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Hung's
DIFFICULT
AND FAILED
AIRWAY
MANAGEMENT
 NOT IC E
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 THIRD EDITION

Hung's
DIFFICULT
AND FAILED
AIRWAY
MANAGEMENT

ORLA N DO R. HU N G, B S c ( PHARMACY), M D, FRC P (C)

Professor, Departments of Anesthesia, Surgery, and Pharmacology
Director of Research
Department of Anesthesia, Pain Management and Perioperative Medicine
Dalhousie University
Queen Elizabeth II Health Sciences Centre
Department of Anesthesia
Halifax, Nova Scotia, Canada

MICHA EL F. MURPHY, M D, FRC P (C)

Professor Emeritus, Department of Anesthesiology and Pain Medicine
University of Alberta
Walter C Mackenzie Health Sciences Centre
Edmonton, Alberta, Canada

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 ASSOCIATE EDITORS
Thomas J . Coonan, M D, F RC P (C)
Professor, Departments of Anesthesia and Surgery
Dalhousie University
Queen Elizabeth II Health Sciences Centre
Department of Anesthesia
Halifax, Nova Scotia, Canada
N a ra s i m h a n Jagan nathan, M D
Associate Chairman, Academic Affairs
Director, Pediatric Anesthesia Research
Ann & Robert H. Lurie Children's Hospital of Chicago
Associate Professor of Anesthesiology
Northwestern University Feinberg School of Medicine
Chicago, Illinois
George Kovacs, M D, FRCP(C)
Professor, Emergency Medicine
Dalhousie University
Attending Emergency Physician
Nova Scotia Health Authority
Queen Elizabeth II Health Sciences Centre
Halifax, Nova Scotia, Canada
J. Ada m Law, M D, F RC P (C)
Professor, Departments of Anesthesia and Surgery
Associate Head
Department of Anesthesia, Pain Management and Perioperative
Medicine
Faculty of Medicine, Dalhousie University
Queen Elizabeth II Health Sciences Centre
Halifax, Nova Scotia, Canada
la n R. Morris, B Eng, M D, F RC P(C), DABA, FAC E P
Professor, Department of Anesthesia
Dalhousie University
Queen Elizabeth II Health Sciences Centre
Department of Anesthesia
Halifax, Nova Scotia, Canada
Ron a l d D. Stewa rt, OC, O N S, E C N S (hon), BA, BSc, M D,
FACEP, DSc (hon)
Professor Emeritus
Departments of Anesthesia and Emergency Medicine
Faculty of Medicine, Dalhousie University
Queen Elizabeth II Health Sciences Centre
Victoria General Hospital Site
Halifax, Nova Scotia, Canada
 DEDICATION

We would like to thank our families for their understanding and support of our aca­
demic and clinical work by dedicating this edition to: Jeanette, Christopher, David,
and Ana Hung and to Debbi, Amanda, Ryan, and Teddy Murphy. We also dedicate
this edition to the tireless efforts of all who teach airway management. We are grateful
for their commitment to the prevention of death and disability related to airway man­
agement failure.
 CON TEN TS

Contributors .................................................................................... xiii

Foreword ........................................................................................xix

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxi

Acknowledgments ............................................................................. xxiii

PRINCIPLES OF AIRWAY MANAGEMENT

1. Evaluation of the Airway .... . . . .....

. . . . . . 2 4. Pharmacology of Drugs Used
Michael F Murphy and in Airway Management . . . . . . . . . . . . . . . . . . 86
Johannes M. Huitink Jonathan G. Bailey, Ronald B. George,
and Orlando R. Hung
2. The Algorithms . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Michael F Murphy, Edward T. Crosby, 5. Aspiration: Risks and Prevention ..... . . . 107
and J. Adam Law Saul Pytka and Edward Crosby

3. Preparation for Awake Intubation .... . . . . 39 6. Human Factors and Airway

/an R. Morris Management .... . . . . . . ....
. . . . . . ..... .128 .

Peter G. Brindley

AIRWAY TECHNIQUES

7. Context-Sensitive Airway 10. Flexible Bronchoscopic Intubation ... . . .172

Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 /an R. Morris
Orlando R. Hung and Michael F Murphy
11. Rigid Fiberoptic and
8. Bag- Mask-Ventilation .. .... . . . . . . .... . . .1 4 3 Video-Laryngoscopes . . . . . . . . . . . . . . . . . . . 198
George Kovacs, Michael F Murphy, and Richard M. Cooper and J. Adam Law
Nicholas Sowers
12. Nonvisual Intubation Techniques .... . . .222
9. Direct Laryngoscopy . . . . . . . . . . . . . . . . . . . . 155 Chris C. Christodoulou, Orlando R. Hung,
Richard M. Levitan and George Kovacs and Jinbin Zhang

vii
viii Contents
1 3. Extraglottic Devices for Ventilation
and Oxygenation .......................238
Liem Ho, Thomas J. Coonan, and
Orlando R. Hung
PRE-HOSPITAL AIRWAY MANAGEMENT
16. What Is Unique About Airway
Management in the Pre-Hospital
Setting? ................................278
Mark Vu, David Petrie, Michael F. Murphy,
and Erik N. Vu
17. Airway Management of a Patient with
Traumatic Brain Injury (T B I) .............287
J. Adam Law, Edward T Crosby, and Andy Jagoda
18. Airway Management of an
Unconscious Patient Who Is Trapped
Inside the Vehicle Following a Motor
Vehicle Collision ........................300
Arnim Vlatten and Matthias Helm
AIRWAY MANAGEMENT IN THE EMERGENCY ROOM
22. Airway Management in the
Emergency Department ................326
John C. Sakles and Michael F. Murphy
23. Patient with Deadly Asthma Requires
Intubation ..............................3 31
Kerryann B. Broderick and Jennifer W Zhan
24. Tracheal Intubation in an Uncooperative
Patient With a Neck Injury...............3 37
Kerryann B. Broderick
25. Airway Management for the
Burn Patient ............................3 41
Laeben Lester and Darren Braude
14. Cricothyrotomy.........................259
Gordon 0. Launcelott, Liane B. Johnson,
David T Wong, and Orlando R. Hung
15. Tracheotomy ...........................270
Timothy F. E. Brown and Liane B. Johnson
19. Airway Management of a Race
Car Driver with a Full-Face Helmet
Following a Crash.......................305
Mark P Vu, Angelina Guzzo, and
Orlando R. Hung
20. Airway Management of a Morbidly
Obese Patient Suffering from
a Cardiac Arrest.........................311
Saul Pytka and Danae Krahn
21. Airway Management with Blunt
Anterior Neck Trauma...................320
David A. Caro
26. Airway Management in a Patient
with Angioedema ......................3 45
Genevieve MacKinnon, Michael F. Murphy,
and David Petrie
27. Airway Management for Penetrating
Facial Trauma...........................350
David A. Caro and Aaron E. Bair
28. Airway Management in a Patient
with a Deep Neck Infection .............355
Kirk J. MacQuarrie

AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT (ICU)
29. Unique Airway Issues in the
Intensive Care Unit .....................364
Shawn D. Hicks, J. Adam Law, and
Michael F. Murphy
30. Management of Extubation of a Patient
Following a Prolonged Period of
Mechanical Ventilation..................370
Richard M. Cooper
31. Airway Management of a Patient in a
Halo-Jacket with Acute Obstruction
of a Reinforced Tracheal Tube...........377
Dietrich Henzler
AIRWAY MANAGEMENT IN THE OPERATING ROOM
35. Airway Management of an
Uncooperative Down Syndrome
Patient with an Upper Gl Bleed..........408
Michael F. Murphy
36. Airway Management of a Patient
with a History of Oral and Cervical
Radiation Therapy ......................413
/an R. Morris
37. Airway Management in Penetrating
Neck Injury .............................424
/an R. Morris
38. Airway Management of a Patient
in Prone Position .......................4 40
Dennis Drapeau and Orlando R. Hung
39. Lung Separation in the Patient
with a Difficult Airway ..................450
ian R. Morris
40. Airway Management of a Patient with
Superior Vena Cava Obstruction
Syndrome ..............................457
Mathieu Asselin and Gordon 0. Launcelott
Contents ix
32. Management of a Patient Admitted to
ICU with Ebola Virus and Impending
Respiratory Failure ......................38 3
Louise Ellard and David T Wong
3 3. Performing an Elective Percutaneous
Dilational Tracheotomy in a Patient
on Mechanical Ventilation ..............390
Angelina Guzzo, Liane B. Johnson,
and Orlando R. Hung
3 4. Management of a Patient with
a Respiratory Arrest in the
Intermediate Care Unit..................400
Peter G. Brindley
41. Airway Management in a Patient with
Aspiration of Gastric Contents
Following Induction of Anesthesia ......46 3
Kathryn Sparrow and Orlando R . Hung
42. Airway Management of a Patient
with History of Difficult Airway
Who Refuses to Have Awake
Tracheal Intubation .....................469
Dmitry Portnoy and Carin A. Hagberg
4 3. Management of a Patient with OSA
for Total Thyroidectomy ................481
Jinbin Zhang, Frances Chung, and
Orlando R. Hung
4 4. Airway Management of a Patient
with a Difficult Airway Requiring
Microlaryngoscopy, Tracheoscopy,
and Pharyngoesophageal Dilation ......492
Jeanette Scott, David Vokes, and L V Duggan
x Contents

AIRWAY MANAGEMENT IN THE PEDIATRIC POPULATION

45. Unique Airway Issues in the 48. Airway Management of a 6-Year-Oid

Pediatric Population ....................508 with Pierre Robin Syndrome for
Narasimhan Jagannathan, Andrea Huang, Bilateral Inguinal Hernia Repair ..........5 35
Anthony Longhini, and John Hajduk Ban C.H. Tsui

46. Management of a 12-Year-Oid 49. Cannot Intubate and Cannot

Child with a Foreign Body in Oxygenate in an Infant After
the Bronchus ...........................524 Induction of Anesthesia.................5 47
Liane B. Johnson Paul A. Baker and Cedric Ernest Sottas

47. Management of a Child with 50. A Neonate with a Difficult Airway

a History of Difficult Intubation and Aspiration Risk .....................555
and Post-Tonsillectomy Bleed ...........5 30 Andrea Huang, Sebastian Bienia, John Hajduk
Arnim Vlatten and Matthias Helm and Narasimhan Jagannathan

AIRWAY MANAGEMENT IN OBSTETRICS

51. What Is Unique About the Obstetrical 5 4. Airway Management of

Airway?.................................562 the Pregnant Trauma
Dolores M. McKeen and Jo Davies Victim ..................................585
Holly A. Muir
52. Airway Management of the Obstetrical
Patient with an Anticipated Difficult 55. Appendicitis in
Airway..................................57 4 Pregnancy ..............................589
Jo Davies and Brian K. Ross A/lana Munro, Ronald B. George and
Narendra Vakharia
5 3. Unanticipated Difficult Airway in an
Obstetrical Patient Requiring an
Emergency Cesarean Section ...........579
Holly A. Muir
 Contents xi

AIRWAY MANAGEMENT IN UNIQUE ENVIRONMENT

56. Unique Challenges of Ectopic 59. Airway Management in Austere

Airway Management....................596 Environments ..........................619
Michael F Murphy Kelly McQueen, Alison B. Froese,
Thomas J. Coonan and Jinbin Zhang
57. Airway Management of the Patient
with a Neck Hematoma .................601 60. Respiratory Management in the
J. Adam Law and Kitt Turney Magnetic Resonance Imaging Suite .....628
Richard D. Roda and Andrew D. Milne
58. Airway Management Under Combat
Conditions .............................612 61. Post-Obstructive Pulmonary
Matthias Helm and Arnim Vlatten Edema ( P O P E) ..........................636
Matthew G . Simms and J . Adam Law

PRACTICAL CONSIDERATIONS IN AIRWAY MANAGEMENT

62. Difficult Airway Carts....................646 6 4. Teaching and Simulation for

Saul Pytka and Michael F Murphy Airway Management....................662
Brian Ross, Jo Davies, Sara Kim, and
6 3. Documentation of Difficult and Failed
Michael F Murphy
Airway Management....................656
Lorraine J. Foley, Michael F Murphy and
Orlando R. Hung

Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
.

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 681
.
This page intentionally left blank
 CON TRIBUTORS

Mathieu Asselin, MD, FRCP(C) Kerryann B. Broderick, BSN, MD

Department of Anesthesia Associate Professor, Department of Emergency Medicine
University of Laval Denver Health Medical Center
Universitaire de Quebec, Pavillon H6pital Enfant-Jesus University of Colorado, School of Medicine
Quebec, Quebec, Canada Denver, Colorado
Chapter 40 Chapters 23, 24
Jonathan G. Bailey, MD, MSc Timothy F.E. Brown, MD, FRCSC
Department of Anesthesia, Pain Management and Department of Otolaryngology
Perioperative Medicine Dalhousie University
Dalhousie University Queen Elizabeth II Health Sciences Centre
Queen Elizabeth II Health Sciences Centre Victoria General Site
Halifax, Nova Scotia, Canada Halifax, Nova Scotia, Canada
Chapter 4 Chapter I5
Aaron E. Bair, MD, MS David A. Caro, MD
Assistant Professor, Emergency Medicine Associate Residency Director
U.C. Davis Medical Center Assistant Professor
Sacramento, California Department of Emergency Medicine
Chapter 27 University of Florida Health Science Center-Jacksonville
Jacksonville, Florida
Paul A. Baker, MBChB, MD, FANZCA
Chapters 2I, 27
Clinical Senior Lecturer
Department of Anesthesiology Chris C. Christodoulou, MBChB, Cum Laude DA
University of Auckland, New Zealand (UK), FRCP(C)
Consultant Anaesthetist Assistant Professor in Anesthesia
Starship Children's Hospital Department of Anesthesia and Perioperative Medicine
Auckland, New Zealand University of Manitoba
Chapter 49 I.H. Asper Clinical Research Institute
Winnipeg, Manitoba, Canada
Sebastian Bienia, MD
Chapter I2
Department of Pediatric Anesthesia
Ann & Robert H. Lurie Children's Hospital of Chicago Frances Chung, MBBS, FRCP(C)
Fellow in Pediatric Anesthesiology Professor, Department of Anesthesiology
Northwestern University Feinberg School of Medicine University of Toronto
Chicago, Illinois Toronto Western Hospital
Chapter 50 Toronto, Ontario, Canada
Chapter 43
Darren Braude, MD, EMT-P, FACEP
EMS Section Chief/Fellowship Director Thomas J. Coonan, MD, FRCP(C)
Professor of Emergency Medicine Professor, Departments of Anesthesia and Surgery
University of New Mexico Dalhousie University
Corrales, New Mexica Queen Elizabeth II Health Sciences Centre
Chapter 25 Department of Anesthesia
Halifax, Nova Scotia, Canada
Peter G. Brindley, MD, FRCP(C), FRCP, Edin
Chapters I3, 59
Adj unct Professor, Department of Anesthesiology and Pain
Medicine Richard M. Cooper, BSc, MSc MD, FRCP(C)
University of Alberta Hospital Professor, Department of Anesthesia
Walter C Mackenzie Health Sciences Center University of Toronto
Edmonton, Alberta, Canada Department of Anesthesia and Pain Management
Chapters 6, 34 Toronto General Hospital
Toronto, Ontario, Canada
Chapters II, 30

xiii
xiv Contri b utors

Edward T. Crosby, MD, FRCP(C) Angelina Guzzo, MD, PhD, FRCP(C)

Professor, Department of Anesthesiology Assistant Professor, McGill University Health Centre
University of Ottawa Department of Anesthesia
Ottawa Hospital-General Campus Montreal General Hospital
Ottawa, Ontario, Canada Montreal, Quebec, Canada
Chapters 2, 5, 11 Chapters 19, 33
Jo Davies, MBBS, FRCA Carin A. Hagberg, MD
Associate Professor, Department of Anesthesiology Joseph C. Gabel Professor and Chair
University of Washington Department of Anesthesiology
Seattle, Washington The University of Texas Medical School at Houston
Chapters 51, 52, 64 Medical Director of Perioperative Services
Memorial Hermann Hospital
Dennis Drapeau, BSc, MD, FRCP(C)
Houston, Texas
Staff Anesthesiologist/Assistant Professor
Chapter 42
Department of Anesthesia
Queen Elizabeth II Health Sciences Centre John Hajduk
Dalhousie University Clinical Research Coordinator
Halifax, Nova Scotia, Canada Department of Pediatric Anesthesia
Chapter 38 Ann & Robert H. Lurie Children's Hospital of Chicago
Chicago, Illinois
Laura Duggan, MD, FRCP(C)
Chapters 45, 50
Anesthesiology and Pediatrics
Assistant Professor Prof. Dr. med. Matthias Helm
Department of Anesthesiology, Pharmacology and Chief Emergency Medicine
Therapeutics Department of Anaesthesiology, Intensive Care Medicine,
University of British Columbia Emergency Medicine and Pain Therapy
Royal Columbian Hospital Armed Forces Hospital
New Westminster, British Columbia, Canada Ulm, Germany
Chapter 44 Chapters 18, 47, 58
Louise Ellard, MBBS, FANZCA, AdvPTEeXAM Dietrich Henzler, MD, PhD, FRCP(C)
Staff Anaesthetist Professor of Anesthesiology
Department of Anaesthesia Ruhr University Bochum, Germany
Austin Health Dalhousie University, Halifax, Nova Scotia, Canada
Victoria, Australia Department of Anesthesia, Surgical Critical Care, Emergency
Chapter 32 and Pain Medicine
Klinikum Herford
Lorraine J. Foley, MD
Schwarzenmoorstr, Herford, Germany
Clinical Assistant Professor of Anesthesia
Chapter 31
Tufts School of Medicine, Boston, Massachusetts
Winchester Anesthesia Associates Shawn D. Hicks, MD, MSc, FRCP(C)
Winchester Hospital Assistant Professor, Department of Anesthesiology
Department of Anesthesia University of Ottawa
Winchester, Massachusetts The Ottawa Hospital, Civic Campus
Chapter 63 Ottawa, Ontario, Canada
Chapter 29
Alison B. Froese, MD, BSc Med, FRCP(C)
Professor Emerita, Queen's University Liem Ho, MD
Departments of Anesthesiology, Pediatrics, and Physiology Department of Anesthesia
Kingston, Ontario, Canada Dalhousie University
Chapter 59 Queen Elizabeth II Health Sciences Centre
Halifax, Nova Scotia, Canada
Ronald B. George, MD, FRCP(C)
Chapter 13
Assistant Professor, Women's & Obstetric Anesthesia
Department of Anesthesia, Pain Management and Andrea Huang, MD
Perioperative Medicine Department of Pediatric Anesthesia
Dalhousie University Ann & Robert H. Lurie Children's Hospital of Chicago
IWK Health Centre Instructor in Anesthesiology
Halifax, Nova Scotia, Canada Northwestern University Feinberg School of Medicine
Chapters 4, 55 Chicago, Illinois
Chapters 45, 50
 Contri b utors xv

