Difficult Airway Letter

Lynette J. Mark

Lorraine J. Foley

Vinciya Pandian

Clinical Scenario:

A 49-year-old woman presents for elective laparoscopic-assisted vaginal hysterectomy under general anesthesia. The patient is 5′ 8″ tall and weighs 250 pounds. On airway examination, she has a Mallampati class II oropharyngeal view and prominent front teeth. The patient is induced for general anesthesia with propofol. Mask ventilation is found to be slightly difficult and an oral airway is placed. Intubation is attempted with direct laryngoscopy with a Macintosh #3 blade and a grade III Cormack and Lehane view is obtained. A second intubation attempt is made with a Miller #3 blade—a grade IIb view was obtained. Intubation with a bougie is unsuccessful. A third attempt with a video laryngoscopy is made. The patient’s vocal cords are visualized and a 7.0 ETT is placed without difficulty. Tracheal intubation is verified with continuous capnography and bilateral breath sounds. At the end of the procedure, the patient is extubated without difficulty. In the postanesthesia care unit, the patient is informed that she has a difficult airway and that she should inform future health care providers of this.

1 I have already documented in the patient’s anesthesia records details about the difficult airway. Why should I provide a Difficult Airway Letter to the patient?

Guidelines from the American Society of Anesthesiologists (ASA) regarding patients with difficult airways recommend examining previous anesthetic records, if available, during preoperative assessments, documenting the presence and nature of the difficult airway in patient medical records, informing the patient about the difficulty encountered, and evaluating and following the patient for potential adverse events related to difficult airway management. Difficult airway information provided verbally to patients or family members before or at discharge may not be retained. Additionally, details pertaining to difficult airway management would probably be beyond a layman’s understanding. Only 44.4% of hospitals use electronic medical record systems. Many institutions store nonelectronic patient medical records offsite, making retrieval of vital information challenging, both for in-house needs and for exchange between institutions.

Comprehensive Difficult Airway Letters are invaluable for individual hospital registries and interhospital communications. Communicating difficult airway information to the patient with a letter enables that patient to help future providers be better prepared for airway management.

2 What should be included in a “Dear Patient” Difficult Airway Letter?

Some practitioners tend to limit the Difficult Airway Letter to a generic one, advising their patient to inform future care providers that they have a “difficult airway.” Although providers appreciate this alert, more detailed information would be beneficial. We recommend that the following comprehensive information be included in the Difficult Airway Letter to the patient: 1) date and institution where difficult airway was identified; 2) provider contact information; 3) patient characteristics, such as anatomic features, body mass index, and significant comorbidities; 4) type of difficulty encountered (mask ventilation, ventilation with supraglottic apparatus, intubation, extubation); 5) unsuccessful and successful techniques with best laryngeal visualization; 6) implications for future care; and 7) recommendations for registration with an emergency notification service.

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