Averting errors in Airway management

Venugopalan Poovathumparambil DA,DNB,MNAMS, MEM[GWU]Director Emergency Medicine

Aster DM Health care

Why ?

Where ?

• Operation theatre

• Intensive Care Units

• Emergency Room

• Pre-Hospital care

Evidence and Source of information Airway errors

• Limitation of literature

• Structured study is difficult

• RCT are unsuitable

• Date collection and analysis is a challenge

Evidence and Source of information Airway errors

Evidence based data for current airway management is low in the hierarchy

Evidence and Source of information Airway errors

• Evidence comprising

• Case reports [Level 4],

• Expert opinion [Level 5]

• Control and cohort studies are rare [Level 3]

• Expert opinions are variable grossly

Evidence and Source of information Airway errors

• Critical Incidents data base

• Litigation datasets

• Both

• Sentinel cases

Evidence and Source of information Airway errors

1. American Society of Anaethesiologists’ Closed Claim Project [ASACCP]- 1991 and 1999

2. NHS Litigation Authority [NHSLA] 1995 to 2007

Closed litigation data base

Evidence and Source of information Airway errors

• Critical incident data base

1. Australian Incident Monitoring Study [AIMS]

2. 4th National Audit Project of Royal College of Anaesthesiologist and Difficult Airway [NAP4]

NAP4 study

Critical incident data base

Incidence of failed intubation 1 in 1–2000 in the elective setting1 in 300 during rapid sequence induction (RSI) in the obstetric setting1 in 50–100 in the emergency department (ED), intensive care unit (ICU),pre-hospital setting.Rate of CICO requiring ESA may rise to 1 in 200 in the ED.

Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway manage- ment in the emergency department: a one-year study of

610 tracheal intubations. Ann Emerg Med 1998; 31: 325–32

The gravity of problem !!!

Incidence ,Causes and Consequences of airway difficulty and Failures

• Tracheal intubation[ DL]

• Face mask ventilation [FMV]

• Laryngeal masks and Supraglottic airways [SAD]

• Video laryngoscopy

• Fiberoptic intubation

Incidence ,Causes and Consequences of airway difficulty and Failures

• Emergency Surgical airway

• Composite failure of airway management

Major airway complications Noted

• Death

• Hypoxia

• Obesity

• Aspiration

• Unrecognised Oesophageal intubation

• Major airway trauma

Averting errors • Poor identification of at risk

patients

• Poor or inadequate planning

• Inadequate provision of skilled staff and equipment to manage these events properly

• delayed recognition of events

• Failed rescue due to lack of or failure of ETCo2

How to prevent airway errors in ED ?

Recommendations from NAP4

How to prevent airway errors in ED ? Recommendations

Capnography

• In all intubations

• All ED anethestization

• Transfers of intubated patients

• Intubation check list - use in all ED intubations[ Preparation of patient, equipment, drugs,Team and back up plans ]

One minute airway check

How to prevent airway errors in ED ? Recommendations

• ED risk assessment - Type of patients , Anticipated airway problems and Plan equipment, training and strategy

• ED equipment to manage anticipatory scenario - Need regular checking, maintenance and replacement after use

How to prevent airway errors in ED ? Recommendations

• Difficult airway trolley - Uniform layout and contents for whole hospital . Need regular checking, maintenance and replacement after use

• Airway comprise : -Secure airway before shifting out of ED, All such shifting are to be made by senior clinician

How to prevent airway errors in ED ? Recommendations

• Establish a robust process to ensure the availability of skilled and senior staff at any time with a reasonable time frame

• Joint training program - Emergency physician anaesthesia and ICU staff

How to prevent airway errors in ED ? Recommendations

• Staff training extra focus : Anticipated clinical presentations, Management of failed intubations ,Emergency surgical airway techniques and airway equipment available in ED

How to prevent airway errors in ED ? Recommendations

• Strong Communication links - Senior ED clinician, Anaesthesia, ICU, ENT surgery ,Other relevant specialities

• Designating consultant leads fro each involved speciality to agree and oversee the management of emergency airway problems in ED

How to prevent airway errors in ED ? Recommendations

• Regular audit should take place of airway management problems or events in the ED

Critical Care Unit How do reduce errors ?

