This is the transcript for an invited talk at the recent Difficult Airway Society (DAS) 2021 virtual conference. It was lovely to be invited and great of the organisers to create a multidisciplinary opportunity for discussion and learning in this area, which can still raise pulses and for which there is still fairly significant variation in practice around the UK.
The talk and references follow below:
Although nothing financial, some brief declarations of interest. I don’t have any specific expertise in acute airway management. My academic interests are centred around venous thromboembolism, coagulopathy and infection. However, I am also a substantive NHS consultant working a full shift pattern as a dual accredited emergency physician and intensivist, in a major trauma and neurosciences centre. So, I suppose I do have an interest in airway management, given that sometimes what I am expected to do upstairs at 3am in critically ill patients, differs quite markedly from what people think I should be doing downstairs in the emergency department during working hours. But my biggest DOI, and I think I should get this off my chest at the start of this talk, is that I personally think emergency airway management in the critically ill patient often needs to be a multidisciplinary undertaking. Because I feel like this, I am a local medical director and instructor on the TEAM course, endorsed by RCOA/RCEM and a big believer in the benefits of an MDT approach to this issue.
I’ve been asked to talk about the UK perspective on learning from airway management in the ED. And so of course, I want to go over some of the advances in understanding, current management and future aspirations in this area. But to start with I think it’s essential that we recognize what we have really learned first and foremost about airway management outside a theatre environment in the critically ill patient over the last 20 years. And the key lesson, is that this is still, and always has been, a risky procedure with a relatively high incidence of adverse events.
One of the many curses of a virtual conference is that I had to record this talk weeks ago, so I am not entirely sure what Professor Cook had to say earlier about NAP4. But I know you have all seen that report, and I suspect he may have referenced the headline findings from their 2011 study – that 1 in 4 major airway events in a hospital are likely to occur in the ED or ICU, and that >30% of those events progress to death or persistent neurological injury. He may also have referred to recent work, a decade later, highlighting some of the ongoing safety challenges in this area. These are results from the INTUBE study, recently published in JAMA and including just under 3000 prospectively captured airway events, with 67% in the ICU and 21% occurring in the ED. The results speak for themselves, I think. But if they don’t speak to you, then the paper can also tell you that any major adverse events conferred a significant increase in the odds ratio for mortality. This is a risky business.
Why is it so risky? Well, it’s worth thinking about that briefly from an emergency medicine perspective. We can talk about the higher rates of reported difficult intubation in this population, conferring a suggestion of anatomical risk. And we are increasingly aware of associated physiological difficulty, which John and I are both planning to discuss. But there are also novel challenges in this cohort who often present or decompensate acutely, for unclear reasons. The first arrow is us in the prehospital environment. Then emergency medicine. Next following an unexpected deterioration in critical care, and last after a thorough preop assessment and a planned surgical procedure. There is more risk to the left, because there is more uncertainty around the index pathology. Does the septic patient have global LV dysfunction and vasoplegia already, which we are about to unmask with induction? Does the trauma patient have bilateral pneumothoraces? Does the patient with suspected SAH already have a Takutsobu cardiomyopathy? Sometimes we just don’t know But sometimes we don’t think about these things, when we could.
There are also significant team dynamics that increase the risk in emergency airway management. Outside a theatre environment, most airway crises will be met by action teams. Individuals may not know each other well. People may be working in unfamiliar environments. High stress levels and acuity could mean limited time for dialogue, preparation, understanding of skill levels and experience. Inexperienced clinicians may be overconfident or may feel forced into rapid action by senior staff with limited accountability. All of these issues are all the more prescient when we have crowded, understaffed hospitals, working within an ongoing respiratory pandemic
So how can we mitigate these risks? What have we learned in the last decade about how to make it better? Lots is the short answer, but 3 is the magic number. So here are 3 topics for discussion today.
- Avoiding Cardiovascular Instability
The first thing nobody asks for but everyone secretly wants in a case of emergency airway management, is notice. This allows maximal opportunity for preparation, cognitive processing and forward planning. Not only does this allow people time to think, but it provides an opportunity for the team to develop psychological safety. No-one wants to admit they have never used your particular type of video laryngoscope in the heat of the moment. But they will tell you if you ask them when things are calm, before the patient has arrived.
We can do this through pre-alerting and preparation time. This is not just about equipment checks. It offers opportunity for a team brief, without which we would never dream of starting a complex anaesthetic case or a percutaneous tracheostomy. Although the evidence base is limited here, work describing the importance of prealerting and the ‘zero point survey’ has been published and discussed at length over the last few years. On a personal note as an ED or ICU consultant about to lead a rapid sequence induction, I find it tremendously valuable to have 5 minutes with my rapidly assembled action team beforehand, in order to ensure I have an acute understanding of skill competence, discuss the expected complications and make sure we all know the likely first plan and rescue measures. A zero-point survey is one of many ways to directly address the risks of error in acute airway management, but you have to make time and room for it.
