SMART Strategies for Managing Unanticipated Difficult Airway: A Unique Cognitive Tool

Managing an unanticipated difficult airway is demanding due to its dynamicity, uncertainty and intense time pressure. In this regard, guidelines are available from various societies to help healthcare personnel worldwide handle oxygenation and ventilation failure.[1-3] Guidelines recommend the best attempts in each lifeline, namely mask ventilation, endotracheal tube and supraglottic airway insertion. Recalling various available options to optimise the attempt is challenging during a crisis. In this regard, the ‘vortex approach’ as a cognitive tool[4] and infographics from the recent 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway[1] have helped in successful airway management. Attempting various strategies is the key to successful airway management. However, the literature does not offer an easily remembered cognitive tool with different possible strategies that will serve as a ready reckoner, as read by another anaesthesiologist not involved in airway management. We attempted to devise a unique cognitive tool for easy recall of multiple options to optimise a lifeline through SMART strategies [Table 1].Table 1: SMART strategies for mask ventilation/endotracheal intubation/SAD insertionSMART stands for S – Source for co-oxygenation and suction, M – Manipulation at Head and Neck OR larynx OR Device, A – Adjuncts, R – Resize and type and T – Tone. Strategies using the acronym SMART are described below. SMART strategies must be attempted consciously for every lifeline; however, no prescribed sequence exists. This evades fixation error, the major human factor for failure in crisis. The described strategies can also be used in routine airway management. The table should be used as a checklist, which is checked by the team leader who also keeps the time. Ensure source for co-oxygenation in all three lifelines. The suction source is crucial in clearing secretions and blood from the airway, and Yankauer suction is superior to conventional suction catheters. Manipulation of the head and neck or larynx or device, use of airway adjuncts and change in size and type of device will assist in optimising the attempt. Ensuring adequate muscle relaxation will overcome difficult mask ventilation related to the functional airway. On failing to secure the definitive airway, always keep an option of using injection sugammadex for emergency reversal of neuromuscular blockade to regain spontaneous breathing. Ensure that the most experienced anaesthesiologist makes at least one attempt. If there is a failure to secure the airway with all three lifeline options and saturation remains at >90%, awakening the patient should be attempted. Surgical airway should be attempted without delay if the oxygen saturation drops <90%. Surgical airway options include (1) bougie-scalpel (#10 blade) technique with 6 mm endotracheal tube, (2) scalpel finger needle, (3) cannula cricothyroidotomy and (4) needle cricothyroidotomy with a pressure-regulated device. Other options include rigid bronchoscopy and extracorporeal membrane oxygenation, if available. The table below acts as a cognitive tool for team members involved in securing the airway. A suggested option is to assign a team leader who reviews various strategies using this cognitive tool to assist healthcare personnel in securing the airway. The team leader also notes the time taken for each strategy to enhance situational awareness. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.