How to manage sharing an airway between two providers in a FESS (Functional Endoscopic Sinus Surgery) procedure?

Managing Shared Airway in FESS Procedures

For FESS procedures, establish clear role delineation between the anesthesiologist (airway manager) and surgeon (proceduralist) with the anesthesiologist maintaining ultimate airway control, using a secured endotracheal tube with continuous capnography monitoring, and implementing structured communication protocols to coordinate surgical access with ventilation needs. 1

Pre-Procedure Planning and Team Coordination

Define Clear Roles and Responsibilities

• The most experienced airway manager should control the airway throughout the procedure - this is typically the anesthesiologist who maintains responsibility for oxygenation, ventilation, and airway protection while the surgeon operates. 1

• Conduct a pre-procedure briefing where both providers discuss the surgical plan, anticipated duration, critical steps requiring communication, and contingency plans for airway emergencies. 1

• Establish a personnel plan with clearly defined inside-room roles: the anesthesiologist manages the airway and monitors, while the surgeon performs the procedure, with support staff assigned specific tasks. 1

Equipment Preparation

• Ensure all necessary airway equipment is present before starting, including the airway trolley, rescue devices (supraglottic airways, cricothyrotomy kit), working suction, and a cognitive aid for managing difficulty. 1

• Set up continuous waveform capnography monitoring - this is the most reliable method for confirming and monitoring endotracheal tube placement throughout the shared airway procedure. 1

• Have videolaryngoscopy available as it allows the operator to maintain distance from the airway while improving visualization if repositioning or troubleshooting is needed. 1

Airway Management Strategy

Secure the Airway Definitively

• Use endotracheal intubation as the primary airway management technique for FESS - this provides the most secure airway, protects against aspiration of blood and surgical debris, and allows controlled ventilation throughout the procedure. 2

• Perform meticulous pre-oxygenation with a well-fitting mask for 3-5 minutes using a closed circuit before induction. 1

• Position the patient appropriately (including ramping in obese patients and reverse Trendelenburg positioning) to maximize safe apnea time and optimize surgical access. 1

• Ensure full neuromuscular blockade before intubation attempts to minimize patient movement and coughing that could compromise the shared surgical field. 1

Tube Positioning and Fixation

• Secure the endotracheal tube in the midline position to allow symmetric surgical access to both nasal cavities while preventing inadvertent extubation or tube migration during surgical manipulation. 2

• Use additional tube fixation methods beyond standard taping, as surgical instruments and manipulation in the nasal passages can dislodge the tube.

• Verify tube position immediately after securing and document this with capnography before surgical incision begins. 1

Intraoperative Communication Protocol

Establish Structured Communication

• Use clear language and closed-loop communication throughout the procedure - the surgeon must verbally confirm receipt of information from the anesthesiologist and vice versa, especially when working in close proximity. 1

• Implement a system where the surgeon announces critical steps that may affect ventilation (e.g., "applying topical vasoconstrictor," "entering sphenoid sinus," "approaching skull base") so the anesthesiologist can anticipate changes in airway dynamics. 1

• The anesthesiologist should immediately communicate any ventilation difficulties, changes in airway pressures, or concerns about tube position to allow the surgeon to pause and assist with troubleshooting. 1

Coordinate Surgical Access with Ventilation

• Establish a rhythm where the surgeon works during exhalation phases when possible, minimizing interference with ventilation mechanics. 2

• If the surgeon needs to manipulate structures near the tube or requires the anesthesiologist to adjust tube position, both providers must coordinate this maneuver with clear verbal communication before, during, and after the adjustment. 1

Monitoring and Troubleshooting

Continuous Vigilance

• Monitor continuous waveform capnography throughout the entire procedure - any loss of waveform or change in pattern requires immediate investigation for tube displacement, obstruction, or circuit disconnection. 1

• Watch for sudden increases in peak airway pressures that may indicate tube obstruction from blood, secretions, or surgical debris requiring suctioning. 1

• Monitor oxygen saturation continuously, recognizing that desaturation in a shared airway procedure may result from surgical bleeding obscuring the airway, tube malposition, or inadequate ventilation. 1

Managing Airway Complications

• If ventilation becomes difficult or impossible, immediately communicate with the surgeon to stop and withdraw instruments from the surgical field while you assess and secure the airway. 1

• Have a cognitive aid readily available for managing unexpected airway difficulty - airway emergencies lead to cognitive overload and a structured algorithm improves decision-making. 1

• Maintain a backup strategy: if the endotracheal tube fails, a second-generation supraglottic airway device (i-gel, LMA ProSeal, LMA Protector) can serve as rescue while you regroup. 1

Common Pitfalls and How to Avoid Them

Prevent Communication Breakdown

• Never assume the other provider knows what you're doing - in shared airway procedures, assumptions lead to complications. Verbalize your actions and intentions explicitly. 1

• Avoid working in silence during critical portions of the procedure; maintain ongoing dialogue about what each provider is doing and what they need from the other. 1

Avoid Premature Extubation

• Do not extubate until the surgeon confirms complete hemostasis and removal of all packing/instruments from the nasal passages, as reintubation with a bloody airway is significantly more difficult. 1

• Ensure the patient is fully awake with intact airway reflexes before extubation, as residual blood and secretions in the pharynx increase aspiration risk. 3

Maintain Situational Awareness

• Do not use techniques you have not used before or are not trained in - a shared airway procedure is not the time to experiment with unfamiliar equipment or approaches. 1

• Keep the smallest number of staff necessary in the room to reduce confusion and communication errors, but ensure adequate help is immediately available outside if needed. 1