Difficult Airway Society E-Zine February 2024

DIFFICULT AIRWAY SOCIETY MEMBERS EZINE February 2024 Edition

February 2024

REMINDER TO DAS MEMBERS Please remember to update your details if your address or email address changes!

Members can update their details by emailing das@anaesthetists.org

WE WANT TO HEAR FROM YOU DAS encourages member participation – we would love to read your comments, contributions and suggestions for future E-Zines. Have you been involved in an interesting airway case? Is there an article that has changed your practice? Do you have an idea for improving airway anaesthesia that you would like to collaborate on? All formats welcome: text, video, photo, infographic… We know you are a creative bunch!

The E-Zine is something we are passionate about and we love to hear from you about it . We want it to be as useful to members as possible so please do get in contact with any suggestions and/or feedback - ezine@das.uk.com or tag us on X / Twitter @dasairway or @dastrainees

@dasairway @dastrainees

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Dif cult Airway Society E-Zine

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February 2024

CONTENTS Executive Updates

Trainees

Editorial

4

Trainee Competition

DAS Executive Update

5

Journal Club - Recommended Reads

DAS Scienti c Of cer Report

7

DAS Professorship Applications

9

2023 Macewen Medal - Prof Anil Patel

10

2023 DAS Professor - Prof Andy Higgs

12

31 32

Miscellaneous Airway Leads Update

33

Dif cult Airway Database

34

Education Conference Corner 2023 DAS ASM Highlights

13

Clinical Dilemma

15

What's new about CICO and eFONA?

20

WAMM 2025

36

Anaesthetic management for patients living with obesity 24 2024 DAS Webinars

28

#JanuAIRWAY - The Compilation

30

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EDITORIAL | Nisha Abraham-Thomas | Moon-Moon Majumdar |

A warm welcome to the February edition of

living with obesity. We thank all of the authors

the Dif cult Airway Society e-zine!

involved for their contributions.

We look back on another successful year for

Our clinical dilemma discusses anaesthesia

the society. We had a fantastic time at the

for laryngeal laser surgery. What do you do?

2023 DAS Annual Scienti c Meeting and

How does your approach differ in the event of

hope you did too! In this month's e-zine we

airway compromise?

share highlights from the conference.

We are incredibly excited to announce this

Congratulations goes to Professor Anil Patel who was awarded the DAS Macewen medal, and to Professor Andy Higgs who was

year's trainee competition - see more details on page 31. We can't wait to see your submissions!

conferred the 2023 DAS Professorship. A huge thank you to the local organising

Finally, we would like to say a special thank

committee for delivering such a high yield

you to our outgoing DAS trainee

educational meeting.

representative Natalie Silvey. We wish her all the best for the future!

2024 has already got off to a great start with the annual #JanuAIRWAY educational series.

As always, we love to hear from you so if you

We are eagerly looking forward to exciting

have any comments, feedback or

events ahead including the 2024 DAS ASM in

contributions, then please get in touch with

London, and the World Airway Management

our editorial team by emailing

Meeting (WAMM) to be held in Florence in

ezine@das.uk.com or tag us on X / Twitter

2025. Save the dates in your diary and

@dasairway or @dastrainees. Now, sit back

register your interest now!

with a coffee and enjoy the read!

The educational articles in this month's

Nisha Abraham-Thomas

edition focus on two hot topics in airway

Moon-Moon Majumdar

management - updates in emergency front of neck access, and anaesthesia for patients

DAS Trainee Representatives

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February 2024

EXECUTIVE UPDATE | Ravi Bhagrath | Imran Ahmad | Fauzia Mir |

Welcome to the rst edition of the DAS ezine

There were also excellent abstract

in 2024. There are a number of updates on

submissions for the poster and oral

the Airway front and numerous new projects

presentations. The enthusiastic presenters

and ideas for all of us at DAS central to

and delegate attendance at these

pursue.

presentations re ected the high quality and interest these generated. Other highlights

We have had a steady increase in our

were the 2023 DAS Professorship being

membership numbers (both associate and

awarded to Professor Andy Higgs, the

full members) with a total number of 3727

Macewen medal awarded to Professor Anil

including 332 new members in the last year.

Patel and the trade partner award going to

The attendance at the Birmingham ASM led

Simon Murray. We also welcomed Nisha

by Dr Achuthan Sajayan re ected this,

Abraham-Thomas, our new trainee

marking the end of a successful year.

representative, and look forward to working

Over 700 delegates attended the two days of Scienti c programme and with all the

The venue will be at one of the most iconic

hugely successful meeting. Delegates from

places in Central London, the Guildhall, lled

all over the world attended the 3 days lled

with history and character along with a

with fun, learning and networking. Amongst

museum to visit and explore the history of the

the excellent speakers from all over the

city. The Gala dinner will be held at the

airway world, we had Dr Richard Harris, the

House of Commons, one to be remembered

Thai cave rescue lead, who shared his experiences with the delegates. His talk was a memorable highlight and he deservedly received a standing ovation from the awe inspired audience.

with her over the next few years.

This year’s DAS ASM will be held in London.

workshops completely full, it was another

for sure. The places are restricted for this unique experience so early registration and booking is recommended, so please look out for the registration details once they are released.

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On the projects front, DAS Intubation

huge amount of interest, the Airway Leads day

guidelines are progressing well with a

led by Dr Sandeep Sudan has been planned

completion date of November 2025 at the

for March and the Regional Airway Meeting

WAMM meeting in Florence, Italy. The Ethics

(https://regionalairwaymeeting.com )in

guidelines are shaping up and nearly

Malaysia are some of the events to note in the

complete. We hope to see a full version of

diaries.

these at the London ASM in November 2024.

The FONA database led by Dr Alistair

The DAS constitution has been in need of updating and this project has now been taken

McNarry is progressing steadily and we will

over and led by Dr Alistair McNarry, so watch

be hearing updates at the next ASM.

this space. We look forward to working on all

We have been updating the DAS website over

of these exciting projects and events over the

the past year and we are delighted to

forthcoming year with you, and hope to see

announce that a new fully functional website

you all in November at the London DAS ASM.

will be launched at the end of this year. It has taken considerable effort, time and organisation by the committee to reach this

Fauzia Mir, DAS Treasurer

stage and we are almost there now!

Imran Ahmad, DAS President

DAS has an exciting year ahead with regards

Ravi Bhagrath, DAS Secretary

to the educational activities planned. A number of DAS webinars (free to DAS members) have been scheduled, the excellent Januairway series has already generated a

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February 2024

SCIENTIFIC OFFICER REPORT | Kariem El-Boghdadly | Airway management remains high-

rolling process of grant funding via

stakes, but we continue to strive to

direct application to DAS.

improve patient safety and quality.

