Chris Poynter on 18-11-2014
I’m going to delve into a contentious issue today.
That issue is airway management in the critically unwell.
It shouldn’t be contentious at all but somehow it is. I suspect that this is because it is a multidisciplinary area with slightly different ED, ICU, Anaesthetic and even pre-hospital approaches. All wish to take ownership within their environments and have different considerations which make them “special”. This colours much of the dialogue between specialities in developing safe and effective strategies. Although effective airway management is a team game, there remains a territorial aspect to it as intubation is an “exciting” procedure which people are hesitant to hand over.
However, the stakes are high. Poor airway management can lead to significant morbidity or even mortality. Rare but disastrous complications mean that it is often easy to get away with bad practice for quite some time before catastrophe strikes.
Before I continue I must make my position and therefore biases clear. I am a dual trained Intensivist/Anaesthetist. I think that this places me in a position to comment on airway management within critical care. I have heard views from two different cultures and can see both perspectives and have formed my own opinions based on my position between specialities.
I don’t think we do as well as we think we do in intensive care. We don’t really know because we don’t tend to monitor our airway outcomes closely. However the NAP4 (the 4th National Audit Project of the Royal College of Anaesthetists in the UK looking at major airway complications in the UK) indicated that ICU and ED are high risk areas for complications in airway management. In fact, when comparing risk, ICU had an estimated 67 times higher risk (see comment by Tim Cook) of airway death than anaesthesia. Some argue that that is not comparing apples with apples due to the many elective anaesthetic airway interventions compared to the critical nature of Intensive Care airway management. This has some truth to it but loses the point: we could be doing better in Intensive Care.
So, what should we do better?
Before I discuss that I’m going to take a short diversion to discuss airways and the Emergency Department. Surprisingly, I think that Emergency Medicine is currently leading the way in developing safer systems for airway management in the critically unwell. They often get a bad rap in airway management facing frequent criticism from their anaesthetic and intensive care colleagues. They are an easy target due to the fact that they lack practical airway experience and therefore often (and appropriately) request assistance. When such assistance arrives, the scene they come across can look ugly. This combines with a lack of symbiosis in the relationship between ED and Anaesthesia and criticism is forthcoming.
I think that in recent times Emergency Departments have noticeably improved their systems to enhance safety. The ED literature is littered with airway safety initiatives including: promoting apnoeic oxygenation; contingency planning such as the vortex and other checklists and aides; and there is now a developing airway registry to gather data and start an Australasian airway management quality assurance cycle.
All of that is fantastic! That is not to let them off the hook though. Some criticism is valid and Emergency department complication rates are high. I think that there is still a lack of acknowledgement within Emergency Medicine culture at the large difference in technical airway management ability between themselves and Anaesthesia.
It is important to point out that Anaesthetists are airway experts over and above the vast majority of non-anaesthetic airway providers. This is sometimes debated but in my opinion this is not a debate. Anaesthetists manage airways multiple times daily and as such develop technical expertise above and beyond any other specialities capacity. Although the system development is good in Emergency Medicine and they are experts in their environment, there is still a reticence to have the best airway technicians in the room which can let the whole system down. Without appropriate technical supervision there is a much higher chance of inability to ventilate, poor views on laryngoscopy, multiple attempts, desaturation and attendant complications, including unnecessary emergency airways.
However, although Anaesthetists are trained to manage critically unwell patients, they are not uniformly comfortable with them. Some are excellent, but there is variability there. The shoe is now on the other foot as they say. Anaesthesia has now largely become so safe that many anaesthetists are not as comfortable in an emergency as an emergency or intensive care doctor. They are also certainly not familiar with ED and ICU environments and therefore, when called into such environments to assist, should manage the airway rather than the scene.
My ideal next step in the Emergency arena is to have an anaesthetist present when available for every intubation (not just predicted difficult ones) in a technical supervisory and educational role. The emergency docs can run the show and perform the intubation but with appropriate backup and feedback. I would add that as video laryngoscopy becomes cheaper, it should be utilised every time in order to maximise the learning opportunity, team communication and safety of intubation.
Intensive care has many of the same problems as described above for Emergency Medicine. We are, though, probably less criticised for our airway management for a number of reasons:
often we have more technical expertise in our ranks due to more anaesthetic requirement in our training, dual trained anaesthetist/intensivists from old college affiliations and a regular stream of anaesthetic trainees rotating through intensive care units.
we have a generally stronger relationship with our anaesthetic colleagues as they often refer patients to us and rely on us and so there is more trust and possibly less scrutiny
critical care is seen as our domain where Emergency doctors are recognised as needing to be more “Jacks of all trades”
airway interventions are often in the setting of very sick patients with multifactorial issues. Complications that occur in this setting are easier to explain away.
