Assembling a Difficult Airway Cart/Kit, declaring “Code D”, and issuing an Airway Alert Card for unanticipated difficult airway management proposed by the All India Difficult Airway Association

Abstract

The All India Difficult Airway Association (AIDAA) guidelines provide a structured framework to ensure safe and effective airway management, with a key emphasis on preparation, timely assistance, and proper documentation. To support these essential elements, AIDAA has introduced a standardised Difficult Airway Cart (DAC), the declaration of “Code D” for summoning trained help, and a dedicated Difficult Airway Alert document for difficult airway management scenarios. Recognising that airway management extends beyond operating theatres, the proposed DAC also suggests a minimal but essential “carry kit.” Timely, specific, and reasoned calls for help are encouraged through “Code D” to ensure appropriate personnel respond promptly. Post-event documentation is considered essential, not only for institutional records but also for providing an alert document for future reference. AIDAA’s updated recommendations integrate these elements—DAC, Code D, and structured documentation—to improve safety, preparedness, and successful airway management.

INTRODUCTION

The All India Difficult Airway Association (AIDAA) guidelines offer a framework for airway management. Successful and uneventful airway management depends on several factors.[1,2,3,4,5,6] Among these, key components are preparation, prompt assistance, and appropriate documentation. Therefore, to streamline these key aspects, AIDAA recommends a standardised difficult airway cart/kit, proposes the declaration of Code D for difficult airway situations, and introduces a Airway Alert document.

Professional airway bodies have highlighted the importance of a difficult airway cart (DAC).[7,8,9] Rather than a simple storage cupboard, the cart must be organised according to a structured approach for airway management. A quality improvement initiative emphasised that an icon-based difficult airway cart enhances equipment recognition and boosts healthcare professionals’ confidence.[10] It is also crucial to minimise the essential airway management equipment, especially for airway management outside the operating room settings, where a kit containing the minimum necessary airway tools should be stored. This proposal from AIDAA is distinctive, recognising that airway management now extends beyond the operating rooms. Human factors play a vital role while calling for timely assistance in an airway crisis.[11] This underscores the need to summon the appropriately trained personnel for a specific type of assistance, rather than a generic “call for help”. The call needs to be specific, purpose oriented, and prompt. With this background, AIDAA introduced “Code D” as a designated mode for summoning help from trained staff.

After managing a difficult airway, it is prudent to document the event as the patient may require further anaesthesia or airway management in future. Although most institutions maintain records, providing a standardised documentation format with details of the nature of airway difficulty faced in the form of an airway alert card for patients and families is equally important.

With this rationale, AIDAA recommends an updated composition for a difficult airway cart, which includes a carry kit, a targeted call for help: Code D, and a standard format for documentation of difficult airway management, including a patient airway alert card.

DIFFICULT AIRWAY CART

Airway management can be complex in some patients in both scenarios of anticipated and unanticipated difficult airways. The DAC should be dedicated, well organised, and easily accessible to handle such challenging situations (both planned and urgent/emergency situations). The AIDAA recommends using the DAC to assist with airway management, from routine intubation to emergency surgical airway procedures, following standardised AIDAA guidelines. It ensures that airway management equipment, including adjuncts and surgical airway kits, is arranged in a structured, stepwise manner [Table 1, Figure 1]. The DAC can be adapted to meet local, regional, or institutional needs. The sizes of these devices need to be stored according to age requirements. The main principles for the DAC are standardisation (consistent layout across all operating rooms and units), modularity (compartment organisation according to plans or steps), portability (a mobile cart), accessibility (a dedicated, mobile cart with labelled compartments), readiness (daily equipment checks and airway management drills), redundancy (backup vital tools such as multiple blades and laryngoscopes), and documentation (event record-keeping aids and algorithm access). At some centres, videoendoscopes/bronchoscopes and videolaryngoscopes are mounted on separate units and must be brought separately when needed. Also, routine airway management equipment like laryngoscopes, tracheal tubes, and supraglottic airway devices is available for all cases, and thus, in such situations, DAC can be decongested with this equipment. Additionally, drugs and other adjuncts are not included in this DAC but need to be immediately available at the workplace [Table 2]. The AIDAA also suggests having an airway management carry kit outside routine operation theatre areas, which includes minimal but essential airway management tools [Table 1, Figure 1].

