Difficult Airway Guidelines

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Definitions

1. Difficult Airway: An airway requiring procedures beyond those used in routine management (e.g. standard bag mask ventilation and direct laryngoscopy). These procedures can be associated with the following clinical situations:
   1. Difficult or impossible face mask ventilation: It is not possible for practitioner to provide adequate face mask oxygenation due to one or more of the following problems: inadequate mask seal, excessive gas leak, active emesis/bleeding, or excessive resistance to the ingress or egress of gas.
   2. Difficult Laryngoscopy: It is not possible to visualize any portion of the glottis after more than two attempts at conventional laryngoscopy, including those performed by experienced providers.
   3. Difficult or failed tracheal intubation: Tracheal intubation is not possible or requires specific or extraordinary measures due to upper airway pathology, tracheal pathology, surgical changes, radiation changes, or anatomical anomalies.
2. Risk Factors and Considerations for Difficult Airway:
   1. Historical factors
   2. History of difficult mask ventilation (Grade 3 or 4)
   3. History of difficult laryngoscopy (Grade 2b or 3 view).
   4. History of difficult (T2) or failed (T3) endotracheal tube passage
   5. Existing tracheostomy
   6. Oral, pharyngeal, laryngeal, or tracheal surgery that requires special airway management
   7. Oral, pharyngeal, laryngeal, or tracheal abnormality
3. Physical Assessment
   1. Limited neck movement, e.g., unable to look up at ceiling from seated position (including immobilization such as halo traction, cervical collar or otherwise physically limited)
   2. Known or possible unstable cervical spine
   3. Small mouth opening (less than 3 cm adults, clinician’s assessment in pediatrics)
   4. Inability to see the patient's uvula with the (patient's) mouth open, or tongue fully protruded (Mallampati 3 or 4)
   5. History of neck radiation therapy
   6. Inability to protrude mandible and lower incisors beyond upper incisors
   7. Thyromental distance < 6cm (adults)
   8. Tracheal deviation
   9. History of new or previous tracheostomy
4. Routine Airway Assessment: Part of the history and physical on all patients undergoing anesthesia or sedation. Also part of history and physical for all admitted patients at risk for requiring airway management for oxygenation and/or ventilatory support based upon presentation. Information collected is pertinent to the specific patient and includes the identification of any risk factors for difficulty as identified in III.B
5. Routine Airway Assessment for anesthesia or sedation: Completed on any patient requiring anesthesia, or sedation analgesia (other than topical analgesia) for diagnostic, therapeutic and minor or major surgical procedures and includes the identification of any risk factors for difficult airway as identified in III.B. (The routine airway assessment for sedation is outlined in Guidelines for the Use of Sedation Analgesia for Diagnostic, Therapeutic and Minor Surgical Procedures.
6. Difficult Airway Note: Completed on any admitted patient who is identified as a difficult airway. The Difficult Airway assessment may be conducted by the following clinical services, either adult or pediatric - Anesthesiology, Critical Care Service*, Emergency Medicine, Plastic Surgery, Oral Maxillofacial Surgery, or Otolaryngology.

* Critical Care Service: A physician service that provides the critical care management of patients who are in an intensive care unit. Examples include but are not limited to, Pediatric Surgery Critical Care, Pediatric Critical Care Medicine, Adult Surgery Critical Care, Adult Emergency Critical Care, Adult Neurocritical Care and Adult Critical Care Medicine.

Guideline Standards

1. A routine airway assessment will be conducted on all admitted patients at risk for requiring airway management for oxygenation and/or ventilatory support based upon presentation, by the primary or consult team as part of the history and physical.
2. A routine airway assessment will be conducted on all patients scheduled to undergo anesthesia by anesthesiology.
3. A routine airway assessment for moderate sedation will be conducted in accordance with Guidelines for the Use of Sedation Analgesia for Diagnostic, Therapeutic and Minor Surgical Procedures.
4. Patients who are on Difficult Airway Precautions shall be transported in accordance with Intra-Hospital Transportation and Hand-Off of Patient Care to Any Temporary Clinical Setting.
5. As with all extubations in critical care areas, at the time of extubation of a patient identified with a Difficult Airway, a time-out is called by Respiratory Care and the Primary Patient Care Team to assure that all necessary clinical personnel and specialty equipment are present at the bedside.
   1. Prior to extubation, the intubated adult ICU patient with risk factors will be assessed using the Extubation for Adults
   2. For PICU patients admitted and intubated with a difficult airway designation:
      • At the time of admission, the pediatric critical care team will discuss with the relevant subspecialists the plan for extubation which will include, at a minimum:
        1. Specialty services needed at the time of extubation,
        2. Equipment needed at the time of extubation (i.e. location of difficult airway cart and confirmation that any equipment necessary that is not on the difficult airway cart is brought to the bedside),
        3. Estimated time/date of extubation,
        4. Potential need for extubation in the operating room.
      • This plan will be re-evaluated and discussed with the relevant specialty services either the evening before or the morning of the planned extubation.
6. Upon re-admission:
   1. For all admitted pediatric patients, the service that last evaluated, managed, and documented the patient to have a difficult airway will be notified to review and revise the prior difficult airway note. These specialty services are listed in III.E. Appropriate updates can then be made to the difficult airway note, order set, and documentation.
   2. For all admitted adult patients at risk for requiring airway management for oxygenation and/or ventilatory support based upon presentation, with difficult airways documented by head and neck surgical services (otolaryngology, oral and maxillofacial surgery, plastic surgery) the service that last evaluated, managed, and documented the patient to have a difficult airway will be notified to review and revise the prior difficult airway documentation.
   3. For all admitted adult patients with documented difficult airways at risk for requiring airway management, if the service caring for the patient is not the service who last updated/placed the difficult airway documentation or desires further evaluation, then they can electively consult the difficult airway team (one of the services previously designated in Section III.E.) to review the patient’s history and airway evaluation and revise the prior difficult airway documentation.

