DAS Members EZINE May 2022 by Difficult Airway Society

DIFFICULT AIRWAY SOCIETY MEMBERS EZINE May 2022 Edition

Dif cult Airway Society E-Zine

May 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

Dif cult Airway Society E-zine

May 2022

CONTENTS Executive Updates

Miscellaneous

Editorial

Letters to the editors

DAS Executive Update

DAS Scienti c Of cer Report

DAS 2022

Proposals to host DAS 2024

Dif cult Airway Database - an update

Conference Corner World Airway Management Meeting 2023

Guy’s Airway Management Course 2022

Education Educational Series - Perioperative Medicine Part 1 11 Clinical Dilemma

#JanuAIRWAY

DAS, OAA, SOBA & RCoA Webinar Highlights

DAS Webinars

Videolaryngoscopy in paediatrics

Trainees Journal Club - Recommended Reads

Dif cult Airway Society E-Zine

May 2022

EDITORIAL | Helen Aoife Iliff | Natalie Silvey | Moon-Moon Majumdar |

2022 started with a bang for the DAS trainee

phase from COVID it is

reps with the month long airway education

reminder of how to prepare our patients for

event that was #JanuAIRWAY and this

surgery, surgery that may have been sadly

continued with the release of the compilation.

delayed due to the impact of the pandemic.

Quite a way to start the year! We have received some really helpful feedback on this and hope it is proving to be a useful resource. Any suggestions for future topics to

a very timely

All the way from Boston USA, we have a brilliant article on the use of paediatric videolaryngoscopy which is a must read. Our clinical dilemma this month also has an

cover are gratefully received. Spring is now very much upon us in the UK and as the weather improves (hopefully) and the days lengthen hopefully life continues to

international spin with a fascinating case from South Africa. How would you manage this patient?

feel more normal after a challenging two

Last, but by no means least, we hoped

years. We are very much looking forward to

everyone enjoyed the joint DAS, OAA, SOBA

October and the face to face DAS 2022 ASM

and RCoA webinar on airway management

and to meeting colleagues in person again

for patients living with obesity. We have more

after such a long absence. The meeting is

webinars in the planning so watch out for the

running from 5-7 October so if you can, book

next one.

your leave now!

Please grab a cuppa and enjoy everything

This edition of the e-zine is lled with some

this edition has in store.

fantastic articles and we would like to start

If you have any feedback or article

with a huge thank you to everyone who has

contributions please get in touch with our

contributed. We have the start of a three part

editorial team by emailing ezine@das.uk.com

series focusing on perioperative medicine. To

or tag us on Twitter @dasairway or

kick this off we have three fantastic articles

@dastrainees.

covering prehabilitation, NELA and shared decision making. As we enter the recovery

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Dif cult Airway Society E-Zine

May 2022

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

To: trainee@das.uk.com From: Trainee Subject: DAS Trainee Competition Many thanks for the opportunity to submit to this competition. It is encouraging to be able apply artistic licence and celebrate creativity within anaesthetics. After all, anaesthetics is an much an art of it is a science. Editors Response: Thank you for this thoughtful comment attached to your entry. As trainee representatives we felt our competition was a real opportunity to invite trainees to showcase some of their amazing creative talents. In a speciality and organisation where scienti c abstracts and writing are plentiful we wanted to see something a bit different. We are delighted the rest of the DAS committee and more importantly our trainee members have embraced the creative brief and we’ve received some outstanding entries. We do not envy the challenge set to our judges and wish all of the entrants the very best of luck.

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Dif cult Airway Society E-Zine

May 2022

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

So, a new year, a new Executive and many

It has been a dif cult year nancially for DAS

plans afoot. The effects of the pandemic

with the rst ever ASM held online and the

seem to be easing but on the back of that we

uncertainty regarding the future meetings.

are seeing an increase in the NHS workload.

DAS has had to accommodate these

We need to look ahead. We’re back to face-

changes with the associated cost

to-face events with restrictions almost gone

implications while trying our best to keep the

nationally and there is an eagerness from

delegate fees low for the ASMs.

clinicians to meet up again to teach and be educated.

Membership numbers continue to grow, both full members as well as associate and

We’ve achieved much with prior online meetings and what a way to draw a line underneath this than the DAS-RCoA Airway Leads day, 2 years on from when Professor Cook brought to our attention the potentially disastrous effects of a new unheard of virus. At the beginning of March organised by the AWL National Lead, Alistair McNarry, many

overseas. The rumblings of the Newcastle DAS Annual Scienti c Meeting this October 5-7 is taking on momentum. The local organising committee are

nalising the programme,

inviting speakers from near as well as friends from EAMS, SAM and ANZCA.

joined to listen to how airway training has

New Guidelines on Ethics in airway

changed in the new curriculum, the

management and Human Factors in airway

continuing development of the eFONA

management are being crafted and honed

database, hopefully to be launched later in

and will hopefully be produced by year-end.

the year, and the Dif cult Airway Database

The Dif cult Airway database continues to

was discussed. Also the Unrecognised

grow with more hospitals joining up as well as

Oesophageal Intubation campaign was

a drive to encourage private hospitals to

promoted to the airway leads to disseminate

partake as well.

to their departments.