Table 1.

Difficult airway cart (DAC)

Arrangement	Airway Strategy	Generic List of Airway Equipment for the Cart*	Equipment in the Carry KIT
Compartment 1	Mask ventilation	• Bag-valve-mask with reservoir bag with oxygen tubing • **Nasal oxygenation devices - nasal cannula and high-flow nasal oxygen cannula	Bag-valve-mask with reservoir bag with oxygen tubing
Compartment 2	Tracheal Intubation aids	• Face masks • Oropharyngeal airways • Nasopharyngeal airways • Laryngoscope handles and blades • Videolaryngoscope with hyper-angulated and Macintosh blades • Flexible videoendoscopes/bronchoscopes • Airway introducers: Stylets, bougies, and airway exchange catheters • Tracheal tubes cuffed and uncuffed • Suction catheter (Yankauer and soft)	• Oropharyngeal airways • Nasopharyngeal airways • Laryngoscope handles and blades • Portable videolaryngoscope • Stylets, bougies, and airway exchange catheters • Tracheal tubes • Suction catheter (Yankauer and soft)
Compartment 3	Supraglottic Airways (SGA)	• Second-generation supraglottic airway device (SGA) devices with introducers/insertion aids • Tracheal tubes and airway exchange catheters e.g AintreeTMexchange catheter (for intubation through the SGA device, if needed)	• Second-generation SGA
Compartment 4	Emergency Cricothyroidotomy	• Surgical cricothyrotomy kit: Scalpel (#10 or #11), bougie, Tracheal Tube #6 • Needle cricothyrotomy kit (14–16 G cannula) • Manual jet ventilation system	Surgical cricothyrotomy kit: Scalpel (#10 or #11), bougie, Tracheal Tube#6

*Devices should be available in different sizes in accordance with the cases managed. ** These devices are required to provide nasal oxygenation throughout airway rescue and may be part of any of the compartments.

Figure 1.

Components of (a) Difficult Airway Cart (b) Carry Kit

Table 2.

Adjuncts, drugs, and monitors for airway management

Types	Items
Medications	• Anaesthesia induction and neuromuscular blocking • Emergency drugs: Adrenaline, Atropine, Succinylcholine • Topical anaesthetics: Lignocaine jelly/spray • Antidotes: Naloxone, Flumazenil, Sugammadex • Nasal decongestants, Lignocaine sprays/jellies • Antisialagogues: Glycopyrrolate
Airway adjuncts	• Laminated charts carrying Airway algorithms • High-flow nasal oxygen device • Bite blocks • Magill forceps • Adhesive tape • Nebuliser mask • Mucosal atomiser • Accessories for providing the Ramp Position
Monitors	• Portable capnograph + colorimetric end-tidal carbon dioxide (EtCO2) detector or oesophageal detector device • Pulse oximeter
Special Considerations	• Paediatric-specific: Separate drawer with smaller-sized devices (e.g., Broselow tape-guided inventory) • Obesity/High-risk: Ramped positioning pillows, long-shaft video laryngoscope blades. • Extubation Failure Kit: Airway exchange catheters, oxygen insufflation capability

IMPLEMENTATION PROTOCOLS AND SUPPORT SYSTEMS

An inventory, usage log, and daily checklist must be maintained for the DAC. It is equally important to have institutional tutorial videos and simulation props, such as cricothyroidotomy pads, for skill practice. Staff training, including airway drills and training, is also recommended. The DAC is essential in operation theatres (primarily where high-risk surgeries are performed), emergency departments, intensive care units, prehospital settings, and simulation centres. A customised DAC is also vital for patient transfer (both inter-hospital and intra-hospital).

“CODE D” – A STANDARDISED CALL FOR HELP FOR DIFFICULT AIRWAY SITUATIONS

Why “Code D”?