Procedure/Actions

1. A routine airway assessment for patients at risk for requiring airway management for oxygenation and/or ventilatory support based upon presentation, as part of the admission history and physical is completed and documented by the patient’s primary or consult service (one of the services designated in Section III.E) and will include the identification of any risk factors for difficult airway.
2. A routine airway assessment for anesthesia or sedation is completed and documented on all patients scheduled to undergo anesthesia or sedation and will include the identification of any risk factors for a difficult airway.
3. Patients who are found to have determined risk factors for a Difficult Airway, should be placed on Difficult Airway Precautions unless the risk factors are not clinically pertinent.
4. If a Difficult Airway is identified or if a patient has a known Difficult Airway, then the clinical service (primary or consult) physically involved with the airway manipulation event that resulted in the difficult airway designation (See E III above) will:
   1. Complete the Difficult Airway Order Set (via Difficult Airway Navigator) and
   2. Document the Difficult Airway Assessment (via Difficult Airway Navigator) in the electronic health record using the “Difficult Airway Note” document type in MiChart. **
   3. For all patients, the difficult airway note will auto-populate the Difficult Airway Sign that will be printed and placed at the patient’s bedside. This will be completed through the Difficult Airway Navigator.
   4. A flag will be created as an FYI (or alternate EHR based flagging system) that will link any reader of the flag to the difficult airway note.

**The Difficult Airway Note shall include the likelihood and anticipated clinical impact of three basic problems (a-c below). These may occur alone or in combination with additional items below, (d-i) below:

1. Difficult or impossible face mask ventilation
2. Difficult Laryngoscopy (Grade View)
3. Difficult (T2) or impossible (T3) tube passage.
4. Pre-formulated plan specific to patient for oxygenation, ventilation, and intubation
5. Ventilation technique (mask, LMA, etc.)
6. Technique for visualizing the airway (endoscopic intubation, video-laryngoscopy, etc.)
7. Visual description and/or drawing or photograph of patient’s anatomy if applicable
8. List of equipment that should be readily available, e.g., ETT size, ETT type, and type of laryngoscope blade (design, size,), need for endoscope, video-laryngoscope, wire cutters, wrench, emergency tracheotomy kit, cricothyroidotomy kit, etc.

Difficult Airway status shall be communicated in the following manner:

1. Using the Difficult Airway Assessment template in the EMR (via Difficult Airway Navigator) as described in “III D” above that then is described in the Difficult Airway Note. An FYI in MiChart will include a hyperlink to this note.
2. Ordering the Difficult Airway Order Set
3. Displaying Bedside Signage to be posted at the head of the bed:
   1. Difficult Airway Sign indicating emergency contact information (Currently Exhibit A; Changing to Exhibit E). Through the Difficult Airway Navigator, entries will auto-populate a Difficult Airway Sign that will be placed on the wall by the patient bedside. (Exhibits D and E)
   2. A copy of the Difficult Airway Note document printed from the EMR when available.
4. Intra-hospital Hand-off Form as appropriate.

Emergency airway management notification:

1. STAT page 
2. Ask the paging operator to page the Difficult Airway Team
   1. For adult patients: This includes the Anesthesia Airway Management Team and Otolaryngology Acute Airway Team 
   2. For pediatric patients: Anesthesia Pediatric Airway Management Team and Otolaryngology Pediatric Acute Airway Team 
3. Answer the paging operators questions when asked (adult or pediatric, location)

Patients who are considered to have a difficult airway shall be transported in accordance with the Intra-Hospital Transportation and Hand-Off of Patient Care to Any Temporary Clinical Setting. Refer to IV D above. The patient will be transported with the following materials:

1. Difficult Airway Sign placed in a readily visible location
2. Any equipment as identified in the Difficult Airway Assessment
   1. Patients presenting with a past history of Difficult Airway and documented Difficult Airway Note should again have an airway assessment completed upon any re-admission. Refer to Section IV F above for details.
   2. Refer to IV. E for extubation planning for intubated difficult airway patients.