The nature of the response to airway management incident reports in high income countries: A scoping review

Adverse events associated with failed airway management may have catastrophic consequences, and despite many advances in knowledge, guidelines and equipment, airway incidents and patient harm continue to occur. Patient safety incident reporting systems have been established to facilitate a reduction in incidents. However, it has been found that corrective actions are inadequate and successful safety improvements scarce. The aim of this scoping review was to assess whether the same is true for airway incidents by exploring academic literature that describes system changes in airway management in high-income countries over the last 30 years, based on findings and recommendations from incident reports and closed claims studies. This review followed the most recent guidance from the Joanna Briggs Institute (JBI). PubMed, Ovid MEDLINE and Embase, the JBI database, SCOPUS, the Cochrane Library and websites for anaesthetic societies were searched for eligible articles. Included articles were analysed and data synthesised to address the review's aim. The initial search yielded 28,492 results, of which 111 articles proceeded to the analysis phase. These included 23 full-text articles, 78 conference abstracts and 10 national guidelines addressing a range of airway initiatives across anaesthesia, intensive care and emergency medicine. While findings and recommendations from airway incident analyses are commonly published, there is a gap in the literature regarding the resulting system changes to reduce the number and severity of adverse airway events. Airway safety management mainly focuses on Safety-I events and thereby does not consider Safety-II principles, potentially missing out on all the information available from situations where airway management went well.

Favour the best in case of emergency cricothyroidotomy-a randomized cross-over trial on manikin focused training and simulation of common devices

Background

Performing an emergency cricothyroidotomy (EC) is extremely challenging, the devices used should be easy to handle and the selected technique reliable. However, there is still an ongoing debate concerning the most superior technique.

Methods

Three different techniques were compared using a standardized, simulated scenario regarding handling, performing, training and decision making: The scalpel-bougie technique (SBT), the surgical anatomical preparation technique (SAPT) and the Seldinger technique (ST). First, anaesthesia residents and trainees, paramedics and medical students (each group n = 50) performed a cricothyroidotomy randomly assigned with each of the three devices on a simulator manikin. The time needed for successful cricothyroidotomy was the primary endpoint. Secondary endpoints included first-attempt success rate, number of attempts and user-satisfaction. The second part of the study investigated the impact of prior hands-on training on both material selection for EC and on time to decision-making in a simulated "cannot intubate cannot ventilate" situation.

Results

The simulated scenario revealed that SBT and SAPT were significantly faster than percutaneous EC with ST (p < 0.0001). Success rate was 100% for the first attempt with SBT and SAPT. Significant differences were found with regard to user-satisfaction between individual techniques (p < 0.0001). In terms of user-friendliness, SBT was predominantly assessed as easy (87%). Prior training had a large impact regarding choice of devises (p < 0.05), and time to decision making (p = 0.05; 180 s vs. 233 s).

Conclusion

This study supports the use of a surgical technique for EC and also a regular training to create familiarity with the materials and the process itself.The trial was registered before study start on 11.11.2018 at ClinicalTrials.gov (NCT: 2018-13819) with Nicole Didion as the principal investigator.

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

PURPOSE

Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA).

METHODS

An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements.

RESULTS

The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care.

CONCLUSION

Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

Impact of airway devices and emergency airway techniques characteristics on airway adverse events in mainland China: a cross-sectional study

BACKGROUND

Novel airway devices are becoming widely available, yet it is unclear whether the techniques or preferences of airway practitioners for airway management have been impacted. Given these facts, a cross-sectional study of the current status of airway management in mainland China was conducted and compared with previous survey findings.

METHODS

The national survey was conducted from November 7th to November 28th, 2022. An electronic survey was sent to the New Youth Anesthesia Forum to examine the availability of airway devices, preference for front-of-neck access (FONA) techniques, the incidence of adverse airway events, and the status of airway management training.

RESULTS

Questionnaires were completed by 3783 respondents, with a response rate of 72.14%. So far, the availability of optical airway devices has improved dramatically, with the availability of videolaryngoscopes reaching 97.18%. When encountering "cannot intubate, cannot ventilate" (CICV) scenarios, the majority of respondents would prefer needle cricothyrotomy to establish FONA. However, less than a quarter of respondents had actually performed it. Moreover, the incidence of airway adverse events from 2016 to 2022 was 11.48%, of which 5.13% were brain damage or death. Multivariate logistic regression analysis revealed that the ability to perform FONA techniques (odds ratio [OR] 0.23, 95% CI: 0.16, 0.32; P<0.001) and the availability of difficult airway management carts or kits (OR 0.59, 95% CI 0.41, 0.85; P=0.005) were associated with a lower incidence of airway adverse events.

CONCLUSIONS

Optical airway devices can overcome some of the challenges posed by difficult airways, yet the CICV scenario remains a major obstacle. The future focus of airway management should be training, particularly for complicated emergency airway techniques.

Swedish consensus regarding difficult pre-hospital airway management: a Delphi study

BACKGROUND

The aim of this study was to establish a consensus among experts in prehospital work regarding the management of difficult airways in prehospital care in Sweden. The results were subsequently used to develop an algorithm for handling difficult airway in prehospital care, as there was none available in Sweden prior to this study.

METHODS

This two-round Delphi study was conducted by forming an expert panel comprising anesthesiologists and anesthesia nurses working in prehospital setting in Sweden. The expert panel responded digital forms with questions and statements related to airway management. The study continued until consensus was reached, defined as more than 70% agreement. The study took place from December 4, 2021, to May 15, 2022.

RESULTS

In the first round, 74 participants took part, while the second round involved 37 participants. Consensus was reached in 16 out of 17 statements. 92% of the participants agreed that an airway algorithm adapted for prehospital use is necessary.

CONCLUSIONS

The capacity to adapt the approach to airway management based on specific pre-hospital circumstances is crucial. It holds significance to establish a uniform framework that is applicable across various airway management scenarios. Consequently, the airway management algorithm that has been devised should be regarded as a recommendation, allowing for flexibility rather than being interpreted as a rigid course of action. This represents the inaugural nationwide algorithm for airway management designed exclusively for pre-hospital operations in Sweden. The algorithm is the result of a consensus reached by experts in pre-hospital care.

