Best Laid Plans

Not that long ago there was a whole post on the redesign of the difficult airway trolley at The Children’s Hospital at Westmead. It was pretty popular, but it was sort of missing (at least) one thing. Dr Andrew Weatherall returns with an update.

If you build it they will come. Apparently.

And they will all share exactly the same vision about how things should be. Allegedly.

That’s exactly how it works with passionate health professionals, right? It has definitely never been like herding cats for anyone, yes?

Actually it turns out that as that difficult airway trolley comes more and more into use, the feedback has been pretty good and people are pretty onboard. One thing that did come up though was a desire for some sort of algorithm or guide for planning difficult airways.

This makes a lot of sense. In paediatrics, anticipated difficult airways make up way more of the actual airway challenges than the unanticipated wild ride. So of course you should have something to guide you on your way as you take on the gnarly wilds of the airway landscape.

Simple, right? Grab an algorithm and slap it on that trolley somewhere.

Well, you’d think that. We certainly thought that. We were wrong.

The Plans Out There

The fact we thought it’d be easy is probably more of a reflection on us than the algorithms. We had this vague notion that we wanted something so anaesthetists could plan how to manage a difficult airway situation with their team. We figured that’d include consideration of what was challenging about the airway. Plus it should make it easy to make a few simple choices and end up with an airway plan that everyone could get on board with. Simpler.

So the first port of call was the Difficult Airway Society guidelines. Which, in my head, included something for the anticipated difficult airway. Except …

DAS Paeds Tube

This actually isn’t for the anticipated case. It’s for the unanticipated one. Same goes for their mask ventilation algorithm. Hmmmm… these are not the droids we’re looking for I guess.

That’s OK, because there is that Royal Children’s Hospital Melbourne one out there, which should cover what we want. Except …

RCH Algorithm

It’s not so much for the anaesthesia situation, but it’s super for teams of differing clinicians. Plus it dives straight into primary and secondary intubation plans, which is entirely appropriate for settings like the emergency department. But what if it’s not an intubation plan we’re after?

Anyway, no matter. There’s that ASA one we all learn for the exam. It’ll have the answers, like …

ASA Algorithm

Please, make it stop.

What’s wrong with this picture? 

None of these are actually what we need. At least a couple of them aren’t for our clinical situation and it’s unreasonable to expect them to suit our particular requirement. They do their job well. The one that is a little more for an anticipated difficult airway already has me in the foetal position, rocking back and forth. It’s a miracle I’m still typing.

I just can’t look at that one and see how I’d plan through an airway. Worse still, imagine trying to find your back into it if you needed to figure out where you were up to in a hurry. Now it’s your turn to get out of the foetal position and keep reading.

The more we looked, the more we formed the opinion that all of the airway algorithms just plain suck. Well at least for what we want in our setting. There are heaps out there but we’re looking for something different. For our purposes they just aren’t the thing.

Well, at least that’s what we were telling ourselves. At the very least we couldn’t really find anyone particularly passionate about the clinical usefulness of one of the algorithms where it had done the job for them.

The truth might be that we were expecting something of the available algorithms they were never designed to do. They probably are brilliant for their own settings. But we realised we needed to metaphorically lean on the standard line (‘it’s not you, it’s me’) and break up with all those algorithms. Time to work on something ourselves.

Resetting the Goals

When it came down to it, there were three main goals for the ‘SHFWILF’ (‘still haven’t found what I’m looking for’) trolley planning algorithm thing. The system needed to:

  • Encourage involvement of the whole team.
  • Support comprehensive airway assessment and planning.
  • Support clever clinicians making the best choice in their hands for the patient in front of them.

And it was at about that time that we started thinking we wanted something that wasn’t an algorithm. Or at least we didn’t want what we thought an algorithm was.

Somewhere to share the thinking, and somewhere to share the planning.

Something that was ….not an algorithm.

The Actual Thing

From that point the first draft took about five minutes. It bounced around amongst some anaesthetists and some anaesthetic nurses and got refined bit by bit before we sent it off to the same designer who helped with the trolley itself, a certain James Hutson who does his thing at explanovision.

So this is where it’s at…

Trolley Top June 12 copy

A section to prompt the thinking and a section for sharing the plans. It’s that simple.

So how about we break it down, starting with the prompts?

1. What’s difficult? 


Too often we just think about the intubation bit. Yet we all know that sometimes the difficult bit is the face-mask ventilation and the intubation is a breeze. Sometimes inserting a supraglottic, either as a primary option or rescue is tricky. Assessment should probably consider what’s actually difficult. One thing? Two things? Everything. We designed a difficult airway trolley, not a difficult intubation trolley. So if you’re going to anticipate a difficult airway, make sure you’re anticipating everything it can throw your way we reckon.

2. What airway do you need?


For elective anaesthesia in kids there is a huge array of procedures for which we invoke general anaesthesia. That includes really short procedures, and plenty of things where access to the patient isn’t that tricky. So there will be some occasions where the safer option might not be intubation, particularly when we know that the smaller kids with tricky airways tend to have more complications if you have a few goes at intubation.

Anaesthesia with face-mask ventilation is a technique used to good effect in paediatric anaesthesia. Same goes for supraglottic airways. So we wanted a prompt to make people think about the actual scenario in which they’re looking after the patient.

This item also is the only one with a sub-clause. Given the increasing complication rates with more attempts, why would we choose the lesser version? So what’s the best first choice in the clinician’s hand? When you list them there actually aren’t many techniques in intubation. There’s a direct laryngoscope (and the evidence just isn’t there that videos are always better in kids at this stage), videolaryngoscopy, putting in the endotracheal tube via a supraglottic airway, using the video laryngoscope with a flexible bronchoscope as a flexible introducer, or just going straight to that fiberoptic bronchoscope.

