DAS E-Zine May 2024

DIFFICULT AIRWAY SOCIETY MEMBERS

EZINE

May 2024 Edition

REMINDER TO DAS MEMBERS

Please remember to update your details if your address or email address changes!

Members can update their details by emailing das@anaesthetists.org

WE WANT TO HEAR FROM YOU

DAS encourages member participation – we would love to read your comments, contributions and suggestions for future E-Zines. Have you been involved in an interesting airway case? Is there an article that has changed your practice? Do you have an idea for improving airway anaesthesia that you would like to collaborate on? All formats welcome: text, video, photo, infographic… We know you are a creative bunch!

The E-Zine is something we are passionate about and we love to hear from you about it . We want it to be as useful to members as possible so please do get in contact with any suggestions and/or feedback - ezine@das.uk.com or tag us on X / Twitter @dasairway or @dastrainees

EDITORIAL

| Nisha Abraham-Thomas | Moon-Moon Majumdar |

Straight to your inbox is our Spring edition of the Difficult Airway Society e-zine! We hope you are looking forward to the sunshine as much as we are. Whilst we wait, we have lots to share with you…

The education articles this month include insights from the largest adult airway service in Europe managing laryngotracheal stenosis, and a summary of the key findings related to airway and breathing complications and associated peri-operative cardiac arrest from the recently published NAP7 report.

We urge you to add the HSSIB report from January 2024 to your reading list, see more on page 30, as well as the recommended reads from our journal club!

Our 2023 DAS Professor, Professor Andy Higgs joins us for a Q&A where he talks to us about his career highlights and inspirations.

This month’s clinical dilemma about epiglottitis prompts you to think about

emergency front of neck access – when did you last receive training and is it time you had a refresher?

We also hear from a current trainee, who has recently completed a global anaesthesia and education fellowship abroad, dealing with advanced airway pathology in a limited resource setting. If you’d like to tell us about your airway fellowship or similar training experience, we’d love to hear from you.

Please get in touch with our editorial team with your comments, feedback or contributions by emailing ezine@das.uk.com or tag us on X / Twitter @dasairway or @dastrainees

We thank all of the authors for their contributions to this edition.

We would also like to thank everyone who submitted an infographic to our recent trainee competition. The committee are set to pick a winner, and we will announce the results soon!

Don’t forget that we have some fantastic events planned for your diary including the 2024 DAS ASM in London and the 2025 World Airway Management Meeting (WAMM) in Florence. Register your interest online now!

There’s also still time to book this month’s joint webinar with Anaesthesia journal, where we are set to discuss top publications and celebrate airway excellence.

We hope you enjoy this month’s jam-packed read!

Nisha Abraham-Thomas

Moon-Moon Majumdar

DAS Trainee Representatives

New guidance: recommended first-line agent for airway anaesthetists!

Image submission by:

Dr Jane Orrock Advanced Airway Fellow

Dr Patrick Ward

Consultant Anaesthetist

St John's Hospital, NHS Lothian Scotland, UK

EXECUTIVE UPDATE

| Ravi Bhagrath | Imran Ahmad | Fauzia Mir |

Recent

Welcome to our Spring edition of the DAS ezine. There’s been much activity on the Airway front and plenty of content for you to peruse, both news and education. Firstly, what has been going on since your last January edition.

In March we had our online DAS-RCoA Airway Leads day organised by Sandy Sudan. A number of topics were presented and discussed; an analysis of airway safety from SALG, a review of NAP7, the most recent HSSIB report (more later) as well as topics on best practice and updates on training and the ever-popular soapbox. A well received day by the airway leads who will have an opportunity to meet at the London ASM in November as well as at a face-to-face meeting at the RCoA next March.

The Health Services Safety Investigations Body (HSSIB) are a newly formed (Oct 2023) independent body of the Department of Health and Social Care. They investigate

patient safety concerns where safety learning could also help to improve NHS care. In January they published a report of a death of a 12-year-old patient with Hunter syndrome. This report may have lasting ramifications and the RCoA-DAS Airway Lead, writes more about it in this edition.

Our most recent webinar was on the RCoA NAP7: perioperative cardiac arrest. This was presented by the College’s NAP Lead, Professor Tim Cook and as ever very popular. DAS members get 4 webinars a year for free and further ones are planned for May, September and December.

Current

So that’s what’s happened in the last busy quarter: ongoing projects continue however, including the development of the new DAS website. This started at the beginning of last year and hopefully will come to fruition by the time Winter London ASM comes around and

you’ll receive more updates in the month ahead.

The Difficult Airway Database is now supported by 236 hospitals and our indefatigable lead on this Achuthan Sajayan maintains his persistence on attaining recognition by ACSA. More than 1600 cases of known difficult airways have been uploaded with several thousand clinicians signed up. We are currently looking at strengthening our IT governance for the database which will encourage yet more UK hospitals to join. Look out for a user survey on the DAD website soon.

Our membership numbers continue to grow, both full members as well as associate and overseas. Our Annual Members Meetings and webinars continuing to entice new members. We’re currently at 2285 UK members and 327 overseas members, a continuing increase.

Our rolling 5-year Constitution review has started, and we welcome any members to offer their opinion via constitution@DAS.uk.com This will be completed and hopefully ratified at the Annual Members Meeting in November.

The eFONA Project (a joint project with the RCoA) is progressing well with much hard work by the eFONA fellow Parineeta Ghosh and Alistair McNarry. The Delphi process was completed last month coinciding with the successful ethical approval in England and

Wales and the web-based database collection tool remains on track to be launched later in the year.

Further DAS guidelines continue apace. The guidelines on Ethics in Airway Management are in the final tidying-up process and are scheduled for launch at the London ASM with a whole session dedicated to discussing their implications on the practice and training in anaesthesia.

Looking ahead

So, looking ahead. If you like the idea of changing your letterhead to include Professor in your title look no further. Applications for the DAS Professor of Anaesthesia and Airway Management have now opened with a closing date of 26 May. Details are on the current website but do also contact the Scientific Officer for guidance (scientificofficer@das.uk.com).