Airway and respiratory complications during anaesthesia and associated with peri-operative cardiac arrest as reported to the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied complications of the airway and respiratory system during anaesthesia care including peri-operative cardiac arrest. Among 24,721 surveyed cases, airway and respiratory complications occurred commonly (n = 421 and n = 264, respectively). The most common airway complications were: laryngospasm (157, 37%); airway failure (125, 30%); and aspiration (27, 6%). Emergency front of neck airway was rare (1 in 8370, 95%CI 1 in 2296-30,519). The most common respiratory complications were: severe ventilation difficulty (97, 37%); hyper/hypocapnia (63, 24%); and hypoxaemia (62, 23%). Among 881 reports to NAP7 and 358 deaths, airway and respiratory complications accounted for 113 (13%) peri-operative cardiac arrests and 32 (9%) deaths, with hypoxaemia as the most common primary cause. Airway and respiratory cases had higher and lower survival rates than other causes of cardiac arrest, respectively. Patients with obesity, young children (particularly infants) and out-of-hours care were overrepresented in reports. There were six cases of unrecognised oesophageal intubation with three resulting in cardiac arrest. Of these cases, failure to correctly interpret capnography was a recurrent theme. Cases of emergency front of neck airway (6, approximately 1 in 450,000) and pulmonary aspiration (11, approximately 1 in 25,000) leading to cardiac arrest were rare. Overall, these data, while distinct from the 4th National Audit Project, suggest that airway management is likely to have become safer in the last decade, despite the surgical population having become more challenging for anaesthetists.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Capnography-An Essential Monitor, Everywhere: A Narrative Review

Capnography is now recognized as an indispensable patient safety monitor. Evidence suggests that its use improves outcomes in operating rooms, intensive care units, and emergency departments, as well as in sedation suites, in postanesthesia recovery units, and on general postsurgical wards. Capnography can accurately and rapidly detect respiratory, circulatory, and metabolic derangements. In addition to being useful for diagnosing and managing esophageal intubation, capnography provides crucial information when used for monitoring airway patency and hypoventilation in patients without instrumented airways. Despite its ubiquitous use in high-income-country operating rooms, deaths from esophageal intubations continue to occur in these contexts due to incorrect use or interpretation of capnography. National and international society guidelines on airway management mandate capnography's use during intubations across all hospital areas, and recommend it when ventilation may be impaired, such as during procedural sedation. Nevertheless, capnography's use across high-income-country intensive care units, emergency departments, and postanesthesia recovery units remains inconsistent. While capnography is universally used in high-income-country operating rooms, it remains largely unavailable to anesthesia providers in low- and middle-income countries. This lack of access to capnography likely contributes to more frequent and serious airway events and higher rates of perioperative mortality in low- and middle-income countries. New capnography equipment, which overcomes cost and context barriers, has recently been developed. Increasing access to capnography in low- and middle-income countries must occur to improve patient outcomes and expand universal health care. It is time to extend capnography's safety benefits to all patients, everywhere.

Non-theatre emergency airway management: a multicentre prospective observational study

Emergency airway management events are common, unpredictable and associated with high complication rates. This multicentre prospective observational study across eight acute NHS hospitals in southeast England reports the incidence and nature of non-theatre emergency airway management events. Data were collected from non-theatre emergency airway management, including adverse events, over a continuous 28-day window, and recorded on an electronic case report form. Events were classified according to type (advanced airway; simple airway; and cardiac arrest). A total of 166 events were recorded, with 111 advanced airway events involving tracheal intubation or tracheostomy management. Senior personnel with three or more years of airway management experience were present for 105/111 (95%) advanced airway management episodes. There was a significant reduction in consultant or equivalent presence out-of-hours (21/64, 33%) vs. in-hours (34/47, 72%) (p < 0.001). We found high utilisation of videolaryngoscopy (95/106, 90%) and universal use of capnography for all advanced airway management events. This was lower during cardiac arrest when videolaryngoscopy was used in 11/16 (69%) of tracheal intubations and capnography in 21/32 (66%) of all cardiac arrest episodes. Adverse outcomes during advanced airway management (excluding during cardiac arrest) occurred in 53/111 (48%) episodes, including hypoxia (desaturation to Sp O2 < 80% in 14/111, 13%) and hypotension (systolic blood pressure < 80 mmHg in 27/111, 25%). Adverse outcomes were not associated with time of day or experience level of airway practitioners. We conclude that there is a disparity between consultant presence for advanced airway interventions in- and out-of-hours; high utilisation of videolaryngoscopy and capnography, especially for advanced airway interventions; and a high incidence of hypotension and hypoxaemia, including critical values, during non-theatre airway management.

Obesity is Unlikely to be an Impediment to First-Pass Success During the Intubation of Critically Ill Patients

Background: Obesity has been described as a potential risk factor for difficult intubation among critically ill patients. Our primary aim was to further elucidate the association between obesity and first-pass success. Our secondary aim was to determine whether the use of hyper-angulated video laryngoscopy improves first-pass success compared to direct laryngoscopy when utilized for the intubation of critically ill obese patients. Study Design and Methods: A retrospective cohort study of adult patients undergoing endotracheal intubation outside of the operating room or emergency department between January 30, 2016 and May 1, 2020 at 3 campuses of an academic hospital system in the Bronx, NY. Our primary outcome was first-pass success of intubation. A multivariate logistic analysis was utilized to compare obesity status with first-pass success. Results: We identified 3791 critically ill patients who underwent endotracheal intubation of which 1417 were obese (body mass index [BMI] ≥ 30). The incidence of hyper-angulated video laryngoscopy increased over the study period. A total of 46.6% of obese patients underwent intubation with hyper-angulated video laryngoscopy as compared to 35.1% of the nonobese group. First-pass success was 79.2% among the entire cohort. Obesity status did not appear to be associated with first-pass success (adjusted odds ratio [OR] 1.07, 95% confidence interval [CI]: 090-1.27; P = .47). Hyper-angulated video laryngoscopy did not seem to improve first-pass success among obese patients as compared to nonobese patients (adjusted OR 1.21, 95% CI: 0.85-1.71; P = .29). These findings persisted even after redefining the obesity cutoff as BMI ≥ 40 and excluding patients intubated during cardiac arrests. Conclusion: We did not detect an association between obesity and first-pass success. Hyper-angulated video laryngoscopy did not appear offer additional benefit over direct laryngoscopy during the intubation of critically ill obese patients.