Johannes M. Huitink, MD, PhD Danae Krahn, BHSc (Hons), MD

Assistant Professor Anesthesiology Chief Resident
Department of Anesthesiology Anesthesiology Residency Training Program
VU University Medical Center Amsterdam Cumming School of Medicine
Founder Airway Management Academy University of Calgary
Amsterdam, The Netherlands Calgary, Alberta, Canada
Chapter 1 Chapter 20
Orlando R. Hung, BSc (Pharmacy), MD, FRCP(C) Gordon 0. Launcelott, MD, FRCP(C)
Professor, Departments of Anesthesia, Surgery, and Department of Anesthesia
Pharmacology Dalhousie University
Director of Research, Queen Elizabeth II Health Sciences Centre
Department of Anesthesia, Pain Management and Halifax, Nova Scotia, Canada
Perioperative Medicine Chapters 14, 40
Dalhousie University
J. Adam Law, MD, FRCP(C)
Queen Elizabeth II Health Sciences Centre
Professor, Departments of Anesthesia and Surgery
Department of Anesthesia
Associate Head
Halifax, Nova Scotia, Canada
Department of Anesthesia, Pain Management and
Chapters 4, 7, 12, 13, 14, 19, 33, 38, 41, 43, 63
Perioperative Medicine
Narasimhan Jagannathan, MD Faculty of Medicine, Dalhousie University
Associate Chairman, Academic Affairs Queen Elizabeth II Health Science Centre
Director, Pediatric Anesthesia Research Halifax, Nova Scotia, Canada
Ann & Robert H. Lurie Children's Hospital of Chicago Chapters 2, 11, 17, 29, 57, 61
Associate Professor of Anesthesiology
Laeben Lester, MD
Northwestern University Feinberg School of Medicine
Assistant Professor
Chicago, Illinois
Co-Director, Johns Hopkins Airway Program
Chapters 45, 50
The Johns Hopkins University School of Medicine
Andy Jagoda, MD, FACEP Department of Anesthesiology and Critical Care Medicine
Professor and Chair Division of Cardiothoracic Anesthesia
Department of Emergency Medicine Affiliate Department of Emergency Medicine
Mount Sinai School of Medicine Baltimore, Maryland
New York, New York Chapter 25
Chapter 11
Richard M. Levitan, MD
Liane B. Johnson, MDCM, FRCSC, FACS Associate Professor, Emergency Medicine
Department of Otolaryngology Thomas Jefferson University
Dalhousie University Department of Emergency Medicine
Department of Pediatric Otolaryngology Philadelphia, Pennsylvania
IWK Health Centre Chapter 9
Halifax, Nova Scotia, Canada
Anthony Longhini, MD
Chapters 14, 15, 33, 46
Department of Anesthesiology
Sara Kim, PhD Northwestern University Feinberg School of Medicine
Associate Professor, Department of Anesthesiology and Chicago, Illinois
Biolnformatics Chapter 45
University of Washington
Genevieve MacKinnon, MD, FRCP(C)
Seattle, Washington
Assistant Professor
Chapter 64
Department of Pain Management and Perioperative Medicine
George Kovacs, MD, MD, FRCP(C) Dalhousie University
Professor Emergency Medicine Attending Physician Anesthesiology
Dalhousie University Nova Scotia Health Authority
Attending Emergency Physician Queen Elizabeth II Health Sciences Centre
Nova Scotia Health Authority Halifax, Nova Scotia, Canada
Queen Elizabeth II Health Sciences Centre Chapter 26
Halifax, Nova Scotia, Canada
Chapters 8, 9
xvi Contri buto rs

Kirk J. MacQuarrie, MD, FRCP(C) Michael F. Murphy MD, FRCP(C)

Departments of Anesthesia, Surgery and Emergency Medicine Professor Emeritus, Department of Anesthesiology and Pain
Dalhousie University Medicine
Queen Elizabeth II Health Sciences Centre University of Alberta
Victoria General Hospital Walter C Mackenzie Health Sciences Centre
Halifax, Nova Scotia, Canada Edmonton, Alberta, Canada
Chapter 28 Chapters 1, 2, 7, 8, 16, 22, 26, 29, 35, 56, 62, 63, 64
Dolores M. McKeen, MD, MSc, FRCP(C) David Petrie, MD, FRCP(C)
Professor Associate Professor of Emergency Medicine
Department of Anesthesia, Pain Management and Dalhousie University
Perioperative Medicine Attending Physician Emergency Medicine
Dalhousie University Nova Scotia Health Authority
IWK Health Centre Queen Elizabeth II Health Sciences Centre
Halifax, Nova Scotia, Canada Halifax, Nova Scotia, Canada
Chapter 51 Chapter 16
Kelly McQueen, MD, MPH Dmitry Portnoy, MD
Professor, Department of Anesthesiology Associate Professor
Director, Vanderbilt Anesthesia Global Health & Department of Anesthesiology and Perioperative Care
Development Staff Anesthesiologist
Director, Vanderbilt Global Anesthesia Fellowship UC Irvine Medical Center
Affiliate Faculty, Vanderbilt Institute for Global Health Orange, California
Vanderbilt University Medical Center Chapter 42
Nashville, Tennessee
Saul Pytka, MD, FRCP(C)
Chapter 59
Associate Professor
Andrew D. Milne, BEng, MSc, MD, FRCP(C) Department of Anesthesiology
Assistant Professor, Department of Anesthesia University of Calgary
Dalhousie University Attending Anesthesiologist
Queen Elizabeth II Health Sciences Centre Rockyview Hospital
Halifax, Nova Scotia, Canada Calgary, Alberta, Canada
Chapter 60 Chapters 5, 20, 62
Jan R. Morris, BEng, MD, FRCP(C), DABA, FACEP Richard D. Roda, BEng, MASc, MD
Professor, Department of Anesthesia Department of Anesthesia, Pain Management and
Dalhousie University Perioperative Medicine
Queen Elizabeth II Health Sciences Centre Faculty of Medicine, Dalhousie University
Department of Anesthesia Queen Elizabeth II Health Sciences Centre
Halifax, Nova Scotia, Canada Halifax, Nova Scotia, Canada
Chapters 3, 10, 36, 37, 39 Chapter 60
Holly A. Muir, MD, FRCP(C) Brian K. Ross, PhD, MD
Chair and Professor Professor, Department of Anesthesiology and Pain Medicine
Department of Anesthesiology, Executive Director Institute for Surgical and Interventional
Keck School of Medicine, Simulation
University of Southern California University of Washington
Los Angeles, California Seattle, Washington
Chapters 53, 54 Chapters 52, 64
Allana Munro, MD, FRCP(C) John C. Sakles, MD, FACEP
Women's & Obstetric Anesthesia Professor, Department of Emergency Medicine
Department of Anesthesiology, Dalhousie University University of Arizona College of Medicine
IWK Health Centre Tucson, Arizona
Halifax, Nova Scotia, Canada Chapter 22
Chapter 55
 Contri b utors xvi i

Jeanette Scott, MBChB, FANZCA Kitt Turney, MD

Anesthesiologist Resident Anesthesiologist, Department of Anesthesia, Pain
Department of Anaesthesia and Pain Medicine Management and Perioperative Medicine
Middlemore Hospital Queen Elizabeth II Health Sciences Centre
Department of Cardiac and ORL Anaesthesia Halifax, Nova Scotia, Canada
Auckland City Hospital Chapter 57
Auckland, New Zealand
Narendra Vakharia, MD, FRCP(C)
Chapter 44
Associate Professor
Matthew G. Simms, MSc, MD, FRCP(C) Dalhousie University
Staff Anesthesiologist Halifax, Nova Scotia, Canada
Department of Anesthesia, Faculty of Medicine Chapter 55
Dalhousie University
Arnim Vlatten, MD
Queen Elizabeth II Health Sciences Centre
Associate Professor
Halifax, Nova Scotia, Canada
Departments of Anesthesia, Pediatric Anesthesia, and
Chapter 61
Pediatric Critical Care
Cedric Ernest Sottas, MD Dalhousie University
Anaesthesia Fellow Queen Elizabeth II Health Sciences Centre
Department of Pediatric Anaesthesia Halifax, Nova Scotia, Canada
Starship Children's Hospital Chapters 18, 47, 58
Auckland, New Zealand
David Vokes, MBChB, FRACS
Chapter 49
Laryngologist, Head and Neck Surgeon
Nicholas Sowers, MD Department of Otorhinolaryngology
Resident, Emergency Medicine Auckland City Hospital
Dalhousie University Auckland, New Zealand
Halifax Infirmary Chapter 44
Halifax, Nova Scotia, Canada
Erik N. Vu, CCP, MD, FRCP(C), DAvMed
Chapter 8
Assistant Professor, Faculty of Medicine, University of British
Kathryn Sparrow, BSc, MD, FRCP(C) Columbia
Department of Anesthesia Departments of Emergency and Critical Care Medicine
Memorial University of Newfoundland British Columbia Emergency Health Services
Faculty of Medicine Vancouver, British Columbia, Canada
St. John's, Newfoundland and Labrador, Canada Chapter 16
Chapter 41
Mark P. Vu, MD, FRCP(C)
Ronald D. Stewart, OC, ONS, ECNS (hon), BA, BSc., Assistant Professor
MD, FACEP, DSc (hon) Department of Anesthesiology, Pharmacology and
Professor Emeritus Therapeutics
Departments of Anesthesia and Emergency Medicine University of British Columbia
Faculty of Medicine, Dalhousie University Department of Anesthesiology
Queen Elizabeth II Health Sciences Centre Vancouver Island Health Authority
Victoria General Hospital Site Victoria, British Columbia, Canada
Halifax, Nova Scotia, Canada Chapters 16, 19

Ban C. H. Tsui, Dip Eng, BSc(Math), BSc(Pharm), David T. Wong, MD, FRCP(C)
MSc(Pharm), MD, FRCP(C), PG Dip Echo Associate Professor
Professor of Anesthesiology Department of Anesthesia
Department of Anesthesiology, Preoperative and Pain Toronto Western Hospital
Medicine University of Toronto
Stanford University School of Medicine Toronto, Ontario, Canada
Stanford, California Chapters 14, 32
Chapter 48
xvi i i Contri butors

Jennifer W. Zhan, MD Jinbin Zhang, MBBS, MMED (Anaesthesiology)

Resident in Emergency Medicine
Denver Health Medical Center
Denver, Colorado
Chapter 23
Consultant, Tan Tock Seng Hospital
Clinical Lecturer, Yong Loo Lin School of Medicine
National University of Singapore
Tan Tock Seng Hospital
Singapore
Chapters 12, 43, 59
 FOREWORD
Although the practice of anesthesia professionals and others
who do airway management is full of unexpected challenges,
perhaps nothing strikes more fear in our hearts than a patient
with a difficult airway. Unlike other events, which may be
limited to certain narrow sub-specialties, challenging airway
management occurs across nearly all domains of patient care,
all patient ages, and many sites of care such as perioperative,
emergency department, ward settings, as well as in unusual sites
such as pre-hospital or combat casualty care. Hence, books such
as this are vital as contextual compilations of up-to-date infor­
mation on approaches and techniques for the myriad needs of
patients for oxygenation and ventilation. Most simply put, the
most fundamental goal of airway management is to accomplish
what for most patients is routine, but for some is so elusive,
which is-as one of my supervising attending and later faculty
colleague (Mervyn Maze) put it years ago, to "get some green
gas in the right hole [U.S . oxygen color code is green] ." This
spirit is exemplified in the modern evolution from the notion of
"can't intubate, can't ventilate" to "can't intubate, can't oxygen­
ate" emphasizing that oxygenation comes first with ventilation
as important, but still secondary.
As noted in the Preface, the third edition of this book con­
tains some important new information and new chapters. I
am particularly pleased by the addition of a chapter on human
factors and airway management. Over the last few decades we
have collectively recognized that all the clinical knowledge or
technical dexterity in the world can come to no avail with­
out appropriate design and use of equipment, systems, pro­
cesses, and teamwork. Another key tenet of human factors is
the importance of cognitive scientist Don Norman's concept of
putting "knowledge in the world" rather than just relying on
"knowledge in the head." The creation of a variety of standard
protocols for airway management, and their representation in
various graphical cognitive aids, is now a well-accepted and
critical aspect of modern airway management preparation and
execution. Thus, the chapter on the algorithms that describes
and compares the many different protocols, mnemonics, and
graphics is particularly useful. No one protocol will suit all cli­
nicians and all sites so knowing their individual strengths and
weaknesses is important.
A particular strength of this book is the numerous descrip­
tions of airway management alternatives and their pros and
cons in a wide variety of specific clinical situations. This is based
on the concept-described in its own chapter-of context­
sensitive airway management; this ties in very strongly with
human factors and algorithms because every situation is indeed
different. The approach of high-reliability organizations is to
standardize where possible, but to remain flexible and resilient
as circumstances demand. Even for readers who do not usually
work in some of the settings described, the well-articulated syn­
thesis of the processes of airway assessment, evaluation of the
overall situation, and choice of options will help everyone to
hone their decision-making skills whatever their usual setting.
In fact, these case discussions are a simple form of "simula­
tion" by storytelling-as clinicians hear or read of a colleague's
tough case, they simulate in their own heads what they would
think or do in a similar situation. Such case studies thus natu­
rally dovetail with the chapter on the use of simulation to teach,
practice, and hone skills of airway management-with simula­
tion techniques ranging from simple procedural task trainers
to full-blown interprofessional mannequin-based simulations.
This book has already stood the test of time, but the third
edition offers a fully modern view of the complexities and
nuances of this life-threatening and life-saving arena of clini­
cal care. The authors, contributors, and I share the hope that
through the knowledge, skills, attitudes, and behaviors con­
veyed by this book the rightful fear of the difficult airway will
be surmounted by mastery and expertise, leading to the preser­
vation or rescue of uncounted hearts, brains, and lives.
David M. Gaba, MD
Associate Dean for Immersive & Simulation-based Learning
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford School of Medicine
Staff Physician and Founder & Co-Director,
Patient Simulation Center
VA Palo Alto Health Care System
Palo Alto, California
xix
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 PREFACE
Since the last edition of our textbook, strategies and guidelines
in managing the difficult and failed airway from the American
Society of Anesthesiologists, the Canadian Airway Focus
Group, the Difficult Airway Society in the United Kingdom,
and other organizations have been updated and revised using
the currently available evidence. These revised recommenda­
tions for the management of the difficult and failed airway are
reflected in all chapters of this edition of the textbook includ­
ing the new chapters. For example, two chapters (Chapters 6
and 34) were added to this edition to address "human factors"
as they relate to the stresses and strains of difficult and failed
airway management. The Difficult Airway Society guidelines
specifically acknowledge the importance of human factors in
crisis resource management. Interpreted in context, the appli­
cation of the four basic methods of oxygenation (bag-mask­
ventilation, use of extraglottic devices, tracheal intubation,
and front of neck access) remains the most logical approach
for managing a failed airway. Furthermore, the National Audit
Project 4 (NAP4) and other studies have consistently identified
difficulties associated with needle (Seldinger technique) crico­
thyrotomy such that it has become clear that when faced with a
"cannot intubate, cannot oxygenate" (CICO) situation, surgical
(open) cricothyrotomies are much more successful than needle
or Seldinger cricothyrotomies. Many chapters of this edition
emphasized the importance of early front of neck access using
open cricothyrotomy in the adult population.
This edition is divided into ten sections: the first section
consists of the foundational information in airway manage­
ment; the second section reviews airway devices and techniques;
the third to the ninth sections discuss airway management in
different clinical settings, including prehospital care, in the
Emergency Department, the Intensive Care Unit, the operat­
ing room, the Post Anesthetic Care Unit, as well as other parts
of the hospital; and the last section highlights practical issues
in airway management. A number of new chapters and clinical
cases have been added to this new edition. As indicated above,
two chapters have been added to discuss human factors in air­
way management. To avoid confusion related to "front of neck"
access, a tracheotomy chapter has been added to this edition.
In addition, chapters discussing the management of patients
with the aspiration of gastric contents, obstructive sleep apnea,
tracheal stenosis requiring jet-ventilation, and airway manage­
ment under combat conditions have been added to this edition.
Videos depicting all airway management techniques are
available at http://DifficultAirwayVideos.com. Bag mask
ventilation, topical anesthesia of the upper airway, and open
cricothyrotomy videos have been added to this edition.
xxi
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 ACKNOWLEDGMEN TS
We would like to thank all the contributing authors for making
this book possible. In addition, we would like to thank all the
associate editors (with rwo additional associate editors) for their
tireless efforts to ensure that the information in this book is clear
and accurate. We wish to thank Sara Whynot for her editorial
assistance, Christopher Hung and David Hung for the production
of the images and videos. We also like to thank all of the McGraw­
Hill editorial and production staff for rheir continuing support.
Orlando Hung, MD, FRCP(C)
Michael F. Murphy, MD, FRCP(C)
xxi i i
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2
CHAPTER 1
Evaluation of the Airway
Michael F. Murphy and Johannes M. Huitink
INTRODUCTION.................................. 2
INCIDENCE OF DIFFICULT AND FAILED AIRWAY..
STANDARD OF CARE. .................... 4
DEVELOPMENT OF DIRECT
LARYNGOSCOPIC INTUBATION .
DEFINITIONS OF DIFFICULT AND FAILED AIRWAYS ..
PREDICTION OF DIFFICULT AND FAILED AIRWAY ...... 9
SUMMARY .......
SELF-EVALUATION QUESTIONS.
INTRODUCTION
''Airway management" may be defined as the application of ther­
apeutic interventions that are intended to effect gas exchange in
patients who are unable to do it for themselves. Gas exchange
is fundamental to this definition.1 A number of devices and
techniques are commonly employed in health care settings to
achieve this goal. These include the use of bag-mask-ventilation
(BMV), extraglottic devices (EGOs), oral or nasal endotracheal
intubation (ETI), and invasive or surgical airway techniques.
The failure to adequately manage the airway has been identified
as a major factor leading to poor outcomes in anesthesia, critical care,
emergency medicine, hospital medicine, and emergency medical
services (EMS).2·3 Adverse respiratory events constituted the largest
single cause of injury in the ASA Closed Claims Project.4 The 4th
National Audit Project (NAP4) conducted in the United Kingdom
over a 1-year period of time identified major airway management
complications in the operating oom (OR), critical care units, and
emergency dep� nts leading to death, brain damage, emergency
3 surgical airway,<or\mexpected ICU admission.5•6 NAP4 reinforced
the findings 0f.the ational Reporting and Learning System in the
United Kingdom �hat found 18% of 1085 airway management
complications in ICU over a 2-year period (2005 to 2007) were
5 directly related to the act of intubation.7
t is critically important to recognize that the single most
important factor leading to a failed airway is the failure to predict
d-ie aifficult airway.3.4 ,s Other factors that can make airway man­
agement challenging are human factors as described in Chapter 6.
Screening tests intended to predict difficult or impossible BMV
and laryngoscopic intubation are unable to predict success or
failure with any degree of certainty in otherwise normal patients.
For this reason, the terms "reassuring" and "non-reassuring" have
been coined to describe one's summative assessment of the vari­
ous operations associated with airway management (e.g., BMV,
EGO, laryngoscopy and intubation, and surgical airway).9 It is
because of this "reliability gap" that airway practitioners need to
be prepared to manage an airway predicted to be difficult appro­
priately (e.g., awake technique) and to resort to surgical airway
management in the event that nonsurgical techniques faiJ.9·11
The fundamental dilemma facing the airway practitioner is to
predict if the airway is "reassuring" or "non-reassuring." The task
is to identify non-challenging versus challenging airways employ­
ing tools with poor predictive value alone and in combination. As
mentioned above, theASA Guidelines have used the terms "reassur­
ing" and "non-reassuring." Huitink and Bouwman12 have recently
advanced the proposition that a trained practitioner should be able
to manage a patient with a reassuring airway (they use the term
"basic airway") employing basic airway management techniques
(BMV and ETI) after proper training. Even more advanced airway
rescue techniques (e.g., EGO) in these patients are expected to be
relatively easy because the anatomy is normal. Conversely, they
maintain that the less reassuring the airway, the greater the need to
prepare for failure. A very common sense approach!

