Last week I had the opportunity to attend the 3rd North West Airway Meeting, hosted at the Manchester Royal Infirmary. As well as the chance to listen to some excellent speakers and catch up with people from across the region, I was also lucky enough to have been invited to talk a bit about NWRAG and our upcoming projects (as well as to present an interesting case that I had been involved in). With the focus of the day, rather unsurprisingly, being about all things airway, I hope that these notes highlight some of the interesting points.
Opening
Dr Zuokumor opened the programme with an interesting case report on a case of difficult airway management. It was a nice reminder that there is still nothing quite as good at getting the pulse going than hearing an unfolding story of a progressively difficult airway. The story involved a presentation of a patient with an undifferentiated neck mass that caused quite significant challenges with intubation, included progressive airway bleeding. Perhaps the key differentiating feature of this case was the ability to maintain bag-mask ventilation throughout the case. This really is such a factor in separating the slightly sweaty scenario from the true ‘brown trousers’ one. For me it was fascinating to hear about the use of an awake mask ventilation test, using remifentanil as sedation before a ‘check’ if mask ventilation was possible. However, as noted by Dr Zuokumor, this may have provided him with some false reassurance about the ability to manage with intubation. The use of an awake fibreoptic intubation remains an important option for cases like this, although still remains an imperfect solution. Indeed, the discussion at the end described a case of airway abscess rupture during AFOI, and a subsequently progressively more challenging airway - a worrying reminder that it isn’t always the safest way to manage an airway. Other key important factors identified included the importance of asking for help and the major benefits of having a clear plan in place beforehand to respond to difficulties (learning points that were repeated through the day).
Awake Videolaryngoscopy
Dr Andrew Smith was next, coming down from Lancaster to give an excellent talk about awake videolaryngoscopic (VL) tracheal intubation that followed on nicely from the initial case. Now this is an approach to airway management that I have not yet encountered in clinical practice, although I have seen some comment about it online and discussed the idea with colleagues. Dr Smith delivered a very interesting opening by prompting us to think a bit about how we actually make decisions. As I am sure many of you will know, we are far from perfectly rational beings so this raises some interesting questions around airway management. A case report he presented from NAP4 highlighted how the two anaesthetists involved in a case had completely different management plans, both of which many of us could imagine arriving at ourselves, but of which one had a disastrous outcome. It therefore seems that our decision making is based upon factors other than carefully thought through reasoning, and potentially more on things such as personality, recent experience, current environment and even what is the least effort (let’s just stick in an LMA…).
The link to the topic was that some features of awake fibre optic intubation (AFOI) may be acting as a barrier to its use because of how it feeds into our decision making. Because of its relative unfamiliarity to a number of anaesthetists, as well as the often perceived undesirability for the patient, there may often be enough to convince practitioners that it actually isn’t needed, even in cases when an awake approach probably would be safer. This is compounded by some of the recognised challenges that we have for adequately assessing the airway preoperatively. This is highlighted nicely in this Cochrane review (here) that shows how, although the specificity of many of the airway assessment tests is pretty good, the sensitivity is not. This isn’t really what we would desire in a screening test.
One of Dr Smith’s points was that the use of awake VL may not share some of these drawbacks of AFOI. I think we are all becoming increasingly comfortable with VL, including more than one brand, and so this moves it quite a bit closer to routine practice. If you are interested in reading more about this technique, it is described in an article in the RCOA Bulletin last year (here). Is there much evidence about using it? Well this paper (here) describes a bit more about the comparison of VL with AFOI and doesn’t really identify a clear difference. Overall, this does seem like a very interesting alternative approach to the difficult airway. Although there are some clear limitations (impaired mouth opening is going to be pretty insurmountable challenge), the generally increased familiarity of anaesthetists with VL is advantageous. And the rest of the technique is not that different from AFOI. I did get Dr Smith’s point that this is a skill set that may be easier to develop and maintain that AFOI for anaesthetists outside of major ‘airway’ centres, and as such can serve as a very useful tool for those cases of a potentially difficult airway.
