Provision of a Difficult Airway Cart
Preparatory provisions may enhance the success of airway management (AM) and minimize the risks and complications associated with difficult airway (DA) management. The immediate availability of alternative and evaluated backup devices for the management of difficult face-mask ventilation (MV) and conventional tracheal intubation in addition to standard AM equipment should be provided for all anesthetizing locations (1-4, 6, 9, 14). This is best accomplished by the provision of a dedicated and well-equipped DA cart in a designated location. Equipment on the DA cart need not duplicate routine AM equipment otherwise available on regular anesthesia carts; the content should be customized to meet the specific needs, preferences, and experiences of the operators. Furthermore, there must be a routine that the DA cart is properly maintained and updated.
The DA cart need not contain the various laryngeal mask airways (LMAs), suitable for rescue ventilation and as dedicated airways for tracheal intubation (5, 8, 13), because they should be routinely stored in all reagular anesthesia carts, primarily intended for routine AM. Anesthetists are now familiar with the various LMAs which should replace invasive techniques of transtracheal ventilation with a high serious complication rate (6, 15) as primary option for failed MV and tracheal intubation. Esophageal-tracheal combitubes should be also stored at all anesthesia working stations to be at hand when LMAs fail.
The DA cart should contain at least one flexible bronchoscope (FB) with a reliable light source and the necessary accessories; for flexible bronchoscopy-assisted tracheal intubation through a dedicated LMA, a pediatric FB may be also necessary. The recently released Airtraq optical laryngoscope (AOL) and the various models and systems of the GlideScope video laryngoscope (GVL) were considered by us as valuable supplements to the FB in patients with difficult conventional laryngoscopy (17, 18). The preliminary favorable results obtained with these devices should be taken into consideration when planning equipment availability and updating formulated strategies for DA management. Furthermore, the DA cart should also contain equipment for tracheal tube exchange and difficult tracheal extubation (2, 6, 15).
Recommendations of the Austrian Working Group for Airway Management
We highly recommend the immediate availability of alternative and evaluated backup devices for difficult MV and conventional tracheal intubation for all anesthetizing locations, best accomplished by a dedicated and well-equipped DA cart in a designated location. Equipment on the DA cart need not duplicate routine AM equipment otherwise available on regular anesthesia carts; the content should be customized to meet the specific needs, preferences, and experiences of the operators, and there must be a routine that it is properly maintained and updated. The DA cart should contain at leat one FB unit with the necessary accessories; preferably, an adult and a pediatric FB should be provided. We further recommend, that the AOL and the GVL should supplement the FB unit. In addition, equipment for tracheal tube exchange and difficult tracheal extubation should be provided. The DA cart may also contain equipment for transtracheal jet ventilation and cricothyrotomy, but these devices should be reserved only for extremely rare and desperate failed ventilation and tracheal intubation situations.
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