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DIFFICULT AIRWAY SOCIETY MEMBERS EZINE

January 2022 Edition

Dif cult Airway Society E-Zine

January 2022

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! Send us your thoughts at ezine@das.uk.com.

@dasairway @dastrainees

Contents

January 2022

CONTENTS Trainees

Executive Updates Editorial

Competition

Letters to the editors

The fellowship of the (cricoid) ring

DAS Executive Update

Journal Club - Recommended Reads

Introducing the new DAS President

Introducing the new DAS Honorary Secretary

DAS Scienti c Of cer Report

Miscellaneous DAS Welcomes

Tribute to Dr Nick Wharton

New DAS Guidelines - management of haematoma after thyroid surgery

Professor Tim Cook: Macewen Medal recipient

Airway complications in the era of enhanced aerosol precautions - the AeroComp project

Unexpected oesophageal intubation

HSRC-DAS eFONA Registry

DAS Surveys Update

Dif cult Airway Database - an update

Education Educational Series - Mark Barley on Processed EEG: Part 2

Clinical Dilemma

Guy’s Airway Management Course 2022

#JanuAIRWAY

Scottish Airway Group 2022

DAS Webinars

DAS 2021 Conference

SALG-DAS Patient Safety Conference

Simulation videos in human factors and ergonomics training

Conference Corner

Interview Peter Young - John Smith Innovation Award Winner

Dif cult Airway Society E-zine

Dif cult Airway Society E-Zine

January 2022

Happy New Year and welcome to your rst

another great clinical dilemma to get you

instalment of the DAS members ezine in

thinking along with updates on

2022! We are delighted to have two new

#JanuAIRWAY, DAS Webinars, the DAS 2021

members to our editorial board (Moon-Moon

Conference and the SALG-DAS Patient

Majumdar and Natalie Silvey) and bid a sad

Safety Conference.

farewell to Valerie Lan-Pak-Kee who has been instrumental in transforming the ezine into what it is today. Thank you Valerie - we will really miss you!

We talk to the John Smith Award for Innovation winner Dr Peter Young. We’re also delighted to launch a new trainee c o m p e t i t i o n , s h a re o u r j o u r n a l c l u b

This edition is jam packed. It kicks off with an

recommended reads and DAS updates on

update from our executive and introductions

new personnel, the eFONA Registry, Dif cult

to our new President (Dr Imran Ahmad) and

Airway Database and Surveys. We also have

Honorary Secretary (Dr Ravi Bhagrath). We

fantastic articles on the use of simulation

also have an update from our Scienti c

videos in human factors and ergonomics

Of cer (Dr Kariem El-Boghdadly) and

training and the AeroComp project that aren’t

information on the new DAS Guidelines on

to be missed.

management of haematoma after thyroid surgery which were published in September. Dr Fiona Kelly has very kindly taken the time to pen a piece on our Macewen medal recipient Professor Tim Cook and a heart warming tribute to former colleague Dr Nick Wharton.

Please grab a cuppa and enjoy everything this edition has in store. If you have any feedback or article contributions please get in touch with our editorial team by emailing ezine@das.uk.com or tag us on Twitter @dasairway or @dastrainees.

Our educational theme continues with learning on unrecognised oesophageal i n t u b a t i o n , p a r t 2 o f M a r k B a r l e y ’s educational series on processed EEG,

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Dif cult Airway Society E-Zine

January 2022

LETTERS TO THE EDITORS | Please get in touch, we love hearing from you! |

To: ezine@das.uk.com From: Dr Patrick Ward, Consultant Anaesthetist, NHS Lothian, Scotland Subject: Changing room humour: Maxillofacial surgeons’ style!

Contents

January 2022

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

Re ecting over the past couple of years

tirelessly over the last six years serving DAS

brings back memories of not only covid and

and its members to a very high standard.

lockdowns, but of the times before covid hit

During their term as the President and

as well. Though we can say we have nearly

S e c r e t o r y, B a r r y a n d I m r a n , h a v e

survived one of the worst pandemics of

accomplished a number of achievements

recent times, the after effects of the disease

such as ATI Guidelines, a hugely successful

still lingers on in the form of memories of

WAMM 2019 conference, several research

loved ones, colleagues and patients we lost

grants, Publication of COVID intubation

to the pandemic. Anaesthesia, being on the

consensus document and the most recent

forefront in the ght against the disease, has

DAS 2021 Conference amongst others. They

seen the worst aspect of the disease in the

have indeed served the Society and its

form of not only losing colleagues but also

members during a very tough time in its

suffering from the effects of an over worked,

history, leading during the pandemic with

burnt out and to a certain extent disengaged

nancial constraints and challenges such as

workforce. Teaching and training has suffered

delayed/postponed ASMs leading to the rst

like it never did before. Although, the

ever online webinar and annual Conference

pandemic has taught us resilience it has

in the history of DAS. We thank them both for

taken away our opportunities to interact with

an excellent period of leadership and service

each other which helped with team building

to the Society and its members.

and development.

We also welcome Imran Ahmad who will join

As we prepare for one of the toughest winters

us as the new President and Ravi Bhagrath

for the NHS in its history, we also celebrate

who has been appointed as the DAS

the coming year with new opportunities and

secretory after the 2021 elections. They have

members joining the team to consolidate the

both brought with them a wealth of

foundations of airway skills, education and

experience and new ideas to incorporate in

research for the years to come. We have had

the running of the Society. The team has also

to say goodbye to Barry McGuire who worked

been joined in by our Trainee reps, Moon-

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Dif cult Airway Society E-Zine

January 2022

Moon and Natalie, who have already

looking forward to the Airway Leads day in

introduced a number of positive changes and

the new year. Dr Alistair McNarry is already

new ideas to the group. We are looking

planning this and is well known for delivering

forward to a new modernised website, new

the most well organised and interesting

look to the trainees competition for the E-Zine

meetings.

and a face to face annual meeting next year.

So, with all the new additions and ideas we

We have had an excellent online Annual

welcome the coming year and the new

Scienti c meeting this year, thanks to the

chapter for DAS which our brilliant DAS

hard work of the organising committee. With

committee along with the support of our

over 850 registrations and a programme full

members is ready to explore. We wish

of new and exciting topics covered by

everyone in the DAS family a very happy

excellent speakers, it was a meeting which

new year and please stay safe during these

will be remembered by all for a long time. We

challenging and unpredictable times.

had excellent debates, clinical topics as well as research and education aspects of airway management and abstracts from all over the world. The new innovation session was universally popular amongst attendees and the how I do it session was well liked by all. In November we also co-hosted the Patient Safety Conference with the Safe Anaesthesia Liaison Group (SALG) and are already

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Dif cult Airway Society E-Zine

January 2022

INTRODUCING THE NEW DAS PRESIDENT | Imran Ahmad |

DAS has been part of my life ever

and guided me towards

since I started anaesthetics back

developing an interest and career

in 2001. I still remember the

in dif cult airway management.

excitement I felt when my abstract

Over the years I continued to

on dif cult airway trolley contents

submit abstracts at subsequent

was accepted as a poster

DAS ASMs, some of which won

presentation at the Oxford ASM in

prizes and this further

2001. This excitement then

strengthened my love for the

changed to a feeling of nervous

Society. I regularly taught on the

tension when I found out that I was presenting

DAS airway workshops and attended almost

this poster in the main session of the ASM on

every ASM. My dream was to one day be part

Day 2! This sense of stress then rapidly

of the DAS committee and maybe one day

changed into a feeling of terror when none

even give a talk at an ASM!

other the legendary Dr Adrian Pearce introduced himself before asking me a

My next major DAS breakthrough was my rst presentation as an invited speaker, again I

question after my presentation!!

was so honoured to share the stage with likes That was my rst introduction to DAS and it

of Anil Patel, Tim Cook and other international

left a mark on me. As a rst year anaesthetist,

airway experts and present my work on

I had contributed to the biggest anaesthetic

advanced airway management. This then

society in the UK and the sense of honour

opened the door for me to join the DAS

and privilege I felt was enormous. I was being

committee as its rst surveys coordinator in

introduced to legends such as John Lehane

2011. Since then I have continuously been in

and Archie Brain and remember thinking I

the DAS committee undertaking various roles.

can’t believe that I am meeting these ‘airway

I am now one of the longest serving

celebrities’!!

committee members in the history of DAS

My training took me through the various

and have served under the Presidencies of

hospitals in the Oxford deanery and this

Ellen O’Sullivan, Jairaj Rangasami, Anil Patel

meant I worked under a number of DAS

and Barry Maguire.

stalwarts such as Mansukh Popat, Chandy

Whilst being on the DAS committee I was

Verghese, Atul Kapila and Jairaj Rangasami.

fortunate enough to be involved in the writing

They were all my mentors and role models

of the 2015 DAS intubation guidelines and 8

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Dif cult Airway Society E-Zine

January 2022

then chair the DAS ATI guidelines which we

It is such a privilege for me to become the

published in 2019 and I have also been a co-

President of DAS and I will do my best to

author on the recently published guidelines on

emulate the excellent work my predecessors

the management of haematoma after thyroid

have done. I have been very fortunate to

surgery. Airway management guidelines are a

inherit an outstanding committee who no

major part of DAS work and I hope to support

doubt will support me in achieving all our

the writing of more guidelines in the future.

goals and continue the exceptional work of

Working under such eminent leadership and

our illustrious Society.

being involved with the DAS committee for so many years I have been fortunate enough gain invaluable experience in dealing with DAS matters and hope to use this experience and knowledge in taking DAS forwards over the next three years. Areas that I would particularly like to focus on include the DAS Website, development of an airway fellowship database, more involvement of trainees and anaesthetic assistants and updating the 2015 intubation guidelines.

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Dif cult Airway Society E-Zine

January 2022

INTRODUCING THE NEW DAS SECRETARY | Ravi Bhagrath | My interest in airway management

years, the head and neck work

as a trainee was encouraged by

challenging and constantly

Adrian Pearce when I ran my rst

evolving but they also allowed me

airway workshop - hunting around

time to stay involved in the

Smith elds Market in the small

teaching and training. DAS has

hours asking for tracheas

been central to my whole career

garnering strange looks from the

and I've been lucky enough to

butchers.

have been involved in the 2015 'Intubation Guidelines' and the

Once appointed as a Consultant at Barts Health, Adrian encouraged us newbies to get more involved in DAS, teaching and

2019 ATI Guidelines with my fellow DAS Execs.

lecturing at the DAS ASMs. This once a year

DAS is a great platform for us to encourage

airway teaching encouraged the RCoA to set-

debate and change in anaesthesia. We're a

up similar workshops which I'm still involved

respected and popular society both at home

with today. This has been a great opportunity

and worldwide. The unfortunate events over

for frequent small group teaching which has

the past months and years show us that we

evolved over the years; we're now teaching

have much work still to do and with the

planning and execution, human factors as

dynamic team on Council and the enthusiasm

well as new bits of kit. It's also been a forum

of the members I know we can achieve much.

for us airway enthusiasts to discuss projects

I look forward to being the Society's new

and teaching, usually at The Square Pig,

Honorary Secretary and to seeing many of you

translating into bringing new ideas and

in person in Newcastle in 2022!

methodology to a larger audience at DAS. A decade of examining for the FRCA was the best form of CPD I've yet to come across but also reinforced the notion that zeal, excellence and a network of likeminded folk can improve the way we practice anaesthesia in the UK. I've had huge support from my department both at Barts and The Royal London over the

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Dif cult Airway Society E-Zine

January 2022

SCIENTIFIC OFFICER REPORT | Kariem El-Boghdadly | As the pandemic has continued to

together as a PhD. DAS will

evolve, with more variants, re-

support applicants throughout the

escalation of transmission

process of a PhD by publication,

precautions, and changes to

including funding support.

every aspect of clinical service

3. DAS Faculty of Professors.

d e l i v e r y, r e s e a r c h h a s

This is an untapped resource that

underpinned our decision-making.

is open to any DAS Member to

Airway management research, in

reach out to for guidance, support

particular, continues to thrive, with national

or advice on any academic matters, including

studies seeking to understand the implications

grant applications and study design.

of new ways of working on patient outcomes. DAS has continued to play a vital role in supporting academic anaesthesia with several exciting opportunities worth considering.

