Operating room with surgeons and anesthesiologist

The Most Critical Factor in Tracheal Intubation: Your Clinical Judgment, Planning and Preparation

Posted on 12/17/19 by Allied Anesthesia

As long as the field of anesthesiology has been around, so has been the two-fold challenge: intubation and oxygenation. If you have been in practice for any amount of time, you are quite familiar with “can’t intubate, can’t oxygenate” emergencies. Tracheal intubation is difficult if not, at times, downright impossible. This is a given that comes with the territory. So, what can we do about it?

First, what can we learn from the history of tracheal intubation, and where can we go from there?

As you may know, in 1993, the first difficult airway guideline — the Peterson report [i] — was published. It has subsequently been updated twice. In our field, we have also recently seen the invention of video laryngoscopies as well as supraglottic airway devices, both aimed at making the role of the anesthesiologist less difficult in achieving the flawless tracheal intubation.

What Is Difficult Intubation and Why Does This Matter?

Difficult intubation is defined as multiple attempts at tracheal intubation, or failed intubation. In a study [ii] conducted by Peterson et al. of cases (that led to claims) that occurred between 2000 and 2012, difficult intubation was identified as the primary damaging event leading to patient injury. Patient injury ranges from tracheal injury to brain damage to death.

The Critical Factor: Your Clinical Judgment, Planning and Preparation

The most important finding in this study is something completely within your power. This study found that the judgment of the anesthesiologist was by far one of the most important, and critical, factors leading to poor surgical outcomes. Here’s what the study, Management of Difficult Tracheal Intubation: A Closed Claims Analysis, found:

“Almost three fourths of 2000 to 2012 claims exhibited judgment failures, including lack of a proper airway management plan and, during a ‘can’t intubate, can’t oxygenate’ emergency, the failure to utilize a supraglottic airway as a bridge to oxygenation and delay in attempting a surgical airway.”

While “deficiencies in clinical judgment” occurred in the majority of recent claims (73%; n = 71 of 97) that could be adequately assessed in the study, this North American study is not alone or unique in its findings. The Danish Anesthesia Database produced similar findings (over a six-year study period) [iii] — as well as the Fourth National Audit Project of the Royal College of Anaesthetists in the United Kingdom, which found that “nontechnical skill deficits” were major contributors to poor patient outcomes. [iv]

What Can Be Done About Judgment Errors? Make an Airway Strategy

First, be aware of their high probability, the likelihood for occurrence within the area of tracheal intubation. Plan for it. The study[v] found that “a lack of adequate planning for intubation difficult or failure” contributed to poor outcomes. This is something that we have the power to change.

1. Formulate an Airway Strategy

Do you have an airway strategy, or a coordinated series of airway plans that you can turn to in case of difficulties? It is of particular importance that this airway strategy be in place when your patient presents preoperative predictors of difficulty.

Making an airway strategy includes situational awareness. What factors are present in your context? What equipment do you have on hand? Do you have the skills to use other devices should your device of choice fail you? Are you lacking in a secondary device should your primary device(s) fail? Are you and your team able (as well as willing and prepared) to move on — and quickly — if the technique you are using is not working?

Remember, current guidelines suggest that anesthesiologists deploy a supraglottic device while concurrently preparing “to perform an immediate emergency ‘surgical airway’” should the supraglottic airway fail.[vi]

Are you prepared to do that — have you been implementing this best practice in your operating room?

2. Get Familiar With All of Your Equipment

Get to know all of the equipment available to you.

 “Practitioners must familiarize themselves with locally available airway equipment, which should be placed appropriately within the construct of published difficult airway guidelines. Simple task trainers and/or dedicated manikins should be used to train appropriate handling of this equipment.”[vii]

Have dress rehearsals. Rehearse. Practice makes perfect. So, practice the correct application of your equipment. Plan for difficult — and seemingly impossible — airway situations. With your team, focus on applying and honing your technical skills.

3. Don’t Be Ashamed to Use Cognitive Aids

Teams should consider practicing managing “the inevitable” airway emergency as well as deploying cognitive aids in the operating room.[viii] “Incorporation of cognitive aids specific to difficult airway management may cue practitioners to the need to move on to another plan in their airway strategy while ‘in the heat of the moment.’”[ix]


Today, practitioners are presented with the opportunity to stop and evaluate our current practices and methodologies in light of these findings. It offers us the opportunity to reevaluate how we conduct our training for airway management and how we might implement positive changes in our future practice.



[i] Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW: Management of the di cult air- way: A closed claims analysis. Anesthesiology 2005; 103:33–9[ii] Ibid

[iii] Rosenstock C, Hansen EG, Kristensen MS, Rasmussen LS, Skak C, Østergaard D: Qualitative analysis of unanticipated di cult airway management. Acta Anaesthesiol Scand 2006; 50:290–7

[iv] Cook TM,Woodall N, Frerk C; Fourth National Audit Project: Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Di cult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011; 106:617–31
__Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project: Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: Intensive care and emergency departments. Br J Anaesth 2011;106:632–42

[v] Aaron M. Joffe, Michael F. Aziz, Karen L. Posner, Laura V. Duggan, Shawn L. Mincer, Karen B. Domino; Management of Difficult Tracheal Intubation: A Closed Claims Analysis. Anesthesiology 2019;131(4):818-829. doi: https://doi.org/10.1097/ALN.0000000000002815.

[vi] Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, Connis RT, Guidry OF, Nickinovich DG, Ovassapian A; American Society of Anesthesiologists Task Force on Management of the Di cult Airway: Practice guidelines for management of the di cult air- way: An updated report by the American Society of Anesthesiologists Task Force on Management of the Di cult Airway. Anesthesiology 2013; 118:251–70
__Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM, Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey S, Turkstra TP, Wong DT; Canadian Airway Focus Group: The di cult air- way with recommendations for management–part 1–di cult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth 2013; 60:1089–118
__Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O’Sullivan EP, Woodall NM, Ahmad I; Di cult Airway Society Intubation Guidelines Working Group: Di cult Airway Society 2015 guidelines for management of unanticipated di cult intubation in adults. Br J Anaesth 2015; 115:827–48

[vii] Joffe, Aaron M., et al.

[viii] Duggan LV, Brindley PG, Law JA: Improving communication, teamwork, and action during a “can- not intubate cannot oxygenate (CICO)” emergency: Employing CICO as a cognitive aid mnemonic. Can J Anaesth 2018; 65:1087–92

[ix] Joffe, Aaron M., et al.



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