Management of a Dying Airway
In a dying airway emergency, immediate progression through a structured algorithm is essential, with rapid transition between techniques if initial attempts fail, and emergency surgical airway access should be performed without delay when non-surgical methods fail. 1
Definition and Recognition of a Dying Airway
A dying airway refers to a critical situation where a patient's airway is rapidly deteriorating, leading to imminent respiratory arrest if not addressed immediately. Recognition is the first step:
- Severe respiratory distress with stridor, retractions
- Rapidly decreasing oxygen saturation
- Altered mental status
- Inability to phonate
- Drooling or inability to handle secretions
Immediate Management Algorithm
Step 1: Call for Help
- Immediately activate emergency response system
- Call for airway experts (anesthesia, ENT, critical care)
- Request emergency airway equipment
Step 2: Initial Assessment and Oxygenation
- Apply high-flow oxygen via non-rebreather mask (15L/min)
- Consider high-flow nasal oxygen (HFNO) at 30-70 L/min if available 2
- Position patient appropriately (head elevated position) 2
- Prepare for rapid progression through airway algorithm
Step 3: Decide Between Awake vs. Post-Induction Approach
Awake Approach (Preferred for Anticipated Difficult Airway):
- Indicated when there is:
- Anticipated difficult intubation or ventilation
- Increased risk of aspiration
- Risk of rapid desaturation 1
- Techniques:
- Flexible bronchoscopic intubation
- Videolaryngoscopy
- Direct laryngoscopy
- Combined techniques 1
Post-Induction Approach:
- Only if airway assessment suggests low risk and adequate time
- Ensure backup plans are immediately available
- Limit attempts at each technique to prevent deterioration 1
Step 4: Failed Intubation Management
- Limit attempts to maximum of three per technique 2
- Ensure at least one attempt is by the most experienced clinician 1
- Provide oxygenation between attempts
- Progress rapidly through algorithm if unsuccessful
Step 5: Cannot Intubate, Can Oxygenate
- Insert second-generation supraglottic airway device
- Confirm ventilation with capnography
- Consider awakening patient if possible
- Prepare for definitive airway while maintaining oxygenation
Step 6: Cannot Intubate, Cannot Oxygenate (CICO)
- Immediately proceed to emergency front of neck access (FONA)
- Use scalpel-bougie-tube technique for surgical cricothyroidotomy 1
- Do not delay this step - should take less than 15 minutes from first airway intervention to FONA if needed 1
Special Considerations
Tracheostomy Patients
For patients with existing tracheostomy experiencing acute deterioration:
- Assess tracheostomy tube patency with suction catheter
- If blocked, deflate cuff to allow air passage around tube
- If no improvement, remove tracheostomy tube
- Oxygenate via stoma and/or oro-nasal route
- Consider reinsertion of tracheostomy tube or oral intubation 1
Equipment Preparation
- Ensure immediate access to:
Post-Stabilization Care
- Confirm tube placement with continuous waveform capnography
- Secure airway device properly
- Document depth of tube insertion prominently
- Arrange for definitive care (ICU admission, surgical intervention)
- Document airway difficulties for future reference 2
Pitfalls to Avoid
- Delaying the call for expert help
- Multiple attempts with the same failing technique
- Failure to recognize unsuccessful ventilation
- Delayed transition to surgical airway
- Inadequate pre-oxygenation
- Task fixation during failed attempts 1, 2
Remember that airway-related deaths often occur after prolonged attempts (45-60 minutes) with multiple providers making repeated attempts. The key to preventing mortality is recognizing failure early and progressing rapidly through the algorithm without undue repetition of failing techniques 1.