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doi: 10.1093/bja/aew190
Advance Access Publication Date: 28 July 2016
Special Issue
Abstract
Background: The emergency surgical airway (ESA) is the final option in difficult airway management. We identified ESA
procedures registered in the Danish Anaesthesia Database (DAD) and described the performed airway management.
Methods: We extracted a cohort of 452 461 adult patients undergoing general anaesthesia and tracheal intubation from the DAD
from June 1, 2008 to March 15, 2014. Difficult airway management involving an ESA was retrieved for analysis and compared
with hospitals files. Two independent reviewers evaluated airway management according to the ASAs’2003 practice guideline
for difficult airway management.
Results: In the DAD cohort 27 out of 452 461 patients had an ESA representing an incidence of 0.06 events per thousand (95% CI;
0.04 to 0.08). A total of 12 149/452 461 patients underwent Ear-Nose and Throat (ENT) surgery, giving an ESA incidence among
ENT patients of 1.6 events per thousand (95% CI; 1.0–2.4). A Supraglottic Airway Device and/or the administration of a
neuromuscular blocking agent before ESA were used as a rescue in 6/27 and 13/27 of the patients, respectively. In 19/27 patients
ENT surgeons performed the ESA’s and anaesthetists attempted 6/27 of the ESAs of which three failed. Reviewers evaluated
airway management as satisfactory in 10/27 patients.
Conclusions: The incidence of ESA in the DAD cohort was 0.06 events per thousand. Among ENT patients, the ESA Incidence
was 1.6 events per thousand. Airway management was evaluated as satisfactory for 10/27 of the patients. ESA performed by
anaesthetists failed in half of the patients.
Key words: airway management; complications; general anaesthesia; intubation; otorhinolaryngologic surgical procedures;
tracheostomy
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Table 2 Summary of findings. DAM, difficult airway management; Daytime, 8 am to 4 pm; ENT, ear, nose, throat; ESA, emergency surgical
airway; Night shift, 4 pm to 8 am; N, the number of patients within categories; NMBA, neuromuscular blocking agent; SAD, supraglottic
airway device
N N N
to respiratory insufficiency. Chest compressions were provided preferably videolaryngoscopy on both occasions. Patient ID 14
with the return of spontaneous circulation. The patient could and 27 were registered with one subsequent anaesthetic and
be mask ventilated, whereas intubation was impossible, there- both were intubated using a flexible optic scope. Patient ID 18
fore she was moved to the operating theatre for a definitive air- was intubated with a flexible optic scope on one occasion and
way ( patient ID 22). Thirteen patients died a median (range) of on the second anaesthetic intubated using another method
7 (0–42) months after the procedure. However, none of the pa- than direct laryngoscopy, most likely videolaryngoscopy. The re-
tients died in immediate relation to, or as a result of the provided maining four patients were tracheal intubated without complica-
airway management and no patient suffered from brain damage tions by direct laryngoscopy on subsequent anaesthetics and all
as a consequence of ESA. Type of ESA procedure according to had reversible reasons for difficult airway management on the
managing specialty, degree of urgency, non-fatal complications occasion of the ESA.
and presence/absence of cardiac arrest is depicted in Table 4. Six-
teen out of 27 patients underwent emergency surgery. A consult-
ant in anaesthesia was present in 25/27 patients; no files
Reviewers’ evaluation of airway management
documented the call for assistance of another consultant in Reviewers evaluated the provided airway management as
anaesthesiology. satisfactory in 10/27 (37%) patients. Reasons for reviewers evalu-
ating the provided airway management as adequate, were re-
cords documenting that the difficult airway algorithm had been
Primary airway management technique adhered to, after the anticipation of difficult airway management
The first scheduled, but failed airway management was: flexible in 8/10 patients. These patients were undergoing intubation with
optic intubation with preserved spontaneous respiration (7/27 preserved spontaneous respiration and when this procedure
patients); I.V. anaesthesia induction followed by direct laryngos- failed the next step was an ESA. In the remaining 2/10 patients
copy (11/27 patients); Sevoflurane inhalation followed by direct or where reviewers evaluated airway management to be satisfac-
videolaryngoscopy (3/27 patients); I.V. anaesthesia induction fol- tory airway management difficulties could not have been antici-
lowed by videolaryngoscopy (3/27 patients); I.V. anaesthesia in- pated. These two patients were handled appropriately according
duction followed by placement of a SAD (2/27 patients); and to the ASAs’ 2003 practice guideline for unanticipated difficult
finally tracheostomy in local anaesthesia (1/27 patients). airway management.