Efficacy and adverse events profile of videolaryngoscopy in critically ill patients: subanalysis of the INTUBE study

BACKGROUND

Tracheal intubation is a high-risk procedure in the critically ill, with increased intubation failure rates and a high risk of other adverse events. Videolaryngoscopy might improve intubation outcomes in this population, but evidence remains conflicting, and its impact on adverse event rates is debated.

METHODS

This is a subanalysis of a large international prospective cohort of critically ill patients (INTUBE Study) performed from 1 October 2018 to 31 July 2019 and involving 197 sites from 29 countries across five continents. Our primary aim was to determine the first-pass intubation success rates of videolaryngoscopy. Secondary aims were characterising (a) videolaryngoscopy use in the critically ill patient population and (b) the incidence of severe adverse effects compared with direct laryngoscopy.

RESULTS

Of 2916 patients, videolaryngoscopy was used in 500 patients (17.2%) and direct laryngoscopy in 2416 (82.8%). First-pass intubation success was higher with videolaryngoscopy compared with direct laryngoscopy (84% vs 79%, P=0.02). Patients undergoing videolaryngoscopy had a higher frequency of difficult airway predictors (60% vs 40%, P<0.001). In adjusted analyses, videolaryngoscopy increased the probability of first-pass intubation success, with an OR of 1.40 (95% confidence interval [CI] 1.05-1.87). Videolaryngoscopy was not significantly associated with risk of major adverse events (odds ratio 1.24, 95% CI 0.95-1.62) or cardiovascular events (odds ratio 0.78, 95% CI 0.60-1.02).

CONCLUSIONS

In critically ill patients, videolaryngoscopy was associated with higher first-pass intubation success rates, despite being used in a population at higher risk of difficult airway management. Videolaryngoscopy was not associated with overall risk of major adverse events.

CLINICAL TRIAL REGISTRATION

NCT03616054.

Quantifying Intubation Forces on Incisors and Tongue Base Across Exposure Difficulty and Experience in a Simulator

OBJECTIVE

Laryngoscopy simulators quantifying forces on critical structures in progressively challenging airways and operator expertise are lacking. We aimed to quantify laryngoscopy forces across expertise and exposure difficulty.

STUDY DESIGN

Prospective observational study Setting: Tertiary care medical center Methods: Force gauges were affixed to a difficult airway mannequin to quantify teeth and tongue forces across increasingly challenging airway exposure. Medical students (n=10), residents (n=11), and otolaryngology staff (n=10) performed direct laryngoscopy using a Miller size 3 laryngoscope with 1) normal neck/jaw mobility, 2) restricted neck extension, 3) restricted jaw opening, and 4) restricted neck/jaw mobility. Incisor and tongue pounds of force (lbf) were continuously measured.

RESULTS

As the difficulty setting increased, forces exerted by the students, residents, and staff on the incisors and tongue base increased (p=0.01). Between normal and maximally restricted settings, force delivered to the incisors increased by 6.95 lbf (standard error (SE) 1.29), 5.93 lbf (SE 0.98), and 5.94 lbf (SE 0.70) for the students, residents, and staff, respectively. At the tongue base, force increased by 0.37 lbf (SE 0.18), 0.46 lbf (SE 0.14), and 0.73 lbf (SE 0.15) for the students, residents, and staff, respectively. Esophageal intubations occurred in 50% of the students, 23% of the residents, and 45% of the otolaryngology staff at maximal difficulty, with none at the easiest setting (p=0.33). Compared to the residents, the staff applied significantly increased pressure on the tongue base during laryngoscopy (p=0.02).

CONCLUSION

Forces exerted on the incisors and tongue base varied across exposure difficulty and expertise levels, suggesting that they may be useful markers for training and competence assessment.

Pre-Existing Right Ventricular Dysfunction as an Independent Risk Factor for Post Intubation Cardiac Arrest and Hemodynamic Instability in Critically Ill Patients: A Retrospective Observational Study

BACKGROUND

Post intubation cardiac arrest and hemodynamic instability are serious adverse events encountered in critically ill patients. The association of pre-existing right ventricular (RV) dysfunction with post intubation cardiac arrest and hemodynamic instability in critically ill patients is unknown.

METHODS

This is a retrospective matched cohort study of adult critically ill patients who underwent intubation from July 2016 to December 2019. The study was conducted at a quaternary medical center in Houston, Texas. A total of 340 critically ill patients who underwent intubation in the intensive care units, wards, and the emergency room were included. The study cohort was categorized into 4 groups based on the pre-existing RV function: normal function, mild dysfunction, moderate dysfunction, and severe dysfunction. Cardiac arrest and/or hemodynamic instability within one hour post intubation were the primary study outcomes. Secondary outcomes included in hospital and 60-day mortality.

RESULTS

Study patients were of mean age of 61.95 ± 14.28 years, including 132 (39%) females and 208 (61%) males. The primary outcomes were significantly worse in mild, moderate, and severe RV dysfunction groups compared to the normal RV function group (34.12%-P = 0.014, 47.06%-P < 0.001, 51.67%-P < 0.001, vs. 17.56%). In a multivariable logistic regression analysis, pre-existing moderate (OR = 2.65, P = 0.013) and severe RV dysfunction groups (OR = 2.66, P = 0.015) were associated with statistically significant higher cardiac arrest and hemodynamic instability post intubation. Pre-existing severe RV dysfunction was associated with statistically significant higher in hospital mortality (62.35%-P < 0.001). The multivariable Cox-regression analysis showed that pre-existing severe RV dysfunction was associated with a statistically significant higher 60-day mortality (HR = 2.57, P = 0.001).

