Education in airway management.

In airway management, poor judgment, education and training are leading causes of patient morbidity and mortality. The traditional model of medical education, which relies on experiential learning in the clinical environment, is inconsistent and often inadequate. Curriculum change is underway in many medical organisations in an effort to correct these problems, and airway management is likely to be explicitly addressed as a clinical fundamental within any new anaesthetic curriculum. Competency-based medical education with regular assessment of clinical ability is likely to be introduced for all anaesthetists engaged in airway management. Essential clinical competencies need to be defined and improvements in training techniques can be expected based on medical education research. Practitioners need to understand their equipment and diversify their airway skills to cope with a variety of clinical presentations. Expertise stems from deliberate practice and a desire constantly to improve performance with a career-long commitment to education.

Manikin study of fibreoptic-guided intubation through the classic laryngeal mask airway with the Aintree intubating catheter vs the intubating laryngeal mask airway in the simulated difficult airway.

In this randomised crossover manikin study of simulated difficult intubation, 26 anaesthetists attempted to intubate the trachea using two fibreoptic-guided techniques: via a classic laryngeal mask airway using an Aintree intubating catheter and via an intubating laryngeal mask airway using its tracheal tube. Successful intubation was the primary endpoint, which was completed successfully in all 26 cases using the former technique, and in 5 of 26 cases using the latter (p < 0.0001). The former technique also proved quicker to reach the vocal cords with the fibrescope (median (IQR [range])) time 18 (14-20 [8-44]) s vs 110 (70-114 [30-118]) s, respectively; p = 0.008); and to first ventilation (93 (74-109 [52-135]) s vs 135 (79-158 [70-160]) s, respectively; p = 0.0038)]. We conclude that in simulated difficult intubation, fibreoptic intubation appears easier to achieve using a classic laryngeal mask airway and an Aintree intubating catheter than through an intubating laryngeal mask airway.

Effects of caffeine or diphenhydramine on visual vigilance.

The effects of two drugs having opposite effects on the central nervous system were investigated using a newly developed visual vigilance task. Twenty-four male volunteers (median age = 20) performed the task on three separate occasions; after consuming placebo, caffeine (200 mg), or diphenhydramine (25 mg), in a double-blind, Latin Square design. At least 2 days intervened between drug administrations. Caffeine use was restricted for 10 h and smoking for 3 h before drug administration. When compared with placebo, caffeine significantly increased the number of correct responses and decreased response times, whereas diphenhydramine decreased the number of correct responses and increased response times. Low habitual consumers of caffeine (< 100 mg/day) and non-smokers had more correct responses than did high habitual caffeine consumers (> 100 mg/day) and smokers, but only in the placebo condition. Non-smokers had faster response times than smokers only in the placebo condition. Both caffeine and diphenhydramine altered certain aspects of mood.

A persistent 'can't intubate, can't oxygenate' crisis despite rocuronium reversal with sugammadex.

A 'can't intubate, can't oxygenate' airway crisis is a rare event which most anaesthetists will never experience during their career(1,2). This report highlights the outcome of time-critical decisions in a potential airway catastrophe. Rocuronium was used as an alternative muscle relaxant for rapid sequence induction. The use of sugammadex in 'can't intubate, can't oxygenate' crises is discussed and highlights how, despite adequate reversal of neuromuscular blockade, the 'can't intubate, can't oxygenate' situation failed to resolve. An asymptomatic vallecular cyst was the causal factor in this scenario. Anaesthetic issues surrounding this pathology are discussed.

Emergency surgical airway in life-threatening acute airway emergencies--why are we so reluctant to do it?

