**3. Areas outside the OR**

*Special Considerations in Human Airway Management*

**2. Anticipating difficulty is key**

put patients at an increased risk of airway complications. This chapter addresses the important facets of this invaluable skill when used outside the operating room, taking into consideration both anesthesiologists and non-anesthesiologists as operators. Since the intensive care unit is a highly specialized area, similar to the OR, a separate chapter has been written for airway management in the ICU. Therefore, this chapter will concentrate on other areas outside the OR. It will not address resuscitation scenarios where immediate airway management is unplanned and is a life-saving procedure, and may be needed in any area of the hospital and beyond.

As with any skill, preparation is fundamental and is the secret to avoiding harm to patients. Ideally, all patients needing airway manipulation outside the OR should be assessed for potential difficulty, and prepared just as they would be for an elective procedure in the OR. One of the reasons airway management is more difficult outside the OR than inside is due to the fact that there may not be enough time to learn about the patient's physical condition and to predict risk of difficult airway or aspiration. Whenever possible patients should be assessed for comorbidities, drug allergies and fasting status. An airway assessment should be completed. There are many aides-memoires to help with a quick but relatively thorough assessment of the airway to predict difficulty with mask ventilation and intubation. These should be available in all areas for the physician to refer to, ideally attached to the difficult airway trolley. Risk factors for difficult mask ventilation include an increased body mass index (BMI), history of obstructive sleep apnea (OSA), presence of a beard that may disrupt the seal of the face mask, being edentulous and having limited mandibular protrusion. A difficult laryngoscopy is anticipated when a patient has limited mouth opening, a Mallampati score of III or IV, limited head and neck

Patient preparation is also important. A patient who is not fasting adequately is at a higher risk of aspiration of gastric contents during induction of anesthesia and intubation. Standard airway equipment and monitoring that conforms to international safety standards should be readily available. These are discussed below. For intubating patients, it is sometimes difficult to get optimal positioning of the patient outside the OR. The OR tables allow all kinds of position changes, but the trolleys and ward beds are not as versatile. In obese patients, one has to try to achieve the ramp position to aid intubation. Outside the OR, one may need to improvise to achieve this. The Oxford HELP® (Head Elevating Laryngoscopy

movements, is obese and has an increased neck circumference.

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**Figure 1.**

*Troop Elevation Pillow® System.*

There are many areas in hospitals outside of operation theaters and ICUs where sedation or general anesthesia is given for various reasons. This could be to aid uncomfortable diagnostic or therapeutic procedures or for patients who do not have the capacity to understand the need for such essential procedures. The medication that a patient receives defines where on the continuum of sedation (**Table 1**) they lie, which in turn decides the airway support needed.

Every hospital facility will have different areas where airway management will be required or needed to be on standby. Airway management in some areas such as the ICU and prehospital setting will be discussed in other chapters. These are some of the other areas:
