http://journals.lww.com/anesthesiolo..._Closed.9.aspx

Above is a link to a closed claim database for difficult intubations. Very interesting read and very pertinent. The article makes several good points. A significant number of difficult airways arose outside of the OR (ICU, floors etc.). A good portion of these involved tube exchanges. I've seen many tube exchanges go poorly, and the potential for disaster is often no appreciated by others. A number of deaths involved patients with failed awake FOI who were then induced. I would say a good rule is that if you think they need an awake intubation then GA is not a good first and definitely not a good second option. Early tracheostomy was successful if performed early. This is often hard since most of us don't want to have a patient trach'ed. However in cases where obtaining an airway by conventional means proves difficult (angioedema, large retropharyngeal abscess) an early call for awake trach in a controlled setting is much better than an emergent trach with sat's in the toilet. Persistent intubation was associated with poor outcomes. Seems intuitive but some will DL many times before proceeding with a different plan. I think the suggestion of DL x 2 then go to plan B is a wise one. Persistent DL leads only to a bloody, swollen airway and will quickly turn a controlled situation into a bad one. Finally, needle cric and jet ventilation were associated with poor outcomes. These measures were often instituted at a moment of desperation and usually lead to pneumothorax and pneumo-mediastinum. One of my attendings in training told me that if you ever arrived here then you've already lost. Most of us have little to no experience with this technique, and I don't feel great about trying it out. I would much rather take care of business much earlier in the algorithm. Anyway, it's a good, quick read. A little dry but very applicable.