Management for 2022. This is an award national/international standing in the

eld of

Direct Grants. To ensure continuity and

airway management as established by

s u s t a i n a b i l i t y o f g r a s s - ro o t s a i r w a y

outstanding contributions through

management research, we have now agreed

p u b l i c a t i o n s , c re a t i v e w o r k o r o t h e r

to have a rolling process of grant funding via

appropriate forms of scholarship, and through

direct application to DAS. Applications for

teaching and administration.

funding of up to £5,000 for studies broadly

More details can be found by contacting me

related to airway management will be peer-

and keep your eye out for the adverts soon!

reviewed. Further details will soon be available on the DAS website or can be obtained by contacting me. ✦

DAS Professor of Anaesthesia and Airway conferred in recognition of a member’s

1. DAS Grants. ✦

We will also soon open applications for the

Our vision remains to continue to develop academia for DAS and airway management, and begin to harness, design and develop

NIAA Grants. Through bi-annual funding

our own projects with our enthusiastic,

through the NIAA, DAS funds project grants

creative and brilliant membership. Don’t

up to £15,000 and small grants up to £5,000.

hesitate to reach out and get involved!

Applications are made via the NIAA, so keep your eyes on the website for the next funding Kariem El-Boghdadly

rounds 2. DAS PhD Programme. This programme

DAS Scienti c Of cer

gives support to researchers who have a list of

Scienti c-of cer@das.uk.com

publications that may be suitable to put

@elboghdadly

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Dif cult Airway Society E-Zine

January 2022

NEW DAS GUIDELINES: MANAGEMENT OF HAEMATOMA AFTER THYROID SURGERY | Helen Aoife Iliff | Kariem El-Boghdadly | Guidelines from the Dif cult Airway Society, British Association of Endocrine and Thyroid Surgeons (BAETS) and ENT-UK on the management of haematoma after thyroid surgery were published in September 2021 in Anaesthesia Journal. The guidelines have been written primarily to improve patient safety and we would encourage everyone to read it—it is open access and available here. They have been presented at a number of anaesthetic and surgical meetings including the DAS, BAETS and ENT-UK annual scienti c meetings with overwhelmingly positive feedback. While these guidelines are speci c to thyroid surgery there may be wider applicability to other forms of neck surgery. We would encourage local multidisciplinary team discussions around implementation and training opportunities. We thank the Royal College of Anaesthetists for joining ourselves, BAETS and ENT-UK to host a webinar on the guidelines on the 25th November. It proved very popular with >1150 registrants and fantastic feedback from those who attended live. We would particularly like to thank Gunjeet Dua (DAS Education co-lead) for her work in organising the webinar, and Imran Ahmad, Jeremy Davis, Allison Harris, Shahab Khan, Jo O'Connor and Taran Tatla for their contributions. You can watch the webinar here:

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Dif cult Airway Society E-Zine

January 2022

PROFESSOR TIM COOK: MACEWEN MEDAL RECIPIENT | by Fiona Kelly and Barry McGuire | | Consultant Anaesthetist, Friend and Colleague, Bath | | Consultant Anaesthetist, Immediate Past President DAS, Dundee | Professor Tim Cook needs li le introduc on to DAS members. He is a consultant in Anaesthesia & Intensive Care Medicine at the Royal United Hospital in Bath; DAS Professor; Director of Na onal Audit Projects and an RCoA advisor on Airway. DAS were delighted to award him the Macewen Medal at our virtual conference in 2021. The Macewen Medal is awarded to recognise and honour dis nguished members of the society for their service to DAS and airway management. It is a pres gious mark of excellence and the highest award given by DAS. It is a great pleasure to provide this

sharing expert re ection and

citation for Professor Tim Cook,

learning on the issues surrounding

who has been awarded the DAS

these cases . Many would say that

Macewen Medal 2021 in

this is the most important piece of

recognition of all that he has done

airway research in a generation – it

for airway management, patient

has been extensively cited and has

safety and anaesthesia.

made a lasting impact on airway management all over the world. His

Tim is an internationally recognised

other publications are numerous

authority on airway management.

and hugely varied, and include work

Tim’s academic output is extraordinary, with

related to videolaryngoscopes, supraglottic

more than 400 publications to date: this is

airways, capnography, emergency front of

even more remarkable bearing in mind that

neck airways and airway databases, plus

he is a fulltime clinician in a busy DGH with

emergency laparotomies, neuraxial

no recognised academic time. There can be

connectors, NAP3 (neuraxial blocks), NAP5

few anaesthetists in the UK with a more

(accidental awareness under anaesthesia),

impressive CV.

NAP6 (anaphylaxis) and more recently

Tim’s airway work includes being lead author

COVID-19.

of NAP4, a landmark study published in 2011, that aimed to capture all serious complications of airway management in the UK during a one year period, determining the frequency with which these occurred and

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Dif cult Airway Society E-Zine

January 2022

Tim’s support of the anaesthetic trainees here

practice everywhere. Other stand out

in Bath means that many (including me) have

attributes include his enthusiasm and real

learnt from him about research, writing papers

desire to provide the very best care he can for

and abstracts, applying for grants and

our patients, his extensive knowledge of the

replying to a journal editor-in-chief who initially

literature and his apparent need for minimal

rejects your paper - indeed his list of

sleep. His drive and determination are key to

publications does read a little like a list of

his success – I can remember one airway lead

trainees who have worked in Bath over the

complaining on the phone (while being

past 20 years. When I was a registrar, Tim

harangued by Tim for NAP4 data) that Tim

had multiple supraglottic airway studies in

had the “tenacity of a tax inspector!”

progress at any one time which he encouraged us to get involved with, and it was unusual to pick up a copy of Anaesthesia that did not include at least one article written by him.

What those of you who see him speak at conferences and read his papers may not realise is that Tim is also a wonderful colleague. He is the rst to offer to help with a tricky patient, swap an on-call if he can or

Airway training has been a big priority for Tim

cover for you if you are sick. He is

over the years – he set up regular

mischievous, funny, kind and caring beneath

multidisciplinar y out-of-theatre airway

his ‘legend’ exterior – he loves a good pun

workshops in Bath over 15 years ago, and for

and a witty comment in our department

the past ve years has been instrumental in

WhatsApp groups. Despite his international

those becoming mandatory for all permanent

work, he prioritises his work for our

members of staff in our department. He

department, doing numerous M&M

supported the DART (Dif cult Airway Rescue

presentations, designing and redesigning our

Techniques) course when it was set up in

anaesthetic chart, leading our enhanced

Severn 14 years ago, and has taught on

recover y programme and emergency

airway workshops at DAS, RCoA, WAMM and

laparotomy work and having a view on most

worldwide.

things! When shielding during the COVID-19

Many things make Tim stand out from the rest of us - one is his ability to look at a problem from a different perspective to everyone else. When all our standard Macintosh laryngoscopes needed replacing in Bath in 2013, it was Tim who suggested that we put the money required to replace them into a business case to acquire enough

pandemic rst wave, while all other sensible consultants in a similar position used the opportunity to get out on their bikes, do some DIY/gardening and bake sour dough, Tim took to his desk, putting in 16+ hour days and p ro d u c i n g i n t e r n a t i o n a l l y re c o g n i s e d guidelines, protocols and papers in a truly proli c manner.

videolaryngoscopes to enable their use for all

I have been told that the DAS Macewen Medal

intubations in our hospital. It was a completely

is awarded for ‘Airway Greatness’ – an ‘Airway

novel idea at the time, but one that has now

Legend’ award as it were. We are thrilled in

been implemented in other hospitals around

Bath to see Tim’s hard work recognised in this

the world and may one day become standard

way – very many congratulations to you Tim.

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January 2022

UNEXPECTED OESOPHAGEAL INTUBATION | Learning from events | Many DAS members will be familiar with the case of Mrs Glenda Logsdail, a former NHS Radiographer, who tragically died after being anaesthetised for a ‘straight-forward’ case of acute appendicitis. The Coroner recorded the cause of her death as “hypoxic-ischaemic encephalopathy resulting from a failure to correct a misplaced endotracheal tube.” He went on to add, “Her death was wholly avoidable and was contributed to in major part by neglect.” The Coroner subsequently issued a Regulation 28: Report to Prevent Future Deaths, speci cally identifying the Royal College of Anaesthetists as a body who had the power to prevent such deaths in the future. [The primary purpose of a Regulation 28 order is to prevent other deaths from similar causes or risks, so it's sent to those who are in a position to take action to reduce the risk] The Presidents of the RCoA, DAS and the Association of Anaesthetists issued a joint letter in response which recognised the importance of Human Factors, a attened hierarchy ( attened authority gradient) and in situ multidisciplinary team training in dealing with emergency situations. The letter can be viewed here. The case is currently featured on the RCoA website, was discussed during Professor Cook’s keynote lecture at the recent DAS annual scienti c meeting, presented in detail at the joint DASSALG meeting also in November 2021, and will have had an entire session dedicated to it during the College’s Winter Symposium in December 2021. Any discussion of the events surrounding Mrs Logsdail’s death must be sensitive and sympathetic but should recognise and build on her family’s commitment to ensure that this does not happen again. So what do we know about unrecognised oesophageal intubation already? In the last ve years the President of the RCoA has received seven Regulation 28 orders related to the airway and undetected oesophageal intubation has been sadly a recurring theme. NAP41 was clear that, even during a cardiac arrest, an attenuated capnograph waveform should be seen with a tracheal tube in situ. Other causes of a at capnography trace do exist but in the event of a at capnograph trace active exclusion of oesophageal intubation should be the rst priority.

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Dif cult Airway Society E-Zine

January 2022

[image taken from the NAP4 report] Given the Coroner’s report, the ‘No Trace Wrong Place’ video is essential viewing for every anaesthetist, who must consider its implications for their practice. Much like the pre-take off safety brie ng on an aircraft, even those who have seen it before, anaesthetists and anyone who manages the airway would bene t from seeing it again. Watch the “No Trace Wrong Place” video here.

In the case of Mrs Logsdail, the coroner speci cally highlighted the role of Human Factors, including the facts that we, as humans, are fallible and liable to make mistakes however well trained, hardworking and conscientious we are. Our physiological make up means that we tend to perform less well in high pressure situations (in short, everything that makes us behave entirely unlike a predictable machine). But what does that mean in practice? No one involved in airway management would ever intentionally place a tracheal tube in the oesophagus. Similarly, every anaesthetist knows that an absent CO2 trace means that accidental oesophageal intubation must be excluded. So, what goes wrong and, more importantly, how can it be prevented? The suggestions below encompass the Human Factors and Ergonomics subjects of Design, (stopping errors from occurring in the rst place), Barriers (a way of trapping/ identifying errors and preventing harm) and Mitigations (strategies for reducing the potential impact of an error). For a more technical analysis of these aspects please see the article by Joy and Kelly.

