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Difficult and Failed Airway Drills

Video run-through of pre-hospital difficult and failed airway drills
In the videos to follow, we will discuss and demonstrate an approach to managing a failed intubation. We use a clear structure when faced with this scenario so that in times of high stress, we know the next step to take to attempt to secure the airway. We use what we call 30-second drills. And these are a standardised approach in the management of a difficult airway. The drills are so named as they should be easily completed before a normally pre-oxygenated patient would start to desaturate. The content of the drills are set, but the sequence may be adapted to the particular situation.
The drills are as follows– suction; cricoid off; BURP manoeuvre, which stands for Backwards, Upwards, Rightwards Pressure; advancing the laryngoscope all the way into the airway and then retracting it slowly in an attempt to optimise the view; changing the patient position; changing the intubator’s position; changing the equipment; and changing the operator. We would expect to complete the 30-second drills as part of plan A of our difficult airway algorithm. But if we find ourselves in a situation of not being able to intubate and not being able to ventilate, we would proceed through plan B and C as a priority.
We’re now going to run through the first part of our 30-second drills. And you’ll be able to see those in action. Go on. OK. Our patient saturations are good. You ready to go? Ready to start. OK. Go ahead then. OK. So mask off and to my right. Can I have that? Guedel out and to my left. If I could have blade, please? Thank you. So I see lips and teeth and tongue. Sweeping the tongue, lifting up, I have a great full view. I can’t see anything. Is there anything we can do to optimise that? Could I have some suction, please? Yeah, suction there. Thank you very much. So suctioning– Saturations are still good– Hasn’t improved my view.
So I’m just going to do some manipulation here. So I’m going to give some backwards, upwards, and rightwards pressure. That hasn’t changed anything. Can you take the cricoid off for me, please? Thank you very much. Now, I’m going to insert the blade the whole way. Yeah. OK. The saturations are still good. Thank you. And I’m going to pull out slowly. Does that change anything? No difference in view. So I’m going to come out until I have an I-Gel, please. Come out here. There’s an I-Gel there now. Thank you. OK, we’ll do that. I-Gel going in. OK. Now, we’re connected. Connected. There you go. Thank you. There you go. Now, what we can do now– And we’re ventilating. We’ve ventilating happily.
Yeah. Saturations are coming up. Yeah. Should we discuss what we saw and how we can change it for the next attempt? Yeah, that sounds good. So in the first part of the video, we attempted 30-second drills. But we were not able to secure the airway. We’re ventilating on an I-Gel. And in the next part of the video, we are going to work our way through the second part of the 30-second drills to see if we can optimise our airway. These will be considering changing the patient position, considering changing the operator position, considering changing the equipment, and considering changing the operator.
OK. So the saturations are good now. They’re back to their normal. So should we give another go now? Yeah. Let’s consider changing our patient position. I think we could probably lift the head up a little bit. OK. Would you mind lifting the head up for me, please? We’ve got something we can put under the head there. Thank you very much. There we go. Great. You have a look at that. Yeah. OK. OK. That has changed the patient position. It has. Yeah. I’m happy with my position. And I think we could maybe attempt a different piece of kit. So if you try the McCoy blade on this occasion– Yeah, we can try that, because you can obviously use that otherwise. Yeah.
And then if that doesn’t work, then I think we’ll consider chaining operator. OK. No worries. Happy to proceed? Yeah, absolutely. And if we don’t succeed on this, we can then go back to the I-Gel because we can know we can happily ventilate the patient. Happy with that as a plan. All right. OK. So I-Gel’s coming out. It’s going to my right. That’s to me. I have that. McCoy to me. Thank you. So again, I see lips and teeth and tongue. And I’m sweeping the tongue. And I’m engaging the McCoy. Patient saturations are still good. Thank you. Does that change anything for you? This has not made any difference to my view at all. I can’t see anything else.
Are you happy with your position? I’m happy with my position. I can’t change anything additionally here. So I’m going to come out and we’re going to go back to the I-Gel, please. That’s fine. Numbing out. There you go. There’s the I-Gel. Back to the I-Gel. Let’s go on circuit. And we should still be ventilating. And we are ventilating happily. Great. Great. OK. Thank you. OK. So next thing to do is we could consider changing the operator. So you and I could swap positions. And we could try those drills again. OK. Absolutely. In the last video, we were in a situation where we couldn’t intubate, but could ventilate.
In the next scenario, we’re going to be in a position where we can’t intubate and can’t ventilate. And we’re going to run through the rest of our drills and end up doing a surgical airway. So I think this gentleman looks like he may have a difficult airway. So we’ll have a low threshold for moving straight through the 30-second drills if we’re not able to ventilate. And I think it would be a good idea just to mark the position of surgical airway before we start, if that’s OK. Absolutely. You got a pen down there, please? Yeah, I have. There you go. Thanks. So marking my landmarks, I’m just going to draw the position there. OK. I’m still pre-oxygenating. Great. Thanks. Excellent.
I’ll leave it to you. Thank you. Great. OK.
The mask is out and to my right. I have that. Guedel is out and to my left. Can I have the laryngoscope, please? There you go, laryngoscope. Thank you. So I see lips and teeth and tongue– sweeping the tongue. Stats are good. Thank you. I’ve still got a grade-four view here. There’s quite a lot of secretions here. Can I have some suction? Suction. Thank you for suctioning. That hasn’t helped. I’m just going to reach over. Can I just push your hand down? So we’re going to do some backwards, upwards, rightwards position. The stats are good for the moment. Thank you. That hasn’t made any difference at all. Can you take cricoid off there, please?
Are you going to insert the blade? Yeah, I’m going to insert the blade the full way. And then I’m going to withdraw it very slowly. And the saturations are just starting to dip a little bit. Thank you. And I can’t make any difference in the airway. So I’m going to come out. Can I have an I-Gel, please? OK. Let me see. Coming out. There you go, I-Gel. An I-Gel is going in. And circuit is coming on. Thank you very much. OK. So we’re ventilating there? I can’t ventilate. OK, not ventilating. We’re not ventilating. OK. So I’m going to come out with the I-Gel. OK. Thank you. I’m going to put the Guedel back in.
And let’s have a face mask, please. There’s the face mask. Thank you. I’m going to do two-hand technique there. How are we doing now? We’re ventilating? I still can’t ventilate. I can’t– Still can’t ventilate. Let me try once more. Pull that right into the mask there. The saturations are still deteriorating. OK. So I think we need to do a surgical airway. OK. OK. Have that. Can I have the blade, please? Here’s the blade. Thank you. So I’m feeling my positions. And I’m going to go through my mark, and I’m going to do a stab and rocking technique. I’m going to keep my blade in. And can I have the hook, please? New hook. Thank you.
I’m placing the hook and lifting up. And I’m going to take my blade out and to my left. Are you happy with that? Bougie to me. Thank you. Here’s the bougie. So passing bougie, I can feel rings. OK. Happy with that? Thank you. Yeah, happy. Tube’s coming down. Thank you. OK. I have the bougie. I have, too. Threading tube over bougie. That’s gone through. OK. Happy with that? Thank you. Happy. Bougie is coming out. Bougie out.
Cup is up. That feels good. Thank you. Circus is attached. OK. We have misting with the tube. Great. We have rise and fall of the chest. Great. We have a tidal. Great. And the saturations are starting to come up. Excellent. Thank you. I’m going to come out with the hook. I have the tube. Thank you very much. And then we’ll tie that in place then. Yeah. Great. Great. Thank you. Thank you.
In this video Eyston Vaughan-Huxley (KSS HEMS Doctor) and Ben Clarke (KSS HEMS Paramedic) demonstrate protocolised strategies to manage difficult or failed airway scenarios in the pre-hospital setting.