Combine the above with the fact that now Intensive Care has developed into a speciality in its own right and therefore has increasingly weaker links with anaesthesia, and there is potential for us to drop to the bottom of the pack unless we focus on developing a more stringent culture of safety in airway management.
How should that be done?
Quality assurance - Our unit has just started auditing our airway interventions and gathering data will hopefully provide direction for quality improvement. Should Intensive Care have an airway registry similar to the Emergency Medicine one? Or should we simply combine with them?
Training - multidisciplinary simulation and hands-on technical practice with anaesthesia and in the simulation lab will help provide skill base. Trainees should also be directed towards online resources to upskill.
Roles - as mentioned above, airway management is a team game. Any airway intervention should have clear role allocation. This could include anaesthetic involvement in a similar vein to that described for ED above. This will enable any stress to be spread and important relationships to develop.
Equipment - As described for ED, I think that every intubation should be done with a video laryngoscope in ICU. Every intubated patient should have ETCO2 monitoring all the time, not just peri-intubation. Difficult airway and emergency tracheostomy kits should be easily available all of the time.
Finally, due to the multi-disciplinary nature of airway management, inter-disciplinary relationships should be nurtured and valued. Audit and education programs can run in parallel. Checklists, airway trolleys, difficult intubation kits and contingency algorithms can be developed between departments to provide unity of practice within a hospital.
So that’s my take on this contentious issue. No speciality is spared my criticism. With the current turf warfare mentality to the issue, I think that everyone misses out, especially the patient. I look forward to your feedback. Is this an accurate portrayal of the problems in your neck of the woods or have I overgeneralised? What are you and your department doing to improve airway management?
Here is an excellent compilation of resources in the mean time:
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KIdocs.org from Australia wrote 11-18-2014 05:33:36 pm
Nice one Chris - certainly a contentious issue - some of the FOAMed community will be aware of a draft 'consensus statement for accepted modificaitons to standard RSI' that has been circulated and now submitted for review.
The arguments often occur on various fora, and I think you've done a nice job of sterring through the morass of arguments pro/con
Standardise and audit where possible
Checklists - use 'em, even if expert (see http://kidocs.org/2014/03/real-airway-doctors-use-checklists/)
VL vs DL : I'm not sure of benefits of current VL; different technique with a LOT of the devices and risk of deskilling. Dont work well in presence of blood/vomitus. Can accelerate learning curve and be useful for audit (if can video record every intubation). Awaiting the low cost, DL technique device that works in presence of soiling. No such device exists as yet...
Best operator - not sure having anaes there is recommended or even feasible. At 3am the ''senior anaes" may be an anaes reg....and in smaller centres or prehospital, there is no anaes present - having a backup intubator and clear plans for failed or difficult airway is recommended
I hope to have the 'accepted modifications to standard RSI' paper out early next year - important I feel as that there is often tension between craft groups, which can lead to post hoc criticism of adverse events without appreciation of different and accepted modifications to practice.
Whilst use or not of cricoid force is the classic example, there are other examples in the medicolegal arena of modifications to RSI that have been heavily criticised by experts inc use of propofol not thiopentone, choice of neuromuscular blockade, bolus vs titrated dosing, patietn positioning. Clearly a LOT has changed since Stept & Safar's original description of RSI and it would be sensible to reach a consensus on accepted modifications that incorporate modern practice for intubation of the critically unwell...
Christopher from New Zealand wrote 11-18-2014 11:51:25 pm
Thanks for your comments Tim.
I agree with you re:checklists and feel that they are underutilised in every field of medicine because we have been trained to think that it is important for us to rely on our memories as doctors.
I think that VL is the way of the future. That doesn't mean that it can expect to replace suction of a soiled airway - direct laryngoscopy doesn't work any better in that respect. If VL becomes the standard, then there is no deskilling and it most can (and should) be used as direct laryngoscopes. The video is an awesome for teaching and audit but its best aspect is in communicating to the whole team at the bedside what the view is. It also allows less experienced intubators to either have a go with easy supervision, and, if then elbowed aside to still learn from the experience.
I agree that there is a lot of retrospective damning involved with airway incidents and having accepted variations to standard RSI sounds very pragmatic. It is amazing how medicolegal experts can quote unproven dogma to criticise reasonable practice after a complication
And, of course, the most contentious issue I raised appears to be the presence of an airway expert every time intubation takes place. As you are aware I have previously waded into online discussions about this and then slowly backed away as the sparks fly! Having as many characters as I wish to explain my position now is certainly better than trying to negotiate this hornet's nest on Twitter.