The link to the topic was that some features of awake fibre optic intubation (AFOI) may be acting as a barrier to its use because of how it feeds into our decision making. Because of its relative unfamiliarity to a number of anaesthetists, as well as the often perceived undesirability for the patient, there may often be enough to convince practitioners that it actually isn’t needed, even in cases when an awake approach probably would be safer. This is compounded by some of the recognised challenges that we have for adequately assessing the airway preoperatively. This is highlighted nicely in this Cochrane review (here) that shows how, although the specificity of many of the airway assessment tests is pretty good, the sensitivity is not. This isn’t really what we would desire in a screening test.
One of Dr Smith’s points was that the use of awake VL may not share some of these drawbacks of AFOI. I think we are all becoming increasingly comfortable with VL, including more than one brand, and so this moves it quite a bit closer to routine practice. If you are interested in reading more about this technique, it is described in an article in the RCOA Bulletin last year (here). Is there much evidence about using it? Well this paper (here) describes a bit more about the comparison of VL with AFOI and doesn’t really identify a clear difference. Overall, this does seem like a very interesting alternative approach to the difficult airway. Although there are some clear limitations (impaired mouth opening is going to be pretty insurmountable challenge), the generally increased familiarity of anaesthetists with VL is advantageous. And the rest of the technique is not that different from AFOI. I did get Dr Smith’s point that this is a skill set that may be easier to develop and maintain that AFOI for anaesthetists outside of major ‘airway’ centres, and as such can serve as a very useful tool for those cases of a potentially difficult airway.
The Vortex Approach
The final session of the morning was the debate on the Vortex model. Similar to my experience with awake VL, I will confess that the vortex approach to managing the difficult airway is not one that I was particularly familiar with before today. Now I had seen it pop up regularly on Twitter and in the literature, but I was always pretty happy with the Difficult Airway Society (DAS) Guidance; this being the algorithm that I had regularly trained with for a ‘can’t intubate, can’t oxygenate’ (CICO) scenario.
The proside of the debate was well argued by Dr Pete Groom. The advantages described related to many of the human factors that are at play in the horror-show of a CICO scenario. The model of the Vortex can supposedly improve this team communication, providing a shared model for the whole team to work with. The visual representation of the Vortex, along with the prompts included alongside it (suction, neuromuscular blockade, adjuncts). The simulation training he had done with the team as his local site had shown positive results in terms of performance and participant satisfaction with this approach.
Professor Akbar Vohra led the ‘con’ side of the debate. A key opening point was that the DAS CICO guidance still fulfilled many of the advantages ascribed to Vortex. He went back through a number of the previous work on CICO over previous decades and the majority of the messages were the same: recognition of the human factors, train at the basics, prepare appropriately. He argued that the focus of learning should be elsewhere in the process, such as focusing on developing expertise in the core skills involved in airway management. Be a reflective learner, identifying how you can develop competencies to the point of mastery so that these can make the difference in outcome. If you need to use a CICO algorithm, finding a fancy new one is pointless, as this is probably not where the benefits arise. The benefits are more to be gained from not getting there in the first place, and if you do find yourself there, the Vortex model has no clear benefits over the others, such as DAS.
My personal impression is that the Vortex approach doesn’t add much above the DAS algorithm, and being someone who has had most of my CICO training based around this, I don’t see the justification for a change. Having a suitable approach is clearly essential, but I worry that trying to change this approach risks adding additional variability in practice, for little extra benefit, which in itself my impart risk. I will admit that I have no direct experience with using it, and I may find that if I get chance to do simulation with it I will be converted by its practical benefits. Indeed, if we could start again from scratch I appreciate that the Vortex approach is valid, but that is not the current state of things. I will look into it some more when I get chance, but I have just not been able to be convinced of the clear benefit above what we already have.