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Dif cult Airway Society E-Zine

May 2022

I’m sure you’ve been the recipient of the high-

our guidelines to be translated into other

quality surveys which continue to gauge the

languages for airway societies globally.

practice and opinions of the membership. Our Scienti c of cer continues to maintain the high-standard of projects that we assign grants to as well as overseeing applications for the DAS Professorship and PhDs.

Projects are apace looking at standardisation of anaesthetic charts, an airway fellow database and a programme for ODP / nurse airway education amongst the many we are working on.

The DAS website, often a rst port-of-call is going to be experiencing a major, long overdue overhaul and we will keep you apprised of this.

In the meantime the society is pushing ahead from its exuberant origins as an airway enthusiast’s group to a professional multi-media platfor m for education,

On the social media aspect, we’ve had a campaign on Twitter with #JanuAIRWAY and a couple of joint webinars with the RCoA on management of haematoma after thyroid surgery and with our friends at the OAA and SOBA on airway management in patients living with obesity.

standards and data collection. Finally, we do hope that you can attend the DAS ASM in Newcastle, so please do book your leave now.!! Please also contribute with posters and oral presentations. After a long hiatus, It’s such an opportunity to further develop one’s own knowledge as well as

Our Lay representative has collaborated with

useful networking amongst airway

committee members to compile a patient

enthusiasts. Enjoy this new edition of our

information lea et for awake tracheal

DAS musings and continue to participate.

intubation and we continue to be asked for

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Dif cult Airway Society E-Zine

May 2022

SCIENTIFIC OFFICER REPORT | Kariem El-Boghdadly | Airway management research has

together as a PhD. DAS will

continued to thrive, with several

support applicants throughout the

national studies being conducted

process of a PhD by publication,

that will help us to understand and

including funding support.

improve practice further. This year

4. DAS Faculty of Professors.

will see more important work

This is an untapped resource that

being published, including

is open to any DAS Member to

practice-changing guidelines and

reach out to for guidance, support

o r i g i n a l re s e a rc h . D A S h a s continued to play a vital role in supporting academic anaesthesia, with a renewed

or advice on any academic matters, including grant applications and study design.

interest in some of our academic support

5. DAS Professor of Anaesthesia and

through a number of exciting academic

Airway Management for 2022. This is an

opportunities.

award conferred in recognition of a member’s

1. Direct DAS Grants. To ensure continuity and sustainability of grass-roots airway management research, we have a rolling process of grant funding via direct application to DAS. Applications for funding of up to £5,000 for studies broadly related to airway management will be peer-reviewed.

national/international standing in the

eld of

airway management as established by outstanding contributions through 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 appropriate forms of scholarship, and through teaching and administration. The applications for this are open until 27 May 2022.

Further details are available on the DAS

Our vision remains to take continue to

website or by contacting me directly. We

cultivate academia through DAS and airway

have already had a number of applications,

management, and begin to support, design

and we hope to receive more.

and develop our own projects with our

2. DAS Grants via the NIAA. DAS funds up to £20,000, split between large Project Grants

enthusiastic, creative and brilliant membership. Don’t hesitate to reach out and get involved!

(up to £15,000) and Small Grants (up to £5,000). Applications for 2022 closed in April and are now undergoing review. Applicants

Kariem El-Boghdadly

will be noti ed of outcomes in due course.

DAS Scienti c Of cer

3. DAS PhD Programme. This Programme

Scienti c-of cer@das.uk.com

gives support to researchers who have a list of publications that may be suitable to put

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Dif cult Airway Society E-Zine

January 2022

BOOK YOUR LEAVE AND REGISTER TODAY

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Dif cult Airway Society E-Zine

January 2022

PROPOSALS TO HOST OUR ANNUAL SCIENTIFIC MEETING IN 2024!! We are delighted to welcome proposals from those interested in hosting the DAS ASM in 2024. Proposals should contain information on the proposed venue(s) and costs, hotel accommodation nearby and transport links as a minimum.

Key Dates: Submission of Proposals Window Opens: 1st July 2022 Deadline for Submissions: Midnight, 16th September 2022 Shortlisted proposals will be invited for presentation in October 2022 DAS expect all those considering a bid to contact us and discuss what is involved in hosting prior to submission. Email: secretary@das.uk.com for more details.

Submissions should be emailed to the DAS Secretariat at: das@anaesthetist.org @dasairway @dastrainees #DASeducation

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Dif cult Airway Society E-Zine

May 2022

PERIOPERATIVE MEDICINE | Introduction to our new Educational Series | | Natalie Silvey | The COVID-19 pandemic has lead to

All of us working in the NHS will

a huge rise in the number of patients

have seen the impact that the

waiting for treatment and globally

National Emergency Laparotomy

health systems are thinking about

Audit (NELA) has had on the care

how to tackle such backlogs. Many

of our patients undergoing an

of our patients have faced huge

emergency laparotomy. Anastasia

delays to their surgeries and I am

Legga from University Hospitals of

sure each and every one of us has

Morecambe Bay NHS Foundation

seen this impact rst hand. For some of our

Trust looks at NELA in detail and its

patients this time period has been hugely

importance. To complete this rst part of the

detrimental to their health and wellbeing as

series, Nathan Grower and Douglas

they wait for the procedures they need.

