Chapter 54. Unique Challenges of Ectopic Airway Management

A 42-year-old obese man is undergoing renal dialysis in a hospital dialysis unit when he suddenly suffers a cardiac arrest. He is diabetic with a history of cerebrovascular disease, peripheral vascular disease, and angina. He is a nonsmoker. He had no premonitory symptoms.

You are called to manage his airway. When you arrive on the scene from your unit, you see a cyanotic male looking older than his stated age, reclining at 45 degrees in a dialysis chair. He is still connected to a dialysis machine via a vascular shunt in his left arm. The head of the chair, which is not on wheels, is against the wall. A dialysis technician is straddling the patient performing cardiopulmonary resuscitation and a nurse is delivering ineffective bag-mask-ventilation (BMV) from the right side of the patient. You are informed that he receives dialysis three times a week. His dry weight is 414 lb (188 kg).

The crash cart has arrived, containing both oral and nasal airways, endotracheal tubes, a laryngoscope handle, and #3 and #4 Macintosh blades. There is an intubating stylet as well. This is the third time this year you have been called to this unit. Unfortunately, the equipment you prefer to use for airway management is never available in the dialysis unit, despite continuous reminders that you prefer a Miller blade.

54.2.1 What Is Meant by the Term "Ectopic Airway Management"?

Anesthesia practitioners, emergency physicians, intensivists, hospitalists, and other health care providers with airway management expertise often become involved in emergency and urgent airway management outside of their usual operating milieu. This is referred to as "ectopic" airway management.

54.2.2 What Are the Common Examples of Ectopic Venues?

There are several areas of a hospital where it should be anticipated that emergency airway management will be required occasionally, or even perhaps regularly. These include but are not exclusive to:

• Post-anesthetic care unit (PACU)
• Diagnostic imaging locations where emergency and intensive care unit (ICU) patients are taken; particularly CT, MRI, ultrasound, and angiography units
• Units where procedural sedation is undertaken:
  • Endoscopy
  • Invasive cardiology
  • Interventional imaging
  • Pediatric clinics, such as dentistry, ophthalmology, EEG, ENT, and others
  • Lithotripsy
  • Cardiac stress testing facilities
  • Medical and surgical inpatient units
  • Obstetrical delivery suites

Outpatient clinics, medical offices, and non-patient care areas (eg, cafeterias, residences, waiting rooms, administrative offices, and the areas immediately external to the health care facility) are occasionally the site of an airway emergency.

54.3.1 What Issues Are the Unique Challenges of Ectopic Airway Management?

Managing a difficult airway is always anxiety provoking and somewhat dysphoric. Most ectopic airway management is difficult for a variety of reasons: some are related to the patient's airway anatomy; others to the patient's condition; and some are unique to the situation. The result is performance anxiety that may lead to less than optimal performance. Consider the following unique challenges inherent in managing the ectopic airway:

• Medicolegal risk
• Consistency of airway kits/carts
• Unfamiliar environment
• Unknown patient medical conditions
• Assistants unfamiliar with airway management
• Emotionally charged environment; stressed response
• Postintubation management

54.3.2 What Are the Medicolegal Risks Associated with Ectopic Airway Management?

Ectopic airway management is associated with an element of medicolegal risk in the event of a poor outcome. Peterson et al published an update of the Management of the Difficult Airway: A Closed Claims Analysis in 2005. Out of 179 claims for difficult airway management, 86 (48%) were from events occurring from 1985 to 1992 and 93 (52%) were from events occurring from 1993 to 1999. The majority of claims for difficult airway management (156 out of 179 or 87%) involved perioperative care and 23 claims (13%) involved ectopic locations. Out of these 23 cases of airway management misadventures outside the operating room environment, 25% involved endotracheal tube change, and nearly half were not related to surgical procedures. Reintubation on the ward or ICU some time after a surgical procedure was related to neck swelling with respiratory distress. The procedures included cervical fusion (n = 3), total thyroidectomy (n = 1), intraoral/pharyngeal procedures (n = 2), and fluid extravasation from a central catheter (n = 1).1

The typical scenario coming to litigation has the following features:

• The patient is unknown to the airway practitioner.
• It is an emergency situation:
  • Which is emotionally charged and chaotic
  • In which events preceding the airway emergency are unclear
  • In which the amount of information about the patient is limited
  • In which action is needed immediately
  • With a difficult airway (eg, post-thyroidectomy in PACU; patient in a halo jacket)
  • In which evaluation of the airway for difficulty is inadequate
  • In which paralytic agents are inappropriately given
  • In which the management strategy is poorly thought out and executed, leading to a failed airway

The fact that the airway practitioner is thrust into an emotionally charged and unfamiliar environment provides little if any legal protection or indemnification. Furthermore, the defense of lack of familiarity or lack of desired equipment may be discredited. This is particularly so if it can be established that emergency airway management is expected to occur from time to time in that unit and that the individual charged with airway management in such situations (ie, you) knew or ought to have known that they might be summoned to do so.