The DAS Committee are hard at work on our latest ASM which I hope you all know now is in London on the 28-29 November https:// www.das2024.co.uk/ It’s to be held at the stunning Guildhall, near St. Paul’s Cathedral and the City of London’s civic and ceremonial centre. It was originally the site of London’s amphitheatre in AD70 with the first references to a guildhall from the 13th Century where citizens would come to pay their taxes (hopefully not required at this meeting).

The 13th Century is also the time that our ASM dining venue also began to evolve, the House of Commons, the lower house of Parliament. When we were last in the Stranger’s Dining Room in 2017 there was a prior tour of the Palace of Westminster where one of our DAS Professors was nearly excommunicated for a breach of etiquette! We hope to again to have a tour so book the dinner early as soon as we open bookings (and be on your best behaviour).

Imran Ahmad, DAS President

Ravi Bhagrath, DAS Secretary

Fauzia

Mir, DAS Treasurer

Lastly, we have opened the call for the Annual Society Meeting in 2026, contact the Secretary for details and what this exciting prospect may entail (secretary@das.uk.com).

Enjoy this issue and as ever continue to get involved, we remain the world’s largest anaesthesia airway society!

SCIENTIFIC OFFICER REPORT

| Kariem El-Boghdadly |

DAS aims to be a global leader in safety in airway management. To maintain and elevate this, we provide several academic opportunities to members. It is down to you, the DAS Membership, to take advantage of these opportunities, develop yourselves professionally, get engaged in academia, and, importantly, harness the chance to improve patient care. Importantly, the DAS Professor of Anaesthesia and Airway Management 2024 applications are open until 26/05/2024!

More information below!

£5,000 for studies broadly related to airway management will be peer-reviewed. Further details are available on the DAS website or by contacting me directly. We have already funded one application, and we are always open to receive more. Reach out for more information on this today!

2. DAS Grants via the NIAA. DAS funds up to £20,000, split between large Project Grants (up to £15,000) and Small Grants (up to £5,000). Last year saw a single application round, with one application of £15,000 being received. Keep your eye on the second round later this year.

A CALL TO APPLY FOR OPPORTUNITIES

1. Direct DAS Grants. To ensure continuity and sustainability of grass-roots airway management research, we have a rolling process of grant funding via direct application to DAS. Applications for funding of up to

3. DAS PhD Programme. This Programme gives support to researchers who have a list of publications that may be suitable to put together as a PhD. DAS will support

applicants throughout the process of a PhD by publication, including funding support.

4. DAS Faculty of Professors. This is an untapped resource that is open to any DAS Member to reach out to for guidance, support or advice on any academic matters, including grant applications and study design.

5. DAS Professor of Anaesthesia and Airway Management for 2024. This is an award conferred in recognition of a member’s national/international standing in the field of airway management as established by outstanding contributions through publications, creative work or other appropriate forms of scholarship, and through teaching and administration.

Following an extremely competitive series of previous rounds, the application is now open!

Find out more here: https://das.uk.com/ das_professor_2024

Our vision remains to take continue to cultivate academia through DAS and airway management, and begin to support, design and develop our own projects with our enthusiastic, creative and brilliant membership. Don’t hesitate to reach out and get involved!

Kariem El-Boghdadly DAS Scientific Officer

scientific-officer@das.uk.com

DAS PROFESSOR OF ANAESTHESIA AND AIRWAY MANAGEMENT: APPLICATIONS OPEN

| Kariem El-Boghdadly |

We are delighted to announce that applications for the DAS Professor of Anaesthesia and Airway Management 2024 are open! DAS Professor of Anaesthesia and Airway Management is an award conferred in recognition of a member’s national/international standing in the field of airway management as established by outstanding contributions through publications, creative work or other appropriate forms of scholarship, and through teaching and administration.

DAS Professors of Anaesthesia and Airway Management have been awarded since 2012. Please follow the links for the criteria and application form.

Applications close at midnight on 26/05/2024. Awards will be presented at the next DAS ASM.

https://das.uk.com/das_professor_2024

Q&A WITH DAS PROFESSOR 2023 ANDY HIGGS

| Moon-Moon Majumdar |

Why/when did you first become interested in difficult airway management?

I first became interested in airway management as a junior – I qualified in 1989 & went into anaesthetics in 1992. There was a lot of variation of practice, back in the day there were no guidelines or standards and it was oftentimes the wild west of anaesthetic practice. People had their pet techniques –some of which were good and some bad.

As a junior, I would do fibreoptic intubations on straightforward lists. As long as I didn’t use the suction, the ODPs agreed they wouldn’t [formally] clean the scope (they would just run it under the tap and we would use it on the next one). What is acceptable has changed a bit since then! As a result, as a junior I did about 150 fibreoptic intubations – all on asleep patients. A lot of this was at Aintree hospital, Liverpool, a big head & neck centre.

I did my first awake one as a Senior Registrar in Melbourne doing ICU. It was about 4am, a big guy after a cervical fusion deteriorated with a post-op pneumonia. I called the boss and they asked if I had done an awake intubation before. I said I hadn’t. He asked “are you happy to crack on?”, and I said yes –because I was confident: I had done so many asleep. He started on his way in, but by the time he had arrived I had already tubed the patient.

then take the intubated patient into theatres for surgery. I was intubating 15+ patients/day as a novice. I remember saying I was a bit upset to be spending all my time intubating when I wanted to be getting experience with these new LMAs! Things are the other way round for novices now…

What do you think the biggest development in airway management has been during your career?

I may be biased - I have done a lot of guidelines, but the development and adoption of practical guidelines. I think that newer anaesthetists may not appreciate the massive historical variation in practice, and to be honest a lot of weird stuff going on.