Blackwood of the Royal Free London NHS

When discussing potential topics for our new educational series it became obvious very quickly that there was one topic of such importance to focus on and as such we are delighted to present the

rst part of our 3

part preoperative medicine series.

Foundation Trust and University College London NHS Foundation Trust respectively describe how vital shared decision making is as a pillar of patient care. In our next part of the series we will have articles looking in detail at frailty, CPET and

The Centre for Perioperative Care published

risk assessment.

a brie ng in August 2020 looking at the

We hope you enjoy reading these articles as

opportunities for better health and

much as we have.

preoperative care in the COVID-19 era. Many of our patients are more deconditioned as a result of the pandemic and therefore the focus on perioperative medicine and preparing our patients for surgery is vital. In this

rst part we have three fantastic

articles. We start with an introduction to perioperative medicine from Tom Poulton, Bernhard Riedel and Hilmy Ismail from the Peter MacCallum Cancer Centre Melbourne.

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Dif cult Airway Society E-Zine

January 2022

PERIOPERATIVE MEDICINE: AN INTRODUCTION | Tom Poulton, Bernhard Riedel, Hilmy Ismail | Perioperative medicine is the medical care of

planning of suitable individualised

patients from the time of initial contemplation

perioperative management but it can also

of surgery, throughout the operative period,

identify areas of modi able risk where

and onwards until full recovery. Thankfully

targeted intervention can alter the speci c

signi cant adverse outcomes attributable

patient’s risk pro le. This includes areas such

directly to anaesthesia have become rare,

as optimising the management of pre-existing

however avoidable morbidity and mortality

comorbidities; addressing factors such as

after surgery remain issues that will only

anaemia, frailty, and malnutrition; offering

increase in prevalence as the global

input into smoking cessation and reducing

population ages, accompanied by a higher

alcohol consumption; improving exercise

burden of comorbid disease and the need for

tolerance and functional status through

more surgery to be performed.

supervised exercise programmes; and

When de ning value in healthcare to be the sum of patient outcomes, safety, and satisfaction per unit cost, much of the current

providing support for any psychosocial barriers to engagement in preparation for and recovery from surgery.

system’s performance can be considered to

Certain aspects of preoperative optimisation

be suboptimal. This can largely be attributed

or prehabilitation are of universal bene t to all

to variability in care delivery and avoidable

patients undergoing surgery, however the

adverse events, including the “failure to

broader approach should be individualised

rescue” following complications after surgery.

based on the combination of patient- and

With the exception of a small number of

surgery-speci c risk factors. The holistic

outliers, the impact of individual clinicians on

nature of the interventions requires input from

surgical outcomes is limited. Instead,

a range of medical specialties and allied

perioperative medical care is the sum of its

health craft groups, and should ideally be

parts. Therefore, perioperative medicine can

considered at the earliest stages of the

be considered to be a multidisciplinary

pathway towards surgery. This includes

strategy to increase the value of surgical care

engagement with colleagues in primary care.

for patients.

In the post-COVID era it has been postulated

One of the main tenets of perioperative

that it may take up to ten years to clear

medicine is appropriate risk assessment

surgical backlogs in the National Health

through the use of objective tools coupled

Service. It has been proposed that “waiting

with clinical experience. Not only does this

lists” be reconsidered to be “preparation

allow for risk strati cation and aid in the

lists”, allowing prehabilitation programmes to

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Dif cult Airway Society E-Zine

May 2022

Fig 1: Conceptual model depicting the theoretical bene ts of prehabilitation. British Journal of Anaesthesia Education 2017; 17: 401–405

be implemented to serve this purpose. The

standardised where applicable, however

preoperative period is also an opportunity to

appropriately senior clinician input is needed

educate patients and their families in aspects

to ensure that such protocols are not followed

of prehabilitation and rehabilitation. Surgery

blindly and that the care is appropriate to the

Schools and “virtual” Surgery Schools using

patient and their speci c circumstances.

technology enabled aids are being

Additionally, if a patient’s condition deviates

increasingly used for the purpose of

from the expected trajectory, for example due

encouraging healthy lifestyle choices and

to an unexpected complication, it is essential

psychological preparedness for surgery and

that senior clinicians are involved in the

rehabilitation.

management decisions at an early stage. All

Where possible, unwarranted variation in perioperative care and processes should be avoided with the aims of reducing postoperative complications, shortening lengths of hospital stay, and reducing the risk of mortality. Evidence-based protocols, pathways, and care bundles can help to ensure that clinical management is

of this requires the development and con guration of perioperative services, both within individual hospitals and across networks within regions. This requires c o o rd i n a t e d i n p u t f ro m f u n d e r s a n d policymakers, and must be backed by robust data collection that is regularly reviewed for the purposes of clinical audit, benchmarking,

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Dif cult Airway Society E-Zine

May 2022

a n d q u a l i t y i m p ro v e m e n t . T h e w i d e r

(as de ned by the patient themselves), this

introduction of electronic medical records

should include goal congruent shared

extends the role of the perioperative physician

decision making. Less radical or even non-

to a ‘data translator’, bringing together health

surgical options should be presented to the

infor matics, data analytics, computer

patient such that the chosen approach most

scientists, and implementation science

closely aligns to the patient’s own wishes and

experts into the wider sphere of activity of

values, and is evidence-based.

perioperative medicine.

