CASE STUDY

KEYWORDS Shared airway / Teamwork / Difficult airway

Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication July 2016.

Perioperative teamwork
for the patient with a
shared airway: a case study
by G Jones
Correspondence address: LMT(ODP) G Jones, Royal Navy Operating Department Practitioner, Albert House, Theatres, Defence Medical Group South (DMG South), Queen Alexandra
Hospital, Cosham, Portsmouth, PO6 3LY. Email: gareth.jones345@mod.uk

Teamwork is an essential element of perioperative care. Shared airway surgery requires

additional considerations for the perioperative team. This article analyses a case study of a
patient undergoing thyroid surgery. Whilst the anaesthetic team is responsible for maintaining
the patient’s airway, the theatre and surgical teams have their own individual roles to assist in
airway management and surgical care.

Introduction members at this early stage can identify

In all specialties of perioperative practice,
teamwork is essential to provide safe
patient care. For head and neck surgery,
good teamwork is vital to facilitate shared
airway management. A shared airway
occurs where the operative site shares
or is in close proximity to the patient’s
airway (Allman & Wilson 2011). Konieczny
et al (2013) remarked that there is
limited literature to support the concept
of teamwork in head and neck surgery.
However when caring for a patient with
a shared airway it is essential that the
anaesthetic, surgical and theatre teams
communicate with each other and work
together to achieve optimal surgical
outcomes (Patel 2001). This paper analyses
the role of teamwork in head and neck
surgery and specifically examines the role
of the anaesthetic-, surgical- and recovery-
operating department practitioner (ODP) in
relation to patient care and safety with a
shared airway. The role of the ODP in this
paper can also apply to a registered nurse
trained to the appropriate standard.
The patient
Patient A, a 54 year old male, underwent
a hemi-thyroidectomy to remove a thyroid
nodule. The patient was otherwise fit and
well. Local anaesthetic (LA) for thyroid
surgery is rare but can be performed in
patients with a number of co-morbidities
(Elisha et al 2010). LA is administered
via a cervical plexus block however, due
to the proposed length of this operation,
Team leader (registered nurse)
Anaesthetic operating department
practitioner
Scrub operating department practitioner
Circulator – registered nurse
Operating theatre healthcare support
worker (circulating)
Operating department practitioner recovery
Table 1 Head and neck theatre team for
case study
general anaesthesia (GA) was deemed
more suitable as it provides the patient with
a more comfortable experience (Allman
& Wilson 2011). Preoperative patient
assessment identified the need for general
anaesthesia. The theatre team consisted of
a consultant head and neck surgeon and a
consultant anaesthetist supported by the
theatre team members listed in Table 1.
Team brief
Before the theatre list commenced the
theatre team, surgeon and anaesthetist
assembled for the preoperative team
brief (NPSA 2009). Adedeji et al (2010)
offered that prior planning, communication
and preparation is important in caring for
patients in the operating theatre. The main
aim of the team brief is to avoid a never
event or near miss and is an effective way
to reduce the risk of complications during
surgery and improve patient safety (NPSA
2009). Communication between all team
potential problems, avoiding adverse effects
for the patient (Alnaib et al 2012).
The anaesthetist anticipated a difficult
intubation for patient A and planned to
intubate the patient with a reinforced nerve
integrity monitor endotracheal (NIMET)
tube using video laryngoscopy. During the
team brief, the surgeon requested for the
tube to be secured away from the surgical
field to allow for optimal surgical access
whilst maintaining sterility of the surgical
field (Allman & Wilson 2011). The surgeon
notified the team that the patient would
initially need to be placed in the supine
position and that he would direct additional
positioning when required during the
operation (Kotansky et al 2009).
During the team brief, the team leader
allocated structured managed airway
response team (SMART) roles (Table 2).
SMART is used in a number of hospitals
to treat life threatening airway conditions
such as a ‘can’t intubate, can’t ventilate’
(CICV) situation (Faulkner 2013). SMART
allows staff to anticipate airway difficulties
by responding quickly and appropriately
within their pre-allocated role. All team
members were required to remain in
theatre in case SMART was activated and
each member required to commence their
role. During a difficult airway situation,
the presence of a head and neck surgeon
is recommended in order to perform a
lifesaving cricothyroidotomy in the event
of a CICV event (DAS 2007). A breakdown
in teamwork in the event of a difficult
>>

