**4. Challenges in these areas**

*Special Considerations in Human Airway Management*

The Ear, Nose and Throat clinic usually has a procedure room to carry out minor procedures. Local anesthesia of the airway is usually used to access the laryngeal inlet for vocal cord injections. The clinic also performs tracheostomy tube changes and tracheostomy wound management. Routine tracheostomy changes must be done only during the daytime and during working hours except in an emergency. At least two trained practitioners are required during the tracheostomy tube change procedure. No drugs are usually given to hamper the patient's respiratory efforts, but the difficult airway trolley should always be available along with a good functioning suction machine.

The resuscitation areas in the ED are usually equipped to intubate and ventilate patients. In the other acute areas of the ED, procedures may be done for non-fasted patients (such as cardioversions, TEEs and fracture reductions). These areas should be well equipped with anesthetic machines and airway trolleys. One needs to keep in mind the need for a fiberoptic scope in case of airway swelling in severe allergies

The resuscitation team may need to intubate a patient in any area of the hospital. Basic airway kit and intubation equipment are available in all ward areas (**Figure 3**).

**3.8 ENT procedure room**

**3.9 Emergency department**

**3.10 Wards and other areas**

or burns.

**42**

**Figure 3.**

*A resuscitation trolley with airway equipment on the ward.*

Working in different areas outside the OR comes with its own difficulties. These may be specific to the area like the radiology suite or can be general differences to the OR.

**Dark rooms:** Rooms where fluoroscopy or ultrasound is used tend to have low lighting to enable visual clarity of the images for the operator (**Figure 4**). This makes it difficult to observe the patient and to monitor notes. An alternate source of light should always be available [2]. The monitor should be clearly visible in this environment (**Figure 5**).

**Remote location:** When airway management is undertaken away from other trained personnel and specialist equipment, it is important to formulate a plan to getting help quickly in case of a crisis.

**Unfamiliar equipment:** Different areas are equipped with different airway kit. The anesthetic machines may be basic models with minimal monitors. It is important to familiarize oneself with the equipment available prior to use, as they may be very different to those available in the OR.

**Lack of skilled staff:** As mentioned above, skilled support staff may be at a distance, and having a plan to inform and seek help needs to be in place before starting.

**Limited patient access during procedures:** Whether the patient is in the MRI tunnel or fully draped on the interventional radiology table, it is difficult to manipulate the patient's airway once the procedure has begun. The decision to maintain the patient's airway using a particular technique should be taken keeping this in mind.

**Crowded rooms:** The rooms mentioned above can be very crowded with equipment essential to the procedure being performed (**Figure 4**). In the

**Figure 4.** *A dimly-lit crowded interventional radiology room.*

#### **Figure 5.** *Basic monitoring.*

fluoroscopy rooms, the C-arms of the fluoroscope will move in multiple axes and can come in the way of airway or monitoring equipment intra-procedure. Very little consideration is given to airway equipment placement in these areas as not all procedures require patient sedation or airway manipulation. It is therefore important to reshuffle equipment, in discussion with the operator, to make sure airway maintenance and management is kept safe throughout the procedure.

**Radiation exposure:** Patients and staff are exposed to high doses of ionizing radiation in the radiology suite. Radiation exposure poses a significant health risk. Measures taken to minimize exposure and risk during the procedure include wearing protective lead aprons, thyroid shields, eye protection, radiation exposure badges (to log exposure) and distancing oneself as far as possible from the radiation source.
