In an airway emergency it is paramount that the right equipment is immediately available. The best way to ensure rapid access to difficult airway equipment is to keep it in an airway trolley. This is advocated in several published analyses of airway critical incidents including the 4th National Audit Project of the Royal College of Anaesthetists (NAP4).1
An example is shown below: from The Royal North Shore Hospital Intensive Care Unit.
The trolley consists of 4 drawers corresponding to Plans A, B, C and D of the Difficult Airway Society guidelines for the management of unanticipated difficult intubation.2 The symbols used to depict these Plans are from the Vortex cognitive aid.3
The first drawer (Plan A, Endotracheal Tube) contains all the equipment necessary for endotracheal intubation by laryngoscopy, including Storz C-Mac blades for use with the monitor attached to one of the upright poles on the back of the trolley.
The second drawer (Plan B, Supraglottic Airway Device, SAD) contains second-generation SADs (igels) for airway rescue. If circumstances allow (i.e the patient can be oxygenated via the SAD, and it is thought appropriate), the SAD can be converted to an endotracheal tube with the use of the Ambu aScope, using the monitor attached to the other upright pole, with or without the Aintree Intubating Catheter (AIC). The AICs and bronchoscopes are located in the side baskets.
Note that the C-Mac and Ambu aView screens can be turned round, so that the intubator can see them while allowing the airway assistant access to the drawers.
The third drawer (Plan C, Facemask) contains facemasks, nasopharyngeal and oropharyngeal airways of various sizes.
The fourth drawer (Plan D, CICO rescue) contains equipment for cannula, surgical and Seldinger cricothyroidotomy techniques. It also contains an Airway Exchange Catheter and Staged Extubation Kit.
For Intensive Care and Emergency clinicians, the goal is almost always endotracheal intubation. We appreciate that this is not the case in the operating department, where a SAD may be the first choice. The drawers are arranged in the order outlined above for the sake of standardisation.
On the side of the trolley is a file containing our Emergency Intubation Checklist and Emergency Airway Cognitive Tool, which combines the DAS and Vortex approaches to difficult airway management. We believe that the DAS guidelines should be used for forward planning and to help with the choice of techniques, while the Vortex cognitive aid helps the team with decision making, such as when to abandon a technique and move onto the next.
The Airway Trolley
Move your cursor over the various parts of the trolley and click on the links for further information.
1. Cook TM, Woodall N, Harper J, Benger J, Fourth National Audit P. 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. British journal of anaesthesia. 2011;106(5):632-642.
2. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British journal of anaesthesia 2015;115(6):827-48.
3. Chrimes N. The Vortex: a universal ‘high-acuity implementation tool’ for emergency airway management. British journal of anaesthesia 2016;117 Suppl 1:i20-i27.