Secondly I have to say [supraglottic devices]: when I started in anaesthesia, I did hour long cases on a facemask with a Clausen harness…things have changed a lot. The year I started anaesthesia was more or less the year that laryngeal mask airways (LMAs) became widely available in the UK…That makes me sound really old – I don’t think I am that old! I’m 58…For my first two months as a first year SHO in Anaesthesia I was based 3-4 days a week at the eye hospital in Liverpool. The new Anaesthetic SHO spent their whole day in the Anaesthetic Room inducing and intubating patients, and the consultants would

I would also say – airway management being ‘a thing’ in itself – has evolved massively over the course of my career as well. Taking airways seriously is relatively new in anaesthesia, ICU & ED. Airway management wasn’t actually taught as a subject – you just picked it up as you trained . As long as there wasn’t a trail of dead bodies out of your theatre on a regular basis it was assumed you knew vaguely how to do it. There wasn’t an airway chapter in my FRCA textbook (a bit about anaesthetising for ENT, yes, but it focused on hypotensive anaesthesia and Moffat’s solution). Back in the day 1 or 2 hospitals in a region would have one person who was an enthusiast with a fibreoptic scope and most of the rest of the department would find them amusing. Initially when I trained quite a few hospitals had no consultants who could do a fibreoptic intubation.

Of which aspects of your career are you most proud/what has been the highlight of your career?

The highlight of my career has been writing guidelines for the management of tracheal intubation in critically ill adults https:// www.bjanaesthesia.org/article/

S0007-0912(17)54060-X/fulltext . What NAP 4 showed (I wasn’t involved in NAP4) – was that there were two main danger areas for airway management – ENT/maxfax and ICU/critically ill patients. There was a lot of airway morbidity and mortality outside of theatres that was really not recognised. NAP 4 actually quantified this. I used to do a theatre list on a Monday – if the ODP said the capnograph wasn’t working we simply wouldn’t go near the patient to anaesthetise them. I then did a 20 bed ICU ward round on Tuesday – our sickest patients – and NONE of them had a capnograph – this just demonstrates the disparity. The guidelines have been widely adopted around the world. It’s the first guideline with all the non-doctor groups e.g. patients, ICU/ED/Theatre nurses and ODPs represented in their production. It’s the first national airway guideline endorsed by the RCoA. I’m proud that we were able to bring together the RCoA, the faculty of ICM, ICS and DAS. RCEM also had a named representative who reviewed the drafts before publication .

The timing was in a way fortuitous as the guidelines were published in 2018, then in late 2019 when the pandemic struck¬ – we had an ICU intubation guideline ready to go (the algorithm only needed slight modification for COVID – and therefore able to be written very quickly). The initial Critically ill adult guideline was still the most downloaded article from BJA website last year – very unusual for a paper which is 5 years old. We have now written the first ever GPIC (Guidelines for the Provision of Intensive Care Services) standard for airway management in ICU – this is fallout

from the guideline, which in turn follows on from NAP4.

I was also part of the 2012 DAS extubation guidelines group – still the most cited extubation guidelines. Again - NAP 4 showed 1/3 of issues occurred at extubation. In recent years I have become involved with PUMA (Project for the Universal Management of the Airway). There was a problem with the DAS extubation guideline in that we never fully worked out how you might decide if an extubation was high risk– it doesn’t describe in specific detail how to make a diagnosis of ‘high risk’. We haven’t published the PUMA guidance yet (although it has been released at conferences), but we have now come up with a practical approach to decide what constitutes high risk and I hope takes extubation to the next stage.

PUMA’s main work so far has been the Prevention of Unrecognised Oesophageal Intubation (PUOI) guideline, which I think is very important. Particularly the concept of sustained exhaled CO2 (rather than no trace wrong place – as many of the patients who die as a result of UOI have some etCO2 trace, but it is abnormal). That’s been a big success. In the next year to 18 months – we will publish all the PUMA documents (7 guidelines) – each one takes 3 years to write, but we are writing them in parallel. They will be released in (hopefully) rapid succession.

All of these things I have set out to do because I think they needed to be done –

responding to patient safety and trying to improve our approach to avoiding them or managing them.

What's the best tip you have learned from a trainee?

A long time ago I was taught by a then trainee how to do ultrasound – then I started ultrasounding all my percutaneous tracheostomies!

Any final things you want to convey?

I am a DGH consultant. You can still have an impact as a DGH consultant!

Who is an inspiration to you?

I have been lucky enough to work with the first two DAS professors – they were appointed in the same year: Mansukh Popat (Oxford) & Pete Charters (Liverpool).

One final thing I think is quite exciting – we have started work on a project with a Warrington company to develop a biodegradable videolaryngoscope. I do feel a bit guilty going around the world saying everyone should use VL as it isn’t very sustainable. We will probably have to compromise and have plant-based plastic which is a step forward but not as revolutionary as the reason I originally joined the project.

What is the biggest issue facing the anaesthesia workforce now?

The general chaos that the NHS is descending into unfortunately. I think healthcare in this country is not working as well as in the past and I worry that you’ll start to see loss of standardisation and loss of oversight by the royal colleges. One thing that the UK is good at is setting standards and enforcing adherence. We can do that because of the NHS. I think that what we will see is a breakdown in the NHS, and anaesthesia (as well as lot of a lot of other specialties) seeking local answers to the problems that arise. This will result in loss of standardisation.

But the eventual end goal is to have VL blades that are totally biodegradable. One that you can take from your list and (if the laws of the land allowed) you could then put in your garden compost heap and it would disappear in 9 months time. We haven’t got degrading facilities in the UK yet (they have them in the Netherlands & Germany) – but at some point in the future that will become the industry standard. And I think that will be massive.

CLINICAL DILEMMA

| What Would You Do?

|

A 50 year old gentleman presents to A&E with a 48 hour history of feeling generally unwell with worsening sore throat and intermittent fevers. He complains of new onset difficulty swallowing and difficulty in breathing over the last few hours. He has no significant past medical history.

On clinical examination the patient looks uncomfortable. He has a respiratory rate of 22, saturating 98% on room air. There is no audible stridor at present. His voice is hoarse and he has recurrent pooling of saliva in his mouth. Flexible nasendoscopy reveals a grossly swollen and erythematous supraglottis. True cords are visualised.

ADULT ACUTE EPIGLOTTITIS / SUPRAGLOTTITIS

- What criteria or clinical predictors do you consider in deciding when to perform airway intervention in these patients?

Repeat flexible nasendoscopy shows worsening supraglottic swelling, with difficulty clearly visualising vocal cords.

- What would be your primary or preferred technique for airway management in this patient?

Rate of failed intubation has been reported as high as ~4% in adult epiglottitis, with some cases requiring emergency front of neck access

- In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best delivered?