CONCLUSIONS

Pre-existing moderate and severe RV dysfunctions were independently associated with significantly higher cardiac arrest and/or hemodynamic instability post intubation in critically ill patients. Pre-existing RV function may serve as a mortality predictor in critically ill patients undergoing endotracheal intubation.

Influence of airway trolley organization on efficiency and team performance: A randomized, crossover simulation study

BACKGROUND

Failed management of unanticipated difficult airway situations contributes to significant anesthesia-related morbidity and mortality. Optimization of design and layout of difficult airway trolleys (DATs) may influence outcomes during airway emergencies. The main objective of the current study was to evaluate whether a difficult airway algorithm-based DAT with integrated cognitive aids improves efficiency and team performance in difficult airway scenarios.

METHODS

In a crossover design, 16 teams (anesthetist, nurse anesthetist, assistant nurse) completed two high-fidelity simulated unanticipated difficult airway scenarios. Teams used both an algorithm-based DAT and a comparison, standard DAT, in the scenarios and were randomized to order of trolley type. Outcome measures included objective efficiency parameters, team performance assessment and subjective user-ratings. Linear mixed models ANOVA, including DAT type and order of condition as main factors, was utilized for the primary analyses of the team results.

RESULTS

Usage of the algorithm-based DAT was associated with fewer departures from the difficult airway algorithm (p = .010), and reduced number of unnecessary drawer openings (p = .002), but no significant differences in time to retrieval of airway devices or time to first effective ventilation, compared to the standard DAT. There were no significant differences in team performance, although participants expressed strong preference for the algorithm-based DAT (all user-rated measures p < .0001). Higher percentage of female members of the team improved adherence to the difficult airway algorithm (p = .043).

CONCLUSIONS

Algorithm-based DATs with integrated cognitive aids may improve efficiency in difficult airway situations, compared to traditional DATs. These findings have implications for improvement of anesthetic practice.

Design and Implementation of Airway Response Teams to Improve the Practice of Emergency Airway Management

Emergency airway management (EAM) is a commonly performed procedure in the critical care setting. Despite clinical advances that help practitioners identify patients at risk for having a difficult airway, improved airway management tools, and algorithms that guide clinical decision-making, the practice of EAM is associated with significant morbidity and mortality. Evidence suggests that a dedicated airway response team (ART) can help mitigate the risks associated with EAM and provide a framework for airway management in acute settings. We review the risks and challenges related to EAM and describe strategies to improve patient care and outcomes via implementation of an ART.

Unrecognised oesophageal intubation: time for action

Patients worldwide die every year from unrecognised oesophageal intubation, which is an avoidable complication of airway management usually resulting from human error. Unrecognised oesophageal intubation can occur in any patient of any age whenever intubation occurs regardless of the seniority or experience of the airway practitioner or others involved in the patient's airway management. The tragic fact is that it continues to happen despite improvements in monitoring, airway devices, and medical education. We review these improvements with strategies to eliminate this problem.

Big data: Airway management at a university hospital over 16 years; a retrospective analysis

Purpose

Little is known about the current practice of airway management in Germany and its development over the last decades. The present study was, therefore, designed to answer the following questions. Which airway management procedures have been performed over the last 16 years and how has the frequency of these procedures changed over time? Is there a relationship between patient characteristics or surgical specialisation and the type of airway management performed?

Methods

In the present study, we used our in-house data acquisition and accounting system to retrospectively analyse airway management data for all patients who underwent a surgical or medical procedure with anaesthesiological care at our tertiary care facility over the past 16 years. 340,748 airway management procedures were analysed by type of procedure, medical/surgical specialty, and type of device used. Logistic regression was used to identify trends over time.

Results

Oral intubation was the most common technique over 16 years (65.7%), followed by supraglottic airway devices (18.1%), nasal intubation (7.5%), mask ventilation (1.6%), tracheal cannula (1.3%), double lumen tube (0.7%), and jet ventilation (0.6%). On average, the odds ratio of using supraglottic airway devices increased by 17.0% per year (OR per year = 1.072, 95% CI = 1.071–1.088) while oral intubation rates decreased. In 2005, supraglottic airway devices were used in about 10% of all airway management procedures. Until 2020, this proportion steadily increased by 27%. Frequency of oral intubation on the other hand decreased and was about 75% in 2005 and 53% in 2020.

Over time, second-generation supraglottic airway devices were used more frequently than first-generation supraglottic airway devices. While second-generation devices made up about 9% of all supraglottic airway devices in 2010, in 2020 they represented a proportion of 82%.

The use of fibreoptic intubation increased over time in otorhinolaryngology and dental, oral, and maxillofacial surgery, but showed no significant trends over the entire 16-year period.

Conclusion

Our data represent the first large-scale evaluation of airway management procedures over a long time. There was a significant upward trend in the use of supraglottic airway devices, with an increase in the use of second-generation masks while a decrease in oral intubations was observed.

Airway misadventures in adult critical care: a concise narrative review of managing lost or compromised artificial airways

PURPOSE OF REVIEW

Loss or compromise of artificial airways in critically ill adults can lead to serious adverse events, including death. In contrast to primary emergency airway management, the optimal management of such scenarios may not be well defined or appreciated.

RECENT FINDINGS

Endotracheal tube cuff leaks may compromise both oxygenation and ventilation, and supraglottic cuff position must first be recognized and distinguished from other reasons for gas leakage during positive pressure ventilation. Although definitive management involves tube exchange, if direct visualization is possible temporizing measures can often be considered. Unplanned extubation confers variable and context-specific risks depending on patient anatomy and physiological status. Because risk factors for unplanned extubation are well established, bundled interventions can be employed for mitigation. Tracheostomy tube dislodgement accounts for a substantial proportion of death and disability related to airway management in critical care settings. Consensus guidelines and algorithmic management of such scenarios are key elements of risk mitigation.

