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A I R W A Y M A N A G E M E N T STANDARDIZING PRACTICE Defining the Difficult Airway W hat's a "difficult airway" anyway? Although there's no formal, standard definition, the American Society for CONSENSUS DESCRIPTION The ASA task force has provided a way to define and describe difficult airways in patient documentation. Anesthesiologists Task Force on the Difficult Airway sought to create one based on the literature and a consensus involving consultants, experts and members practicing nationwide. This process devised a streamlined definition: "The clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both." The task force suggests further describing a LIGHT THE WAY Difficult airway carts should include a variety of equipment, including a rigid fiber-optic laryngoscope and flexible fiber-optic intubating equipment. Take No C Airway difficult airway in case documentation these ways: 1. Difficult facemask or supraglottic airway (SGA) ventilation. This includes situations in which, despite use of a laryngeal mask airway, intubating LMA and laryngeal tube, the anesthesia provider can't provide adequate ventilation. Issues may include one or more of the following: inadequate mask or an you always predict a SGA seal, excessive gas leak, or excessive resistance to the ingress or egress of gas. Physical signs difficult airway? No, and include the following: absent or inadequate chest movement, absent or inadequate breath sounds, aus- that's why the new cultatory signs of severe obstruction, cyanosis, gastric air entry or dilatation, decreasing or inadequate American Society of Anesthesiologists Task Force on For Granted oxygen saturation (SpO2), absent or inadequate exhaled carbon dioxide, absent or inadequate spirometric measures of exhaled gas flow, and hemodynamic changes associated with hypoxemia or hypercar- the Difficult Airway guidelines bia (hypertension, tachycardia, and arrhythmia, for example). are so important. The upshot of 2. Difficult SGA placement. SGA placement requires multiple attempts, in the presence or absence of the soon-to-be-published document: Never get caught off-guard by a challenging intubatracheal pathology. tion. Here's what you need to know about assessing, recognizing and managing the dan- 3. Difficult laryngoscopy. It's not possible to visualize any portion of the vocal cords after multiple gers inherent in difficult airways. attempts at conventional laryngoscopy. Recognize red flags You can think of some airways as being predictably difficult some of the time: patients 4. Difficult tracheal intubation. Multiple attempts are required, whether or not tracheal pathology is present. 5. Failed intubation. Endotracheal tube placement fails after multiple attempts. who've had airway issues in the past or those with severe or untreated sleep apnea, pre- 8 SUPPLEMENT TO O U T PAT I E N T S U R G E R Y M A G A Z I N E | J A N U A R Y 2013 — Robert Caplan, MD J A N U A R Y 2013 | S U P P L E M E N T TO O U T PAT I E N T S U R G E R Y M A G A Z I N E 9