jurnal Airway
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Editorials © The Intensive Care Society 2012 Volume 13, Number 2, April 2012 JICS 100 I ntensive care training in the UK is undergoing change. Traditionally, the majority of intensive care medicine (ICM) clinicians were from an anaesthetic background with trainees and consultants receiving specific training and experience in basic and advanced airway management. As ICM becomes a stand-alone specialty with intake of trainees from other acute medical backgrounds, these airway skills can no longer be taken for granted. Advanced ICM trainees require only six months of training in anaesthesia, which could mean that the management of the difficult airway from intubation through to successful extubation will become increasingly challenging for those without advanced airway skills. The recent Royal College of Anaesthetists NAP4 audit aimed to identify and study major complications of airway management in the UK. It described many of these events as likely to have been avoidable, with a disproportionately high number of adverse airway incidents occurring in the intensive care unit (ICU) and emergency department. 1 When compared with ‘anaesthetic’ airway incidents, ICU airway events were more likely to be managed by doctors with less airway experience, occur out of hours and lead to more frequent permanent harm and death. Similar findings are echoed in the report written on behalf of the UK National Patient Safety Agency. 2 Both of these reports highlight an increased risk of airway-related incidents occurring in the obese patient and during patient movement (for physiotherapy, nursing care, invasive procedures and radiological investigations), and that preparation of the patient, environment and equipment is often inadequate. Of note, NAP4 recommends algorithms for the management of extubation and re-intubation, and provides a suggested checklist for intubation and documentation of back- up plans for at-risk airways. We will all experience a serious airway problem during our career, and the themes described above are usually evident, especially in the ICU. Contrast a healthy, anaesthetised, day case patient moved onto the theatre table with four assistants including an anaesthetist holding onto the airway device, with two nurses rolling a critically hypoxic patient in the ICU. Similarly, how many times has the successfully managed patient with a difficult airway been admitted to the ICU for a few days, just long enough for the successful management strategy to become forgotten in an emergency or lost in handover? Harm has resulted from a lack of basic understanding of airway anatomy and procedures, including confusion with tracheostomies and laryngectomies. 3 Bedhead signs and airway alert forms are as applicable in the ICU as they are in the anaesthetic room or wards of our hospitals. 4,5 The case report by Simpson and Duffy in this issue of JICS highlights how our critically ill patients are at increased risk of airway complications. 6 Tim Cook reminds us in his commentary that there is little point merely stocking airway equipment if we don’t know what it does, what its limitations are and how to use it safely. We should ensure that all medical and nursing staff covering our units (including consultants) are familiar with the ever-changing airway equipment that is available. With the increasing availability of portable high fidelity simulation, it is possible to devise airway scenarios that play out on the ICU in real time, using the airway equipment and team members that would manage a critical incident. The availability of a dedicated difficult airway trolley, fibreoptic endoscope, algorithms and practice in emergency airway access techniques has also been encouraged. 7 It may be appropriate to modify current guidelines and courses to make them ICU and out-of-theatre specific. 8 Intubation has long been considered a potentially unstable period for a critically ill patient and many international guidelines for the management of difficult intubation are available. The recognition that extubation can be equally fraught has prompted the UK Difficult Airway Society to publish guidelines for the management of tracheal extubation. 9 It promotes the concept of having an ‘extubation strategy,’ involving pre-procedure planning and preparation, and post- procedure monitoring and care. Almost all patients extubated on ICU could be considered at risk of developing complications. There is often no guarantee that the airway will be easily managed after several days of intubation, and the altered cardio-respiratory physiology of the critically ill mandates that airway management needs to be timely and decisive. Although primarily aimed at peri-operative extubation, these guidelines are applicable to critical care patients with similar techniques and equipment advocated when managing high-risk extubations, requiring familiarity, training and experience. Preventable patient harm has been well described in patients with tracheostomies in critical care and beyond, with familiar causes. 10 In response, the Intensive Care Society (ICS) has recently collaborated with and subsequently endorsed work by the National Tracheostomy Safety Project. This multidisciplinary initiative has produced emergency algorithms, along with educational resources for all staff managing ‘neck breathing’ patients, available from www.tracheostomy.org.uk. End-tidal CO 2 monitoring is mandatory during anaesthesia. In a recent survey, only a third of all ICUs in the UK always used it for intubation, and only a quarter always use it for continuous monitoring. 11 Again, as NAP4 highlighted, correct Airway management in critical care — new guidelines, old problems B McGrath, EA O’Donohoe, C Waldmann
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Transcript of jurnal Airway
Editorials © The Intensive Care Society 2012
Volume 13, Number 2, April 2012 JICS100
Intensive care training in the UK is undergoing change.Traditionally, the majority of intensive care medicine (ICM)
clinicians were from an anaesthetic background with traineesand consultants receiving specific training and experience inbasic and advanced airway management. As ICM becomes astand-alone specialty with intake of trainees from other acutemedical backgrounds, these airway skills can no longer betaken for granted. Advanced ICM trainees require only sixmonths of training in anaesthesia, which could mean that themanagement of the difficult airway from intubation through tosuccessful extubation will become increasingly challenging forthose without advanced airway skills.
