This document discusses evidence and recommendations for improving airway management to prevent errors. It notes that evidence for current practices is limited. Data on airway errors comes from case reports, expert opinions, and rare cohort studies. Two key sources of data are the American Society of Anesthesiologists’ Closed Claim Project and the NHS Litigation Authority closed litigation database in the UK. The document recommends practices like using capnography for all intubations, developing intubation checklists, recognizing difficult airway risks and having backup plans, training staff, and conducting regular audits to improve airway management in emergency departments, intensive care units, and other clinical settings.

1. Averting errors in Airway
management
Venugopalan Poovathumparambil
DA,DNB,MNAMS, MEM[GWU]
Director Emergency Medicine
Aster DM Health care

2. Why ?

3. Where ?
• Operation theatre
• Intensive Care Units
• Emergency Room
• Pre-Hospital care

4. Evidence and Source of information
Airway errors
• Limitation of literature
• Structured study is difficult
• RCT are unsuitable
• Date collection and analysis is a challenge

5. Evidence and Source of information
Airway errors
Evidence based data for current airway management is
low in the hierarchy

6. 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

7. Evidence and Source of information
Airway errors
• Critical Incidents data base
• Litigation datasets
• Both
• Sentinel cases

8. 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

9. 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]

10. NAP4 study

11. Critical incident data base

15. Incidence of failed intubation
1 in 1–2000 in the elective setting
1 in 300 during rapid sequence induction (RSI) in the obstetric
setting
1 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 !!!

16. 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

17. Incidence ,Causes and Consequences
of airway difficulty and Failures
• Emergency Surgical airway
• Composite failure of airway
management

18. Major airway complications
Noted
• Death
• Hypoxia
• Obesity
• Aspiration
• Unrecognised Oesophageal
intubation
• Major airway trauma

19. 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

23. How to prevent airway errors in ED ?
Recommendations
from NAP4

24. How to prevent airway errors in ED ?
Recommendations
Capnography
• In all intubations
• All ED
anethestization
• Transfers of
intubated
patients

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

26. One minute
airway check

27. 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

28. 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

29. 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

30. 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

31. 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

32. How to prevent airway errors in ED ?
Recommendations
• Regular audit should take place of airway
management problems or events in the ED

34. Critical Care Unit
How do reduce errors ?

35. 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

36. 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

37. What can be done to improve airway
management in ICU?
Intubation check list - develop and us e in all intubations
in critically ill patients

38. 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

39. 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

40. 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

41. 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

42. 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 ]

43. 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

44. 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

45. 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

46. Paediatric airway
Very special and unique

48. Avoidance of airway complications
Golden tips

49. 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

50. 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

51. 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

52. 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

53. 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.

55. Standard crash algorithm vs Vortex 4
step approach

56. Vortex

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

58. Vortex model

59. Vortex for failed RSI

60. Vortex for non RSI Intubation

61. Vortex for planned spontaneously
breathing anaesthesia

63. Airway management skills-Multifactorial
approach
Focused and integrated various interphases involving
clinical performance

64. Research opportunities
now open in emergency airway management

66. Questions??

67. Thank you so much !!!