I accept that it is not feasible every time and sometimes expert help can be a long way away. Your examples of prehospital and smaller centres are just such cases. For those times emergency clinicians need to have the skills to act to control an airway safely. This is precisely why every other opportunity to have expert supervision and associated teaching should be taken - it enables upskilling in a safer environment and reduces risk in general.
Having a backup intubator if available and clear plans for failed or difficult airway is ok in the above circumstances but I don't think appropriate if more skilled assistance is available and not utilised. An experienced intubator can avoid all manner of problems and it can be too late if you find yourself in trouble mid-procedure.
The concept that "I can always perform emergency surgery if worst comes to worst", although theoretically correct, is best avoided entirely if possible. None of us are very experienced in emergency airways and the reality is not as simple as the theory. It is easy to say but less easy to safely perform.
I would also caution against underestimating the technical ability of anaesthetic registrars at 3am too. They often come with an anaesthetic technician, and after a couple of years of anaesthesia are more airway proficient than most non-anaesthetic airway docs. They may be appropriately uncomfortable in the situation of being called to assist in ED or ICU and shouldn't be expected to lead but don't forget that their technical skills are current and they get practice in managing airways all day every day. As always, when a team assembles for a task it is best to introduce and allocate roles appropriately.
KIdocs.org from Australia wrote 11-19-2014 02:13:56 pm
Yep, agree with all that. Freely admit that my view is skewed - I practice as a rural/remote clinician which means that must be autonomous - there IS no back up. Similarly when in my (current) retrieval role, the expertise resides within the team.....
...which leads of course to the issue of WHO is the expert. We often get into circular arguments - yes anaes are the experts in airway management; similarly EM are the experts in dynamic airways and critical illness/resus.
So - my take on it - forget the craft group - train the individual (and the team) to the required standard. At the roadside I really don't give a flying $%^& who intubates me, so long as he/she is appropriately trained, equipped and audited to perform drug-assisted RSI on technically challenging airways. My opinion is that, in an ideal world and a TRUE highly-performing prehospital team, then either Dr, nurse or paramedic should have interchangeable roles - no reason could not have the same model in ED, ICU as well as OT...
Christopher from New Zealand wrote 11-19-2014 03:22:28 pm
Again I agree with you re:training people and teams to the required standard Tim. One of my greatest frustrations with this whole airway dialogue is the territorialism and sensitivities surrounding different specialities roles in airway management. At the end of the day it is simply important that the job is done as safely as possible with a minimum of fuss. That involves having the right systems in place, training well and assembling the best team for the job.
However, I do think that role and skill differentiation between personnel is inevitable (and desirable) and therefore different roles should have different skills and knowledge that they can bring to the table rather than striving for interchangability.
DanW from New Zealand wrote 01-28-2015 02:46:14 pm
That was an insightful blog Chris. I think part of this comes down to perception and view point. I'm an Australasian trained Emergency Physician so come with my own set of biases.
I pretty much agree with KIdocs.org's comments above. Most Emergency Physicians would consider themselves "experts at resuscitation" rather than "jacks of all trades". Certainly most of us do 6-12 months anaesthetics and 6-12 months of ICU as registrars. We're also fairly good at situational awareness and team leading.
It probably depends on the centre where we work but as a senior registrar I performed far more RSIs in ED than I did during my ICU attachment, and possibly nearly as many as I did while working in theatre doing anaesthetics. Currently though I freely admit the number of intubations I do at work has fallen significantly and there is a danger of loosing some of the skill that you automatically build up through doing a manual task day in and day out. My anaesthetic rotation as a registrar certainly taught me respect for the airway and it taught me above all how to be safe - or at lease as safe as is possible in any ED!
I support the notion of having an anaesthetist ready to assist as back-up for RSI in patients with difficult airways, although not necessarily in the room. The chain of command does need to be strictly adhered to though - I've seen plenty of cases where the anaesthetist does their own thing at the head end with minimal communication, and all of a sudden the patient has received 200mg ketamine as an analgesic "adjuvant" and needs to be intubated. Please please please don't bring the metaraminol to ED either! Rant over...
I think there is a very easy explanation as to why intestivists receive less criticism that emergency physicians. Intensivists don't refer to anyone (or at least if you do it's to another ICU). Working in ED is like working in a glass-house. Everyone sees what you do and gives their two cents worth. I don't particuarly mind this - you develop a thick skin over the years. It was an eye opener when I went to work in ICU and all of a sudden was in an environment where the reverse was true!
