CHAPTER 62: Difficult Airway Carts

INTRODUCTION

Why Are Difficult Airway Carts Necessary?

The concept of difficult and failed airway carts is not a novel one. These carts usually serve two purposes:

• Managing the anticipated difficult airway. As such they contain special devices (e.g., atomizers, Jackson Crossover forceps) and medications (e.g., lidocaine 5% ointment, lidocaine 4% aqueous) used to perform an awake intubation (see Chapter 3).

• Managing the failed airway. To this end they have devices (e.g., extraglottic devices [EGDs]) and prepackaged kits (e.g., open cricothyrotomy) used to manage the failed airway in an emergency.

Ordinarily, a single “airway” cart serves both functions and the contents do not vary significantly from unit to unit, except perhaps in regard to pediatrics where size-related variations must be accounted for. The equipment, supplies, devices, and medications that they contain ordinarily are not otherwise immediately available on the majority of clinical units. For example, the difficult airway cart for the operating room (OR) rarely contains endotracheal tubes (ETTs), laryngoscopes, and stylets, as they are in every OR. On the other hand, in the post-anesthesia care unit (PACU), the critical care unit (CCU), and the emergency department (ED) difficult airway carts may well have these devices in the cart.

It has long been acknowledged that having emergency equipment readily available in a reliable location is a standard of care. The “cardiac crash cart,” for example, is a mandatory addition to ORs, EDs, and other patient care areas where they may be required. Many labor and delivery rooms have an “emergency cart” ready for unanticipated “crash” cesarean sections, while trauma units have an emergency surgical setup for occasions when a chest or abdomen must be rapidly opened.

Although the literature is relatively silent on the actual benefits of having a difficult airway cart available for an emergency, there is strong consensus among experts that the ready access to alternative devices for airway management has the potential for reducing risks and complications in the management of the unanticipated difficult airway.^1-3 In 1993, the American Society of Anesthesiologists Task Force on Management of the Difficult Airway published their Practice Guidelines for Management of the Difficult Airway.¹ This document, subsequently updated in 2003 and 2013, contained a clear statement that “at least one portable storage unit that contains specialized equipment for difficult airway management should be readily available.”^2,4 They followed with a suggested list of specialized equipment that this “storage unit,” or cart, should contain (Table 62–1).