Patient label

Baylor Scott & White Anesthesiology – Central Texas

2401 South 31st Street, Temple, Texas 76508

Telephone (254) 724-2407 - Fax (254) 724-5369

History of a Difficult Airway – Provider Information

To Our Anesthesia Colleagues:

On	this patient (weighing	kg) with a BMI of	was found to be
difficult to intubate by direct laryngoscopy at a Baylor Scott & White – Central Texas Facility.

Reasons for difficulty include:

Prominent Teeth	Reduced Neck Mobility	Large Tongue
Anterior Larynx	Reduced Mouth Opening	Immobile Epiglottis
Tumor	Other:

Ventilation by mask was:

Easy	without an airway device or	with an	oral or a	nasal airway
Difficult	without an airway device or	with an	oral or a	nasal airway
Unsuccessful
Achieved using an LMA size: __________
Other:

asleep,	awake by using:

Intubation was unsuccessfully attempted with the patient

Mac # _______blade	Miller # ______blade
Fiberoptic Bronchoscope	Intubating Stylet
Retrograde Technique	Blind Nasal Intubation
Intubating LMA size _____________	Videolaryngoscopy
Other:

was not secured and the case was cancelled OR
Was secured with the patient	asleep,	awake by using:

Ultimately the airway

Mac # _______blade	Miller # ______blade
Fiberoptic Bronchoscope	Intubating Stylet
Retrograde Technique	Blind Nasal Intubation
Cricothyrotomy	Tracheostomy
Intubating LMA size _____________	Videolaryngoscopy
Other:

Any additional comments:

Date	Time	Physician Last Name (Print)	Physician signature
Practice Facility:	Contact Number:

Patient label

Baylor Scott & White Anesthesiology – Central Texas

2401 South 31st Street, Temple, Texas 76508

Telephone (254) 724-2407 - Fax (254) 724-5369

To the patient:

During your care on ______/______/______(date), it was more difficult than usual to place an endotracheal tube (an airway breathing tube) for you.

During most general anesthetics (sleep for surgery) it is necessary to put an airway breathing tube into the patient’s trachea (windpipe). This tube assures the flow of oxygen into the lungs and from there to the heart, brain and other vital organs.

It is very important that you show the attached Provider Information letter to any anesthesia provider (anesthesiologist or anesthetist) taking care of you in the future. This note is to inform them that it was more difficult to place the breathing tube for you than it is for most people.

Your anesthesia provider will be in a much better position to take good care of you if he/she is warned of this situation.

In addition you may wish to consider getting and wearing a Medic Alert Bracelet stating: “Difficult Tracheal Intubation”, (This is available from www.medicalert.org and others.)

Date	Time	Physician Last Name (Print)	Physician signature
Practice Facility:	Contact Number: