Portal de Periódicos da CAPES

Welcome to the era of universal airway management

2020; Wiley; Volume: 75; Issue: 6 Linguagem: Inglês

10.1111/anae.14998

1365-2044

N. Chrimes, A. Higgs, John C. Sakles,

Foreign Body Medical Cases

The landscape on which airway management is practised is rapidly changing. Anaesthetists are no longer perceived to have sole ownership of the airway. Although global practice varies, clinicians across several specialties now independently undertake, and often have great expertise in, airway management. Concurrently, the expanding array of equipment means it is increasingly difficult for individual clinicians to maintain proficiency in the entire suite of available airway management techniques and devices. Even among anaesthetists, this has raised questions regarding what constitutes the core skills expected of every airway operator 1. In recent years, there has also been an emphasis on all airway operators maintaining the technical skills required to rescue a cannot intubate, cannot oxygenate (CICO) situation using a front-of-neck approach 2-5. This has lead clinicians primarily involved in approaching airway management from above the glottis, into the domain of surgeons. Perhaps, above all, recognition of the contribution of human factors to effective airway management demands that different professional groups are able to work together and anticipate each other's needs in a timely fashion 2, 6, 7. This necessitates collaboration, not only with airway operators from different clinical backgrounds but also with the clinicians who work as airway assistants. Human factors considerations also require input from human factors experts, who may not always be clinicians, to refine aspects such as equipment design, environmental layout, language, processes and culture 7, 8. In short, collaboration between multiple individuals, each with distinct areas of expertise, is essential to the development and implementation of effective approaches to modern advanced airway management. The best interests of patients will not be served by individual clinician groups operating in silos. Fortunately, global digital technology, the internet has enabled unprecedented interaction between airway management clinicians around the world. This interaction between clinicians from a diverse range of backgrounds, geographies and specialities represents an enormous opportunity but can also breed division. Benefitting from the perspectives and expertise of this spectrum of individuals can be impeded by the assumption that each group faces challenges that are fundamentally different, and that their skills, knowledge, experience and insights are not transferrable. Yet, although varied clinical settings might make specific airway management decisions more or less likely, logic dictates that the underlying principles that inform these decisions must remain constant. Defining these core underlying principles can facilitate exchange of expertise between the myriad of individuals contributing to airway care, encourage greater consistency across specialty boundaries and make airway management safer. The term 'universal' has been used to describe an approach to airway management, founded on these unifying principles, that is not only internationally consistent but can be applied independent of level of training, discipline or context – including in both routine and emergency settings 6. The Vortex Approach 6, 9 (see http://www.vortexapproach.org) was the first airway resource specifically developed to be used as a universal tool. However, although the Vortex Approach is intended to complement existing guidelines, it is not a guideline in itself – it is an 'implementation tool' that prompts potential airway management options in real time. In contrast, guidelines are 'foundation tools', more detailed documents intended to be consulted before embarking on airway management 3, 6, that inform the choices between these options. In a recent issue of Anaesthesia, Edelman et al. presented a review identifying 38 airway 'algorithms' and their associated guideline documents 10. The majority of these purport to be tailored approaches to meet the needs of a particular subset of airway operators in various countries, disciplines and subspecialty areas of practice. These include a smorgasbord of algorithms for anaesthesia, emergency medicine, intensive care and pre-hospital providers directed at managing adults, children, pregnant women, trauma and critically ill patients requiring tracheal intubation and extubation. This creates a situation in which even a single specialty group may require proficiency in several different algorithms. For instance, a UK-based District General Hospital anaesthetist manages airways in the operating theatre in adults, children and pregnant women and in critically ill adults and children anywhere in the acute hospital setting – and as such has to be familiar with the respective algorithms for each of these contexts. Conversely, such a practitioner may be presented with a pregnant woman who is critically ill following major trauma. Which algorithm now applies? Strikingly, the review by Edelman et al. also exposes a major omission in the existing airway management guidelines: the overwhelming majority exclusively address the clinical situation in which the intended airway is a tracheal tube and cannot be directly applied when the plan is to place a supraglottic airway. The multiplicity of airway algorithms is both a cause and effect of the professional silos clinicians currently occupy: Having different algorithms for specific clinical contexts reinforces the erroneous notion that the issues encountered and/or the strategies to address them are unique to each context, deterring collaboration. This lack of collaboration perpetuates the development of context-specific algorithms. Yet even as they survey the crowded field of 'unrelated' guidelines, Edelman et al. discern a