A lady in her thirties presented for endoscopic sinus surgery and septoplasty. Preoperative assessment found only a congenitally fused neck vertebra and use of nasal decongestant spray for long-standing sinusitis. Despite a slight restriction in neck movement, there was nothing to suggest a problem with airway management. For example, there was minimal restriction in neck flexion extension and rotation. Mouth opening and thyromental distance were normal, and the Mallampati was Grade II.

An experienced and diligent anesthesia practitioner planned to avoid tracheal intubation by inserting a laryngeal mask airway (LMA). However, following induction with a remifentanil infusion (0.3 mcg·kg⁻¹ min⁻¹) and propofol (200 mg), the LMA could not be inserted. Fifty additional milligrams of propofol were given but repeated attempts (including two different sizes of LMA) were also unsuccessful. By 2 minutes the patient’s oxygen saturation had decreased to 75% and she looked cyanosed. By 5 minutes her oxygen saturation deteriorated to 40%. Administration of 100% oxygen using a face mask and oral airway failed to raise the oxygen saturation, and the heart rate decreased to 40 seconds.

The anesthesiologist then administered atropine and succinylcholine. He attempted tracheal intubation and was joined by a second anesthesia practitioner (who had additional airway training). Laryngoscopy provided only a Cormack and Lehane Grade 3 view (meaning tracheal intubation is likely to be very difficult, if not impossible). Other staff entered the room, including the surgeon. Between attempts at laryngoscopy, patient ventilation was extremely difficult, despite use of a four-handed technique. At no point did anyone announce that this was a “failed airway,” a “can’t intubate, can’t oxygenate” situation, or an “airway emergency.”

Both anesthesiologists made further unsuccessful laryngoscopic intubation attempts. The second anesthesia practitioner attempted tracheal intubation using a flexible bronchoscope but without success, and other staff collected additional equipment including a tracheotomy set. Next the surgeon attempted intubation by direct laryngoscopy with an Eschmann tracheal introducer; he was also unsuccessful. By 20 minutes, an intubating laryngeal mask was inserted which allowed partial ventilation. The patient’s blood pressure and heart rate increased as did the oxygen saturation but not above 90%.

Blind attempts were made to insert a tracheal tube through the intubating laryngeal mask (as the device is intended to work) and then using a flexible bronchoscope. The surgeon failed to pass the scope through the end of the LMA (a recognized problem with this device). After more than 30 minutes, it was decided to abandon the procedure and let the patient wake up. The LMA was removed and an oral airway inserted. Oxygen saturation gradually improved to 95%. The anesthesiologist transferred her to the recovery room and told staff that he expected the patient to wake. Both anesthesia practitioners carried on to their next cases.

While the patient did breathe on her own, her level of consciousness did not improve and her vital signs remained erratic. After at least an additional hour, a third anesthesia practitioner transferred the patient to an intensive care unit (ICU). On ICU admission, it was clear that the patient had marked brain damage. Finally the ICU staff inserted a nasotracheal tube. Her clinical course failed to improve and led to her ultimate removal from the ventilator, and her death from anoxic brain damage.

Why Should We Focus on Human Factors in Medical Crises Such as the Management of Difficult and Failed Airway?

This chapter as well as a subsequent chapter on airway management in the ICU patient (see Chapter 34) offer a basic primer on human factors as they relate to the management of difficult and failed airway. These chapters are important because nontechnical skills likely have the greatest impact upon patient safety and outcome.^1,2 Similarly, inadequate crisis resource management (which includes teamwork, leadership, situational awareness, resource utilization, and communication) appear to be the most common reason for preventable error.^1–6 To illustrate this point, it is worth emphasizing that the above case is not fictional: it is the tragic case of Elaine Bromiley. While it is impossible to say what would have happened if her management had been optimized, there were many things that could have been done better.⁷ Regardless, the team “lost control”⁷ and it contributed to the death of a 37-year-old woman, wife and mother of two. It was the wish of her husband Martin, a pilot and expert in Aviation Human Factors, that she “…not die in vain.” The hope is to offer practical insights from this case for those who manage the difficult and failed airway. In short, the true airway expert should understand that factual knowledge in isolation is rarely enough to rescue the patient-in-peril. It is, therefore, time that our “team dexterity” and “verbal dexterity” matched our manual dexterity.