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Dif cult Airway Society E-Zine

January 2022

i. Use the best tools – the process of tracheal intubation is a technical skill which can be taught and learnt. The Cochrane Review in 20162 proved that videolaryngoscopy (VL) is more effective than conventional (direct) laryngoscopy at successfully placing a tracheal tube. Therefore, using the best equipment will make this easier, freeing up headspace for nontechnical skills. The VL screen allows a shared view of intubation, but it must be positioned in a way that helps an assistant see exactly what is happening. If using a device with an integrated screen, the operator and assistant must consider how to share the view. ii. Use the best assistance – trained practitioners to assist the anaesthetist are vital. To provide best assistance (and therefore improve team performance) we must: a. Train Together – Ahead Ahead of the 2019 grand prix season the Williams Formula 1 Team (responsible for two cars in a race) had practised pitstops over 1200 times to make the team as ef cient as possible.3 The option of rehearsing an intubation with the same team 1200 times before doing it is clearly unrealistic but training together is vital. DAS has always been at the forefront of encouraging training together – please see the details of the SMART Course from 2011 here. [This doesn’t mean that there us anything wrong with an individual’s attendance at a (national) airway workshop – but it is vital that the learning is shared locally upon their return] b. Train locally – Develop an institutional awareness and knowledge. One of the problems in this case was that the airway pressure trace was mistaken as the capnograph trace by one doctor. Standardisation of theatre monitor layout within a hospital (perhaps nationally or even internationally), both in terms of colour and position on the screen, could help prevent this. c. Empower colleagues – Multidisciplinary team training and good brie ng can empower nonanaesthetists, and less senior colleagues, to speak up. If they are concerned that the tracheal tube may be incorrectly positioned anyone, regardless of grade, should be able to say “if there is ‘No Trace’ we should actively exclude oesophageal intubation”. In a crisis anyone can become task- xated and ‘inadvertently blind’ to other possibilities. iii. Space and Time – Since the introduction of the 2015 guidelines (which state that a right handed person should stand on a patient’s left to perform eFONA) the amount (or lack) of available space to conduct procedures in the anaesthetic room has been a recurring issue amongst delegates attending airway workshops. The cramped conditions of an anaesthetic room were highlighted by the Coroner in his report. Is it time for all emergency cases to be anaesthetised in theatre – or at least time for a rethink on where we anaesthetise our patients in the UK? Patients are routinely anaesthetised in the operating theatre in other countries and COVID-19 has made us more familiar with this style of working.

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Dif cult Airway Society E-Zine

January 2022

Time to train – multidisciplinary training requires team members to be free to attend training together – short, targeted interventions e.g. before the start of a list may make this possible. None of these suggestions will be new to anaesthetists, but they are important considerations to integrate into the behaviour of an individual, a department and an institution – indeed for every team member involved in airway management. There are of course topics for discussion; many Airway Leads already provide excellent local training in airway management for the multidisciplinary team. Asking the question “should provision or attendance at such events be mandatory?”, is much more complex than it

rst

appears as it will require the collaboration of many stakeholders to achieve. However, in light of this case, aspiring to mandatory local provision of multidisciplinary training must remain rmly on the DAS agenda. The Dif cult Airway Society will be working together with the Royal College of Anaesthetists and the Association of Anaesthetists to ensure that the lessons of the case are effectively communicated such that future events can be avoided.

Dr Imran Ahmad

Dr Barry McGuire

DAS President

DAS Immediate Past President

Dr Alistair McNarry

Dr Abhijoy Chakladar

Dr Lewys Richmond

Airway Leads Co-ordinator

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Dif cult Airway Society E-Zine

January 2022

Image courtesy of Dr Fiona Kelly, highlighting that well designed systems are better at preventing errors than any other intervention.

References 1.

Cook T, Woodall N, Frerk C. 4th National Audit Project of The Royal College of Anaesthetists and The Dif cult Airway Society (NAP4) Major complications of airway management in the United Kingdom. Report and ndings. Cook T, Woodall N, Frerk C, editors. London;

Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. In: Lewis SR, editor. Cochrane Database Syst Rev [Internet] UK: John Wiley & Sons, Ltd; 2016 [cited 2017 Jun 13]. p. CD011136 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27844477

No Title [Internet]. [cited 2021 Nov 29]. Available from: https://www.formula1.com/en/ l a t e s t / a r t i c l e . g o n e - i n - 1 - 8 8 s - p u t t i n g - t o g e t h e r- t h e - p e r f e c t - f 1 - p i t stop.3lLKnEoPKdJgACsUn9IltC.html

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INTRODUCTION TO PROCESSED EEG: PART 2 Educational Series | Mark Barley

Many thanks to Mark Barley, consultant anaesthetist at Nottingham University Hospital, for this second part of his two part series on pEEG. In this article Mark talks us through monitoring the anaesthetised brain, the effect of different agents, and what happens during emergence.

Maintenance of Anaesthesia A more intuitive way of interpreting the EEG is via the Density Spectral Array (DSA) or ‘spectrogram’. This is available on the Masimo Sedline, Narcotrend and BIS (after upgrading the user interface software to v3.5)1. The spectrogram clearly demonstrates the changes in EEG frequency over time and makes the EEG “patterns” of anaesthesia with a variety of drugs easy to appreciate. The brain-states associated with unconsciousness have been repeatedly demonstrated with ultra-slow induction and emergence of anaesthesia correlated with high-density EEG and stimulus-response clinical assessment [1] as well as fMRI, primate, human lab and clinical studies. A density spectral array is constructed from a Fourier Transform of a time period (epoch) of EEG to produce a power spectrum, where frequency is plotted against amplitude. This is a good way of visualising the distribution of the EEG signal and has high temporal resolution as it is rapidly updated. Despite being a component of all algorithms, a power spectrum is only displayed on the Narcotrend system. For those not familiar with the Density Spectral Array and how useful it is, a brief overview is presented here:

https://www.medtronic.com/covidien/en-us/support/software/patient-monitoring-products/bis-software.html

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Propofol Anaesthesia maintained with propofol has a characteristic alpha/delta pattern – the 8-12Hz alpha pattern arises from highly structured thalamocortical oscillations which interfere with cortical information processing. The delta oscillations arise from impaired local cortico-cortical communication[1] – this fragmentation of communication between brain regions contributes to the state of anaesthesia.

Alpha Delta Figure 1 Propofol Spectrogram - clear alpha/delta pattern. Narcotrend [72m TIVA TCI, 2uV window]

The EEG pattern can be observed in this clip:

Volatiles Like propofol, the GABAergic effect of volatiles produces an alpha/delta pattern, however volatiles have effects at a wider range of receptors. As the end-tidal concentration of a volatile agent increases beyond 0.8 aaMAC50, theta (5-7Hz) oscillations become obvious[2], producing “ ll in” of the alpha/delta tramlines seen with propofol. The suggested mechanism is a dosedependent agonism of T-type calcium channels producing profound thalamic deafferentiation[3]. Low frequency beta oscillations are also more apparent.

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Theta ' ll in'

Figure 2 Sevo urane spectrogram – note “ ll in”. Narcotrend [55F Sevo, Thyroidectomy. 10uV window]

It’s helpful to refer to the raw EEG and power spectrum (if available) to appreciate the formation of the DSA:

Figure 3 Anaesthesia with propofol and sevo urane have different EEG morphologies; with sevo the power in the theta band is appreciable on both the power spectrum and spectrogram. Composite diagram from Narcotrend data. [top, 22F TIVA Tonsillectomy, bottom 26M Sevo Lap Appendix. Both DSA @ 10uV]

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“The Gap” NAP5 highlighted “the gap” as a time of risk for awareness. This is the pharmacokinetic delay in reaching an adequate effect-site volatile concentration following rapid redistribution of an IV induction bolus. The complex 4-compartment kinetics of sevo urane leads to a 2.25-minute delay from an “adequate” end-tidal concentration equilibrating with the brain[4]. Stimulation during this period may cause arousal. Transient washout can be observed when moving from the anaesthetic room to theatre to an unprimed anaesthetic machine. This can be minimised by careful overpressure or the use of continuous anaesthetic delivery with TIVA TCI. These pharmacokinetic effects can be visualised as a loss of theta oscillations:

Ketamine Processed EEG devices are calibrated with EEGs recorded from patients undergoing anaesthesia with GABAergic agents, where the characteristic frequency slowing, increasing amplitude, phase relationships and reduced entropy are readily distinguishable from the “awake” EEG. Ketamine presents a problem for most pEEG devices as the dissociative anaesthetic state is created by reducing GABA release causing neuronal excitation and higher frequency oscillations[5] – these high frequency oscillations are hypothesised to create unconsciousness by disruption of connectivity in fronto-parietal neural networks[6,7], a different mechanism to the GABAergic agents. A bolus of ketamine for induction produces a ‘gamma burst’ pattern with alternation between alternating slow-delta and gamma frequencies[8].

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Subhypnotic doses of ketamine (0.2-0.5 mg.kg) during TIVA maintenance produce a characteristic 15Hz oscillation[9], with onset around 2 minutes after administration.

Figure 4 Raw EEG pre/post 30mg ketamine, note higher frequency oscillations following administration

Figure 5 ”Ketamine kick” – the effect of 35mg ketamine, note shift to higher frequencies with loss of alpha power after around 2 minutes. [54m TIVA TCI, OGD, Narcotrend]

This video clip clearly illustrates the temporary increase in frequency:

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Burst suppression Burst suppression refers to a brain state of alternation between high amplitude “bursts” of activity on a background of a suppressed or at EEG baseline (generally +/- 0.5uV). The morphology of the bursts is agent speci c, with propofol displaying the smallest amplitude and briefer duration compared with iso urane[10]. Despite differences in the calculations used[11], the suppression ratio can be generally considered as the % of every minute where the EEG is essentially isoelectric. Burst suppression is a pathological brain state associated with post-operative delirium[12,13]. Older male patients with underlying cardiac disease have the greatest incidence of suppression[14]; it is thought to indicate a brain susceptible to the effects of anaesthesia indicating overdose[13,15,16].

Figure 6 Raw EEG – Burst suppression

Although an excessive dose of anaesthetic agent is the commonest cause of burst suppression particularly post induction, it is important to rule out other physiological processes affecting brain metabolism such as hypotension, hypoxaemia, hypoglycaemia and hypothermia.

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This video demonstrates a period of suppression following induction:

Emergence Emerging from general anaesthesia isn’t the opposite of induction, seven distinct “emergence trajectories” have been described, some associated with an increased incidence of postoperative delirium[17-19]. The emergence patterns for volatiles and TIVA are different:

Figure 7 Emergence trajectories of sevo urane (left) and propofol (right). Notice the loss of theta oscillations as ETaa falls below MAC50 with sevo before the delta and alpha amplitude decreases (cooler colours)

When using pEEG devices with a signi cant lag time, patients can awaken with index values still within the supposed optimal range for anaesthesia. This is partly explained by delay calculating the index value, which is always “behind” the EEG and also as older brains, which generate less alpha power don’t always emerge via an alpha or spindle oscillatory pattern of higher frequencies (with higher index values). In gure 14, the increasing alpha to beta frequency power will produce an increasing index value whereas in contrast the bottom DSA trace will remain at a lower index value until the point of eye opening – context (decreasing ETaa or Ce/Cp), stimulus and vigilance for cranial nerve signs of awakening[20] are key in anticipating eye opening and timing smooth extubation.