This chapter deals with the identification of the difficult and
failed airway, particularly in an emergency, in which case evalu­
ation and management must be done concurrently in a com­
pressed time frame and canceling the case or delaying airway
management is not an option.
Successful airway management is generally governed by four
interrwined factors that constitute the "context" in which that
airway is managed (see Chapter 7) :
• A clinical situation of varying urgency, venue, and resources
• Patient factors including airway anatomy and vital organ
system reserve
• Available airway resources
• Skills of the airway practitioner
Because the airway practitioner must choose a method of airway
management from an array of techniques, precision of language
and communication is essential. Success or failure to effect gas
exchange in an apneic patient may occur with any single method:
• Bag-mask-ventilation
• Extraglottic device ventilation
• Direct laryngoscopy or DL (e.g., straight or curved laryngo­
scope blades)
• Indirect laryngoscopy (e.g. , video-laryngoscopy [VL] , flexible
endoscopy)
• Emergency oxygenation and ventilation techniques (e.g. ,
Ventrain'M or Manujet'M)
• Invasive surgical airway (e.g., cricothyrotomy)
Airway practitioner may find any of these methods "diffi­
cult," and difficulty with one does not necessarily indicate that
another will be difficult though there tends to be a relation­
ship. 13' 14 Strategies to identifY difficult BMV, difficult ventila­
tion employing an LMA, difficult DL and intubation, difficult
VL, and difficult surgical airway will identifY predictors unique
to the method (e.g., surgical airway would be difficult in a
patient with an anterior neck hematoma or tumor mass) , and
predictors associated with some of the other methods (e.g.,
male sex) or all of the other methods (e.g. , history of neck and
upper airway radiation therapy or the application of cricoid
pressure) . This expands on the definition of difficult as pro­
mulgated by the American Society of Anesthesiologists (ASA)
beyond difficult BMV and intubation to include the complete
array of methods that may be employed to manage an airway. 10
Any method may fail in which case the terminology "failed
BMY," "failed ETI," or "failed EGD" may be employed.
Conventionally, if all of these methods fail the airway is called
a "failed airway," and is equated with a "cannot intubate, can­
not oxygenate" (CICO) airway. 1 1 In the past, this situation has
been called "cannot intubate, cannot ventilate" (CICV) , though
CI CO is more accurate and currently more commonly employed.
For more clarity, a failed intubation defined narrowly as the
failure to intubate the trachea on three attempts9·15 (the DAS
20 1 5 Guidelines permit one additional attempt by an expert:
3+ 1) 1 1 may not constitute a failed airway if one is able to affect
gas exchange with BMV or with an EGD. However, intubation
failure ought to conjure a sense of urgency and mandates the
airway practitioner to rapidly switch to a failed airway manage­
ment sequence or drill because such a situation may become
Eva l u ation of t h e Ai rway 3
life-threatening if gas exchange cannot be provided expeditiously
and adequately by other means. Furthermore, the alternative air­
way technique employed must have the highest degree of success
in the practitioner's skill set. It is inappropriate to make random
disorganized attempts to manage the airway in the hope that one
of the airway techniques might work. Rather, one should have
a planned strategy (see the algorithms in Chapter 2) including
invasive techniques such as cricothyrotomy. 1 1•16•17
Caveat:
Failure to Evaluate the Airway and Predict Difficulty is the
Single Most Important Factor Leading to a Failed Airway.
(ASA Closed Claims Database)4
This assumes that the practitioner acts on the prediction and
selects the most appropriate technique.
I NC I D E NCE OF D I F F I C U LT A N D
FAI LED AI RWAY
• How Common Are the Difficult and
Failed Airway?
Bag-mask-ventilation, the use of EGDs, ETI, and surgical air­
way management constitute the four primary avenues by which
gas exchange is provided in the event patients are unable to do
so adequately for themselves. In each category, difficulty and
failure may be encountered. Failure of all four, ordinarily, leads
to death or brain damage.
Until recently, the success or failure of airway management
has been defined in terms of BMV and orotracheal intuba­
tion. The introduction of EGDs and the heightened profile of
cricothyrotomy have broadened such concepts. Fortunately, tra­
cheal intubation is usually straightforward, particularly in the elec­
tive setting of the OR, though it should be realized that tracheal
intubation can be performed in many different ways with direct or
indirect techniques and each technique has its own complication
and failure rates. The same cannot be said for venues outside of
the OR where airways are often anything but "straightforward."
Airways that are difficult to manage are fairly common in anes­
thesia, emergency medicine, critical care, and EMS practice, with
some estimates as high as 20% of all emergency intubations.9-1 2•18-2 1
However, the incidence of intubation failure is quite uncommon
(ranging 0.5% to 2.5%), and the disastrous situation of being
unable to intubate or ventilate rarely occurs (0. 1 o/o to 0.05%) . 2•18-26
This translates to a "can't intubate, can't oxygenate" failure rate of
about 1 : 1 000 to 1 :2000 patients in a general surgical population.
The incidence is strikingly higher in the parturient undergoing
cesarean section (1 :280), an almost tenfold increase. 27-29 Further,
the gold standard awake flexible bronchoscopic intubation also has
a defined failure rate as high as 1 3%.30
• How Do We Avoid Airway Management
Failu re?
Although circumstances can vary widely, the expectation is the
same: timely, effective airway management executed without
patient injury. In circumstances of multiple trauma, facial or
4 Pri n c i p l es of Ai rway M a n a g e m e n t
airway swelling, abnormal upper airway anatomy, upper airway
hemorrhage, or a myriad of other difficult airway scenarios,
intubation may be difficult, or even impossible, and even BMV
can fail. Many other "contextual" factors can make airway man­
agement challenging such as location, human factors, available
resources, and experience of the medical team. Nevertheless,
the goal remains that the patient's airway be promptly secured
and oxygenation be maintained.
Responding to an identified need to reduce the incidence
of airway management failure, the American Society of
Anesthesiologists (ASA) issued guidelines and an algorithm for
management of the difficult airway in 1 993, with subsequent
revisions in 2003 and 20 1 3 .9'10'31 The guidelines stressed the
importance of performing an airway evaluation for difficulty
prior to inducing anesthesia and paralyzing the patient.
Planned awake intubation, awakening the patient in the pres­
ence of a failed airway, and acquiring skills in alternative airway
management techniques are hallmarks of the 1 993 guidelines.
The 2003 guidelines reemphasize the importance of the airway
evaluation and incorporate the laryngeal mask airway (LMA)
as a discrete step in the algorithm, should failure occur. In the
20 1 3 guidelines VL is incorporated as a first airway manage­
ment plan. The DAS have come up with simplified guidelines
for management of the unanticipated difficult intubation in
adults in 20 1 5 emphasizing emergency oxygenation and ven­
tilation techniques. 1 1
Unfortunately, the ASA and DAS guidelines are less use­
ful outside the OR, especially in circumstances in which tra­
cheal intubation must be accomplished quickly and awakening
the patient is not an option. Even in the OR setting, explicit
guidelines for the rapid evaluation of an airway for occult dif­
ficulty and the prioritization of rescue maneuvers in the event
of a mandated immediate intubation are not well handled by
the ASA or DAS guidelines and algorithms (see Chapter 2) .
Furthermore, these guidelines do not take into consideration
patients who are uncooperative (e.g. , young children or men­
tally challenged patients) or different patient populations (e.g. ,
pediatrics and near term parturients [see Chapter 5 1 ] ) .
Further complicating this issue are the many new, effective,
and safe airway devices that have been introduced to assist with
difficult and failed airway management. Flexible endoscopic
and video-intubating bronchoscopes have become more por­
table and easier to use and have been joined by a collection of
rigid optical devices and stylets (e.g. , Shikani Optical Stylet'",
Bonfils Stylet'", Levitan FPS Scope'", Clams Optical Stylet'",
etc.) , hybrid devices employing cameras or fiberoptics, such
as video-laryngoscopes (e.g. , GlideScope•, McGrath• Series 5
video-laryngoscope, McGrath• MAC, King Vision•, AirTraq•,
Storz CMAc•, see Chapter 1 1 ) , and disposable camera tubes
(Vivasight, ET View Medical) .
The LMA and intubating laryngeal mask airway (ILMA or
LMA Fastrach'") have assumed a distinct role in the manage­
ment of both the difficult and the failed airway. In the pre­
hospital setting the iGel (lntersurgical) and Air-Q (CookGas)
have assumed a more prominent role for initial airway man­
agement, and rescue during rescucitation.3 2 The Combitube'"
had been used in the past as a lifesaving rescue device, though
now largely replaced by the King Laryngeal Tube airway (Ambu
Medical) and the EasyTube. Lighted stylet methods may per­
mit light-guided (transillumination) intubation in situations
in which the vocal cords cannot be visualized, but in the era
of vision guided intubation aids, there is a decrease in use of
this device. With the realization that airway rescue techniques
should be done quickly, the so called "one second intubation
technique" employing disposable camera tube devices (ET
VIEW Vivasight•) are gaining popularity when used in combi­
nation with an EGO such as the iGel or Air-Q. Certain airways
are impossible to manage by any means other than cricothy­
rotomy, a procedure that all airway practitioners ought to be
competent to perform. Several techniques have been advocated,
including the "no drop" cricothyrotomy and the "fast surgical
airway'' technique, a 4-step bougie-scalpel-tube technique1 1•33
(see Chapter 1 4) .
The challenge for any airway practitioner i s to b e able to
accurately predict when a difficult airway is present, to imme­
diately recognize when an intubation failure has occurred, and
to reliably and reproducibly ensure continuous gas exchange in
both of these unnerving circumstances.
STA N DARD OF CARE
• Is There a Prevailing Standard of Care in
Managing the Difficult and Fa iled Ai rway?
How Is It Defined?
The growth in knowledge and evidence related to the practice
of airway management is relentless. Advances in airway man­
agement over the past two decades have significantly improved
patient outcome with a reduction in the incidence of death and
disability.34 1he challenge for the practitioner is to keep abreast
of new information and new techniques to practice within the
standard of care.
Black's Law Dictionar/ 5 defines the "standard of care" as:
The average degree of skill, care and diligence exercised by
members of the same profession, practicing in the same
or similar locality in light of the present state of medical
and surgical science.
This definition incorporates several important features:
• Average degree of skill
• Same or similar locality
• Present state of knowledge
Taking these into consideration, the standard of care is the
conduct and skill of an average and prudent practitioner that
can be expected by a reasonable patient. A bad result due to a
failure to meet the standard of care is generally considered to
be malpractice. There are two main sources of information as
to exactly what is the expected standard of care:
• The beliefs and opinions of experts in the field.
• The published scientific evidence, standards of care, practice
guidelines, protocols.
Driven by the complex nature of this clinical dilemma and
the need for successful solutions that are easily learned and
maintained (and cost-effective) , the standard of care in airway

management is exceedingly dynamic. Continuing evolution of
new devices and techniques, or ways of thinking, modify the
existing standard of care on an ongoing basis. It is incumbent
on practitioners to keep abreast of new devices and techniques
and remain facile with existing rescue techniques. They can do
so by continually perusing the literature and attending educa­
tional programs related to airway management.
• What Is the Role of Professional
Organizations in Establishing the
Standard of Care?
International, national, regional, and local professional orga­
nizations generally address issues relevant to airway manage­
ment in a variety of ways. Most national societies, such as the
ASA, the Difficult Airway Society (DAS-UK) , the American
College of Emergency Physicians (ACEP) , the Canadian
Anesthesiologists' Society (CAS), and others, engage in crafting
practice guidelines. 10'1 1'16'17'36
In the event of an untoward outcome, the reasonable patient
expects the published guidelines to be observed by the prudent
practitioner. Organizations that craft and publish such practice
guidelines are careful to stipulate that such guidelines do not
constitute the standard of care. 10'1 1•16 Unfortunately, guidelines
are often perceived as the standard of care, particularly in a
medical-legal context.
Professional organizations often provide educational ini­
tiatives to ensure that their members practice at the prevailing
standard. The ASA, DAS , CAS , ACEP, and the Society for
Airway Management (SAM) are good examples. SAM, DAS ,
and European Airway Management Society (EAMS) are orga­
nizations committed to advancing knowledge and improving
the quality of airway care to all patients no matter who cares
for them. These societies blend the expertise of anesthesi­
ology, otolaryngology, head and neck surgery, critical care,
and emergency medicine to the airway management debate.
They also serve as sounding boards for new devices and tech­
niques and those wishing to challenge traditional dogma to
advance new frontiers. Those with a specific interest in airway
management are well advised to become involved in these
organizations.
• How Can We I nteg rate the Standard of Ca re
into Our Clin ical Practice?
Despite all these initiatives, the standard of care remains elu­
sive, particularly when applied to the management of the dif­
ficult and failed airway. It means different things to different
practitioners and is situation dependent. For example,
• To the plaintiff's attorney, it must be precisely defined in
minute details
• To the practitioner, it is what they do every day
• To the defendant practitioner, it is consistent with their
actions
It is perhaps easier to articulate what it is not:
• It is neither much better nor much worse care than that
delivered on average by one's peers.
Eva l u ation of t h e Ai rway 5
• It is not the same as the care provided by experts managing
difficult and failed airways every day.
• It is not what ivory tower academic experts think it ought
to be.
• It is not a single study published in a reputable journal last
week, or a position advocated by experts in an editorial in a
similarly reputable journal.
We do know that the standard of care is dynamic and our
patients expect to receive it at a minimum.
Perhaps the best test with respect to difficult and failed air­
way management is to ask a specific question: "Should the aver­
age, reasonable, and prudent practitioner . . . "
• Be able to recognize and manage an anticipated difficult
airway?
• Be able to manage an unanticipated difficult airway?
• Be able to use a flexible bronchoscope to intubate the trachea
of a patient?
• Be able to recognize and manage the failed airway?
• Be facile with one or two rescue devices or techniques in the
face of a failed airway?
• Be able to work in a team, communicate clearly, and be able
to perform under stressful circumstances?
• Be able to perform a surgical airway? Or at the least, trans­
tracheal oxygenation and ventilation?
It is reasonable to expect that most practitioners charged
with managing airways would answer yes to all of these ques­
tions and thereby define the standard of care.
DEVELOPMENT OF DI RECT
LARYNGOSCOPIC I NTU BATION
• How Did the Design of Direct
La ryngoscopes and the Basic Tech nique
of Ora l Laryngoscopy Evolve?37
Herholdt and Rafn are generally credited with first describ­
ing blind oral intubation in 1 796. Subsequently, Desault
described blind nasal intubation in 1 8 1 4. Although Sir
William Macewen described direct vision oral intubation
in 1 880, it is generally accepted that the first description of
laryngoscopic-aided oral intubation was by Kirsten in 1 89 5 .
B y 1 907, Chevalier Jackson, an ENT surgeon o f considerable
renown, introduced distal lighting to the laryngoscope, and
Janeway in 1 9 1 3 , innovated the insertion of electric batteries
into the handle of a laryngoscope to facilitate the procedure.
Magill and Rowbotham engineered the straight Magill blade in
the 1 920s by cutting a wedge out of the side of the blade of the
ENT surgeon's anterior commissure laryngoscope to facilitate
intubation (Figure 1- 1 ) . Across the Atlantic, this design (with
minor modifications) became known as the Miller blade in the
1 940s. The Macintosh blade was also introduced in the 1 940s
by Sir Robert Macintosh.
Magill is credited with introducing the "retro-molar" or
"paraglossal" approach, reasoning that placing the blade as far
to the corner of the mouth as possible when attempting to
bring the glottis into view (as opposed to being in the midline)
ought to minimize the distance to the glottis and enhance the
6 Pri n c i p l es of Ai rway M a n a g e m e n t
F I G U R E 1 - 1 . T h e Mag i l l l a ryngoscope.
degree to which it is visible. This technique has been resur­
rected by Henderson who developed the Henderson blade'"
(Karl Storz Germany) .38
• How Did the Design of Endotracheal Tu bes
Evolve?
It was also Sir Ivan Magill (circa 1 9 1 4) who recommended a
left-sided bevel (Magill bevel) be created on the distal tip of an
endotracheal tube (ETT) (Figure 1 -2) . At that time, blind nasal
intubation using a non-beveled, gum-elastic tube was popular.
Magill observed that, as the right nostril is usually largest and
most anesthesia practitioners are right handed, nasotracheal
intubation was usually first attempted through the right nostril.
The natural tendency for a tube introduced through the right
nostril was to deviate leftward as it transited the nasopharynx
and oropharynx and to deflect off the left glottic structures into
the left pyriform recess. Magill reasoned that the left-sided bevel
would deflect the ETT into the glottis. 39 Left-side bevel ETTs
continue to be the most commonly used tubes to this day.
Curare was first used in the 1 940s and succinylcholine was
introduced into anesthetic practice in 1 952. These drugs led to
the need for positive pressure ventilation through a tube with
a tracheal seal being achieved by packing gauze (at times oil
soaked) around the glottic opening. A more effective seal could
be obtained by incorporating a balloon (initially rubber, thick
walled, high pressure, and removable) onto the ETT. However,
the possibility that the beveled orifice of the distal tip could
rest against the wall of the bronchus in the event of a right
mainstem intubation permitting positive pressure inspiration
but not passive expiration was noted. This led to the creation
F I G U R E 1 -2. The l eft-sided Mag i l l bevel on the e n d otra c h e a l
tu be.
of the Murphy eye opposite the bevel orifice (i.e., facing the
right side) .
The bulk of the ETT and balloon hindered its passage
through the channel of laryngoscope blades, and this led
the Eschmann Corporation to develop a tracheal introducer
(invented by Sir Robert Macintosh) to facilitate a Seldinger­
type intubation over the introducer in 1 949.40
• How Has Our Understanding of How
the Difficult Ai rway Might be Predicted
Developed Over the Yea rs?
The use of neuromuscular blockade to facilitate orotracheal
intubation followed the introduction of curare into anesthetic
practice in the early 1 940s and succinylcholine in the late
1 940s. Up until that time, orotracheal intubation was largely
performed with the patient breathing spontaneously under
inhalational anesthesia. The consequence of a failed intuba­
tion was mitigated by the fact that the patient continued to
breathe spontaneously. The threat of failure to intubate in the
face of neuromuscular blockade and apnea required anesthesia
practitioners to evaluate the airway for difficulty, leading to a
landmark publication by Cass in 1 956Y 1his study identified
those anatomical features that might predict difficult laryn­
goscopic intubation. Thus, the clinical use of neuromuscular
blocking agents became inseparable from the ability to perform
an airway evaluation and the ability to rescue the airway in the
event of failure. Many practitioners still fail to recognize a dif­
ficult airway when one exists or they overlook the evaluation
altogether. 4•9
The literature regarding the difficult airway was relatively
quiet until the mid- 1 980s when Patil offered the proposition
that a thyromental distance of less than 6 em was associated
with orotracheal intubation difficulty.42 During the 1 990s,
Savva did the same by using the sternomental distanceY
The importance of Patil's dimension rests not in the distance
described, or in its lack of sensitivity, specificity, or positive
predictive value with respect to airway management difficulty,