Prealerting and preparation time also affords a chance to discuss resuscitation strategy, prior to airway intervention. Is anyone in the team trained to do point of care ultrasound in the shocked patient? Systematic review data suggests this is a good way to rule in pathology and identify how best to resuscitate, prior to induction. Do we need invasive blood pressure monitoring and a vasopressor infusion commencing? [4, 5] Is there free fluid in the abdomen of the young trauma patient, suggesting blood may be required? What is the potassium in your elderly patient requiring intubation for acute pulmonary oedema? A thorough clinical assessment also gives you time to carefully consider your induction regimen, tailored to the individual patient in front of you. There is a fine line to tow between ensuring any emergency airway intervention is as safe as it can be, and ensuring it is not overtly delayed. This line can move, depending on the clinical scenario. But there is a line. And we should be thinking about it for every case.
And if we are talking about preparation, we also need to talk about checklists. A recommended intervention following NAP4, highlighted through national guidance and now featuring in cross college frameworks, but one that remains slightly contentious. We found some evidence of benefit following a tongue in cheek short cut systematic review in 2016. Further papers have been more skeptical however, and a systematic review in 2020 including 11 studies and >3000 patients has recently concluded a reduction in hypoxic events (RR 0.75, 95% CI 0.59 to 0.95) but no reduction in mortality. Limited evidence of benefit on clinically relevant outcome measures? Maybe. Evidence of harm? Definitely not. Tricky to study? Absolutely. Any trial of checklist introduction, no matter how clever, has specific issues with regard to a predetermined open label design, Hawthorne effect, likely contamination of the control sample and limited washout if using step wedge design. No one is running a study with a placebo checklist, where you ensure that everyone knows what they are having for dinner, or what they are planning to watch on TV later. Add to that a plethora of national guidelines now recommending use of a checklist, and I’m not sure we’ll get more good data in this area. For me as an individual, practicing this intervention relatively infrequently with an action team, checklists are a good idea and I will continue to use them.
2. Avoiding Severe Hypoxia
Oxygenation prior to any emergency airway procedure and during, are absolutely vital elements of care. If a procedure in this cohort has a 10% risk of critical desaturation, then of course we want to do everything we can to mitigate that. And we have seen some new learning and new evidence in this area over the last decade, which can potentially help, if implemented safely and reliably.
First up is the concept of facilitating preoxygenation in the agitated or distressed critically ill patient. You can of course just ‘get on with things’ while your patient is ripping the mask off and turning blue. But you can also now consider the concept of delayed sequence induction, prior to neuromuscular blockade. This is really just a trendy term simply meaning sedation to facilitate good preoxygenation. But the concept is interesting, although the evidence remains weak. Case series like the one below demonstrate the value of facilitated preoxygenation above simple low flow oxygen measures and also report a low rate of adverse events. Case series during the recent pandemic again highlight this technique as an option, to ensure maximal preoxygenation in the agitated critically ill patient. Not level 1 evidence by any stretch. But worth thinking about, on a case by case basis.
Once our patient has been induced and neuromuscular blockade administered, should we still stand still and wait? Or can we further mitigate the risk of critical hypoxia? Everyone has an urge to do something during this time. Why can’t we do something useful? Conventional teaching has always suggested concerns around increasing the aspiration risk with manual ventilation following rapid sequence induction. Recent evidence has challenged this, through publication of a randomized controlled trial in the New England Journal of Medicine. 401 patients were enrolled to this study and randomized to a manual ventilation strategy or control. The results as presented suggest a significant reduction in critical hypoxia; half the relative risk with ventilation throughout induction, and the NNT to prevent one episode of critical desaturation would appear to be 9. Impressive stuff, but not without caveats. This trial excluded patients who were pregnant or when the treating clinical team lacked equipoise, so we need to be careful with assumptions about generalizability. The authors also don’t report the use of cricoid pressure, NGT placement or gastric decompression prior to randomization. However, in addition to the improvements in oxygenation, the authors highlight no increase in aspiration rates between groups. In fact, there were more aspiration events in the control group. Interesting stuff, already creeping into practice and a welcome distraction for that 1 minute of patient waiting for the onset of neuromuscular blockade.