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Figure 8 DSA traces from a "young" brain and "old" brain demonstrating different emergence patterns. Final marker arrow indicates eyes open.

Conclusion Processed EEG monitoring is increasingly available and will undoubtedly play a greater role in delivering more personalised anaesthetic dosing. Practice and pattern recognition beyond “numbers” is a very learnable skill and satisfying as correlation with pharmacokinetics and dynamics is readily observable. The neuroscience behind the mechanisms of action of our hypnotic drugs is mature and bene ts in addition to avoiding AAGA accumulate. Some 85 years since Gibbs, Gibbs and Lennox rst observed the characteristic EEG changes of anaesthesia, the time is right to make pEEG routine.

Learning resources: www.eegforanesthesia.iars.org www.icetap.org

References available here

Share your comments on twitter @chronotrope @dastrainees or email us at ezine@das.uk.com

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CLINICAL DILEMMA | What Would You Do? |

Many thanks to Moon-Moon Majumdar, ST5 Anaesthetic Reg, for this edition’s challenging case:

26 year old female

presents following an attempted suicide, and has

injured her anterior neck with a hedge trimmer. On examination, she is anxious. She has air and a small amount of blood specks coming out of her anterior neck (her neck is bubbling) through a 2cm jagged wound. When she covers her wound with her hand she is able to speak, and gives you a history. She has no added airway noises. She has a respiratory rate of 28 and saturations of 96% on room air. Her heart rate is 100 and her BP is 110/65. She is GCS 15. Her primary survey suggests isolated neck injury. She has had a CT neck and chest excluding major vascular injury and showing no obvious bony c-spine injury. However, it demonstrates partial tracheal disruption, and a hole in the anterior trachea. The ENT surgeons would like to perform a tracheal ‘patch’ to seal the defect. She is slim (BMI 20, weight approximately 55kg), Mallampati 1, and is able to sublux/protrude her jaw. She is currently reluctant to extend her neck to demonstrate to you the range of motion of her cervical spine. 1. What is your plan? 2. What would you do if this patient was unstable/uncooperative?

What Would You Do? Contact us on twitter with your thoughts! @dasairway @dastrainees

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WHATWOULDYOUDO? DAS Expert Corner Airway Expert 1: Thoughts: 1. Urgency. There is time to ensure everything is ideal prior to GA.......Best team, best location [ENT theatre], full MDT planning. 2. FNE with all present to assess airway and damage. 3. Assumption that tracheal hole is extra thoracic [otherwise need to ensure thoracic surgical presence and even potential need for ECMO] 4. Need agreement that it will be possible to get ETT with cuff BELOW the hole. Clearly positive P ventilation via upper airway must be avoided so options are spot vent GA or ATI. I would favour ATI to allow very careful tube passage. 5. ATI. This should be straightforward but one issue may be impingement of railroaded ETT so i would want to try to visualise pass ETT passage if possible [with VL or a second FB]. It may only be possible to view the hole with primary FB - in which case, railroading will have to be done with great care and operator must stop if tube passage has any resistance. 6. If safe ATI:FB cannot be performed successfully, i would be proposing an alternative awake technique, most likely tracheostomy. I would deliver low ow nasal oxygen [and avoid HFNO] and Remi conscious sedation during this. If an awake technique was impossible, then i would plan for sport vent GA with slow TIVA propofol/ low dose Remi. I would have Rocuronium 1.2/kg drawn up if airway instrumentation impossible without paralysis and obvious need to convert to paralysis to enable atraumatic tube passage or rigid bronch. I would have my surgeon scrubbed and ready for 1. Emergency tracheostomy assuming access to the trachea at or below level of hole is possible. 2. Rigid bronchoscope to get past the hole to deliver oxygen if needs be [with jet ventilator and sidearm connector]. Finally, repeat importance of MDT discussion; worth involving thoracic surgeons even if they conclude they are not needed.

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Airway Expert 2: Considerations in securing the airway in this case: 1. avoid extending the hole in the trachea 2. avoid passing an ET tube into a false passage Blind passage of a bougie must be avoided. An awake tracheostomy is an option – but clearly will not facilitate the placement of a patch. Ideally you want to visualise the tube over a conduit entering the distal trachea (ie past the hole). So an awake technique with a exible bronchoscope might be appropriate- but note the bleeding which might limit visualisation Alternative which depends on skill set would be to perform a Video-assisted exible intubation using a videolaryngoscope to identify the glottis but using the

exible bronchoscope to

visualise the inside the trachea and avoid inadvertent diversion of the tube from the end of the tube. In an ideal world this could be conducted awake, but this technique would also work in an asleep patient ( ie if uncooperative). In either case a skilled team of operators are required

Airway Expert 3: This patient appears to have an isolated anterior tracheal injury. Spontaneous ventilation appears preserved, however in the event of apnoea and a need for positive pressure ventilation, this may be dif cult and indeed may instigate surgical emphysema. The patient is therefore best managed with an awake tracheal intubation (ATI) with spontaneous ventilation in the operating theatre with all staff ready for an emergency front-neck-airway (eFONA). The ATI technique would be as follows: Oxygenation: HFNO Topicalisation: 10% lidocaine spray with 4–10% administration via a MAD. Sedation: Remifentanil TCI 2–3.5 ng/ml Procedural performance: Flexible bronchoscope to be able to assess the internal damage and ensure cuff of the tracheal tube will be able to bypass the tracheal disruption. Oral approach with a reinforced tracheal tube. If it is a bloody airway, then consider awake videolaryngoscopy. If the patient was unstable and uncooperative, I would transfer them to the operating theatre if possible with oxygen ongoing. If the patient is unable to tolerate or cooperate with an awake technique, a rapid sequence induction wiht a videolaryngoscope and surgeons scrubbed and ready for eFONA. My RSI would include high dose rocuronium, propofol and a hyperangulated blade videolaryngoscope with a reinforced tracheal tube and no bag-mask ventilation.

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Airway Expert 4: Assessment: ABCDE approach A. no airway noises so no inspiratory stridor (no obstruction above the vocal cords) or expiratory stridor (intrathoracic obstruction) B. Tachypnoeic but just maintaining SpO2 C. Tachycardia, okay BP, no obvious vascular injury D. GCS 15 E. No mention (also consider full stomach)

Plan A 1. Expedite that the anterior tracheal laceration and disrupted trachea is covered but not sealed completely to prevent bleeding and surgical emphysema 2. Transfer to theatres once low ow O2 and IV uids established 3. Team brief outlining both Plans A and B - have an experienced airway Consultant Anaesthetist and Consultant Head and Neck surgeon present 4. Pre-O2 in theatre (with surgeons scrubbed and tracheostomy set open) with low

humidi ed O2 with patient sat up (avoid high- ow as this will exacerbate surgical emphysema) 5. Have TIVA set up (remi TCI /propofol TCI) and another anaesthetist to aid with sedation 6. ATI - nasal exible bronchoscopic with 6.0ETT by most experienced operator - possible blood in airway and maybe only a single attempt will be possible - so it make the best attempt. 7. Have suction at hand 8. sTOP: sedation with remifentanil TCI only / Topicalise with cophenylcaine (nose) and lidocaine 10% spray / O2 with Opti owTM / Perform (from front of patient) 9. Once ETT at carina in ate cuff gently (Pt not starved)

Plan B Same above set-up but if not cooperative for ATI then RSI (with rocuronium 1.2mg/kg already drawn-up) with gentle cricoid and VL of choice (#3blade).

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Airway Expert 5: This case nicely demonstrates the difference between an anatomically dif cult airway and a physiologically dif cult airway. From the history I see no reason why this patient would have a dif cult laryngoscopy, the neck wound is small and the CT

ndings don't report any

haematoma or upper airway disruption. The area of concerns is subglottic, in the trachea, which can all be managed asleep. Even with a small tracheal laceration I wouldn't expect intubation to be dif cult as it is unlikely that the ETT will pass through the defect during intubation. My plan A: ✦

Meticulous pre-oxygenation in head up position

✦

GA then intubate with a VL using a size 7 reinforced ETT, ensuring the tube is placed distally to the tracheal defect, but not into the R main bronchus (check position with a FB)

✦

I would avoid positive pressure ventilation as this may make any surgical emphysema worse, but if necessary then I would but with gentle pressure applied over the wound covered with a dressing

Plan B & C: ✦

If unable to intubate then use a SAD to ventilate and consider using this as a conduit to pass an ETT over a FB, again applying gentler pressure over the neck wound during this process

Plan D: ✦

If unable to intubate or ventilate then I would pass a 6.0

ETT directly into the trachea

through the defect in the trachea which may require some dissection so I would ask the surgeon to assist me with this But I am not anticipating having to move on from Plan A with this history, examination and CT ndings

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THOUGHTS FROM OUR CASE SETTER | Moon-Moon Majumdar | General thoughts: the issue here is not necessarily dif culty passing the ETT through the vocal cords (nothing in the history to suggest dif cult laryngoscopy), but the risk of creation of a false passage lower down. Presented with a similar case in the future, would consider a breoptic technique in a cooperative patient, with the ENT team ready to perform an awake tracheostomy under breoptic guidance as a back up technique (although a trache wouldn't help them much with their patch surgery). In an uncooperative patient, an RSI with breoptic scope assisted video-laryngoscope technique is probably best. In either case, the breoptic scope would make sure you are actually in the trachea, not in the soft tissue of the neck (and with the cuff past the defect but above the carina). Things to consider are: 1. To identify which patients with traumatic airway injuries need their airways secured (in this case, the indication was curative surgery). 2. To place a cuffed tracheal tube into the lumen of the airway distal to the location of the injury while avoiding hypoxia. 3. To avoid exacerbating a potential or actual airway disruption and/or migrating an endotracheal tube (ETT) outside the airway. 4. To avoid creating or exacerbating subcutaneous emphysema: ✦

Careful/gentle placement of the ETT is necessary when the patient has a partial transection of the trachea. Consider a smaller tube size to minimize secondary injury.

✦

Bag valve mask (BVM) ventilation should be minimized as it can cause dissection of air into the neck/surgical emphysema and worsen airway distortion

✦

Paralysis may theoretically cause airway obstruction by relaxation of muscles (though this is not born out in the literature)

This CT image - not the real patient - this is from https:// radiologykey.com/tracheobronchial-injuries/ shows CT image depicts displacement of the endotracheal cervical tube (arrowheads) through a wall defect consistent with a cervical tracheal injury. This nding was con rmed by bronchoscopy.

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#JANUAIRWAY 2022 | Happening NOW @dastrainees |

A FREE, MONTH LONG TWITTER EDUCATION EVENT! Daily tweetorials on a range of airway topics

Tell your colleagues and come join us to #LearnTogether this

#JanuAIRWAY @dastrainees @vapourologist #DASeducation

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DAS WEBINARS 2022 | Gunjeet Dua |

PROGRAMME ANNOUNCEMENTS COMING SOON!