While traditional metrics such as length of stay

Since each patient will have their own goals

and mortality are useful from the perspective

and expectations that will guide what they

of healthcare services, perioperative medicine

believe to be a favourable outcome from

services should also aim to capture more

surgery, the patient’s own speci c risks and

patient-centred metrics through the use of

likely postoperative trajectories should be

patient reported outcomes and experience

considered as part of the overall consenting

measures (PROMs and PREMs). These data

process. Where the expected outcomes

will help to more accurately re ect the impact

include a high risk of mortality, major

that surgery has on patients and their quality

morbidity, or a serious impact to quality of life

of life, shift the focus onto interventions that deliver the best overall value to patients, which in turn feeds back into providing better informed consent and shared decision making in the future. Perioperative medicine has a broad scope and is holistic in nature. It does not belong to any one speciality or professional craft group, but instead requires the input from a full multidisciplinary team as well as patients themselves to provide the best long-term outcomes in an increasingly complex surgical landscape.

Fig 2: The multidisciplinary prehabilitation team. With the patient as the key member, involvement of all clinical and non-clinical staff in the preoperative pathway as members of the prehabilitation team is crucial to facilitate optimal use of available preoperative time and ‘make every contact count’ to support behaviour change prior to surgery. James Durrand et al. Clinical Medicine 2019; 19: 458-464

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Dif cult Airway Society E-Zine

May 2022

PERIOPERATIVE MEDICINE: THE NATIONAL EMERGENCY LAPAROTOMY AUDIT PROJECT (NELA) | Anastasia Legga | Perioperative care is the practice

Since its of cial start in 2012,

patient-centred,

NELA has published seven

multidisciplinary and integrated

reports. Every report provides a

medical care of patients from the

number of recommendations and

moment of contemplation of

standards against which every

surgery until full recovery1.

hospital can benchmark their performance and use the data to

The National Emergency

reduce variation and increase

Laparotomy Audit (NELA) is a great example of how setting perioperative pathways and use multidisciplinary approach can improve quality, safety and

quality of care. This is also in line with the Get It Right First Time (GIRFT) project4. The outcomes reported in NELA were thirty-

outcomes in emergency surgery. The NCEPOD report 2011 “Perioperative Care: Knowing the risk”2 was a landmark

day inpatient mortality and length of hospital stay.

report and although it included both

The key themes quickly identi ed to improve

emergency and elective inpatient surgery, it

outcomes were:

highlighted a small population of patients

✦

(approximately 10%) who had increased morbidity and a hospital mortality rate of

Timeliness of care with early input by senior multidisciplinary clinicians

✦

10-15% with high resource utilisation.

Quick recognition of acute abdominal pathology with treatment of antibiotics and

NELA was commissioned, shortly after this report, as part of the National Clinical Audit

prompt escalation ✦

and Patient Outcomes Programme

Early risk assessment, including frailty that is an independent risk factor increasing

(NCAPOP), overseen by the Healthcare

morbidity and mortality

Quality Improvement Partnership (HQIP) following evidence of high incidence of

✦

Prompt access to theatres

death, and a wide variation in the provision

✦

Appropriate post-operative management in

of care and mortality, for patients undergoing emergency laparotomy in hospitals across England and Wales. The project has secure funding until 30 November 20223.

critical care. It was very early recognised that older patients, over 65 years old, had worse outcomes. This cohort of patients had higher

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Dif cult Airway Society E-Zine

May 2022

30-day mortality (15.3 versus 4.9%, P<0.001)

SARS-COV-2 infection to be considered in the

and 90-day mortality (20.4 versus 7.2%,

risk assessment, it has also urged hospitals to

P<0.001) rates. Perioperative geriatric

gather data on the “negative” emergency

assessment was recommended and indeed

laparotomies- that is emergency surgery

increased over the years and along with other

proved it didn’t need to happen but with

interventions such as enhanced recovery, this

potential severe consequences for patients. It

was the cohort of patients that had the

also included intraoperative deaths and data

greatest reduction in mortality rates5,6.

on end-of-life care pathways.

Τhe key themes are all recognised to be

In the context of perioperative medicine, the

interlinked and improve results as part of

project has helped transfor m patient

being a bundle of care instead of working

p a t h w a y s p re s e n t i n g f o r e m e r g e n c y

individually. Using quality improvement tools,

abdominal surgery, in a meaningful way for

NELA has engaged all hospitals in England

the patients, based on evidence. The silos

and Wales, to benchmark themselves against

between different disciplines (emergency

national standards, reduce unwarranted

physicians, surgeons, anaesthetists, nurses,

variation and improve by establishing their

geriatricians, radiographers, intensivists,

own pathways. A national driver for hospitals

pharmacists, palliative care) had to be broken

to adhere to the recommendations was the

in order to provide continuity of care.

introduction of Best Practice Tariff.