Reviewers reasons for assessing airway management as poor
were: overlooking a history of difficult airway management,
Patients with subsequent anaesthetics abstaining from using information from preoperative nasophar-
After the episodes of ESA, eight patients were registered with yngoscopy, failure to plan for awake intubation also through the
subsequent general anaesthetics, including airway management cricothyroid membrane, lack of rescue plans, using SAD’s as a
(Patient ID 2, 6, 13, 14, 18, 20, 21 and 27), Tables 3 and 4. Patient ID solution for final airway management in patients with a high
13 was registered with two subsequent anaesthetics and was in- risk of failure with this device, lack of relevant equipment, airway
tubated using another method than direct laryngoscopy, management initiated in remote locations, insufficient skills for
Pt. Sex Age ASA BMI Priority of Time of CV- Expected SAD NMBA Progression in airway management
Id surgery surgery CI DAM used used 1. technique 2. technique 3. technique 4. technique 5. technique
(attempts) (attempts) (attempts) (attempts) (attempts)
1 M 83 2 24 Elective 10:30 am No No Yes No SAD (1) Dir Lar (2) SAD (1) ESA
2 F 82 2 24 Emergency 04:00 am No No No Yes Dir Lar (2) ESA
3 M 54 1 26 Emergency 03:00 pm Yes Yes No No Flex. optic (1) ESA
4 M 54 3 27 Emergency 01:00 pm Yes Yes No Yes Video Lar (1) ESA
5 M 65 NS 26 Emergency 12:00 am Yes No Yes Yes Dir Lar (3) I-LMA (1) Retrogr.(1) ESA
6 F 32 2 24 Emergency 04:00 am Yes Yes No No Dir lar+Sevo (2) ESA
7 M 63 2 20 Elective 01:00 pm No No No No Dir lar (2) Video lar (1) ESA
8 M 45 1 36 Elective 04:00 pm Yes No No Yes Dir lar (1) Video lar (1) ESA
9 F 54 1 25 Elective 11:00 am Yes No Yes Yes Dir lar (?) I-LMA (?) SAD (?) Flex. optic (?) ESA
10 M 46 1 28 Elective 01:00 pm No No No No Video lar+Sevo ESA
(1)
11 M 61 2 29 Emergency 02:00 am No No No Yes Dir lar (5) Combitube (1) ESA (2) failed Flex. optic (1)
12 M 72 3 29 Emergency 05:15 pm Yes Yes No No Flex. optic (2) ESA
13 F 52 2 20 Elective 02:00 pm Yes Yes No Yes Flex. optic (1) Dir lar (1) Video lar (1) ESA
14 F 59 2 23 Elective 08:00 am Yes Yes Yes No Video lar (2) SAD (?) ESA
15 M 85 3 19 Elective 12:00 am Yes Yes No No Dir lar (1) Flex. optic (1) ESA
16 M 58 3 18 Emergency 06:15 pm Yes Yes No No Flex. optic (5) ESA
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Table 4 Characteristics of the emergency surgical airways of the 27 individual patients. Anaesth., anaesthetist; Cricothyr., Cricothyroidotomy; DAM, difficult airway management; Dil. Trach.,
dilatation tracheostomy; ENT, ear, nose, throat surgeon; ESA, emergency surgical airway; LA, local anaesthesia; Trach., tracheostomy
Pt. ESA performed Type of ESA Time of ESA Priority of Type of Surgical procedure/clinical conditions Complication related to ESA/surgery Cardiac
Id (attempted) by ESA surgery arrest
ESA access, and finally inadequate rescue methods when dealing study.4 This implicates that all patients undergoing anaesthesia
with uncooperative patients during attempts at awake intub- should be questioned for prior ENT surgery. In case of present
ation. We performed a univariable logistic regression analysis ENT surgery a preoperatively, interdisciplinary evaluation by
to determine if the incidence of ESA changed over the years of ob- both the anaesthetist and the ENT surgeon, also involving infor-
servation. We did not find any statistically significant association mation from nasopharyngoscopy and airway imaging, should be
with time. performed in order to plan for optimal airway management.16 17
We were unable to evaluate from the written documentation
whether ENT patients in this study were properly interdisciplin-
Discussion ary discussed. Flexible optic intubation and sevoflurane inhal-
We found an ESA incidence of 0.06 events per thousand in con- ation used as primary airway management techniques, in
nection with general anaesthesia. This is 3–10 times higher awake or sedated patients, failed with apparently loss of the air-
than reported in previous studies in the UK and USA.4 5 Among way necessitating a surgical airway. The described techniques
ENT patients we found an ESA incidence of 1.6 events per thou- can be highly challenging and has previously been documented
sand. Underreporting was mentioned as an explanation of the to result in severe complications.18 When preparing the airway
lower incidence found in the NAP4 study, but statistical data management strategy it is essential to include escape plans
analysis was inconclusive leaving no evidence of this. Excluding in case of failure of the primary technique.4 Flexible optic intub-