significant underlying commonality in the approach each of them advocate. Recognising how this fragmented context-specific advice might compromise effective care, they call for a single universally endorsed algorithm for airway management. As members of the working group for the Project for Universal Management of Airways (PUMA, http://www.UniversalAirway.org), an initiative directed at defining universal principles for airway management, we strongly support that call. Some readers will lament the solution to the perceived problem of too many guidelines being 'yet another guideline', but it should be emphasised that PUMA is intended to be a unifying project that complements existing guidelines. Although it will extend the scope of current recommendations to address new areas on which some or all of the existing guidelines have been silent, every effort has been made to avoid it being in conflict with any existing guideline recommendations. Instead, the goal is to reconcile these apparently disparate documents and provide simplicity and clarity by emphasising common principles that transcend the specific context in which airway management is conducted. Such a universal approach 11-13 could provide a platform for collaboration between all airway clinicians. In isolation, however, a universal guideline is likely to be insufficient to achieve a truly universal approach to airway management and attention to other domains is necessary. The advantages of exchanging ideas, knowledge and experience between clinicians from diverse backgrounds seem intuitive. However, if not conducted with humility and respect, such interactions often entrench existing silos and promote tribalism. Consider social media forums: productive dialogue certainly occurs, but anonymity and restricted word counts can predispose to misunderstanding, antagonism and reductive binary debates, stripped of the contextual nuances which permit reasonable people to legitimately hold different opinions. Alternatively, face-to-face interactions in both formal and informal settings better support genuine cross-fertilisation and in this way the shift to universal airway management is already underway. Specialist airway societies are traditionally anaesthesia dominated but are increasingly engaging clinicians from intensive care, emergency medicine, surgery and pre-hospital backgrounds. The newly formed Australian and New Zealand Safe Airway Society warrants particular mention due to its involvement, at an executive level, of physicians, paramedics and the nurses and other practitioners who work as highly skilled airway assistants. Multidisciplinary conferences such as Social Media and Critical Care (SMACC) and the World Airway Management Meeting (WAMM) have further enhanced the global interaction between different disciplines. These forums provide opportunities to share not only technical knowledge but also to address teamwork considerations that can make airway management safer. Yet despite the emphasis on teamwork, the content offered by many airway conferences is directed solely at the airway operator (particularly physicians) and not the practitioners from other backgrounds who work alongside them as airway assistants. It is worth emphasising that 'exchange of ideas between airway clinicians' is not merely code for 'anaesthetists guiding the practice of other disciplines' – the benefits run both ways. Intensivists and emergency physicians were using peri-intubation apnoeic oxygenation techniques many years before high-flow humidified nasal oxygen was adopted into anaesthetic practice 14. Similarly, the concept of 'priming' for emergency front-of-neck-airway (FONA), which encourages structured, pre-emptive escalations in readiness to perform emergency FONA before a declaration of CICO, has its origins in emergency medicine (see http://i1.wp.com/emcrit.org/wp-content/uploads/2014/08/criccon2.png). Priming has since been incorporated into the Vortex Approach 6, 15, the Australian and New Zealand College of Anaesthetists transition document 4, 5 and the Difficult Airway Society (DAS) 2018 guidelines for intubation of the critically ill 11. Collaborative interactions between airway clinicians should not be restricted to those specialising in management of the airway from above. 'Upper airway' clinicians can benefit greatly from the expertise of otolaryngologists in accessing the airway via the front-of-the-neck. However, although surgeons may have significant experience with elective or semi-elective FONA, most rarely perform this procedure in the setting of acute airway obstruction (emergency FONA). Extensive emergency FONA training programmes 16 mean that upper airway clinicians are increasingly becoming the most expert in the specific techniques for restoring alveolar oxygen delivery via the front-of-neck in time-critical CICO emergencies. As such, it may not necessarily be appropriate for the upper airway clinician to automatically defer to the otolaryngologist during a CICO event. Interprofessional collaboration is required to optimally coordinate the technical and contextual expertise of airway practitioners from different backgrounds to ensure appropriate technique and role allocation when a CICO incident arises. This approach is perhaps best exemplified by formalised difficult airway response team 17. Shared training opportunities between disciplines, both within and between different airway specialties, provide another valuable vehicle for professional interaction. In addition to the educational content provided, such sessions also allow participants to foster professional relationships outside the clinical setting. When conducted 'in house', involving clinicians who may potentially work together clinically, inter-professional training can enhance familiarity with individuals, equipment and environments as well as positively impact workplace culture 18 with the potential for improved patient care. The 4th UK National Audit