Management of the unexpected difficult airway

Abstract

We write regarding the new Difficult Airway Society (DAS) guidelines for management of the unexpected difficult airway [1]. The authors have produced a landmark paper that will serve as a hugely important resource for teaching of and discussion around airway management. However, like other published guidelines/algorithms [2–5], those of the DAS have sacrificed simplicity and user-friendliness for comprehensiveness when it comes to acute management of a crisis. While being valuable for teaching purposes or for prior planning, such guidelines would be difficult to use during an actual emergency. Indeed, out of over 150 trainees attending courses in airway management at our simulation centres over the last 4 years, not one, when asked, was able to reproduce any officially sanctioned algorithm. Close analysis of most difficult airway algorithms reveals common themes that can be distilled to produce a simplified plan for oxygenating a patient on failure either to intubate or to ventilate. We have developed this plan into a simple, easy to follow, algorithm for immediate management of a ‘failure-to-ventilate’ crisis, which now forms the core of a simulator course that we have established at the simulation centres at both Barts & the London and the Chelsea and Westminster Hospital. This course (Difficult Airway Management – Information and Techniques (DAMIT)) is now taught to all London anaesthetic Specialist Registrars when they pass through one of the two simulation centres during their training programme. We believe that an algorithm suitable for use by the bedside must be simple and easy to follow in an emergency, without complicated substeps and provisos. The DAMIT algorithm has only one plan with three steps and can be used as a substitute for all three DAS algorithms and the ASA guidelines. Furthermore, it is easily remembered and reproduced in an emergency. It starts with the failure to ventilate, and when following it one moves rapidly through three steps: basic manoeuvres; laryngeal mask airway; and cricothyrotomy (Fig. 2). These steps are easily remembered using the phrase ‘Fiddle, Larry, Stick’. Once ventilation and oxygenation is achieved, there are only two options: wake up or continue. The latter choice leads to options that can be undertaken at a more controlled pace and as help arrives. The expected or suspected difficult airway is a completely different proposition. Anaesthesia can be planned pre-operatively and experienced help and specialised equipment can be readily available. This is where the DAS and other guidelines can be particularly useful practically., We are currently validating the DAMIT algorithm with trainees who have attended the DAMIT simulator courses, but our experience over the last 4 years suggests it is easily remembered and practised. Indeed, the algorithm has proved so successful that it has been adopted by both our hospitals for the management of the unexpected difficult airway. The ‘DAM-IT’ airway algorithm and accompanying text.