Case History

A colleague in your department has had a challenging clinical case where there had been some criticism of the management of a critically ill patient with a known difficult airway who required emergency surgery late at night. The case required securing the airway in critical care before transfer to the operating theatre. During this difficult procedure there was profound haemodynamic instability and brief cardiac arrest. The case review offered feedback that the team assembled did not fully understand the potential difficulty of the clinical situation and were unclear on the intended clinical plan. Your colleague is keen to use this difficult case to improve the processes in your hospital. Drawing on national data, what advice can you offer your colleague?

What Is the Question?

What are the challenges of airway management in the critically ill patient and how could they be overcome?

Discussion

Introduction

This case raises a number of issues identified by the UK 4th National Audit Project (NAP4) of the Royal College of Anaesthetists, which explored the epidemiology and themes underlying major complications of airway management.¹^,² Among these is the context of airway management ‘who does what to whom, when, where and why?’ and the chosen airway strategy adopted – ‘the how?’.

While much attention is focused on the latter, to overlook the circumstances of this case – a critically unwell patient, with a known difficult airway requiring emergency surgery out of hours – would be to ignore the all-important context. NAP4 studied complications of airway management in anaesthesia, Critical Care Unit (CCU) and the Emergency Department. Within these three areas, the CCU was notable for the higher rate of complications, poorest outcomes and the greatest gap between ideal and observed practices. Importantly, NAP4 revealed to us that major complications illustrated in the case above are critically affected by ‘human factors’ at organisational, team and individual levels. If we want to improve processes and safety, we must have a holistic understanding of these complex underlying human factors.

NAP4 – Epidemiology and Recurring Themes

We work in a high-risk setting where our actions may result in significant adverse consequences for our patients. This clinical case presented typifies the high-risk environment often seen in NAP4 and echoes the epidemiological findings and recurring themes that contributed to poor outcome (see Infographic).

Human Factors in Airway Management

Although we are unable to change the complexity of our patients, we are able to change our systems, processes and attitudes to make care safer. Human factors and ergonomics are those factors that influence the behaviour and performance of individuals and teams in interaction with their environment.

They can be readily understood using the concept of error chains, whereby adverse incidents are the product of a combination of ‘latent errors’ within the system (e.g. lack of equipment) and ‘active errors’ (e.g. not administering oxygen). It is short-sighted and inefficient when seeking to reduce harm to focus on (or blame) the individual, for what is essentially an accident waiting to happen. NAP4 identified four main domains that could be improved for safer airway management: the practitioner(s), the environment, the equipment available and preparedness for difficulty.

The Practitioner(s)

NAP4 found that senior practitioners were present in only 36 per cent of CCU incidents at night compared with 80 per cent in the day, suggesting that management is undertaken by more junior staff without direct supervision in the highest-risk emergency patients, who often cannot wait for intervention to be delayed until routine hours. This is exemplified in this case of a physiologically unstable patient with a known anatomically difficult airway who cannot safely be transferred to the operating room without prior resuscitation and medical intervention. Junior medical staff on CCU are increasingly from non-anaesthetic backgrounds. This, and the relative infrequency of complex airway management on CCU, may mean that medical and nursing staff do not have the necessary training or experience in managing these complex patients. This applies not only to ‘airway managers’ but critically also to those assisting (e.g. managing airway equipment, applying cricoid force, etc.). Out-of-hours staffing is usually reduced compared with the day and assembling an appropriate team may be challenging. This may compromise the non-technical skills – the behaviours, interpersonal skills (communication, team-working) and cognitive skills (situation awareness, problem solving) – exhibited by the attending personnel. Overall this may result in poor judgement (the second most common contributing factor to adverse events in NAP4) and communication, leading to lack of understanding among the team, as seen in this case.

Environment

In contrast to the operating theatre, the CCU is rarely designed with airway management in mind. Access to the head end of the patient’s bed may be difficult and the bed itself, monitors and other equipment may all compromise ease of airway management.

Equipment

NAP4 identified major disparities (and deficiencies) between the equipment available in the CCU and Emergency Department compared with the operating theatre. Lack of access to airway equipment such as videolaryngoscopy, supraglottic airway devices or flexible optical bronchoscopy compromises or prevents airway rescue and oxygenation techniques. If complex airway management is to take place in the CCU it is mandatory that the necessary equipment and monitoring are immediately available and that those who may use it are trained in its use. Take a moment to think about the department in which you work.

There are of course significant organisational implications. A conscious effort is necessary to change the system, standardise equipment and provide staff with education and training in its use. Monitoring is equally important: failure to use or correctly interpret capnography contributed to 70 per cent of CCU deaths in NAP4, because of failure to recognise accidental oesophageal intubation or tracheal tube/tracheostomy displacement. Waveform capnography is now routinely used in all patients who are dependent on an artificial airway and those attending must be trained to understand normal and abnormal capnography traces.

Planning for Difficulty (the Strategy)

As any single airway plan or device may fail, safe airway management requires a series of sequential plans, each consequent on the failure of the previous one with clear points at which to transition from one to the next. Together, this forms an airway strategy. This requires recognition of potential difficulty, availability of equipment and staff to execute that strategy and communication of the strategy to the team – before starting.