That's probably enough opinionated guff from me. In any given situation I think you want the best trained person available for the job. Often the best trained airway technician will be an anaesthetist and if they are readily available to assist they will always be welcome in my department, especially if they're going to give me (or my registrar) some one-on-one teaching.
Christopher from New Zealand wrote 01-30-2015 09:12:10 am
Thanks for your comments. I apologise if the "Jack of all trades" comment sounded perjorative. I guess I intended to point out the breadth of clinical skills required for emergency medicine incorporating all specialities at all levels of presentation compared to intensive care focussing on only the critically unwell. I agree that ED physicians should own the resus bay and provide leadership and situational awareness.
My main ongoing debate with ED docs centres around technical competence compared to anaesthetists. On that matter I still hold to my assertion that many complications can be avoided by having an airway expert in the room for airway interventions and that the average ED doc simply does not have the exposure to consider themselves a technical expert no matter how safe their approach is on paper. If uncomplicated, there are still teaching opportunities to be had to fine tune those skills and often calling for help when required misses those benefits to enhance the system.
I agree that it is important to acknowledge the team aspect of an emergency intubation and that the chain of command/leadership is important. It can always be tricky when there are several "experts" in the room trying to achieve the same thing in slightly different ways. In this respect, it is important to discuss the plan and leadership roles early in the piece. Having more regular involvement should improve quality of those interdepartmental relationships and the subsequent role differentiation and communication too...
I wholeheartedly agree with your comparison of ED vs Intensivist levels of scrutiny (ie. glass house vs ivory tower?) As stated above, I think that puts us at increased risk in ICU as we may not question our own practices enough.
I'm glad to have opened up some discussion though and even gladder to not have been shouted out of the room. I really enjoy these cross-speciality dialogues. It is so easy to become cynical and sanctimonious when locked in one's silo
Alfalah12345 from United Arab Emirates wrote 12-19-2015 07:28:17 pm
Yep, agree with all that. Freely admit that my view is skewed..http://www.afu.ac.ae/en/Admission-&-Registration/duties-and-responsibilities/
SAMEER from India wrote 01-20-2016 03:52:12 pm
I practice in India and feel that all the technitians must be trained to assist in cases of intubation in emergencies.
Absolute essential checklist
Very good suction apparatus
Technitian to apply cricoid pressure
Gum elastic bogiey helps in most cases
Flexometalic armoured tube easy to pass
Choose asmaller size tube to pass to gain the airway
VL is always a option
Emergecy tracheostomy must be always ready.
Robert from United States Of America wrote 03-21-2016 12:42:49 pm
As admirable as the desire to have an anesthesiologist routinely at bedside in the ED for intubations, I doubt that that is practical, at least in the US, where I work. As emergency airways are sporadic, you cannot have an anesthesiologist in the department twiddling their thumbs during the 99% of the time when no airway management is taking place.
So, call then. Right away that makes the thing less useful because, and let's face it, the really scary airways are not usually the ones that will wait patiently for 15 minutes for a provider to come down.
But most community hospitals in the US don't have an anesthesiologist in the hospital at night. Now they are coming in from home, not once a week for an emergency surgery, but twice a night for tubes. If you call sell them on that, godspeed.
The utility of this is limited because only about 5% of airways are difficult and < 0.05% become failed airways (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2657243/). So anesthesia would answer that pager 20 times for every case where their expertise MIGHT make a difference (rough estimate; routine airways can be refined, and many difficult airways are easy for an experienced ED provider), and 200 or more times for every case where their skills would very likely be of benefit.
I would modify the program as follows: 1. Anesthesia responds when paged in the shortest practical time, 15 minutes max except for rural areas. 2. Routinely paged out for anticipated difficult airway (as per objective criteria + attending discretion) 3. ED docs train with anesthesia one week per year, every year, min 50 intubations, with a focus on peer-to-peer mentorship and refining airways skills.
That would be expensive, but less so than have anesthesia at every intubation. While I appreciate bedside teaching (and have no problem with being a student at the bedside as an attending) I think it is more practical to separate that from emergency airway management -- where in 2016, the prosaic fact in that if you have 30 minutes or an hour to prepare an intubation, you can often prevent the intubation itself.
FREOKUMAR from Australia wrote 12-16-2019 03:41:51 pm
I thank and appreciate author for this blog!!
This is very high quality blog which accurately raises contentious issues surrounding variable practices in different specialities dealing with the challenging practice of airway management .This blog certainly has god discussion and very useful information including an excellent compilation of resources given at the end of the blog. Hence its a must read for all ICU, anaesthetic and ED docs !!!