SUMMARY

Management of lost or otherwise compromised artificial airways is a key skill set for adult critical care clinicians alongside primary emergency airway management.

Major complications of airway management: a prospective multicentre observational study

We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with 'predicted easy' airways were rare (approximately 1 in 14,200), but 45 times more common in those with 'predicted difficult' airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high-flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.

Formation of an Airway Lead Network: an essential patient safety initiative

We outline the history, implementation and clinical impact of the formation of an Airway Lead Network. Although recommendations to improve patient safety in airway management are published and revised regularly, uniform implementation of such guidelines are applied sporadically throughout the hospital and prehospital settings. The primary roles of an Airway Lead are to ensure supply, quality and storage of airway equipment, promote the use of current practice guidelines as well as the organisation of training and audits. Locally, the Airway Lead may chair a multi-disciplinary airway committee within their organisation; an Airway Lead Network enables Airway Leads to share common problems and solutions to promote optimal airway management on a national level. Support from governing bodies is an essential part of this structure.

Carbon dioxide monitoring in the newborn infant

Carbon dioxide (CO₂ ) monitoring is vital during mechanical ventilation of newborn infants, as morbidity increases when CO₂ levels are inappropriate. Our aim was to review the uses and limitations of such noninvasive monitoring methods. Colorimetry is primarily utilized during resuscitation to determine whether successful intubation has occurred. False negative and positive results can however lead to delays in detecting tracheal versus esophageal intubation. Transcutaneous carbon dioxide sensors have limited use during resuscitation, but can be utilized to provide continuous trend data during on-going ventilation. End-tidal capnography can provide clinicians with quantitative end-tidal CO₂ (EtCO₂ ) values and a continuous real-time capnogram waveform trace. These devices are becoming more widely accepted for use in the neonatal population as the new devices are lightweight with minimal additional dead space. Nevertheless, they have been reported to have variable accuracy when compared to arterial CO₂ measurements, however, divergence of results may be related to disease severity rather than technological limitations. During resuscitation EtCO₂ can be detected by capnography more rapidly than by colorimetry. Furthermore, capnography can be currently utilized in neonatal research settings to determine the physiological dead space and ventilation inhomogeneity, and thus has potential to be beneficial to clinical care. In conclusion, novel modes of noninvasive carbon dioxide monitoring can be safely and reliably utilized in newborn infants during mechanical ventilation. Future randomized trials should aim to address which device provides the most optimal form of monitoring in different clinical contexts.

Capnography use in the critical care setting: why do clinicians fail to implement this safety measure?

Tracheal intubation is among the most frequently performed manoeuvres in the critical care setting, and can be life-saving in critical illness, though also associated with serious adverse events such as oesophageal intubation or tracheal tube obstruction, displacement, or disconnection from the ventilator. A key finding of the 4th National Audit Project (NAP4) was identification of waveform capnography as the single intervention with the highest potential for reducing morbidity and mortality during tracheal intubation and maintenance of an artificial airway. In the INTUBE study, penetration of capnography into ICUs was low, and was not in use in 70% of the episodes of oesophageal intubation. To reduce harm and avoidable death, there is a need for a global initiative to increase access to and use of capnography in ICUs.

Seven years on from the Canadian Airway Focus Group Difficult Airway Guidelines: an observational survey

PURPOSE

Numerous clinical guidelines are available for management of the unanticipated difficult airway. It is unclear if practice recommendations are endorsed on regional, local, or individual levels. The objective of this observational study was to examine local and regional use of airway guidelines by anesthesiologists within a hospital partnership in Southwestern Ontario.

METHODS

Using a paper survey, distributed locally to consultant and trainee anesthesiologists in a tertiary hospital, we examined individual clinical and educational practices regarding guideline use in airway management. Respondents were asked to report which published guideline they used for unanticipated airway difficulty. The effectiveness of dissemination of the national Canadian airway guidelines-the Canadian Airway Focus Group (CAFG) Difficult Airway Guidelines-was examined. We invited anesthesia department heads within the regional hospital partnership to complete an electronic survey investigating departmental adoption of guidelines.

RESULTS

The response rate was 70% locally (79/112 anesthesiologists) and 52% regionally (11/21 department heads). Approximately 80% (64/79) of respondents reported using a formal clinical guideline if unanticipated difficulty with airway management was encountered. Seventy-two per cent of respondents (57/79) were aware of the published CAFG guidelines. Approximately 30% (16/51) of consultant anesthesiologists reported using the CAFG guidelines in clinical practice. Within the hospital partnership, 36% (4/11) of departments formally endorsed use of a specific airway management guideline.

CONCLUSIONS

Despite widespread awareness of the national CAFG Difficult Airway Guidelines, they are not widely adopted in clinical practice. Further research is warranted to explore barriers to adoption of airway management guidelines for both individual anesthesiologists and anesthesia departments.

Current practice of German anesthesiologists in airway management : Results of a national online survey

BACKGROUND

There is a worldwide consensus among experts that guidelines and algorithms on airway management contribute to improved patient safety in anesthesia. The present study aimed to determine the current practice of airway management of German anesthesiologists and assess the safety gap, defined as the difference between observed and recommended practice, amongst these practitioners.

OBJECTIVE

To determine the effect of implementing the guidelines on airway management practice in Germany amongst anesthesiologists and identify potential safety gaps.

METHODS

A survey was conducted in September 2019 by contacting all registered members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) via email. The participants were asked about their personal and institutional background, adherence to recommendations of the current German S1 guidelines and availability of airway devices.