Applications for funding of up to

In recent months, we have seen

£5,000 for studies broadly related

practice-changing publications,

to airway management will be

several projects with wide-

peer-reviewed. Further details are

reaching implications, and

available on the DAS website or by

continued interest in research.

contacting me directly. We have

DAS remains at the global forefront

already funded one application,

of this, providing several academic

and we are always open to receive more.

opportunities to members. It is down to you,

Reach out for more information on this today!

the DAS Membership, to take advantage of these opportunities, develop yourselves

2.

professionally, get engaged in academia,

DAS Grants via the NIAA. DAS funds

up to £20,000, split between large Project

and, importantly, harness the chance to

Grants (up to £15,000) and Small Grants (up

improve patient care.

to £5,000). Last year saw a single application

A CALL TO APPLY FOR OPPORTUNITIES...

round, with one application of £15,000 being

1.

received. The rst round of 2024 closes in

Direct DAS Grants. To ensure

continuity and sustainability of grass-roots

February. We look forward to receiving

airway management research, we have a

applications through this stream.

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3.

February 2024

appropriate forms of scholarship, and through

DAS PhD Programme. This

Programme gives support to researchers who

teaching and administration. Following an

have a list of publications that may be

extremely competitive series of previous

suitable to put together as a PhD. DAS will

rounds, the application will open early in 2024.

support applicants throughout the process of a PhD by publication, including funding

Our vision remains to take continue to

support.

cultivate academia through DAS and airway management, and begin to support, design

4.

and develop our own projects with our

DAS Faculty of Professors. This is

an untapped resource that is open to any

enthusiastic, creative and brilliant

DAS Member to reach out to for guidance,

membership. Don’t hesitate to reach out and

support or advice on any academic matters,

get involved!

including grant applications and study design.

Kariem El-Boghdadly 5.

DAS Professor of Anaesthesia and

DAS Scienti c Of cer

Airway Management for 2024. This is an award conferred in recognition of a member’s

scienti c-of cer@das.uk.com

national/international standing in the eld of airway management as established by outstanding contributions through publications, creative work or other

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February 2024

DAS PROFESSOR OF ANAESTHESIA AND AIRWAY MANAGEMENT: APPLICATIONS | Kariem El-Boghdadly | We are delighted to announce that applications for the DAS Professor of Anaesthesia and Airway Management 2024 will open in March! DAS Professor of Anaesthesia and Airway Management is an award conferred in recognition of a member’s national/international standing in the eld of airway management as established by outstanding contributions through publications, creative work or other appropriate forms of scholarship, and through teaching and administration.

DAS Professors of Anaesthesia and Airway Management have been awarded since 2012.

Please follow the links for the criteria and application form.

Applications open on 11/03/2024 and close at midnight on 26/05/2024. Awards will be presented at the next DAS ASM.

https://das.uk.com/das_professor_2024

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DAS MACEWEN MEDAL 2023 PROFESSOR ANIL PATEL | Ellen O’Sullivan | Professor Anil Patel graduated from University College London in 1991 and was appointed a consultant at The Royal National Throat Nose & Ear Hospital in 1999.

He is now a Consultant Anaesthetist at University College London Hospitals NHS Foundation Trust and DAS Professor of anaesthesia & airway management. He is an exceptional leader, innovator and, most importantly, clinician in his chosen area of airway management.

Locally he continues to

revolutionised oxygenation for critical airway

develop and re ne the largest individual experience of anaesthetising complex adult airway patients (>6,000) in the UK and

patients, signi cantly impacting on their safety during intubation, and for this reason has been adopted worldwide. He is a

probably worldwide.

renowned innovator and has also developed

In the last decade, industry has invested

an award winning videolaryngoscope. He has

large sums of money in his ideas. Nationally

been involved in numerous seminal

& internationally he is best known for

publications including NAP4, the 2015 DAS

introducing a new anaesthetic technique for

guidelines and the 2019 DAS Awake Tracheal

airway procedures, Transnasal Humidi ed

Intubation Guidelines, all of which changed

Rapid Insuf ation Ventilatory Exchange

practice. He received the Humphry Davy

(THRIVE). The resulting publication was

award from the Royal College of

voted best paper in Anaesthesia in 2015. His

Anaesthetists, and the Distinguished

introduction of the THRIVE technique has

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February 2024

Research Award from the International Airway

Dif cult Airway Society, his commitment to

Management Society.

clinical anaesthetic work, teaching & research. He is passionate in his quest to

He is a superb communicator and is a sought

improve patient safety from airway

after lecturer worldwide. He has 130 + peer

management complications. He richly

reviewed publications, 25 book chapters and

deserves the DAS Macewen Medal for his

an h-index of 23. He completed three years as

extraordinary contribution to the eld of airway

DAS President and in this role he coordinated

management.

expert groups to develop national guidance on important clinical areas of practice. Anil is

Prof Ellen O’Sullivan

Executive Director of WAAM (World Alliance for Airway Management) & co-chaired WAMM

Past President College of Anaesthetist of

1 in Dublin in 2015, and WAMM 2 in

Ireland

Amsterdam in 2019.

Past Vice President AAGBI

He has contributed to this subspecialty through his exemplary leadership of the

Past President Dif cult Airway Society

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February 2024

DAS PROFESSOR 2023 PROFESSOR ANDY HIGGS | Kariem El-Boghdadly| It is with absolute pleasure we report that DAS conferred the 2023 DAS Professor of Anaesthesia and Airway Management upon Andy Higgs.

Professor Higgs is well known for his sustained, highimpact contributions in the eld of anaesthesia and airway management.

In particular, Professor Higgs’s contributions to DAS as the Treasurer for 7 years, leading the DAS Guidelines on tracheal intubation in critically ill adults, and contributing to a further ve guidelines. He has been a global leader in airway management, being a core member of the ongoing PUMA Guidelines project, and authoring 32 peer-reviewed papers in airway management, of a total of 69 publications.

An expert in teaching and training, Professor Higgs has also delivered education in a wide range of forums, including courses, conferences, book chapters, educational manuals, and online. It is safe to say that Professor Higgs has had an instrumental role in improving quality and safety in airway management globally, and this award could not be more deserved.

