Summary Both the American Society of Anesthesiologists and the Difficult Airway Society of the United Kingdom have published guidelines for the management of unanticipated difficult intubation. Both algorithms end with the ‘can't intubate, can't ventilate’ scenario. This eventuality is rare within elective anaesthetic practice with an estimated incidence of 0.01–2 in 10 000 cases, making the maintenance of skills and knowledge difficult. Over the last four years, the Department of Anaesthetics at the Royal Perth Hospital have developed a didactic airway training programme to ensure staff are appropriately trained to manage difficult and emergency airways. This article discusses our training programme, the evaluation of emergency airway techniques and subsequent development of a ‘can't intubate, can't ventilate’ algorithm.

Background: Front-of-neck airway rescue in a cannot intubate, cannot oxygenate (CICO) scenario with impalpable anatomy is particularly challenging. Several techniques have been described based on a midline vertical neck incision with subsequent finger dissection, followed by either a cannula or scalpel puncture of the now palpated airway. We explored whether the speed of rescue oxygenation differs between these techniques. Methods: In a high-fidelity simulation of a CICO scenario in anaesthetised Merino sheep with impalpable front-of-neck anatomy, 35 consecutive eligible participants undergoing airway training performed scalpelefingerecannula and scalpelefingerebougie in a random order. The primary outcome was time from airway palpation to first oxygen delivery. Data, were analysed with Cox proportional hazards. Results: Scalpelefingerecannula was associated with shorter time to first oxygen delivery on univariate (hazard ratio [HR]¼ 11.37; 95% confidence interval [CI], 5.14e25.13; P<0.001) and multivariate (HR¼8.87; 95% CI, 4.31e18.18; P<0.001) analyses. In the multivariable model, consultant grade was also associated with quicker first oxygen delivery compared with registrar grade (HR¼3.28; 95% CI, 1.36e7.95; P¼0.008). With scalpelefingerecannula, successful oxygen delivery within 3 min of CICO declaration and 2 attempts was more frequent; 97% vs 63%, P<0.001. In analyses of successful cases only, scalpelefingerecannula resulted in earlier improvement in arterial oxygen saturations (e25 s; 95% CI, e35 to e15; P<0.001), but a longer time to first capnography reading (þ89 s; 95% CI, 69 to 110; P<0.001). No major complications occurred in either arm. Conclusions: The scalpelefingerecannula technique was associated with superior oxygen delivery performance during a simulated CICO scenario in sheep with impalpable front-of-neck anatomy.

Serious deep neck infections may result in life-threatening airway complications. The aim of this study was to review the management of patients requiring surgical drainage with deep neck infections and to identify possible factors that may predict a greater risk of airway complications. In this study the authors reviewed the notes of patients requiring surgical drainage of deep neck infections who were admitted to Royal Perth Hospital over a seven-year period (2000 to 2007). One hundred and twenty-nine suitable patients were identified, of whom 15.5% encountered airway complications including one death due to airway obstruction. Airway complications were more common if there was no consultant anaesthetist present (odds ratio 4.01 [confidence interval 1.20 to 13.46], P=0.02). Deep neck infections are still relatively common and are associated with significant morbidity and mortality. Patients with deep neck infections represent an anaesthetic challenge which should be managed by those with an appropriate level of experience.

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