Unwarranted variation in different hospitals

The data gathered helped to create the NELA risk score7. This is a more accurate risk assessment tool of the risk of death within 30

became evident and was a drive to investigate reasons behind this and try to improve.

days of emergency abdominal surgery. It is a

The latest NELA report showed that national

p re re q u i s i t e t o c o m p l e t e b e f o re a n y

30-day mortality has fallen 8.7% (11.8% in

emergency laparotomy case and helps to

year 1). Patients’ average hospital stay has

inform decisions about surgery, decide the

fallen from 19.2 days in year 1 to 15.1 days in

most appropriate post-operative care setting

year7. There are still challenges ahead like

and facilitate discussions with the patient. It is

theatre access, geriatric assessment,

easy to complete and exists as an app. The

consultant anaesthetic and radiographer input

NELA score takes into consideration some

before surgery but there can be no denial that

surgery and patient co-morbidity factors but

this project has been a lever for national

as every risk assessment tool, it isn’t complete

quality improvement on the outcomes of

as it doesn’t take into account other factors

emergency laparotomy patients.

that contribute to the outcome such as

frailty8.

Nevertheless, it has been shown to be more accurate than the P-POSSUM calculator or SORT for emergency laparotomy patients9,10,11. NELA has followed the change of times and the same way it has included frailty and

Another integral aspect of perioperative medicine that became also part of NELA pathways was Shared Decision Making (SDM). Shared decision making (SDM) is the process whereby patients and clinicians work together

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Dif cult Airway Society E-Zine

May 2022

Fig 1: NELA Patient Audit 2021 - Results Infographic https://www.nela.org.uk/reports

to make evidenced based decisions centred

and beliefs: just because we can do

on patient values and preferences. This may

surgery it doesn’t mean we should if it’s not

be to select a test or intervention such as

in the interest of the patient.

going ahead with surgery. SDM ensures individuals are supported to make decisions which are right for them by sharing information and videos. Patients at high risk of medical complications contemplating major surgery are the cohort of patients that may bene t most from individualising care according to their needs

Link to references

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Dif cult Airway Society E-Zine

May 2022

SHARED DECISION MAKING | Nathan Grower and Douglas Blackwood | E v e r y d a y, i n e v e r y

spectrum the patient is

clinical setting, patients

unsupported in their

make choices about their

decision making;

care. Some decisions

abandoned once their

carry few consequences

competence

or implications but for

established; facing a

others the effects can be

decision they lack the

long lasting and far

knowledge or experience

reaching. In head and

to make. Shared decision

neck surgery these decisions can affect the

making should sit in the middle of these

activities and characteristics that make us

extremes creating a partnership between an

who we are. Given this gravity it is incumbent

informed and empowered patient and an

on healthcare professionals to involve,

expert clinician.

engage, and empower patients to make the

This is particularly important in head and neck

decision that is best for them. In this article

surgery. These surgeries, which are often

we will de ne shared decision making,

cancer related, can carry signi cant mortality

explain its importance for head and neck

risk as well as the possibility of serious

surgery, and present a model you can

morbidity. In particular this morbidity can

employ in your own practice.

touch on the very character of a person. We

Shared decision making should be a

derive joy from eating and drinking,

collaborative process whereby healthcare

communicate through speaking and laughing,

professionals support patients in reaching

and our look and smile can characterise who

decisions about treatments. The conversation

we are. Losing, damaging, or even altering

should bring together a clinicians’ expertise

these facets of an individual’s life may be as

including available treatment options,

important to one person as achieving clear

evidence, risks, and bene ts, with a patient’s

margins is to another. The heterogenous

preferences relating to personal

nature of our patients make it impossible to

circumstances, goals, values, and beliefs. It

universally prioritise any single outcome and

sits in the middle of a spectrum of

even in cases where we are aiming for the

approaches to decision making. At one

same outcome, the grossly differing condition

extreme is a paternalistic approach that

in which patients arrive at surgery alters the

might appear in a 1920s medical drama. The

chances of achieving it. Shared decision

doctor makes the decision: determining the

making provides a framework for us to tailor

patient’s preferences and assigning value to

our care to an individual.

various outcomes. At the other end of the

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Dif cult Airway Society E-Zine

May 2022

All good in principle but how does this look in

may well cure a cancer but signi cantly

practice? The acronym BRAN (Bene ts, Risks,

impact quality of life.

Alternatives, and doing Nothing) was developed by Choosing Wisely UK and can be used as a framework for these discussions.

