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Difficult Airway Bracelets

Doing Our Part: Communicating the Difficult Airway

 

A simple solution after you have secured the difficult airway

 

Anticipating a difficult airway while preparing for intubation makes even an experienced physician nervous.  The only thing worse is the unanticipated difficult airway.

Studies have shown that the overall rate of difficult intubation is 4%.  There are many predictors for a difficult airway on physical exam; however a previous difficult intubation is a better predictor of a future difficult intubation.  Communication of a difficult airway should be standardized across your hospital and healthcare system.

Our method includes a Difficult Airway bracelet placed on all patients identified to have a difficult intubation at the first encounter with the airway, and all future encounters with your healthcare system.  We suggest including Difficult Airway on their allergy list so it remains prominent in their chart.

Actual Patient Case

A middle-aged male was brought to the ED by EMS for unresponsiveness. After a prolonged resuscitation effort that included a difficult airway with anterior anatomy requiring bougie guidance, the patient was admitted to the ICU. His difficult airway was verbally communicated to the admitting physician. Over the next few hours the patient’s mentation improved and he was extubated. The next day his condition deteriorated and he required intubation. The respiratory therapists made multiple unsuccessful attempts, and after 30 minutes of O2 saturation ~50% an ED physician was called to the ICU to attempt intubation. The ED physician was able to intubate the patient after three attempts. The patient ultimately died.

Rewind One Step

The ED physician arrives in the ICU with the difficult airway kit because it was communicated that the patient was a difficult intubation.

Rewind Two Steps

As the patient began to decompensate in the ICU, anesthesia was notified early to intubate because the patient was known to have a difficult airway.

Rewind Three Steps

The patient remained intubated despite initial improvement until he was clinically stable because the attending physician knew he would be difficult to re-intubate.

Rewind Four Steps

The ED physician placed a blue DIFFICULT AIRWAY wrist band on the patient after he secured the airway and added “Difficult Intubation” to his allergy list.

The Learning Point

In this patient’s case, his original presenting condition carried with it a poor prognosis and the outcome would likely have been the same, however it uncovered an area of process improvement that could greatly benefit future patients.