Early recognition and prompt action to “Call for help” are crucial in unanticipated difficult airway scenarios. The AIDAA airway management algorithms provide a step-by-step approach for airway management attempts. However, human factors, including the arrival of expert assistance after a “Call for help,” remain central to achieving success. The terminology and process of calling for help with a “Call for help” announcement can often be vague and lack clarity about the specific assistance needed. This ambiguity may delay the arrival of the appropriate help required, such as additional human resources and equipment, at the right time. To address this communication gap, the AIDAA proposes using a standardised alert term, “Code D” (D = Difficult Airway) [Figure 2]. This specific terminology will serve as a clear, context-specific, and time-sensitive signal for requesting additional help during airway emergencies. The activation of the emergency code has been found to improve the success for airway management outside the operating rooms scenarios.[12]

Figure 2.

“Code D” – A Standardised Call For Help For Difficult Airway Situations

When to use “Code D”

Code D should be announced promptly in cases involving a difficult airway where immediate rescue is required. Regular audits can be carried out to monitor response times, outcomes, and identify opportunities for system improvements. It is essential to prepare for specific clinical scenarios that require increased readiness, such as head and neck cancer surgeries, morbid obesity or obstructive sleep apnoea, airway trauma or burns, paediatric airway anomalies, and critical care settings with airway swelling or infection. For obstetric patients who may have difficulty with positioning or are at risk of aspiration, it is wise to declare a high airway risk beforehand and to include a Code D plan in the anaesthesia checklist.

DIFFICULT AIRWAY REPORTING FORM AND AIRWAY ALERT CARD

Despite advances in airway management techniques, newer airway devices and the presence of airway guidelines, airway-related complications continue to occur. In this context, AIDAA recommends that when an unanticipated difficult airway occurs, all details of the difficulty, the airway management plan, and any complications should be recorded in a standard format [Figure 3]. For future reference, a copy should be stored in the medical records and provided to the patient or their surrogate (if the patient is a minor or lacks capacity). A printable ‘Airway Alert Card’ for the patient is a lifelong safety tool, especially in areas where electronic medical records are not yet accessible.

Figure 3.

Difficult Airway Reporting Form. Dl = direct laryngocopyl VL = videolaryngoscopy; SGA = supraglottic airway device; ICU = intensive care unit

The standardised ‘Difficult Airway Reporting Form’ serves several key purposes. It records the history for future airway management, particularly if the patient requires anaesthesia again. It also offers a valuable record for audit and root cause analysis of airway management. This form can be linked to a central registry and is a useful tool for tailoring management strategies to regional needs.

AIDAA suggests that while the basic structure of the standardised ‘Difficult Airway Reporting Form’ should remain unchanged to ensure consistency and auditability, local adaptations are permitted. In addition, it is the prerogative of tertiary care centres performing specialised procedures, such as laryngotracheal reconstructions, complex oncosurgeries, or high-risk obstetrics, which may include multi-disciplinary team alerts, anticipated reintubation plans, or preoperative imaging references directly within the form. To conclude, appropriate availability and timely use of difficult airway cart/kit, declaring Code D, and issuing of Airway Alert Card remains during airway management.

Study data availability

Not applicable

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references.

Authors contributions

RG, SMA, SNM, APS, VR, AP, SRS, JVD, JRD, PK: conceptualised the idea for this manuscript. RG and SMA conducted the literature search and drafted the manuscript. All authors provided input, revised and approved the manuscript.

Conflicts of interest

Dr Amit Shah- inventor of Patwashahi video laryngoscope (non-commercial), designer of HFNO device HuFlo2. Dr Apeksh Patwa-inventor of Patwashahi video laryngoscope (non-commercial), designer of HFNO device HuFlo2. Rakesh Garg, Syed Moied Ahmed, Sheila Nainan Myatra, Jeson R Doctor, and Pankaj Kundra, who are co-authors of this manuscript, are editors of this journal. They were not involved in the decision-making process, and an independent editor handled this manuscript. Other authors declare that they have no conflicts of interest.

Funding Statement

All expenses related to the development of the guidelines were entirely funded by the All India Difficult Airway Association (AIDAA).