Without an alternative is there really a true choice? Some alternatives may come easily to our mind: surgical or medical management; chemotherapy or radiotherapy. But it is worth reminding ourselves to remain patient focussed – would a delay in treatment be an option? Would treatment in a different location be possible? These are not always natural considerations, but for a patient to be closer to family or feel well through a signi cant life event before starting treatment may be important. We are all driven to try and help our patients and it is not unreasonable to presume that surgeons offer surgery and oncologists offer chemotherapy because they believe it will bene t the patient. But for some individuals doing nothing may be the right decision. This may feel alien to us as healthcare

Fig 1: Choosing Wisely BRAN patient information infographic.

professionals however it is important to acknowledge that this option exists and

The bene ts of an operation may include cure,

good reasons may motivate a patient to take

prolonging life, alleviating symptoms, or

it. If patients are to be truly empowered then

improving quality of life. In some cases a

they must, at minimum, be informed that

treatment may do all of these but it is not hard to

doing nothing is an option.

imagine a treatment that may achieve one to the detriment of others.

Modern medicine has shown an incredible growth in complexity and capability resulting

Risk is the cornerstone of consenting a patient

in treatments which would have been

for any procedure. But, for this information to be

unimaginable even decades before. As

useful it must be individualised considering the

health professionals it is our role not only to

patient and their medical and social history. As

understand and utilise these, but to explain

well as common side effects and possible

them to our patients and help them balance

complications this part of the discussion should

the bene ts, risks and alternatives and

provide a patient with information about how the

marry these to their own ambitions and

treatment may affect them even if successful. In

beliefs. Shared decision making should

head and neck surgery radical resections

therefore be thought of as a fundamental

twinned with chemotherapy and radiotherapy

pillar of patient care.

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Dif cult Airway Society E-Zine

May 2022

CLINICAL DILEMMA | What Would You Do? |

Many thanks to Ross Hofmeyr and Francois van Heyningen for this edition’s challenging case from Cape Town, South Africa: A 33-year-old woman with severe rheumatoid ar thritis is booked for elective bilateral temporomandibular joint replacement.

She is

wheelchair bound due to xed exion deformities of both hips and knees. Airway examination demonstrates that she is edentulous with an intergum mouth opening of 15 mm and has signi cantly limited range of motion of her neck. In addition to the presenting and surgical problems, she is currently in her third month of treatment for multidrug-resistant pulmonary tuberculosis, and has iron-de ciency anaemia (Hb of 6.7g/dL). She is frail but alert; nervous but co-operative.

What is your plan?

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

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WHATWOULDYOUDO? DAS Expert Corner Airway Expert 1: Issues: 1. Everyone needs to agree that surgery is the right plan, particularly the patient - surgery needs to provide expectation of life quality improvement as it is extremely HIGH RISK. 2. Needs a nasal TT 3. Predicted Dif cult Intubation. Intra-oral airway rescue may be impossible, making eFONA risk higher. May have crico-arytenoid dysfunction secondary to RA 4. Predicted hypoxaemia + hypercapnia risk 5. Reduced oxygen carrying capacity. Strategy: 1. MDT to agree best timing with TB Rx and optimising haematology. Don’t see why there is a huge rush here, ie optimise chest so respiratory docs say that it’s as good as it gets; optimise Hb under haematology guidance 2. Cannot nd any reason NOT to perform ATI. Needs MDT to agree best personnel, time, venue, strategy etc 3. Mark the neck for potential eFONA 4. ATI:FB nasally with HFNO. Remi awake + LA. Small exible tube. Careful rail-roading as has RA which may involve glottis. Ideally i would like to visualise tube passage but this is tricky with 15mm MO so probably just [a] involve expert and [b] take care! 5. Surgeon ready to perform eFONA if control lost 6. Safe awake extubation assuming airway is safe. Again awareness that may have RA of larynx. Probably HDU post-op with clear escalation plan agreed between anaes/ICU + OMFS

Airway Expert 2: 1.

It’s an elective case which should be delayed as she has a Hb of 6.7. She should have oral or parenteral Iron and her treatment should be guided by monitoring Hb and serum iron concentrations.

When she has an appropriate Hb she should have an elective ATI - exible bronchoscopy nasally with the team in PPE if using Opti ow (because of her TB).

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Airway Expert 3: This is the case of a frail, medically complex patient with a predicted dif cult airway with an infectious disease posing risks to staff. First, I would work to ensure that the patient is medically optimised. This patient sounds like she may need to have her anaemia addressed with pre-operative i.v. iron ± transfusion. This is important because she has concurrent pulmonary pathology and is at risk of hypoxaemia, thus oxygen delivery must be optimised. Airway management is about oxygen delivery to end organs, and we must optimise all steps along this ladder. In terms of airway management, once the patient is optimised, there are clear indications that this patient must avoid hypoxia and has a dif cult airway, therefore awake tracheal intubation (ATI) is indicated. This patient would need counselling for it, and a clear discussion and consent. My technique would follow the DAS ATI guidance: ✦

Oxygenation: HFNO 50-70 l/min

✦

Topicalisation: Lidocaine 10% spray to oropharynx. Co-phenycaine to the nose. Ensure dosing are weight-adjusted.

✦

Sedation: Very judicious use of remifentanil only (TCI 2-3 ng/ml)

✦

Procedure: exible bronchoscope, size-appropriate Portex blue nasal tube (≤6.0mm). Induction of anaesthesia after a two-point check (CO2, visualisation of tube above the carina).