What Would You Do?

Contact us on X with your thoughts!

@dasairway @dastrainees

WHATWOULDYOUDO? DAS Expert Corner

Airway Expert 1:

What criteria or clinical predictors do you consider in deciding when to perform air intervention in these patients?

This is an airway emergency and always makes me nervous as any delays in the management of these patients can make the clinical situation worse. I would take into consideration a global, overall view of the clinical situation when deciding how and when to manage the airway in this scenario. Is the patient distressed and what is the posture like, is there stridor, is the patient working hard to breathe, is the patient tiring and is the respiratory rate increasing? If the answer to all of these questions is yes, then I would want to secure the airway as soon as possible as the patient is struggling and airway obstruction is imminent. If I feel that I have time, then I would closely monitor the patient and start some conservative measures such as adrenaline nebulisers, supplemental O2, intravenous steroids and be prepared for intubation if the situation does not improve.

For this case, I feel that we can start conservative measures, but I would closely monitor the patient for any signs of deterioration, in which case I would plan for intubation.

What would be your primary or preferred technique for airway management in this patient?

My preferred technique would be an awake tracheal intubation using a flexible bronchoscope in theatre with the surgical and scrub team immediately available. I would modify my standard ATI technique by minimising sedation, and downsizing the ETT to the smallest possible size. One could also consider ATI using a VL, but this would be challenging and should only be done in experienced hands. The third option would be to perform an asleep VL intubation, this has the advantage of familiarity with the technique, but the disadvantages of not knowing whether BMV is possible once asleep or whether the view of the glottis will be adequate to enable intubation, therefore additional back up to perform eFONA should be planned for.

In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best delivered?

eFONA is a life saving procedure that is rarely performed by anaesthetists and therefore training to gain and maintain competency in this procedure is important. Currently this is dependant on individual anaesthetists taking the responsibility to do so, but I am not sure of the uptake of this. Airway Leads can facilitate this by providing local training and national bodies such as DAS and RCOA can provide training courses, the more accessible this is the more likely the uptake will be better. However, there are early discussions as to whether this requirement should be mandatory or not and if so who mandates it and how. We must also remember that it is not just anaesthetists that need this training but also anaesthetist assistants and other airway managers (eg in the Emergency department and critical care).

Airway Expert 2:

What criteria or clinical predictors do you consider in deciding when to perform airway intervention in these patients?

It is a difficult situation as the course of the disease is very unpredictable and decision making can be exceptionally hard specially deciding when to intervene. Understanding the progression of disease and regularly reviewing the patient to see the early signs of disease progression and airway compromise area good guide to decide when to actively intervene. Any signs of progressive airway compromise eg swelling, swallowing difficulty, pooling of saliva, tachypnoea, stridor are indicative of airway compromise. Oxygen saturation levels can be a late sign and may not be a suitable indicator for early airway compromise. I will tend to secure the airway in a timely manner when patients condition is indicative of early airway compromise and disease progression.

What would be your primary or preferred technique for airway management in this patient?

Adult epiglottitis patients requiring airway intervention can be done using awake or asleep techniques depending on the experience of the operator, skills of the team and patient compliance. My preferred technique will be to perform an awake Tracheal intubation using a fibreoptic technique if the patient is compliant. This patient has had 2 flexible nasendoscopies and therefore the anaesthetist will have an idea of the airway and potential technical difficulties.

In cases where there is very obvious airway compromise or the patient is noncompliant or compromised, I will consider a GA and video laryngoscope to secure the airway. This technique in my view will be useful as a VL will give a wider angle of view compared with a flexible scope and in the presence of severe airway swelling may give better working conditions and view to secure the airway. In both scenarios I will ensure the presence of a skilled ENT surgeon to perform an eFONA if needed in an emergency situation.

In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best delivered?

eFONA training is an essential component of regular airway training to be undertaken by all anaesthetists. Fading of skills after training/ teaching sessions is recognised and needs to be kept in mind when planning training sessions. In my view eFONA training should be delivered at least twice a year either using simulation labs or in the form of tea trolley teaching or a combination. This should be made mandatory for all anaesthetists and ideally individual departments should plan and deliver the training locally.

Airway Expert 3:

Acute epiglottis is a medical emergency (the exam answer!)

So HFNO, IV access (take bloods for cultures) and broad spectrum IV antibiotics immediately. No imaging or airway manipulation. Place the patient in an area of safety, ICU if stabilising or theatres if not. Inform senior ENT surgeon and anaesthetist.

What criteria or clinical predictors do you consider in deciding when to perform airway intervention in these patients?

Increasing fever, increasing difficulty in breathing with falling SpO2, dysphonia and stridor, needing to sit-up, further irritability and any reduction in level of consciousness.

What would be your primary or preferred technique for airway management in this patient?

For a start the FNE should not be repeated. The patient should be in theatre and a clear plan discussed with the team - a consultant ENT surgeon scrubbed and a tracheostomy tray open with the most experienced airway consultant anaesthetist as the operator.

Consider one best attempt at an ATI but with a low threshold for a surgical front of neck.

In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best delivered?

Once a year eFONA training and this is best done in a simulation suite but if not available part-task trainers in a dedicated teaching session.

This once a year training should be mandatory with other modules requiring to be repeated in a 3year period much akin to the Australian/NZ consultant CPD model.

Airway Expert 4:

This patient has predictors of disease that are concerning. I would take a full history and examination, including performing a full airway assessment. The patient needs intravenous access and will likely need antibiotics due to presumed sepsis. Wild also administer intensive steroids for oedema. I would urgently request the ENT consultant to attend, communicate with the theatre team early and transfer the patient to the operating theatres for definitive airway management.

What criteria or clinical predictors do you consider in deciding when to perform airway intervention in these patients?

First, his systemic symptoms started 48 hours ago. Next, his airway symptoms have progressed rapidly over a few hours. Furthermore, his symptoms of hoarse voice, difficulty swallowing and difficulty in breathing suggest the involvement with his airway is now significant.

What would be your primary or preferred technique for airway management in this patient?