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. 36

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DAS 2021 CONFERENCE: HIGHLIGHTS | Imran Ahmad | Traditionally the DAS Annual

Over the next few months,

Scienti c Meetings (ASMs) have

fortnightly (and often weekly)

been held in November. This has

meetings were held where we

always been the highlight event of

meticulously planned every

the DAS calendar where hundreds

aspect, including speaker

of airway enthusiasts from across

selection, chairperson and

the globe come together and learn

moderator allocations, industry

about all matters ‘airway’, mixed in

sponsors, programme content,

with lots of networking and the

abstract handling, technical

legendary DAS gala dinner and other social

onboarding and social media strategies just to

events.

name a few. Considering that everyone on this

The COVID pandemic has unfortunately put a temporary halt to these ASMs and we have been unable to hold one since the 2018

committee also had other clinical commitments and responsibilities, this was no mean feat!

edition in Edinburgh, as 2019 saw us hold the

The programme was nalised by the end of

s e c o n d j o i n t WA M M c o n f e re n c e i n

September with some excellent content,

Amsterdam. Understandably, the scheduled

notably keynote talks by Professors Cook,

ASMs for 2020 and 2021 had both been

Mushambi, Patel and Law, shared learning

postponed, so we decided to run virtual DAS

from other specialities, thought provoking

ASMs as an acceptable compromise in order

debates, trainee presentations, human factors

to offer some form of airway updates during

session, case based discussions, training and

those challenging times.

education sessions, industry sessions and the

Planning for this year’s online conference

entertaining Top Airway Gear!

started in the Spring of 2021. The team

It is testament to the organising committee

comprised of a committee made up of the

that so many speakers from across the world

DAS executives, selected DAS committee

agreed to take part in this event, stretching

members and key members of the

from the North and South America through

Birmingham LOC, who’s ASM was postponed.

Europe, across Asia and Africa, past the Far

This virtual DAS ASM committee then teamed

East into Australia and New Zealand, a truly

up with the excellent Conference Partners

global par ticipation! There were also

International (CPI) to plan the virtual meeting

signi cant contributions from many of the

to be held in November.

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major overseas airway societies and a few

30,000 and thousands of link clicks. This was

non-airway societies too.

a truly global online conference.

The two day meeting ran with military

As virtual meetings go, this DAS online

precision, this was only possible because of

conference was a huge success thanks to all

all the meticulous planning and tireless

those involved in planning and running the

behind the scenes coordination and

meeting. There are so many people to thank,

troubleshooting by the CPI team and

too many to name individually, they include

organising committee. Over 800 delegates

the CPI team, the ASM organising committee,

registered from 50 countries, peak live

the industry partners, the team who so

attendances topped 700 delegates for some

expertly managed all the abstracts, all the

of the sessions and there have already been

speakers chairs and moderators and of

100’s of downloads for the On Demand

course all the delegates who attended.

catch-up recordings. 98% of delegates fed back that their learning objectives were met and over 50% of them gave the conference the maximum rating for overall content.

We are all looking forwards to the very much awaited Newcastle DAS ASM in 2022, after a 4 year absence, this will be like a DAS reunion party!! Hope to see and meet as

The social media metrics for the conference

many of you as possible there!

were also hugely impressive. The conference hashtag generated thousands of Tweets and millions of impressions on Twitter. In total, there were over 10 million impressions recorded and over 500 original Tweets. A lot of interest via Facebook too, with a reach of

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SALG-DAS: PATIENT SAFETY CONFERENCE | Helen Aoife Iliff | Barry McGuire | The Safe Anaesthesia Liaison Group (SALG) Patient Safety Conference was held on 26th November 2021 in partnership with DAS. We were delighted to co-chair the DAS session in the afternoon which focused on improving patient safety: 1. Through learning from events, 2. Through studying airway data, and

fantastic patient safety initiatives that will help

3. Through improving airway education.

to inform our future practice. We would encourage all clinicians to engage with

In the session on improving patient safety

both databases.

through learning from events, Professor Andy Smith presented the tragic Gordon Ewing

In the nal session on improving patient safety

case and Dr Fiona Kelly went on to further

through airway education, cognitive aids,

analyse the case discussing human factors in

simulation, social media and virtual reality

practice. Dr Lewys Richmond discussed

were all discussed by Dr Abhijoy Chakladar,

missed oesophageal intubation and the

Dr Gunjeet Dua, Dr Tom Lawson and Dr Imran

equally tragic Glenda Logsdail case. All three

Ahmad. With fantastic discussion about

excellent talks considered how we can

engaging individuals and multidisciplinary

improve our practice to minimise the chance

team training, we will hopefully all be inspired

of such cases recurring, not least the

to do everything we can to maximise our

importance of capnography, the team

learning and that of our airway team.

approach to airway management and considering ‘wake up’ when in dif culty.

The conference had >200 live attendees and had some brilliant trainee oral presentations in

Dr Fauzia Mir spoke about the DAS Dif cult

the morning session. We would like to thank

Airway Database and Dr Alistair McNarry

all our fantastic speakers and SALG for the

about the HSRC-DAS eFONA registry. Both

opportunity to join them on this occasion.

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Non-technical skills and human factors and

skills using minimal resources, demonstrating

ergonomics (HFE) principles as related to

HFE issues relevant to airway emergencies

airway management [1] can be challenging to

and stimulating discussion regarding

teach, and as the COVID-19 pandemic

strategies for addressing these. These videos

continues the dif culties of delivering teaching

were successful for teaching in a traditional

in a safe manner will remain for the

face-to-face group environment as well as

foreseeable future [2]. We piloted the use of

during remote learning using Zoom during the

four short, speci cally designed simulation

COVID-19 pandemic, when social distancing

videos featuring the evolution of a

ctional

measures have made airway training

airway emergency [3]: they proved to be very

especially challenging [4]. These videos are

effective as a novel educational tool for

freely available on-line [3] and could be used

teaching technical and non-technical airway

by other departments in a similar fashion.

Video 1: Preparation

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Video 2: Can’t Oxygenate Introduction

Zoom: for this, we displayed the lms using

Four short videos were produced for the

screen sharing and used interactive

World Airway Management Meeting (WAMM)

discussion over a video feed. Following

2019 and used during the Opening Session

excellent feedback in 2021 we delivered a

with accompanying panel discussion,

virtual teaching session for acute care

demonstrating the simulated management of

common stem trainees on a regional level

a ctional airway scenario in the Emergency

from a different hospital using Google Meet

Department [3]. Each video was 3-5 minutes

where we could test reproducibility. At each

long, demonstrating an escalating airway

session the four videos were shown with

emergency in an obese patient, culminating in

group discussion after each along with a

a ‘Cannot Intubate, Cannot Oxygenate’

general discussion at the end of the session.

situation [3]. Each video demonstrated several human factors and ergonomics principles, including design of safe systems, strategies for optimising institutional preparedness, the advantages of cognitive aids, checklists and algorithms, non-technical skills and communication, worker wellbeing following an airway emergency [1] as well as technical airway skills. The videos were made freely accessible on-line after the meeting, and we used them for an airway training programme in our department with the aim of improving airway management safety. During 2020 We ran two initial face-to-face teaching sessions for Intensive Care and anaesthetic staff followed a virtual teaching session using

Report Feedback was collected using a 5-point Likert scale plus free text comments during the

participants attended ( ve consultants, three associate specialists,

ve registrars, 10

clinical fellows, 11 core trainees, one advanced critical care practitioner and two foundation year doctors). The feedback return rate was 100%. Results are shown in Table 1. Free comments included “fantastic!! - videos really good to spark conversations about human factors and ergonomics,” “really useful session” and “very interactive.” In our later virtual session, there were 35

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rst three sessions. Thirty-seven

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Video 3: Can Oxygenate attendees at core training level, with 19 from

really good way to present this topic. I really

anaesthesia, 15 from emergency medicine

enjoyed this talk. Those videos made me

and 1 from acute medicine. Feedback rate

really think” and “Excellent use of videos to

was 100%, with 94% nding the session very

facilitate group discussion. Good balance

or extremely useful, and 6% nding it useful.

of clinical / non-clinical information.”

Comments included “Loved the layout, great use of multimedia, interactive,” “This was a

Discussion Teaching sessions using short simulation

Technical airway skills

Feedback

Videos identi ed good technical aspects of the case very well/quite well

97%

Videos identi ed technical skills which could have been improved very well/quite well

100%

Non-technical skills Videos identi ed good aspects of non-technical skills (including communication, team work, situation awareness, leadership) very well/quite well

97%

Videos identi ed non-technical skills which could have been improved very well/quite well

100%

Feedback for teaching overall The teaching was extremely useful

94%

The teaching could probably/de nitely improve airway management safety

97%

Videos de nitely made participants consider how they perform at work

90%

Attendees would strongly recommend/recommend the teaching to other hospitals.

100%

Table 1: Feedback from interactive teaching sessions using four speci cally designed training videos. 42

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Video 4: Cannot Intubate Cannot Oxygenate (CICO) videos to highlight challenging technical and

Correspondence to: Dr T. G. Saunders

non-technical skills was a novel, engaging

(thomas.saunders@doctors.org.uk)

and interactive training method with excellent feedback provided by attendees of all grades. It enabled demonstration of an

References

airway emergency in easy-to-organise and

1. Kelly FE, Bhagrath R, McNarry AF. The

reproducible teaching sessions without the

‘airway spider’: an education tool to assist

need for actors, manikins or simulation

teaching human factors and ergonomics in

equipment. Teaching using remote learning

airway management. Anaesthesia 2018; 73:

via both Zoom and Google Meet worked well

257-258.

and facilitated training in a socially distanced

2. Hickman J, McNarry AF, Kelly FE. Practical

manner as well as during face-to-face

strategies for delivering airway training in the

sessions. Such teaching sessions has

COVID-19 era. British Journal of Anaesthesia

demonstrated to be easily transferable and

2021; 127: 188-191.

reproducible in other hospitals and during wider, regional teaching and could be especially useful during the COVID-19 era. These sessions have also prompted a reorganisation of airway equipment, trolleys

3. Chrimes N, Rehak A, Stacey M et al. WAMM 2 0 1 9 H u m a n F a c t o r s Vi d e o s . h t t p s : / / vimeo.com/showcase/6562237 (accessed 11/03/2021). 4.

and signage in an emergency department.

Cook TM et al. Airway guidance for the

endemic phase of COVID-19, 2020. https:// icmanaesthesiacovid-19.org/airway-gudiance*Presented as a poster presentation at the

endemic (accessed 30/09/2021).

