Checklists are commonly used in medical practice. In preparation for an advanced procedure (including securing an airway) using an acronym or other checklist approach will prove invaluable. One such acronym, originally developed as a simple pre-operative anesthesia checklist, is presented. The MSMAID acronym (Machine, Suction, Monitor, Airway, Intravenous access, Drugs) organizes an approach to preparation for airway management and may also prove useful in preparation for other procedures.

The patient’s condition dictates the available time for a provider to consider all items on this checklist. A rapidly deteriorating patient with airway disruption or compromise will need the airway procedure first and follow-on considerations later. If a patient can be more appropriately classified as semi-urgent (e.g., worsening respiratory status due to an underlying pulmonary cause) the provider will have more time to consider the algorithm and prepare. Logistic considerations, and sometimes considerable time constraints, will affect preparation for advanced procedures. Recommendations follow the “minimum, better, best” format.

Machine

(Equipment required post-intubation)

- Minimum: Bag-Valve-Mask (BVM) with positive end-expiratory pressure (PEEP) valve
- Better: Automated portable ventilator (preferably with PEEP); oxygen concentrator
- Best: Full-feature portable ventilator (e.g. several ventilatory modes, PEEP); supplemental oxygen if available

Managing ventilators or advanced equipment unfamiliar to a provider presents challenges. Initiate telemedicine consultation for best guidance.

PEEP is important for prolonged ventilation. PEEP is the pressure in the airway at the end of the expiratory phase which prevents the alveoli of the lung from completely collapsing. In a spontaneously breathing person, this pressure is maintained by closing the glottis, clearing the throat, coughing, sighing, etc. With an invasive airway, the glottis is bypassed with the tube and “natural” PEEP is lost. PEEP should therefore be introduced into the ventilated patient using a PEEP valve on the BVM or using the PEEP setting on a ventilator. When using BVM or ventilator, provide PEEP (recommended initial setting is 5cm H2O).6

Suction

- Minimum: Improvised suction (i.e. syringe + nasopharyngeal airway [NPA]) and patient positioning if not contraindicated
- Better: Manual suction bulb with adapter
- Best: Powered commercial suction with oral tip and in-line endotracheal tube suction adapter

Suction should be available when establishing and maintaining an airway to remove excessive secretions or blood. It is particularly important to utilize suction to facilitate view of the vocal cords during endotracheal intubation. In addition, suction should be available for routine patient care and maintenance requirement for any intubated patients. Suction should be utilized as needed to remove secretions, mucous or blood from the airway device or oropharynx. In the event of high airway pressures, suction may be used to remove mucus/mucus plugs or to clear obstructions. In the case of thick secretions, a saline flush of 1-2 mL followed by in-line suctioning of the endotracheal tube may be useful. Note: During in-line suctioning of tubes, the suction should only be applied when withdrawing the catheter and not upon initial insertion.

Monitor

(Monitoring and telemedicine support)

- Minimum: Pulse oximeter (SpO2), assistant to monitor respirations and record manual vital signs. Trending vital signs documentation. PFC flow sheet is recommended. Refer to PFC Documentation CPG.7 Voice or data connections to perform telemedicine communication
- Better: Portable Capnometry (ETCO2)/capnography in addition to SpO2. Transmit photographs from smartphones or personal devices to augment telemedicine communications.
- Best: Automatic vital signs monitor with SpO2, ETCO2/waveform capnography, +/- electrocardiogram (EKG); Synchronous (real-time continuous) telemedicine using video or remote patient monitoring systems

Monitoring is the active process of assessing the patient throughout a procedure. It involves the gathering, documenting and interpretation of vital signs and other data, and the continuous assessment of their clinical status. Telemedicine can be an important adjunct and critical capability to employ when monitoring a patient undergoing complex procedures.

Airway

- Minimum: Medic is prepared for a ketamine cricothyroidotomy.
- Better: Add ability to provide continuous sedation.
- Best: Add a responsible rapid-sequence intubation capability (to include chemical paralysis) with airway maintenance (to include suction) and continuous sedation.

Per the PFC Capabilities Position Paper, a definitive airway requires control of the patient’s airway with an inflated cuff in the trachea. In addition, sedation is needed to keep the patient comfortable and sustain the airway.8

A proposed algorithm was developed by Mabry RL et al for an awake surgical airway (Figure 1).9 This algorithm incorporates the skills recommended for Tactical Combat Casualty Care and presents the decision process deemed adequate (minimum standard) for definitive airway control in PFC. The airway algorithm is presented in its published form and surgical airway is synonymous with cricothyrotomy. As noted above, the indications for surgical airway include disrupted face or neck anatomy, as well as a need for prolonged positive pressure ventilation in a resource constrained PFC environment. Consider temporizing, if possible, with basic airway maneuvers or other airway adjuncts (e.g.; NPA, SGA). Please see Table 1.