F I G U R E 1 -3. The Pati l 's tria n g le. (A) The secon d 3 of the eva l u ate
3-3-2; (B) the 2 of the eva l uate 3-3-2; (C) the thyromenta l d i sta nce.
but in the fact that it alludes to the geometry of the airway. The
thyromental line constitutes the hypotenuse of a right angle tri­
angle (Figure 1-3) . The axis is length of the floor of the mouth
(a dimension of the mandibular space) , and the abscissa locates
the larynx in relation to the base of the tongue. The length of
the oral axis affects the ease with which the glottis is exposed
during conventional laryngoscopy: the glottis cannot be visual­
ized beyond the horizon of visibility if it is too long; the larynx
is shielded by the base of the tongue (anterior larynx) if it is too
short. Likewise for the location of the larynx in relation to the
base of the tongue: it is beyond the visible horizon if it is too
far down the neck; it is tucked up under the base of the tongue
F I G U R E 1 -4. M a l l a m pati scores.
Eva l u ation of the Ai rway 7
if it is too high in the neck. Furthermore, the dimensions of
the mandibular space (length, width, and depth; or volume)
have important implications. The volume of the mandibular
space must accommodate the tongue, as it is displaced into
this space during laryngoscopy to bring the glottis into view.
Mallampati in 1 983 and 1 985 created a scoring system44,45
modified by Samsoon in 1 987,46 that identified oral and pha­
ryngeal access as an issue of importance in airway management
(Figure 1-4) . Although the score by itself had poor sensitivity,
specificity, and positive predictive value, the notion that access
is important became cemented.
It was during this time that Cormack and Lehane proposed
their laryngeal view grade scoring system in an effort to pro­
vide some structure to the discussion of difficult laryngoscopy
(Figure 1-5) .47 Although found to be subject to considerable
interobserver variability, the scale has been embraced as a valid
measure of difficulty; with Grades 3 and 4 views being equated
with difficult laryngoscopy. By the late 1 990s, other models with
more reproducible scoring systems, such as Levitan's percent­
age of glottic opening (POGO) visible, were proposed.48-50
However, widespread adoption of these systems over the
Cormack/Lehane (C/L) system has yet to occur (Figure 1 -6) .
By the late 1 980s, i t had become apparent that airway man­
agement failure was the most important contributor to poor
patient outcome in anesthesia practice, lawsuits, and financial
settlements.4 The question facing airway practitioners became:
Who should you not paralyze? A variety of investigators pursued
univariate and multivariate systems of analysis that attempted
to answer this question, but none with reliable success5 1 :
• Wilson ( 1 988) (Wilson Risk Sum) : Employed a weighted
scoring system 0 to 2 incorporating body weight, head and
8 Pri n c i p l es of Ai rway M a n a g e m e n t
Grade 1 Grade 2
G rade 3 G rade 4
F I G U R E 1 -5. Cormack/Le h a n e l a ryngea l view g ra d i n g score.
neck movement, jaw movement, receding mandible, and
prominent (buck) teeth.5 2
• Bellhouse ( 1 988) : Used x-rays to evaluate for difficulty. 53-57
• Rocke (1 992) : Evaluated 1 500 parturients using a combination
ofMallampati, short neck, receding mandible, and buck teeth. 58
• Savva ( 1 996) : Identified a sternomental distance less than
1 2 em as a risk for difficulry.43
• Tse ( 1 995) : Combined Mallampati, head extension, and
thyromental distance.59
• El-Ganzouri ( 1 996) : In a large study of 1 0, 5 07 patients
looked at mouth opening, Mallampati, neck movement,
mandibular protrusion, body weight, and a positive history
of airway management difficulty.60
• Karkouti (2000) : Evaluated 46 1 patients (38 difficult) and
correlated mouth opening, chin protrusion, adanto-occipital
. 61
extensiOn.
Between 2000 and 20 1 5 studies identified factors that reli­
ably predicted impossible bag mask ventilation and intubation
such as head and neck radiotherapy. 13•14·62-67 Kheterpal and
others identified risk factors for failed video-laryngoscopic intu­
bation such as airway pathology from previous surgery, a local
mass, or radiotherapy to the head and neck. 13·14
Hot on the heels of the "Who should you not paralyze?" ques­
tion is the dilemma: "How is the airway best rescued in the event
that intubation and/or ventilation is impossible, that is, a failed
airway?" In the past, BMV was viewed as the most commonly
performed fallback technique. This technique, difficult to teach,
learn, and perform, is being supplanted by more user friendly
and easily performed EGOs. This has led to a reframing of the
way we think about airway management: In the event laryngos­
copy and intubation fails, is it likely that gas exchange can be
maintained by BMV or one of these EGO devices? Furthermore,
the recognition that while aspiration is undesirable, it is not usu­
ally a deadly occurrence, serves to emphasize the primacy of gas
exchange over intubation and airway protection.
There has also been a substantial change in our thinking
with respect to surgical airway management. In the past, it was
F I G U R E 1 -6. Levita n's perce nt of g l otti c o pe n i ng (POGO): 1 00-if
the c o m p l ete g l ottis ca n be seen; and 0-if n o pa rt of the g l otti s
ca n be see n .
left to the practitioner as to whether to perform a Seldinger
technique or an open cricothyrotomy. In fact, it was taught
that anesthesia practitioners ought to preferentially select a
Seldinger technique as using a needle as opposed to a scalpel
was felt to be psychologically more acceptable. However, it has
become apparent that fellowship trained and certified anes­
thesiologists cannot reliably locate the cricothyroid membrane
in elective surgical patients, particularly if they are female or
obese.5•6·68-70 The report from NAP4 identified that needle tech­
niques were unsuccessful and open techniques were successful.
So it is currently recommended that an open cricothyrotomy be
performed in the CICO situation. 1 1
Cricothyrotomy employed in the setting o f a failed airway
has become emblematic of airway management failure. It is now
taught that if the airway manager considers a CICO airway
even remotely possible that the cricothyroid space be identified
by manual palpation or with ultrasound (Chapter 1 4) and the
incision line marked preemptively. In other words, should a
cricothyrotomy be needed, it is a deliberate "part of the plan"
as opposed to "emblematic of failure." The psychology of this
approach is compelling in motivating individuals to move ear­
lier to a cricothyrotomy as soon as a CICO airway is identi­
fied. Peterson34 and NAP4 both identified delay in performing
cricothyrotomy as substantial issues leading to poor outcomes.
D E F I N ITIONS OF D I F F I C U LT
A N D FAI L E D AI RWAYS
The Difficult Airway is something you antiCipate; the
Failed Airway is something you experience.
(Walls, 2002)
As noted earlier, this chapter explores the concepts of the dif
jicult and thefailed airway. The premise is that the pre-procedure

recogmnon and management of the difficult airway should
minimize the occurrence of a failed airway. Furthermore, rec­
ognizing the failed airway promptly ought to optimize the
chances that failing techniques will be abandoned and replaced
by techniques reasonably anticipated to succeed.
• The Difficult Ai rway
When one is presented with a patient that requires tracheal
intubation, the first decision is whether or not this airway
needs to be managed immediately. If so, immediate action is
indicated.
As discussed above, unlike the failed airway the difficult air­
way is not so easily defined. Rather than a definition, in con­
cept, the difficult airway has several dimensions15:
• Difficult BMV
• Difficult DL
• Difficult VL
• Difficult intubation
• Difficult placement of a EGD
• Difficult cricothyrotomy
These six dimensions can be reduced to four technical
operations:
• Difficult BMV
• Difficult DL or VL and intubation
• Difficult EGD
• Difficult cricothyrotomy
The evaluation of the airway for difficulty may be leisurely
or urgent. In the latter circumstance, it must be done quickly
with care taken not to omit anything important.
The rapid adoption of VL has substantially affected our
approach to difficult airway management in that laryngeal
views are often better with VL than with DL. What is unclear
is whether this "better view" is associated with higher intuba­
tion success rates. It is also noted that many devices have come
to the market without robust clinical research, so now and then
complications with these new devices do occur. There is some
evidence that success rates are higher if one gives oneself "lim­
ited" laryngeal views (POGO 1 0% to 50%, superior to and
superseding the older Cormack Lehane Grades 28 and 3) .71•72
It appears that the deformation of the airway by the VL device
required to get that Grade 1 or 2A view maneuvers the tip of
the VL to push he larynx more anteriorly creating a more acute
angle for the ETT to pass.
Like well-constructed algorithms, mnemonics are efficient
memory-aid strategies that lead to a complete, yet rapid, evalu­
ation. One for each technical operation has been crafted to
permit a rapid and complete evaluation, no matter the clinical
circumstance.
• The Fai led Airway
Orotracheal intubation, BMV, or EGD ventilation may fail in
isolation leading to failed BMV, failed intubation, etc. However,
should all three methods fail, one is faced with a failed airway.
Failure of a single method has generally been defined as:
Eva l u ation of t h e Ai rway 9
• Failed intubation is three failed attempts at orotracheal intu­
bation by a skilled practitioner10•1 1•16•17
• Failed mask ventilation as failure to ventilate despite best
efforts employing airway adjuncts (oropharyngeal and naso­
pharyngeal airways) and two practitioners with or without
neuromuscular blockade63·73
• An EGD has failed if ventilation through the device fails
to detect carbon dioxide on exhalation or improve oxygen
saturations. It has also been defined as an airway inter­
vention requiring device removal and the use of an alter­
native technique to effect gas exchange. (Modified after
Ramachandran74)
The problem in everyday practice is not so much defining
failure; it is recognizing CICO once it has occurred, and then
moving quickly to alternatives.
The intent is to minimize the chance of encountering a
failed airway when one might have easily predicted a difficult
intubation, difficult BMV, difficult EGD ventilation, or a dif­
ficult cricothyrotomy.
The adage in anesthesia practice with respect to neuromus­
cular blockade of a patient who has some effective spontaneous
ventilation has always been "Don't take anything away from the
patient that you can't replace." While such a rigid principle is
not always consistent with the realities of airway management,
it is a useful one to remember!
PREDICTION OF D I F F I C U LT
A N D FAI L E D AI RWAY
The most effective memory aids work well as everyday practice
adjuncts in all clinical situations. The following mnemonics
fall into this category. 15 Though mnemonics may be useful as
memory aids, it is good to consider their inevitable limitations.
In this regard, it is important to consider the results of a
Danish group that recently reported their findings with respect
to predicting the difficult airway in a large cohort of 1 8 8,064
patients, using a pragmatic approach?5 They confirmed that
the prevailing teaching related to predicting difficulty was an
inexact science. Of 339 1 difficult intubations 3 1 54 (93%) were
unanticipated. When difficult intubation was anticipated, 229
of 929 (25%) had an actual difficult intubation. Difficult mask
ventilation was unanticipated in 808 of 857 (94%) cases. They
concluded that no single predictor predicts difficult intuba­
tion. The investigators concluded that while "prediction of dif
jiculties remains a challenging task, there may be ample room for
improvement, based on a rigorous, evidence based and systematic
approach." This very large study serves to emphasize the need
to be prepared for failure every time one manages an airway
because patients unexpectedly show up with difficulties during
airway management.
The landscape is further fraught by the combinations and
permutations of innumerable devices and techniques used
alone or in combination. For example, one could use 1 0 differ­
ent face masks for BMV with or without an oropharyngeal air­
way (Guedel or Berman) , with or without cricoid pressure, in
the half sitting or supine position, with an inspiratory oxygen
fraction of 80% or 1 00%. Denitrogenation can be done for
10 Pri n c i p l es of Ai rway M a n a g e m e n t

3 minutes, 1 0 minutes, or after eight deep inhalations?6 Should

TA BLE 1 -2. M a s k Ventilation Sca l e a n d I ncide nce
we decide to use DL, we could choose between 30 different
blades; for VL there are at least 1 5 different models. These indi­ Grade Description N (%}

rect scopes have at least 1 0 different blades with or without 1 Ve nti l ated by m a s k 3 7 , 8 5 7 (7 1 .3)
tube guidance channels, with plastic disposable or metal reus­ 2 Ve nti l ated by m a s k with o ra l 1 3,966 (263)
able blades with angulated or hyper angulated curves. Should a i rway/a dj uva nt with or
one decide to perform a flexible bronchoscopic intubation, we without m u scle re laxant
could do that face to face or from the head of the patient, awake 3 Diffi c u l t ve ntilation (i nadeq u ate, 1 1 4 1 (2.2)
or asleep, with or without a jaw thrust maneuvers to optimize u n sta b l e, o r req u i ri n g two
visualization through the eye piece or on the monitor screen p rovi d e rs) with or without
connected to a thin or thick flexible scope with fiberoptic bun­ m u scle re laxant
dles or a "chip in the tip" video camera systems. The ETT can 4 U n a b l e to m a s k ve nti l ate with o r 77 (0. 1 5)
be introduced nasally or orally. A disposable camera/tube device without m u scle re laxant
may be used without a laryngoscope or flexible bronchoscope Tota l cases 53,04 1
at all.77 In the event that plan B or C needs to be activated, 20
different extraglottic airway devices (EGD) with or without a
gastric suction channel, with or without a cuff, flexible or stiff,
with our without a bite block are on the market. First or second
(and perhaps even third) generations of EGDs compound the
list of choices. 1 2,78
Ultimately, one might elect to perform an emergency surgi­
cal airway with a scalpel, a Seldinger over-the-wire technique
or simply a Frova Intubating Catheter (Cook Medical) or
Eschmann Tracheal Introducer (commonly known as "bougie")
inserted through an incision in the neck. When one considers
the medication options that might be employed, there are a
large number of options to oxygenate a patient.
The possibilities are enormous!

• Difficult BMV: MOANS

The degree of difficulty encountered while performing or
attempting to perform BMV has been classified by several
authors. The classification schemes of Han (Table 1 - 1 ) and
Kheterpal Ramachandran (Table 1 -2) are presented.63•73
The importance of BMV in airway management is not taken
lightly by airway practitioners, particularly as a rescue maneu­
ver when orotracheal intubation has failed. If the airway prac­
titioner is uncertain that neuromuscular blockade facilitated
tracheal intubation will be successful, they must be confident
that BMV will be adequate, the use of an EGD will be success­
ful, or at the very least, a successful cricothyrotomy can rapidly
be performed.
TA BLE 1 - 1 . H a n's M a s k Ventilation C l a ssification a n d
Description Sca l e
Classification Description/Defi n ition
G ra d e 0 Ve ntilation by m a s k not atte m pted
G ra d e 1 Ve nti l ated by m a s k
G ra d e 2 Ve nti l ated b y m a s k w i t h o ra l a i rway o r
ot h e r a dj uva nt
G ra d e 3 Diffi c u lt mask ve nti lation ( i n a d eq uate,
u n sta b l e, or req u i ri n g two
p ractit i o n e rs)
F I G U R E 1 -7. Opti m u m m a s k h o l d to a c h i eve a m a s k sea l u s i n g a
two- h a n d tec h n i q ue.
The bag-mask devices most commonly used in resuscita­
tion settings are capable of generating 50 to 1 00 em of water
pressure in the upper airway, provided that they do not have
positive pressure relief valves, and an adequate mask seal can be
obtained (Figure 1 -7) .
Pediatric and neonatal devices often incorporate positive
pressure relief valves that can be easily removed if needed. This
degree of positive pressure is often sufficient to overcome the
moderate degree of upper airway obstruction offered by redun­
dant tissue (e.g., the obese) or edematous tissue (e.g. , angio­
edema, croup, or epiglottitis) . Research has validated many of
those anatomical features that over the years have been impli­
cated in heralding difficult BMV (difficult mask-ventilation
or DMV) . 1 3·62-67•79·80 Those features can be grouped into five
indicators that can be easily recalled by using the mnemonic
MOANS15:
Mask seal, high Mallampati grades, Minimal jaw protrusion,
•

or Male gender: Bushy beards, crusted blood on the face, or

G ra d e 4 U na b l e to m a s k ve ntil ate
a disruption of lower facial continuity are the commonest