Annual Scienti c Meeting of the Dif cult Airway Society, September 2021

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INTERVIEW | Peter Young, Consultant Anaesthetist | Winner of the John Smith Innovation Award 2021 Dr John Smith graduated from Liverpool University in 1969 and was appointed as a consultant at Selly Oak Hospital, Birmingham in 1982. He is regarded as a pioneer in the use of breoptic laryngoscopes and he developed one of the rst breoptic training courses in the UK. He has authored several articles on dif cult airway management in peer reviewed journals. The inaugural John Smith Award for Innovation was awarded at DAS 2021 to Dr Peter Young, for the creation of the Oxyblade. We asked him about himself, the oxyblade and what advice he has for any budding innovators out there. I was very happy to be awarded the

teams at the Queen Elizabeth

inaugural John Smith Innovation

Hospital, Kings Lynn have, in the

Award at DAS 2021 in November on

main, encouraged my teams

behalf of the team at the Queen

innovation programmes, some

Elizabeth Hospital, King’s Lynn for

through NHS ownership and

the OxyBlade. I have been involved

development with the NHS

in innovation for patient safety for

Innovation agencies and some

the last 25 years, my rst patent led

directly with industry – depending

in 1996 and over 20 patents since

upon the route of most likely

have resulted in 6 devices on the

success. Some of our work is here

market and 4 others on the way. Finding

on our hospitals website, some is here and

pathways through the innovation and

much is on manufacturer and distributors

implementation systems in the UK has been

websites. There has been “blood on the

a challenge over the years but fortuitously the

carpet” along the way and any NHS innovator

NHS has embraced bedside clinical

will tell you that the need for resilience and

innovation following the publication of

persistence is important in innovators. The

“Innovation, Health and Wealth” by the

need for understandings and agreements

Department of Health in 2011. There is now

with the organisations in which one works and

direct support for clinical innovators for

with industry should be unambiguous and it is

example through the NHS Clinical

paramount to nail down understandings at

Entrepreneur Programme, the Association of

the earliest stage. This should not be just

Anaesthetists Innovation Awards and the

verbally but formally in writing as there may

NHS Innovator Accelerator programme.

be frequent changes in management

There can however be a disconnect between the national agenda and local views. I have been fortunate that successive management

structures locally in the NHS with changes of direction and philosophy combined with a lack of institutional memory over time.

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Dif cult Airway Society E-Zine

January 2022

A wonderful spin off of bedside innovation,

high ow rotameters, and are not available in

over and above the provision of safety

all situations especially outside operating

devices to patients worldwide, is the ability to

theatres. Importantly, most modern portable

involve and inspire trainees and provide

oxygen cylinders can achieve a maximum ow

educational opportunities. Our group is proud

rate of 15 l/min which is insuf cient for HFNO.

to have been able to attract funding to allow

If the nasal passages are blocked or the

over 100 nurses and doctors passing through

airway not suf ciently maintained, then HFNO

our institution to present abstracts at

may also be imperfect. The use of HFNO at

congresses around the world. I would advise

induction and intubation requires a change in

budding innovators to persist for the love of

practice (mask pre-oxygenation and manual

innovating and the hope of providing

ventilation before intubation may be absent)

widespread bene t. A

so a substantial skill set and specialist

equipment provision is required. Individual

misconception that this

THRIVE failures due to the learning curve of

will lead to a pot of

clinicians was demonstrated.

gold is misleading and

It may be advantageous in some

if this is your primary

circumstances to maintain practice as close

goal, I would advise

to the normal intubation process as possible

sticking to the day job!

and but also have oxygenation continuing during laryngoscopy. The normal process of intubation normally involves mask pre-

Oxyblade

oxygenation, induction then either apnoea or

The Oxyblade is an

mask ventilation, apnoeic intubation with a

innovative and novel, convenient and intuitive

direct of indirect bladed laryngoscope and

oxygenating laryngoscope blade (now

then positive pressure ventilation through the

marketed as the OxyBlade™, Patent: US

endotracheal tube. With our innovation, we

10,849,489 B2. Peter J Young. Dec. 1 2020).

have addressed the ability to continue to

The Oxyblade was born from my team’s early

perform a normal intubation process, but also

work in the development of High Flow Nasal Oxygenation (HFNO) with Fisher and Paykel. This is now becoming increasingly commonly used in the operating theatre environment as an adjunct to improving the safety window for safe intubation. For comfort, HFNO must be humidi ed for patient tolerance and this can be conveniently placed pre-induction and maintained for apnoeic oxygenation during intubation. However, the systems available for HFNO are somewhat complex, with the requirement of humidi cation chambers and

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January 2022

have optimal apnoeic oxygenation during

The panel of expert discussion following the

laryngoscopy at a standard 15 L/min oxygen

John Smith Award presentation was very

ow rate.

encouraging. I would like to see this applied

During development, we discovered that a smaller aperture at the distal end of the blade produced suboptimal oxygenation due to the Venturi effect resulting in air entrainment. The oxygenation tubing has therefore been calibrated (length and internal diameter) to

to a wide range of laryngoscopes and invite clinicians and airway experts to discuss this with their industry contacts and manufacturers to contact me to facilitate discussions with the owners of the patent to enable widespread application and use.

allow maximal pharyngeal/laryngeal oxygen concentration at the laryngeal inlet by allowing bulk

ow from a larger aperture at the

Peter Young MD

proximal blade positioned so as not to

Consultant, Critical Care, Queen Elizabeth

obstruct the clinician’s view or instrumentation

Hospital, King’s Lynn.

(see comparison graph).

@peterjyoung101

Using the Health Research Authority Decision Tool ethical approval was not required. Institutional R&D approval was granted. This was performed on a modi ed mannequin with a Clark electrode (Ohmeda 5120 Oxygen monitor) in the upper trachea. The OxyBlade™ has been assigned to, developed, recently marketed and funded by one company (Venner Medical, Singapore) on the MAC and dif cult airway blades of the APA™ laryngoscope.

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TRAINEE COMPETITION | BREAKING: THERE ARE NOW TWO CATEGORIES | We are pleased to announce the 2022 DAS Trainee Competition: for which there are now TWO separate categories: 1. creative writing (our essay competition) 2. creative media (this may be whatever you wish: painting, video, poetry, photo series...etc) The winner of each category will receive £100 in prize money and will have their work published in the DAS newsletter and displayed at the 2022 DAS ASM. We invite submissions on the following title, for you to interpret as you wish:

“The Airway Training of Dreams" 1.

Entries are invited on the above title. One entry per person to EITHER the essay OR the media category will be accepted. The author/creator must be a DAS member.

Members of the DAS committee will judge anonymised entries.

For essays: We will be looking for a well-developed viewpoint. Word count 1500 words maximum (excluding references). Please use Times New Roman size 12 font and double line spacing. References should be formatted as for the BJA.

Label your le either ‘DAS Trainee Competition Essay – your DAS Membership Number’, or ‘DAS Trainee Competition Media – your DAS Membership Number’. 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.

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

Prize money of £100 and a certi cate will be awarded to the author of the top essay and the creator of the top media submission. The winning submissions in BOTH categories will be published in the DAS newsletter, as well as displayed at the 2022 DAS ASM.

Winners will be contacted by email.

Deadline for receipt of emailed essays: Midnight on 14th April 2022

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January 2022

THE FELLOWSHIP OF THE (CRICOID) RING | Tom Lawson | “All that is gold does

The topic of our debate was a contentious

not glitter, not all

one: “Airway fellows make training worse for

those who wander

the rest of us”.

are lost”

proponent doesn’t truly believe in their

Speaking at an international meeting, to most, would seem like a tantalising prize; the DAS ASM 2021 was my rst with such a role.

The opportunity to collaborate

with leaders in your eld, to share ideas with

As with any debate, if a

proposition, they begin at a disadvantage, one that exponentially increases with an opponent of Gunjeet’s calibre. So it came as no surprise that the post-debate poll nal results showed a 6 6 . 7 % d i s a g re e i n g w i t h t h e i n i t i a l proposition.

Neither was the mild ribbing I

received for my Bilbo Baggins reference during the debate.

curious minds and to, in some small way, feel

In truth, I am amongst the 66.7%.

as if those many, long, years of training and

fellowships, whatever the nomenclature,

toil have culminated in something quite

provide trainees with knowledge, skills (both

special, was heady brew.

technical and non-technical), attitudes and the

This is, of course, until you are told you have to debate Dr Gunjeet Dua (her airway credentials are too numerous to list, and would give the editors palpitations considering my limited word count). That was the moment that warm and glowing feelings of self-congratulation, melted away to be replaced by op-sweat and dread. I joined the DAS committee in June 2021 as one of two educational leads (the other being my erstwhile debate opponent, Gunjeet). My immediate focus has been the creation of a database of the available airway fellowships in the UK. As a former airway fellow, this was an enticing project, and now some 4 months later

Airway

philosophy required to not only manage complex airways themselves, but to promote and promulgate the same. This was re ected in the post-debate round of questioning, with broad agreement between Gunjeet and myself; which I suspect took a bit of the spice out of things, to the chagrin of our chair; Dr Abhijoy Chakladar. There is a serious challenge facing airway mangement education. A challenge, in which, trainers and trainees alike must strive to maximise every opportunity beyond simply making airway training an exercise in chasing numbers.

The COVID-19 pandemic has

opened up exciting new avenues for

the database is nearing completion.

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January 2022

education, and airway management is no

what opportunities are available in each

different with the potential for: -

centre.

• Local, regional, nataional and international teaching / training

If you havent already, please consider adding your airway fellowship to our database, by scanning the QR code below, lling in your

• Secondment to major tertiary centres

details via bit.ly/airwayfellowship or emailing

• Research and innovation

me directly; thomas.lawson@wales.nhs.uk

• ENT clinics / MDTs

There is a gap that needs to be bridged,

• Tea-trolley training

beyond higher rotations, between CCT and practicing independently. The Royal College

• Video-based learning

of Anaesthesia presents key capabilities for

• Simulation

SIA modules; however, at the time of writing

• Human factors training

(as far as I am aware) there are no airway

The creation of an airway fellowship database is not the end.

It is a

rst step.

Having

assessed what is available in the United Kingdom, both in terms of dedicated airway fellowships and specialist interest area (SIA) modules in ‘Anaesthesia for Patients with

fellowship standards worldwide.

It is this

space, into which the airway fellowship database will most likely move.

Whilst the

endgame is still in distance, we’ve embarked on an interesting journey there (and back again).

Complex Airway’ (the new badge for previous ‘advanced airway modules’), the next step is to compare and contrast these posts to examine

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January 2022

JOURNAL CLUB | Recommended Reads | Welcome to the new DAS Journal Club - Recommended Reads. Papers are chosen my members of the DAS committee, with short citations/summaries by members of the ezine editorial team. This editions recommended reads come from Kariem El-Boghdadly with summaries by Natalie Silvey. We hope you enjoy this addition to the DAS ezine and would welcome members feedback on how it can be improved in the future - please tweet us @dastrainees or @dasairway or email us at ezine@das.uk.com.

BOUGIE Study ✦

Driver BE, Semler MW, Self WH, Ginde AA, Trent SA, Gandotra S, Smith LM, Page DB, Vonderhaar DJ, West JR, Joffe AM, Mitchell SH, Doerschug KC, Hughes CG, High K, Landsperger JS, Jackson KE, Howell MP, Robison SW, Gaillard JP, Whitson MR, Barnes CM, Latimer AJ, Koppurapu VS, Alvis BD, Russell DW, Gibbs KW, Wang L, Lindsell CJ, Janz DR, Rice TW, Prekker ME, Casey JD; BOUGIE Investigators and the Pragmatic Critical Care Research Group. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2021 Dec 8. doi: 10.1001/jama.2021.22002. Epub ahead of print. PMID: 34879143.

