Airway management for tonsillectomy: a national survey of UK practice

Abstract

In 1996 a new variant of Creutzfeldt-Jakob disease (vCJD) was described [1]. Subsequently, the infectious agent was found to be a prion protein. In response to concerns about the prion's infectious nature, its resistance to decontamination and the possibility of asymptomatic carriage of prions in tonsillar tissue, the UK Department of Health and the Royal College of Anaesthetists produced guidelines for airway management of tonsillectomy, stressing the use of disposable equipment [2, 3]. We have conducted a national survey to examine current practice in airway management for tonsillectomy. Several additional questions were asked to explore knowledge both of guidelines and of vCJD. A postal questionnaire was sent to all College Tutors in the UK in July 2005. If the questionnaire was not returned within six weeks, a repeat questionnaire was sent. Microsoft Excel was used to aid the data analysis of the questionnaire. Of the 305 questionnaires sent, 33 replies stated that their hospital did not carry out ENT procedures. Positive replies were received from 183 departments, a response rate of 67%. Not all respondents answered all the questions. The tracheal tube was the most frequently used airway across all age groups: 87% (150/173) for <3 years old; 79% (139/176) for 3–16 years old; and 73% (131/179) for adults). Of respondents using a laryngoscope blade, 57% (96/167) protected the laryngoscope blade with a disposable sheath or used a disposable blade, while 43% (71/167) used a reusable laryngoscope blade without protection of the blade. Only 14% (24/167) protected the laryngoscope handle, as recommended. When a re-usable classic or flexible laryngeal mask airway was used, 45% (20/44) reused it after routine sterilisation. When questioned about the guidelines, 38% (68/180) were unaware that guidelines existed. Only 16% (27/180) were fully compliant with the guidelines. Just under half (45%, 70/154) agreed with the guidelines and of this number 84% (59/70) still did not fully comply with the guidelines. The commonest reasons for not complying were unavailability of equipment or mistrust of disposable equipment. In order to comply with the guidelines published by the Royal College of Anaesthetists, all laryngeal mask airways used should be disposed of whether the device is a disposable type or re-usable; if tracheal intubation is used the laryngoscope blade must either be a disposable blade or the standard metal blade must be covered by a disposable transparent plastic sheath. A clear disposable cover for the laryngoscope handle is also recommended; if bougies or stylettes are used these should also be disposable, and single-use disposable gloves must be worn by the anaesthetist. In this survey we have shown widespread non-compliance with, and lack of knowledge of, national guidelines.