The recent Royal College of Anaesthetists NAP4 audit aimedto identify and study major complications of airwaymanagement in the UK. It described many of these events aslikely to have been avoidable, with a disproportionately highnumber of adverse airway incidents occurring in the intensivecare unit (ICU) and emergency department.1 When comparedwith ‘anaesthetic’ airway incidents, ICU airway events weremore likely to be managed by doctors with less airwayexperience, occur out of hours and lead to more frequentpermanent harm and death. Similar findings are echoed in thereport written on behalf of the UK National Patient SafetyAgency.2 Both of these reports highlight an increased risk ofairway-related incidents occurring in the obese patient andduring patient movement (for physiotherapy, nursing care,invasive procedures and radiological investigations), and thatpreparation of the patient, environment and equipment is ofteninadequate. Of note, NAP4 recommends algorithms for themanagement of extubation and re-intubation, and provides asuggested checklist for intubation and documentation of back-up plans for at-risk airways.
We will all experience a serious airway problem during ourcareer, and the themes described above are usually evident,especially in the ICU. Contrast a healthy, anaesthetised, daycase patient moved onto the theatre table with four assistantsincluding an anaesthetist holding onto the airway device, withtwo nurses rolling a critically hypoxic patient in the ICU.Similarly, how many times has the successfully managedpatient with a difficult airway been admitted to the ICU for afew days, just long enough for the successful managementstrategy to become forgotten in an emergency or lost inhandover? Harm has resulted from a lack of basicunderstanding of airway anatomy and procedures, includingconfusion with tracheostomies and laryngectomies.3 Bedheadsigns and airway alert forms are as applicable in the ICU asthey are in the anaesthetic room or wards of our hospitals.4,5
The case report by Simpson and Duffy in this issue of JICS
highlights how our critically ill patients are at increased risk ofairway complications.6 Tim Cook reminds us in hiscommentary that there is little point merely stocking airwayequipment if we don’t know what it does, what its limitationsare and how to use it safely. We should ensure that all medicaland nursing staff covering our units (including consultants) arefamiliar with the ever-changing airway equipment that isavailable. With the increasing availability of portable highfidelity simulation, it is possible to devise airway scenarios thatplay out on the ICU in real time, using the airway equipmentand team members that would manage a critical incident. Theavailability of a dedicated difficult airway trolley, fibreopticendoscope, algorithms and practice in emergency airway accesstechniques has also been encouraged.7 It may be appropriate tomodify current guidelines and courses to make them ICU andout-of-theatre specific.8
Intubation has long been considered a potentially unstableperiod for a critically ill patient and many internationalguidelines for the management of difficult intubation areavailable. The recognition that extubation can be equallyfraught has prompted the UK Difficult Airway Society topublish guidelines for the management of tracheal extubation.9
It promotes the concept of having an ‘extubation strategy,’involving pre-procedure planning and preparation, and post-procedure monitoring and care. Almost all patients extubatedon ICU could be considered at risk of developingcomplications. There is often no guarantee that the airway willbe easily managed after several days of intubation, and thealtered cardio-respiratory physiology of the critically illmandates that airway management needs to be timely anddecisive. Although primarily aimed at peri-operativeextubation, these guidelines are applicable to critical carepatients with similar techniques and equipment advocatedwhen managing high-risk extubations, requiring familiarity,training and experience.
Preventable patient harm has been well described in patientswith tracheostomies in critical care and beyond, with familiarcauses.10 In response, the Intensive Care Society (ICS) hasrecently collaborated with and subsequently endorsed work bythe National Tracheostomy Safety Project. Thismultidisciplinary initiative has produced emergencyalgorithms, along with educational resources for all staffmanaging ‘neck breathing’ patients, available fromwww.tracheostomy.org.uk.
End-tidal CO2 monitoring is mandatory during anaesthesia.In a recent survey, only a third of all ICUs in the UK alwaysused it for intubation, and only a quarter always use it forcontinuous monitoring.11 Again, as NAP4 highlighted, correct
Airway management in critical care — newguidelines, old problemsB McGrath, EA O’Donohoe, C Waldmann
JICS Volume 13, Number 2, April 2012 101
use and interpretation of the capnography trace is essential.This is particularly pertinent in critical care where a singlebedside capnography device can frequently be attached eitherto a breathing circuit used for resuscitation or to the ventilatorcircuit, causing confusion in an emergency when swappingbetween the two circuits. The ICS recommends waveformcapnography monitoring for all intubations performed oncritically ill patients, and others recommend continuouswaveform capnography in those receiving ventilation via anyartificial airway.12-14
The ICS is attempting to further understand the root causeof airway incidents occurring in critical care and should beapplauded for examining this area in detail.15 Thiscomprehensive information should allow us to determine ratesof airway complications and to focus our attention onprevention, including challenges to industry to develop better,safer airway equipment and devices. There also is a clearchallenge to individual units and intensivists from allbackgrounds to ensure that we understand our airways andknow how to manage an emergency using equipment,procedures and guidelines that all of our staff are familiar with.