Make that first choice count though. After all that’s what the sheet says.

3. + O2. 


It’s not all about THRIVE it turns out. I mean I say this but we did initially have this listed as “THRIVE – Yes/No”. There are some other great techniques for delivering oxygen though and there isn’t evidence that THRIVE beats them all. So delivery of oxygen to the pharynx is effective a variety of ways, and THRIVE does pretty well via the nose of course.

And this item now reflects that. Having said that, we might change that up to read “Nasal” and “Pharyngeal” because it’s not quite THRIVE. Precision matters.

4. Stop or carry on?


This one seems pretty self-explanatory in terms of being here, although the reasons to choose one either maintenance of spontaneous ventilation vs paralysis might have a few variants. It certainly seems like it’s fair game for a chat with the team so everyone understands the plan.

5. The team


Then of course there’s the all important team to think about. And yes we’re after “bonus” practitioners, because we just thought that asking for “extras” might sound a little bit like those additional team members are a bit of a third wheel rather than helpful. I mean, who doesn’t want a bonus? Plus we already know that you, clever person that is part of the airway management team, you are excellent. We’re just offering you the joys of a bonus person to add to your excellence. Words count.

6. The Right Side

The right side then becomes the space where you apply your assessment and team planning to come up with the best plan in your hands with this particular patient in front of you in this particular situation. Perhaps ‘Plan A’ is a supraglottic airway and ‘Plan B’ is maintain good face-mask ventilation as the airway plan. You might then get to C and think “actually this could wait and we’ll wake up”.

Or maybe you open with an endotracheal tube using videolaryngoscopy and the fibreoptic bronchoscope as your best first option. The plan should be obvious from your team chat, simple to express and simple for everyone to know where they are.


Oh, and just on the off chance you hadn’t got your bonus people and you need to listen to a little voice that will remind you that more hands might be needed, there’s a little speech bubble there with some reminders. Reminders that get a little more insistent as you go.

7. The Middle

All we asked for was a border. We assumed it would be simple. The designer James had a much better idea. How about an outline putting the patient in the middle? If we have any more details about this particular patient that might help, we now have a place to write them. Plus the visual impact of breaking it all up a bit more is truly excellent.


What about using it?

Of course there’s what you design, how you hope it will be used and the uncertainty of the real world. We’ve trialled this in draft form a couple of times, but that was with someone who is pretty keen on it. Will everyone be as keen on it? Absolutely not. But we do have some ideas as to how we hope it will get used.

1. It’s a big space for work

The idea with this is to have it laid out over the whole top surface of the airway trolley. The whole of the operating bench will be that huge planning system. Our first trial will be of some form of hard-wearing sticker so you can just write on it with a whiteboard marker as you plan with the team, then wipe it clean when you’re done.

For the case you have your planning easily accessible and straight away it’s ready to move on to the next paint.

We considered tear-off sheets of paper, or smaller laminated options but in the end this seems like the most sustainable option that is always right there for people to check out with minimal scope for mess.

2. It’s for the team

The hope is that people will use it to work through their assessment and plan with the team before they kick off. That way everyone gets to share the same mental map, ask questions where they need to and plan to get the right equipment to put those plans into action.

We also sort of hope it will be particularly useful for junior members of the team. It’s not always easy to make this sort of conversation happen if you’re a junior member of the team. But now that you’ve got a whole trolley asking the same questions, maybe there’s a different way to make sure you have the chat you need.

3. Straight talk

The act of planning and verbalising out loud serves more than a single function. Beyond the obvious advantages of spending some time planning as a team, the act of verbalising decisions and writing them down should hopefully really focus people’s thinking about all the elements of airway management.

By bringing people together with a useful tool, we’re also sort of hoping people will share more and more of the same terminology when they are thinking about airways. Teamwork will probably be easier in the same language.

4. Tracking what we do

We’re also hoping to use this to track what we do. Wherever possible we’re hoping people will take a photo of their plan and send it through. Not with patient details mind you. Just a sketch of the clinical situation, and whether the plan worked or not.


Which pretty much brings us to where we are right now.

With a story of how we built an algorithm that is not an algorithm.

That still doesn’t have a name.

It seems to be going well though. Maybe we should tackle that herding cats problem next?

I mean, how hard could it be?



This is a thing in its early stages of being trialled and there’s a good chance we’ll have to update it down the track. We’re not saying it will work for everyone either. There’s every chance other places just work differently.

We are saying we want to keep thinking about how to do it better, so if you have excellent ideas you should absolutely drop a comment somewhere. While you’re hanging out you could sign up for email updates when the posts come out.

There are a few interesting papers out there about difficult paeds airways. You might well like these ones as a starting point, though there are plenty more and spending time with the source literature is rewarding.

Sunder RA, Haile DT, Farrell PT, Sharma A. Pediatric airway management: current practices and future directions. Pediatric Anaesthesia. 2012;22:1008-1015.

Fiadjoe JE, Nishisaki A, Jagannathan N, et al. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) Registry: a prospective cohort analysis. Lancet Resp Med. 2015;4:37-48.

Did you get this far? Wow. Well maybe you’d like to enjoy this entirely different design for a piano keyboard. I sort of hope the planning thing is more successful to be honest.

2 responses to “Best Laid Plans

  1. Pingback: Best Laid Plans — Songs or Stories | Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds·

  2. Pingback: The 2018 Year in Review | Songs or Stories·

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