Kariem El-Boghdadly DAS Scienti c Of cer

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DAS ASM 2023 HIGHLIGHTS FROM THE LOC TRAINEE REPS | Carl Groves | Niladri Das | After many months of

Next up was an

organisation, the DAS

engaging session

scienti c meeting was

on speciality

nally here and what a

airways covering

jam packed

paediatrics,

programme it was! Let

obstetrics and

us re ect on a

bariatric surgery.

successful 28th Annual

Swiftly followed by

Scienti c Meeting of the

Professor Cyprian

Dif cult Airway Society (DAS) UK, held at

Mendonca sharing his years of experience

the International Convention Centre (ICC) in

in interprofessional education at Coventry

Birmingham.

and beyond. Just before we descended on the lunch queue and viewed everyone’s

The meeting commenced with traditional

latest projects and posters, we were treated

and cadaveric workshops run

to a fascinating presentation of ‘How I do it’

simultaneously. The human cadaveric

scenarios.

airway workshop was held at University Hospitals Coventry and Warwickshire (UHCW). This enabled delegates to hone their practical skills with specialist airway equipment and novel airway techniques, including videolaryngoscopy, breoptic intubation and airway ultrasonography.

Delegates were also provided a rare handson experience with emergency cricothyroidotomy in the human cadaver.

The 2-day scienti c programme featured presentations from airway experts across the world to include keynote speakers Dr Richard Harris, Professor Tim Cook and Dr Malin Jonsson Fagerlund.

After a delicious lunch, we were treated to an international themed look at airway

The rst day of the scienti c programme

emergencies and the physiologically

kicked off with Professor Tim Cook giving

dif cult airway as we were visited by our

his keynote address revealing some of the

colleagues of the American, Australasian

key ndings from NAP7 into perioperative

and Turkish airway societies.

cardiac arrest.

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We were then honoured to be joined by Dr

The highlight of the afternoon session was a

Malin Jonsson Fagerlund who delivered a

battle for the ages: Professor William

keynote address on apnoeic oxygenation -

Harrop-Grif ths vs Dr Imran Ahmad in a

when, why and how? Dr Fagerlund gave an

controversial debate on airway

engaging talk enjoyed by all present. After a

management guidelines.

quick coffee break and a chance to browse

The day concluded with the DAS Presidents

the posters and projects, we were then

session taking us through the history of the

engaged in an international case based

Dif cult Airway Society and its many

discussion.

achievements.

It was a packed schedule and we were only half way through, the gala dinner awaited us!

Once again we would like to thank the organising committee for a grand conference and look forward to seeing you at DAS 2024, London, UK.

The nal day of the scienti c programme opened with an Education & Research and ODP session run in parallel. Here, alongside oral presentations, we discussed the latest in research, training opportunities and importance of human factors and ergonomics in airway anaesthesia. This was followed by a session on patient information and consent.

The morning came to a close with a captivating and awe-inspiring talk from Dr Richard Harris who shared a moving account of his involvement in the Thai Cave Rescue and received an extremely well-deserved standing ovation.

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February 2024

CLINICAL DILEMMA | What Would You Do? |

This month, we have a non-emergency clinical question for you...

Talk us through the key points of how you perform anaesthesia for laryngeal laser surgery

- How would your strategies differ if the lesion is subglottic/tracheal?

- How would your strategies differ in case of a patient with severe airway compromise?

What Would You Do? Contact us on X / Twitter with your thoughts! @dasairway @dastrainees

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February 2024

WHATWOULDYOUDO? DAS Expert Corner Airway Expert 1: Fundamental concerns with laser laryngeal surgery are airway re (requires the re triangle: oxygen, heat, fuel) and shared airway.

Principles are: Communicate with team re: risks of airway re Be prepared for airway re Use lowest safe oxygen concentration during laser Use safest equipment that will not form a source of fuel for a re Airway aims: tracheal intubation with a laser-resistant tracheal tube. If awake tracheal intubation is required, then perform ATI with a nasal tube, induce anaesthesia, and then change the tube under general anaesthesia to an oral laser tube. Use the smallest acceptable laser tube to facilitate access. Ensure the cuff is in ated with saline. Ensure neuromuscular blockade throughout. Use TIVA. Reduce FiO2 during lasering.

How would your strategies differ if the lesion is subglottic/tracheal?

For a subglottic lesions, a laser tube would not be suitable. In this setting, I would induce anaesthesia in the operating theatre with the surgeon ready to perform the procedure. When the patient is paralysed, the surgeon would place the rigid laryngoscope, and I would then perform subglottic jet ventilation with 100% oxygen. I would stop jetting before laser begins, and restart when done. I would not use continuous oxygen during laser, such as HFNO.

How would your strategies differ in case of a patient with severe airway compromise?

I would ensure a tracheostomy kit is available and ready. I would scan the neck and mark the cricothyroid membrane. I would have HFNO cannulae on the patient for when the patient is getting on the table and before the rst lasering. I would turn the HFNO off during lasering and only turn it on again once lasering is complete.

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Airway Expert 2: History, examination, investigation always

rst with these patients. Previous surgery, presenting

degree of airway symptoms and what did the last FNE look like.

Team plan - the management of these patients solely depends on your surgeons and your skill set.

You may use an MLT placed asleep, an ATI to place the MLT, or a tubeless eld with HFNO or highpressure source jet ventilation (HFJV).

How would your strategies differ if the lesion is subglottic/tracheal?

Team planning crucial here. Management depends on how subglottic the lesion is which will be determined by pre-op FNE and imaging. Your plan may then be as for a glottic lesion (above) or require cardiothoracic input.

How would your strategies differ in case of a patient with severe airway compromise?

With severe airway compromise consider a double set-up (see Canadian Airway Focus Group guidelines 2021).

Induce in theatre with surgeons prepared for a FONA. Manage as in section 1 with the best anaesthetic and surgical operator doing the rst attempt.

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Airway Expert 3: How would your strategies differ if the lesion is subglottic/tracheal?

This is a common clinical scenario on our airway list, especially following the COVID pandemic where many patients underwent prolonged intubations and tracheostomy related complications, resulting in subglottic stenosis. The key airway considerations are: 1. Inability to intubate, therefore a tubeless technique will need to be considered, and 2. a laser safe technique will need to be planned.

Options available are: [1] apnoeic oxygenation using a THRIVE technique [2] supra-glottic jet ventilation using manual jet ventilator via the suspension laryngoscope [3] supra-glottic HFJV using a jet ventilator like the Twinstream or Monsoon [4] Sub-glottic HFJV via a laserjet catheter and a jet ventilator My preferred technique would be: Start the patient on HFNO using Opti ow Switch nasal prongs and compatible humidi er TIVA technique for the anaesthesia Induce anaesthesia in theatre Theatre team already primed and ready Once patient is asleep and paralysed, FMV can be started over the Switch, until suspension laryngoscope has been successfully positioned Commence HFJV via the suspension laryngoscope Turn off the HFNO Reduce the FiO2 to 30-40% Can commence laser, once all safety checks completed How would your strategies differ in case of a patient with severe airway compromise?

