Airway Assistant

OVERVIEW

The airway assistant is a nurse or doctor who assists the intubator during airway management. The term airway ally may also be used, emphasising their active role in team-based airway management and advocacy.

This CCC entry focuses on the role as performed in many ICUs in Australia and New Zealand. There may be local differences in your clinical setting.

RESPONSIBILITIES

These responsibilities are shared with the intubator and both clinicians should take ownership of the airway management process.

The airway assistant:

1. ensures appropriate positioning of self, the patient, and airway equipment
2. checks and understands the airway plan (Plan A, B, C, D), including what equipment is required when.
3. uses the airway drop sheet (if available) and intubation checklist
4. ensures airway equipment is checked and ready to use
5. Passes equipment to and from the intubator correctly and performs airway manoeuvres when required (e.g. assist with mouth opening, jaw thrust, assist with bag-valve-mask apparatus, laryngeal manipulation to assist laryngoscopy, adjusts patient position).
6. independently checks and verbalises that  “sustained exhaled carbon dioxide” and adequate oxygen saturation are present/ absent after an intubation attempt
7. Ensures that the endotracheal tube is secured after intubation

TIPS AND PITFALLS

Positioning of airway equipment

• The airway equipment is ideally positioned on a small trolley to the right of the intubator (and patient) so that equipment can be easily passed to the intubator’s right hand. However, this requires preparation and planning, and may require re-positioning of other equipment such as the ventilator and infusion pumps.

Speak up! 

• The airway assistant should always feel empowered to speak up if something isn’t clear about airway management, if they are unclear about what is planned, or if they have a suggestion.
• It is a shared responsibility of the intubator and the airway assistant to ensure that the airway plan is clearly communicated and able to be executed effectively.

Use cognitive aids

• “Dump sheets” are useful visual guides to help make sure you have all the required equipment.
• Intubation checklists help maintain a shared mental model and ensure nothing important is missed out. It is best used as a call and response check after everything is ready, rather than as a “recipe” to guide airway planning and preparation.
• The checklist is usually called out with the whole team listening, but in true emergencies the airway sub-team may just perform the checklist and report to the team leader that they have completed it themselves and are ready to proceed.

Avoid multi-tasking

• The airway assistant role is vital and requires focus on the task at hand.
• Do not try to perform multiple tasks at once as performance will be affected. Avoid being distracted by noise, alarms, or other events. Notify the team leader if there are conditions that affect your ability to do this.

Avoid role re-allocation

• Once allocated the airway assistant should not switch roles as this is high risk for errors.
• On the rare occasions that role re-allocation is necessary it should be explicit (e.g. Team Leader should announce to the team the new role assignments)and the new airway assistant should restart the checking process from the beginning to avoid errors.

Important equipment mistakes to avoid: 

• Not being clear about what equipment is required for each of Plan A, B, C, or D
• Failing to ensure oxygen is connected and flowing – always follow oxygen tubing all the way from the source to the oxygen delivery device and ensure that oxygen is flowing. In particular, when multiple oxygen delivery devices are used (e.g. nasal prongs, non-rebreather, bag-valve-mask) there is risk of confusing which device is attached to which tubing/ source.
• Handing over a bougie or ETT upside down
• Not controlling the bougie when railroading an ETT over it (e.g. no one holding onto bougie or bougie getting snagged on ETT connector)
• Passing bougies or ETTs to an intubator’s left hand, rather than the right hand (the laryngoscope is always held in the left hand)
• Passing over wrong type or size of equipment
  • Size 3 or 4 laryngoscope blade for direct laryngoscopy?
  • Size and type of supraglottic airway (SGA) device?
  • Video laryngoscopy blade – standard geometry or hyperangulated blade? Size?
    • If multiple VL devices are available, ensure the correct one is obtained. For instance, confusion between McGrath (video attached to blade, stored on airway trolleys) and C-Mac video laryngoscopes (has separate video screen, stored near airway trolley in each pod) is common among those unfamiliar with the two devices.
  • Using the wrong airway trolley – departments should have standardised airway trolleys. For instance, where I work each ICU pod has an intubation trolley for airway emergencies with everything required for Plan A, B, C, D and for tracheostomy emergencies. There is a separate “advanced airway equipment” trolley that has additional equipment that is less commonly used (e.g. equipment for awake intubation and insertion of double lumen tubes). Equipment required for a specific patient is taken from the airway trolley and placed on a small trolley that is taken into the patient’s room and easily cleaned.

SUGGESTED COMPETENCIES

The airway assistant role in ED and ICU usually does not require specific credentialing. However, it is a role that requires specific skills. 

Proposed airway ally competencies include:

• Airway equipment expertise
• Airway strategy development and preparation
• Implementation of airway plans (including laryngoscopy, face mask ventilation, supraglottic airway insertion, front-of-neck access, and tracheostomy emergencies)
• Effective communication

REFERENCES

FOAM and web resources

• Krstin Bantug – Airway Ally (15 min video presentation)