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JPP March 2017.indd 37 15/02/2017 10:41

 CASE STUDY
Perioperative teamwork for the patient with a shared airway:
a case study
Continued
1st anaesthetist – announces a ‘difficult
airway’. Disseminates information and
briefs team members accordingly
Anaesthetic operating department
practitioner (or anaesthetic nurse) remains
with the anaesthetist
Theatre staff one (ODP surgical) – Records
baseline observations and actions taken
by the team and documents in patient’s
notes. Announces when oxygen saturation
levels fall below 90%
Timekeeper
Theatre staff two (support worker) –
Collects the difficult airway trolley and other
equipment as required. Fast bleeps 2nd
anaesthetist. Offers help as required
Theatre staff three – Collects the fibreoptic
laryngoscope. Completes further tasks as
required by lead clinician
The above roles are standard in all theatres
in the trust according to local policy. Any
member can be nominated, however those
listed above were the roles allocated for
this case study.
Table 2 Structured Managed Airway Response
Team (SMART) roles (from Faulkner 2013)
airway could lead to a patient death,
due to loss of situational awareness,
teamwork, communication and human
factors (Bromiley 2009). SMART aids in
preventing this communication breakdown
by encouraging the sharing of information
and structured planning to promote patient
safety in the event of a difficult airway
(Faulkner 2013).
Anaesthetic care
As with every GA, the anaesthetist aimed
to reduce the patient’s sensory experience
using the triad of anaesthesia. The patient’s
levels of narcosis, pain sensation and
muscle relaxation were altered in order to
facilitate a safe operation. A long acting
muscle relaxant was not recommended in
this case due to the need to monitor the
patient’s recurrent laryngeal nerve (RLN)
function during thyroid surgery (Elisha et al
2010). The intubation therefore required
the use of the short acting muscle relaxant
suxamethonium. Muscle relaxation would
have subsequently worn off prior to the
skin incision so a remifentanil infusion was
38
JPP March 2017.indd 38
Class I: soft palate, fauces, uvula, pillars easily
viewed
Class II: soft palate, fauces and portion of uvula
partially viewed
Class III: soft palate and base of uvula only viewed
Class IV: hard palate only viewed
Figure 1 Mallampati score (Neacsu 2002)
Grade I: glottis completely visible
Grade II: anterior glottis not seen
Grade III: only epiglottis seen
Grade IV: epiglottis not seen surgery (Medtronic 2013). O’Neill and
Figure 2 Wanderley et al (2013)
required in order to maintain anaesthesia
in the absence of a long acting muscle
relaxant. This combination not only provided
intraoperative anaesthesia and allowed
for intraoperative assessment of the RLN,
but also helped to create a bloodless field
for the surgeon by reducing cardiac output
(Malhotra & Sodhi 2007, Adams & Davies
2009). The infusion was set up by the
ODP-anaesthetics as prescribed by the
anaesthetist.
Although considered only a guide, the
Mallampati classification (Neacsu 2002)
(Figure 1) is a tool used by the anaesthetist
preoperatively to estimate the likelihood
of a difficult intubation (Anaesthesia UK
2010). In addition to this, a Cormack
and Lehane grade (Figure 2) is useful for
predicting the likelihood of successful
intubation using laryngoscopy since
blind intubation attempts can result in
airway trauma for the patient possibly
March 2017 - Volume 27 - Issue 3 - ISSN 1750-4589
leading to oedema of the neck and airway
compression (RCoA & DAS 2011). The
anaesthetist informed the ODP-anaesthetics
that this patient’s Mallampati score was a
Grade 3.
The ODP-anaesthetics ensured that
a reinforced size 7.5 NIMET tube was
available with an intubating stylette.
Patients with thyroid disease often have
altered anatomy, therefore the stylette
helps the anaesthetist to intubate a patient
with a potentially difficult airway as it can be
shaped into the desired position (Williams
& Smith 2008). Dionigi (2010) noted that
monitoring the RLN reduces the risk of vocal
cord palsy which is a known complication
of thyroid surgery. This inadvertent damage
may lead to breathing difficulties and affect
the patient’s ability to generate speech.
Abadin et al (2010) analysed 143 cases of
malpractice litigation after thyroid surgery.
Fifteen of these cases were for RLN damage
where no monitoring equipment was
used resulting in harm to the patient. An
additional advantage of using a reinforced
NIMET tube is that it has greater rigidity
than a standard ET tube thus reducing
the possibility of kinking of the tube, or
accidental extubation when manoeuvring
the patient’s head prior to and during
Fenton (2008) advised that RLN monitoring
as a risk minimising adjunct should not
be relied upon whereas Calo et al (2013)
suggested that monitoring helps to reduce
the risk of damage to the vocal cords and is
particularly useful in high risk surgery where
there is a risk of mortality or morbidity.
There are alternative methods for RLN
monitoring during thyroid surgery. O’Neill
and Fenton (2008) examined several
studies using a laryngeal mask airway
with RLN stimulation. The RLN was viewed
through a bronchoscope to evaluate its
integrity. However, this technique presents
a risk of pseudolaryngospasm occurring in
25% of patients. Direct RLN stimulation can
also be used by the surgeon and should
be available during surgery if required
for any case of thyroid surgery (O’Neill &
Fenton 2008).
A video laryngoscope (VL) was used
as a pre-emptive measure in favour
of standard laryngoscopy techniques
due to the patient’s possible altered
15/02/2017 10:41