The proside of the debate was well argued by Dr Pete Groom. The advantages described related to many of the human factors that are at play in the horror-show of a CICO scenario. The model of the Vortex can supposedly improve this team communication, providing a shared model for the whole team to work with. The visual representation of the Vortex, along with the prompts included alongside it (suction, neuromuscular blockade, adjuncts). The simulation training he had done with the team as his local site had shown positive results in terms of performance and participant satisfaction with this approach.
Professor Akbar Vohra led the ‘con’ side of the debate. A key opening point was that the DAS CICO guidance still fulfilled many of the advantages ascribed to Vortex. He went back through a number of the previous work on CICO over previous decades and the majority of the messages were the same: recognition of the human factors, train at the basics, prepare appropriately. He argued that the focus of learning should be elsewhere in the process, such as focusing on developing expertise in the core skills involved in airway management. Be a reflective learner, identifying how you can develop competencies to the point of mastery so that these can make the difference in outcome. If you need to use a CICO algorithm, finding a fancy new one is pointless, as this is probably not where the benefits arise. The benefits are more to be gained from not getting there in the first place, and if you do find yourself there, the Vortex model has no clear benefits over the others, such as DAS.
My personal impression is that the Vortex approach doesn’t add much above the DAS algorithm, and being someone who has had most of my CICO training based around this, I don’t see the justification for a change. Having a suitable approach is clearly essential, but I worry that trying to change this approach risks adding additional variability in practice, for little extra benefit, which in itself my impart risk. I will admit that I have no direct experience with using it, and I may find that if I get chance to do simulation with it I will be converted by its practical benefits. Indeed, if we could start again from scratch I appreciate that the Vortex approach is valid, but that is not the current state of things. I will look into it some more when I get chance, but I have just not been able to be convinced of the clear benefit above what we already have.
I was (just slightly) reminded of this comic from XKCD, which I hope you might like.
A link to some further reading on the Vortex Approach is available here.
A link to some further reading on the Vortex Approach is available here.
Research
The afternoon session opened with a short session looking at the topic of research. Dr Gaby Land presented on her investigation into the use of THRIVE in ECT. Even though it is still not fully understood, the use of ECT is on the rise. A small number of these procedures have complications, although the incidence has decreased. It is well recognised that ECT anaesthesia can be challenging due to the remote site nature, as well as the comorbidity that may accompany the mental illness that are the indications for ECT. In addition, there may be an improved ‘seizure quality’ arising from higher oxygen levels. These features suggest possible benefits from the use of THRIVE, by optimising the patient’s oxygenation, reducing alveolar collapse (potentially important in patients having repeated procedures), and reducing the risk of desaturation. Despite the initial discomfort that is often associated with just leaving a patient apnoeic (I know what she means) the results have been promising and are worth keeping an eye out for in the future. Dr Naomi Fleming also gave a short presentation about a project that she is currently looking at in the region around the idea of consent in anaesthesia. I find this a very interesting area given the challenges of getting informed consent on the morning of surgery when the anaesthesia is about facilitating their actual interventional decision. This will be a project to look out for in the near future.
Whilst I won’t go on about it much here, I was very grateful to have the opportunity to attend on behalf of NWRAG and present an update on current and future projects. If you are trainee in the Northwest and have any sort of interest in QI, research and/or audit work, be sure to visit our website to see what activities are going on and what opportunities there are for getting involved. The key one to let you know about is our current project aiming to better explore how we assess frailty in our patients perioperatively (if we do). It’s led by Dr Ananya McCarthy and at the current stage is a fairly straightforward survey investigating clinician understanding of frailty and exploring the systems in place at different sites. We have a number of local leads taking this forward at most sites across the region, but If you haven’t yet heard about this and are keen to get involved please get in touch through our website.