RESULTS

A total of 1862 DGAI members completed the questionnaire (response rate 17%). The main outcome was that anesthesiologists mostly adhered to the guidelines, yet certain recommendations, particularly pertaining to specifics of preoxygenation and training, showed a safety gap. More than 90% of participants had a video laryngoscope and half had performed more than 25 awake intubations using a flexible endoscope; however, only 81% had a video laryngoscope with a hyperangulated blade. An estimated 16% of all intubations were performed with a video laryngoscope, and 1 in 4 participants had performed awake intubation with it. Nearly all participants had cared for patients with suspected difficult airways. Half of the participants had already faced a "cannot intubate, cannot oxygenate" (CICO) situation and one in five had to perform an emergency front of neck access (eFONA) at least once. In this case, almost two thirds used puncture-based techniques and one third scalpel-based techniques.

CONCLUSION

Current practice of airway management showed overall adherence to the current German guidelines on airway management, yet certain areas need to be improved.

All India Difficult Airway Association guidelines in practice-A survey

Background and Aims:

The All India Difficult Airway Association (AIDAA) has come up with difficult airway (DA) guidelines to suit the Indian context. We conducted an online survey with the primary aim to find out the awareness about AIDAA guidelines and adherence to them in clinical practice. The secondary aims were to explore variations in practice with respect to experience or the type of the institute.

Methods:

An online web-based questionnaire survey was sent to all practising anaesthesiologists who attended an airway workshop. The validated and piloted questionnaire consisted of 23 questions and the practice patterns were asked to be graded on a Likert scale of four.

Results:

The response rate was 66%. Awareness about AIDAA guidelines was high (81%) but adherence varied. Apnoeic nasal oxygen insufflation was always practised by only 19.59%.Only 79.7%of the respondents always used capnography to confirm intubation. While 23.64% did not ensure a safe peripheral oxygen saturation (SpO₂) level of 95% to do repeat laryngoscopy, 64% chose supraglottic devices after three failed laryngoscopic attempts. A departmental debriefing of a DA event and issuing an alert card to the patient was practised by 58.78% and 52.7%, respectively. Although 50% had training to do cricothyrotomy, only 41% had ready access to a cricothyrotomy set in their workplace. The use of capnography was more prevalent in private institutions. The survey revealed a safety gap with some recommendations like debriefing of a DA event, alert card, nasal oxygenation etc.

Conclusion

Awareness about AIDAA guidelines is high among our practising anaesthesiologists, but adherence to the recommendations varied and there is room for improvement, especially for debriefing a DA event, issuing an alert card, the use of capnography and nasal oxygenation.

Using supraglottic airways by paramedics for airway management in analogue microgravity increases speed and success of ventilation

In the next few years, the number of long-term space missions will significantly increase. Providing safe concepts for emergencies including airway management will be a highly challenging task. The aim of the present trial is to compare different airway management devices in simulated microgravity using a free-floating underwater scenario. Five different devices for airway management [laryngeal mask (LM), laryngeal tube (LT), I-GEL, direct laryngoscopy (DL), and video laryngoscopy (VL)] were compared by n = 20 paramedics holding a diving certificate in a randomized cross-over setting both under free-floating conditions in a submerged setting (pool, microgravity) and on ground (normogravity). The primary endpoint was the successful placement of the airway device. The secondary endpoints were the number of attempts and the time to ventilation. A total of 20 paramedics (3 female, 17 male) participated in this study. Success rate was highest for LM and LT and was 100% both during simulated microgravity and normogravity followed by the I-GEL (90% during microgravity and 95% during normogravity). However, the success rate was less for both DL (60% vs. 95%) and VL (20% vs. 60%). Fastest ventilation was performed with the LT both in normogravity (13.7 ± 5.3 s; n = 20) and microgravity (19.5 ± 6.1 s; n = 20). For the comparison of normogravity and microgravity, time to ventilation was shorter for all devices on the ground (normogravity) as compared underwater (microgravity). In the present study, airway management with supraglottic airways and laryngoscopy was shown to be feasible. Concerning the success rate and time to ventilation, the optimum were supraglottic airways (LT, LM, I-GEL) as their placement was faster and associated with a higher success rate. For future space missions, the use of supraglottic airways for airway management seems to be more promising as compared to tracheal intubation by DL or VL.

Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries

IMPORTANCE

Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events.

OBJECTIVE

To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients.

DESIGN, SETTING, AND PARTICIPANTS

The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents.

EXPOSURES

Tracheal intubation.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality.

RESULTS

Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%.

CONCLUSIONS AND RELEVANCE

In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently.

Macintosh Videolaryngoscope for Intubation in the Operating Room: A Comparative Quality Improvement Project

BACKGROUND

"Macintosh"-videolaryngoscopes (VLs) are VLs that allow both direct and indirect laryngoscopy for intubation. We describe the decision-making and implementation-processes that our hospital used regarding the choice of device. We compared the performances of 4 Macintosh-VLs both in direct and indirect laryngoscopy.

METHODS

A quality-improvement-project for airway management aiming at implementing Macintosh-VL for all intubation procedures performed in the operating room, involving 4 Macintosh-VLs (McGrath-Mac, C-MAC-S, C-MAC-S-Pocket-Monitor [PM], and APA). Three consecutive steps were described: (1) direct laryngoscopy with Macintosh-VL, (2) indirect laryngoscopy with Macintosh-VL (intubation attempt with Macintosh-style blade in case of Cormack I or II), (3) intubation attempt with hyperangulated blade in case of Cormack III/IV or failure of Macintosh-style blade. The main end point was the need to move to step III and use a hyperangulated blade. A mixed-effects multivariable logistic regression analysis was performed to compare devices on the main end point while considering site as a random effect. Comparison of means was performed using analysis of variance and Tukey's test for multiple comparisons (number of laryngoscopy attempts, numeric rate scale [NRS] difficulty of intubation and NRS user-friendliness). Comparison of percentages was performed using a χ2 test for the need to move to step III and a Kruskal-Wallis test for the quality of image (bad, passable, good, very good, excellent). A P value ≤.008 was considered statistically significant.