This makes the whole process a lot more challenging and the airway technique chosen will depend on the reason for / location of the airway compromise.

If this is because of the stenosis then you may need to consider placing a SGA so that one can ventilate through this via the anaesthetic machine or using the Twinstream jet ventilator during the laser treatment (which will have to be via a exible CO2 laser).

If the cause is supra-glottic, then I would use a 2 stage technique. Stage 1 is to safely secure the airway and stage 2 is to safely perform the surgery. I would initially perform an awake nasendoscopy in theatre, assess the level of the airway obstruction and subglottic stenosis and decide whether it would be possible to intubate this patient. If possible then I would like to do this awake. Once intubated, then I would induce anaesthesia and consider the best options for stage 2. This could be any of the techniques mentioned above, but obviously the ETT would have to be removed to allow for surgical access.

If I decided that it is not possible to intubate from above then I would consider a tracheostomy.

I would also warn the patient that they may require a surgical tracheostomy, regardless of the level of the airway compromise

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February 2024

WHAT'S NEW ABOUT CICO AND EFONA? | Paul Baker | Pre-hospital FONA

Introduction

A recent systematic literature

The concept of emergency front

search of prehospital FONA

of neck access (FONA) is not

attempts found an overall

new. There have been plenty of

crude mean success rate of

name changes and variations in

100%.2 This was a review of

techniques through the

69 studies and 1229 patients.

centuries, but the basic concept

The study included patients

remains the same. If a person

after 2017 when a UK pre-

cannot breathe because their

hospital practice guideline

airway is obstructed, and reasonable attempts have failed to relieve that obstruction above the neck, the inevitable life-saving manoeuvre requires establishment of an airway below the obstruction. Success is determined by rapid application of knowledge, skill and behaviour by the rescuer. The outcome from this

promoted a scalpel bougie technique.3 In this review, pooled overall FONA median success rate was 88%, surgical technique success was 100%, and needle success was 50%. Paediatric results were insuf cient to reach any conclusion about optimum technique in this age group.

emergency depends on the speed of

The study concluded that success rate for

treatment. A closed claims study in the USA

FONA is high, with surgical techniques for

found that in over 60% of cases where there

FONA appearing to be more successful than

was a cannot intubate, cannot oxygenate

needle techniques. This conclusion supports

(CICO) event, a surgical airway was

current guidelines from the UK and other

obtained, but was too late to avoid a poor

countries.4-6 More research is required to

outcome.1

determine the most effective paediatric

This article aims to provide an update on

FONA technique.

emergency FONA. The content will include

These latest remarkable success rates with

an overview of adult and paediatric

scalpel bougie technique in prehospital

recommendations, and a discussion of the

patients have not been replicated in the

important issues surrounding this subject.

hospital environment. However, a success rate of 100% has been reported before by Lockey et al, from the London Air Ambulance service.7 In a BJA podcast, Lockey

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February 2024

Table 1. Keys to FONA success. Taken from BJA podcast, D Lockey

discussed the keys to the FONA success.

was detected with some skills declining as

(Table 1).

early as one month. The authors recommended a FONA skill “brush-up” at three months. This type of training is

Other tools used by pre-hospital clinicians to

particularly important for infrequent high

optimise FONA success include check lists

stakes events such as CICO, where skills

and standardisation.8 By reducing choices

cannot be maintained by normal daily clinical

and standardising the operator reacts faster.

activity.11

Increasing choice increases reaction time.

According to the Hick-Hyman Law, increasing the number of choices will increase the decision time logarithmically.

Reaction time increases by 35% when a choice increases from one to two.9,10 This is an argument to remove the menu of emergency FONA devices, and standardise to one technique.

Human factors Clinician behaviour is another important aspect of emergency airway management.

Human factor issues have recently been highlighted with two comprehensive reviews of human factors associated with airway management.12,13 Many airway practitioners will see out their entire career without ever having to perform an emergency airway.

Education

Unless regular training is used to simulate

As with any procedural skill, regular practice

this life-threatening event, the average airway

is required to maintain pro ciency. A recent

practitioner may nd themselves thrown into

study of eFONA performance found retention

this unexpected event, unprepared. Regular

of this single technical skill was up to three

training for adult and paediatric patients is

months. After this period some loss of skill

recommended. Practitioners’ stress and

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February 2024

Table 2. Strategies to improve task management during stressful situations. Taken from Kelly FE, Frerk C, Bailey CR, et al. Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Dif cult Airway Society and the Association of Anaesthetists: Guidelines from the Dif cult Airway Society and the Association of Anaesthetists. Anaesthesia. 2023;78(4):458-478.

anxiety can be modi ed to improve task

a baby in airway distress can be particularly

management in these stressful situations.

daunting. Due to the maldistribution of paediatric healthcare in some countries, specialist adult airway practitioners may nd

Paediatric FONA

themselves called in an emergency. Prior

Approximately 25% of the world’s population

training for paediatric FONA is therefore

are children, aged 15 yrs or less. In

recommended for all airway practitioners.

underdeveloped countries the percentage

A practice guideline for infants and neonates

increases to 40%. This group, particularly the

has recently been published.14 Although it

neonate and infant age group, is under-

states that there is little evidence to support a

represented in the literature. When

strong recommendation, the guideline

considering CICO and FONA some airway

proposes that a surgical tracheostomy

guidelines omit infants and neonates. These

represents the preferred emergency access

babies can be some of the most demanding

to the trachea in neonates and infants. This is

patients for airway management due to their

based on dif culty inserting needles into an

unique anatomy and physiology. Airway

infant’s trachea, the compliant nature of the

management for these patients also requires

infant trachea and the contraindication of a

age dependent equipment and modi ed

cricothyroidotomy, due to the risk of trauma,

techniques. For airway practitioners who

small dimensions and the location which is

specialise in adults, being called to manage

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February 2024

relatively high in the neck and anteriorly

application of any airway management

inclined.

technique or tool in three or more attempts

Animal studies have de ned the details of a

without deviation or change, or the return to a

FONA for infants and neonates. One

technique or tool that was previously

publication includes a helpful video.15

unsuccessful.” This common fault was

Another study compares two similar scalpel

identi ed in 25% of closed claims in the

techniques, concluding that a scalpel-bougie

latest ASA study.20

tracheotomy was slightly faster, more popular

Considerable progress has recently been

and associated with fewer tracheal injuries.16

reported concerning FONA. Lessons can be

The other consideration for infant FONA is

learnt from this research. The next important

ventilation. This becomes more important if

step is to adopt and implement new

the chosen option is a cannula. A recent

recommendations.21 Over to you!

bench study demonstrated excessively high pressures and ows consistent with barotrauma, or inadequate ow when using

Paul A Baker

most recommended cannula ventilation

Associate Professor, Department of

devices.17 When completing FONA, it is

Anaesthesiology, University of Auckland

important to consider the safety of

President, Society for Airway Management

subsequent ventilation. Cannula ventilation, with most recommended devices, requires a high-pressure ventilation source which needs

Link to references

to be regulated and monitored in the interest of safety.