examples of conditions that may make an adequate mask seal
difficult. Several studies have identified additional risk factors
for DMV, including male sex, Mallampati III or IV airways,
and limited jaw protrusion.62•63•81
• Obese or Obstructing lesions: Patients who are obese defined
by Langeron et al.79 as BMI >26 kg-m- 2 as opposed to
the conventional definition of obese as 30 to 35 kg·m - 2 ;
Kheterpal62 identified a BMI > 30 kg·m - 2 as being associated
with difficult BMV BMV can also be difficult in parturients
at term and in patients with upper-airway obstruction,
angioedema, Ludwig angina, upper airway abscesses (e.g. ,
peritonsillar) , and epiglottitis.
• Aged: Age greater than 55 is associated with a higher risk of
difficult BMV, perhaps because of a loss of muscle and tissue
tone in the upper airway. 62,79
• No teeth or Neck radiation or fixed flexion deformity: An
adequate mask seal may be difficult in the edentulous patient
as the face tends to cave in. An option is to leave dentures
in situ (if available) for BMV and remove them for intuba­
tion. Alternatively, gauze may be inserted in the cheeks to
puff them out in an attempt to improve the seal (vigilance to
prevent dislodgement into the airway is required) . Radiation
therapy in the past to the head and neck62 and fixed cervical
spine deformity17 may hinder mask ventilation.
• Snores or Stiff: For the former, this mnemonic affords one
a reminder to check for sleep apnea, an increasingly impor­
tant consideration in anesthetic practice today. BMV may be
difficult or impossible in the face of substantial increases in
airways resistance (e.g., deadly asthma) or decreases in pul­
monary compliance (e.g. , pulmonary edema) .
As discussed in Chapter 8, several studies involving large
patient populations have validated the above findings. In a
large study by Kheterpal et a!. involving over 50,000 adult
patients receiving a general anesthetic at a tertiary care hospi­
tal, the reported incidence of impossible BMV (IMV) defined as
"the inability to establish face-mask ventilation despite multiple
airway adjuncts and rwo-hand mask ventilation" was 0. 1 5%.63
Despite there being a diverse clinician group (trainees; nurse
and physician anesthetists) , having a j unior anesthesia provider
was not found to be an independent predictor for IMV The
presence of three or more predictors (neck radiation, male,
OSA, Mallampati III or IV, beard) significantly increased the
risk of IMV with an odds ratio of 8.9 compared to patients
without these risk factors. Another important finding from
this study is that of the IMV group, 25% were also difficult to
intubate. It should be remembered, however, that these studies
did not examine the incidence of DMV in patients requiring
emergency airway management.
• Difficult DL I ntu bation: LEMON
Difficult DL and intubation ordinarily implies that the practi­
tioner had a poor view of the glottis. Cormack and Lehane47
provided some clarity to the way we think of the difficult air­
way by parsing the act of intubation into its rwo subcompo­
nents: laryngoscopy and intubation. They also introduced the
most widely utilized system of categorizing the degree to which
the glottis can be visualized during laryngoscopy (Figure 1 -5).
Eva l u ation of t h e Ai rway 11
Cormack/Lehane view Grades 3 (epiglottis only visible) and
4 (no glottic structures at all visible) are often used as surrogates
to define a difficult laryngoscopy and predict difficult intubation.
View Grades 1 (visualization of the entire laryngeal aperture) and
2 (visualization of the posterior cords and arytenoids) are not typ­
ically associated with difficult intubation, though some Grade 2s
may be difficult or impossible to intubate. Tough Grade 2s and 3s
are tailor-made for intubating introducers such as the Eschmann
Tracheal Introducer and Frova devices (see Chapter 1 2) .
As can b e gleaned from the descriptions, the Cormack/
Lehane grading system is insensitive to the degree to which the
laryngeal aperture is visible during laryngoscopy: a little bit of
it (Grade 2) or all of it (Grade 1 ) . The question often asked
is: How much of the cords must be viewed to assure intuba­
tion success? How much is enough? Some authors have created
a 2A view to indicate that some of the cords are visible, and
Grade 2B if only the arytenoid cartilages are seen. 8 2 Likewise,
the Grade 3 view has been divided into 3A where the epiglot­
tis is sitting upright and bougie intubation is possible, and 3B
where the epiglottis is flipped backwards over the glottic aper­
ture and bougie-guided intubation is not possible. In attempt­
ing to provide a framework or an approach to answering the
question "how much of the glottis is visualized?," Levitan
et al.48-50 devised a scoring system (POGO) to quantify glottic
view. While attractive in many ways, this scale has yet to gain
wide acceptance (Figure 1 -6) .
The Cormack/Lehane grading system is predicated upon grad­
ing during the best attempt at conventional DL, and best attempt
in turn requires definition. Benumof8 defines best attempt as
being composed of six components:
1. Performance by a reasonably experienced practitioner
2. No significant muscle tone
3. The use of the optimal sniffing position
4. The use of external laryngeal manipulation (backward upward
righrward pressure [BURP] or optimum external laryngeal
manipulation [OELM] )83
5. Length of the blade
6. Type of blade
Most times, an intubation demands that the first attempt
be the best attempt, particularly in an emergency, although
some compromises may be necessary (e.g., residency training) .
Should an orotracheal intubation attempt fail and an addi­
tional attempt be contemplated, it seems reasonable to change
something on the subsequent attempt to enhance the chances of
success. That something may be one, some, or all of these fac­
tors. Reminding oneself of the components of the optimum or
best attempt provides a framework to address "what to change?"
Optimization of all six components may not be in the
patient's best interest in an emergency. For example, if difficulty
is anticipated, it may not be advisable to paralyze the patient.
Additionally, in the event the cervical spine is immobilized,
it may not be possible to place them in the sniffing position.
Most experts in airway management agree that positioning the
head and neck is an important step in optimizing conventional
laryngoscopy as a prelude to orotracheal intubation.84
If it is possible to consistently and precisely predict direct
laryngoscopic intubation failure, the initial selection of direct
12 Pri n c i p l es of Ai rway M a n a g e m e n t
laryngoscopic oral intubation could be eliminated as a strategy
and alternative techniques entertained (e.g., VL intubation, flex­
ible bronchoscopic intubation, cricothyrotomy) . However, they
may be technically more challenging, risky, and time consuming.
During the last several decades, this has not proven to be possi­
ble. Lists of anatomical features, radiologic findings, and complex
scoring systems have all been explored without consistent success.
Therefore, we are left to assemble the known risks, and other
contextual issues such as time of day, location, position, avail­
abiliry of devices, sophistication of assistance coupled with the
skill, experience, and judgment of the practitioner, and make
a decision: Does this airway meet the threshold of being suffi­
ciently difficult to warrant using a Difficult Airway Algorithm,
or am I safe to proceed directly to induction, paralysis, and
intubation (e.g., rapid sequence intubation or rapid sequence
induction, commonly known as RSI) . 1 5
S o , how d o we quickly identify as many o f the risks associ­
ated with DL intubation as possible? The mnemonic LEMON
is a useful guide:
• look externally: If the airway looks difficult, it probably is
(Figure 1-8) . A litany of physical features have been asso­
ciated with difficult laryngoscopy and intubation-a small
mandible may indicate that the tongue is retro -fitted over the
larynx; a large mandible elongates the pharyngeal axis serv­
ing to extend the distance to the larynx and perhaps move it
beyond the horizon of view. Buck teeth block access to the
oral caviry and elongate the length of the oral axis. A high,
arched palate is often associated with a long, narrow oral cav­
iry making access a problem. A short neck may mean the
larynx is positioned higher in the neck relative to the base of
the tongue making it more difficult to bring the glottis into
view. Lower facial disruption is inconsistent with adequate
mask seal and may make the glottis impossible to find. It
F I G U R E 1 -8. Th i s patient provides an i ma g e recog n iza b l e
i n sta ntly a s a d iffic u l t a i rway.
is often said that when it comes to orotracheal intubation,
the "tongue is your enemy" because it gets in your way and
the "epiglottis is your friend" because once you find it, you
ought to be able to find the glottic opening. However, in the
event it is difficult to bypass a large epiglottis with a bougie
or other device, a flexible bronchoscopic-assisted intubation
may be indicated. With upper airway disruption, the tongue
may actually be a friend as it leads to the epiglottis and the
glottic opening.
• Evaluate 3-3-2: Although there is no scientific basis to sup­
port the 3-3-2 rule, it serves to ensure that the relevant geom­
etry of the upper airway is assessed adequately. The first 3
assesses the adequacy of oral access (Figure 1 -9) . One ought
to be able to open one's mouth three of one's own finger
breadths (approximately 5 em) . The second 3 and the 2 rec­
ognize the interplay of the geometric relationships among the
various components of the upper airway as first articulated by
Patil in 1 983.44 A thyromental distance of less than 6 em was
associated with difficult intubation (Figure 1 -3) . As described
earlier, the thyromental distance is the hypotenuse of Patil's
triangle (Figure 1 -3), the base being the length of the mandi­
ble (Figure 1 - 1 O) and the third leg being the distance berween
F I G U R E 1 -9. Ai rway eva l uation: The fi rst 3 of 3-3-2 eva l uation
i n d icates the extent of the mouth o pe n i n g .
F I G U R E 1 - 1 0. Ai rway eva l uation: T h e s e c o n d 3 o f 3 - 3 - 2 eva l uation
i n d icates the length d i m e n s i o n of the m a n d i b u l a r s pace.

the base of the tongue (neck-mandible junction at the level
of the hyoid bone) and the top of the larynx (Figure 1 - 1 1) .
One ought to b e able to accommodate three o f one's own
fingers (approximately 5 em) berween the tip of mentum
and the mandible-neck junction (Figure 1 - 1 0) and fit rwo
fingers berween the mandible-neck j unction and the thyroid
notch (Figure 1 - 1 1 ) . The second 3 steers one in assessing the
capacity or volume of the mandibular space to accommo­
date the tongue on laryngoscopy. More than, or less than,
three fingers (approximately 5 em) are associated with greater
degrees of difficulty in visualizing the larynx. The length of
the oral axis is elongated if it is longer than three fingers, and
the mandibular space may be too small to accommodate the
tongue during laryngoscopy if it is shorter than three fingers,
leaving it to obscure the view of the glottis. This mandibular
space volume is determined by three dimensions: its length,
its width, and its depth. The 2 identifies the location of the
larynx in relation to the base of the tongue. If more than
rwo fingers are accommodated, meaning the larynx is further
below the base of the tongue, it may be difficult to visualize
the glottis on laryngoscopy because it is too far down the
neck and beyond the visual horizon. Fewer than two fingers
may mean that the larynx is tucked up under the base of the
tongue and may be difficult to expose. This condition is often
called "anterior larynx."
Mallampati class: Mallampati studied the relationship
•
berween the visibility of the posterior oropharyngeal struc­
tures and success rate of laryngoscopic intubation.44-46 He
had patients sit on the side of the bed, open their mouth as
widely as possible, and protrude their tongue as far as pos­
sible, without phonating. Figure 1 -4 depicts how the scale
is constructed. Although Class I and II patients are associ­
ated with low intubation failure rates, circumspection with
respect to the wisdom of utilizing neuromuscular blockade
to facilitate intubation rests with those in Classes III and IV,
particularly Class IV in which intubation failure rates may
exceed 1 0% . This scale, by itself, is neither sensitive nor
specific.85 However, it is commonly used because it is easily
performed, particularly in an emergency, and it may reveal
F I G U R E 1 - 1 1 . Ai rway eva l uation: The 2 of 3-3-2 eva l uation i n d i­
cates the position of the l a rynx re l ative to the base of the ton g ue.
Eva l u ation of the Ai rway 13
important information about access to the oral cavity and
potentially difficult glottic visualization.
• Obstruction: There are three cardinal signs of upper air­
way obstruction: muffled voice (hot potato voice) ; difficulty
in swallowing secretions, either because of pain or obstruc­
tion; and stridor. The first two signs do not ordinarily herald
imminent total upper airway obstruction. The presence of
stridor generally indicates that the diameter of the airway
has been reduced to 4.0 mm or less.86 Upper airway obstruc­
tion should always be considered a difficult airway and man­
aged with extreme care. The administration of small doses of
opioids and benzodiazepines to manage anxiety may induce
total obstruction as the stenting tone of the upper airway
musculature relaxes.
• Neck mobility: The ability to position the head and neck is
one of the six components of achieving an optimal view of
the larynx on oral laryngoscopy. Although there is some dis­
sention,84 it has long been taught that the "sniffing the morn­
ing air," or "sipping English tea'' positioning (neck flexion,
head extension) of the head and neck, when possible, is at
least the best place to start. While cervical spine immobiliza­
tion alone may not constitute a difficult laryngoscopy, airway
practitioners should be cautious in managing patients with
limited cervical spine movement.
• Difficult VL I ntubation: CRANE
Video-laryngoscopy when compared to OL has been shown
to produce better laryngeal views than OL in difficult airways,
improve first pass success rates in difficult and emergency
incubations, and reduce the incidence of serious complica­
tions associated with laryngoscopic intubation.71•87-89 However,
on the down side it has been shown that VL intubation takes
slightly longer than OL intubation.89
This technology has clearly benefited the field of difficult air­
way management. However, failures do occur and it should not
deter a practitioner from performing an awake intubation in a
nonemergency patient. Neither should it delay the performance
of an open cricothyrotomy in the face of a CICO failed airway.
Predicting difficult VL intubation can be recalled employing
the mnemonic CRANE:
C Contamination and CL 3 or 4 with OL88•89
R Radiation70
A Abnormal anatomy: mass; previous surgery; decreased
mouth opening87'90
N Neck thick or flexion deformity70
E Epiglottitis or enlarged tongue
• Difficult Use of an EGO: RODS
The insertion of an EGO may be a planned backup maneu­
ver (Plan B) when faced with a failed conventional orotracheal
intubation. It may also serve as a bridging technique to rees­
tablish gas exchange in a CICO setting while one prepares to
perform a cricothyrotomy (see Chapter 2) . To minimize wast­
ing valuable time, airway practitioners should place the EGO
concurrently while setting up to perform a surgical airway real­
izing that a perfect seal is not required for rescue oxygenation.
14 Pri n c i p l es of Ai rway M a n a g e m e n t
In the former case, when Plan B is an EGO, one ought to
have performed an evaluation for difficult EGO placement
before it is relied on as a primary or backup plan. While there
are no prospective studies to evaluate predictors of difficult
use of EGOs, there are many clinical reports of difficult use of
EGOs, such as the LMA.
RODS is a mnemonic that is intended to identify problem
patients when an EGO is contemplated:
• Restricted mouth opening: Depending on the EGO to
be employed, more or less oral access may be needed. For
instance, at least 2 em of mouth opening is required to
accommodate an LMA Fastrach'".91•92
• Obstruction: Upper airway obstruction at the level of the lar­
ynx or below. An EGO will not bypass this obstruction. The
use of an LMA can be potentially difficult in patients with
lingual tonsillar hypertrophy.93•94
• Disrupted or Distorted airway: At least in as much as the seat
and seal of the EGO may be compromised.95
• Stifflungs or Stiff cervical spine: Ventilation with an EGO may
be difficult or impossible in the face of substantial increases
in airway resistance (e.g. , deadly asthma) or decreases in pul­
monary compliance (e.g., pulmonary edema) . Seal may be
exceedingly difficult or impossible to achieve in the face of
a fixed flexion deformity of the neck. In addition, there are
reports of difficult LMA insertion in patients with limited
neck movement (e.g. , ankylosing spondylitis)96·97
• Difficult Cricothyrotomy: SHORT
There are no absolute contraindications to performing an emer­
gency cricothyrotomy. However, some conditions may make it
difficult or impossible to perform the procedure, making it imper­
ative to identify those conditions up front, particularly if one is
relying on a rapidly performed cricothyrotomy as a rescue tech­
nique. Similarly, while there are no prospective trials to determine
predictors of difficult cricothyrotomy, a number of clinical reports
have identified situations associated with difficulties in perform­
ing a surgical airway. The mnemonic SHORT is used to quickly
identify features that may indicate a difficult cricothyrotomy:
• Surgery/ disrupted airway: The anatomy of the neck may be
subtly or obviously distorted due to previous surgery, making
the airway difficult to access. Patel98 reported a case of dif­
ficult surgical airway following a recent thyroidectomy.
• Hematoma or infection: An infective process or hematoma
in the pathway of the cricothyrotomy incision may make the
procedure technically difficult but should never be consid­
ered a contraindication in a life-threatening situation.
• Obese/access problem: A number of studies have reported
difficulry in identifying the cricothyroid membrane in obese
subjects.68-70 Patel98 reported a case of surgical airway failure
in a patient with an obese and short neck. A fixed flexion
deformiry of the cervical spine, halo traction, and other situ­
ations may also make access to the neck difficult.
• Radiation: The tissue changes associated with past radiation
therapy may alter tissues, making the procedure difficult.
• Tumor: Tumor either in or around the airway may present
difficulry, both from an access perspective as well as bleeding.
S U M MARY
Failure to evaluate the airway and predict difficulry is the sin­
gle most important factor leading to a failed airway. Despite
decades of study, no system of evaluation is able to discern with
certainry ( 1 00% reliability) those airways that can be managed
with conventional laryngoscopic intubation and those where
an alternative method is advisable. For this reason, each and
every airway management episode must be approached with
a view that some other devices or techniques may be neces­
sary should the primary plan fail. Many factors can make air­
way management a challenge, such as human factors, location,
experience, and clinical situation. The context is very impor­
tant. Furthermore, the airway practitioner must evaluate the
airway for difficulry relative to each of the alternatives contem­
plated. Once Plan A has failed, it is too late to suddenly real­
ize that Plan B is also impossible because a factor which could
have been detected had a prior evaluation for difficulty been
conducted.
While not exhaustive in covering all of the features of a
difficult airway, the mnemonics MOANS, LEMON, CRANE,
RODS, and SHORT provide guidance in evaluating all airways
for difficulry, even though they are specifically designed to be
employed rapidly in the face of an urgent or emergency clinical
circumstance.
Finally, recognizing that one is in the midst of a failed air­
way is crucial in embarking on maneuvers that may rescue the
airway. Persisting with a failing technique is a fundamental con­
tributor to bad outcomes in airway management.
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St Louis, MO: Mosby; 1 996:666-685.
87. Aziz MF, Healy D, Kheterpal S, et al. Routine clinical practice effectiveness
of the Glidescope in difficult airway management: an analysis of 2,004
Glidescope incubations, complications, and failures from two institutions.
Anesthesiology. 20 1 1 ; 1 1 4: 34-4 1 .
8 8 . Paolini J-B, Donati F, Drolet P. Review article: video-laryngoscopy:
another tool for difficult intubation or a new paradigm in airway manage­
ment? Can ] Anesth. 20 1 3;60: 1 84- 1 9 1 .
89. Sakles JC, Patanwala AE , Mosier J , e t al. Comparison o f the reusable stan­
dard GlideScope' video laryngoscope and the disposable cobalt GlideScope•
video laryngoscope for tracheal intubation in an academic emergency
department: a retrospective review. Acad Emerg Med. 20 1 4; 2 1 :408-4 1 5 .
90. Byhahn C , lber T, Zacharowski K , e t al. Tracheal intubation using the
mobile C-MAC video laryngoscope or direct laryngoscopy for patients
with a simulated difficult airway. Minerva Anestesiol. 2 0 1 0;76:577-5 83.
9 1 . Preis C, Czerny C, Preis I, et al. Variations in ILMA external diameters:
another cause of device failure. Can ] Anaesth. 2000;47:886-889.
92. Teoh WH, Lim Y. Comparison of the single use and reusable intubating
laryngeal mask airway. Anaesthesia. 2007;62:38 1 -384.
93. Fundingsland BW, Benumof JL. Difficulty using a laryngeal mask
airway in a patient with lingual tonsil hyperplasia. Anesthesiology.
1 996;84: 1 2 65 - 1 266.
94. Parmer JL, Colonna-Romano P. Harrow JC, et al. The laryngeal mask air­
way reliably provides rescue ventilation in cases of unanticipated difficult
tracheal intubation along with difficult mask ventilation. Anesth Analg.
1 998;87:66 1 -665.
95. Buckham M, Brooker M, Brimacombe J, et al. A comparison of the
reinforced and standard laryngeal mask airway: ease of insertion and the
influence of head and neck position on oropharyngeal leak pressure and
intracuff pressure. Anaesth Intensive Care. 1 999;27:628-63 1 .
96. lshimura H , Minami K, Sara T, et al. Impossible insertion o f the laryngeal
mask airway and oropharyngeal axes. Anesthesiology. 1 995;83: 867-869.
97. Olmez G, Nazaroglu H, Arslan SG, et al. Difficulties and failure of laryn­
geal mask insertion in a patient with ankylosing spondylitis. Turk J Med.
2004;34:349-352.
98. Patel RG. Percutaneous transtracheal jet ventilation: a safe, quick, and
temporary way to provide oxygenation and ventilation when conventional
methods are unsuccessful. Chest. 1 999; 1 1 6: 1 689-1 694.
SELF-EVALUATION QU ESTIONS
1 . 1 Th e most common factor leading t o a failed airway is
A. morbid obesity
B. distorted airway anatomy
C. upper airway obstruction
D. failure to predict a difficult airway
E. not knowing enough rescue techniques well
1 .2 The standard of care in airway management is related to
all of the following EXCEPT:
A. the skill of an average practitioner
B. similar localities
C. procedures that give the best results
D. the expectations of the reasonable patient
E. opinions offered by experts
1 .3 The standard of care expects that the average, reason­
able airway practitioner ought to be able to do all of the
following EXCEPT:
A. be able to manage an unanticipated difficult airway
B. be an expert and be able to use a flexible bronchoscope
to intubate immediately in the face of a CICV airway
C. be facile with one or two rescue devices or techniques
in the face of a failed airway
D. be able to perform a surgical airway
E. be able to recognize and manage a failed airway