I would perform awake tracheal intubation with a flexible bronchoscope and using an oral tube with glottic suction port to allow management on ICU. Oxygenation with HFNO, sedation with remifentanil, topicalisation with a mucosal atomising device with 10% lidocaine. I would scan the next with ultrasound and mark the cricothyroid membrane. I would ask the ENT surgeon to be scrubbed with a tracheostomy kit ready.

In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best delivered?

This should be done annually, and can be done with tea trolley training and in training courses or meetings (come to DAS ASM 2024 in London!)

POST-INTUBATION LARYNGOTRACHEAL STENOSIS AND MORE:

INSIGHTS FROM A MAJOR AIRWAY SERVICE

| Annabel Lim | Guri Sandhu | John Myatt |

Prof Guri Sandhu, Consultant Airway and Head and Neck Surgeon, leads the airway service at Charing Cross Hospital in London, the largest adult airway service in Europe managing laryngotracheal stenosis. In this article we explore some insights from our clinical practice.

Tracheostomy Indications: Expected and Unexpected Surgical Scenarios

Tracheostomy may be expected as a planned airway technique during surgery, most commonly for major head and neck cancer resections. However, situations may arise where a tracheostomy is required due to complications during surgery, despite not being part of the primary airway plan. From our experience, surgical procedures where this can occur include thyroid goitre/tumour (especially second side), thyroglossal duct/ cyst surgery, squamous neck cancer resection, carotid endarterectomy (especially second side), and anterior approaches to

cervical spine surgery. Consent for tracheostomy as a risk of these operations should therefore be gained. The increased risk with second side surgery occurs in the instance that there has been vocal cord paralysis from the first surgery which the patient had compensated for. If this is undetected preoperatively, subsequent damage to the vocal cord on the second side leads to stridor and unanticipated requirement for tracheostomy. In order to reduce this risk, patients should have a preoperative outpatient flexible nasal endoscopy, including saying “eee” followed by a sniff, as a check for abduction of the vocal cords.

Laryngotracheal stenosis: High rates of acquired pathology

Laryngotracheal stenosis is a long term condition which often requires serial surgical treatment for symptom management. Endoscopic procedures such as balloon

dilatation, intralesional steroid injections and CO2 laser treatment, are used to increase tracheal diameter and may be repeated at intervals ranging from every few months to a year or two. While laryngotracheal stenosis can occur in the setting of cancer, our patient population has demonstrated the wide range of pathology that can lead to benign laryngotracheal stenosis. Significantly, a high proportion of stenosis is acquired following prolonged ventilatory support in ICU, through an endotracheal tube or tracheostomy. While tracheostomy provides benefits in long term (over 7-10 days) ventilatory support such as improved increased patient mobility and comfort, facilitating decreased sedation, allowing oral nutrition and limited speech, and avoiding glottic injury, there is actually a similar incidence of laryngotracheal stenosis compared to the use endotracheal tubes.

Post-intubation stenosis and risk factors

As a large proportion of benign laryngotracheal stenosis is secondary to iatrogenic causes, this highlights the need to

take care in preventing post-intubation injury as much as possible. Acquired laryngotracheal stenosis can occur in the subglottic (66%) or tracheal (34%) areas, and can also be accompanied by vocal cord mobility impairment. A national database of over 600 000 patients in the USA1 recorded adult patients who were readmitted to ICU for mechanical ventilation within 45 days of an original admission where mechanical ventilation was used. It showed the incidence of new laryngeal or tracheal stenosis was 1.98 per 1000 discharges. While this is a low percentage of all ICU patients, it still results in a significant number of patients requiring long term follow up and surgical treatment, with a substantial impact on the patients’ lives. Long term evidence from patients requiring tracheostomy in ICU have shown that the change from use of low volume, high-pressure cuffs to high volume, lowpressure cuffs has helped to significantly reduce laryngotracheal stenosis, and therefore should be routinely chosen.

Post-intubation stenosis in the COVID-19 population

The COVID-19 pandemic caused an unprecedented surge in need for mechanical ventilation, with many patients undergoing prolonged intubation in ICU, often in a prone position to aid respiratory mechanics. Compared to pathology where more knowledge was widespread about the natural progression of disease, in the earlier period of COVID-19 patients, tracheostomy was often relatively delayed. This was due to a range of aspects such as lack of hospital resources, unfamiliarity with best management for long-term outcomes due to the novel nature of the disease, and protocols to reduce aerosol transmission. It was therefore hypothesised that there may be a higher incidence of laryngotracheal injury in this cohort of patients, forming a new group of patients in the coming years who require long term care and follow up in airway services. Recently published case series reports2-4 have started to characterise the laryngotracheal complications and sequelae of COVID-19. Interestingly, some COVID-19 patients who were not intubated still developed issues such as muscle

tension dysphonia, prolonged laryngitis, glottic oedema and unilateral vocal cord paresis, suggesting that there may be additional effects from the virus and inflammatory response, themselves contributing to risk of airway injury. Patients who were intubated were significantly more likely to develop glottic injury (oedema, erosion or granuloma), laryngotracheal stenosis, and posterior glottic diastasis. Modifiable risk factors associated with increased injury were increased endotracheal tube size and longer duration of intubation, while patient factors included type 2 diabetes mellitus, obesity, hypertension, cardiovascular disease, and smoking. However, the data currently published has only come from small case series. We therefore look forward to gaining more information in the near future in order better characterise the patient cohort, and optimise both prevention and treatment of post-intubation airway injury.

Link to references

AIRWAY AND RESPIRATORY COMPLICATIONS AND PERI-OPERATIVE CARDIAC ARREST:

KEY FINDINGS FROM THE 7TH NATIONAL AUDIT PROJECT OF THE ROYAL COLLEGE OF ANAESTHETISTS (NAP7)

| Jasmeet Soar | Fiona Oglesby | Tim Cook |

The NAP7 report was published in November 2023 and included a section on airway and respiratory complications and associated peri-operative cardiac arrest.

The key findings included:

• In the last 10 years the surgical population are likely to have become more complex from an airway perspective. The NAP7 Activity Survey which assesses overall anaesthetic activity showed the population is older, more obese and more comorbid in comparison to previous NAPs.

