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British Journal of Anaesthesia May 2011This project was devised to estimate the incidence of major complications of airway management during anaesthesia in the UK and to study these events.
Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.
BACKGROUND
This project was devised to estimate the incidence of major complications of airway management during anaesthesia in the UK and to study these events.
METHODS
Reports of major airway management complications during anaesthesia (death, brain damage, emergency surgical airway, unanticipated intensive care unit admission) were collected from all National Health Service hospitals for 1 yr. An expert panel assessed inclusion criteria, outcome, and airway management. A matched concurrent census estimated a denominator of 2.9 million general anaesthetics annually.
RESULTS
Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics [95% confidence interval (CI) 38-54] or one per 22,000 (95% CI 1 per 26-18,000). Anaesthesia events led to 16 deaths and three episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8-8.3): one per 180,000 (95% CI 1 per 352-120,000). These estimates assume that all such cases were captured. Rates of death and brain damage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management was considered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only three deaths was airway management considered exclusively good.
CONCLUSIONS
Although these data suggest the incidence of death and brain damage from airway management during general anaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airway management indicates that in a majority of cases, there is 'room for improvement'.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Airway Management; Airway Obstruction; Anesthesia, General; Child; Emergencies; Female; Humans; Hypoxia, Brain; Intensive Care Units; Male; Medical Audit; Middle Aged; Prospective Studies; State Medicine; United Kingdom
PubMed: 21447488
DOI: 10.1093/bja/aer058 -
Anaesthesia Sep 2019The primary aim of this study was to identify, describe and compare the content of existing difficult airway management algorithms. Secondly, we aimed to describe the... (Review)
Review
The primary aim of this study was to identify, describe and compare the content of existing difficult airway management algorithms. Secondly, we aimed to describe the literature reporting the implementation of these algorithms. A directed search across three databases (MEDLINE, Embase and Scopus) was performed. All articles were screened for relevance to the research aims and according to pre-determined exclusion criteria. We identified 38 published airway management algorithms. Our results show that most facemask employ a four-step process as represented by a flow chart, with progression from tracheal intubation, facemask ventilation and supraglottic airway device use, to a rescue emergency surgical airway. The identified algorithms are overwhelmingly similar, yet many use differing terminology. The frequency of algorithm publication has increased recently, yet adherence and implementation outcome data remain limited. Our results highlight the lack of a single algorithm that is universally endorsed, recognised and applicable to all difficult airway management situations.
Topics: Airway Management; Algorithms; Humans
PubMed: 31328259
DOI: 10.1111/anae.14779 -
Anaesthesia Nov 2015The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and...
The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training.
Topics: Airway Management; Algorithms; Anesthesiology; Female; Humans; Intubation, Intratracheal; Laryngeal Masks; Obstetrics; Pregnancy; Societies, Medical
PubMed: 26449292
DOI: 10.1111/anae.13260 -
JAMA Aug 2018The optimal approach to airway management during out-of-hospital cardiac arrest is unknown. (Comparative Study)
Comparative Study Randomized Controlled Trial
Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial.
IMPORTANCE
The optimal approach to airway management during out-of-hospital cardiac arrest is unknown.
OBJECTIVE
To determine whether a supraglottic airway device (SGA) is superior to tracheal intubation (TI) as the initial advanced airway management strategy in adults with nontraumatic out-of-hospital cardiac arrest.
DESIGN, SETTING, AND PARTICIPANTS
Multicenter, cluster randomized clinical trial of paramedics from 4 ambulance services in England responding to emergencies for approximately 21 million people. Patients aged 18 years or older who had a nontraumatic out-of-hospital cardiac arrest and were treated by a participating paramedic were enrolled automatically under a waiver of consent between June 2015 and August 2017; follow-up ended in February 2018.
INTERVENTIONS
Paramedics were randomized 1:1 to use TI (764 paramedics) or SGA (759 paramedics) as their initial advanced airway management strategy.
MAIN OUTCOMES AND MEASURES
The primary outcome was modified Rankin Scale score at hospital discharge or 30 days after out-of-hospital cardiac arrest, whichever occurred sooner. Modified Rankin Scale score was divided into 2 ranges: 0-3 (good outcome) or 4-6 (poor outcome; 6 = death). Secondary outcomes included ventilation success, regurgitation, and aspiration.
RESULTS
A total of 9296 patients (4886 in the SGA group and 4410 in the TI group) were enrolled (median age, 73 years; 3373 were women [36.3%]), and the modified Rankin Scale score was known for 9289 patients. In the SGA group, 311 of 4882 patients (6.4%) had a good outcome (modified Rankin Scale score range, 0-3) vs 300 of 4407 patients (6.8%) in the TI group (adjusted risk difference [RD], -0.6% [95% CI, -1.6% to 0.4%]). Initial ventilation was successful in 4255 of 4868 patients (87.4%) in the SGA group compared with 3473 of 4397 patients (79.0%) in the TI group (adjusted RD, 8.3% [95% CI, 6.3% to 10.2%]). However, patients randomized to receive TI were less likely to receive advanced airway management (3419 of 4404 patients [77.6%] vs 4161 of 4883 patients [85.2%] in the SGA group). Two of the secondary outcomes (regurgitation and aspiration) were not significantly different between groups (regurgitation: 1268 of 4865 patients [26.1%] in the SGA group vs 1072 of 4372 patients [24.5%] in the TI group; adjusted RD, 1.4% [95% CI, -0.6% to 3.4%]; aspiration: 729 of 4824 patients [15.1%] vs 647 of 4337 patients [14.9%], respectively; adjusted RD, 0.1% [95% CI, -1.5% to 1.8%]).