Part of the solution to this problem is to prevent failure by establishing policies and procedures with respect to the availability of airway management equipment and its maintenance in areas where it is predictable that emergency or urgent airway intervention will occasionally be required. This requires that the disciplines involved take ownership of this issue and communicate with each other, and among themselves, about the specifics of such policies that will ensure safe, and hopefully litigation free, ectopic airway management.

54.3.3 What Airway Equipment or Carts Should Be Available in These Ectopic Facilities?

Airways are managed virtually every day in the operating rooms, emergency departments, and ICUs of most hospitals. These units ordinarily assemble routine and rescue airway management equipment into varying configurations of storage units where they are checked regularly (eg, daily or with shift change) for availability and function, and are easily accessed in an emergency. Routine and difficult/failed airway equipment may be arranged in separate drawers in the storage areas of the same cart (eg, emergency departments and ICUs); or sometimes in different carts (eg, the operating room's difficult airway cart, see Chapter 59 for details). The literature, albeit limited, provides little guidance as to what ought to be stocked in these carts, or alternatively in a carry out kit that the practitioner takes along to an airway management event.2-6

The equipment on the carts is typically determined by the consensus among the practitioners or staff who respond to manage an airway emergency in these units. The equipment should be arranged in a consistent fashion such that the drawers always contain the same airway equipment. This site-to-site consistency is particularly important when large specialty groups cover several facilities. Such consistency will likely avoid wasting valuable time to find the proper airway equipment in an emergency situation. Chapter 59 addresses the policy and content aspects of difficult airway carts in operating suites, emergency departments, and ICUs. It also serves as a resource for contacting equipment manufacturers and suppliers.

In areas of the hospital where airway management may be required on a regular basis, or patients are placed at risk for respiratory failure (see discussed earlier), it is recommended that routine and rescue airway management equipment be immediately available. Furthermore, the storage of this equipment should be consistent from area to area, and the equipment should be checked for inventory and function daily.

Carry out emergency airway satchels that can be quickly retrieved and carried to the site of an airway emergency are used by some practitioners and departments. The same issues arise with these kits as with permanent on-site carts, including:

• It is in a location that is less than familiar to the airway practitioner.
• The same issues arise with these kits as with permanent on-site carts such as:
  • Consistent location of kits to permit rapid retrieval
  • Contain both routine and rescue devices
  • Organized consistently to permit rapid access to the desired equipment
  • Regular inspections to ensure that the kits are complete and replenished after each use
  • Daily inspections of each kit to ensure proper function of all devices

Some areas may have unique needs that require special equipment. The most common example is an area serving pediatric patients. Some areas of a health care facility may see this population from time to time, while others may not.

54.3.4 What Are the Challenges Associated with Managing the Airway in the Ectopic Environment?

Leaving the comfort of one's usual environment and venturing into unfamiliar territory should not hinder appropriate airway management. Practitioners who may be summoned to ectopic areas to manage airways should familiarize themselves with the staff, the equipment, and the storage systems before the emergency arises. Participating in the decisions as to what is stored, where it is stored, and how it is maintained (ie, policy) is only reasonable.

The scene on arrival is generally chaotic, emotionally charged, and boisterous. As there are substantial expectations placed on the responding airway practitioner, it is critical that the airway practitioner does not participate in or inflame the chaos, which fosters bad airway management decisions.

54.3.5 Why Is Airway Management in an Ectopic Location More Challenging?

Patients requiring airway management in these ectopic locations are generally not known to the airway practitioners. Most of these patients are not prepared for airway management (eg, often have a full stomach with a higher risk of gastric regurgitation and aspiration). Furthermore, airway assessment is often hurried and incomplete. Thus, the formulation of a rational and well thought out airway management plan is unlikely. As indicated previously, the single most important factor leading to a failed airway is failure to properly assess a patient and predict a difficult airway.1,7,8 Consequently, it is more common to encounter a difficult airway in an ectopic environment.