• In the Activity Survey, since NAP4, supraglottic airway (SGA) use has decreased (56% to 45% of general anaesthetics) but second generation SGA use has increased (from 10% to 65%). As body mass index (BMI) increased, when a SGA was used, the proportion of first to second generation devices changed minimally. Use of a tracheal tube only rose notably at or above a BMI of 40 kg m-2

• Among 24,721 surveyed cases, airway and respiratory complications were

the second (2% incidence and 22% of all complications) and fourth (1% incidence and 14% of all complications) most common complications, respectively. The most common airway complications were laryngospasm (38% of airway complications), airway failure (30%) and aspiration (6.4%). The incidence of a cannot intubate and cannot oxygenate (CICO) situation or the need for an emergency front of neck airway (eFONA) was 1 in 8370 (95% confidence interval, CI, 1 in 2296 to 1 in 30,519). The most common respiratory complications were severe ventilation difficulty (37% of all respiratory complications), hyper- or hypocapnia (24%) and hypoxaemia (23%).

• Among the 881 cases of perioperative cardiac arrest reported to NAP7 over a one year period, airway and respiratory complications were a leading cause of cardiac arrest, accounting for 13% of all cardiac arrests and 9% of deaths. Hypoxaemia was the primary cause of these events. Although survival after cardiac arrest due to airway and respiratory events was

higher than for other events, a disproportionate number of survivors experienced a severe outcome, indicating permanent harm or prolonged critical care stay.

• Airway events were twice as common as respiratory events (63% vs 37%) prior to cardiac arrest, but mortality from airwayrelated cardiac arrest was much higher than for respiratory-related cardiac arrest (45% vs 18%).

• Patients with obesity (BMI ≥ 35 kg m-2) were overrepresented, with extubation and recovery representing a particularly high-risk period for this group of patients.

• Infants (age range 28 days to less than 1 year) were overrepresented, with cases occurring in theatres, in paediatric critical care and during preparation for retrieval.

• Airway issues in cases of cardiac arrest of the critically ill child were prominent.

• Out-of-hours cases were overrepresented in airway and respiratory related cardiac arrests.

• While supervision of anaesthetists in training was generally good, there were examples of patients with a predictably higher-risk airway being inappropriately managed by junior anaesthetists.

• Lack of monitoring during transfer to recovery areas contributed to unrecognised hypoxaemia and cardiac arrest in several cases.

• 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 and notably less prominent than in NAP4.

• Most cases of aspiration occurred during rapid sequence induction (RSI) for acute abdominal surgery. There was a single case of aspiration associated with supraglottic airway (SGA) use. This is in contrast to NAP4.

• There were six cases of unrecognised oesophageal intubation with three resulting in cardiac arrest. Failure to correctly interpret capnography was a recurrent theme in these events.

• A lack of familiarity with or misuse of airway and breathing equipment contributed to cardiac arrest in some cases.

• Overall, the data, while distinct from NAP4, suggest that airway management is likely to have become safer in the last decade, despite the surgical population having become more anaesthetically challenging.

The full NAP7 report including the section 'Airway and respiratory complications associated with perioperative cardiac arrest' (Chapter 21) can be accessed here

A publication in the journal Anaesthesia can be accessed here

Jasmeet Soar is NAP7 Clinical Lead and Consultant in Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.

Fiona C. Oglesby is a NAP7 Steering Group Member and Specialty Registrar, Bristol School of Anaesthesia, Severn Deanery, Bristol, UK.

Tim M Cook is Director of National Audit Projects, Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital Bath, and Honorary Professor of Anaesthesia, University of Bristol School of Medicine, UK.

DAS WEBINARS 2024

| Gunjeet Dua | Tom Lawson | Moon-Moon Majumdar | Nisha Abraham-Thomas |

Thank you for joining us at our NAP 7: Key Airway Messages webinar on 25th March 2024. We hope you enjoyed it! Recordings are still available to those who registered.

SIGN UP NOW FOR OUR NEXT WEBINAR

13th May 2024

Exploring Airway Excellence: Top airway publications by Anaesthesia Journal and Difficult Airway Society

Still to come later in the year… webinars on: oxygenation, and patient information & consent

For all members of the multidisciplinary team

#LearnTogether

@dastrainees #DASeducation

Members will be emailed details of upcoming webinars including registration details from the DAS Secretariat. Please ensure your email address is up to date so as not to miss information on events.

COMMENTARY ON HSSIB REPORT INVOLVING ADVANCED AIRWAY MANAGEMENT

| Sandeep Sudan |

The Health Services Safety Investigations Body (HSSIB) is an independent body, who investigate safety concerns (in a no blame fashion) in both the NHS and independent healthcare settings. Their investigators of different backgrounds (including healthcare workers, military, aviation, law and human factors) work with patients/families and health professionals to make recommendations and safety observations.

As you may be aware, HSSIB recently published a report concerning the advanced airway management in a patient with known complex disease (Advanced airway management in patients with a known complex disease (hssib.org.uk)

It centres around the case of a 12-year-old boy, Ethan, who had Hunters syndrome (known difficult airway). He presented to the emergency department having had a seizure at home. Ultimately when it came to intubation, attempts failed (including eFONA), and he sadly died.

Key stakeholders such as DAS, RCoA, AoA and NHSE are collaborating to discuss how they can implement the recommendations from the report which include:

A framework in managing patients with an ANTICIPATED difficult airway

A more sustainable and inclusive difficult airway database

To implement MDT critical incident training

An emphasis on training with videolaryngoscopy and rescue techniques

There are similar themes within the recent NAP7 report, within the airway and breathing section: 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.

Whilst any change on a national level will need due process and therefore take time, individual and institutional change (towards ‘airway preparedness’) can happen sooner. Your AirWay Lead (AWL) is a key player in this but needs the support of the department. To remind us all:

1. If your department hasn't already signed up to the DAS difficult airway database, please do have a look at DAS Airway Alert Card and Difficult Airway Database | Difficult Airway Society.

2. Use this HSSIB report, alongside the RCoA GPAS document for head and neck surgery (Chapter 12: Guidelines for the Provision of Anaesthesia Services for ENT, Oral Maxillofacial and Dental surgery 2024 | The Royal College of Anaesthetists), as evidence for why we must have access to videolaryngoscopy, High Flow Nasal Oxygenation (HFNO) and emergency front of neck kits - in addition to any other kit needed for advanced airway management.

