When the flight attendant calls for a physician, the cabin crew is relieved when an anesthesiologist shows up. We readily manage common events such as nausea and vomiting, but we are equally facile with acute life-threatening events such as heart attacks, loss of consciousness, and anaphylaxis. By far, our most important skill in any emergency is that we can manage an airway.
An hour out of London, I responded to “is there a doctor on board?” A post-ictal passenger was turning dark blue. A simple jaw lift opened the airway. I added a little oxygen. In a minute the passenger became pink. The next minute he awoke from his post-ictal stupor. (A minute later he threw up on me; no good deed goes unpunished.)
By the end of training, newly minted anesthesiologists are highly proficient at managing airways. They have seen thousands of easy airways. They have also seen dozens, or perhaps hundreds, of deeply treacherous airways. Intense residency training appropriately leads to confidence in airway management. However, are they perhaps too confident? Have they seen everything there is to see?
The Nobel prize winning psychologist Daniel Kahneman talks about the cognitive bias “what you see is all there is.” It is easy to conclude from our training and experience that we have seen all the airway challenges that exist. That’s what I thought. Having practiced anesthesiology for decades, I believed I had seen pretty much everything.
My self-confidence was quickly shattered by the fourth edition of Hung’s Difficult and Failed Airway Management. In 67 concisely written and well-referenced chapters, the authors introduce aspects of airway management I had never even considered. Chapters on unusual scenarios comprise a little shop of airway horrors: blunt anterior neck trauma, deadly asthma, penetrating facial trauma, deep neck infection, obstructive sleep apnea with goiter. Have you been called to the ICU for a patient in a halo jacket who has bitten his wire-reinforced endotracheal tube? What will you do for an unconscious motorist with a compromised airway trapped in an overturned motor vehicle, or a motorcyclist with a full helmet and severe head injury. When did you last encounter the “cannot intubate/cannot oxygenate” scenario in an infant? The list goes on and on. This is the stuff of anesthesiologists’ nightmares.
Nearly all of these are accompanied by case scenarios. The prone airway scenario starts “A 35-year-old intoxicated male 179 cm tall and weighing 110 kg (BMI 34 kg·m−2) presents to the emergency room with a 12-inch hunting knife lodged in his upper thoracic spine after an altercation at a cottage party” What the hell happens in Halifax?
The book is also an endless string of pearls. Using scenarios to capture the reader’s interest and harness his or her clinical imagination, the chapters offer practical, evidence-based advice. Consider the patient with the 12-inch hunting knife in his upper thoracic spine. The patient needs to be in the prone position, so you would likely consider face-mask ventilation or the use of an extraglottic device. But, what about tracheal intubation? It would be challenging. Would you have considered positioning two operating room tables side by side? With two tables placed side by side, the patient can be supine with the knife in the gap between the tables, permitting management of a supine patient airway. Alternatively, you might place the patient prone but advance the body caudad until the head is fully supported by an assistant. In this position the table can be placed in full reverse Trendelenburg, elevating the head so you can face the patient directly to facilitate fiberoptic intubation.
I have no way of knowing if reading this book will change clinical outcomes. However, I believe the author’s use of case scenario → background information → tips and tricks → case resolution → knowledge assessment questions represents state-of-the-art written didactic teaching. The vivid cases are readily envisioned, such as the patient with the 12-inch hunting knife. The stress of the anesthesiologist is palpable. Wrapping these envisioned cases with strings of clinical pearls commits the tips and tricks to memory. That is why anesthesiologists should read the book now, before they encounter these cases in real life. There is no time to look up a reference in the intensely focused seconds of airway compromise. But, there is time to call for help, of course, which the authors repeatedly identify as the first step in managing a difficult airway.
The authors also present the most recent advances in airway management. For example, I was completely unfamiliar with the rapid deployment of ECMO in anticipated difficult or impossible airways, or the use of ECMO in the ER where a difficult airway might arrive any second by ambulance. This is a huge advance! The authors also discuss the use of artificial intelligence, including the development of new airway management devices that use AI image recognition to facilitate tracheal intubation.
During my residency in the early 1980s, the “best anesthesiologist” at University of Pennsylvania was the one who could shove a 7.0-mm ID endotracheal tube into any trachea using a MAC-3 blade. We were in awe of these masters. However, they had nothing on modern anesthesiologists. We come to the operating room armed with video laryngoscopes, an array of extraglottic devices, novel fiberoptic or chip-guided scopes, and high-flow nasal cannulae. Our everyday skills are far beyond yesteryear’s masters of MAC-3 intubation.
Hung’s Difficult and Failed Airway Management shows that our everyday airway skills pale in comparison to our potential. It’s a masterful textbook, beautifully conceived, well organized, clearly written, extensively referenced, and utterly relevant to our most important task as anesthesiologists.
On a personal note, Dr. Orlando Hung was one of my first fellows at Stanford. Orlando and his family have remained close personal friends. He trained at Stanford in Clinical Pharmacology (and the pharmacology section of the textbook is excellent). What research mentors want for their mentees, and what friends want for their friends, is to make a difference in the world. This book fills me with joy and pride, because my mentee and friend continues to make profound contributions to the well-being, and survival, of the patients we serve.
Steven L. Shafer, MD
Professor Emeritus of Anesthesiology, Perioperative and Pain Medicine
Editor-in-Chief of Anesthesia & Analgesia (2006–2016)