References1. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway
management in the UK: results of the Fourth National Audit Project of theRoyal College of Anaesthetists and the Difficult Airway Society. Part 2:intensive care and emergency departments. Br J Anaesth 2011;106: 632-42.
2. Thomas AN, McGrath BA. Patient safety incidents associated with airwaydevices in critical care: a review of reports to the UK National PatientSafety Agency. Anaesthesia 2009;64:358-65.
3. National Patient Safety Agency. Protecting patients who are neck breathers.2005. www.nrls.npsa.nhs.uk/resources/?entryid45=59793 Accessed8/2/2012.
4. Difficult Airway Society. Airway Alert Form. 2009. www.das.uk.com/guidelines/downloads.html Accessed 8/2/2012)
5. National Tracheostomy Safety Project. 2011. www.tracheostomy.org.uk.(accessed 8/2/2012).
6. Simpson J, Duffy M. Airway injury and haemorrhage associated with theFrova intubating introducer. JICS 2012;13:151-54.
7. Nolan JP, Kelly FE. Airway challenges in critical care. Anaesthesia2011;66:81-92.
8. Walters J. Airway management on the intensive care unit – is it time forour own training and guidelines? JICS 2011;12:163-64.
9. Popat M, Mitchell V, Dravid R et al. Difficult Airway Society Guidelinesfor the management of tracheal extubation. Anaesthesia 2012;67:318-40.
10.Cook TM, Harper J, Woodall N. Report of the NAP4 airway project. JICS2011;12:107-111.
11.Georgiou AP, Gouldson S, Amphlett AM. The use of capnography andthe availability of airway equipment on intensive care units in the UK andthe Republic of Ireland. Anaesthesia 2010;65:462-67.
12.Association of Anaesthetists of Great Britain and Northern Ireland. AAGBI.The use of capnography outside the operating theatre. London: 2011.www.aagbi.org/sites/default/files/Safety Statement - The use of capnographyoutside the operating theatre May 2011_0.pdf Accessed 3/8/2011.
13.Whitaker DK. Time for capnography – everywhere. Anaesthesia2011;66:544-49.
14.European Section and Board of Anaesthesiology. EBA Recommendation forthe use of Capnography. www.eba-uems.eu/resources/PDFS/EBA-UEMS-recommendation-for-use-of-Capnography.pdf Accessed 6/10/2011.
15.Incident reporting in critical care – a pilot project on behalf of thestandards committee of the Intensive Care Society. 2012.http://www.ics.ac.uk/intensive_care_professional/incident_reportingAccessed 8/2/2012.
Brendan McGrath Consultant in Anaesthesia & Intensive Care,
University Hospital of South Manchester NHS Foundation Trust
Elizabeth O’Donohoe ST year 5 Anaesthetics, Oxford Deanery
Carl Waldmann Consultant in Anaesthesia and Intensive Care
Royal Berkshire Hospital, Reading
Editorials
JICS mission statement
TThe purpose of JICS is to represent the breadth and depthof the specialty in the UK and beyond. It should be a
platform not only for publishing original work but also fordescribing and discussing current trends and developments, forraising issues of topical concern and for expressing the broaderchurch of opinion relating to current practice. It should beinclusive and involve all those from the full spectrum of thespecialty, whether clinical, basic science, audit, education,medico-legal or ethics. This encompasses not just medical, butnursing and all allied professionals (NAHP) working in criticalcare, reflecting the multidisciplinary nature of our specialty. Itshould be interesting to read and should encompass the bestaspects of both tabloid and broadsheet.
Just as the starting positions of the Lancet, BMJ and JAMAwere focused on providing platforms for the dissemination ofmedical knowledge, so is JICS; but as Wakely suggested of theLancet, it should entertain, instruct and reform: ‘an archedwindow to let in the light or… a sharp surgical instrument to
cut out the dross.’ The New England Journal of Medicine startedby ‘documenting’ the first demonstration of ether, ‘describing’clinical entities and ‘reporting’ medical successes. So, inessence, to borrow sentiments from eminent predecessors, thepurpose of this journal should be to achieve a position where‘all health professionals involved in critical care should findsomething of interest.’
Neil Soni Co-editor JICS, Consultant Intensivist, Chelsea and
Westminister Hospital
Carl Waldmann Co-editor JICS
Jane Harper Associate editor JICS
