Difficult airway trolley contents and das principles

8 min read Last updated April 8, 2026

DAS principles (adult, unanticipated difficult intubation) — structure of management

  • Aim: maintain oxygenation, minimise trauma, call for help early, and move through a structured plan with clear triggers to stop and progress.
  • Plan A: tracheal intubation (initial attempts)
    • Maximise first-pass success: optimal positioning (head-elevated), pre-oxygenation, apnoeic oxygenation, suction ready, appropriate neuromuscular blockade.
    • Limit attempts: typically no more than 3 attempts at laryngoscopy, with a 4th by a more experienced operator if it is likely to succeed.
    • Between attempts: re-oxygenate, change one variable (blade, bougie, video laryngoscope, operator, patient position).
    • Use adjuncts early: bougie/stylet, external laryngeal manipulation, video laryngoscope if available.
  • Plan B: oxygenation via supraglottic airway device (SAD)
    • Insert 2nd generation SAD (preferred) to restore oxygenation; limit attempts (usually up to 3, with a change of size/type/operator).
    • If oxygenation restored: decide wake the patient, intubate via SAD (e.g., Aintree + fibreoptic), or proceed with surgery with SAD depending on context and aspiration risk.
  • Plan C: facemask ventilation (FMV) and wake up
    • If SAD fails, attempt FMV with two-person technique, airway adjuncts (OPA/NPA), optimise head position and jaw thrust.
    • If oxygenation adequate: wake the patient (unless immediate life-threatening need for surgery).
  • Plan D: emergency front-of-neck access (eFONA) for CICO
    • Trigger: cannot intubate, cannot oxygenate (SpO2 falling despite best efforts). Declare CICO, call for help, start eFONA immediately.
    • Recommended technique (adult): scalpel-bougie cricothyroidotomy (scalpel–finger–bougie–tube).
    • After eFONA: confirm ventilation (capnography), secure tube, convert to definitive airway when appropriate (often surgical tracheostomy in theatre/ICU).
  • Human factors embedded in DAS: clear leadership, role allocation, closed-loop communication, cognitive aids, and early declaration of failure.

Difficult airway trolley — practical principles of design and use

  • Standardisation: same layout across sites; labelled drawers; sealed/checked; compatible connectors; clear cognitive aid on top.
  • Accessibility: positioned where airway management occurs; easy to move; contents organised by DAS Plans A–D.
  • Readiness: daily/shift checks; expiry dates; battery charging (video laryngoscope, fibreoptic light source); oxygen supply for jet ventilation if stocked.

Suggested difficult airway trolley contents (mapped to DAS Plans A–D)

  • Top of trolley / immediate access
    • DAS adult unanticipated difficult airway algorithm + local emergency numbers.
    • Capnography confirmation reminder; suction catheter/Yankauer; lubricant; tape/tube ties; scissors.
    • PPE for airway (eye protection, gloves) and head torch (optional).
  • Plan A drawer: intubation optimisation
    • Laryngoscopes: Macintosh blades (range), alternative blades (e.g., McCoy), spare handles/batteries/bulbs.
    • Video laryngoscope with a selection of blades; anti-fog; spare battery/charger.
    • Tracheal tubes: multiple sizes; reinforced tubes; preformed (RAE) if relevant; cuff syringes.
    • Bougies: standard bougie; angled-tip bougie; stylets/introducers; tube exchangers.
    • Adjuncts: Magill forceps (adult/paeds if mixed area), bite block, airway topicalisation kit if used locally.
  • Plan B drawer: supraglottic airway rescue
    • 2nd generation SADs in multiple sizes (e.g., i-gel, LMA Supreme/Protector) + syringes for cuffed devices.
    • 1st generation SADs (optional, depending on local policy) as backup sizes/types.
    • Gastric access: appropriate gastric tubes for 2nd gen SAD drain ports; lubricant.
    • Intubation via SAD kit (if stocked): Aintree intubation catheter, fibreoptic-compatible connectors, stabilising rod for certain LMAs.
  • Plan C drawer: facemask ventilation adjuncts
    • Oropharyngeal airways (Guedel) range; nasopharyngeal airways range + lubricant.
    • Facemasks range; harness/straps (optional); two-person technique aids (e.g., mask cushions).
    • Nasal vasoconstrictor spray (optional) if NPAs/nasal techniques commonly used.
  • Plan D drawer: emergency front-of-neck access (eFONA) — adult
    • Scalpel (size 10 preferred) + spare; bougie; cuffed tracheal tube size 6.0 (and 5.0) with syringe; tube tie.
    • Alternative eFONA set (if used locally): cricothyrotomy kit (e.g., Seldinger) clearly labelled; ensure staff trained in chosen technique.
    • Skin prep swabs (optional) — do not delay oxygenation attempts for sterility in CICO.
  • Fibreoptic / awake airway drawer (often separate airway scope trolley, but may be included)
    • Flexible bronchoscope with working suction; light source/processor; anti-fog; suction tubing.
    • Airway topicalisation: lidocaine sprays/nebules, mucosal atomiser device, syringes/needles, transtracheal injection kit if used locally.
    • Sedation safety: capnography nasal cannulae, oxygen delivery options; local policy for remifentanil/DEX/propofol TCI (drugs usually stored separately).
    • Intubating airways: Ovassapian/Berman, Williams airway (if available), bite blocks.
  • Paediatric considerations (if trolley serves mixed areas)
    • Age/weight-appropriate SADs, masks, OPAs/NPAs, tubes (cuffed/uncuffed per policy), and a paediatric eFONA plan (often needle technique; local guideline).