What can be done to improve airway management in ICU?

• Capnography should be used in all intubations

• Continuous capnography should be used in all ICU patients with tracheal tubes [including tracheostomy

• If capnography is not used , reason should be documented and reviewed regularly

What can be done to improve airway management in ICU?

• Clinical staff training to interpret capnography- Identification of airway obstruction, tube displacement ,abnormal capnograph trace during CPR

What can be done to improve airway management in ICU?

Intubation check list - develop and us e in all intubations in critically ill patients

What can be done to improve airway management in ICU?

Recognition of difficulty and back up planning:

A. Algorithms for intubation, extubation and reintubation

B. Patients at risk for airway events - identification and care

C. Plan primary and back up - document ,communicate , additional equipment

D. Hand over and conformation

What can be done to improve airway management in ICU?

Tube displacement

A. Staff education to recognise and emphasis

B. Airway displacement can occur at any time

C. Frequent in Obese , Tracheostomy ,during or after movements , during sedation hold

What can be done to improve airway management in ICU?

Obesity

1. Increased risk for airway complication like tube displacement and harmful events - need meticulous plans

2. Responsible bodies can explore better tube design [Tracheostomy tubes] and optimal mode of fixation

What can be done to improve airway management in ICU?

Airway equipment

A. Immediate access to difficult airway trolly [uniform content and layout ]

B. Need regular checking, maintenance and replacement after use and proper documentation

C. Immediate access to fibroscope

What can be done to improve airway management in ICU?

Cricothyroidotomy

A. Training of staff - regular , manikin based performance, identification of landmarks [obesity ]

B. Research to identify equipment and technique [obesity ]

What can be done to improve airway management in ICU?

Transfers

A. Intra / inter hospital - high risk episode

B. Need airway assessment include patient , equipment, back-up, staff skills

C. Made before transfers

What can be done to improve airway management in ICU?

Staffing

A. Trainee medical staff - proficient in simple emergency airway management

B. Access to senior medical staff with advanced skill at all hours

C. If senior intensivist do not has anaesthesia back ground - need experienced anaesthetic cover to assist difficult cases

What can be done to improve airway management in ICU?

Education and training

A. Junior staff need to get training in basic airway skills , algorithms , predictable airway complications , interpretation of capnography , mechanism to summoning experienced clinician

B. Regular audit on airway problems and critical events

Paediatric airway Very special and unique

Avoidance of airway complications Golden tips

Avoidance of airway complications

Golden tips

• Believe the history and act on a history of previous airway difficulty

• Assess every patient for risk of airway difficulty and aspiration

• Identified risk - ensure the airway strategy- technique , devices and back up plans

Avoidance of airway complications

Golden tips

• Never fail to be prepared for failure - Full preparation involve training , institutional preparedness and personal preparedness

• Do Communicate strategies to team before undertaking

• Do what you can but do not what you cannot - seek help whenever needed , Doing your best is not good enough if your best is not the right thing for the patient

Avoidance of airway complications

Golden tips

• Do not intubate when it is not indicated

• Do intubate when indicated

• Adequate pre-oxygenation

• Know and practice a wide range of airway management skills

Avoidance of airway complications

Golden tips

• Learn techniques you think you will never use - CICO is the biggest disaster in airway management

• If one technique is not working do try different - A technique which fail twice , it is unlikely to succeed and alternative techniques have better chance of success

Avoidance of airway complications

Golden tips

• Do not ever forget the possibility of oesophageal intubation and always confirm with capnography

• Unrecognised oesophageal intubation will cause death and it is 100 percent avoidable

• Treat ICU and ED as places of danger.

Standard crash algorithm vs Vortex 4 step approach

Vortex

Vortex Difficult airway Algorithm Simple ..easy …Visually based cognitive tool

Vortex model

Vortex for failed RSI

Vortex for non RSI Intubation

Vortex for planned spontaneously breathing anaesthesia

Airway management skills-Multifactorial approach

Focused and integrated various interphases involving clinical performance

Research opportunities now open in emergency airway management

Questions??

Thank you so much !!!