Project (NAP4) 2 gathered data on complications of airway management from across all airway disciplines. Its analysis identified divergent practice between specialties and has prompted significant changes in access to difficult airway trolleys, as well as the peri-intubation use of capnography and airway checklists, that have helped close this safety gap 19. Still, discrepancies between disciplines persist with respect to practices such as the use of audible pulse oximetry (SpO2) tones, modulation of the SpO2 tone with desaturation and end-tidal oxygen monitoring during airway management. Numerous inconsistencies can also be identified in the availability and use of airway equipment between different clinical settings. The self-inflating bag-valve-mask (BVM) has become a ubiquitous ventilation device for use by airway clinicians outside of anaesthetic practice. However, apart from the pre-hospital or patient transport environment, where importantly it provides the ability to continue ventilation in the absence of an oxygen source, the BVM offers no obvious benefit to offset its variable inspired oxygen concentration 20, 21 and impaired ability to detect mask leaks, gauge lung compliance and accurately assess the effectiveness of ventilation compared with the collapsible bags used in anaesthetic practice. The basis for this variation in practice would appear to be more cultural than practical in nature. Equally, small diameter microlaryngoscopy tubes useful to facilitate tracheal tube passage across a narrowed glottis are widely available in anaesthetic settings, but almost unheard of elsewhere. Recently, considerable emphasis has been given to optimising and standardising not only the type but also the presentation, of airway equipment across different clinical environments 2, 7. Reducing variation in non-familiar locations has obvious benefits in crisis management. In Australia and New Zealand, emergency FONA kits are not only standardised but have been moved from centralised difficult airway trolleys to become point-of-care kits, kept at the bed-side in every anesthetising location 22. The benefits of this approach have been proposed to extend beyond just the improved proximity of equipment 7. A universal approach to airway equipment would not dictate that all areas necessarily employ identical equipment and layout, but rather ensure that all areas select and present equipment according to consistent principles, such that any differences reflect genuine variations in need. The absence of equipment in one area that is viewed as important in another area should be a deliberate choice, founded on clinical evidence or at least logical rationale, rather than lack of awareness of the differences between, or availability of, devices. Edelman et al's review also notes the miscellany of terms used in guidelines, especially those referring to the emergency procedure for urgently accessing the airway via the anterior neck to restore alveolar oxygen delivery in CICO events 10. The current dominant term in the literature, emergency or eFONA, is vulnerable to having the 'emergency' prefix dropped for expediency. This may mean that operators fail to distinguish between front-of-neck procedures appropriate for time-critical CICO emergencies and those more time consuming FONA techniques (e.g. surgical tracheostomy) only suitable in contexts where alveolar oxygen delivery from above remains possible. That the acronym 'eFONA' is incomprehensible to the uninitiated and only decipherable to English-speakers also weakens its universality 23. A recent survey of anaesthetists 22 found the dominant term to be 'emergency cricothyroidotomy', suggesting a disconnect between the terminology of the literature and the clinical environment. These issues are not unique to emergency FONA terminology. Lack of precision and consistency of terms for patient positioning, videolaryngoscope blade geometry and classification of supraglottic airways have implications not only for airway management but also research. By engaging with clinicians, journals and airway societies internationally, a current DAS initiative is striving to achieve terminology consensus rather than simply add to the volume of alternative terms and the potential for confusion this creates. The prospective benefits of a universal approach to airway management are obvious and such an approach has been gaining momentum for several years. The effort and expense of organising the extensive international collaborative interactions necessary to produce universal consensus would once have been prohibitive but the internet now allows groups of well-informed, although geographically disparate, clinicians to explore concepts and technical details in real time, almost at will. The only limitations are their availability and the reality that prime time somewhere in the world is night time somewhere else. Thus, as we enter the third decade of the 21st century, the time has come for the disciplines involved in airway management to adopt a more deliberate focus on working collaboratively and seeking opportunities for mutual learning: Welcome to the era of universal airway management. NC is the creator of the Vortex Approach but has no financial interest in this material which is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. NC is also the project lead for the Project for Universal Management of Airways and the co-founder of the Safe Airway Society. NC's partner is employed by Verathon, Inc. AH is the Treasurer of the Difficult Airway Society, a board member of the Safe Airway Society and a member of the Executive Committee of the Project for Universal Management of Airways. He has received an honorarium from Cook Medical. JS is a Consultant to Verathon, Inc and is a member of the Working Group for Project for Universal Management of Airways. The Project for Universal Management of Airways receives no external funding. No other competing interests declared.