Key DAS behavioural/technical points often examined

  • Oxygenation is the priority: re-oxygenate between attempts; avoid repeated laryngoscopy causing trauma/oedema/bleeding.
  • Use capnography for confirmation of tracheal intubation and after eFONA; treat absent ETCO2 as oesophageal intubation until proven otherwise (unless low flow states).
  • Early help: second anaesthetist, ODP, ENT/maxfax, ICU; allocate roles (airway, drugs, cricoid release, scribe/timekeeper).
  • Cricoid pressure: if impeding ventilation/intubation/SAD insertion, reduce or release (with clear communication).
  • Neuromuscular blockade: adequate paralysis can improve mask ventilation and laryngoscopy; avoid “can’t intubate, can’t ventilate” due to inadequate depth/relaxation.
  • Post-event: document difficulty, inform patient, provide airway alert letter, consider referral to difficult airway service; restock trolley and debrief team.
Describe the contents of a difficult airway trolley in your hospital and how they map to the DAS algorithm.

Structure your answer by Plans A–D and include checking/standardisation.

  • Top: DAS algorithm, emergency numbers, suction, capnography reminder, tape/ties, scissors, lubricant.
  • Plan A: laryngoscopy + intubation aids (Mac blades, video laryngoscope, bougie/stylet, tubes, tube exchanger, Magill forceps).
  • Plan B: 2nd generation SADs (sizes), gastric tubes, Aintree catheter for intubation via SAD (if stocked).
  • Plan C: FMV adjuncts (OPA/NPA, masks, two-person technique).
  • Plan D: scalpel-bougie-tube set (scalpel 10, bougie, cuffed 6.0 tube, syringe, tie).
  • Governance: standard layout, sealed drawers, daily checks, battery charging, expiry checks, staff training in chosen eFONA technique.
Talk me through the DAS adult unanticipated difficult intubation algorithm (Plans A–D) and the triggers to move on.

Emphasise oxygenation, limiting attempts, and declaring CICO early.

  • Plan A: optimise and attempt intubation; limit attempts (3 + 1 by expert); re-oxygenate between attempts; change one variable each time.
  • Plan B: insert 2nd gen SAD to restore oxygenation; if successful decide wake/intubate via SAD/proceed depending on context.
  • Plan C: FMV with adjuncts and two-person technique; if oxygenation adequate, wake patient.
  • Plan D: if CICO, declare CICO and perform eFONA immediately (scalpel-bougie cricothyroidotomy).
In a failed intubation, how many attempts are acceptable and what changes would you make between attempts?

Examiners want a safe attempt limit and a systematic approach.

  • Attempt limit: usually 3 attempts, with a possible 4th by a more experienced operator if likely to succeed; re-oxygenate between attempts.
  • Change one variable: operator, patient position (head-elevated), device (video laryngoscope), blade type/size, bougie/stylet use, external laryngeal manipulation, suctioning secretions/blood.
  • Avoid repeated trauma: stop if worsening view/bleeding/oedema; move to Plan B early if oxygenation threatened.
You cannot intubate and the SAD is failing. What immediate actions do you take before eFONA?

Focus on oxygenation and team actions; do not delay eFONA if CICO.

  • Call for help and declare emergency; allocate roles; ensure 100% oxygen and high fresh gas flows; suction.
  • Optimise FMV: two-person technique, jaw thrust, OPA/NPA, correct head position; consider reducing/releasing cricoid pressure.
  • If still failing and SpO2 falling: declare CICO and proceed immediately to eFONA (do not persist with repeated attempts).
Describe the scalpel–bougie cricothyroidotomy technique (adult eFONA).

A common FRCA viva: give a clear stepwise method and confirmation.

  • Identify cricothyroid membrane (CTM); stabilise larynx; make a horizontal stab incision through skin and CTM with scalpel (size 10).
  • Rotate scalpel 90° (blade pointing caudally) to open the tract; insert finger to maintain opening and confirm tracheal lumen.
  • Pass bougie alongside finger into trachea; railroad a cuffed size 6.0 tube over bougie; inflate cuff and ventilate.
  • Confirm with capnography; secure tube; plan for definitive airway and post-event care.
How does a 2nd generation SAD differ from a 1st generation SAD, and why does it matter in the DAS algorithm?

Link device features to rescue oxygenation and aspiration risk.

  • 2nd generation SADs have improved seal pressures and a gastric drain channel to reduce insufflation/aspiration risk.
  • They are preferred for rescue oxygenation in Plan B and may facilitate intubation via SAD in selected cases.
What are the key human factors in managing a difficult airway and how would you apply them in theatre?

Examiners want practical behaviours, not just buzzwords.

  • Leadership and role allocation: airway operator, assistant, drugs, cricoid, runner, scribe/timekeeper.
  • Closed-loop communication; verbalise plan and triggers to move on; use cognitive aid (DAS algorithm).
  • Early declaration of failure/CICO; avoid fixation; maintain situational awareness (SpO2 trend).
After a difficult airway event, what documentation and follow-up should occur?

Often asked as a governance/safety viva.

  • Document: grade of view, devices used, number of attempts, complications, successful technique, and recommended future plan.
  • Inform patient and provide written airway alert; update electronic alerts; consider referral to difficult airway/ENT if relevant.
  • Team debrief; restock/check trolley; incident reporting if appropriate.

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