patients undergoing rapid sequence induction, awake or asleep ation and inhalation techniques may be considered as fail proof,
flexible optic intubation and awake tracheostomy is a likely ex- with the implication that the need for back-up plans may be ne-
planation for the lower ESA incidence found in the Kheterpal glected. Patients suffering from upper airway obstruction may be
and colleagues study.5 We cannot exclude the possibility of uncooperative. However, ablation of spontaneous respiration or
underreporting in our study, so that the true ESA incidence in rendering patients unconscious by anaesthesia induction may
Denmark might be even higher. In contrast to the NAP 4 study, be highly dangerous and the anaesthetists should master sed-
no patient died as an immediate consequence of the difficult ation and local anaesthesia techniques that enable securing the
airway management. This raises the question whether patients airway in the spontaneously breathing uncooperative patient.19
were exposed to an unnecessary ESA leaving other non-invasive Anaesthetists performed few ESAs in this study, but in half of
airway management options untried. We assessed airway man- the patients, the procedure failed. Guidelines state that the ESA
agement using the 2003 ASA difficult airway management procedure is an essential skill for us as a specialty to master. So
algorithm, because it would be unfair using the updated 2013 even if the situations is rarely encountered, all anaesthesia
guideline as most cases were dated before 2014.9 10 Updated departments should offer necessary skill- and team- training
guidelines now state that if not previously attempted, a SAD with suitable regular intervals.3 Causes of distorted airway anat-
and/or an NMBA should be administered before performing an omy are multifactorial and unfortunately no single device will
ESA.3 4 One of these options might have prevented some of the solve all possible airway management difficulties encountered.
surgical airways registered in our study. We have no national Da- Studies have documented that simple algorithms and access to
nish guideline for difficult airway management and no knowl- adequate but limited types of equipment, associated with appro-
edge of the content of individual local departmental guidelines. priate training, increases difficult airway management success.20
Therefore variations in- or lack of- local algorithms may offer The recent updated Difficult Airway Society 2015 guidelines, for
some explanation of the infrequent use of SADs and NMBA’s management of unanticipated difficult intubation in adults,
in this study. Additionally, the use of NMBA’s in association should be commended for taking this into account with further
with difficult airway management was previously discredited algorithm simplification and the encouragement of practitioners
and this historical controversy could also influence our results. to stop and think in case of sufficient oxygenation.3 It is left to the
Prospective studies dating from 2003 have now documented im- departments to adjust guidelines to local conditions, including a
proved mask ventilation after the administration of an NMBA.11–14 limited number of suitable difficult airway management devices,
The decision to perform a surgical airway relies on a subtle in order to improve patient management.
balance between following a correct airway management strat- Proficient difficult airway management relies on knowledge,
egy and saving the life of a patient. Thought processes, the ability experience, skills and behavioural factors. The results of this
to think creative and maintaining an overview over a situation is study are based only on the written documentation from hospital
impaired during stress, leading to potential bypasses or signifi- files and the DAD, with the obvious limitations in evaluating
cant delays of important steps in an algorithm, endangering the aforementioned factors. It would have been desirable to per-
the patient in question.15 On the other hand, no patients died form a contributory factor analysis, but that would have required
or suffered severe complications in relation to the ESA proce- team member interview and case audit in immediate relation
dures in this study, which could argue for a timely decision and to the event and that was unfortunately beyond the scope of
relevant action by the anaesthetist in relation to re-establishing our study. We have only examined ESA in association with
oxygenation. patients undergoing general anaesthesia registered in the DAD.