CONCLUSIONS AND RELEVANCE
Among patients with out-of-hospital cardiac arrest, randomization to a strategy of advanced airway management with a supraglottic airway device compared with tracheal intubation did not result in a favorable functional outcome at 30 days.
TRIAL REGISTRATION
ISRCTN Identifier: 08256118.
Topics: Aged; Aged, 80 and over; Airway Management; Allied Health Personnel; Cardiopulmonary Resuscitation; England; Female; Glottis; Humans; Intubation, Intratracheal; Male; Middle Aged; Out-of-Hospital Cardiac Arrest; Survival Rate; Treatment Outcome
PubMed: 30167701
DOI: 10.1001/jama.2018.11597 -
BioMed Research International 2015
Topics: Airway Management; Airway Resistance; Emergency Medicine; Humans; Intubation, Intratracheal; Respiration, Artificial
PubMed: 26199941
DOI: 10.1155/2015/425715 -
JAMA Aug 2018Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with... (Comparative Study)
Comparative Study Randomized Controlled Trial
Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.
IMPORTANCE
Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown.
OBJECTIVE
To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA.
DESIGN, SETTING, AND PARTICIPANTS
Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017.
INTERVENTIONS
Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals.
MAIN OUTCOMES AND MEASURES
The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events.
RESULTS
Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%).
CONCLUSIONS AND RELEVANCE
Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02419573.
Topics: Aged; Airway Management; Cardiopulmonary Resuscitation; Cross-Over Studies; Female; Humans; Intubation, Intratracheal; Larynx; Male; Middle Aged; Out-of-Hospital Cardiac Arrest; Survival Rate; Treatment Outcome
PubMed: 30167699
DOI: 10.1001/jama.2018.7044 -
British Journal of Anaesthesia Jul 2020
Topics: Airway Management; Emergencies; Humans; Trachea
PubMed: 32402374
DOI: 10.1016/j.bja.2020.04.008 -
Acta Clinica Croatica Apr 2023Neurosurgical patients have specific airway management. Various conditions and diagnoses make intubation difficult and may also cause neurological damage. Spinal... (Review)
Review
Neurosurgical patients have specific airway management. Various conditions and diagnoses make intubation difficult and may also cause neurological damage. Spinal pathology, neurotrauma, cervical spine surgery, and pituitary gland surgery are just some examples. The aim of this review article is to present a broad spectrum of neurosurgical operations and potential complications in maintaining airway patency related to these issues. Quality perioperative preparation is a prerequisite to avoid the potentially irreversible consequences of difficult airways with a poor neurological or even fatal outcome. Patients with tumors of the pituitary region who present with Cushing's disease are prone to difficult ventilation, tracheal obstruction and difficult intubation. Awake craniotomy is also a challenge for the anesthesiologist, given that access to the airway is problematic due to the fixed frame. Unstable cervical spine occurs in cases of rheumatoid arthritis or blunt trauma, requiring precautions to be taken with spinal stabilization during intubation and induction. Pharyngeal edema and hematomas, possible complications of cervical spine surgery can endanger airway patency after extubation; postoperative patient supervision is thus required. Due to the potential threat to the patient's airway during neurosurgical procedures, quality anesthetic preoperative preparation is necessary to avoid irreversible damage and death.
Topics: Humans; Airway Management; Neurosurgical Procedures; Anesthesia; Intubation, Intratracheal; Neuroanesthesia
PubMed: 38746598
DOI: 10.20471/acc.2023.62.s1.15 -
Intensive Care Medicine Dec 2017
Topics: Airway Management; Humans; Intensive Care Units; Intubation, Intratracheal; Monitoring, Physiologic; Respiration, Artificial; Respiratory Insufficiency
PubMed: 29082415
DOI: 10.1007/s00134-017-4982-y -
Critical Care (London, England) Aug 2018After cardiac arrest a combination of basic and advanced airway and ventilation techniques are used during cardiopulmonary resuscitation (CPR) and after a return of... (Review)
Review
After cardiac arrest a combination of basic and advanced airway and ventilation techniques are used during cardiopulmonary resuscitation (CPR) and after a return of spontaneous circulation (ROSC). The optimal combination of airway techniques, oxygenation and ventilation is uncertain. Current guidelines are based predominantly on evidence from observational studies and expert consensus; recent and ongoing randomised controlled trials should provide further information. This narrative review describes the current evidence, including the relative roles of basic and advanced (supraglottic airways and tracheal intubation) airways, oxygenation and ventilation targets during CPR and after ROSC in adults. Current evidence supports a stepwise approach to airway management based on patient factors, rescuer skills and the stage of resuscitation. During CPR, rescuers should provide the maximum feasible inspired oxygen and use waveform capnography once an advanced airway is in place. After ROSC, rescuers should titrate inspired oxygen and ventilation to achieve normal oxygen and carbon dioxide targets.
Topics: Airway Management; Cardiopulmonary Resuscitation; Heart Arrest; Humans; Respiration, Artificial; Resuscitation
PubMed: 30111343
DOI: 10.1186/s13054-018-2121-y