■ Safety of care:

Improving patient safety and reducing risks

The unanticipated complicated airway: Are you ready?

Originally published September 2018

Airway management is an advanced technical skill that many physicians are proficient in—but when things don’t go as planned, this can be harmful for the patient and stressful for the team. The CMPA took a close look at legal cases involving rare, serious complications in airway management in all age groups and found that lost situational awareness, inadequate preparation, and poorly coordinated teams were underlying themes.

The CMPA legal cases

While the CMPA closed over 9,000 civil legal cases between 2008 and 2017, only 45 cases focused on difficulties securing an airway.1 Most of the time (35 cases) peer experts in the legal cases were critical of the care provided and in 25 of these cases in which a physician did not meet the standard of care, the patient outcome was serious brain injury or death.

Nearly all care with peer expert criticism occurred in hospital, often in the intensive care unit (ICU) (13 cases) or emergency department (6 cases). Care was in the operating room (OR) for 14 cases. The most commonly involved specialties were anaesthesia, emergency medicine, pediatrics/neonatology, and internal medicine. Esophageal intubations and post-extubation incidents were common among the 35 cases with criticism.

What factors contributed?

Situational awareness

Situational awareness is about knowing what is going on around you. It involves getting information, understanding it, and thinking ahead.2 In the following case an anesthesiologist had good situational awareness during an unfortunate, rare complication.

Case example: Rapid response to a complicated extubation

An obese, elderly man with a history of asthma undergoes bronchoscopy to investigate a lung mass. In the post-anaesthesia care unit, an anesthesiologist extubates the patient, but soon afterward the patient’s oxygen saturation decreases. The physician suspects a bronchospasm and re-intubates. Within seconds, he notes absence of air entry and queries esophageal intubation. He re-intubates a second time and confirms proper tube positioning. Still the physician notes that oxygen saturation is not improving and the patient’s abdomen is distended. He inserts a nasogastric tube, but the patient becomes bradycardic. The surgical team begins resuscitation—including emergency bilateral percutaneous needle thoracentesis and chest tube insertion—but they are unsuccessful. Following autopsy, the patient’s death is attributed to cardiovascular collapse due to tension pneumoperitoneum secondary to an acute gastric rupture, a rare event associated with emergency assisted ventilation.

Ultimately, all parties consented to dismiss the case and there was no criticism of care. Peer experts opined that the physician’s documented pre-surgical evaluation met the standard of care. They also acknowledged the quick speed at which the physician recognized and responded to the esophageal intubation and distended abdomen.

In contrast, other CMPA legal cases showed evidence of "tunneling" or focusing attention on one aspect of a procedure while other aspects were ignored2 such as the elapsed time. Peer expert opinions in the CMPA cases suggested a common theme (as follows):

  • When managing an airway, seek signs of problems early; recognize and react in a timely manner. In an airway emergency, ask a team member to alert you of key time intervals.


The following case demonstrates the importance of preparing for airway complications from a provider, team, and system perspective.

Case example: An esophageal intubation goes undetected

A child is in the ICU with severe head trauma, awaiting transfer to another centre. An anesthesiologist plans an elective intubation, for transfer. He notes that the saturation monitor is malfunctioning, but proceeds to intubate using a video laryngoscope. Soon afterward, he realizes the end-tidal CO2 monitor is unavailable and requests an urgent chest X-ray. The physician tries to confirm placement with auscultation and finds decreased air entry on the right side; he queries pneumothorax. He attempts to access the X-ray images, but nobody in the room knows the computer password. Rapidly recognizing that the patient has no pulse, the team begins resuscitation. Once gaining computer access, they confirm esophageal intubation on the X-ray. The physician immediately and easily re-intubates. The patient dies several days later from complications secondary to cerebral anoxia.

The peer experts commenting on this case in the legal action suggested that a lack of team and system readiness contributed to the outcome. Since this was an elective intubation, there was opportunity for a pre-procedure huddle to confirm that a CO2 monitor and a functional SaO2 monitor were available. In the end, the CMPA paid a settlement on behalf of the anesthesiologist. Among CMPA legal cases, peer expert opinions were consistent with the following risk reduction strategy:

  • When possible before airway management, verify with team members that critical equipment is available (e.g. using a checklist) and be familiar with the contents of the airway cart. Flag and report any missing or malfunctioning equipment to the stocking team and appropriate management, if possible.

