As emergency physicians, we deal with a lot of unexpected challenges. Being prepared for any challenge that comes through the door is an attribute that makes us stand out among other medical specialties. This calling is one of the reasons why we as a specialty have earned the public’s trust as highlighted by their appreciation during the COVID pandemic. One of the benefits of always being prepared is that the emergency physician will be at ease when it comes time to ask for help or implement a backup plan.  As emergency physicians, we are specialists in a variety of fields including airway specialists. Every emergency physician has encountered problematic airways at some point in their career, and every emergency physician can express how they dealt with those difficult airways. Challenging airways are best controlled with the use of a backup plan, or a series of backup plans. How can you be confident in your backup strategy for airway management?

Factoring in Challenges

There are several factors which contribute to a difficult airway. Some of the conditions surrounding the patient’s presentation may make an airway problematic, such as trauma, smoke inhalation, soft tissue infection and bleeding disorders, to mention a few. This discussion is a commentary on the case report in the April edition of Annals of Emergency Medicine. Few encounters in medicine can be as taxing as the difficult airway in a nine-month-old infant. Intubations in this age group are infrequently required and, of course, intubation success, as with other procedures, requires experience. Infants with trisomy-21 have anatomic variants, as well as the considerations that infants in general have a large tongue and floppy epiglottis. Surgical cricothyrotomy is difficult. Supraglottic airway devices and equipment for airway management in pediatric patients is beyond the scope of this article for now, but can be a topic for another day.^1,2  

In the case study by Strobel, et al., in the April issue of Annals, the anatomy and physiology of the patient presenting with a problematic airway was discussed in detail. One may argue that a pediatric airway qualifies as challenging, but adding the complicating factors of a genetic anomaly, as in Strobel’s case report, can increase the complexity of establishing an airway. 

Understanding Adjuncts 

Certainly, the patient described in Strobel’s case report is exceptional, but it should serve as a reminder to every emergency physician of the need for feeling comfortable with the use of airway adjuncts. Extraglottic airways (EGA) are often used in the pre-hospital setting. Using EGAs can be beneficial since they provide the emergency physician more time while attempting to secure a definitive airway in the patient. The use of cuffed endotracheal tubes has grown more common in the pediatric population, and they are considered a valuable adjunct in the treatment of some of the most difficult airways. The pediatric bougie is a tool with which every emergency physician should be familiar. Strobel, et al., showed how this airway adjunct might be useful in more severe situations. In the Strobel case report, the use of these three airway adjuncts aided the emergency physicians in managing their challenging patients. These airway specialists should be applauded not just for their ease in employing these adjuncts, but also for the overall success of the challenging airways that they confronted.

Simulation as a Method of Understanding 

Emergency physicians can utilize a variety of airway adjuncts that are readily available. Some of these will be unique to one’s clinical site. If there are airway adjuncts that are not currently accessible at your institution, it would be advantageous not only to one’s colleagues, but it would also be beneficial to future patients if your institution could procure and familiarize its staff with these adjuncts. Video laryngoscopy has been more widely available because of technological advancements in recent years. Even though some emergency physicians may not have had formal training in the use of video laryngoscopy, there are several airway courses available to help them improve their skills. Although video laryngoscopy has significant limits when it comes to some patient presentations, it can also assist an emergency physician in managing some exceedingly challenging airways. When it comes to the treatment of problematic airways, the ever-expanding field of simulation can be quite useful. Emergency physicians can practice with airway adjuncts that they may not be accustomed to employed in their clinical practice through the use of simulation. The use of airway adjuncts in simulation provides the ability for real-time feedback without the risk of patient deterioration. Emergency physicians should continually challenge themselves to become more comfortable with the airway adjuncts that are easily available to our practice—such as videolaryngoscopes, EGAs, cuffed pediatric tubes, and the pediatric bougie. There are many tools at our disposal; simulation can help us feel more comfortable utilizing them in times of crisis. 

Dr. Tagliaferro is assistant professor, of emergency medicine at Case Western Reserve University, and a faculty member at MetroHealth Medical Center/Cleveland Clinic Residency Program of Emergency Medicine.

Dr. Glauser is professor of emergency medicine at Case Western Reserve University, and a faculty member at MetroHealth Medical Center/Cleveland Clinic Residency Program of Emergency Medicine.

References 

1. Stein ML, Park RS, Kovatsis PG. Emerging trends, techniques, and equipment for airway management in pediatric patients. Pediatric Anesthesia 2020; 30: 269-279.
2. Sanders JE, Spina LA. Supraglottic airway devices for pediatric airway management in the emergency department. Pediatric Emergency Medicine Practice. October 2020; 17(10).