RESULTS

From May to September 2017, 589 patients were included. Using the McGrath-Mac (22/180 [12%]) was associated with less use of hyperangulated blade than using the C-MAC-S (39/132 [30%], odds ratio [OR] [99.2% confidence interval {CI}] 0.34 [0.16-0.77], P = .0005), the APA (35/138 [25%], OR [99.2% CI] 0.42 [0.19-0.93]; P = .004), but not the C-MAC-S-PM (29/139 [21%], OR [99.2% CI] 0.53 [0.23-1.2]; P = .04).Overall, the number of intubation attempts was significantly lower using the McGrath Mac than the C-MAC-S or the C-MAC-S-PMVLs. Subjective appreciation of intubation difficulty and user-friendliness of the devices showed respectively lower and higher NRS scores for the McGrath-Mac compared to the other devices, whereas subjective assessment of image quality showed higher quality for the C-MAC-S and C-MAC-S-PM compared to the APA or McGrath-Mac.

CONCLUSIONS

Among 4 single-use Macintosh-VLs, glottic visualization in direct and indirect laryngoscopy with the Macintosh-style blade was significantly improved with the McGrath-Mac compared to other Macintosh-VLs, leading to a less frequent need to resort to the hyperangulated blade and reduced overall number of intubation attempts.

Training of airway management for anesthesia teams - Measurement of transfer into daily work routine by questionnaire

THEORY

Problems in airway management are rare in anesthesia but when they occur, they have serious consequences for the patient. For this reason, training is recommended for professionals involved in anesthetic care. Here we investigated, if a newly developed technical/ non-technical hybrid airway training would be relevant for daily practice in a tertiary referral hospital.

HYPOTHESES

We hypothesized that: (a) both parts of the validated questionnaires meet the quality criteria for the application in anesthesia teams, (b) even though the team regularly deals with airway management, airway management training is relevant to all professions and (c) contents of the developed training can be integrated into the behaviour of the teams.

METHOD

In this observational study, 104 professionals took part in a one-day technical/non-technical hybrid airway training programme. Participants received a questionnaire six months after training, based on selected scales of the validated tools; "Training Evaluation Inventory" and "Transfer Climate Questionnaire".

RESULTS

The scales of "perceived usefulness", "task cues" and "positive reinforcement" showed good internal consistency and all were rated higher than 3.9 on a 5-point Likert scale (1=complete rejection; 5=fullest approval). The scale "negative reinforcement and punishment" showed satisfactory internal consistency for physicians (rated 2.75 ± 0.8). By removing an item in each case, the scales "attitude towards training" (rated 4.93 ± 0.2) and "extinction" (rated 3.02 ± 0.8) showed satisfactory internal consistency for nurses and anesthetic technicians. "Social Cues" did not meet qualitative criteria. There was no difference in the assessment by the professional groups.

CONCLUSIONS

The presented training course was perceived as useful by both professional groups equally, which supported the interprofessional concept. The content was positively reinforced in practice six months after training and is relevant for professionals who are regularly confronted with the topic "airway management". Scales which meet qualitative criteria for only one profession and the scale "social cues" should be reconsidered in the context of an interprofessional team.

Anesthesiologists' airway management expertise: Identifying subjective and objective knowledge gaps

BACKGROUND

Failure in airway management continues to cause preventable patient harm, and the recommended continuing education is challenged by anesthesiologists' unknown knowledge gaps. This study aimed to identify anesthesiologists' subjective and objective knowledge gaps as well as areas where anesthesiologists are incorrect and unaware.

METHODS

An adaptive E-learning program with 103 questions on adult airway management was used for subjective and objective assessment of anesthesiologists' knowledge. All anesthesiologists in the Capital Region of Denmark were invited to participate.

RESULTS

The response rate was 67% (191/285). For preoperative planning, participants stated low confidence (subjective assessment) regarding predictors of difficult airway management in particular (69.1%-79.1%). Test scores (objective assessment) were lowest for obstructive sleep apnea as a predictor of difficult airway management (28.8% correct), with participants being incorrect and unaware in 33.5% of the answers. For optimization of basic techniques, the lowest confidence ratings related to patient positioning and prediction of difficulties (57.4%-83.2%), which agreed with the lowest test scores. Concerning advanced techniques, videolaryngoscopy prompted the lowest confidence (72.4%-85.9%), while emergency cricothyrotomy resulted in the lowest test scores (47.4%-67.8%). Subjective and objective assessments correlated and lower confidence was associated with lower test scores: preoperative planning [r = -.58, P < .001], optimization of basic techniques [r = -.58, P = .002], and advanced techniques [r = -.71, P < .001].

CONCLUSION

We identified knowledge gaps in important areas of adult airway management with differing findings from the subjective and objective assessments. This underlines the importance of objective assessment to guide continuing education.

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

George J. A prospective randomised simulation trial comparing our novel AIR-BOX to standard airway equipment storage modalities

Background

There is little evidence guiding equipment handling during emergency endotracheal intubations (EEI). Available evidence and current practice are either outdated, anecdotal or focused on difficult-not emergency-intubation. In this study, we describe and evaluate our equipment handling unit: the AIR-BOX.

Methods

This is a proof-of-concept, prospective, randomised simulation trial. A convenience sample of 50 airway course participants voluntarily underwent randomisation: 21 to the AIR-BOX group, 14 to the intubation box group, and 15 to the crash cart group. The volunteers were asked to intubate a manikin using the equipment from the storage unit of their randomisation. Outcome measures included time-to-readiness, time-to-intubation, first-pass success, and subjective operator experience.

Results

The mean time-to-readiness was 67.2 s with the AIR-BOX, 84.6 s with the intubation box, and 115 s with the crash cart. The mean time-to-intubation was 105 s with the AIR-BOX, 127 s with the intubation box and 167 s with the crash cart. A statistically significant difference was achieved between the AIR-BOX and the crash cart. No statistically significant difference was found between the three groups with regard to first-pass success or the time between intubation readiness and intubation.

