Prof Ellen O'Sullivan

Airway Management –a core element of anaesthetic practice

When you read the interesting case of a can’t intubate and can’t oxygenate (CICO) scenario described in this newsletter all practicing anaesthetists are reminded of the fact that we could find ourselves in this difficult clinical situation at any time. A number of trainees have shared their experiences recently of managing this rare complication, CICO, and rescuing an airway emergency by successfully performing emergency front of neck airway (eFONA). The contribution of human factors has been highlighted and is widely accepted (1) The Difficult Airway Society 2015 guideline on Management of the Unanticipated Difficult Airway in Adults was published in 2015 at the World Airway Management Meeting (WAMM) in Dublin.(1) This publication has been one the highest cited papers in the British Journal of Anaesthesia highlighting the need for concise recommendations and algorithms. These guidelines were the first to emphasise importance of oxygenation techniques, human factors and to outline a didactic approach to the CICO situation i.e. Plan D. The latter wasn’t an easy decision and deviated from the original 2004 DAS guidelines.(2)We felt it was important from a human factor standpoint to have a recipe to follow which includes readily available equipment. The surgical approach recommended using a scalpel, bougie, and tube technique has led to a flurry of international correspondence and debate.(3,4,5) We defend it using NAP 4 data, closed claims data, and large series including David Lockey’s compelling human evidence from the London Air Ambulance service.(6,7,8) Statements from various surgical organisations including ENT- UK supported this approach. As this is a rare event, with an incidence of 0.0019% reported in the literature,(9) management of eFONA should be regularly rehearsed by all anaesthetists and cadres involved in airway management. The College of Anaesthesiologists of Ireland (CAI) was one of the first colleges to mandate attendance at the CAI National Airway Management training course by all trainees.(10) It is interesting that in this case report the trainee commented that they had received training in the technique of eFONA at this course. The Australian and New Zealand College of Anaesthetists (ANZCA) has mandated that every specialist anaesthetist should complete a “cannot intubate, cannot oxygenate” (CICO) module at least once every 6 years. DAS and the Royal College of Anaesthetists are establishing a FONA database to monitor compliance and success of the DAS recommended FONA technique. A group of us led by Dr Laura Duggan, Canada, have developed an AIRWAY App that collects anonymous first –hand details regarding eFONA procedures via a free smartphone and desktop application.(11) The data is showing the variation in practice and what works best, and data published to date confirms the increased use and success of the surgical approach. Please report your eFONA experiences on this app. Ultimately we hope that with the introduction of Airway Leads Network (see below) more frequent local training will be introduced.

Establishing a CAI Airway Leads Network (AWLN) To improve airway teaching and training the concept that each hospital should have an Airway Lead (AWL) has been adopted by a number of organisations.(12) Establishing a National Airway Lead Network has been approved by the CAI and a database is being established. All anaesthetic departments countrywide have responded with a supportive and positive attitude to the concept of AWLs and revealed that many departments already have an Airway Lead in place. Through the activities of a coordinated group of AWL, we hope to achieve national progress and improvement in airway management. The job description for the AWL includes establishing and maintaining local guidelines for emergency airway management, oversight of airway equipment provision and harmonisation, training in airway management and airway rescue and co-ordination between the three departments most intimately involved in airway management – anaesthesia, intensive care and emergency medicine. Arguably the role is about addressing issues of organisational preparedness and to hone individual preparedness. Airway leads are involved in the mandatory airway training courses run by the CAI for all trainees. Biennial Airway Lead “Train the Trainers” meetings will be held at the College to provide the opportunity for shared learning, use of best practice examples and collaboration. Examples include standardisation of airway equipment and trolleys, various approaches to in theatre education, e.g. tea trolley training & Tracheostomy Tracey and training programmes.(13,14) The ethos of the airway lead remains -someone who “work(s) collegially with their colleagues to ensure appropriate systems are in place” and “an airway lead as an anaesthetist working at grass roots level who promotes safe airway management within their hospital.”16 Airway misadventure continues to occur and given the complexity of delivering safe airway management this cannot be a surprise. The need for airway leads has perhaps never been more pressing and their role is central in disseminating learning from sentinel events in order to try to improve standards and patient care. The purpose of an airway lead is not to dictate how an individual anaesthetist manages a specific airway but to ensure, among other things, that the individual anaesthetist has the tools to manage any airway they are faced with. In the aftermath of major airway events airway leads provide a local support or signposting service to ensure clinician well-being while also sensitively coordinating airway morbidity and mortality review so that all anaesthetists and assistants and their departments can learn practical and institutional lessons or identify training needs. Ideally all departments should have regular airway teaching provided by their airway lead. In the future it is envisaged that AWLs should contribute to a database of the most serious adverse anaesthetic events so that information can be effectively shared among all anaesthetists.(15)This will require careful consideration of patient and practitioner confidentiality to allow appropriate dissemination of relevant learning points aimed at prevention rather than investigation. The Departmental Airway Lead concept has been successfully implemented in the UK (98% of departments have AWLs) and in New Zealand (16) and is in progress in Australia (17) and is being developed through the Society of Airway Management (SAM) in the USA. The time has come for all institutions where airway management is practised to recognise the benefits of establishing and participating in an Airway Leads Network.

Airway management and COVID-19

Airway Management remains a cornerstone of our practice. The importance of skills in airway management and ventilation has been acutely illustrated since the onset of the COVID-19 pandemic. The advantages of working together and disseminating learning and advice quickly has never been more urgent. Existing guidelines were adapted and knowledge shared rapidly through networks. The DAS 2015 guidelines for both anaesthesia and critical care were adapted to produce Airway Management guidelines in the COVID era.(18) Intubation teams were set up and simulation undertaken to acquire the advanced skills of intubating often physiologically compromised patients in unfamiliar environments with personal protective equipment (PPE). One of the consequences of the COVID 19 pandemic is the cancellation of mandatory courses especially those with hands-on interactive components. However innovative ways of delivering theses course have to be introduced. An interactive CAI Advanced Airway Management Masterclass is planned for May 2021 for trainees at their hospital sites. The lectures and technique demonstrations will be delivered remotely from the College HUB to each site and locally the AWLs will instruct & assess the delegates at the spoke site and interact with the hub. This may be a model for increasing access to more participants to complete this training and the resources can all be available electronically. For further details contact


The airway practitioner needs to be able to apply a range of airway techniques in order to cope with the complexities of a difficult airway. Achieving front of neck access under emergency conditions may be the final pathway, but appropriate judgement and skill earlier in the patient’s care could potentially avoid such a crisis. Education in airway management should reach far beyond the formative stages of a trainee.(11) It should be seen as an ethical obligation for all practitioners to keep up to date through lifelong learning; an obligation which should be facilitated by governing bodies mandating a comprehensive airway management training program. The establishing of a CAI Airway Lead network will be an opportunity to improve institutional and personal preparedness for airway management.

Prof Ellen O’Sullivan Airway Lead Advisor, College of Anaesthesiologists of Ireland