As with every GA, the anaesthetist aimed to reduce the patient’s sensory
experience using the triad of anaesthesia
ASA Grade 1 Normal healthy patient (that is
without any clinically important
comorbidity and without clinically
significant past/present medical
history)
ASA Grade 2 A patient with mild systemic
disease
ASA Grade 3 A patient with severe systemic
disease
ASA Grade 4 A patient with severe systemic
disease that is a constant threat
to life
Table 3 American Society of Anesthesiologists
(ASA) grades of anaesthesia (NICE 2016)
anatomy. This enabled the anaesthetist
to view the vocal cords from a different
perspective (Mushambi & Francis 2013).
A laryngoscope with a standard McCoy or
McIntosh blade could have been utilized,
however in comparison the VL provides
a superior view of the glottic opening
(Fitzgerald et al 2015). For patients with
an anticipated difficult airway a flexible
fibreoptic scope can also be used to
negotiate a potentially displaced larynx
(Allman & Wilson 2011). Alternatively, the
anaesthetist could have opted to administer
an inhalational induction technique,
allowing the patient’s airway to be tested
due to its gradual onset (Hardcastle 2007).
Awake intubation is another option as this
would enable the patient to maintain their
own airway, however this has been known
to increase patient anxiety levels (Cook
& Simpson 2013). Whilst Fitzgerald et al
(2015) called for greater use of awake VL
techniques, Swarbrick and Turner (2015)
advised caution since there is no guarantee
that the skill of performing anaesthetised
intubation will transfer to awake intubation.
Patient A was successfully intubated using
the VL and NIMET tube.
The ODP-anaesthetics applied tape to close
the patient’s eyelids, in order to prevent
corneal abrasions which could result in a
loss of vision, and then secured padding
over the eyes for extra protection (Allman
& Wilson 2008). Padding the eyes in head
and neck surgery reduces the risk of eye
damage due to the close proximity of
surgery; padding has been shown to be
more effective than ointment (Corbridge
& Steventon 2010). Grixti et al (2013)
recommended the use of bio-occlusive
eye dressings however, these are at an
March 2017 - Volume 27 - Issue 3 - ISSN 1750-4589
JPP March 2017.indd 39
additional cost to the healthcare provider
and were not available in the NHS trust.
Time out
The patient was transferred out of the
anaesthetic room and into theatre. The
’time out’ procedure was performed
following local protocol (NPSA 2009).
The patient’s American Society of
Anesthesiologists (ASA) grade was
confirmed as grade 2 (Table 3) and the
locally produced patient consent form was
analysed to confirm the patient, operative
site and procedure. Concerns highlighted
during the team brief were reiterated, in
addition to team members being made
aware of the location of the difficult airway
equipment should the NIMET become
dislodged during the procedure. The time
out involves many different factors and an
in depth discussion is beyond the focus of
this article.
Patient positioning
All team members were involved in the
positioning of the patient on the operating
table. The surgeon directed the team
to initially position the patient in the
supine position with the 30 degrees neck
extension. In order to reduce the risk of
neck hyperextension and pressure ulcers
a gel head ring and shoulder supports
were placed under the patient. The patient
was then tilted into reverse Trendelenburg
(Elisha et al 2010). Placing the patient
in reverse Trendelenburg maintains
cardiovascular stability and increases
drainage from the operative site (Hamlin et
al 2009, Washington & Smurthwaite 2009).
Washington and Smurthwaite (2009)
suggested that teamwork between theatre
staff in positioning the surgical patient is
essential. Elisha et al (2010) recommended
that correct positioning should be a focus of
anaesthetic management, but responsibility
for safe patient positioning should be
shared equally between all team members
(Hamlin et al 2009). Poor positioning
is associated with significant morbidity
(Washington & Smurthwaite 2009). Correct
patient positioning optimises tissue viability;
cushioning under the shoulders and other
bony prominences relieves pressure