Airway Expert 4: This is a really good case to discuss as lots of our patients need more than airway management. The patient needs sorting out rst (elective case): I. The TB II. The anaemia - cause and treatment III. The extent of the RhA - has anyone imaged her neck, checked it for stability/ subluxation Next: What do the surgeons want and need in terms of access - how can that be accommodated anaesthetically? Finally STOP, plan and prepare for airway management (obviously taking account of the patient’s weight) and with a skilled second anaesthetist in attendance Personal preference would be for a nasal ATI appropriate topicalised and sedated (but check the albumin before setting off given the active infection). As always I would use HFNO, it just makes it easier. Tube selection - I have done it with both narrow bore armoured and soft ‘ivory’ tubes, both have their place but I always use merocele packs to stop nasal ischaemia.

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Airway Expert 5: 1. I would ask for a multidisciplinary team meeting which would include the surgical team, respiratory team and myself to decide if the case can be delayed until he patient is optimised for surgery with regards to treatment for TB and her anaemia. 2. I would also like to have an informed discussion with the patient to establish the risks and bene ts of the timing of the surgery. 3. Ideally I would like her to have completed her TB therapy and start iron replacement therapy prior to surgery. 4. With regards to airway management this patient has limited mouth opening and limited neck movement therefore my plan would be to intubate using an ATI technique as per DAS ATI guidelines, in particular focusing on ef cient and rapid intubation with minimal coughing by using remifentanil TCI as the sedative agent. 5. All members of staff involved in the case should be made aware that the patient has multi-drug resistant pulmonary TB, or that she has recently completed

therapy for this (depending on the

timing of the case). 6. Due to the patient's history of multi-drug resistance pulmonary TB I would minimise the number of people present in theatre during intubation and extubation episodes, whilst taking full respiratory PPE precautions. 7. Post operative care also needs to be considered as the patient will certainly be a more dif cult intubation if required, so a robust airway plan will need to be in place and the patient should be admitted to ICU on the rst post op night.

Airway Expert 6: This is an elective case with several important considerations along with an extremely challenging airway. It is likely to be a long case with issues around airway management, multidrug resistant TB, iron de ciency anaemia and frailty of the patient. Positioning the patient on the operating table for a long case with xed exion deformities will also require planning along with other members of the team. If it was an urgent procedure, I would opt for an awake nasal

breoptic intubation for airway

management. If the patient is fully compliant with the TB medications, the risk of infection is low however I will consider wearing a personal protective mask based on infectious control teams advice. Since this is an elective procedure, I will ask for a proper MDT discussion around treating her iron de ciency anaemia, optimisation around her weight and seek advice on her ongoing TB treatment and an accurate assessment of spread of infection to health care providers. I will also discuss if the case can be done as a unilateral TMJ replacement to reduce the intraoperative time. I will ask for physio input regarding positioning of the patient for the procedure and arrange HDU care postoperatively. I will also involve the nutritional team to optimise her preoperatively. I will have a detailed discussion with the patient as well regarding the risks involved for this procedure.

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THOUGHTS FROM OUR CASE SETTER | Ross Hofmeyr and Francois van Heyningen |

Issues Identi ed: 1.

Dif cult airway

✦

Limited mouth opening and edentulous

✦

C-Spine instability

✦

Limited head extension; some exion

✦

Unable to exclude laryngeal involvement of RA

BVM

– would likely be possible with the use of OPA or NPA

LMA

– limited mouth opening would make passing of LMA very challenging

Asleep DL/VL – likely not possible due to points above ATI

– best option dependent on quality of sedation/topicalisation and patient cooperation

FONA

- access to cricothyroid membrane adequate

Risk of environmental contamination with MDR TB during aerosolizing airway procedures

RA-associated end-organ damage and severe anaemia

Our Plan: Plan A - awake tracheal intubation using exible bronchoscope: ✦

Thorough topicalization using hypersonic nebulizer with 4% lignocaine/adrenaline mix, as well as direct ‘spray-as-you-go’ topicalization of vocal cords during endoscopy

✦

Ultrasound guided identi cation of cricoid membrane, transmembrane placement of 20G IV cannula and sub-laryngeal topicalization. Cannula left in place as landmark for FONA in an emergency

✦

Dexmedetomidine sedation with slow loading dose and subsequent infusion

✦

Nasal intubation with head in neutral position/limited C-Spine movement

✦

Once ETT secured and coupled to anaesthetic machine, bolus of Propofol as induction

Plan B - perform BVM ventilation with or without an OPA/NPA if the patient became apnoeic. Intubation could be reattempted after optimization of position and conditions Plan C - quick attempt at insertion of a slim-pro le LMA Plan D - FONA, with a cricothyroidotomy set nearby and surgeons in theatre on standby ✦

Reassessment of mouth opening after induction – VL blade carefully passed as reassurance that VL with bougie can be used in an emergency, including at extubation

✦

All staff in theatre aware of exposure risk and wearing appropriate PPE

✦

Care taken with patient positioning

✦

Transfused 2 units of red-cell concentrate intraoperatively

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#JANUAIRWAY 2022 | Helen Aoife Iliff and Tom Lawson | The #JanuAIRWAY twitter educational event concluded on 31.01.2022. It consisted of daily tweetorial threads which include a series of one-pagers on topics related to airway management – posted via the @dastrainees twitter account. There has been an overwhelmingly positive response online to the series with excellent feedback. Thank you to everyone who took the time to provide us with feedback. We are delighted the series was so widely accessed, not just globally but also across professional domains, specialities and training grades.