C H A PT E R 2
The Al gorithm s
Michael F. Murphy, Edward T. Crosby, and J. Adam Law
I NTRODUCTION . 17
AI RWAY EMERG E NCI ES . . . 19
D I F F I C U LT A N D FAI L E D AI RWAY . . . . . . . 19
AI RWAY ALGO RITHMS . . . . . . . . . . . . . . . . . . . . . . . . . . 22
T H E D I F F I C U LT AI RWAY CO U RSE A I RWAY
ALGORITHMS . . . . . . . . . . . . . 31
S U M MARY . . . . . . . . . . . . . . . . . . . . . . . 36
SELF-EVALUATIO N Q U ESTI O N S . . . . . . . . . . . . . . . . . . . . 38
I NTRODUCTION
• What Is the Challenge of Difficult and Failed
Airway Management?
Competency with regard to airway management is fundamen­
tal to the practice of anesthesia, emergency medicine, emer­
gency medical services (EMS) , critical care medicine, hospital
medicine, and other acute care specialties. The focus of this
chapter is the management of the difficult and failed airway in
an emergency or urgent situation. Management of the predicted
difficult intubation is dealt with in Chapter 3 and in Section
2 of this book.
The airway practitioner in an urgent or emergency situation
is faced with two particular challenges: to be able to accurately
and expeditiously predict a difficult airway, and to be able to
recognize when airway management has failed. 1 No matter the
situation, reliably and reproducibly ensuring timely and effec­
tive oxygenation and ventilation is imperative.
17
Appropriate planning, selection of the airway devices and
techniques, clear communication of that plan and calm execu­
tion based on learned methods and experience enhances success
even in these most difficult cases. The need for clearly commu­
nicated Plan A (first line or initial plan) , B (backup or salvage
plan) , and C (failed airway plan) cannot be over emphasized.
• How Reliably Can We Predict a
Difficult Airway?
There are five means through which effective ventilation occurs:
• Spontaneous patient driven
And ventilation provided through:
• Bag-mask (BMV)
• Extraglottic device (EGO)
• Endotracheal intubation
• Surgical airway
The latter four of these are artificial or nonnatural interven­
tions, or methods of active airway management. In the event
that a patient is unable to sustain adequate spontaneous gas
exchange, or if in the course of therapy, the patient's ability to
maintain adequate gas exchange (e.g., due to the use of medica­
tions) is compromised or eliminated, one of these four methods
must be employed successfully to assure survival. They consti­
tute the four dimensions of airway management. Hence, the
assessment for anticipated difficulty should focus on these four
independent operations:
Difficult BMV
•
Difficult laryngoscopy and orotracheal intubation (direct
•
laryngoscopy [DL] or video-laryngoscopy [VL] )
Difficult EGO
•
Difficult surgical airway
•
Ordinarily mask-ventilation and orotracheal intubation
are the usual methods employed in managing the airway of
18 Pri n c i p l es of Ai rway M a n a g e m e n t

patients unable to adequately breathe for themselves. If a dif­ 4. no perceptible chest wall movement during ventilation;
ficult airway is anticipated, and it is not to be managed "awake," 5. the need to perform a two-handed mask technique; or
EGDs and surgical airway techniques are usually considered 6. changing the practitioner.
rescue options. Importantly, they ought not be considered
The anesthesia practitioner was asked to identifY ventilation
"defacto" evidence of "failure" if they are "part of the plan," a
as difficult only if the difficulty was perceived to be clinically
fundamental concept advanced in this text. Techniques under
relevant, that is, potentially leading to a patient threat. In 5%
consideration as first line or back up depend in large part
of the patients ventilation was considered difficult, and in only
on the context of the situation such as the condition of the
one patient was ventilation impossible. Following multivariate
patient, the skill of the practitioner, the availability of skilled
analysis, five criteria were recognized as independent factors for
assistance, the location and equipment available, and the time
DMV: age more than 5 5 years; BMI greater than 26 kg·m- 2 ;
of day (see Chapter 7: Context Sensitive Airway Management) .
lack of teeth; presence of a beard; and a history of snoring (see
Acute care practitioners ought to be able to determine
section "Difficult BMV: MOANS " in Chapter 1 ) .
whether or not a patient is adequately ventilating and oxygen­
Kheterpal e t al.3.4 confirmed that obesity (BMI > 30 kg·m - 2) ,
ating on their own and whether or not they will be able to
snoring and sleep apnea, age ( > 56 years), and Mallampati of
sustain adequate respiration in the near term (i.e. , What is the
Grade III or IV were risk factors for difficult ventilation and, in
anticipated clinical course over the next minutes to hours?) . It
addition, noted that a history of radiation therapy to the neck
is therefore only reasonable to expect that if an airway practi­
and severely limited jaw protrusion predicted difficult BMV
tioner is to intervene in such a manner that spontaneous ven­
(see Chapter 8 for a detailed discussion) . Han5 and KheterpaJ3
tilation is to be compromised (e.g. , a neuromuscular blocking
proposed DMV scales for the purposes of clarity and commu­
agent [NMBA] is to be used) , the practitioner must also be
nication (see Tables 2- 1 and 2-2) _5.3
able to predict that an alternative artificial method of effecting
DMV in patients under general anesthesia is likely to occur
ventilation will be successful.
in 2% to 5% of patients and impossible mask-ventilation on
In elective situations, difficulty with mask-ventilation is
the order of one event per thousand anesthetics. 2·3•6
uncommon. Langeron et al. 2 was the first to address the issue
In the emergency situation, other factors may become rele­
of codifYing "difficult mask-ventilation" (DMV) prospectively
vant when considering whether difficulty with mask-ventilation
reviewing the management of 1 502 patients undergoing elec­
is more likely to be encountered. Trauma to the face with resul­
tive surgery under general anesthesia. DMV was defined as:
tant edema, bleeding or debris in the airway, and the need to
1 . an inability to maintain Sa0 greater than 92% while using maintain in-line C-spine immobilization when required may
2
1 00% 0 via the anesthesia circuit bag-mask unit; increase the degree of difficulty with mask-ventilation. In addi­
2
2. significant gas leak around the face-mask; tion, the use of cricoid pressure, often perceived to be necessary
3. a need to increase the fresh gas flow to rates greater than in emergency intubations, is recognized to increase the like­
1 5 Lmin- 1 and to use the flush valve more than twice; lihood of DMV Petito and RusseW evaluated the impact of

TA BLE 2-1 . C l a ssification of Diffic u lt Bag-Mask-Venti l ation Accord i n g to H a n

Classification Description/Defi n ition N o. of Selections % of Cases

G ra d e 0 Ve ntilation by m a s k not atte m pted 449 24.2

G ra d e 1 Ve ntilation by m a s k 1 01 0 54.4
G ra d e 2 Ve ntilation by m a s k with o ra l a i rway or oth e r a dj uva nt 366 20.0
G ra d e 3 Difficult mask-ventilation (inadeq uate, u n sta ble, or req u i ri n g two practitioners) 22 1 .2
G ra d e 4 U na b l e to m a s k ve nti l ate 1 0.05
Co m m e nts 6 0.3
Tota l 1 854

Reprod u ced with perm ission fro m Han R, Tre m per KK, Kheterpa l S, et a l . G ra d i n g sca l e fo r mask ve nti lati o n . Anesthesiology.
2004; 1 0 1 ( 1 ) :267.

TA BLE 2-2. C l a ssification of Diffic u lt Bag-Mask-Venti l ation Accord i n g to Kheterpal

Grade Descri ption N (%)

1 Ve nti l ated by m a s k 37,857 (7 1 .3)

3 Ve nti l ated b y m a s k with o ra l a i rway/a dj uva nt w i t h o r w i t h o u t m u sc l e re l axa nt 1 3,966 (26.3)
3 Diffi c u l t venti lation (inadeq uate, u n sta ble, or req u i ri n g two providers) with or without m u scle re laxa nt 1 ,1 41 (2.2)
4 U na b l e to m a s k ve nti l ate with o r without m u sc l e re l axa nt 77 (0. 1 5)
Tota l cases 53,04 1

Reprod u ced with perm ission fro m Kheterpa l S, M a rt i n L, S h a n ks AM, Tre m p e r KK. Pred iction a n d outcomes of i m poss i b l e
m a s k ve nti latio n : a review o f 5 0,000 a n esthetics. Anesthesiology. 2009; 1 1 0 (4):89 1 -897.

cricoid pressure on lung ventilation during BMV Fifty patients
were randomized to either with or without cricoid pressure
applied during a 3-minute period of standardized mask-ventila­
tion. Patients who had cricoid pressure applied were considered
more difficult to ventilate (36% vs. 1 2%), and these patients
tended to have more air in the stomach than those patients
considered easy to ventilate without applied cricoid pressure.
Most of the studies dealing with assessment of the airway
in anticipation of tracheal intubation using a laryngoscope
have limited applicability to currently available alternative
devices (e.g., rigid endoscopic devices, intubating EGDs, and
video-laryngoscopes) . S - J O Modification of Mallampati's original
schema1 1 as well as alternate strategies to assess the airway (see
section "Difficult DL Intubation: LEMON" in Chapter I )
have been proposed. These have ranged from using simple
anatomical descriptors, ranking and summating anatomical
scoring systems, and using logistic regression to create predic­
tive scales to derive performance indices. These strategies share
some common characteristics: they have high sensitivity but
low specificity and low positive predictive value with respect
to predicting failure. For example, Shiga et al. 1 2 employing a
meta-analysis to assess combined Mallampati and temperoman­
dibular joint displacement scores found a positive association
with difficult intubation of only 9.9%. Additionally, many of
the tests have only moderate inter-observer reliability. 13' 14 Such
limitations may help to explain why these tests often fail to pre­
dict difficult tracheal intubation, and why perhaps some practi­
tioners question the ability of preanesthetic airway assessments
to accurately and with certainty predict or rule out difficulty. 15
A number of new schemes and techniques used to predict
potential airway difficulty have been described; their accuracy and
widespread applicability are not yet determined. However, it is
likely that they will have a low positive predictive value, similar
to current strategies, because of the low incidence of airway diffi­
culty.15' 16 Furthermore, we know that even with careful evaluation,
difficulty will not be predicted in many instances. 16·17 Therefore,
strategies to manage the unanticipated difficult airway should be
preformulated and practiced to minimize adverse outcomes result­
ing from the inevitable occurrence of false-negative predictions.
AI RWAY EMERG E N C I ES
• How Is Airway Management in an
Emergency Setting Different?
Airway management in an emergency setting may be compli­
cated by a multitude of factors. Trauma to the face and neck
may distort anatomical features or obscure them with blood and
debris. Additionally, blood in the airway may absorb a signifi­
cant amount of the light cast by airway devices making recog­
nition of anatomic features more difficult. The requirement for
in-line stabilization in patients with spinal injury or perceived
to be at-risk for a spinal injury may make DL more difficult.18
Unprepared patients are often associated with a full stomach
and are at a higher risk of regurgitation and aspiration of gastric
contents. The controversy regarding cricoid pressure has been
debated and a rational statement based on the current state
of evidence published by the Canadian Airway Focus Group
(CAFG) , echoing an editorial by Ovassapian in 2009 . 1 9•20 These
The A l g orith m s 19
statements take into account that the evidence supporting
the use of cricoid pressure is observational only. There is evi­
dence that the maneuver imposes an element of obstruction
to the passive regurgitation of gastric contents2 1 and anecdotal
evidence that it has prevented aspiration. 22 • 23 On the other
hand it has been shown to be difficult to teach and perform, 24
may not protect against aspiration in all patients at risk, 2 5-27
and hinders BMV, EGD insertion and ventilation, and tracheal
intubation. 2 8-30 Even a recently published Cochrane Review is
unable to resolve the controversy as to whether cricoid pressure
should or should not be abandoned in high-risk patients.31
The position of the CAFG is as follows: ''As cricoid pressure
is likely to have potential benefits, its continued use seems pru­
dent during rapid sequence intubation in the patient at high risk
of aspiration (strong recommendation for, level of evidence C) .
However, if difficulty is encountered with face-mask-ventilation
or tracheal intubation, or if EGD insertion is needed, progres­
sive or complete release of cricoid pressure is justified." 2 0 The
removal of cricoid pressure may improve the view obtained
at laryngoscopy and seems unlikely to make the view worse.
Harris et al.32 reported the experience of 402 pre-hospital emer­
gency anesthetics and noted that, in settings where the appli­
cation of cricoid pressure was associated with poor laryngeal
view, removal of the pressure resulted in improved view in 50%
of patients. In the remainder, there was no improvement in
view and other measures (BURP or laryngeal manipulation)
were employed in an attempt to improve the view and did so
in about rwo-thirds. In no patient was the removal of cricoid
pressure associated with a worse view.
Emergency situations and hemodynamically unstable patients
may contraindicate the use of drugs to facilitate laryngoscopy,
resulting in intubating conditions which may be less than ideal.
Finally, a chaotic emergency environment may distract the prac­
titioner, making it more difficult to manage the airway.
D I F F I C U LT A N D FAI LED AI RWAY
• What Does Experience Tel l Us About
Rescuing the Difficult Airway?
Evidence has emerged that having automatic default-to strategies
improves the success of rescue airway interventions and reduces
the occurrence of adverse outcomes.33 Conversely, there are
also data demonstrating that persisting with failing techniques
rather than defaulting to rescue strategies results in higher rates
of morbidity and mortality.34·35 Rose and Cohen1 reported that
difficult laryngoscopy in anesthesia practice was most often
managed with persistent attempts at DL, and the use of alter­
native approaches to tracheal intubation was uncommon. In
these patients, there was a higher incidence of desaturation,
esophageal intubation, dental damage, and unexpected ICU
admissions. Similarly, Mort,36 in reviewing the airway man­
agement of 2833 critically ill patients outside of the operating
room, noted that the most common strategy implemented for
managing difficult intubations was, again, repeated DL. There
was a significant increase in the rate of airway-related complica­
tions as the number of laryngoscopic attempts increased (:::; 2
vs. >2).36·37 1hese complications included hypoxemia, regurgi­
tation, aspiration, bradycardia, and cardiac arrest.36-38
20 Pri n c i p l es of Ai rway M a n a g e m e n t
Contrary to the experiences reported by Rose and Cohen
and Mort, Hung et al.39 noted that immediately choosing an
alternate technique (e.g. , a lightwand device) when DL had
failed was typically rewarded with rapid tracheal intubation.
Complications were both rare and minor and generally attribut­
able to the preceding attempts at DL. Heidegger et al.40 reported
on a protocol for management of both anticipated and unan­
ticipated difficult intubations that emphasized defaulting to the
flexible bronchoscope early when difficult laryngoscopy was
anticipated or observed. Applied in 1 3,248 intubations, the pro­
tocol failed in only six patients (0.045%) ; again this strategy was
associated with minimal morbidity. Similarly, Combes et al.41
reported on the efficacy of an institutional protocol employ­
ing the intubating laryngeal mask and a "bougie" (Eschmann
Tracheal Introducer) . One hundred cases of unanticipated dif­
ficulties occurred among 1 1 ,257 tracheal intubations. There
were three deviations from the protocol and two patients were
awakened without further airway management. The tracheas
of all patients managed by the protocol were successfully intu­
bated and ventilated. Finally, Mort42 compared the outcomes of
patients undergoing emergency tracheal intubation in his insti­
tution before and after the application of the American Society
of Anesthesiologists (ASA) guidelines. The rate of cardiac arrest
during emergency intubation was reduced by 50%.
Connelly et al.43 noted that alternatives to DL were far more
likely to be successful than persistent use of DL in setting of
multiple failed attempts.
It is clear that early conversion to adjuncts and alternatives
to direct-vision laryngoscopy when DL proves difficult results in
a higher salvage rate with low patient morbidity than persistent
use of the direct laryngoscope. The evidence is that the choice
of the alternative may be less important than the fact that it is
a practiced alternative and chosen early in a planned approach
when DL has proven to be difficult or has actually failed.
• Is There a Pattern to the Way Airway
Practitioners Behave in the Face of a
Difficult or Failed Airway?
Tracheal intubation is still predominantly performed orally
under DL. Difficulties related to airway management largely
involve failure to achieve tracheal intubation due to difficult
DL. A number of innovative new tools for tracheal intubation
have been presented in recent years, which address many of the
factors that give rise to difficult DL.44
The direct laryngoscope is designed to facilitate tracheal
intubation by establishing a line-of-sight from the mouth to
the larynx. As has already been noted, there are multiple patient
factors, which individually or in combination may conspire to
obstruct a laryngeal view. The ability to predict all patients in
whom it will be impossible to establish a line of sight during
laryngoscopy is sufficiently imprecise that sole reliance on the
laryngoscope to perform tracheal intubation is a precarious
strategy.
It is likely that reliance on limited conventional airway tech­
niques is a risk-enhancing behavior, which predisposes patients
to increased rates of morbidity and mortality. There is evi­
dence that such behavior has been common among anesthesia
practitioners. Rosenblatt et al.45 surveyed a random sample
of the active membership of the ASA. The survey presented
difficult airway scenarios involving cooperative adult patients
who required tracheal intubation and physicians were asked to
identify their preferred management technique. In a scenario
described as a patient with a history of previous difficult intuba­
tion, 60% of practitioners would induce general anesthesia and
59% would proceed with DL. Experienced practitioners tended
to use higher risk induction techniques and were more likely to
use the laryngeal mask airway (LMA) in situations commonly
agreed to be unconventional or contraindicated. Use of alterna­
tive devices including the Bullard laryngoscope, a lightwand,
and other adjuncts was uncommon, occurring in less than 5o/o
in all scenarios.
Jenkins et al.46 surveyed 833 Canadian anesthesiologists
to assess difficult airway management, training, and access to
airway equipment. Respondents were asked to indicate their
management choices in 1 0 difficult airway scenarios. DL was
the preferred technique overall, with the flexible bronchoscope
being the second most commonly used device. More experi­
enced, male, and older practitioners were more likely to choose
asleep induction for high-risk scenarios, a finding similar to that
of Rosenblatt. Respondents were not asked to indicate their
degree of comfort in using the alternatives that were chosen
to manage the clinical scenarios described in the survey. Wong
et al. surveyed Canadian anesthesiologists by mail regard­
ing their management preferences in two situations: difficult
intubation and cannot intubate, cannot ventilate (now more
commonly referred to as cannot intubate, cannot oxygenate
[CICO] ) . In the difficult intubation scenario, the preferred
alternative airway devices were lightwand (45%) , flexible bron­
choscope (26%) , and intubating LMA (20%) . Only 57% of
respondents had encountered a CICO situation in real life. In
the CICO scenario, preferred invasive techniques were needle
cricothyrotomy (5 1 o/o) , open cricothyrotomy (28%), and tra­
cheotomy by surgeon ( 1 4%) . In general, anesthesia practitio­
ners had little experience with and were uncomfortable with
open surgical airways, although those that had practiced on
mannequins were more comfortable using them in patients.47
There has also been a substantial change in our thinking
with respect to surgical airway management as presented in
Chapter 1 . To review, in the past it was left to the airway prac­
titioner as to whether to perform a Seldinger technique or an
open cricothyrotomy. In fact, it was taught that anesthesia prac­
titioners ought to preferentially select a Seldinger technique as
using a needle as opposed to a scalpel was felt to be psychologi­
cally more acceptable. However, Lamb,48 Aslani,49 and Elliot50
demonstrated that fellowship trained and certified anesthesiolo­
gists cannot reliably locate the cricothyroid membrane in elec­
tive surgical patients, particularly if they are female or obese.
Subsequently, the Fourth National Audit Project of the Royal
College of Anaesthetists and the Difficult Airway Society (DAS)
in the United Kingdom (NAP4)34•35 identified that needle tech­
niques were often unsuccessful and open techniques were more
successful, although in many instances in the NAP4 reports,
surgeons were more likely than anesthesia practitioners to per­
form the open techniques. It is currently recommended that an
open cricothyrotomy be performed in the CICO situation or
Another random document with
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 THE SICK CHAMBER

The New Monthly Magazine.]