Just as important as extracting learning from patients where Obviously, ESA also occurs in relation to intensive care- and
airway management was less optimal, is the information that prehospital- management. Therefore the true ESA incidence in
can be derived from patients with satisfactory performance. In Denmark is unknown and further research on this topic is
ten patients airway management were evaluated as satisfactory needed in relation to intensive- and prehospital- care. We were
with files documenting a correctly followed difficult airway man- unable to document whether registration of ESA in the DAD
agement algorithm. was missing for some patients, as we based our cohort on pa-
In all ENT patients the possibility of securing the airway by a tients registered in the DAD. But as false positive ESAs occurred
tracheostomy in local anaesthesia might not have jeopardized in the DAD, false negatives may occur as well. Questions in the
patients and should always be carefully considered before DAD regarding the anticipation of difficult airway management
surgery. Twenty out of 27 (74%) patients with an ESA were ENT were before 2012 defaulted as ‘no’. The anaesthetist had to
patients, thereby confirming previous findings of the NAP4 actively change this, if difficult airway management was in fact
anticipated. This may explain the discrepancy between the DAD laryngoscopy: a report from the multicenter perioperative
and the hospital files regarding anticipated difficult airway man- outcomes group. Anesthesiology 2013; 119: 1360–9
agement.6 Therefore we have given the information on the an- 6. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A,
aesthetic file, regarding anticipation of difficult airway Lundstrøm LH. Diagnostic accuracy of anaesthesiologists’
management a higher weight compared with corresponding prediction of difficult airway management in daily
data in the DAD. Finally, despite using a predefined structured clinical practice: a cohort study of 188 064 patients registered
scoring approach we cannot exclude the possibility of reviewer- in the Danish Anaesthesia Database. Anaesthesia 2015; 70:
, hindsight- and outcome- bias when evaluating the provided pa- 272–81
tient management. 7. Law JA, Broemling N, Cooper RM, et al. The difficult airway
with recommendations for management - Part 1 - Intubation
encountered in an unconscious/induced patient. Can J Anesth
Conclusion
2013; 60: 1089–118
We found an incidence of ESA of 0.06 events per thousand among 8. Han R, Tremper KK, Kheterpal S, O’Reilly M. Grading scale for
patients undergoing general anaesthesia registered in the DAD. mask ventilation. Anesthesiology 2004; 101: 267
Among ENT patients the ESA incidence was 1.6 events per 9. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guide-
thousand. Seventy per cent of the ESA patients were registered lines for management of the difficult airway: an updated
with a CICV. Airway management was evaluated as satisfactory report by the American Society of Anesthesiologists Task
for 10 out of 27 patients. ESA performed by anaesthetists, failed Force on Management of the Difficult Airway. Anesthesiology
in three out of six patients. Supraglottic airway devices and 2003; 98: 1269–77
NMBA’s were used infrequently in order to achieve oxygenation. 10. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guide-
Proficient difficult airway management relies on simple algo- lines for management of the difficult airway. Anesthesiology
rithms and suitable equipment and knowledge, experience, skills 2013; 118: 251–70
and behavioural factors. 11. Ikeda A, Isono S, Sato Y, et al. Effects of muscle relaxants on
mask ventilation in anesthetized persons with normal
upper airway anatomy. Anesthesiology 2012; 117: 487–93
Authors’ contributions
12. Goodwin MWP, Pandit JJ, Hames K, Popat M, Yentis SM. The
Study design/planning: C.V.R., A.K.N., L.H.L. effect of neuromuscular blockade on the efficiency of mask
Study conduct: C.V.R., A.K.N., L.H.L. ventilation of the lungs. Anaesthesia 2003; 58: 60–3
Data analysis: C.V.R., A.K.N., J.W., L.H.L. 13. Warters RD, Szabo TA, Spinale FG, Desantis SM, Reves JG. The
Writing paper: C.V.R., A.K.N., J.W., L.H.L. effect of neuromuscular blockade on mask ventilation.
Revising paper: all authors Anaesthesia 2011; 66: 163–7
14. Kheterpal S, Han R, Tremper KK, et al. Incidence and predictors
Acknowledgements of difficult and impossible mask ventilation. Anesthesiology
2006; 105: 885–91
The Danish Anaesthesia Database. 15. Greenland KB. Art of airway management: the concept of
‘Ma’ (Japanese: [Foreign language], when ‘less is more’). Br J
Declaration of interest Anaesth 2015; 115: 809–12
None declared. 16. Rosenblatt W, Ianus AI, Sukhupragarn W, Fickenscher A,
Sasaki C. Preoperative Endoscopic Airway Examination
(PEAE) provides superior airway information and may reduce
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