Hindawi
Anesthesiology Research and Practice
Volume 2019, Article ID 6780254, 12 pages
https://doi.org/10.1155/2019/6780254
Review Article
The Difficult Airway Trolley: A Narrative Review and
Practical Guide
Martin F. Bjurström , Mikael Bodelsson, and Louise W. Sturesson
Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Anesthesiology and Intensive Care,
Lund, Sweden
Correspondence should be addressed to Martin F. Bjurström; martin.fl
[email protected]
Received 19 September 2018; Revised 6 December 2018; Accepted 1 January 2019; Published 27 January 2019
Academic Editor: Michael Frass
Copyright © 2019 Martin F. Bjurström et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Death and severe morbidity attributable to anesthesia are commonly associated with failed difficult airway management. When an
airway emergency develops, immediate access to difficult airway equipment is critical for implementation of rescue strategies.
Previously, national expert consensus guidelines have provided only limited guidance for the design and setup of a difficult airway
trolley. The overarching aim of the current work was to create a dedicated difficult airway trolley (for patients>12 years old) for use
in anesthesia theatres, intensive care units, and emergency departments. A systematic literature search was performed, using the
PubMed, Embase, and Google Scholar search engines. Based on evidence presented in 11 national or international guidelines, and
peer-reviewed journals, we present and outline a difficult airway trolley organized to accommodate sequential progression
through a four-step difficult airway algorithm. The contents of the top four drawers correspond to specific steps in the airway
algorithm (A � intubation, B � oxygenation via a supraglottic airway device, C � facemask ventilation, and D � emergency invasive
airway access). Additionally, specialized airway equipment may be included in the fifth drawer of the proposed difficult airway
trolley, thus enabling widespread use. A logically designed, guideline-based difficult airway trolley is a vital resource for any
clinician involved in airway management and may aid the adherence to difficult airway algorithms during evolving airway
emergencies. Future research examining the availability of rescue airway devices in various clinical settings, and simulation studies
comparing different types of difficult airway trolleys, are encouraged.
1. Introduction
Critical airway incidents are arguably the most severe and
feared complications to anesthesia practice. The comprehensive 4th National Audit Project (NAP4) of the Royal
College of Anaesthetists and the Difficult Airway Society
[1, 2] provides the most current detailed analysis of airway
complications. In the United Kingdom, over the course of a
year, out of 2.9 million general anesthetics performed, 16
airway-related deaths and 133 major complications were
found. Closed claims analyses related to management of the
difficult airway confirm the low, but critical, risk for brain
damage and death [3, 4]. Importantly, detailed reviews of
airway incidents show that most of the catastrophic outcomes could have been avoided, given improved, structured
management of these emergencies.
When an unanticipated difficult airway scenario unfolds,
it is key to act in a structured and coordinated manner, with
no unnecessary delays. Essential equipment for management
of the difficult airway must be rapidly accessed, and these
tools should be logically organized. In contrast, qualitative
analysis of the NAP4 data shows that there were often delays
in providing airway equipment, even for basic items such as
endotracheal tubes (ETTs), stylets, nasopharyngeal airways,
and supraglottic airway devices (SADs) [1, 2]. Once a difficult airway situation evolves, the risk of cognitive overload
and stress-induced deterioration of decision-making and
situational awareness increases [5]. Hence, the design and
setup of a dedicated difficult airway trolley (DAT) should, in
addition to containing the adequate equipment, also ideally
facilitate adherence to difficult airway algorithms to decrease
risk of human factor mistakes. Importantly, to reap the
2
benefits of a well-designed DAT, it is crucial that those who
use the DAT are knowledgeable about its organization and
have acquired expertise on all included devices through
clinical training and simulations. As a dedicated DAT is
often present in sites providing general anesthesia, this is not
consistently the case according to recent audits and surveys
[6, 7]. Importantly, as most airway emergencies develop
during the induction phase, incidents can occur throughout
the anesthetic process, including extubation [8] and all the
way to the postanesthesia care unit. Other high-risk locations for difficult airway scenarios include intensive care
units (ICUs) and emergency departments where specific
patient and environmental factors increase the complexity
and challenges of airway management [9].
Despite several national guidelines on management of the
anticipated and unanticipated difficult airway [10–20], with
separate guidelines for pediatric [21–23], obstetric [24], and
intensive care [9, 25] settings, only limited effort has been
directed towards developing specific suggestions regarding
the contents of a DAT. Many of the guidelines provide relatively generic advice, for example, that the content of the
trolley should be set up in accordance with local regulations,
chosen based on favorable evidence, or skills and preferences
of the individual anesthesiologist. Some guidelines suggest a
“minimum equipment” setup which does not suffice for the
individual department or hospital.
Here, based on evidence presented in peer-reviewed
journals, the most recent national guidelines, and expert
consensus, we outline a difficult airway trolley for patients
>12 years old, which can be implemented in any hospital
location where general anesthesia or advanced airway
management is conducted.
Anesthesiology Research and Practice
obstruction” and “endotracheal intubation.” Inclusion of
specific device terms did not improve the search algorithm.
For inclusion of a guideline, at least generic advice regarding difficult airway equipment and/or a DAT was required. Articles and guidelines regarding the pediatric difficult
airway were excluded since this area was beyond the scope of
the review. If an airway society had provided >1 version of a
guideline, only the most recent version was considered for
inclusion. Figure 1 shows the PRISMA flow diagram mapping
the guideline article selection process. Only one article was
excluded based on the language criterion [27].
3. Results
3.1. Included Guidelines. Through the systematic search
process, eleven guidelines with highly varying degrees of
information and details regarding diffic (...truncated)