Team coordination and communication

Airway management remote from the OR can be particularly challenging since it often involves ad hoc teams.3

Case example: An unexpected, difficult extubation in the ICU

A middle-aged woman, injured in a motor vehicle collision, suffers a C1-C2 subluxation injury. She undergoes surgical repair and wears a cervical spine collar post-operatively. Two days later during ICU morning rounds, the attending intensivist (a respirologist) asks a respiratory therapist to extubate the patient given her successful weaning protocol, but is unaware that her blood hemoglobin dropped significantly overnight. The respirologist leaves the hospital. When the respiratory therapist extubates the patient, she immediately notes the patient struggling to breathe and attempts manual bag-mask ventilation. Minutes later the patient is non-responsive. The respiratory therapist, with limited experience performing emergency re-intubations, pages medical staff for help. A general surgery resident and anesthesiologist arrive, repeatedly attempt to manage the airway and intubate, and eventually perform an emergency cricothyroidotomy. The patient suffers hypoxic brain injury from upper airway obstruction and dies several days later.

In this case, the CMPA (on behalf of the member respirologist) and the hospital paid a joint settlement to the patient’s family.

This case demonstrates lack of critical information sharing across the team. Peer experts criticized the physician’s decision to extubate when the patient’s hemoglobin had dropped, although she insisted the message was not relayed to her during rounds. Furthermore, a positive air leak test (suggesting readiness for extubation) was undocumented because it was hospital policy to document only failed leak tests. This policy led experts on the legal case to believe that the test was not done.

This case also highlights supervision issues. Experts felt the physician should have anticipated airway obstruction, given the patient’s neck surgery, and therefore ensured that experienced personnel were present for extubation. Notably, residents were involved in nearly one-third of CMPA airway civil legal cases with criticism, but rarely were they found to be ultimately responsible for the outcome. Peer experts noted resident deficiencies in performing intubation, delays or failures in recognizing or acting on complications, and delays in seeking help. Assessing resident competence and appropriate supervision are crucial for safe airway management. The following risk reduction strategies are consistent with peer expert opinions in the CMPA cases:

  • In non-emergency airway situations, conduct and document a comprehensive airway assessment, and seek markers for a difficult airway (e.g. history of difficult airway).
  • In emergency airway situations, conduct a rapid airway assessment and anticipate how to manage complications.
  • When intubation is difficult, or repeated attempts are unsuccessful, promptly consult a colleague for help. Closely supervise less experienced team members.
  • Prior to extubation, consider using strategies, such as a team huddle, to reach consensus that timing is appropriate for the patient and the team is ready.

The bottom line

Despite technological advancements, ultimately "hands, brains, and voices"4 determine patient safety. To manage your medical-legal risk during airway management:

  • Engage in strategies to acquire, maintain, and recover situational awareness.
  • Prepare for difficult airways from a provider, team, and system perspective.
  • Practice team communication strategies and coordination methods to facilitate safe airway management.

Additional reading

Other resources

  • A video by the National Health Service Institute for Innovation and Improvement re-enacting the Elaine Bromiley case: "A routine operation."


  1. Events occurred between 1998 and 2013
  2. Parush A, Campbell C, Hunter A, et al. Situational awareness and patient safety. Ottawa (CA): The Royal College of Physicians and Surgeons of Canada; 2011, 35 p. Available from: http://www.royalcollege.ca/rcsite/documents/canmeds/situational-awareness-patient-safety-full-e.pdf
  3. Brindley PG, Beed M, Law JA, et al. Airway management outside the operating room: how to better prepare. Can J Anesth. 2017;64(5):530-9
  4. Brindley PG, Beed M, Duggan LV, et al. Updating our approach to the difficult and failed airway: time to "stop and think." Can J Anesth. 2016;63(4):373-81

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.