A further safety observation within the report does also refer to supporting more routine use of videolaryngoscopy to increase clinical experience.

3. Use this HSSIB report as evidence for the need to have the time to train everyone in advanced airway skills. This can be both task-based training (such as Tea Trolley Training) but also critical incident training.

The discussion on whether this should be MANDATED is once again up for debate. Perhaps it's time that we follow the example set by the Australian and New Zealand College of Anaesthetists (ANZCA). Their CPD

requirement requires those on the specialist register to demonstrate one (out of 10) emergency response activity each year. Two of these are airway related (Can't intubate, can't oxygenate and COVID-19 airway management). eFONA and unrecognised oesophageal intubation are probably the top two examples of what everyone needs to maintain skills in and understand.

It goes without saying that we are reliant on working in teams, and as we know those that work together must train together, including our surgeons.

The recommendations cited within the report do provide a real opportunity for us to further improve airway safety at a local level. Nationally, alongside the stakeholders mentioned before, DAS has an integral and important part to play.

Sandeep Sudan

RCoA / DAS Airway Lead Advisor

JOURNAL CLUB

| Recommended Reads |

Welcome to the DAS Journal Club - recommended reads. Papers are chosen by members of the DAS committee, with short citations/summaries by members of the e-zine editorial team. This edition's recommended reads come from Kariem El-Boghdadly with summaries by Nisha Abraham-Thomas.

Use these papers to facilitate your journal club and let us know your thoughts and feedback.

Please get in touch @dastrainees or @dasairway or email us at ezine@das.uk.com.

✦ Ruetzler K, Bustamante S, Schmidt MT, et al. Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. JAMA. 2024;331(15):1279–1286. doi:10.1001/jama.2024.0762

This cluster randomised clinical trial sought to investigate the effect of initial video laryngoscopy or direct laryngoscopy on the number of intubation attempts for a variety of elective and emergent surgical procedures. Whilst video laryngoscopy has been reported to improve glottic view, does this reduce intubation attempts? The authors found that hyperangulated blade video laryngoscopy reduced the number of attempts compared with direct laryngoscopy.

What are your thoughts on on routine first-line use of video laryngoscopy for all surgical procedures? When do you choose to use the hyperangulated blade video laryngoscope?

✦ Crístian de Carvalho C, Iliff HA, Santos Neto JM, Potter T, Alves MB, Blake L, El-Boghdadly K. Effectiveness of preoxygenation strategies: a systematic review and network metaanalysis. Br J Anaesth. 2024 Apr 9:S0007-0912(24)00130-2. doi: 10.1016/j.bja.2024.02.028. Epub ahead of print. PMID: 38599916.

This systematic review and meta-analysis included 52 studies of 3914 patients and found that pre-oxygenation with high-flow nasal oxygen in the head-up position prior to induction of general anaesthesia was the most effective strategy in prolonging safe apnoea time compared with other strategies.

Consider your strategy for pre-oxygenation. What technique do you use and how do you position your patients?

FROM LONDON TO LUSAKA: A JOURNEY IN AIRWAY MANAGEMENT

| Mary Madden |

In August 2023, after finishing my ST6 year of training, I packed up my life in London and moved to Lusaka for a 6 month Out of Programme Experience. I was delighted to finally be making this trip after initially applying for a fellowship with the Zambia Anaesthesia Development Programme (ZADP) three years prior, in February 2020. So now, after a global pandemic and a FRCA out of the way, I was arriving as a Senior ZADP Fellow, rather than the Junior Fellow role I had initially envisioned.

ZADP is a partnership between the Global Anaesthesia Development Partnerships (GADP) and the Society of Anaesthetists of Zambia (SAZ), established in 2012. Like many countries in sub-Saharan Africa, Zambia has very few physician anaesthetic providers; 79 for a population of over 16 million1 This is far below what is needed to support the consistent, safe delivery of surgery and perioperative care. It is a medical specialty which is still largely in its

infancy. Recruitment and training of local physician anaesthetists are therefore fundamental to increasing and strengthening the workforce.

One of the main areas of delivery of the ZADP partnership is by the visit of in-country fellows, who work alongside local consultants to deliver the anaesthesia and critical care training program. As a fellow, time is mostly spent in the 1655-bedded tertiary referral centre of Zambia (University Teaching Hospital, Lusaka) which housed 6 theatre complexes. Outreach visits to Ndola Teaching Hospital, 300km north of Lusaka are also provided by fellows. Due to the scarcity of consultant anaesthetists, the residents and nonphysician anaesthesia providers largely work independently from a very junior level. Therefore, a large component of the incountry fellow is to provide daily clinical and non-clinical support to residents. This is complemented by remote fellows from around the globe that facilitate multiple online weekly teaching sessions.

Being an in-country fellow is a truly immersive experience. Upon my arrival, I quickly became embedded in a busy clinical environment whilst being warmly welcomed by the local staff. I felt that my postponed arrival to Zambia was rather fortuitous as I had just finished a 6-month Specialist Interest Area rotation in Advanced

The University Teaching Hospital, Lusaka

Airway Management at Guy's Hospital. I now felt comfortable managing complex airways and navigating the fibreoptic bronchoscope. However, from being a trainee in a wellresourced system where clinical procedures are almost prescriptive, I now found myself not just being the trainer, but having to be very adaptive and innovative based on the equipment and resources available. Complex airway management in this setting was met with multiple new challenges - it was bidirectional learning, to say the least.

I was now in an environment where sourcing a working direct laryngoscope could be a challenge in itself and no capnography was the norm. Supply chain issues and lack of consumables meant that basic drugs and equipment were not available, this could even include oxygen on some days. The advanced airway armamentarium largely consisted of lidocaine, atropine, ketamine and a couple of re-used bronchoscopes and nasal tubes.