Conclusions

This study supports the AIR-BOX as a viable tool that can improve and simplify access to emergency intubating equipment. It also opens doors for multiple future innovations that can positively impact equipment handling practices. Future studies can focus on assessing whether applying the AIR-BOX will yield a clinically significant impact on patient outcomes.

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.

The VL3 videolaryngoscope for tracheal intubation in adults: A prospective pilot study

Background:

Videolaryngoscopy (VLS) is recommended by international guidelines for the management of difficult airways. We conducted an observational prospective pilot study to assess the efficacy of the new VL3 videolaryngoscope for routine tracheal intubation (TI) in adults; in terms of success rate, the number of attempts, and maneuver duration, including both normal and difficult airways.

Methods:

This prospective observational pilot study comprised a sample of 56 adult patients undergoing elective general anesthesia. For each patient, we performed VLS by VL3 recording the following data: successful TI rate, number of attempts, time of intubation, time to glottis visualization, Cormack-Lehane grade (CL), need for external laryngeal pressure, and presence of post-laryngoscopy side effects.

Results:

TI was successfully carried out in the totality of patients. In only 4 out of 56 cases, the VL3 offered a CL II. The first attempt intubation was achieved in 48 patients (85.7%). In one case, external laryngeal pressure was needed. No CL III or CL IV were observed. We did not find any significant difference between the predicted difficult airways sample and the rest of the population.

Conclusion:

VL3 videolaryngoscope showed to be an effective and safe device for routine TI, even in those patients with predicted difficult airway. More studies are needed to confirm our findings and verify its efficacy even in other settings.

Anatomic accuracy of airway training manikins compared with humans

Airway simulators, or training manikins, are frequently used in research studies for device development and training purposes. This study was designed to determine the anatomic accuracy of the most frequently used low-fidelity airway training manikins. Computerised tomography scans and ruler measurements were taken of the SynDaver^® , Laerdal^® and AirSim^® manikins. These measurements were compared with human computerised tomography (CT) scans (n = 33) from patients at the University of Michigan Medical Center or previously published values. Manikin measurements were scored as a percentile among the distribution of the same measurements in the human population and 10 out of 27 manikin measurements (nine measurements each in three manikins) were outside of two standard deviations from the mean in the participants. All three manikins were visually identifiable as outliers when plotting the first two dimensions from multidimensional scaling. In particular, the airway space between the epiglottis and posterior pharyngeal wall, through which airway devices must pass, was too large in all three manikins. SynDaver, Laerdal and AirSim manikins do not have anatomically correct static dimensions in relation to humans and these inaccuracies may lead to imprecise airway device development, negatively affect training and cause over-confidence in users.

Airway Leads and Airway Response Teams: Improving Delivery of Safer Airway Management?

Purpose of Review

Airway management remains a source of significant morbidity and mortality. This review considers recent summaries of complications and looks toward strategies to improve practice using a coordinated approach.

Recent Findings

A safety gap can exist between national recommendations and local practice. A lack of attention to end tidal carbon dioxide has repeatedly contributed to airway mismanagement. Clinicians must be trained in newer airway devices (videolaryngoscopes or supraglottic airways) to use them effectively. Time must be found to teach rarely performed skills (e.g., front-of-neck access). Both larger and smaller hospitals have benefitted from an airway lead or response team, coordinating education programs, ensuring the adoption of guidelines, standardizing equipment, and recognizing the role of human factors and ergonomics.

Summary

Even in the twenty-first century, the incidence of airway-related morbidity and mortality can be reduced, by an institutionally supported, coordinated approach to the whole process of airway care.

Nasal high-flow oxygen in pediatric anesthesia and airway management

Nasal High-Flow (NHF) is weight-dependent in children, aimed to match peak inspiratory flow and thereby deliver an accurate FiO₂ with a splinting pressure of 4-6 cm H₂ O. During apnea in children, NHF oxygen can double the expected time to desaturation below 90% in well children but there is no ventilatory exchange; therefore, children do not "THRIVE". Total intravenous anesthesia competency to maintain spontaneous breathing is an important adjunct for successful NHF oxygenation technique during anesthesia. Jaw thrust to maintain a patent upper airway is paramount until surgical instrumentation occurs. There is no evidence to support safe use of NHF oxygen with LASER use due to increased risk of airway fire.

Availability and organization of difficult airway equipment in Swedish hospitals: A national survey of anaesthesiologists

BACKGROUND

Airway complications account for almost one third of anaesthesia-related brain damage and death. Immediate access to equipment enabling rescue airway strategies is crucial for successful management of unanticipated difficult airway situations.

METHODS

We conducted a nationwide survey of Swedish anaesthesiologists to analyse availability and organization of difficult airway trolleys (DATs), and multiple factors pertaining to difficult airway management, to highlight areas of potential improvement.

RESULTS

Six hundred and thirty-nine anaesthesiologists completed the 14-item survey. Whereas DATs were almost ubiquitous (95%) in main operating departments of hospitals, prevalence was low in remote anaesthetizing locations (20.3%) and electroconvulsive therapy units (26.6%). Approximately 60% of emergency departments had a DAT. Immediate (within 60 seconds) access to videolaryngoscopes in all units where general anaesthesia is conducted was reported by 56.8%. Almost half of anaesthesiologists reported that all DATs at their workplace were standardized. Forty-six per cent reported that the DATs were organized according to a difficult airway algorithm; almost 90% believe that such an organization can impact the outcome of a difficult airway situation positively. Only 36.2% of DATs contained second-generation supraglottic airway devices exclusively. Most Swedish anaesthesiologists use the Swedish Society of Anaesthesiology and Intensive care Medicine difficult airway algorithm, but almost one fifth prefer the Difficult Airway Society algorithm. Less than half of respondents underwent formal difficult airway training annually.

CONCLUSION

Our results motivate efforts to (a) increase availability of DATs in remote anaesthetizing locations, (b) increasingly standardize DATs and organize DATs according to airway algorithms, and (c) increase the frequency of difficult airway training.