[August, 1830.

What a difference between this subject and my last—a ‘Free

Admission!’ Yet from the crowded theatre to the sick chamber, from
the noise, the glare, the keen delight, to the loneliness, the darkness,
the dulness, and the pain, there is but one step. A breath of air, an
overhanging cloud effects it; and though the transition is made in an
instant, it seems as if it would last for ever. A sudden illness not only
puts a stop to the career of our triumphs and agreeable sensations,
but blots out and cancels all recollection of and desire for them. We
lose the relish of enjoyment; we are effectually cured of our romance.
Our bodies are confined to our beds; nor can our thoughts wantonly
detach themselves and take the road to pleasure, but turn back with
doubt and loathing at the faint, evanescent phantom which has
usurped its place. If the folding-doors of the imagination were
thrown open or left a-jar, so that from the disordered couch where
we lay, we could still hail the vista of the past or future, and see the
gay and gorgeous visions floating at a distance, however denied to
our embrace, the contrast, though mortifying, might have something
soothing in it, the mock-splendour might be the greater for the actual
gloom: but the misery is that we cannot conceive any thing beyond or
better than the present evil; we are shut up and spell-bound in that,
the curtains of the mind are drawn close, we cannot escape from ‘the
body of this death,’ our souls are conquered, dismayed, ‘cooped and
cabined in,’ and thrown with the lumber of our corporeal frames in
one corner of a neglected and solitary room. We hate ourselves and
everything else; nor does one ray of comfort ‘peep through the
blanket of the dark’ to give us hope. How should we entertain the
image of grace and beauty, when our bodies writhe with pain? To
what purpose invoke the echo of some rich strain of music, when we
ourselves can scarcely breathe? The very attempt is an impossibility.
We give up the vain task of linking delight to agony, of urging torpor
into ecstasy, which makes the very heart sick. We feel the present
pain, and an impatient longing to get rid of it. This were indeed ‘a
consummation devoutly to be wished’: on this we are intent, in
earnest, inexorable: all else is impertinence and folly; and could we
but obtain ease (that Goddess of the infirm and suffering) at any
price, we think we could forswear all other joy and all other sorrows.
Hoc erat in votis. All other things but our disorder and its cure seem
less than nothing and vanity. It assumes a palpable form; it becomes
a demon, a spectre, an incubus hovering over and oppressing us: we
grapple with it: it strikes its fangs into us, spreads its arms round us,
infects us with its breath, glares upon us with its hideous aspect; we
feel it take possession of every fibre and of every faculty; and we are
at length so absorbed and fascinated by it, that we cannot divert our
reflections from it for an instant, for all other things but pain (and
that which we suffer most acutely,) appear to have lost their pith and
power to interest. They are turned to dust and stubble. This is the
reason of the fine resolutions we sometimes form in such cases, and
of the vast superiority of a sick bed to the pomps and thrones of the
world. We easily renounce wine when we have nothing but the taste
of physic in our mouths: the rich banquet tempts us not, when ‘our
very gorge rises’ within us: Love and Beauty fly from a bed twisted
into a thousand folds by restless lassitude and tormenting cares: the
nerve of pleasure is killed by the pains that shoot through the head or
rack the limbs: an indigestion seizes you with its leaden grasp and
giant force (down, Ambition!)—you shiver and tremble like a leaf in a
fit of the ague (Avarice, let go your palsied hold!). We then are in the
mood, without ghostly advice, to betake ourselves to the life of
‘hermit poor,
‘In pensive place obscure,’—

and should be glad to prevent the return of a fever raging in the

blood by feeding on pulse, and slaking our thirst at the limpid brook.
These sudden resolutions, however, or ‘vows made in pain as violent
and void,’ are generally of short duration; the excess and the sorrow
for it are alike selfish; and those repentances which are the most loud
and passionate are the surest to end speedily in a relapse; for both
originate in the same cause, the being engrossed by the prevailing
feeling (whatever it may be), and an utter incapacity to look beyond
it.
‘The Devil was sick, the Devil a monk would be:
The Devil grew well, the Devil a monk was he!’

It is amazing how little effect physical suffering or local

circumstances have upon the mind, except while we are subject to
their immediate influence. While the impression lasts, they are every
thing: when it is gone, they are nothing. We toss and tumble about in
a sick bed; we lie on our right side, we then change to the left; we
stretch ourselves on our backs, we turn on our faces; we wrap
ourselves up under the clothes to exclude the cold, we throw them off
to escape the heat and suffocation; we grasp the pillow in agony, we
fling ourselves out of bed, we walk up and down the room with hasty
or feeble steps; we return into bed; we are worn out with fatigue and
pain, yet can get no repose for the one, or intermission for the other;
we summon all our patience, or give vent to passion and petty rage:
nothing avails; we seem wedded to our disease, ‘like life and death in
disproportion met;’ we make new efforts, try new expedients, but
nothing appears to shake it off, or promise relief from our grim foe: it
infixes its sharp sting into us, or overpowers us by its sickly and
stunning weight: every moment is as much as we can bear, and yet
there seems no end of our lengthening tortures; we are ready to faint
with exhaustion, or work ourselves up to frenzy: we ‘trouble deaf
Heaven with our bootless prayers:’ we think our last hour is come, or
peevishly wish it were, to put an end to the scene; we ask questions
as to the origin of evil and the necessity of pain; we ‘moralise our
complaints into a thousand similes’; we deny the use of medicine in
toto, we have a full persuasion that all doctors are mad or knaves,
that our object is to gain relief, and theirs (out of the perversity of
human nature, or to seem wiser than we) to prevent it; we catechise
the apothecary, rail at the nurse, and cannot so much as conceive the
possibility that this state of things should not last for ever; we are
even angry at those who would give us encouragement, as if they
would make dupes or children of us; we might seek a release by
poison, a halter, or the sword, but we have not strength of mind
enough—our nerves are too shaken—to attempt even this poor
revenge—when lo! a change comes, the spell falls off, and the next
moment we forget all that has happened to us. No sooner does our
disorder turn its back upon us than we laugh at it. The state we have
been in, sounds like a dream, a fable; health is the order of the day,
strength is ours de jure and de facto; and we discard all uncalled-for
evidence to the contrary with a smile of contemptuous incredulity,
just as we throw our physic-bottles out of the window! I see (as I
awake from a short, uneasy doze) a golden light shine through my
white window-curtains on the opposite wall:—is it the dawn of a new
day, or the departing light of evening? I do not well know, for the
opium ‘they have drugged my posset with’ has made strange havoc
with my brain, and I am uncertain whether time has stood still, or
advanced, or gone backward. By ‘puzzling o’er the doubt,’ my
attention is drawn a little out of myself to external objects; and I
consider whether it would not administer some relief to my
monotonous languour, if I could call up a vivid picture of an evening
sky I witnessed a short while before, the white fleecy clouds, the
azure vault, the verdant fields and balmy air. In vain! The wings of
fancy refuse to mount from my bed-side. The air without has nothing
in common with the closeness within: the clouds disappear, the sky
is instantly overcast and black. I walk out in this scene soon after I
recover; and with those favourite and well-known objects interposed,
can no longer recall the tumbled pillow, the juleps or the labels, or
the unwholesome dungeon in which I was before immured. What is
contrary to our present sensations or settled habits, amalgamates
indifferently with our belief: the imagination rules over imaginary
themes, the senses and custom have a narrower sway, and admit but
one guest at a time. It is hardly to be wondered at that we dread
physical calamities so little beforehand: we think no more of them
the moment after they have happened. Out of sight, out of mind.
This will perhaps explain why all actual punishment has so little
effect; it is a state contrary to nature, alien to the will. If it does not
touch honour and conscience (and where these are not, how can it
touch them?) it goes for nothing: and where these are, it rather sears
and hardens them. The gyves, the cell, the meagre fare, the hard
labour are abhorrent to the mind of the culprit on whom they are
imposed, who carries the love of liberty or indulgence to
licentiousness; and who throws the thought of them behind him (the
moment he can evade the penalty,) with scorn and laughter,
‘Like Samson his green wythes.’[25]

So, in travelling, we often meet with great fatigue and

inconvenience from heat or cold, or rather accidents, and resolve
never to go a journey again; but we are ready to set off on a new
excursion to-morrow. We remember the landscape, the change of
scene, the romantic expectation, and think no more of the heat, the
noise, and dust. The body forgets its grievances, till they recur; but
imagination, passion, pride, have a longer memory and quicker
apprehensions. To the first the pleasure or the pain is nothing when
once over; to the last it is only then that they begin to exist. The line
in Metastasio,
‘The worst of every evil is the fear,’

is true only when applied to this latter sort.—It is curious that, on

coming out of a sick room, where one has been pent some time, and
grown weak and nervous, and looking at Nature for the first time, the
objects that present themselves have a very questionable and spectral
appearance, the people in the street resemble flies crawling about,
and seem scarce half-alive. It is we who are just risen from a torpid
and unwholesome state, and who impart our imperfect feelings of
existence, health, and motion to others. Or it may be that the
violence and exertion of the pain we have gone through make
common every-day objects seem unreal and unsubstantial. It is not
till we have established ourselves in form in the sitting-room,
wheeled round the arm-chair to the fire (for this makes part of our
re-introduction to the ordinary modes of being in all seasons,) felt
our appetite return, and taken up a book, that we can be considered
as at all restored to ourselves. And even then our first sensations are
rather empirical than positive; as after sleep we stretch out our
hands to know whether we are awake. This is the time for reading.
Books are then indeed ‘a world, both pure and good,’ into which we
enter with all our hearts, after our revival from illness and respite
from the tomb, as with the freshness and novelty of youth. They are
not merely acceptable as without too much exertion they pass the
time and relieve ennui; but from a certain suspension and deadening
of the passions, and abstraction from worldly pursuits, they may be
said to bring back and be friendly to the guileless and enthusiastic
tone of feeling with which we formerly read them. Sickness has
weaned us pro tempore from contest and cabal; and we are fain to be
docile and children again. All strong changes in our present pursuits
throw us back upon the past. This is the shortest and most complete
emancipation from our late discomfiture. We wonder that any one
who has read The History of a Foundling should labour under an
indigestion; nor do we comprehend how a perusal of the Faery
Queen should not ensure the true believer an uninterrupted
succession of halcyon days. Present objects bear a retrospective
meaning, and point to ‘a foregone conclusion.’ Returning back to life
with half-strung nerves and shattered strength, we seem as when we
first entered it with uncertain purposes and faltering aims. The
machine has received a shock, and it moves on more tremulously
than before, and not all at once in the beaten track. Startled at the
approach of death, we are willing to get as far from it as we can by
making a proxy of our former selves; and finding the precarious
tenure by which we hold existence, and its last sands running out, we
gather up and make the most of the fragments that memory has
stored up for us. Every thing is seen through a medium of reflection
and contrast. We hear the sound of merry voices in the street; and
this carries us back to the recollections of some country-town or
village-group—
‘We see the children sporting on the shore,
And hear the mighty waters roaring evermore.’

A cricket chirps on the hearth, and we are reminded of Christmas

gambols long ago. The very cries in the street seem to be of a former
date; and the dry toast eats very much as it did—twenty years ago. A
rose smells doubly sweet, after being stifled with tinctures and
essences; and we enjoy the idea of a journey and an inn the more for
having been bed-rid. But a book is the secret and sure charm to bring
all these implied associations to a focus. I should prefer an old one,
Mr. Lamb’s favourite, the Journey to Lisbon; or the Decameron, if I
could get it; but if a new one, let it be Paul Clifford. That book has
the singular advantage of being written by a gentleman, and not
about his own class. The characters he commemorates are every
moment at fault between life and death, hunger and a forced loan on
the public; and therefore the interest they take in themselves, and
which we take in them, has no cant or affectation in it, but is ‘lively,
audible, and full of vent.’ A set of well-dressed gentlemen picking
their teeth with a graceful air after dinner, endeavouring to keep
their cravats from the slightest discomposure, and saying the most
insipid things in the most insipid manner, do not make a scene. Well,
then, I have got the new paraphrase on the Beggar’s Opera, am fairly
embarked on it; and at the end of the first volume, where I am
galloping across the heath with the three highwaymen, while the
moon is shining full upon them, feel my nerves so braced, and my
spirits so exhilarated, that, to say truth, I am scarce sorry for the
occasion that has thrown me upon the work and the author—have
quite forgot my Sick Room, and am more than half ready to recant
the doctrine that a Free Admission to the theatre is
—‘The true pathos and sublime
Of human life’:—

for I feel as I read that if the stage shows us the masks of men and
the pageant of the world, books let us into their souls and lay open to
us the secrets of our own. They are the first and last, the most home-
felt, the most heartfelt of all our enjoyments.
 FOOTMEN

The New Monthly Magazine.]

[September, 1830.

Footmen are no part of Christianity; but they are a very necessary

appendage to our happy Constitution in Church and State. What
would the bishop’s mitre be without these grave supporters to his
dignity? Even the plain presbyter does not dispense with his decent
serving-man to stand behind his chair and load his duly emptied
plate with beef and pudding, at which the genius of Ude turns pale.
What would become of the coronet-coach filled with elegant and
languid forms, if it were not for the triple row of powdered, laced,
and liveried footmen, clustering, fluttering, and lounging behind it?
What an idea do we not conceive of the fashionable belle who is
making the most of her time and tumbling over silks and satins
within at Sewell and Cross’s, or at the Bazaar in Soho-square, from
the tall lacquey in blue and silver with gold-headed cane, cocked-hat,
white thread stockings and large calves to his legs, who stands as her
representative without! The sleek shopman appears at the door, at an
understood signal the livery-servant starts from his position, the
coach-door flies open, the steps are let down, the young lady enters
the carriage as young ladies are taught to step into carriages, the
footman closes the door, mounts behind, and the glossy vehicle rolls
off, bearing its lovely burden and her gaudy attendant from the gaze
of the gaping crowd! Is there not a spell in beauty, a charm in rank
and fashion, that one would almost wish to be this fellow—to obey its
nod, to watch its looks, to breathe but by its permission, and to live
but for its use, its scorn, or pride?
Footmen are in general looked upon as a sort of supernumeraries
in society—they have no place assigned them in any Scotch
Encyclopædia—they do not come under any of the heads in Mr. Mill’s
Elements, or Mr. Maculloch’s Principles of Political Economy; and
they nowhere have had impartial justice done them, except in Lady
Booby’s love for one of that order. But if not ‘the Corinthian capitals
of polished society,’ they are ‘a graceful ornament to the civil order.’
Lords and ladies could not do without them. Nothing exists in this
world but by contrast. A foil is necessary to make the plainest truths
self-evident. It is the very insignificance, the nonentity as it were of
the gentlemen of the cloth, that constitutes their importance, and
makes them an indispensable feature in the social system, by setting
off the pretensions of their superiors to the best advantage. What
would be the good of having a will of our own, if we had not others
about us who are deprived of all will of their own, and who wear a
badge to say ‘I serve?’ How can we show that we are the lords of the
creation but by reducing others to the condition of machines, who
never move but at the beck of our caprices? Is not the plain suit of
the master wonderfully relieved by the borrowed trappings and
mock-finery of his servant? You see that man on horseback who
keeps at some distance behind another, who follows him as his
shadow, turns as he turns, and as he passes or speaks to him, lifts his
hand to his hat and observes the most profound attention—what is
the difference between these two men? The one is as well mounted,
as well fed, is younger and seemingly in better health than the other;
but between these two there are perhaps seven or eight classes of
society, each of whom is dependent on and trembles at the frown of
the other—it is a nobleman and his lacquey. Let any one take a stroll
towards the West-end of the town, South Audley or Upper
Grosvenor-street; it is then he will feel himself first entering into the
beau-ideal of civilized life, a society composed entirely of lords and
footmen! Deliver me from the filth and cellars of St. Giles’s, from the
shops of Holborn and the Strand, from all that appertains to middle
and to low life; and commend me to the streets with the straw at the
doors and hatchments overhead to tell us of those who are just born
or who are just dead, and with groups of footmen lounging on the
steps and insulting the passengers—it is then I feel the true dignity
and imaginary pretensions of human nature realised! There is here
none of the squalidness of poverty, none of the hardships of daily
labour, none of the anxiety and petty artifice of trade; life’s business
is changed into a romance, a summer’s dream, and nothing painful,
disgusting, or vulgar intrudes. All is on a liberal and handsome scale.
The true ends and benefits of society are here enjoyed and
bountifully lavished, and all the trouble and misery banished, and
not even allowed so much as to exist in thought. Those who would
find the real Utopia, should look for it somewhere about Park-lane or
May Fair. It is there only any feasible approach to equality is made—
for it is like master like man. Here, as I look down Curzon Street, or
catch a glimpse of the taper spire of South Audley Chapel, or the
family-arms on the gate of Chesterfield-House, the vista of years
opens to me, and I recall the period of the triumph of Mr. Burke’s
‘Reflections on the French Revolution,’ and the overthrow of ‘The
Rights of Man!’ You do not indeed penetrate to the interior of the
mansion where sits the stately possessor, luxurious and refined; but
you draw your inference from the lazy, pampered, motley crew
poured forth from his portals. This mealy-coated, moth-like,
butterfly-generation, seem to have no earthly business but to enjoy
themselves. Their green liveries accord with the budding leaves and
spreading branches of the trees in Hyde Park—they seem ‘like
brothers of the groves’—their red faces and powdered heads
harmonise with the blossoms of the neighbouring almond-trees, that
shoot their sprays over old-fashioned brick-walls. They come forth
like grasshoppers in June, as numerous and as noisy. They bask in
the sun and laugh in your face. Not only does the master enjoy an
uninterrupted leisure and tranquillity—those in his employment
have nothing to do. He wants drones, not drudges, about him, to
share his superfluity, and give a haughty pledge of his exemption
from care. They grow sleek and wanton, saucy and supple. From
being independent of the world, they acquire the look of gentlemen’s
gentlemen. There is a cast of the aristocracy, with a slight shade of
distinction. The saying, ‘Tell me your company, and I’ll tell you your
manners,’ may be applied cum grano salis to the servants in great
families. Mr. N—— knew an old butler who had lived with a
nobleman so long, and had learned to imitate his walk, look, and way
of speaking, so exactly that it was next to impossible to tell them
apart. See the porter in the great leather-chair in the hall—how big,
and burly, and self-important he looks; while my Lord’s gentleman
(the politician of the family) is reading the second edition of ‘The
Courier’ (once more in request) at the side window, and the footman
is romping, or taking tea with the maids in the kitchen below. A
match-girl meanwhile plies her shrill trade at the railing; or a gipsey-
woman passes with her rustic wares through the street, avoiding the
closer haunts of the city. What a pleasant farce is that of ‘High Life
Below Stairs!’ What a careless life do the domestics of the Great lead!
For, not to speak of the reflected self-importance of their masters
and mistresses, and the contempt with which they look down on the
herd of mankind, they have only to eat and drink their fill, talk the
scandal of the neighbourhood, laugh at the follies, or assist the
intrigues of their betters, till they themselves fall in love, marry, set
up a public house, (the only thing they are fit for,) and without habits
of industry, resources in themselves, or self-respect, and drawing
fruitless comparisons with the past, are, of all people, the most
miserable! Service is no inheritance; and when it fails, there is not a
more helpless, or more worthless set of devils in the world. Mr. C——
used to say he should like to be a footman to some elderly lady of
quality, to carry her prayer-book to church, and place her cassock
right for her. There can be no doubt that this would have been better,
and quite as useful as the life he has led, dancing attendance on
Prejudice, but flirting with Paradox in such a way as to cut himself
out of the old lady’s will. For my part, if I had to choose, I should
prefer the service of a young mistress, and might share the fate of the
footman recorded in heroic verse by Lady Wortley Montagu.
Certainly it can be no hard duty, though a sort of forlorn hope, to
have to follow three sisters, or youthful friends, (resembling the
three Graces,) at a slow pace, and with grave demeanour, from
Cumberland Gate to Kensington Gardens—to be there shut out, a
privation enhancing the privilege, and making the sense of distant,
respectful, idolatrous admiration more intense—and then, after a
brief interval lost in idle chat, or idler reverie, to have to follow them
back again, observing, not observed, to keep within call, to watch
every gesture, to see the breeze play with the light tresses or lift the
morning robe aside, to catch the half-suppressed laugh, and hear the
low murmur of indistinct words and wishes, like the music of the
spheres. An amateur footman would seem a more rational
occupation than that of an amateur author, or an amateur artist. An
insurmountable barrier, if it excludes passion, does not banish
sentiment, but draws an atmosphere of superstitious, trembling
apprehension round the object of so much attention and respect;
nothing makes women seem so much like angels as always to see,
never to converse with them; and those whom we have to dangle a
cane after must, to a lacquey of any spirit, appear worthy to wield
sceptres.
But of all situations of this kind, the most enviable is that of a
lady’s maid in a family travelling abroad. In the obtuseness of
foreigners to the nice gradations of English refinement and manners,
the maid has not seldom a chance of being taken for the mistress—a
circumstance never to be forgot! See our Abigail mounted in the
dicky with my Lord, or John, snug and comfortable—setting out on
the grand tour as fast as four horses can carry her, whirled over the
‘vine-covered hills and gay regions of France,’ crossing the Alps and
Apennines in breathless terror and wonder—frightened at a
precipice, laughing at her escape—coming to the inn, going into the
kitchen to see what is to be had—not speaking a word of the
language, except what she picks up, ‘as pigeons pick up peas:‘—the
bill paid, the passport visé, the horses put to, and au route again—
seeing every thing, and understanding nothing, in a full tide of
health, fresh air, and animal spirits, and without one qualm of taste
or sentiment, and arriving at Florence, the city of palaces, with its
amphitheatre of hills and olives, without suspecting that such a
person as Boccacio, Dante, or Galileo, had ever lived there, while her
young mistress is puzzled with the varieties of the Tuscan dialect, is
disappointed in the Arno, and cannot tell what to make of the statue
of David by Michael Angelo, in the Great Square. The difference is,
that the young lady, on her return, has something to think of; but the
maid absolutely forgets every thing, and is only giddy and out of
breath, as if she had been up in a balloon.
‘No more: where ignorance is bliss,
’Tis folly to be wise!’