Summary Simple concepts for airway management include maintaining oxygenation and avoiding trauma.18 In adult and paediatric patients where CICO leads to FONA, these simple concepts need to be kept in mind. A recent systematic review with meta-analysis con rmed that apnoeic oxygenation in children during tracheal intubation increases rst-pass success and helped maintain stable conditions by sustaining normal oxygenation.19 Avoiding trauma could apply to perseveration which is de ned in the 2019 ASA Closed Claims Analysis as “the consistent

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ANAESTHETIC MANAGEMENT FOR PATIENTS LIVING WITH OBESITY IT IS EVERY ANAESTHETIST’S JOB | Eleanor Warwick | Becky Black | BMI have an Background

increased risk

Patients living with

of airway,

obesity are

breathing,

increasingly

circulatory

presenting for

and metabolic

anaesthesia in all

complications,

surgical

this has also

specialities.1

been

Regardless of

previously

where anaesthetists

reported. In

work, we are all going to be managing the

the BIGAA study those patients living with

care of these patients and, as such need to

obesity were signi cantly more likely to

be able to do this safely. The 7th National

experience complications when undergoing

Audit Project (NAP 7) was published in

anaesthesia than their non obese

November 2024 and quoted that 1 in 3

counterparts, unsurprisingly the

patients presenting to anaesthetists are living

complications increased with the class of

with obesity. Worryingly the increases in BMI

obesity.3

are most prevalent in the higher classes of obesity (>35 kg m2) and the trends in

Anaesthesia and those living with obesity

increased BMI in those presenting for anaesthesia are above that of population

As anaesthetists the management of the

trends.2 These

airway is at the forefront of everything we do

ndings con rm previous

study results where the incidence of obesity

and safe prediction and planning for dif cult

in those presenting for surgery was found to

airway management is key to delivering care

be 32%,3 compared to an incidence in the

to our patients. The 4th National Audit Project

general population of 26%.4 The prevalence

(NAP 4)6 stated that too often obesity is not

of obesity is also greatest in deprived areas

identi ed as an airway risk factor and

(33%) whereas it falls to 20% in the least

anaesthetic technique is not modi ed and

deprived areas4 and the rates of childhood

with NAP 7 citing more airway complications,

obesity are rising; over 10% of reception age

what does this actually mean for airway

children are classed as obese and this

management? Is a high BMI associated with

increases to over 23% by age ten.5 NAP 7

dif cult intubation? Studies have shown that

highlighted the fact that patients with a high

this is not the case,7,8 but this doesn’t mean

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Dif cult Airway Society E-Zine

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we can be complacent. By far the most

can also provide up to date patient

common airway complication is desaturation.

information12 and initiate shared decision

Without appropriate planning, a patient living

making conversations about treatment

with obesity can end up with hypoxia and

options. Patient facing language and a non-

other airway complications such as

stigmatising stance is absolutely key13,14 in all

reintubation, aspiration, failed face mask

the interactions perioperatively, not only for

ventilation, airway trauma, and oesophageal

the success of the procedure but also

intubation. All of these events can make

because positive patient health interactions

ultimately securing the airway more dif cult

may improve a patient’s health in the long

and more stressful for those involved. We all

term.15

dread the perilous sound of a dropping saturation monitor and avoiding this for the safety of our patients and our own

Planning for airway management and

performance is key. So, what can we do?

optimisation Perhaps of most interest to the readers of this

Robust perioperative planning and risk assessment

article, when presented with patients with a high BMI we need to think about the airway and how we are going to safely manage this.

It is key when presented with patients with a

To do this, we must consider the impact of a

high BMI in the elective or emergency

high BMI on a patient’s anatomy and

situation, time is taken to appreciate the BMI

physiology and what implications this has on

of the patient and the impact this may have

airway management. As we have stated

on comorbidities, and them as an individual.

earlier, intubation may not necessarily be

Effectively managing the airway and safety of

more dif cult but to set ourselves up for safe

the patient is integrally linked to this. With

airway management, thought must be given

over 7.6 million patients on elective surgical

to optimising our chances of success. A brief

waiting lists,9 there is time preoperatively to

revision of the FRCA is needed here. Patients

start treating obesity as a chronic disease,10

living with obesity have anatomical changes:

recognise concordant comorbidities like

increased deposition of fat in the upper

diabetes, hypertension, cardiovascular

airway; particularly the tongue and

disease, and obstructive sleep apnoea

pharyngeal walls and increased fat

(OSA) and use the time preoperatively to

deposition in the upper back, neck and

plan anaesthetic management of these

chest. We know these changes can make

patients in an evidenced based way

preoxygenation and bag mask ventilation a

(guidelines currently under review).11 The

lot harder so we should be prepared for this.

time preoperatively should also be used to

The functional residual capacity (FRC)

instigate appropriate risk assessment,

reduces exponentially with body mass

regardless of whether the patient is waiting 1

index16 and the FRC may become less than

hour for surgery or over 1 year. Risk

the closing capacity (CC) causing airway

assessment is something that was identi ed

collapse, atelectasis and increased risk of

as missing in this patient group in NAP 7. We

hypoxia. The relationship between FRC and

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Dif cult Airway Society E-Zine

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February 2024

CC is further exacerbated by anaesthesia

continued for apnoeic oxygenation after

and the supine position. Patients with a high

induction, can be successful.17 It is important

BMI have an increased basal metabolic rate

to remember that HFNO does not allow

and work of breathing.16 Taking these

measurement of ETO2, relies on a patent

anatomical and physiological facts together

airway, and any desired PEEP effect also

in clinical terms, simply means those living

needs the patient to have their mouth closed.

with obesity have a smaller reserve of oxygen and they use it quicker. This, coupled with the fact that they may be harder to preoxygenate and/or or mask ventilate when asleep, means desaturation can occur rapidly. So, what do we do? The good news is that simple modi cations can make a huge difference.