Can Insights be Learnt from Other High-Stakes Industries and Applied to the Management of Difficult and Failed Airway?

These two chapters, the second specifically focusing on communication (given that it is likely the most important of the nontechnical skills), offer crisis management strategies from other high-stakes professions. While, the idea of directly translating ideas from aviation to medicine can be oversimplified, health care workers ought to be open to usable insights, no matter their origin. This is especially important since health care has been a latecomer to the study of human factors and team dynamics.^1,2 For example, human factors training has been compulsory for pilots since the 1990s. Accordingly, aviation currently offers the most readily available strategies regarding how we can make a “science of reducing complexity,” and a “science of team performance.” The first lesson is that airway management, much like aviation, is increasingly a team sport. Second, teamwork is rarely innate, and therefore should not be left to chance.

The largest aviation disaster (to date) occurred in 1977 when KLM 4805 and Pan Am 1736 collided. Investigators concluded that it was wholly preventable, and occurred largely because cockpit crews had “failed to take the time to become a team.”¹ Eerily similar is the clinical case presented above.⁷ As pointed out at the Bromiley inquest, she likely died not just because of difficulty intubating, but because her team “lost control.” Of note, the inquest concluded that there was nothing lacking in the staffing, training, facilities, preoperative assessment, anesthetic choice, the initial use of an LMA, or with tracheal intubation once the LMA failed. What was found was that despite being senior anesthesia practitioners and nurses, they failed to identify (and verbalize) that they had a failed airway; they failed to expedite appropriate alternatives strategies, and they failed to sound the alarm. Ultimately, it was the patient (and her husband and children) who paid the price. Much like the KLM flight investigators summarized: it might have been “preventable…if they had taken time to become a team.”¹

Teamwork is commonly defined as “cooperative efforts to achieve a common goal.” It is more than simply subordinates obeying an “all-knowing leader.”² Instead, it is about maximizing mental and physical problem-solving capabilities, such that the sum exceeds the parts.² Moreover, task demands (rescuing the patient) and social demands (running the team) work in parallel. This means that airway experts must manage both.^2,8 Leaders need strategies to turn individuals into team players, and this starts with accepting that individuals will not share their abilities unless they feel “safe” to do so.² This does not mean that we no longer need hierarchy and leadership, but does mean we cannot create the teams that we want unless we create the culture that we need.⁸

Culture is complex. However, it includes the knowledge, beliefs, customs, and habits of a group, and it powerfully influences behaviors, attitudes, and action.⁸ Culture cannot be forced and takes time to develop. Moreover, culture typically matters more than the latest greatest study: “culture eats data for breakfast.” All these observations mean that true airway experts invest time in building a culture of safety before the airway disaster occurs. To do so requires that they understand the pros and cons of our medical culture. For example, acute care medicine has a laudable culture of patient-ownership and self-reliance. However, like the western culture it mirrors, we typically focus on the individual agenda rather than the cohesion of the team.² Similarly, we typically presume that success results from individual efforts (and failure from individual shortcomings), rather than the team, environment, or culture.² This also means that we do not naturally ask for help, or naturally offer help, and that we commonly blame individuals not systems.^2–6,9 All these need to change.

One of the most common team failings is the inability to optimize resource utilization including personnel. This matters because airway management requires a coordinated combination of skills, opinions, medications, and technologies. More specifically, low functioning teams are less likely to assign roles and responsibilities; to hold team members to account; to articulate a position or a corrective action; to use check-backs, for example, “closed-loop communication” (see Chapter 34); to seek usable information as opposed to just “data”; to prioritize tasks; and to cross-monitor other team members.² In short, airway experts realize that a “team of experts is not an expert team” (see Table 6–1).²