Strategies for the prevention of airway complications – a narrative review

Abstract

SummaryDespite being infrequent, complications of airway management remain an important contributor to morbidity and mortality during anaesthesia and care of the critically ill. Developments in the last three decades have made anaesthesia safer, and this has been mirrored in the equipment and techniques available for airway management. Modern technology including novel oxygenation modalities, widespread availability of capnography, second-generation supraglottic airway devices and videolaryngoscopy provide the tools to make airway management safer still. However, technology will only take safety so far, and non-technical aspects of airway management are critically important for communication and decision making during airway crises, acknowledging a 'cannot intubate, cannot oxygenate' situation and transitioning to emergency front of neck airway. Randomised controlled trials provide little useful information about safety in this setting, and data from registries and databases are likely to be of more value. This narrative review focuses on recent evidence in this area.

Checking expertise in anticipated difficult airway situations

“…Although predominantly based on patients undergoing cardiothoracic surgery, this review correlates with previous work which showed that ROTEM-and TEG-based transfusion algorithms reduce transfusion requirements and outperform standard coagulation tests in the setting of peripartum and trauma haemorrhage [2,3].…”

“…Awake fibreoptic intubation of a patient with an obstructed upper airway is among the more challenging of airway procedures [1]. A multidisciplinary approach to safe management is essential [2], with an experienced Ear, Nose and Throat (ENT) surgeon immediately available to perform emergency surgical tracheostomy should awake fibreoptic intubation performed by an experienced anaesthetist fail to secure the airway.…”

The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patients

“…Numerous studies have evaluated individual patient‐related risk factors as dichotomous stand‐alone tests for predicting difficult airway management, but with limited overall diagnostic value . Multivariate sum scores, or the combination of several risk factors, gather more information and potentially increase the diagnostic accuracy . Like stand‐alone tests, a multivariate sum score may be used as a dichotomous test with a single cut‐off value to discriminate between easy and difficult airway management.…”

A BRILL idea? The benefits, risks, insights, learning and limitations of an emergency airway registry in pre‐hospital and retrieval medicine

“…Clinical trials can be difficult to conduct in emergency settings due to the diverse caseload, obtaining consent, confounding factors, funding and human factors . It is now recognised that observational data and audit of quality improvement initiatives can lead to substantial improvement in patient care …”

“…12,13 It is now recognised that observational data and audit of quality improvement initiatives can lead to substantial improvement in patient care. 14 With careful planning, consensus can be achieved to allow standardised reporting formats. 15,16 Collaboration and merging of databases can investigate large numbers of patients across multiple different services and countries.…”