'Can't intubate, can't oxygenate' scenarios are rare but are often poorly managed, with potentially disastrous consequences. In our opinion, all doctors should be able to create a surgical airway if necessary. More practically, at least all anaesthetists should have this ability. There should be a change in culture to one that encourages and facilitates the performance of a life-saving emergency surgical airway when required. In this regard, an understanding of the human factors that influence the decision to perform an emergency surgical airway is as important as technical skill. Standardisation of difficult airway equipment in areas where anaesthesia is performed is a step toward ensuring that an emergency surgical airway will be performed appropriately Information on the incidence and clinical management of 'can't intubate, can't oxygenate' scenarios should be compiled through various sources, including national coronial inquest databases and anaesthetic critical incident reporting systems. A systematic approach to teaching and maintaining human factors in airway crisis management and emergency surgical airway skills to anaesthetic trainees and specialists should be developed: in our opinion participation should be mandatory. Importantly, the view that performing an emergency surgical airway is an admission of anaesthetist failure should be strongly countered.

Equipment to manage a difficult airway during anaesthesia.

Airway complications are a leading cause of morbidity and mortality in anaesthesia. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/ resources/professional-documents). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]).

Difficult double-lumen tube placement due to laryngeal web.

We present a case of difficult intubation in a patient with a laryngeal web. A 33-year-old male patient presented for open thoracotomy and had a previously undiagnosed laryngeal web, which complicated the placement of a double-lumen tube. A single-lumen tube was placed with the use of a bougie through the narrowed airway. With the subsequent use of an airway exchange catheter a double-lumen tube was positioned. Techniques for managing narrowing of the supraglottic airway are presented and the literature dealing with laryngeal webs is reviewed. In the setting of an unusual airway and thoracic surgery, ventilation via simpler techniques takes precedence over insertion of more complex tubes.

A survey of anaesthetists' perspectives of communication in the operating suite.

We surveyed 222 anaesthetists attending a University of Western Australia conference (n = 110) and two public hospitals in Perth (n = 112) by anonymous questionnaire in March 2006 regarding communication issues in the operating suite. Forty-one percent (n = 92) responded. Questions concerned communication skills, experiences of good and poor communication and relationship to outcome, attitudes to music and communication courses. Stress in anaesthetists due to poor communication, staff naming practices, information on courses with communication content attended and attitudes to non-verbal communication were also surveyed. Anaesthetists' communication skills were self-rated as "very good" by 52% and "average" by 39% of respondents. It was strongly agreed that good verbal communication leads to better patient outcome (57%) and was important between surgeons and anaesthetists (76%). Regarding the current state of surgeon/anaesthetist communication, 25% (23/92) agreed this was acceptable, 33% (30/92) were undecided and 42% (39/92) regarded this as poor. Silence in theatre was generally not desired, 71% preferring background music. Ninety-nine percent of respondents believed good communication decreased stress and 89% felt personally stressed in situations where poor communication occurred. Email/text communication was not preferred to spoken language regarding case information. Sixty-four percent of respondents would attend a communications course voluntarily, with implementation of a compulsory communications course supported by 45%. Most anaesthetists surveyed used staff first names and 94% believed poor communication caused procedural delay. The data suggest that further work is required to improve communication in the stressful operating room environment, particularly at the surgeon/anaesthetist interface.

Survey of airway skills of surgeons in Western Australia.

Our objective was to survey all consultant surgeons, including obstetricians/gynaecologists, in the State of Western Australia to assess their experience with, and readiness to assist anaesthetists with a difficult or failed airway. Survey questionnaires were mailed to all surgeons registered in Western Australia (n = 445). A total of 238 responses (53%) were received, mostly from general surgeons, obstetrician/gynaecologists and orthopaedic surgeons. Forty percent had provided non-surgical assistance with a difficult airway and 60% had assisted with a surgical airway. All ear nose and throat surgeons who responded to the survey had assisted with an emergency surgical airway and 47 surgeons reported having performed six or more surgical airways. However 26% of respondents had never performed a surgical airway and 37% did not feel confident in performing an urgent surgical airway Seven percent of respondents reported witnessing a failed airway that resulted in death or neurological damage. Seventy percent of respondents had undergone formal training in tracheostomy and 26% had advanced trauma life support or early management of severe trauma training. These findings indicate that surgeons in Western Australia perform surgical airways infrequently and only occasionally assist anaesthetists with difficult airway management. However, some surgeons lack confidence and training in surgical airway management. Because anaesthetists cannot always rely on their surgical colleagues to provide a surgical airway during a crisis, we recommend that anaesthetists discuss airway management with their surgical colleagues for all patients with identified difficult airways and that anaesthesia training should include surgical airway management.