Difficulty May Be Categorised As

Anatomical – where the patient’s anatomy impacts on conduct and safety of airway management
Physiological – where the patient’s physiology impacts on the safety or options for airway management (e.g. hypoxia) or anaesthesia (e.g. cardiovascular instability)
Logistical – where the environment, equipment or team factors impact on ease of airway management
Educational – where individual or team training impacts on the conduct and safety of airway management

Ways to Improve

Safety in complex airway management requires organisational preparedness and individual preparedness. The former – involving provision of structures, policies, equipment and training – creates the potential for safe care to be provided. The latter – involving personal knowledge of local policies, equipment and training – enables actual delivery of safe care.

Improving structures such as staffing is challenging, but not impossible. For instance, intelligent rostering of staff to ensure that at least one airway-trained person is on shift, and running airway workshops to improve education and training among existing staff. Establishing local policies and relationships between departments (e.g. anaesthesia and CCU) enables them to support each other. Novel multidisciplinary Difficult Airway Response Teams, analogous to Medical Emergency Teams, can be deployed to airway emergencies within the hospital.³

Other issues, such as equipment, have simpler solutions, such as using standardised difficult airway trolleys, now present across most UK CCUs. However, changes in structure alone will be of limited benefit without putting in place processes to improve safety culture, training and education. At a national level these include efforts to improve awareness such as the ‘No Trace = Wrong Place’ campaign by the Royal College of Anaesthetists.⁴ At a local level, use of guidelines and algorithms, such as those produced by the Difficult Airway Society, may empower the team to understand their roles and next steps in an airway emergency (Figure 1).⁵

Figure 1. Difficult Airway Society algorithm for airway management of ICU patients ⁵

Reproduced from Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.⁵

Embedded safety-based processes help to ingrain a safety-conscious mentality into the organisational culture. A good example is the World Health Organization perioperative surgical safety checklist used across the UK, which encourages all team members to address potential areas of patient risk. Similar ‘briefs’ and checklists can act as cognitive aids before other safety-critical procedures such as airway management on CCU (Figure 2). Without such structures, planning and communication rely heavily on the individual and, as in our case, may inadvertently result in the loss of a ‘common goal’ among the team. Providing human factors training through multidisciplinary simulations, using these tools, may also enable practice of infrequently used technical skills.

Figure 2. An example of a checklist for use before undertaking emergency airway management in critically unwell patients.⁵
Reproduced from Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.⁵

Creating a Safety Culture

Improving systems and processes requires us to recognise areas of deficiency, report these (e.g. using incident reporting systems) and respond appropriately. This should occur after serious incidents or ‘near misses’ in order to identify latent risks within the system before they can cause harm. For this to work, events must be reported, and an organisational climate must be fostered whereby the practitioners involved do not feel the agenda is to ascribe blame, but rather feel empowered to speak up in the common interest of patient safety to prevent such events happening again. For example, the clinical case described could usefully be formally reviewed to determine whether there are organisational (and individual) safety gaps that require attention to improve future safety. Numerous tools are available, but those that actively seek to examine the system around the event (e.g. the Yorkshire Contributory Factors Framework ⁶ or NHS ‘Five Whys’ tool ⁷) are likely to promote improved learning compared with those that simply seek to identify a ‘root cause’.

It is uncertain whether in this case technical care was optimal, but what is clear is that communication was not. Cases such as this where the consultant was criticised for their management may hamper honest reflections from those involved – unless the embedded environment is one of open discussion and learning across the entire department (and the organisation). Ensuring regular morbidity and mortality meetings and including case discussions in governance meetings are two ways to foster a culture of constructive dialogue and collaboration. Flattening of hierarchies during such discussions is useful but requires mutual respect from those involved. The aim should be one of constant learning and improvement – individually and organisationally – to reduce the incidence of avoidable harm and improve the reliability of future care.

Conclusion

Reducing complications from airway management requires the creation of a system within which it is less likely that mistakes will be made. There should be a patient-centred safety culture. Part of this is the acceptance that individuals will make mistakes. These are an opportunity to learn and improve.

Video

Article Summary Infographic

Click the infographic preview for an at-a-glance overview of the key points.

Further Learning

Read the latest authoritative guidance on tracheal intubation in critically unwell patients here

Watch Dr Jane Harper’s (Intensive Care Society) presentation about NAP4’s section about airway events in intensive care.

Conflict of Interests

The author/s declares no conflict of interests with this work.

References

1. Cook TM, Woodall N, Frerk C; Fourth National Audit Project. 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. British Journal of Anaesthesia> 2011;106: 617–31.

2. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. 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 2: intensive care and emergency departments. British Journal of Anaesthesia> 2011;106:632–42.

3. Mark L, Lester L, Cover R, Herzer K. A Decade of Difficult airway response team: lessons learned from a hospital-wide Difficult Airway Response Team Program. Critical Care Clinics 2018 Apr;34(2):239–51.

4. Royal College of Anaesthetists. https://www.youtube.com/watch?v=t97G65bignQ&t=

5. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM, Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia> 2018;120(2):323–52.

6. Lawton R, McEachan RRC, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Quality and Safety> 2012;21(5):369–80.

7. National Health Service. https://improvement.nhs.uk/resources/root-cause-analysis-using-five-whys/

Article Information

Title: Airway Management in Critical Care
Author: Shamir Karmali
Publisher: UCL Press
Publication date (Electronic): 31 January 2020
DOI: 10.14324/111.444.9781787356917.03
Copyright statement: © 2020 The Author.
License: This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY) 4.0 https://creativecommons.org/licenses/by/4.0/, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

UCL Press

Case Studies in Perioperative Medicine

Edited by the Centre for Perioperative Medicine, UCL

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