Go-to pros need high level of competency
Anesthesiologists are the go-to professionals for difficult airway management in the hospital, researchers reported. This demand for anesthesia airway services increases the importance of advanced airway training programs to improve the competency of anesthesia providers.
“Here at Vanderbilt we’re regularly called for difficult airways,” noted Brian O’Hara, MD, chief resident at Vanderbilt University Medical Center, in Nashville, Tenn. “I’ve noticed over the course of my residency that patients are getting sicker and the airways more complicated. So a few of us decided to look at our data on prevalence of difficult airways and the fastest way to secure the airway.”
To that end, Dr. O’Hara and his colleagues examined 4,277 complete airway records from a collaborative perioperative database. They found that the total rate of labeled difficult airways was 11%. Among these, there were five failed airways with patient deaths.
Anesthesia personnel responded to 54% of the airway calls. “We were surprised how often anesthesia is called, not just in the perioperative setting, to these difficult airways,” he noted. “So whether it’s in the emergency room or the ICU, we’re getting called—it’s not just around the operating room.”
Of note, anesthesia service labeled only 3% of the airways as difficult, a significantly lower percentage than emergency medicine, surgical and medical services did when responding to the airway emergencies. “So not only do we have a lot of airways that we respond to, [but] we also have a lot of difficult airway patients, which prompts the question of how those airways were secured,” Dr. O’Hara said in an interview with Anesthesiology News.
It was found that the rate of portable video laryngoscopy usage was 4.6%, compared with 6.8% for direct laryngoscopy usage during intubations labeled as difficult airways. “On difficult airways we are, at times, using less sophisticated equipment,” Dr. O’Hara said. “Nevertheless, 24% of the time we are having success after two or more attempts by switching to video laryngoscopy, supporting literature that video laryngoscopy should be available for all responses to emergency airways [Anesthesiology 2013;118:251-270].”
As part of the investigation, the researchers queried the institution’s faculty anesthesiologists and residents about surgical airway management and previous training. Among 88 respondents, they found that only 32% were comfortable performing emergency surgical airway interventions.
“This led us to question whether we need a more formal curriculum, including an airway series that teaches us not only about the use of advanced equipment, such as fiber-optic intubation equipment and video laryngoscope equipment, but also surgical airway management,” Dr. O’Hara said.
The answer, Dr. O’Hara noted, was a resounding yes, which prompted the institution to create the advanced airway curriculum. As part of the course, one resident per month learns advanced airway skills. “We also have an anatomy lab that will better define the anatomy of emergency cricothyrotomies,” he said. “And we’re going to be starting airway simulations, creating scenarios that run residents down the American Society of Anesthesiologists’ difficult airway algorithm. It’s an entire series, with the goal that our residents will end up being true airway experts.” Indeed, previous research has shown that residents who undergo cadaver-based airway instruction increase their level of confidence in performing a cricothyrotomy by 70% (Anesth Analg 2006;103:1205-1208).
“In sum, while it may seem obvious to some people, here we’re proving that anesthesia presence in a large hospital is responsible for the majority of airways, which are becoming more difficult, with sicker patient populations being seen in centers such as Vanderbilt.
“These are settings where you may not have all your equipment available like you do in an operating room,” he added. “So we’re seeing more difficult airways in more remote environments, which means we likely need more formalized training in difficult airways, potentially even surgical intervention training to keep airway management safe for this new patient population.”
Dr. O’Hara originally presented his findings at the 2015 annual meeting of the International Anesthesia Research Society (abstract S-14).