A retrospective analysis of deep neck infections at Royal perth hospital.

Serious deep neck infections may result in life-threatening airway complications. The aim of this study was to review the management of patients requiring surgical drainage with deep neck infections and to identify possible factors that may predict a greater risk of airway complications. In this study the authors reviewed the notes of patients requiring surgical drainage of deep neck infections who were admitted to Royal Perth Hospital over a seven-year period (2000 to 2007). One hundred and twenty-nine suitable patients were identified, of whom 15.5% encountered airway complications including one death due to airway obstruction. Airway complications were more common if there was no consultant anaesthetist present (odds ratio 4.01 [confidence interval 1.20 to 13.46], P = 0.02). Deep neck infections are still relatively common and are associated with significant morbidity and mortality. Patients with deep neck infections represent an anaesthetic challenge which should be managed by those with an appropriate level of experience.

Personal digital assistant (PDA) use amongst anaesthetists: an Australian survey.

We report an email questionnaire survey of Personal Digital Assistants (PDA) use amongst members of the Australian Society of Anaesthetists (ASA). PDAs are becoming increasingly popular and they have many applications within the healthcare community. Seventy-eight per cent of members of the ASA have an email address (1870/2385) although only 38% (900/2385) of members are regular uses of email. We surveyed 1870 members of the ASA and received 215 responses (11% response rate). We found that 91% of anaesthetists answering the survey used a PDA and of these 72% use a Palm operating system, which reflects current market trends. Anaesthetists use PDAs for a wide range of facilities: appointments, drug reference, contact details and "tasks to do" being the most utilized. The most common software programs added to the operating system were pharmacopoeias, contact managers and database programs.

Analgesia following thoracotomy: a survey of Australian practice.

This survey examines pain management after thoracotomy in Australian hospitals. Questionnaires were sent to senior thoracic anaesthetists at 27 hospitals (16 public and 11 private) with thoracic surgical units. Twenty-six anaesthetists replied and 24 responses were included in the analyses. Seventy-two percent of respondents were from hospitals with acute pain services (APS), and in 94% of these hospitals patients are reportedly visited by the APS. The most frequently used analgesic modalities are epidural analgesia, intravenous patient-controlled analgesia (IVPCA), and nurse-controlled intravenous opioid infusions. Over half of the anaesthetists reported using local anaesthetic intercostal nerve block, non-steroidal anti-inflammatory drugs (NSAIDs), or paracetamol. Combinations of analgesic techniques were cited frequently. Respondents reported that cryoanalgesia, interpleural blockade, paravertebral blockade, subarachnoid infusions, ketamine, and transcutaneous electrical nerve stimulation are used infrequently. Anaesthetists from public hospitals reported using epidural analgesia, IVPCA and NSAIDs more frequently than those from private hospitals. When epidural analgesia is used, most respondents place the catheter in the mid-thoracic region (91%), use a regimen of opioids plus local anaesthetic (96%), use a constant infusion technique (100%), and continue analgesia for up to three days (83%). Over half of the respondents reported that post-thoracotomy patients are nursed in a high-dependency area. Seventy-nine percent of respondents selected epidural analgesia as the best available analgesia technique, whereas 21% consider IVPCA to be the best. Only 75% of respondents reported that the type of analgesia they consider best is also the type which they use most frequently.

Life-threatening pulmonary oedema secondary to tracheal compression.

We present a case of negative pressure pulmonary oedema due to an overlooked cause. A 45-year-old female patient presented to the emergency department unconscious with severe pulmonary oedema. Subsequent investigations revealed a thyroid goitre causing significant tracheal compression. This case report highlights an extremely rare but potentially dangerous sequela of upper airway obstruction.