difficult airway history or relate a vague history. In an emergency situation, patients who are unconscious cannot relate any difficult airway/intubation information they may have been told.

D Dissemination of Information via Letters

Beginning in 1992, the Johns Hopkins Anesthesia Consultant Report (described previously) was distributed by letter to the patient’s surgeon and referring physician.¹¹ In 2000, the Department of Anesthesiology at Mayo Clinic Scottsdale began providing written notification to patients about their difficult airway in the form of letters mailed 1 week postoperatively. However, in a follow-up survey 2 years later, 20% of patients could not recall receiving the letter. To improve communication, the Clinic followed up with a telephone call to confirm receipt of the letter and to emphasize the importance of the difficult airway/intubation. A MedicAlert Foundation brochure was also included in the letter. The survey found that of those patients who remembered receiving a difficult airway/intubation letter, 41% had informed their primary care physician of their difficult airway, and 95% who subsequently had surgery had informed their surgeons or anesthesiologist or both. The survey concluded that the patients were able to inform subsequent care providers that they had a difficult airway even though most of them did not understand how “difficult airway” affected their subsequent anesthesia and airway management.³⁴

More recently, various publications have reiterated the need for some type of standard written notification or airway alert form to be distributed to the patient, the primary care provider, and the surgeon.^7,³⁵

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