54.3.6 What Are the Challenges Faced by the Practitioners Managing These Patients' Airways in Ectopic Locations?

Emergency airway management presenting in PACU (eg, post-thyroidectomy bleed) may be quite different from those occurring in the CT scanner (eg, pediatric patients). Airway practitioners have varying skills and few are expert at managing all types of situations.

In addition, unlike the situation in the operating room, PACU, ICU, or emergency department, airway management assistants in these ectopic locations may be unfamiliar with even the basic needs of the airway practitioner. Maneuvers, such as cricoid pressure, external laryngeal manipulation (BURP), head lift, or even passing the endotracheal tube correctly to the airway practitioner, may not be fully understood.

To minimize these difficulties, institutions should provide basic training to both airway practitioners and assistants to manage the airways of patients that present in various ectopic locations.

54.3.7 How Should the Airway Be Managed in Ectopic Locations?

The following simple rules of engagement may be helpful:

• Remain calm and take control of the scene.
• Speak firmly and give clear instructions to assistants without shouting.
• Consider titration of intravenous haloperidol and/or ketamine (not succinylcholine) if the patient's behavior hinders adequate management of ventilation and oxygenation.
• If patient behavior management is not an issue, managing oxygenation and ventilation or gas exchange must be achieved quickly:
  • Move to the head of the patient and establish ventilation and oxygenation.
  • Establish airway patency.
  • Take over BMV and avoid aggressive ventilation (ie, avoid high-frequency, large tidal volume, and high airway pressure).
  • Insert an oral airway and two nasal trumpets if needed.
  • If this fails, inserting an LMA is reasonable.
  • Gather your wits and composure as you establish adequate gas exchange.
• While maintaining gas exchange, it is important to evaluate the airway and formulate a plan.
  • Formally evaluate the airway using the mnemonics described in Chapter 1 (eg, with MOANS, LEMON, RODS, SHORT).
  • Identify Plans A, B, and C; assemble the required equipment and drugs.
  • Avoid muscle paralysis if the ability to maintain ventilation or gas exchange is uncertain.
  • Optimize conditions—invest time to properly position the patient at the head of the bed, elevate the bed to the proper height, and place the patient's head and neck in the appropriate (eg, sniffing) position.
  • Execute the plan in a deliberate and a controlled manner.

When faced with inadequate equipment (or skills) in an ectopic location, it is important to think of alternatives:

• Call for assistance if available. A colleague or an assistant can contribute with suggestions, expertise, and more importantly, moral support.
• Does the patient really need tracheal intubation right now or will a BMV or an extraglottic device (eg, LMA) suffice until additional equipment or expertise arrives?
• Are there any other options (eg, blind nasal intubation)?

Finally, Mort compared the outcomes of patients undergoing emergency tracheal intubation in his institution before and after the application of the American Society of Anesthesiologists (ASA) guidelines.9 The rate of cardiac arrest during emergency intubation was reduced by 50%.

54.4.1 What Should Be Done Following Tracheal Intubation in Ectopic Locations?

While confirmation of tracheal intubation is critical following intubation, proper equipment (capnography or an esophageal detection device [EDD] self-inflating bulb) may not be available. This important equipment, together with hemodynamic monitors such as a BP cuff and pulse oximetry, should be called for if they are not available. Ensure that the airway device (eg, ETT, LMA) is secured properly. Longer-term neuromuscular blockade may be necessary to facilitate mechanical ventilation and ensure that the patient does not self-extubate. Ensure that appropriate mechanical ventilation parameters are established if indicated.

Following airway management in these unusual environments, it is essential to document the following elements:

• Any evaluation that indicates that the airway might be difficult
• Ensure that the resuscitation record or nurses' notes accurately record the time you were summoned, arrived, completed key interventions, etc.
• Ensure that drug doses are accurately recorded
• Document the airway management, and the intratracheal verification methods employed (end-tidal carbon dioxide detection is the standard of care)

To minimize the risk, adverse outcome, and the anxiety associated with airway management of patients in an ectopic environment, it is important to:

• Participate in crafting hospital and departmental policies regarding airway management equipment in areas where you are called to manage them (see Chapter 59).
• Familiarize yourself with different hospital units and their staff
• Minimize the chaos
• Assess the airway and formulate airway strategies quickly
• Call for assistance early
• Avoid paralyzing the patient if the ability to artificially maintain post-paralysis gas exchange is uncertain
• Document the airway management episode