And then during laryngoscopy, can we mitigate this risk further? Apnoeic oxygenation has had a lot of attention here, based on good proof of concept work and case series data using THRIVE (transnasal humidified rapid insufflation ventilatory exchange) protocols. This is another intuitive intervention – if there is any chance of an oxygen diffusion gradient in your patient’s lungs, then why not fill and keep filling the airways with oxygen? Sud and Patel report generalisable evidence of extended safe apnoea time using this therapy in variable populations, variable patients and variably challenging airways, in a nice editorial. HFNO is becoming readily available in critical care units and in Emergency Departments. There are also nasal cannula round every corner. Is there any reason not to use it? Well, some are skeptical about use in the emergency department citing the potential for interference with adequate preoxygenation strategies, increased droplet transmission and potential for microaspiration. Several trials restricted to individual clinical areas have also failed to demonstrate clear superiority.[12, 13] Some departments don’t stock the kit. However, several systematic reviews and meta-analyses published in 2017 report overall benefits in both an emergency department (1822 cases) and intensive care setting (518 cases), regarding a reduction in critical desaturation events and improvement in first pass success rates.[14, 15] Certainly worth considering for your sicker patients, whether through simple nasal cannula or HFNO as available.
Optimising First Pass Success
This picture is a good introduction to the importance of FPS. And a picture paints a thousand words, as they say…
Personally, I think the key lessons over the last decade, have been mainly about trying to make life easy for ourselves here. Some of the giant process steps in classically described rapid sequence induction have been under increasing scrutiny in the last decade, based on the concept that they may actually make life harder for the team/laryngoscopist, and may not confer the original intended benefit. Of course, MILS and Cricoid pressure are topics worthy of lengthy individual discussion, which we don’t have time for. But I would urge you all to think hard about when you use these elements of care and how you use them, if you do. There is an excellent commentary on MILS published this year in Anaesthesia by Matt Wiles, which asks us to carefully evaluate why we persist with this intervention despite evidence of harm and negligible evidence of benefit. There are lots of pro-con debates on Cricoid Pressure available and we have even seen a randomized controlled trial of Sellicks maneouvre compared to a sham intervention, published in 2019.[18-21] Although there are significant limitations with the design and reporting of this trial, it still gives us data on just under 3500 patients regarding the use of cricoid pressure in a pragmatic clinical setting. An aspiration rate of 1:200 patients within no difference between groups doesn’t fill me with enthusiasm to keep using it. Also, a higher proportion of Grade 3 or 4 laryngoscopy and prolonged time to intubation in the cricoid pressure group, ask hard questions about continuing recommendation within guidelines. As does the now legendary talk from John Hinds on how we would approach cricoid pressure if it was a new drug…
But there have been other lessons on endotracheal tube delivery. Adjuncts such as the Bougie or the stylet seem to now have a fairly robust supporting evidence base, as published in recent years. But which is best? Latimer and colleagues report the bougie to improve first pass success rate in out-of hospital paramedic intubations in a cohort study of 1500 patients. The STYLETO study recently reported the stylet to improve first pass success in a randomized controlled trial of 999 critically ill ICU patients, with an equivalent complication rate. Previous to these studies, Driver et al randomized 757 emergency department patients with any single feature predicting a potentially difficult intubation to endotracheal intubation using a routine bougie, or a stylet. The bougie group had a higher first pass success rate, with an absolute increase of 11%. Interesting. So, which is best? And does it really matter, providing you maintain your skills and competence and are happy with the use of either technique? Cue the next circular discussion over a decade, more trials and a breadth of pro/con debates across a range of journals.
