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Major Complications of Airway Management in the United Kingdom

We manage airways day in day out and usually without any issue at all, but then every so often, disaster strikes.

In 2008-2009, led by Drs Cook and Woodall, the ever-diligent team in the NAP 4 Audit set out to see what adverse outcomes were typically being seen with airway management, and whether there were any trends, and importantly - anything we can improve.

Take home messages

  • Expect the unexpected
  • Use the Difficult Airway Society guidelines
  • Surgical front of neck access is scary, but usually works

The Findings and Recommendations

The following points are paraphrased from the specific recommendations in the freely available pdf referenced below:

  • Poor assessment of the airway contributed to bad outcomes
  • Not having a proper airway plan also resulted in worse outcomes
  • Assuming everything is going to be fine is generally a bad idea
Plan for failure
"Insanity is repeating identical behavior and expecting a different result"
- Werner Erhart
  • If something isn't working, change your approach. Repeatedly trying to intubate after failed attempts leads to airway trauma and an even more hostile airway
  • If you're needing to access the front of the neck, scalpel-bougie-tube is the most reliable technique (see below)
Aspiration is the biggest cause of death
  • Of all the major problems occurring as a result of airway (mis)management, aspiration of gastric content, blood or whatever else was hanging around was the leading cause of death. Be clear about fasting status and use RSI when needed.
The landing is riskier than the take off
  • 33% of problems happened during emergence from anaesthesia, and the most common cause of said problems was airway obstruction, often with post-obstructive pulmonary oedema

Be sure to plan for hiccups (as well as actual hiccups) by:

  • Preoxygenating prior to extubation
  • Suctioning the pharynx
  • Inserting a bite block
  • Waiting until the patient is definitely going to protect their airway

If your patient is waking up agitated and is unsafe, there's no shame in doing a go-around by giving some propofol and trying again.

No trace, wrong place

You'll probably have seen this plastered all over social media, and hopefully someone at your trust will have handed you something laminated with something similar written on it at some point.

This is a very simple concept - if there isn't a reassuring ETCO2 trace on the monitor, then it's safest to assume you haven't intubated the trachea.

Even in cardiac arrest, there should still be a steady CO2 reading, even if it is very small.

nuff said.

Front of Neck

I've done it in SIM a few times and that's it, not yet in real life.

It's the scenario we dread and drill - we hope will never come but are ready and waiting for when it does.

"The hardest part of front of neck is the decision to cut"

It's a terrifying prospect but when you need it, it can bail you out of some serious badness.

There are three steps:

  • Transverse stab incision through cricothyroid membrane
  • Twist through 90° (sharp end facing the feet) and insert bougie
  • Slide size 6 cuffed oral endotracheal tube into trachea

In the NAP 4 study, this was pretty much always successful. Techniques such as cannula cricothyroidotomy are specialist and need particular teaching and practice before they become superior to the surgical technique.

Location Location Location
  • More than 25% of airway problems occurred in ED or ICU, and the problems were bigger problems.

Clearly it is likely these patients were more unwell and may have had other issues going on as well, however it is important to recognise the logistic and infrastructure challenges when intubating in an unfamiliar environment.

Take the time to use checklists and ensure you have enough equipment and backup.

Risk factors for airway issues in ICU and ED

  • Identification of at-risk patients
  • Lack of a proper plan
  • Lack of skilled staff
  • Delayed recognition of problems
  • Lack of adequate equipment
  • Failure t0 correctly use and interpret capnography*

*This is thought to have contributed to over 70% of the reported deaths in ICU in NAP 4, and routine use of capnography in ICU is likely to make the biggest difference to patient outcomes.

One of the particular risks on ICU was displacement of tracheostomy, and the inability to effectively re-intubate in time.

Never forget the third rule

If you've thought about a tube, it's time to tube. There were several cases of aspiration where a patient who should almost certainly have been intubated or even RSI'd was managed with a supraglottic device, and a first generation one at that.

Work with your team

There's a particular sense of imposter syndrome, I find, when attempting to intubate in front of an ENT surgeon, knowing full well they'd most likely be vastly more useful than you.

And that's okay.

Use this to your advantage, especially in head and neck surgery with tricky airways - your friendly surgeon may well be able to get you out of a sticky situation if only you ask them for help.

Don't forget the awake tracheostomy under local anaesthesia can be a literal lifesaver.

The Official RCoA video

All I care about is DO2.

Oxygen delivery, particularly to the brain, is the most important fundamental physiological parameter to maintain.

It's very easy to become task focused in medicine, especially in something so immediately high stakes as intubation.

Instead of thinking 'I need to intubate this patient', one should focus on 'I need to oxygenate this patient'. This seemingly subtle distinction becomes very important when you find yourself struggling to slot that tube between the cords.

Free CRQs from

Useful Tweets and Resources

Airway CRQs
Below are all the airway CRQs grouped together: ApnoeaDownload Awake fibreoptic intubationDownload Difficult intubationDownload Jet ventilationDownload Laser for laryngeal surgeryDownload Obstetric…

References and Further Reading

NAP4 Presentation | Difficult Airway Society

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