1)

Anaesthetise your patient in the

operating theatre. Position your patient on the operating table in a ramped position. Sit the table up, use a wedge like the oxford pillow or use pillows underneath the shoulders and head. Positioning on the operating table also means the patient does not need to be supine for transfer from the bed and can position themselves to help protect pressure areas. Consider a hover mattress under the patient to aid with transfer at the end. You will also need a stool to access the airway so make sure one of these is handy.

2)

Preoxygenate your patient thoroughly

and effectively. There is no gold standard technique and different anaesthetists will do this in a variety of ways but know what works for you. Five minutes via a good tting face mask with ve vital capacity breaths prior to induction is many bariatric anaesthetist’s technique of choice, with the option to add

3)

Induce anaesthesia basing most

drugs on ideal or lean body weight (IBW or LBW) and titrate to effect as you would for any other anaesthetic. However, check drug dosing and whether you should use IBW, LBW or, actual body weight using the SOBA app.

4)

Have an aggressive ventilation

strategy to maintain oxygenation after induction of anaesthesia and paralyse the patient effectively and rapidly. Strategies for ventilation include use of an immediate Guedel, two hand mask technique and using the ventilator or an assistant to ventilate for you, monitoring tidal volumes. A top tip is to also have a second-generation laryngeal mask (LMA) handy as this may make ventilation prior to intubation a lot easier. As we mentioned above, HFNO can be used in the apnoeic stage in experienced hands, with a patent airway and in the correct position.

5)

Plan and execute intubation: Use a

videolaryngoscope as PLAN A provided airway assessment has not agged up any indications for warranting another technique.

Brief the anaesthetic team about plans for failure.

5cmH2O positive end expiratory pressure (PEEP) via the APL valve. This also allows for

Extubation and postoperative recovery

end tidal oxygen measurement. However,

planning

studies have shown that the use of high ow nasal oxygen (HFNO), which can then be

NAP 7 has highlighted an increase in postoperative events in patients living with

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Dif cult Airway Society E-Zine

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obesity2 and anaesthetists must be alert to airway complications in the postoperative period. Often, extubation and post operative

Conclusions

destination are overlooked. This is not to say

Whether or not you anaesthetise for

every patient living with obesity requires

metabolic surgery, the reality is we are all

Level 2 or 3 care, day surgery may well be

becoming bariatric anaesthetists. We have

appropriate, but attention must be paid to

highlighted the key areas where we feel

planning the appropriate post operative

anaesthetists must focus their efforts when

destination.

caring for those living with obesity: robust

The same attention to detail is needed at extubation as it is at intubation, and this is not unique to those living with obesity.

1)

Make sure that you have a patient

preoperative evaluation and risk assessment; planning for airway management; and optimsation of extubation and post operative destination. The techniques suggested are practical and effective and can be done by

who is optimally positioned, sat up and

anyone regardless of level of training and

already transferred to their bed. This will

institution. With the ever increasing rates of

avoid any movement and lying the patient at

obesity, it really is time to make optimal care

when their airway is no longer secure.

of these patients a priority for all

2)

anaesthetists.

Ensure the neuromuscular blockade

is fully reversed and we would advocate routine use of sugammadex.

3)

Dr Eleanor Warwick

Ventilate the patient with 100%

oxygen until they are awake and cooperative, bearing in mind patients with a high BMI

ST6 Anaesthetics and SOBA Trainee representative

tolerate spontaneous ventilation poorly in the supine position.

Dr Becky Black

4)

Consultant Anaesthetist and Vice President of

Only remove the endotracheal tube

when you are sure the patient can maintain

SOBA

their own airway. Consider extubation onto HFNO or CPAP depending on the patient’s Link to references

history.

5)

Ensure continuous postoperative

monitoring as per guidelines18 and set clear

View the Society for Obesity and Bariatric

targets for recovery. Review patients for any

Anaesthesia (SOBA) one page guidance

concerning signs postoperatively. If things

sheet here

have not gone to plan or you are concerned about a patient, re-evaluate the original postoperative plan.

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DAS WEBINARS 2024 | Gunjeet Dua | Tom Lawson | Moon-Moon Majumdar | Nisha Abraham-Thomas |

After excellent feedback from last year's webinars, in 2024 we are planning further events!

Watch this space for upcoming webinars on...

• NAP 7 • Oxygenation • Patient information • Top airway management publications from the journal Anaesthesia For all members of the multidisciplinary team #LearnTogether @dastrainees #DASeducation

Members will be emailed details of upcoming webinars including registration details from the DAS Secretariat. Please ensure your email address is up to date so as not to miss information on events.

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Dif cult Airway Society E-Zine

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metrics will de ned by your SMART aim but

often shared at the team Tuesday meeting.

have agreed to help with a mentoring service, for future patients, which is in development. ✦ Wider Organisation

Those stakeholders funding your service will need a clear business plan alongside the vision for your service.

Celebrating wins within the team is vital in

Empower Action

maintaining drive and enthusiasm but

Establishing overall service goals and setting

should also be widely shared to sustain

aims empowers all members of the team to

change.

drive new services forward.

Leverage and Sustaining Change

Assigning

smaller projects, based on speci c aims, and

Leverage Wins to Drive Change

regular meetings to discuss progress allows individuals to work independently but within a

The prehabilitation service successes have

supportive team environment.

been presented in forums ranging from local presentations to inter national

Celebrate Quick Wins

meetings. Demonstrating value increases

Some project outcomes may take months or

credibility and creates leverage when

years to become apparent, for example

redesigning aspects of your service or

changes in length of stay or mortality.

when persuading other teams to engage.

It is

therefore important to consider what demonstrates success in the short term. This could be as simple as receiving the

rst

referrals and interacting with the rst patient cohort.

Celebrating achievements maintains drive, encourages others to adopt practices and is one step towards embedding the process in culture so that engagement becomes the norm rather than the

An early ‘win’ experienced by the UCLH team was the

rst quanti able improvement in

CPET results seen in a patient who had

exception.

Embed in Culture

The sense of

Sustaining change can be just as

achievement helped unite and motivate the

challenging as implementing a new

team.

service.

completed the programme.

Conviction in the service was further

compounded by patient feedback which was

Projects which rely on a single

individual or have unintended adverse consequences are especially vulnerable.

The UCLH prehabilitation service bene ts f ro m h a v i n g a t e a m o f m o t i v a t e d colleagues such that when individuals are not available the service continues to run.

Planning future developments can also

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#JANUAIRWAY 2022 THE COMPILATION | freely available and downloadable on issuu |

AVAILABLE HERE!