And does any of this matter anyway, if we are using video laryngoscopy? Surely that is the answer to all of our airway problems? Well yes and no, if you look at the evidence. There are clear and obvious benefits to VL regarding shared visualisation, a faster learning curve, improved training opportunities and event recording for debrief. However, the latest evidence on clinical and cost effectiveness has limitations. An overall Cochrane review in 2017 reported no demonstrable benefit in clinically relevant endpoints with VL. The recent MacMAN trial, randomizing critically ill patients on the ICU undergoing endotracheal intubation to DL or VL reported no increase in FPS rates and a higher rate of complications with VL. We looked at the evidence last year, including a recent publication from the ED based NEAR registry (which John will talk more about later) and concluded a probable overall improvement in FPS and reduced oesophageal intubation rates, when VL is used as first line in the emergency department setting.[28, 29] An important caveat to our work though; most of these studies report little difference in first pass success or oesophageal intubation rates when VL is compared with DL in experienced operators. This evidence suggests that when the operator is highly proficient with DL, the gains from adoption of VL may be marginal
And speaking of the laryngoscopist, last but not least, are the eternal questions? Who should be the first operator? Does their base specialty matter? And what do people need to maintain their competence? These are tricky topics for a single slide. But essentially, we now have good UK data to suggest that in the context of a framework that provides opportunity for ongoing competence, the base specialty of the first intubator does perhaps not matter as much as we may think.[30, 31] We also have good data for Australia, regarding the safety of rapid sequence induction delivered within an emergency medicine training network. The US data is most compelling, signaling a high first pass success and minimal complication rate within a national Emergency Medicine service which delivered 95% of over 17,000 ED endotracheal intubations during a 10 year study period. But there are still questions. How many do you need to do before you are competent? Does the initial assessment of competency, enshrined in our ACCS training, transfer equally and robustly to Emergency Departments and Intensive Care Units, and how long is it valid in the absence of ongoing practice? Do we get enough exposure in routine practice to stay competent? This paper by Simon et al suggests that in a North American healthcare system containing 18 ED’s, 25% of ED clinicians had no exposure to tracheal intubation procedures during a calendar year. Assuming the answer is not 0, how many endotracheal intubations do you need to perform or lead per year, to maintain your competence.? The paper from Gillet et al is a mannequin study, but reports high levels of objective proficiency in clinicians performing an average of 3 endotracheal intubations per year, or supervising an average of at least 5 annually. Does that sound like enough to you? I’m not so sure. Which is why many of us do other things to ensure we maintain key competencies in this area.
So, lots of good learning within our 3 main themes over the last decade or 2. And lots of questions that still remain. But if we want to improve patient care, all this learning needs to be embedded in local process. In your system response. So that when it is 2 in the morning, and several theatres are running, and ICU are putting a vascath in, and it is the ST3 in Emergency Medicine left as first responder to the acute airway issue in ED, there are clear supportive guidelines, a framework for practice and support. This is why the MDT approach is so vital, as the situation in which emergency airway management is conducted, is often variable. And this is where choice architecture can create assurance, psychological safety and optimized performance, no matter who is at the top end of the bed.
To do this properly, you need an MDT committee to provide senior leadership and facilitate change. You also need to own the data. Over the last 10 years in response to anecdotal local concerns, we formed a multidisciplinary ED/Anaesthesia/Critical care committee and developed a electronic data collection tool for airway management outside a theatre environment. We then introduced a variety of clinical changes, with monitored response. We have moved from multiple individual drug labels to single patient episode rolls, from glass vials to prefilled syringes and from refridgerated to room temperature muscle relaxants ensuring rapid and reliable ease of access. Finally, we have expanded our aseptic & pharmacy teams leading to eventual creation of a bespoke airway box, stocked and checked by pharmacy colleagues containing a variety of options for rapid sequence induction across a range of pathology. Boxes are now available in all relevant clinical areas. We have also added in supporting local guidance to these boxes and try to continually reinforce best practice through MDT simulation. Our difficult airway trolley is unified throughout the trust. Our resus trolleys were purchased and designed with anaesthetic and critical care input, with a bespoke tagging process. We’ve even bought brightly coloured videolaryngoscopes to make sure they don’t walk out of our emergency department…. This project has led to iterative sustainable change which is now embedded in routine practice, and which we have disseminated through publication.
What about the future?
I think our stakeholder organisations have a fairly clear idea on this in the UK. That emergency airway management outside a theatre environment should be collaborative, not restrictive. This is not really about geography dictating who should be the team leader or primary intubator. This is about how we align our skills to work effectively, safely and provide maximal benefit to our patients. Relevant stakeholders in the UK are already doing this, coming together to describe minimum standards, shared governance structures and aspirations for sustained excellence in care.[36-38]
Our trainees and allied health professional colleagues are also leading the way, through collaborative research initiatives, dual accreditation and integrated training programmes. This is a recent example of pandemic research, delivered through collaboration of three trainee networks and reporting across a range of specialty journals.[39-41]
And of course, the future involves gadgets. It wouldn’t be the future if it didn’t. Oxygenating laryngoscopes. Fibreoptic scopes in the ED. Universal single stylet/bougie devices. QR code guided LoccSIPS and database records. Real time recording of physiology during RSI at the touch of a button, which can facilitate accurate debrief, accountability and ongoing QI work. And I am sure there will be more developments in emergency airway care, and more for us to learn over the next decade.
What I think is really important though, is that we learn it together. So that we provide the same quality of emergency airway care to the sick patient in the anaesthetic room, that we do to the sick patient in critical care, that we do to the sick patient who has just arrived in the emergency department. Most of our trainees already work across multiple clinical areas. A shared mental model of evidence-based care in emergency airway management is the key here. If you have that within your organization, then I would suggest it won’t matter quite so much who is actually doing it within the emergency department.
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