Making the standard airway trolley less difficult in critical care

Dear Editor

The difficult airway is not an uncommon scenario in the ICU. In one study of 1502 patients, the incidence of difficult mask ventilation was 5% of which only 17% were predicted ¹ . Elsewhere, the incidence of difficult intubation on ICU has been reported between 1.5 and 8.5% ² . Airway management training often centres around the adherence to guidelines, which highlights a step-wise strategy in a plan A, B, C and D format in order to manage the airway as safely as possible ³ . In the Royal College of Anaesthetsists National Audit Project 4 (NAP-4): “Major Complications of airway management in the UK”, there were a higher rate of adverse airway events in the ICU or ED compared with theatres ⁴ . Clinical themes that contributed to poor airway outcomes included the lack of a clear strategy when a potentially difficult airway is identified, failure to plan for failure and worsening airway problems when difficult intubation was managed by multiple repeat attempts. As such, one of the recommendations from NAP-4 was the formal adoption of the difficult airway society guidelines (DAS) as departmental policy ³ .

The “difficult airway trolley” (DAT) describes a trolley that contains airway adjuncts to aid with the difficult airway ⁵ . In the theatre complex, it is usually stored in a location that is accessible and known to all staff and used when needed. The DAS gives guidance of how this trolley should be arranged, where each draw corresponds to each plan along the DAS airway management (plan A, B, C and D) algorithm, ensuring more timely and efficient use of equipment as it is needed ⁴ . Although invaluable to safer airway management and used appropriately in the theatre complex, the term “difficult airway trolley” may be counterintuitive on the ICU. Patients on the ICU often have limited respiratory or cardiovascular reserve and are often intubated in extremis - a far less controlled manner compared to patients undergoing elective surgery. Furthermore, time or clinical status may not allow as detailed and thorough airway assessment compared to the elective setting. It could therefore be argued that best practice should allow for appropriate planning of the unexpectedly difficult airway in ALL ICU patients and include a plan A, B, C and D before intubation is attempted routinely. Is it therefore time to rename the “difficult airway trolley” to one which implies routine use? This might allow standardisation and potentially safer practice in airway management in the critical care environment.