@dastrainees @vapourologist #DASeducation

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TRAINEE COMPETITION | Infographic competition | We are pleased to announce the 2024 DAS Trainee Competition:

DESIGN A DAS INFOGRAPHIC! The winner will receive £100 in prize money, will have their work published in the DAS E-

zine, and displayed at the 2024 DAS ASM. Infographics are an innovative way to display information and explain concepts clearly and memorably.

We invite you to design an infographic on any topic related to dif cult airway

management.

Consider how you can present this in a visual format and create your infographic!

Infographics should be visually appealing and generally contain little text. Any images used should be cited (creative commons, public domain, or personally taken or designed).

Infographics must be original work.

1.

Entries are invited on any dif cult airway management topic, but must be original. The author/creator must be a DAS member and trainee.

2.

Members of the DAS committee will judge anonymised entries.

3.

We will be judging infographics based on content and relevance to DAS, depth of information conveyed and ease of interpretation, and how visually pleasing they are/ calibre of artistry/originality.

4.

Label your le ‘DAS Trainee Infographic Competition’. The name of the author/creator, author/creator’s institution or other identi able information should NOT be included in the le title or content.

5.

Please submit les in .jpeg or .pdf format in high resolution, as one page/image only

6.

Please send in your infographic to trainee@das.uk.com, along with a completed submission form which can be requested from trainee@das.uk.com or downloaded from the DAS website.

7.

Prize money of £100 and a certi cate will be awarded to the rst prize winner. The infographic will be published in the DAS E-zine, as well as displayed at the 2024 DAS ASM.

8.

Winners will be contacted by email.

9.

Deadline for receipt of emailed infographics: Midnight on 14th April 2023

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JOURNAL CLUB | Recommended Reads | Welcome to the DAS Journal Club - Recommended Reads. Papers are chosen by members of the DAS committee, with short citations/summaries by members of the ezine editorial team. This edition's recommended reads come from Kariem El-Boghdadly with summaries

by Moon-Moon Majumdar. We welcome member feedback and thoughts on the papers featured and also what discussion occurred at your journal club - please get in touch @dastrainees or @dasairway or email us at ezine@das.uk.com.

✦ Baettig

SJ, Filipovic MG, Hebeisen M, Meierhans R, Ganter MT. Pre-operative gastric

ultrasound in patients at risk of pulmonary aspiration: a prospective observational cohort study. Anaesthesia. 2023 Nov;78(11):1327-1337.

This study categorised patients undergoing elective or emergency surgery as 'low risk' (empty, gastric volume ≤1.5ml/kg of body weight) or 'high risk' (solid, mixed or gastric

uid volume

>1.5ml/kg body weight) and asked examiners whether they would make any changes to their aspiration risk management plan.

Would you change your aspiration prevention plan based on a pre-operative gastric ultrasound?

✦ Broms J, Linhardt C, Fevang E, Helliksson F, Skallsjö G, Haugland H, Knudsen JS, Bekkevold

M, Tvede MF, Brandenstein P, Hansen TM, Krüger A, Rognås L, Lossius HM, Gellerfors M. Prehospital tracheal intubations by anaesthetist-staffed critical care teams: a prospective observational multicentre study. Br J Anaesth. 2023 Dec;131(6):1102-1111.

This study looked at 422 drug-assisted tracheal intubations and examined rst-pass success for tracheal intubation. The rate of rst-pass success was 89.2% for intubations in-cabin vs 86.3% outside the cabin - is this a signi cant difference? Is the on-scene time affected by this decision?

Read the article and make up your mind!

We would love to hear what transpired from your journal club! Get in touch @dastrainees or email ezine@das.uk.com

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AIRWAY LEADS UPDATE | Sandeep Sudan | question here by Monday 19

This is directed towards our Airway

February 2024. You may be

Leads (AWLs) network.

selected to present for three

It was great to catch up with some

minutes at the online event on

of you in Birmingham - and maybe

your topic for discussion. If there

we can make this a regular item at

are multiple submissions on the

DAS ASMs. In the meantime, RCoA

same theme, then we may only

and DAS are delighted to announce

take one speaker, selected at

the 7th Airway Leads Day to be

random.

held online on Friday 15 March 2024. This is a free event but does require advance booking, which you can do here.

Airway Leads Day 2024 | 15 March 2024 Soapbox - have your say!

Programme coming soon but we will include

Please do consider contributing to this day

talks on the paediatric airway, sustainability,

in either format, especially if you haven't

NAP7, debrie ng and safety reports.

done so before.

Based on the positive response to the Best

If you have any queries about this day, or

Practice presentations delivered at past

indeed anything else related to your role,

Airway Leads days, we would again like to

please contact awl@rcoa.ac.uk. Which

invite submissions to be included in the

reminds me, any updates or omissions to

2024 programme. You are invited to submit

the AWLs network in your area, please do

1 page of A4 on an aspect of your role as

let us know so that we maintain an up to

an AWL. If there are aspects of your work

date database.

and role that are exemplary and could be

BW

bene cial to others, then don’t miss the chance to disseminate and showcase your work. Up to ve AWLs will be invited to

Sandeep Sudan RCoA-DAS Airway Lead Adviser

present for 10-minutes at the event, followed by a moderated discussion with the virtual audience around the issues raised.

We would also like to invite questions for the ‘Soapbox – have your say!’ session. Do you have a pertinent question or an unresolved issue? Would you like to raise a topic that you think AWLs should be addressing? If so, then do submit your

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February 2024

WORLD AIRWAY MANAGEMENT MEETING | Ellen O’Sullivan | Following on from the success of WAMM 1 in Dublin in 2015, and WAMM 2 in Amsterdam in 2019, WAMM 3 is set for 2025 in Florence!

Register your interest today!

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WHAT'S NEW ABOUT CICO AND EFONA? | References 1/2 | 1. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the Dif cult Airway: A Closed Claims Analysis. Anesthesiology. 2005;103(1):33-39.

2. Morton S, Avery P, Kua J, O'Meara M. Success rate of prehospital emergency front-of-neck access (FONA): a systematic review and meta-analysis. Br J Anaesth. 2023;130(5):636-644.

3. Lockey DJ, Crewdson K, Davies G, et al. AAGBI: Safer pre-hospital anaesthesia 2017: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2017;72(3):379-390.

4. Frerk C, Mitchell VS, McNarry AF, et al. Dif cult Airway Society 2015 guidelines for management of unanticipated dif cult intubation in adults. 2015;1(6):827-848.

5. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the dif cult airway: part 1. Dif cult airway management encountered in an unconscious patient. Can J Anaesth. 2021;18:18.

6. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the dif cult airway: part 2. Planning and implementing safe management of the patient with an anticipated dif cult airway. Can J Anaesth. 2021;08:08.

7. Lockey D, Crewdson K, Weaver A, Davies G. Observational study of the success rates of intubation and failed intubation airway rescue techniques in 7256 attempted intubations of trauma patients by pre-hospital physicians. Br J Anaesth. 2014;113(2):220-225.

8. Burgess MR, Crewdson K, Lockey DJ, Perkins ZB. Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists. Emerg Med J. 2018;35(9):532-537.

9. Hick WE. On the rate of gain of information. Quarterly Journal of Experimental Psychology. 1952;4(1):11-26.

10. Hyman R. Stimulus information as a determinant of reaction time. Journal of Experimental Psychology.

1953;45(3):188-196.

11. Nielsen MS, Lundorff SH, Hansen PM, et al. Anesthesiologists' skills in emergency cricothyroidotomy mandate a brush-up training after 3 months-A randomized controlled trial. Acta Anaesthesiol Scand. 2023;20:20.

12. Kelly FE, Frerk C, Bailey CR, et al. Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Dif cult Airway Society and the Association of Anaesthetists: Guidelines from the Dif cult Airway Society and the Association of Anaesthetists. Anaesthesia. 2023;78(4):458-478.

13. Kelly FE, Frerk C, Bailey CR, et al. Human factors in anaesthesia: a narrative review. Anaesthesia.

2023;78(4):479-490.

14. Disma N, Asai T, Cools E, et al. Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Br J Anaesth. 2024;132(1):124-144.

15. Berger-Estilita J, Wenzel V, Luedi MM, Riva T. A Primer for Pediatric Emergency Front-of-the-Neck Access. A A Pract. 2021;15(4):e01444.

16. Riva T, Goerge S, Fuchs A, et al. Emergency front-of-neck access in infants: A pragmatic crossover randomized control trial comparing two approaches on a simulated rabbit model. Paediatr Anaesth. 2023;10:10.

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WHAT'S NEW ABOUT CICO AND EFONA? | References 2/2 |

17. Mann CM, Baker PA, Sainsbury DM, Taylor R. A comparison of cannula insuf ation device performance for emergency front of neck airway. Paediatric anaesthesia. 2021;11:11.

18. Henderson JJ, Popat MT, Latto IP, Pearce AC. Dif cult Airway Society guidelines for management of the unanticipated dif cult intubation. Anaesthesia. 2004;59(7):675-694.

19. Fuchs A, Koepp G, Huber M, et al. Apnoeic oxygenation during paediatric tracheal intubation: a systematic review and meta-analysis. Br J Anaesth. 2023;28:28.

20. Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB. Management of Dif cult Tracheal Intubation: A Closed Claims Analysis. 2019;1(4):818-829.

21. Kelly FE, Frerk C. Guidelines are only as effective as their uptake and implementation. 2023;1(7):918-919.

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ANAESTHETIC MANAGEMENT FOR PATIENTS LIVING WITH OBESITY IT IS EVERY ANAESTHETIST’S JOB | References 1/2 | 1. Kane AD, Soar J, Armstrong RA et al. Patient characteristics, anaesthetic workload and techniques in the UK: an analysis from the 7th National Audit Project (NAP7) activity survey. Anaesthesia 2023; 78: 701–11.

2. NAP7 report on perioperative cardiac arrest | The Royal College of Anaesthetists.https://www.rcoa.ac.uk/news/nap7report-perioperative-cardiac-arrest (accessed January 3, 2024).

3. Shaw M, Waiting J, Barraclough L et al. Airway events in obese vs. non-obese elective surgical patients: a crosssectional observational study. Anaesthesia 2021; 76: 1585–92.

4. Overweight and obesity in adults. NHS Digital. https://digital.nhs.uk/data-and-information/publications/statistical/ health-survey-for-england/2021/overweight-and-obesity-in-adults (accessed January 17, 2024).

5. Baker C. Obesity statistics. 2024 Jan 17.

6. NAP4: Major Complications of Airway Management in the United Kingdom | The Royal College of Anaesthetists.https://www.rcoa.ac.uk/research/research-projects/national-audit-projects-naps/nap4-majorcomplications-airway-management (accessed January 18, 2024).

7. Moon TS, Fox PE, Somasundaram A et al. The in uence of morbid obesity on dif cult intubation and dif cult mask ventilation. Journal of Anesthesia 2019; 33: 96–102.

8. Mehta AR, Maldonado Y, Abdalla M et al. Association between body mass index and dif cult intubation with a double lumen tube: A retrospective cohort study. Journal of Clinical Anesthesia 2022; 83: 110980.

9. NHS backlog data analysis. The British Medical Association is the trade union and professional body for doctors in the UK. https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis (accessed January 19, 2024).

10. RCP calls for obesity to be recognised as a disease. RCP London, 2019. https://www.rcplondon.ac.uk/news/rcpcalls-obesity-be-recognised-disease (accessed June 22, 2023).

11. Members of the Working Party, Nightingale CE, Margarson MP et al. Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia. Anaesthesia 2015; 70: 859–76.

12. Anaesthesia and your weight | The Royal College of Anaesthetists.https://www.rcoa.ac.uk/patients/patientinformation-resources/lea ets-video-resources/anaesthesia-your-weight (accessed January 3, 2024).

13. GUIDELINES. SOBA UK. https://www.sobauk.co.uk/guidelines-1 (accessed June 22, 2023).

14. Selak T, Selak V. Communicating risks of obesity before anaesthesia from the patient’s perspective: informed consent or fat-shaming? Anaesthesia 2021; 76: 170–3.

15. Moonesinghe SR. The Anesthesiologist as Public Health Physician. Anesthesia & Analgesia 2023; 136: 675.

16. Pelosi P, Croci M, Ravagnan I et al. The effects of body mass on lung volumes, respiratory mechanics, and gas exchange during general anesthesia. Anesthesia and Analgesia 1998; 87: 654–60.

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February 2024

ANAESTHETIC MANAGEMENT FOR PATIENTS LIVING WITH OBESITY IT IS EVERY ANAESTHETIST’S JOB | References 2/2 | 17. Schutzer-Weissmann J, Wojcikiewicz T, Karmali A et al. Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high- ow nasal oxygen delivery. British Journal of Anaesthesia 2023; 130: 103–10.

18. Klein AA, Meek T, Allcock E et al. Recommendations for standards of monitoring during anaesthesia and recovery 2021. Anaesthesia 2021; 76: 1212–23.

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Winter 2019

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