As a large component of the teaching and hands-on support was in the clinical environment, I found I naturally placed myself in various airway lists or cases where there were potential airway challenges, whilst mentoring trainees in other theatres. The range of maxillofacial pathology was extremely diverse, often with late presentation of progressive disease. Large maxillofacial tumors, airway and facial burns with subsequent strictures and impending airway obstructions were frequently encountered. Emergencies were most often managed with awake tracheostomy due to the lack of equipment availability and trained anaesthetic staff. However, with effective team working with surgeons, enthusiastic

residents and adapting our limited armamentarium we were able to jointly manage some extremely challenging airways safely and successfully. There were two working videolaryngoscopes available and a focus was to promote the role of its use, where possible. I encouraged and supervised trainees in its elective use, supporting recognition of its role when it came to difficult airway management. Again, this is a resource that was not readily available throughout the whole hospital. However, by the end of my time there, I was delighted to see it being requested by junior residents in their plan when faced with a patient with a potentially difficult airway. The development of the residents’ experience and confidence was evident.

To supplement in-theatre supervision we ran biweekly simulation training sessions, covering common anaesthetic and critical care emergencies. This included scenarios to incorporate safe airway management, embedding the DAS 2015 and recent PUMA guidelines, adapted to the local setting. I co-devised a 4-day novice induction

Local faculty and ZADP members at the Society of Anaesthetists of Zambia annual scientific meeting, November 2023.

program for the newly recruited residents, with 1 of the days based on airway assessment and management. We ran this to align with the RCoA Novice Guide for Initial Assessment of Competence including SIM scenarios. This was the first novice induction delivered in UTH with local faculty and ZADP support, and hopefully the first of many more. I was also honoured to have the opportunity to present at the annual SAZ conference themed ‘Improving Peri-operative Obstetric Care in Zambia’. Here, I presented on the management of the obstetric airway, focusing on local, context-specific practice aligning it with recommendations from the DAS obstetric guidelines and how to promote safety in this high-risk population, where unfortunately maternal mortality related to anaesthesia is still disproportionate.

Supporting leadership, management, and academic activities including quality improvement is another aspect of the teaching role. Alongside another visiting fellow we supervised local residents’ airway QI’s projects. This included the implementation of eFONA ‘tea trolley’ teaching and packs as well as creating the first Difficult Airway Trolley at UTH. This initial

trolley was rolled out in the elective theatres with much anticipation and support from the wider theatre team. Work is undergoing to roll this out in other theatre blocks, with a priority being obstetric theatres.

Other non-clinical roles included exam support. This included setting up a weekly morning written final exam club and running mock OSCE and VIVA exams. Although residents undergo FRCA-level exams, a lot of the material they learn is not available or routine in their clinical practice. Despite this, I was in awe of their depth of knowledge and clinical skills. Additionally, I increasingly recognised my mentoring role required providing pastoral and well-being support to the residents. This was a space I took great pride in providing, particularly after witnessing fi rst-hand the demanding conditions the residents so tirelessly and resiliently work in daily and their commitment to advancing the specialty.

The ZADP teaching fellowship has so many facets and opportunities to focus on based on your individual interests. It was a privilege to have the opportunity to be so actively involved in promoting safe airway management not just to residents but all

Introducing the Difficult Airway Trolley to main elective theatres in UTH. A QIP led by Dr Katongo Mumba, 3rd year resident.

Novice trainees about to embark on their training after successfully completing the induction to anaesthesia course.

members of the theatre team. It offered a window of experience into the critical and challenging area of global health, highlighting the role of international collaboration working to support and embed sustainable practice. Personally, this OOPE was an experience that helped me develop in more ways than I could have ever imagined and one I'm sure will stay with me throughout my career. My only regret was not extending it for a longer time. Zambia is a beautiful country, and a lasting memory is just how friendly and welcoming the local people were. Getting ‘down-time’ was also a necessity during the busy program and one is truly spoilt with just so much spectacular wildlife and landscapes to explore, including one of the awe-inspiring natural wonders of the world, Victoria Falls.

I would highly recommend this experience to anyone interested in global anaesthesia and education. I can't wait to return someday!

If you would like to find out more about Global Anaesthesia Partnerships please contact:

Website: https://gadpartnerships.com/

Email: info@gadpartnerships.com

X: @gadpartnerships

Dr Mary Madden

ST7 Anaesthetics, South West London School of Anaesthesia

References:

1. Workforce Map - WFSA (wfsahq.org)

The daily commute to UTH, under the majestic flame trees.

A quiet moment overlooking the Luangwa river valley in South Luangwa National Park

WORLD AIRWAY MANAGEMENT MEETING

| Ellen O’Sullivan |

Following on from the success of WAMM 1 in Dublin in 2015, and WAMM 2 in Amsterdam in 2019, WAMM 3 is set for 2025 in Florence!

Register your interest today!

POST-INTUBATION LARYNGOTRACHEAL STENOSIS AND MORE:

INSIGHTS FROM A MAJOR AIRWAY SERVICE

| References |

1. Johnson RF, Bradshaw S, Jaffal H, Chorney SR. Estimations of laryngotracheal stenosis after mechanical ventilation: a cross-sectional analysis. Laryngoscope 2022;132(9):1723-8

2. Neevel AJ, Smith JD, Morrison RJ, Hogikyan ND, Kupfer RA, Stein AP. Postacute COVID-19 Laryngeal Injury and Dysfunction. OTO Open. 2021 Aug 24;5(3):2473974X211041040. doi: 10.1177/2473974X211041040. PMID: 34458661; PMCID: PMC8392819.

3. Naunheim MR, Zhou AS, Puka E, Franco RA Jr, Carroll TL, Teng SE, Mallur PS, Song PC. Laryngeal complications of COVID-19. Laryngoscope Investig Otolaryngol. 2020 Oct 30;5(6):1117-1124. doi: 10.1002/lio2.484. PMID: 33364402; PMCID: PMC7752067.

4. Allisan-Arrighi AE, Rapoport SK, Laitman BM, Bahethi R, Mori M, Woo P, Genden E, Courey M, Kirke DN. Long-term upper aerodigestive sequelae as a result of infection with COVID-19. Laryngoscope Investig Otolaryngol. 2022 Mar 9;7(2):476-485. doi: 10.1002/lio2.763. PMID: 35434347; PMCID: PMC9008172.