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Utility versus Familiarity in the Psychologically Difficult Airway

Michael Macias


By Michael Macias


The incorporation of video laryngoscopy (VL) and other airway adjuncts into airway management in the emergency department has been rapid and welcoming. Many recent publications have shown utility of VL over direct laryngoscopy (DL) in terms of higher rates of first pass success as well as superior views of the glottic opening. A recent quality improvement study looking at difficult airways in an academic center also showed great correlation with improved first pass rates using VL in the presence of difficult airway characteristics (i.e. airway edema, cervical immobility, facial/neck trauma, large tongue, obesity, etc.).

One of many tools for predicting difficult airway based on patient's characteristics.

This has not only been exciting news for airway enthusiastic emergency department residents who are eager to try out new gadgets and techniques, but it has also provided senior residents and attending physicians with a higher comfort level during intubations by junior residents. The ability to see what a amateur airway operator is seeing and guide them in the right direction gives the onlookers a sense of control over the situation and a piece of mind. 

I am an avid technology and airway enthusiast and often opt for the 'cooler' airway adjunct when available and appropriate. However as an junior resident, who continues to learn and build on my airway algorithms, I would like to make a argument that utility loses to familiarity in what I would define as an alternative form of a difficult airway. That is the psychologically difficult airway.


How I feel during stress.


I am in 100% agreement with the fact that VL is at least as good and maybe even better than DL and that in many niche situations, will provide a better view. However most of the studies that have been done regarding 'difficult airways' are defined as difficult based off patient characteristics. But what about the psychology the difficult airway? These studies do not include the 'temperature' of the room, the acuity of the situation, the heat of your attending breathing down your back. STRESS. That is what makes a straight forward airway difficult, or a difficult airway (by standard definitions) borderline impossible.

So you are presented with a patient that is rapidly decompensating in front of you. They are minimally responsive and hypotensive. Blood oozing from the oropharynx. You are head of the bed, bag mask in hand, pumping life saving oxygen into your patient who is trying to die. The room is loud, commotion everywhere, access being obtained, fluids being started, orders being given, monitors buzzing in your ear. You set up your airway tools, suction at bedside, patient positioned, preoxygenation is as good as it's going to get. You call out drug orders as you are told 'you have one look bud, I would use a glidescope for this one.' Glidescope? You've only used it a few times. You look up and gasp (only in your head of course) as over 20 eyes are starring at you. You're up. Ready to go?


Stress and its impact on our performance.


This is a more appropriate example of a difficult airway in the eyes of a less experienced airway operator. Stress is extremely high, pressure is on and there is a conflict between what your seniors think you should use versus what you are most comfortable with. So what do you do? Your heart is racing, your hyperventilating. You definitely are not at your sharpest cognitively. Your motor skills are declining. Is a new innovative technology going to save you now? 

Plenty of studies on stress and cognition, have shown that under stress we rapidly fail in making appropriate decisions and performing complex motor activities. We were taught about the sympathetic nervous system beginning in high school biology. It's simple, 'fight or flight' that was what the system was created for. What comes to the surface in these circumstances is our underlying training, what he have done over and over again. Instincts, engrained motor pathways, and actions that require minimal cognitive demand.


Adrenaline is a key component to our cognitive decline during our stress response. 


At times of high adrenaline output where mental faculties are at bay, auto-pilot is our best friend. While in theory an alternative airway adjunct may provide a better view for the experienced user, or in a large study it may show increased success rates of first pass intubation, it may not be the right tool for the specific situation at hand. Use what you know. Use what you are comfortable with and use what requires the smallest amount of new motor activity. Remember that it's your airway and the more confident, comfortable and relaxed you are, the smoother the intubation will go. Take a few deep breaths before you dive in with your laryngoscope and give yourself a pep talk (have a mantra to build your confidence).

Novel is not always better, learn when to stick with what you know best. 

FOAMed Resources:


  • De Jong et al. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis. Intensive Care Medicine 2014, 40 (5): 629-39.

  • Sakles et al. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department. Internal and Emergency Medicine 2014, 9 (1): 93-8.

  • Jestin et al. Does the use of video laryngoscopy improve intubation outcomes?Annals of Emergency Medicine 2014, 64 (2): 165-6.
  • Siddle, Bruce K. Sharpening the Warrior's Edge. Belleville, IL: Distributed by PPCT Research Publications, PPCT Management Systems, 1995. Web.