Pulmonary medicine expert witness Kathleen S. Adams, RCP, RRT-NPS, is an instructor and owner of Packmule Education & Consulting Services in Southern California. Also the president-elect of the California Society for Respiratory Care, here she writes on difficult airways.
Difficulty or inability to perform adequate bag-mask ventilation can be predictable in some patients, such as those with obvious facial trauma or beards that may interfere with obtaining an adequate seal. There are more subtle challenges-such as obstruction by the tongue, either by falling back or by swelling; airway edema or spasm; or blockage due to foreign body.
Difficult tracheal intubation can be related to the inability to visualize the glottic opening or those procedures requiring multiple and/or unsuccessful attempts to place the endotracheal tube. Reasons for these are many, including, but not limited to, upper airway edema, trauma, airway anomalies, obesity, limited neck mobility, or limited opening of the mouth. This could also be related to a lack of skill or use of improper technique by the practitioner. Without proper training in the endotracheal intubation procedure and/or proper use of a selected device, the practitioner can actually turn what could be a normal intubation procedure into a difficult one and increase the risk of complications to the patient as a result. To avoid this situation, practitioners expected to perform such tasks should first receive good basic training in the endotracheal procedure. They should then receive special training necessary for intubation pertinent to their patient population, followed by training for a specific device or technique in addition to standard laryngoscopy. No technique or device can replace good airway management training.
This article appears in RT for Decision Makers Magazine March 2009.