English servants abroad, notwithstanding the comforts they enjoy,

and although travelling as it were en famille, must be struck with the
ease and familiar footing on which foreigners live with their
domestics, compared with the distance and reserve with which they
are treated. The housemaid (la bonne) sits down in the room, or
walks abreast with you in the street; and the valet who waits behind
his master’s chair at table, gives Monsieur his advice or opinion
without being asked for it. We need not wonder at this familiarity
and freedom, when we consider that those who allowed it could
(formerly at least, when the custom began) send those who
transgressed but in the smallest degree to the Bastille or the galleys
at their pleasure. The licence was attended with perfect impunity.
With us the law leaves less to discretion; and by interposing a real
independence (and plea of right) between the servant and master,
does away with the appearance of it on the surface of manners. The
insolence and tyranny of the Aristocracy fell more on the
tradespeople and mechanics than on their domestics, who were
attached to them by a semblance of feudal ties. Thus an upstart lady
of quality (an imitator of the old school) would not deign to speak to
a milliner while fitting on her dress, but gave her orders to her
waiting-women to tell her what to do. Can we wonder at twenty
reigns of terror to efface such a feeling?
I have alluded to the inclination in servants in great houses to ape
the manners of their superiors, and to their sometimes succeeding.
What facilitates the metamorphosis is, that the Great, in their
character of courtiers, are a sort of footmen in their turn. There is
the same crouching to interest and authority in either case, with the
same surrender or absence of personal dignity—the same submission
to the trammels of outward form, with the same suppression of
inward impulses—the same degrading finery, the same pretended
deference in the eye of the world, and the same lurking contempt
from being admitted behind the scenes, the same heartlessness, and
the same eye-service—in a word, they are alike puppets governed by
motives not their own, machines made of coarser or finer materials.
It is not, therefore, surprising, if the most finished courtier of the day
cannot, by a vulgar eye, be distinguished from a gentleman’s servant.
M. de Bausset, in his amusing and excellent Memoirs, makes it an
argument of the legitimacy of Napoleon’s authority, that from
denying it, it would follow that his lords of the bed-chamber were
valets, and he himself (as prefect of the palace) no better than head-
cook. The inference is logical enough. According to the author’s view,
there was no other difference between the retainers of the court and
the kitchen than the rank of the master!
I remember hearing it said that ‘all men were equal but footmen.’
But of all footmen the lowest class is literary footmen. These consist
of persons who, without a single grain of knowledge, taste, or feeling,
put on the livery of learning, mimic its phrases by rote, and are
retained in its service by dint of quackery and assurance alone. As
they have none of the essence, they have all the externals of men of
gravity and wisdom. They wear green spectacles, walk with a peculiar
strut, thrust themselves into the acquaintance of persons they hear
talked of, get introduced into the clubs, are seen reading books they
do not understand at the Museum and public libraries, dine (if they
can) with lords or officers of the Guards, abuse any party as low to
show what fine gentlemen they are, and the next week join the same
party to raise their own credit and gain a little consequence, give
themselves out as wits, critics, and philosophers (and as they have
never done any thing, no man can contradict them), and have a great
knack of turning editors, and not paying their contributors. If you get
five pounds from one of them, he never forgives it. With the proceeds
thus appropriated, the book-worm graduates a dandy, hires
expensive apartments, sports a tandem, and it is inferred that he
must be a great author who can support such an appearance with his
pen, and a great genius who can conduct so many learned works
while his time is devoted to the gay, the fair, and the rich. This
introduces him to new editorships, to new and more select
friendships, and to more frequent and importunate demands from
debts and duns. At length the bubble bursts and disappears, and you
hear no more of our classical adventurer, except from the invectives
and self-reproaches of those who took him for a great scholar from
his wearing green spectacles and Wellington-boots. Such a candidate
for literary honours bears the same relation to the man of letters,
that the valet with his second-hand finery and servile airs does to his
master.
 ON THE WANT OF MONEY

The Monthly Magazine.]

[January, 1827.

It is hard to be without money. To get on without it is like

travelling in a foreign country without a passport—you are stopped,
suspected, and made ridiculous at every turn, besides being
subjected to the most serious inconveniences. The want of money I
here allude to is not altogether that which arises from absolute
poverty—where there is a downright absence of the common
necessaries of life, this must be remedied by incessant hard labour,
and the least we can receive in return is a supply of our daily wants—
but that uncertain, casual, precarious mode of existence, in which the
temptation to spend remains after the means are exhausted, the
want of money joined with the hope and possibility of getting it, the
intermediate state of difficulty and suspense between the last guinea
or shilling and the next that we may have the good luck to encounter.
This gap, this unwelcome interval constantly recurring, however
shabbily got over, is really full of many anxieties, misgivings,
mortifications, meannesses, and deplorable embarrassments of every
description. I may attempt (this essay is not a fanciful speculation) to
enlarge upon a few of them.
It is hard to go without one’s dinner through sheer distress, but
harder still to go without one’s breakfast. Upon the strength of that
first and aboriginal meal, one may muster courage to face the
difficulties before one, and to dare the worst: but to be roused out of
one’s warm bed, and perhaps a profound oblivion of care, with
golden dreams (for poverty does not prevent golden dreams), and
told there is nothing for breakfast, is cold comfort for which one’s
half-strung nerves are not prepared, and throws a damp upon the
prospects of the day. It is a bad beginning. A man without a breakfast
is a poor creature, unfit to go in search of one, to meet the frown of
the world, or to borrow a shilling of a friend. He may beg at the
corner of a street—nothing is too mean for the tone of his feelings—
robbing on the highway is out of the question, as requiring too much
courage, and some opinion of a man’s self. It is, indeed, as old Fuller,
or some worthy of that age, expresses it, ‘the heaviest stone which
melancholy can throw at a man,’ to learn, the first thing after he rises
in the morning, or even to be dunned with it in bed, that there is no
loaf, tea, or butter in the house, and that the baker, the grocer, and
butterman have refused to give any farther credit. This is taking one
sadly at a disadvantage. It is striking at one’s spirit and resolution in
their very source,—the stomach—it is attacking one on the side of
hunger and mortification at once; it is casting one into the very mire
of humility and Slough of Despond. The worst is, to know what face
to put upon the matter, what excuse to make to the servants, what
answer to send to the tradespeople; whether to laugh it off, or be
grave, or angry, or indifferent; in short, to know how to parry off an
evil which you cannot help. What a luxury, what a God’s-send in such
a dilemma, to find a half-crown which had slipped through a hole in
the lining of your waistcoat, a crumpled bank-note in your breeches-
pocket, or a guinea clinking in the bottom of your trunk, which had
been thoughtlessly left there out of a former heap! Vain hope!
Unfounded illusion! The experienced in such matters know better,
and laugh in their sleeves at so improbable a suggestion. Not a
corner, not a cranny, not a pocket, not a drawer has been left
unrummaged, or has not been subjected over and over again to more
than the strictness of a custom-house scrutiny. Not the slightest
rustle of a piece of bank-paper, not the gentlest pressure of a piece of
hard metal, but would have given notice of its hiding-place with
electrical rapidity, long before, in such circumstances. All the variety
of pecuniary resources which form a legal tender on the current coin
of the realm, are assuredly drained, exhausted to the last farthing
before this time. But is there nothing in the house that one can turn
to account! Is there not an old family-watch, or piece of plate, or a
ring, or some worthless trinket that one could part with? nothing
belonging to one’s-self or a friend, that one could raise the wind
upon, till something better turns up? At this moment an old clothes-
man passes, and his deep, harsh tones sound like an intended insult
on one’s distress, and banish the thought of applying for his
assistance, as one’s eye glanced furtively at an old hat or a great coat,
hung up behind a closet-door. Humiliating contemplations!
Miserable uncertainty! One hesitates, and the opportunity is gone by;
for without one’s breakfast, one has not the resolution to do any
thing!—The late Mr. Sheridan was often reduced to this unpleasant
predicament. Possibly he had little appetite for breakfast himself; but
the servants complained bitterly on this head, and said that Mrs.
Sheridan was sometimes kept waiting for a couple of hours, while
they had to hunt through the neighbourhood, and beat up for coffee,
eggs, and French rolls. The same perplexity in this instance appears
to have extended to the providing for the dinner; for so sharp-set
were they, that to cut short a debate with a butcher’s apprentice
about leaving a leg of mutton without the money, the cook clapped it
into the pot: the butcher’s boy, probably used to such encounters,
with equal coolness took it out again, and marched off with it in his
tray in triumph. It required a man to be the author of The School
for Scandal, to run the gauntlet of such disagreeable occurrences
every hour of the day. There was one comfort, however, that poor
Sheridan had: he did not foresee that Mr. Moore would write his
Life![26]
The going without a dinner is another of the miseries of wanting
money, though one can bear up against this calamity better than the
former, which really ‘blights the tender blossom and promise of the
day.’ With one good meal, one may hold a parley with hunger and
moralize upon temperance. One has time to turn one’s-self and look
about one—to ‘screw one’s courage to the sticking-place,’ to graduate
the scale of disappointment, and stave off appetite till supper-time.
You gain time, and time in this weather-cock world is everything.
You may dine at two, or at six, or seven—as most convenient. You
may in the meanwhile receive an invitation to dinner, or some one
(not knowing how you are circumstanced) may send you a present of
a haunch of venison or a brace of pheasants from the country, or a
distant relation may die and leave you a legacy, or a patron may call
and overwhelm you with his smiles and bounty,
‘As kind as kings upon their coronation-day;’
or there is no saying what may happen. One may wait for dinner—
breakfast admits of no delay, of no interval interposed between that
and our first waking thoughts.[27] Besides, there are shifts and
devices, shabby and mortifying enough, but still available in case of
need. How many expedients are there in this great city (London),
time out of mind and times without number, resorted to by the
dilapidated and thrifty speculator, to get through this grand difficulty
without utter failure! One may dive into a cellar, and dine on boiled
beef and carrots for tenpence, with the knives and forks chained to
the table, and jostled by greasy elbows that seem to make such a
precaution not unnecessary (hunger is proof against indignity!)—or
one may contrive to part with a superfluous article of wearing
apparel, and carry home a mutton-chop and cook it in a garret; or
one may drop in at a friend’s at the dinner-hour, and be asked to stay
or not; or one may walk out and take a turn in the Park, about the
time, and return home to tea, so as at least to avoid the sting of the
evil—the appearance of not having dined. You then have the laugh on
your side, having deceived the gossips, and can submit to the want of
a sumptuous repast without murmuring, having saved your pride,
and made a virtue of necessity. I say all this may be done by a man
without a family (for what business has a man without money with
one?—See English Malthus and Scotch Macculloch)—and it is only
my intention here to bring forward such instances of the want of
money as are tolerable both in theory and practice. I once lived on
coffee (as an experiment) for a fortnight together, while I was
finishing the copy of a half-length portrait of a Manchester
manufacturer, who had died worth a plum. I rather slurred over the
coat, which was a reddish brown, ‘of formal cut,’ to receive my five
guineas, with which I went to market myself, and dined on sausages
and mashed potatoes, and while they were getting ready, and I could
hear them hissing in the pan, read a volume of Gil Blas, containing
the account of the fair Aurora. This was in the days of my youth.
Gentle reader, do not smile! Neither Monsieur de Very, nor Louis
XVIII., over an oyster-pâté, nor Apicius himself, ever understood the
meaning of the word luxury, better than I did at that moment! If the
want of money has its drawbacks and disadvantages, it is not without
its contrasts and counterbalancing effects, for which I fear nothing
else can make us amends. Amelia’s hashed mutton is immortal; and
there is something amusing, though carried to excess and caricature
(which is very unusual with the author) in the contrivances of old
Caleb, in ‘The Bride of Lammermuir,’ for raising the wind at
breakfast, dinner, and supper-time. I recollect a ludicrous instance of
a disappointment in a dinner which happened to a person of my
acquaintance some years ago. He was not only poor but a very poor
creature, as will be imagined. His wife had laid by fourpence (their
whole remaining stock) to pay for the baking of a shoulder of mutton
and potatoes, which they had in the house, and on her return home
from some errand, she found he had expended it in purchasing a new
string for a guitar. On this occasion a witty friend quoted the lines
from Milton:
‘And ever against eating cares,
Wrap me in soft Lydian airs!’

Defoe, in his Life of Colonel Jack, gives a striking picture of his

young beggarly hero sitting with his companion for the first time in
his life at a three-penny ordinary, and the delight with which he
relished the hot smoking soup, and the airs with which he called
about him—‘and every time,’ he says, ‘we called for bread, or beer, or
whatever it might be, the waiter answered, “coming, gentlemen,
coming;” and this delighted me more than all the rest!’ It was about
this time, as the same pithy author expresses it, ‘the Colonel took
upon him to wear a shirt!’ Nothing can be finer than the whole of the
feeling conveyed in the commencement of this novel, about wealth
and finery from the immediate contrast of privation and poverty.
One would think it a labour, like the Tower of Babel, to build up a
beau and a fine gentleman about town. The little vagabond’s
admiration of the old man at the banking-house, who sits
surrounded by heaps of gold as if it were a dream or poetic vision,
and his own eager anxious visits, day by day, to the hoard he had
deposited in the hollow tree, are in the very foremost style of truth
and nature. See the same intense feeling expressed in Luke’s address
to his riches in the City Madam, and in the extraordinary raptures of
the ‘Spanish Rogue’ in contemplating and hugging his ingots of pure
gold and Spanish pieces of eight: to which Mr. Lamb has referred in
excuse for the rhapsodies of some of our elder poets on this subject,
which to our present more refined and tamer apprehensions sound
like blasphemy.[28] In earlier times, before the diffusion of luxury, of
knowledge, and other sources of enjoyment had become common,
and acted as a diversion to the cravings of avarice, the passionate
admiration, the idolatry, the hunger and thirst of wealth and all its
precious symbols, was a kind of madness or hallucination, and
Mammon was truly worshipped as a god!
It is among the miseries of the want of money, not to be able to pay
your reckoning at an inn—or, if you have just enough to do that, to
have nothing left for the waiter;—to be stopped at a turnpike gate,
and forced to turn back;—not to venture to call a hackney-coach in a
shower of rain—(when you have only one shilling left yourself, it is a
bore to have it taken out of your pocket by a friend, who comes into
your house eating peaches in a hot summer’s day, and desiring you to
pay for the coach in which he visits you);—not to be able to purchase
a lottery-ticket, by which you might make your fortune, and get out
of all your difficulties;—or to find a letter lying for you at a country
post-office, and not to have money in your pocket to free it, and be
obliged to return for it the next day. The letter so unseasonably
withheld may be supposed to contain money, and in this case there is
a foretaste, a sort of actual possession taken through the thin folds of
the paper and the wax, which in some measure indemnifies us for the
delay: the bank-note, the post-bill seems to smile upon us, and shake
hands through its prison bars;—or it may be a love-letter, and then
the tantalization is at its height: to be deprived in this manner of the
only consolation that can make us amends for the want of money, by
this very want—to fancy you can see the name—to try to get a peep at
the hand-writing—to touch the seal, and yet not dare to break it open
—is provoking indeed—the climax of amorous and gentlemanly
distress. Players are sometimes reduced to great extremity, by the
seizure of their scenes and dresses, or (what is called) the property of
the theatre, which hinders them from acting; as authors are
prevented from finishing a work, for want of money to buy the books
necessary to be consulted on some material point or circumstance, in
the progress of it. There is a set of poor devils, who live upon a
printed prospectus of a work that never will be written, for which
they solicit your name and half-a-crown. Decayed actresses take an
annual benefit at one of the theatres; there are patriots who live upon
periodical subscriptions, and critics who go about the country
lecturing on poetry. I confess I envy none of these; but there are
persons who, provided they can live, care not how they live—who are
fond of display, even when it implies exposure; who court notoriety