This video pertains to a non-trauma patient and not all aspects of clinical care are portrayed. The emergency front-of-neck technique is adapted to the setting and differs slightly to the DAS technique presented in Week 2

Why Are Airway Drills Important?

Previous steps have discussed some of the challenges of the pre-hospital setting including environmental issues and human factors. However, it is important not to neglect the technical challenges that add to the risks associated with pre-hospital airway management. It is imperative to have a pre-determined plan for a failed airway scenarios.

Technical Airway Challenges

It is not uncommon to encounter patients with pathology of the head and neck. There may be anatomical disruption of the airway, swelling from injuries such as burns, or significant airway haemorrhage. All of these scenarios can make the technical skills of facemask ventilation, supraglottic airway insertion, laryngoscopy, intubation and front of neck access difficult and, in some cases, impossible.

There may be clues in the history and examination as to the potential for a difficult airway but there is seldom any information to indicate previous airway or anaesthetic complications. In addition, patients are located remotely, where there is limited equipment and almost no option for backup, yet a difficult airway may still need to be managed.

It is precisely for situations like these that preparation is imperative and having well drilled protocols are essential to improve the likelihood of success.

Management Strategies

Regular training is the key to making the difficult airway as easy to manage as possible.

Protocols (see Figure 1) should be introduced during initial training scenarios and reinforced through regular practice during governance days and clinical shifts. Regular rehearsal generates muscle memory and reduces cognitive loading in a crisis. You may remember the top tip offered by Dr Fiona Kelly in the activity on Human Factors: “Good technical skills help improve non-technical skills”

Having a standardised approach to the RSI kit dump and airway drills creates a shared mental model between crew members and builds team confidence to progress through the management options and ultimately secure the airway.

Operators should develop and maintain a wide range of basic and advanced airway skills to optimise first attempt success, including: facemask ventilation, supraglottic airway insertion, competence with a range of direct and video laryngoscopes and experience with front of neck airway techniques.

Training in a range of challenging scenarios develops situational awareness and the communication strategies required in a crisis; this in turn optimises the CRM between the team managing the patient’s airway and the wider team on scene.

Action card displaying pre-hospital emergency airway drillls

Figure 1: Protocolised difficult & failed airway management drills Credit: KSS Standard Operating Procedures

Pre-Hospital Airway Matters footer - UCLH, UCL, KSS Air Ambulance logos

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Airway Matters

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