Airway Management in Emergencies

George Kovacs, and J. Adam Law , editors . New York : McGraw Medical ; 2008 ; 298 pp; $69.95 (softcover ). Airway Management in Emergencies, a recently published book on emergency airway management, is a very welcome addition to the current array of textbooks on this most important topic. As the saying goes, “without a patient airway, nothing else matters.” No matter how much you know about the airway and how much clinical experience you have, there is always something that you can learn by reading more. Although this book is intended for the average practicing clinician dealing with emergency airways, it will be of some use to both the novice and the seasoned clinician. The two editors and lead authors of this text, a Canadian emergency physician (EP) and a Canadian anesthesiologist, each renowned for their clinical, educational, and investigational contributions to the field of emergency airway management, have collaborated to produce a very succinct, easily readable, and clinically oriented text with a refreshing, broad-minded approach. They clearly appreciate the fact that emergency airway management transcends the realm of departmental barriers and is a skill performed by a multitude of health care practitioners. The editors state forthrightly in the preface that “the need for nonanesthesiologists to gain expertise in acute airway management could not be disputed for long…declaring ownership of the airway should not be based on departmental borders, but rather on whether the clinician has the required knowledge and skills to safely manage the patient.” As such, they have created a useful text for any health care provider who is called upon to manage the airway of a patient in an emergency situation. This might be an anesthesiologist, anesthetist, EP, general practitioner in a rural hospital, general surgeon, internist, nurse, paramedic, or respiratory therapist. The book consists of 20 well-written and easy-to-follow chapters. Each chapter opens with a bulleted list of “key points” that summarize the critical principles covered in the chapter. In many of the chapters, case-based scenarios are presented in the beginning and then discussed in detail at the end of the chapter. Virtually every chapter is enhanced by the liberal use of diagrams, line drawings, and photographs. These figures make interpretation of the text much easier for the reader, as airway management is a very visual field. The photographic images span a wide range of material including some of the following: photographs of different airway devices and equipment, photographs demonstrating the use of an airway device on a manikin, photographs of patients being intubated, photographs of cadaveric dissections, fluoroscopic radiographs of the airway, and fiberoptic bronchoscopic photos of the tracheobronchial tree. These photographs supplement the text very nicely. For example, the fluoroscopic radiographs of the head and neck clearly demonstrate the efficacy of the jaw thrust in lifting the tongue and opening the obstructed airway. The photograph of the cadaveric dissection demonstrates the importance of having the tip of the laryngoscope blade well seated in the vallecula to maximally displace the epiglottis upward. The photograph of the patient being intubated with a Trachlight portrays what the “anterior neck glow” should look like when the lighted stylet is correctly entering the larynx. Each chapter ends with a fairly comprehensive reference list. The textbook contains the usual requisite chapters on airway anatomy, airway pharmacology, and tracheal intubation. Some of the more unique and notable chapters, however, warrant mentioning. Chapter 5, “Tracheal Intubation by Direct Laryngoscopy,” is a wonderfully written and illustrated chapter focusing on the technical performance of intubation using a conventional laryngoscope. There are numerous illustrations detailing how laryngoscopy should be properly performed, using both straight and curved blades, as well the novel McCoy “levering” laryngoscope. The chapter is littered with abundant clinical pearls, such as how to best shape the endotracheal tube with the “straight-to-cuff” configuration, how to “ramp up” the bed to achieve the “ear to sternum” line in the morbidly obese patient, and how to use external laryngeal manipulation to facilitate the laryngoscopic view. The proper use of the gum elastic bougie is also thoroughly reviewed in this chapter. Chapter 7 covers the underappreciated topic of rescue oxygenation. Often the emphasis on achieving tracheal intubation is so great that the more important issue of maintaining adequate oxygenation is overlooked. The authors have addressed this issue by having a whole chapter dedicated to rescue oxygenation. Several extra glottic devices (EGDs) that are helpful aids for rescue oxygenation are reviewed including the laryngeal mask airway family (Classic, Unique, ProSeal, Supreme, Fastrach, CTrach) and the esophageal–tracheal combitube. Some newer EGDs such as the King laryngeal tube, the Cobra perilaryngeal airway, and the SLIPA are also mentioned briefly. Finally, the chapter concludes with the ultimate way to achieve rescue oxygenation: surgical cricothyrotomy. Chapter 8, “How to Do Awake Tracheal Intubations–Oral and Nasal,” addresses yet another topic that is often neglected in other airway textbooks. The frenzy that currently surrounds rapid sequence intubation has often resulted in a failure to perform awake intubation. This chapter describes when one should consider this technique and then discusses the approach one must follow to achieve this, including the very important topic of topical anesthesia. The now uncommonly performed awake blind nasotracheal intubation (BNTI) is even included in this chapter, with some very useful clinical pearls. Also in this chapter is an instructive table on diagnosing and correcting malpositioned tubes while performing BNTI. For example, the table describes what the operator should do if the tube appears to be getting stuck in the piriform sinus. Chapter 11, “Approach to Tracheal Intubation,” is another well-written and informative chapter that focuses on the cognitive aspects of intubation. It has a nice discussion of tracheal intubation, including a clear, succinct, well-thought-out airway algorithm. There is also a brief discussion that focuses on the evaluation of the three dimensions of the difficult airway, with a description and diagram of the ever so popular “Sakles triangle.” Particularly helpful is the discussion on the distinction between the management of the difficult airway in both the cooperative and the uncooperative patient. The editors’ appreciation of the varying approach that is necessary in difficult airway patients is a testimony to their substantial clinical experience and excellent clinical judgment. Chapter 12, “Response to an Encountered Difficult Airway,” elaborates on the topic of difficult airway management, touched on briefly earlier in the text. In this chapter, a detailed overview of the difficult and failed airway is presented with a simplified, easy-to-read, and easy-to-understand algorithm. The definition of the failed airway is clearly explained, along with the appropriate steps one should take when in that situation. The chapter concludes with an appendix that contains a list of suggested equipment for an emergency/difficult airway cart, although some of the recommended devices are of questionable utility in my opinion. For example, the Trachlight, although doubtless very successful in the hands of the experienced operator, is unlikely to be helpful to the average “front-line” intubator unexpectedly caught in a difficult or failed airway situation. In summary, Drs. Kovac and Law have distilled years of clinical airway experience into a concise, very readable, and practical book that would be of great value to any practitioner who manages airways on an emergency basis. I have spent my entire career educating health care providers involved in emergency airway management, and I salute these editors and contributors for producing a text that transcends departmental- and specialty-based barriers and seeks to help this varied group of front-line providers. You never know: it might be one of these practitioners who is called upon to manage your airway one day, and you had best hope that he or she has fully read and comprehended this excellent book beforehand.

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