in addition to aiding surgical access
(Adedeji et al 2010). Adedeji et al (2010)
CASE STUDY
commented that it may only take a few
minutes for the effects of poor positioning to
have lasting effects for the patient, resulting
in pressure sores and potentially fatal
sepsis. However, it is hard to prove a direct
relationship between position, intervention
and outcome. Best practice following local
protocol should be carried out by all team
members in order to reduce the risk of harm
due to poor patient positioning.
Skin preparation and
draping
As the patient’s advocate, it is the
professional responsibility of the ODP-
surgical to maintain the sterile field and
manage the risks of infection (AfPP 2011,
HCPC 2012). Skin preparation and patient
draping requires additional consideration
in head and neck surgery as the operative
site is in close proximity to non-sterile
anaesthetic equipment and unscrubbed
team members (Corbridge & Steventon
2010). This can lead to a breach in sterility
and failure to protect the anaesthetic
circuits could result in disconnection of
anaesthetic tubing. Should the NIMET tube
become dislodged the surgeon may be
required to halt surgery until the patient is
re-intubated (Cheshire 2013). Since most
patients undergoing thyroid surgery have
altered anatomy this can take time resulting
in oxygen desaturation, hypoxia or even
death (Cheshire 2013). Throughout the
operation, the ODP anaesthetics and ODP
surgical teams worked in conjunction with
each other to ensure that the anaesthetic
equipment was not disturbed.
Haemostasis
Before the surgeon commenced closure he
evaluated and treated potential areas of
bleeding in order to gain haemostasis. This
stage of the operation required the theatre
team to work together under the direction
of the surgeon. Here the anaesthetist was
asked by the surgeon to create positive
pressure inside the lungs by placing the
patient in the Trendelenburg position. The
ODP-surgical ensured all instrumentation
was secured within the sterile field to
prevent inadvertent desterilisation.
The anaesthetist then administered
a valsalva manoeuvre (VM). One VM
technique involves applying 30cm positive
>>
39
15/02/2017 10:41
 CASE STUDY
Perioperative teamwork for the patient with a shared airway:
a case study
Continued
end expiratory pressure (PEEP) to the
anaesthetic circuit by altering the adjustable
pressure limiting valve. This increases
internal jugular pressure causing a reflux
of venous blood allowing active bleeding
points to be identified and cauterised or
ligated by the surgeon (Moumoulidis et al
2010). Communication failure at this point
by the anaesthetic and surgical teams could
result in a failure to maintain haemostasis
and blood vessels remaining open,
potentially leading to postoperative bleeding
and placing the patient at risk of airway
compromise (Hobbs & Watkinson 2007).
Pharmacological haemostatic agents
can also be applied over the RLN (for
example Surgicel®) to aid haemostasis
whilst preventing neurological trauma from
the surgical drain (Hobbs & Watkinson
2009). Ahluwalia et al (2007) concluded
that surgical drainage is not always
necessary in elective thyroid surgery
and can prolong hospital stay increasing
postoperative infection risk. The surgeon
in this case inserted a suction drain to
monitor postoperative blood loss since
postoperative bleeding can result in
laryngeal oedema, haematoma and tracheal
compression. The suction drain was
opened prior the patient leaving theatre
(Ubhi 2003).
Extubation
Extubation in theatre has the benefit of
having team members and emergency
equipment to hand should the patient
experience airway difficulties. At the end of
the operation the anaesthetist performed
a deep extubation to assess vocal cord
function with a standard laryngoscope
(O’Neill & Fenton 2008). Deep extubation,
where the ET tube is removed whilst the
patient is still fully anaesthetised, reduces
the chance of coughing during emergence.
Coughing during the immediate recovery
phase may lead to suture rupture, wound
dehiscence and oedema (Cheshire 2013).
Suction should be readily available to
remove secretions to reduce the risk
of coughing and prevent laryngospasm
(Furtado 2011).
Sign out
At the end of the operation the sign
out procedure was performed in order
ensure that the patient was safe to
40
JPP March 2017.indd 40
leave theatre. As with the other stages
of the surgical checklist, the sign out
is a standard template designed to be
used in all operations and therefore will
not be discussed in detail in this article
(NPSA 2009).
Post anaesthetic care
It is vital that the ODP-recovery, or nurse
equivalent, is competent in caring for
patients in the postoperative phase. They
should be able to respond appropriately
to patient incidents that may occur during
emergence and recovery from anaesthesia
(AAGBI 2013). The handover was given
to the ODP-recovery by the anaesthetic,
surgical and theatre teams stating pertinent
information to aid in the patient’s recovery
including medication administered and
closure materials used. Patient monitoring
including electrocardiogram (ECG), pulse
oximeter and noninvasive blood pressure
were attached and the ODP recovery
conducted an initial assessment using the
ABCDE approach (Table 4).
Failure to actively monitor the patient
at this stage may lead to undiagnosed
complications (Hatfield 2014). Furtado
(2011) stresses that in thyroid surgery
inadequate assessment may lead to airway
compromise and breathing difficulties.
Consideration was paid to the airway,
breathing and circulation (ABC) elements
of the ABCDE approach (Table 4) in the
immediate recovery phase for the patient.
Circulation will be the main focus of this
article as failure to detect haemorrhage
can lead directly to airway and breathing
problems. Disability and exposure were
performed as standard for all procedures
therefore will not be discussed in detail in
this article.
Airway assessment was the first priority
to make sure that a patent airway was
maintained by the patient throughout
A – Airway
B – Breathing
C – Circulation
D – Disability
E – Exposure
Table 4 ABCDE approach to recovery
(Hatfield 2014)
March 2017 - Volume 27 - Issue 3 - ISSN 1750-4589
recovery. Oxygen was administered
as prescribed through a Hudson non-
rebreathing mask. Assessment of the
patient’s breathing rate was undertaken.
Particular attention was given to the
breathing rate ensuring equal and bilateral
air entry into each lung, allowing the ODP-
recovery to anticipate if the airway was
becoming obstructed (Hatfield 2014).
Circulatory assessment was also used as
an indicator of a sign that the airway might
become compromised due to haemorrhage
at the operative site. Tachycardia and
hypotension may be a sign of postoperative
bleeding (Furtado 2011). Electronic
monitoring should be used in addition
to manual observation, palpation and
assessment to detect haemorrhage. A
small percentage of patients who undergo
thyroid surgery have to return to theatre
due to postoperative haematoma (Morton
et al 2012). Untreated, a haematoma can
compress on the trachea. Whilst in the
initial stages it may not be visible from the
outside, any internal neck swelling could
cause breathing problems (Furtado 2011).
Furtado (2011) advised checking the edge
of the dressing. If the dressing appears
tight, a change in neck circumference may
be an indication of swelling, which cannot
be assessed by monitoring equipment
alone. For patients undergoing a procedure
with a shared airway it is important
to handover the nature of the closure
materials used to the ODP-recovery. In
the event that the wound needs to be
opened urgently to remove a hematoma
compressing on the trachea, staple
removers or suture scissors need to be
readily available to release the closure
material if required (Hobbs & Watkinson
2007). If any of these occur this will need to
be communicated to the senior clinician for
immediate assessment (Furtado 2011).
The anaesthetist informed the ODP-recovery
that the patient has been administered with
dexamethasone, a corticosteroid with anti-
emetic properties (Weir 2013). For patients
undergoing a thyroidectomy the primary aim
of dexamethasone administration is to help
reduce the risk of laryngeal oedema (Allman
& Wilson 2011). It is a further measure
to reduce the risk of pulmonary oedema
as outlined above to avoid intensive care
admission or mortality post-surgery (Cook
& Simpson 2013). It has been suggested
15/02/2017 10:41

Electronic monitoring should be used in addition to manual observation,
palpation and assessment to detect haemorrhage
that dexamethasone can enhance voice
related quality post thyroid surgery,
however a retrospective study by Lachanas
et al (2014) concluded that no benefits
were seen.
The patient was nursed in the reverse
Trendelenburg position which helped
increase vascular drainage whilst
maintaining cardiovascular stability.
Cardiovascular stability requires the
maintenance of a patient’s normal blood
flow and is an essential part of post
anaesthetic care. Reverse Trendelenburg
makes it easier for the ODP-recovery to
assess airway, breathing and circulation
of the patient who has undergone thyroid
surgery (Furtado 2011).
Thyroid surgery requires the ODP-recovery
to be extra vigilant as failure to monitor
the patient may lead to a thyroid storm
(Elisha et al 2010). A thyroid storm (or
crisis) is a rare but serious complication
where the body’s metabolism goes into
overdrive causing severe thyrotoxicosis.
It is common in thyroid surgery due to the
manipulation of the thyroid gland during
surgical excision (Noble 2006). Signs and
symptoms include but are not limited
to: tachycardia, hyperpyrexia, altered
level of consciousness, hallucinations
and excessive sweating. Whilst rare,
thyrotoxicosis is considered to be a medical
emergency. The ODP-recovery should
contact the senior clinician if the patient
displays any of these symptoms. Patient
A’s recovery was uneventful and they were
discharged back to the ward in accordance
with local policy.
Summary
This article has examined the teamwork
required for a patient undergoing surgery
with an airway shared by the anaesthetic,
surgical and theatre teams. It draws on
a wide range of literature as supporting
evidence. The team brief helped to
inform the team of the choice of surgery,
anaesthesia, intubation techniques, patient
position and equipment required. Teamwork
and good communication between the
anaesthetist, surgeon and all members of
the theatre team is essential for patient
safety in shared airway management, in all
phases of perioperative care during head
and neck surgery.
March 2017 - Volume 27 - Issue 3 - ISSN 1750-4589
JPP March 2017.indd 41
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41
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 CASE STUDY

Perioperative teamwork for the patient with a shared airway:

a case study
Continued

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About the author
Gareth Jones
DipHE, ODP Distinction
Royal Navy Operating Department Practitioner,
Theatres, Defence Medical Group South (DMG
South), Queen Alexandra Hospital, Cosham,
Portsmouth
No competing interests declared
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42 March 2017 - Volume 27 - Issue 3 - ISSN 1750-4589

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