59.1.1 Why Are Difficult Airway Carts Necessary?
The concept of emergency difficult airway carts is not a novel one. 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 operating rooms (OR), emergency departments (ED), 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 silent on the actual benefits of having an emergency airway cart available, 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, contained a clear statement that "at least one portable storage unit that contains specialized equipment for difficult airway management should be readily available."2 They followed with a suggested list of specialized equipment that this storage unit, or cart, should contain.
Beyond the scope of the original ASA guidelines, Crosby and a group of consultants reviewed the pertinent literature on airway management in Canada and published recommendations for the management of the unanticipated difficult airway.3 This group recommended that a difficult airway cart be available for emergency airway interventions in addition to the standard airway equipment available in every OR. They also suggested a minimum equipment list for such a cart.
59.1.2 Is There Any Evidence that Airway Carts Are Beneficial in the Setting of Difficult or Failed Airway Management?
The literature is replete with the advantages of using alternative airway devices in situations where a difficult airway is encountered, both expected and unanticipated. Just as emergency drugs and the presence of a defibrillator on the crash cart are indispensable in the management of a cardiac emergency, the readily available rescue airway devices in an airway emergency clearly represent an improvement in patient care.
The increase in morbidity and mortality associated with difficulties in airway management is well recognized.4,5 Both the ASA and Canadian groups recommend limiting the number of attempts at direct laryngoscopy to three and two, respectively.1-3 Mort has shown that the increasing number of attempts at intubation by direct laryngoscopy correlates with an increased incidence of respiratory and hemodynamic complications.6 In this study, a database was created to record complications following emergency airway interventions outside the OR. When three or more attempts were made to secure an airway by direct laryngoscopy, the incidence of hypoxemia ...