Anyone who has performed an emergency intubation in a critically ill patient is well aware of the additional risk involved compared to intubation in the elective setting. Few topics lead to as many strong opinions being voiced as the equipment that should be utilised for such intubations. Whether this is the use of direct or a video-laryngoscope, or the use of adjuncts such as a bougie or stylet, even the briefest search on social media can nd a wide range of opinions being voiced. The recently published BOUGIE trial is a multi centre, unblinded, randomised control trial designed to determine whether use of a bougie or a stylet increases the likelihood of successful intubation in critically ill adults. Patients who were to be intubated were randomly assigned to use of a bougie or endotracheal tube with stylet for intubation and 1102 patients were included in the study which was performed in 7 emergency departments and 8 intensive care units in the US.

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January 2022

The primary outcome was successful intubation on the

rst attempt, with the secondary

outcomes including the incidence of severe hypoxaemia, de ned as a peripheral oxygen saturation less than 80%. The result - the use of a bougie did not signi cantly increase the incidence of successful intubation on the rst attempt compared with use of an endotracheal tube with stylet. Delve deeper into this fascinating paper in your journal club - a well-conducted RCT of a basic airway intervention which continued despite the COVID-19 pandemic, but one with limitations which warrant discussion. Do these limitations signi cantly affect the impact of this study? This, amongst many other questions, should promote a lively debate.

Airway events in obese vs non.obese elective surgical patients: ✦

Shaw M, Waiting J, Barraclough L, Ting K, Jeans J, Black B; Pan-London Peri-operative Audit and Research Network. Airway events in obese vs. non-obese elective surgical patients: a cross-sectional observational study. Anaesthesia. 2021 Dec;76(12):1585-1592. doi: 10.1111/ anae.15513. Epub 2021 Jun 22. PMID: 34156711.

There is rightly an increasing focus on obesity and peri-operative outcomes including the risk of airway events in this patient population. Issues to raise with regards to consent for airway management are part of the recently published SOBA anaesthesia consent for the patient with obesity guidance. The recently published paper in Anaesthesia by the Pan-London Peri-operative Audit and Research Network looked to determine the proportion of obese patients in an elective surgical population and determine the choice of airway equipment and incidence of airway events in obese and non-obese patients. A cross-sectional study was conducted over two 24 hour periods in 39 hospitals across the Greater London area. Data was collected on a total of 1874 patients. The study found that the incidence of obesity in the study population was 32%, higher than the 26% in the general UK population. The study suggests that minor airway events are more common in obese vs nonobese elective patients. This trainee-led prospective observational study is an excellent one for discussion at your journal club. Well conducted, large scale, multi-centre observational studies like this one can add to our body of evidence in a variety of areas yet are often under-utilised. Why not discuss this study at your journal club and focus on the bene ts and limitations of such research? Inspiring front-line clinicians into being involved in research may reap huge bene ts for our patients when the results of such efforts are translated into clinical practice.

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DAS WELCOMES… | Introducing our new Website Leads and Trainee Reps | Dr Craig Johnstone - IT Co-lead Dr Craig Johnstone is a Consultant Anaesthetist at Guy's Hospital with an interest in thoracic anaesthesia and is co-lead for IT within the department. Craig undertook muck of his early training years in following his Undergraduate training in Liverpool, before moving to London where he completed his Anaesthetic training. He is working to implement the Trust's new electronic health record, and has contributed to the running of the Guy's Airway Management Course for several years. Outside of work, Craig enjoys tinkering with various IT projects and running.

Dr Moon-Moon Majumdar - Trainee Rep Hi all! I'm an ST5 Anaesthetic trainee currently working in aeromedical retrieval for the Royal Flying Doctors in rural New South Wales, but I will be back in the UK by August 2022 to nish training. I grew up on the Isle of Wight, did ACCS in sunny Sussex and am now doing my Reg training in north-west London. I'm interested in tricky airways, trauma anaesthesia/ retrieval, and regional, and I'm currently trying to get better at wielding an ultrasound and playing tennis. I'm passionate about teaching and training and I'm one of the organisers of the Imperial School of Anaesthesia Primary viva course. I'm really excited to be one of your new DAS Trainee Reps. I look forward to working hard alongside the dynamic and excellent Drs Iliff and Silvey, to try and improve even further the airway training that DAS provides for trainees. If you have ideas about airway education you would like to see from DAS or tips on how to improve my backhand, e-mail me at moonmoonmajumdar89@gmail.com or tweet me (I'm getting the hang of Twitter now, I've got a pro le picture and more than 11 followers that aren't my mum) @majumdar_moon @dastrainees

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DAS WELCOMES… | Introducing our new Website Leads and Trainee Reps | Dr Natalie Silvey - Trainee Rep I am an ST6 anaesthetic trainee in the Imperial School of Anaesthesia having migrated down to London after completing ACCS training in the Coventry and Warwickshire School. I am nally in the last two years of my training having taken a very non-traditional route to get here. I spent time as a National Medical Director's Fellow at NHS England followed by a year as an Innovation and Improvement Fellow at Chelsea and Westminster Hospital. I returned to training in 2017 and trained less than full time for three years whilst working as Clinical Advisor to the Private Healthcare Information Network. I have now returned to training full time and have just completed 6 months as the Head and Neck Anaesthetic Fellow at Northwick Park Hospital. Outside of work I am learning to knit (having spent many hours of unpicking yarn to get to this point) and am a keen baker whose highest accolade to date is receiving a reply from the one and only Nigella Lawson about one of my cake pictures on Twitter. I am passionate about improving the care our patients receive and learning from patients about their experiences. I am really excited and delighted to be one of the new DAS trainee representatives and looking forward to working with Dr Iliff and Dr Majumdar on representing trainees within DAS. We want to hear your views, ideas and insights on what DAS can do for trainees so please get in contact. I tweet (far too much) @silv24 and can also be found @dastrainees and my email is n.silvey@nhs.net.

Dr Cyrus Razavi - IT Co-lead Cyrus Razavi is an ST7 in Anaesthesia in North Central London. He has an interest in digital health and all things innovation/tech, he is an NHS England Clinical Entrepreneur and is undertaking an MD(Res) at the Centre for Perioperative Medicine, UCL.

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TRIBUTE TO DR NICK WHARTON | 24th July 1971 - 14th August 2021 |

There hangs a great sadness over the hospitals of Bristol and Bath for our lost colleague and great friend Nick Wharton, who passed away in August having lived with thymic cancer for more than four years. Nick was airway lead at the Bristol Royal In rmary for many years and a loyal member of DAS. He set up the DART (Dif cult Airway Rescue Techniques) and Awake Tracheal Intubation courses in the Severn region, as well as regularly teaching on the RCoA airway workshops. He was a kind and patient teacher with a talent for making training fun - his stations always got the best scores! A highly competent airway and obstetric anaesthetist, he was the ‘go to’ person for dif cult cases. His calm and competent manner, combined with his mischievous sense of fun, made him a great person to work with. Out of work, Nick was a keen cyclist, surfer and coffee drinker who always held airway course meetings in our local pub with a pint of real ale in his hand. He was incredibly brave and digni ed during his illness. His wife Vicky and two daughters have gained great solace reading messages from friends and colleagues - if you knew Nick and would like to share any memories, please send them to whartonfamily19@gmail.com.

- Fiona Kelly, Consultant Anaesthetist, Colleague and Friend of Nick

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It’s March of 2020, a wave of COVID-19

complications, and the AeroComp Core Team

infections was fast approaching, resources

was formed.

were focused towards planning for an

management during the pandemic meant that

onslaught of hospital admissions, and the

the previously published data on airway

anxiety amongst staff was almost palpable.

complications was somewhat outdated. The

Research that didn’t involve COVID-19 had

idea was that this would be a mini-NAP-4 for

stopped inde nitely, and it was clear that our

the COVID era, looking speci cally for any

trainee project looking at perioperative

association between airway complications

anxiety in surgical patients was going to

and aerosol precautions: was the use of non-

come very low on the list of priorities.

ergonomically designed PPE associated with

We had planned to roll out our project across the local trainee research network (TRN). Unfortunately, both of the projects previously

The drastic changes to airway

a higher risk of dif cult airway management, or

was

the

increased

selected by our TRN were going to be

During a rapid development phase, the team

signi cantly postponed due to COVID-19. The

recruited airway experts, formalised the

TRN committee therefore gathered together

protocol, developed the data collection tools

all of the project leads with the aim of creating

and sought the involvement of trainee

a new project that would be resilient to COVID

research networks nationwide. We elected to

surges. We rapidly opted to focus on airway

conduct a national service evaluation aiming

videolaryngoscopy protective?

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use

Dif cult Airway Society E-Zine

January 2022

to collect data over a 4-day period, looking for

have been blown away by the support for the

airway complications during general

project and would like to express our

anaesthesia in adult patients.

gratitude to all those involved. We hope that

Despite the multitude of challenges that trainees have faced during the pandemic, the enthusiasm for the project was quite

the project will inform clinical practice, and we look forward to sharing the results with everyone shortly.

remarkable. Dedicated local trainee and consultant teams from 84 hospital sites were recruited by a group of trainee networks

Trainee Research Networks

comprising NWRAG 1 , PLAN 2 , SHARC 3 ,

1. North West Research and Audit Group

SQuARes Net 4 , STAR 5 , WAAREN 6 and

2. Pan-London Perioperative Audit and

WoSTRAQ7,

as well as several sites that

contacted us directly, having heard about the project through DAS and other fora.

Research Network 3. South Yorkshire Hospitals Audit and Research Collaboration

Due to the hard work of all the local investigators, there are now well over 6,500

4. SESSA Trainee Quality Improvement Audit and Research Network

cases uploaded to the electronic data platform. We are currently going through the

5. Severn Trainee Anaesthetic Research

process of cleaning the data, and are waiting

6. Welsh Anaesthesia Audit and Research

for the last cases to be uploaded. We will then start analysing the data, and hope to have the results submitted for publication early next

and Engagement Network 7. West of Scotland Trainee Research Audit

year.

and Quality Improvement Network

The AeroComp project was largely designed, led and facilitated by dedicated anaesthetic trainees throughout the UK.

It is a great

example of the power of collaborative research facilitated by the regional TRNs for which the UK should be justi ably proud. We

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January 2022

HSRC-DAS EFONA REGISTRY | Alistair McNarry | The need to collate cases where an

whether they work the

emergency Front-of Neck Airway is

anaesthesia, critical care or

required or attempted has been

emergency medicine.

discussed since the publication of

elds of

The Registry is now a collaboration

NAP4 over 10 years ago. The lack

between DAS, the HSRC and the

of data was emphasized in the

University of Nottingham (where

DAS 2015 guidelines- not just by

the database actually is). Thanks to

the authors but also by the fact that

ongoing work despite the

of the 314 references in the

pandemic, it was great to be able

complete article, only 8.6% of them

to present footage of the live

related to the plan D section.

database and provide an update alongside

However, creating a UK wide registry of rare

Prof Moppett and Prof Cook at the ASM (see

(and therefore potentially identi able) events

Stream B, Friday 5th November at 1545 for the

is not an easy task and DAS are indebted to

on demand recording of this session).

the team at the HSRC for providing the clinical governance spine of the project without which it would have been impossible to take it forward.

