Training in airway management

Abstract

I have read Dr Cook's editorial [1] several times and I must confess to being somewhat disappointed. Although continuing training of both consultants and trainees is of paramount importance, it would appear that the main thrust of the editorial is orientated to the establishment of a clear airway at induction of anaesthesia. In particular, the editorial seems to focus on the use of supraglottic airways devices, particularly the laryngeal mask airway and variations thereof. There is no mention of subsequent peri-operative problems, in particular extubation of the trachea and airway problems that occur in the recovery room. Furthermore, there is no reference to the most critical aspect of management of the anaesthetised patient, which is the maintenance of adequate oxygenation at all times. A recent and very important publication in Anesthesiology[2] has been totally ignored. This article discusses the lessons that were learned from the Closed Claims Analysis of the management of the difficult airway [2]. In essence, it reported that claims following airway difficulties continue to increase. The proportion of serious claims, for example for death or brain death, in regard to induction of anaesthesia has declined (from 62% in the period 1985–92 to 35% in 1993–99). This decrease is said to reflect the introduction of difficult airway algorithms. However, the number of claims regarding difficulties during the surgical, extubation and recovery periods have remained the same. It is a matter of great concern that similar publications are unavailable in the United Kingdom and Ireland. At the very least, important lessons could be learned which could be reflected in training and future practice, thus enhancing patient safety. Difficulties during the surgical period revolve around the loss of the airway during the procedure. The reasons are several-fold but the majority seem to involve removing the supraglottic airway device and inserting a tracheal tube. I am sure that there are lessons to be learned from these experiences. The difficulties associated with extubation of the trachea vary and include patients with known difficult airways and are predominantly in those who are obese. These reasons are the same in recovery areas but, in addition, multiple attempts at re-intubation of the trachea are cited. It would seem that algorithms and strategies are of great benefit in airway management during the induction of anaesthesia. In contrast, there are no similar guidelines for the management of extubation. Furthermore, practices vary considerably [3] and some of the current practices are cause for considerable concern and, in my opinion, need to be addressed urgently. The data available about the management of patients in recovery areas seem to indicate that the majority of patients require initial upper airway assistance, such as jaw support and oxygen-enriched air therapy. There is concern as these complications should, theoretically, have decreased given the modern pharmacological agents and technological advances in airway conduits. Finally, Dr Cook's editorial does not discuss the treatment of immediate and potentially very serious complications such as laryngeal stridor. The number of patients who have a tracheal tube inserted seems to be decreasing except for those who have a tube inserted as part of a rapid sequence induction. Ironically, it is these patients who are potentially more at risk both at induction and, particularly, at extubation. It is apparent that the opportunities for training in extubation are decreasing and this decrease can, I feel, be placed at the feet of the increased use of supraglottic airway devices. How can such training be achieved? Certainly, training using mannequins is totally fruitless. What therefore are the options? I suggest that strategies and algorithms regarding extubation should be developed and published; each trainee should be required to intubate the trachea in a set number of patients during training, for example whenever neuromuscular agents are included in the anaesthetic technique (this may require curtailing the use of supraglottic airway devices); specific scenarios should be discussed at the time of extubation; each trainee should spend a period in recovery areas as they do in the USA; and each trainee should be well versed in the treatment of laryngospasm. There is an algorithm available as a guideline [4].