Whilst I won’t go on about it much here, I was very grateful to have the opportunity to attend on behalf of NWRAG and present an update on current and future projects. If you are trainee in the Northwest and have any sort of interest in QI, research and/or audit work, be sure to visit our website to see what activities are going on and what opportunities there are for getting involved. The key one to let you know about is our current project aiming to better explore how we assess frailty in our patients perioperatively (if we do). It’s led by Dr Ananya McCarthy and at the current stage is a fairly straightforward survey investigating clinician understanding of frailty and exploring the systems in place at different sites. We have a number of local leads taking this forward at most sites across the region, but If you haven’t yet heard about this and are keen to get involved please get in touch through our website.
Cases
The afternoon closed with a selection of fascinating case stories. The first talk was from Dr Glyn Smurthwaite as a joint anaesthesia and radiology presentation. This described a variety of challenging airway scenarios, including a massive thyroid mass with tracheal compromise (on top of a mallampati 3, Calder C airway), a traumatic tracheal ‘rupture’, and a retropharyngeal abscess with airway obstruction. Dr Laura Cooper followed with her case of a penetrating airway injury, overlaid by some of the interpersonal challenges of managing an acute problems with a team comprising of a multidisciplinary background, each with different perspectives. Next Dr James Masters presented what is probably the epitome of an anaesthetist’s worst nightmare. A case of acute epiglottitis, in severe respiratory distress in A&E, with an unmanageable airway on the forced RSI, that subsequently progresses to hypoxic cardiac arrest and needing a surgical airway. It was excellent to hear about the effective use of the CICO approach that led to a good outcome, despite the (probably inevitable) emergency surgical airway.
These cases had a few common themes running through them. I think the main one that I want to highlight is that the human factors at play in situations like this are really important. Managing difficult airways, especially with an acute presentation, needs a whole range of non-technical skills, from maintaining situational awareness through to skilled communication within a team. Every time I hear about situations like this I repeatedly think to myself “that would a really good thing to do some simulation on”, and I do think that there are big potential benefits here (although still need to get around to organising anything like this). Whilst some of these skills can really be developed in regular clinical experience, I keep coming across cases which combine a perfect storm of rarity, acuity and ‘speed of disaster’ which makes in my mind makes it harder to apply many of our other skills. I hope to look at simulation in more detail at another time, and given the length of this post already I’ll wrap things up here.
These cases had a few common themes running through them. I think the main one that I want to highlight is that the human factors at play in situations like this are really important. Managing difficult airways, especially with an acute presentation, needs a whole range of non-technical skills, from maintaining situational awareness through to skilled communication within a team. Every time I hear about situations like this I repeatedly think to myself “that would a really good thing to do some simulation on”, and I do think that there are big potential benefits here (although still need to get around to organising anything like this). Whilst some of these skills can really be developed in regular clinical experience, I keep coming across cases which combine a perfect storm of rarity, acuity and ‘speed of disaster’ which makes in my mind makes it harder to apply many of our other skills. I hope to look at simulation in more detail at another time, and given the length of this post already I’ll wrap things up here.
Thank you for reading. I hope there have been a few topic here that have caught your interest and that I have managed to capture the essence of some of the ideas that were being discussed today. And thank you again to the organisers of the meeting for a very interesting day. As always, please leave any comments and thoughts that you have on the topics discussed or any links that you think may be interesting.
BW
Tom
BW
Tom
Links & Further Reading
- The Vortex Approach. http://vortexapproach.org/
- Roth, D. et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev. 2018. https://www.ncbi.nlm.nih.gov/pubmed/29761867
- RCOA. Bulletin 111. 2018. https://www.rcoa.ac.uk/document-store/bulletin-111-september-2018
- Alhomary, M. et al. Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta‐analysis. Anaesthesia. 2018. 73(9):1151-1161. https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14299
- North West Research & Audit Group. www.nwrag.co.uk.
Image courtesy of Turmfalke at Pixabay.com.
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