Having a live database however does not mean that we are ready to collect data. Work continues on guiding the eFONA Registry t h ro u g h i t s l a s t f e w re g u l a t o r y a n d

Patient anonymity has been fundamental to the design of the Registry, but we are very much aware of the need to support the

administrative hurdles These include

clinicians involved in an eFONA event rather

i. Appropriate 4 nation approvals

than just demanding that they provide data.

ii. C r e a t i o n o f a n a p p r o p r i a t e a n d

Completing the Registry will be voluntary but

con dentially accessible user guide

we very much hope that all clinicians across

iii. Appointment of an initial review group

the UK* will feel able to submit cases to it-

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January 2022

iv. Finalising the support arrangements for contributors v. Lots and lots of testing Depending on publication lag times the advert for additional clinical members of the review group is just about to be released or will just have been released. So watch this space. The eFONA Registry will be going live over the next few months. If you have any questions or would like to be involved with any aspect of the project, please do email eFONA@das.uk.com

Alistair McNarry

*Whilst this iteration of the Registry is UK based and cannot accept cases from anywhere else DAS is working on plans to have complimentary registry in Ireland.

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January 2022

DAS SURVEYS UPDATE | Abhijoy Chakladar | Happy New Year!

decide on the best/most effective frequency of reminders - there is a

We successfully ran our rst, post-

ne balance to strike between

Covid (peri?), DAS member

interacting with members, nudging,

generated survey in November of

irritation and driving survey apathy.

2021 with colleagues from London.

During our survey in November

It took us a while to get the survey

2021, we elected to send out a

work going again and the process

weekly reminder – 4 emails for the

of getting this rst survey out took

4 weeks the survey was open – and

longer than expected; I'm pleased to say it was received well. I won't share any more details as a short report will follow in a later edition of the DAS e-Zine.

although this may have been annoying for some, they did seemed effective in driving new responses.

We were then excited to be able to support friends and colleagues around the world, who came together to design the VLiCUE collaborative survey considering the in uence of COVID-19 on video laryngoscopy. This is/ was an impressive project, supported by a number of international partner organisations, and to date has been translated in to French, Mandarin Chinese, Spanish, and Portuguese. This kind of collaborative, more inclusive work, has to be the future of international surveys.

For 2022, we have a number of member generated surveys already in the pipeline. We also hope to generate some larger DAS committee surveys, work with our education and guideline sub-committees to support their work, and hopefully look to collaborate with other sub-specialty societies.

When considering surveys, submissions, and requests for support and/or endorsement from sister organisations, we are always aware of the impact of survey requests on our members. Whilst we're committed to

We are always keen to here from members. Please visit the DAS website for more information or drop me a line at surveyscoordinator@das.uk.com .

supporting colleagues, survey work and other societies, we are all very busy and the last

Abhijoy Chakladar

thing we [DAS] want to do is add to that unnecessarily. We are working to improve the

@Chakladar_A

quality of surveys that we distribute and

surveys-coordinator@das.uk.com

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Dif cult Airway Society E-Zine

January 2022

DIFFICULT AIRWAY DATABASE - AN UPDATE | Achuthan Sajayan | We are pleased to report that the DAS Dif cult Airway Database is progressing really well, and many more hospitals have joined the database over the last few months. As of November 2021, • We have 160 participating hospital sites • Database hold the details of 830 patients • 950 doctors, who are not DAS members, have registered with the database. DAS members can access the database with their login details • 2000+ access logins to the database to submit or retrieve data-

How to submit a case to the DAS Database? https://das.uk.com/dad Consent Download the patient information and consent form from the DAS website https://das.uk.com/aac/con sent_form Discuss with the patient and obtain the consent. Please make sure the patient has recovered fully from the effects of anaesthesia. Recovery room is not a place for consenting.

Data submission If you are not a DAS member, you need to register with the database before submitting data. Registration is free and only takes few minutes. Please follow this link https://das.uk.com/das_user/ acaregister

Give one copy to the patient and keep one in the records

Summary document Once the data is submitted, there will be an option to print out the summary of the event. Please print two copies, give one to the patient and keep the other in the patient records.

GP letter There will also be an option to print out a letter to the GP. This can either be sent directly to the GP or give it to the patient with instructions to hand over to their GP.

If you are a trainee or specialty doctor, please discuss with your supervising consultant before submitting the data and provide their name

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Dif cult Airway Society E-Zine

January 2022

The database is endorsed by Society for

any feedback about the database itself or the

Obesity and Bariatric Anaesthesia (SOBA)

process of submission.

and supported by Association of Anaesthetists, Obstetric Association of

Some useful links are given below:

Anaesthetists (OAA) and Safe Anaesthesia

DAS Database main page

Liaison Group (SALG). The database is also

The list of Trusts currently taking part in the

partly supported by an education grant from

project

Karl-Storz UK.

Other project related documents can be found

If your hospital is not yet registered to be part

here

of this database and you are interested in taking the lead role locally, please do get in touch by emailing dad@das.uk.com . If you

Dr Achuthan Sajayan

work in a hospital which is already a part,

Co-Lead, DAS Dif cult Airway Database

please encourage your colleagues to submit the data promptly and let us know if you have

dad@das.uk.com

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Dif cult Airway Society E-Zine

January 2022

GUYS AIRWAY MANAGEMENT COURSE 2022 | 16th & 17th June |

Guy’s Airway Management Course (GAMC) is back for a 2 day spectacular in person event this summer! With a star-studded line up of amazing guest speakers lined up this is not one to be missed. There are also some special awards to be won - best posters, research grants, airway team of the year, anaesthetic assistant prize. Register now so as not to be disappointed. Spaces are limited!

Register Here Complete Guide to Airway Management delivered by International Experts Day One Lectures, Live Broadcast, Expert Sessions • Live Awake Fibreoptic Intubation Broadcast from Guy's Theatres • Review of Recent Airway Publications • Awake bre optic techniques • Videolaryngoscopes - Which ONE ? • Human Factors in Airway Management • DAS Intubation Guidelines • Front of Neck Access • Medicolegal Airway cases • CBD with audience voting • Lively debate on hot controversies • THRIVE and Pre-oxygenation • Obstetrics and Intensive Care Airway Management • Airway and Bariatric Anaesthesia • Next Generation Supraglottic Airways

Day Two WORKSHOPS • • • • • • • • • • • •

Fibreoptic Intubation Skills Awake Fibreoptic Intubation ORSIM - Fibreoptic Simulation Intubation through SADs Ultrasound in Airway Management Percutaneous and Surgical Tracheostomy Jet Ventilation Videolaryngoscopes and New Devices Paediatric Airway Scalpel Cricothyroidotomy Opti ow and THRIVE Virtual Endoscopy

@GAMCLondon2022 #GAMC2022 62

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Dif cult Airway Society E-Zine

January 2022

SCOTTISH AIRWAY GROUP ANNUAL MEETING | 11th March 2022 |

SAVE THE DATE FOR VIRTUAL SAG Friday 11th March 2022 Abstracts Deadline: 31st January 2022 Visit www.scottishairwaygroup.co.uk for registration and submission details.

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Dif cult Airway Society E-Zine

January 2022

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

@dasairway @dastrainees

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Dif cult Airway Society E-Zine

January 2022

INTRODUCTION TO PROCESSED EEG | References | 1 . P u r d o n P L , P i e r c e E T, M u k a m e l E A e t a l .

11. Muhlhofer WG, Zak R, Kamal T et al. Burst-suppression

Electroencephalogram signatures of loss and recovery of

ratio underestimates absolute duration of

consciousness from propofol. Proceedings of the National

electroencephalogram suppression compared with visual

Academy of Sciences 2013; 110: E1142–51.

analysis of intraoperative electroencephalogram. British

2. Hight D, Voss LJ, Garcia PS, Sleigh J. Changes in Alpha

journal of anaesthesia 2017; 118: 755 761.

Frequency and Power of the Electroencephalogram during

12. Fritz BA, Maybrier HR, Avidan MS. Intraoperative

Volatile-Based General Anesthesia. Frontiers in Systems

electroencephalogram suppression at lower volatile

Neuroscience 2017; 11: 36.

anaesthetic concentrations predicts postoperative delirium

3. Akeju O, Westover MB, Pavone KJ et al. Effects of

occurring in the intensive care unit. British Journal of

Sevo urane and Propofol on Frontal Electroencephalogram

Anaesthesia 2018; 121: 241–8.

Power and Coherence. Anesthesiology 2014; 121: 990–8.

13. Fritz BA, Kalarickal PL, Maybrier HR et al. Intraoperative

4. Kennedy R, McKellow M, French R, Sleigh J. Sevo urane

Electroencephalogram Suppression Predicts Postoperative

End-Tidal to Effect-Site Equilibration in Women Determined

Delirium. Anesthesia & Analgesia 2016; 122: 234–42.

by Response to Laryngeal Mask Airway Insertion.

14. Besch G, Liu N, Samain E et al. Occurrence of and risk

Anesthesia & Analgesia 2013; 117: 786–91.

factors for electroencephalogram burst suppression during

5. Akeju O, Song AH, Hamilos AE et al.

propofol–remifentanil anaesthesia. BJA: British Journal of

Electroencephalogram signatures of ketamine anesthesia-

Anaesthesia 2011; 107: 749–56.

induced unconsciousness. Clinical Neurophysiology 2016;

15. Shao YR, Kahali P, Houle TT et al. Low Frontal Alpha

127: 2414–22.

Power Is Associated With the Propensity for Burst

6. Blain-Moraes S, Lee U, Ku S, Noh G, Mashour GA.

Suppression: An Electroencephalogram Phenotype for a

Electroencephalographic effects of ketamine on power,

“Vulnerable Brain.” Anesthesia & Analgesia 2020: 1.

cross-frequency coupling, and connectivity in the alpha

16. Sleigh JW, Gaskell A. Postoperative Delirium: A Mine eld

bandwidth. Frontiers in Systems Neuroscience 2014; 8: 114.

of Markers and Mediators. Anesthesiology 2020; 133: 255–7.

7. Lee U, Ku S, Noh G, Baek S, Choi B, Mashour GA.

17. Hesse S, Kreuzer M, Hight D et al. Association of

Disruption of frontal-parietal communication by ketamine,

electroencephalogram trajectories during emergence from

propofol, and sevo urane. Anesthesiology 2013; 118: 1264–

anaesthesia with delirium in the post-anaesthesia care unit:

75.

an early sign of postoperative complications. British Journal

8. Brown EN, Pavone KJ, Naranjo M. Multimodal General

of Anaesthesia 2018; 122: 622–34.

Anesthesia. Anesthesia & Analgesia 2018; 127: 1246 1258.

18. Hight DF, Dadok VM, Szeri AJ, García PS, Voss L, Sleigh

9. Hayashi K, Tsuda N, Sawa T, Hagihira S. Ketamine

JW. Emergence from general anesthesia and the sleep-

increases the frequency of electroencephalographic

manifold. Frontiers in Systems Neuroscience 2014; 8: 146.

bicoherence peak on the α spindle area induced with

19. Liang Z, Huang C, Li Y et al. Emergence EEG pattern

propofol. British Journal of Anaesthesia 2007; 99: 389 395.

classi cation in sevo urane anesthesia. Physiological

10. Fleischmann A, Pilge S, Kiel T, Kratzer S, Schneider G,

Measurement 2018; 39.

Kreuzer M. Substance-Speci c Differences in Human

20. Reshef ER, Schiff ND, Brown EN. A Neurologic

Electroencephalographic Burst Suppression Patterns.

Examination for Anesthesiologists. 2019.

Frontiers in Human Neuroscience 2018; 12: 368.

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Dif cult Airway Society Newsletter

Winter 2019

Dif cult Airway Society

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@dastrainees 66