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 dont 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 ODonohoe, 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 single
bedside capnography device can frequently be attached either
to a breathing circuit used for resuscitation or to the ventilator
circuit, causing confusion in an emergency when swapping
between the two circuits. The ICS recommends waveform
capnography monitoring for all intubations performed on
critically ill patients, and others recommend continuous
waveform capnography in those receiving ventilation via any
artificial airway.
12-14
The ICS is attempting to further understand the root cause
of airway incidents occurring in critical care and should be
applauded for examining this area in detail.
15
This
comprehensive information should allow us to determine rates
of airway complications and to focus our attention on
prevention, including challenges to industry to develop better,
safer airway equipment and devices. There also is a clear
challenge to individual units and intensivists from all
backgrounds to ensure that we understand our airways and
know how to manage an emergency using equipment,
procedures and guidelines that all of our staff are familiar with.
References
1. Cook TM, Woodall N, Harper J, Benger J. Major complications of airway
management in the UK: results of the Fourth National Audit Project of the
Royal 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 airway
devices in critical care: a review of reports to the UK National Patient
Safety 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 Accessed
8/2/2012.
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 the
Frova intubating introducer. JICS 2012;13:151-54.
7. Nolan JP, Kelly FE. Airway challenges in critical care. Anaesthesia
2011;66:81-92.
8. Walters J. Airway management on the intensive care unit is it time for
our own training and guidelines? JICS 2011;12:163-64.
9. Popat M, Mitchell V, Dravid R et al. Difficult Airway Society Guidelines
for the management of tracheal extubation. Anaesthesia 2012;67:318-40.
10.Cook TM, Harper J, Woodall N. Report of the NAP4 airway project. JICS
2011;12:107-111.
11.Georgiou AP, Gouldson S, Amphlett AM. The use of capnography and
the availability of airway equipment on intensive care units in the UK and
the 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 capnography
outside the operating theatre May 2011_0.pdf Accessed 3/8/2011.
13.Whitaker DK. Time for capnography everywhere. Anaesthesia
2011;66:544-49.
14.European Section and Board of Anaesthesiology. EBA Recommendation for
the 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 the
standards committee of the Intensive Care Society. 2012.
http://www.ics.ac.uk/intensive_care_professional/incident_reporting
Accessed 8/2/2012.
Brendan McGrath Consultant in Anaesthesia & Intensive Care,
University Hospital of South Manchester NHS Foundation Trust
brendan.mcgrath@nhs.net
Elizabeth ODonohoe ST year 5 Anaesthetics, Oxford Deanery
Carl Waldmann Consultant in Anaesthesia and Intensive Care
Royal Berkshire Hospital, Reading
Editorials
JICS mission statement
T
The purpose of JICS is to represent the breadth and depth
of the specialty in the UK and beyond. It should be a
platform not only for publishing original work but also for
describing and discussing current trends and developments, for
raising issues of topical concern and for expressing the broader
church of opinion relating to current practice. It should be
inclusive and involve all those from the full spectrum of the
specialty, whether clinical, basic science, audit, education,
medico-legal or ethics. This encompasses not just medical, but
nursing and all allied professionals (NAHP) working in critical
care, reflecting the multidisciplinary nature of our specialty. It
should be interesting to read and should encompass the best
aspects of both tabloid and broadsheet.
Just as the starting positions of the Lancet, BMJ and JAMA
were focused on providing platforms for the dissemination of
medical knowledge, so is JICS; but as Wakely suggested of the
Lancet, it should entertain, instruct and reform: an arched
window to let in the light or a sharp surgical instrument to
cut out the dross. The New England Journal of Medicine started
by documenting the first demonstration of ether, describing
clinical entities and reporting medical successes. So, in
essence, to borrow sentiments from eminent predecessors, the
purpose of this journal should be to achieve a position where
all health professionals involved in critical care should find
something of interest.
Neil Soni Co-editor JICS, Consultant Intensivist, Chelsea and
Westminister Hospital
n.soni@imperial.ac.uk
Carl Waldmann Co-editor JICS
carl.waldmann@royalberkshire.nhs.uk
Jane Harper Associate editor JICS
jane.harper@rlbuht.nhs.uk