Foreword

Although the practice of anesthesia professionals and others who do airway management is full of unexpected challenges, perhaps nothing strikes more fear in our hearts than a patient with a difficult airway. Unlike other events, which may be limited to certain narrow sub-specialties, challenging airway management occurs across nearly all domains of patient care, all patient ages, and many sites of care such as perioperative, emergency department, ward settings, as well as in unusual sites such as pre-hospital or combat casualty care. Hence, books such as this are vital as contextual compilations of up-to-date information on approaches and techniques for the myriad needs of patients for oxygenation and ventilation. Most simply put, the most fundamental goal of airway management is to accomplish what for most patients is routine, but for some is so elusive, which is—as one of my supervising attending and later faculty colleague (Mervyn Maze) put it years ago, to “get some green gas in the right hole [U.S. oxygen color code is green].” This spirit is exemplified in the modern evolution from the notion of “can’t intubate, can’t ventilate” to “can’t intubate, can’t oxygenate” emphasizing that oxygenation comes first with ventilation as important, but still secondary.

As noted in the Preface, the third edition of this book contains some important new information and new chapters. I am particularly pleased by the addition of a chapter on human factors and airway management. Over the last few decades we have collectively recognized that all the clinical knowledge or technical dexterity in the world can come to no avail without appropriate design and use of equipment, systems, processes, and teamwork. Another key tenet of human factors is the importance of cognitive scientist Don Norman’s concept of putting “knowledge in the world” rather than just relying on “knowledge in the head.” The creation of a variety of standard protocols for airway management, and their representation in various graphical cognitive aids, is now a well-accepted and critical aspect of modern airway management preparation and execution. Thus, the chapter on the algorithms that describes and compares the many different protocols, mnemonics, and graphics is particularly useful. No one protocol will suit all clinicians and all sites so knowing their individual strengths and weaknesses is important.

A particular strength of this book is the numerous descriptions of airway management alternatives and their pros and cons in a wide variety of specific clinical situations. This is based on the concept—described in its own chapter—of context-sensitive airway management; this ties in very strongly with human factors and algorithms because every situation is indeed different. The approach of high-reliability organizations is to standardize where possible, but to remain flexible and resilient as circumstances demand. Even for readers who do not usually work in some of the settings described, the well-articulated synthesis of the processes of airway assessment, evaluation of the overall situation, and choice of options will help everyone to hone their decision-making skills whatever their usual setting.

In fact, these case discussions are a simple form of “simulation” by storytelling—as clinicians hear or read of a colleague’s tough case, they simulate in their own heads what they would think or do in a similar situation. Such case studies thus naturally dovetail with the chapter on the use of simulation to teach, practice, and hone skills of airway management—with simulation techniques ranging from simple procedural task trainers to full-blown interprofessional mannequin-based simulations.

This book has already stood the test of time, but the third edition offers a fully modern view of the complexities and nuances of this life-threatening and life-saving arena of clinical care. The authors, contributors, and I share the hope that through the knowledge, skills, attitudes, and behaviors conveyed by this book the rightful fear of the difficult airway will be surmounted by mastery and expertise, leading to the preservation or rescue of uncounted hearts, brains, and lives.

David M. Gaba, MD

Associate Dean for Immersive & Simulation-based Learning

Professor of Anesthesiology, Perioperative & Pain Medicine

Stanford School of Medicine

Staff Physician and Founder & Co-Director, Patient Simulation Center

VA Palo Alto Health Care System

Palo Alto, California