The compilation was launched on 10th March 2022 and was viewed over 4000 times in more than 80 countries across 6 continents in the rst 3 weeks. It is freely available and fully downloadable via issuu. Please share the link with any colleagues you think may nd it useful.

The series had gained: >3 million

We hope the Journal Club in this members e-

impressions; >13.5 thousand likes and >5

zine will act as a similarly useful resource going

thousand retweets. The DAS education team

forward highlighting some interesting papers

are already using on the feedback received

and recommended reads for our membership.

to plan future content. We’ve already snuck some new #OnePages into the compilation including the one in this edition on oesophageal intubation which was developed with Professor Tim Cook and

Thank you to all of our content contributors, reviewers and to all of those who have taken the time to support the series. We hope you enjoyed it and found the content useful.

Barry McGuire.

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

AVAILABLE HERE!

@dastrainees @vapourologist #DASeducation

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DAS OAA SOBA RCOA WEBINAR: HIGHLIGHTS | Moon-Moon Majumdar and Gunjeet Dua| DAS was delighted to join

period!) and which

the Royal College of

complications are most

Anaesthetists (RCOA), The

common.

Society for Obesity and

The experts agreed that

Bariatric Anaesthesia

whilst intubation itself

(SOBA) and the Obstetric

may not necessarily be

Anaesthetists’ Association

more dif cult in patients

(OAA) for an evening webinar on the 31st March 2022 to discuss airway management for patients living with obesity. I was very excited to co-chair the event with the eminent Dr Gunjeet Dua, DAS Education Co-lead and RCoA Webinars

with obesity; face-mask ventilation and emergency front of neck access are likely to be tricky. These patients desaturate rapidly and we need to modify our techniques appropriately.

Clinical Content Lead for this one and a half

Dr Andrew McKechnie spoke on preparation

hour event.

in the pre-operative period: including tips on

We welcomed experts Dr Imran Ahmad (DAS President), Dr Nuala Lucas (OAA Education Chair, senior editor of IJOA), Dr Andrew

consenting patients (with an emphasis on an individualised approach), positioning, human factors, and careful pre-oxygenation.

McKechnie (SOBA President), and Dr

Dr Nuala Lucas discussed shared decision

Rebecca Black (SOBA Secretary).

making in the high-risk anaesthetic clinic

Dr Rebecca Black was

rst to present on

whether airway management techniques for patients with obesity have on since NAP 4 in 2011. She covered the recently published BIGAA study: including whether obesity is associated with a higher airway complication

antenatally for pregnant women with obesity, and the importance of honesty and compassion in this setting. She also comprehensively covers the evidence around high- ow nasal oxygen (HFNO) in the obstetric population with obesity.

rate, when these complications are most likely

Dr Imran Ahmad covered evidence for HFNO

to occur (hint – don’t forget the post-op

in the non-pregnant population with obesity, and the opti ow switch and how it can be

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Our panel: From top right clockwise, Moon-Moon Majumdar (DAS Trainee Representative), Nuala Lucas (OAA Education Chair). Imran Ahmad (DAS President), Gunjeet Dua (DAS Education Co-Lead), Andrew McKechnie (SOBA President) and Rebecca Black (SOBA Secretary)

used seamlessly for both pre-oxygenation and

Twitter was alight with discussion, led by the

per-oxygenation. The exper ts agreed

excellent Dr Achuthan Sajayan and Dr Helen

wholeheartedly that HFNO is not a rescue

Iliff representing DAS, Dr Selina Ho for SOBA

technique for falling saturations — it should be

and Dr Kate Stoddard for the OAA.

part of ‘plan A’. Imran and Nuala go on to talk about video-laryngoscopy, and Imran also covers indications for awake tracheal intubation (ATI) in patients with obesity and key concerns and modi cations to his ATI

The webinar received excellent feedback, and we are very grateful to the RCoA’s Jodie Phillips for working extremely hard behind the scenes on all the organisational aspects. If you missed it, please do catch up via this

technique. Dr Rebecca Black covered the post-operative period, as well as speci c concerns in patients with obstructive sleep apnoea (particularly the 90% who do not have a formal diagnosis, but in whom there is a high index of suspicion). She details the

link. We hope you nd it useful! Please watch out for more events like this one from DAS education, and let us know what topics you wish to learn about in the future! Tweet us @dastrainees @dasairway or email us at trainee@das.uk.com

practicalities of deciding which patients need overnight admission or the high-dependency unit. We

nished with a panel discussion of a

number of thought-provoking audience questions, and managed to

nish only 9

minutes over time! >600 people watched the webinar live via zoom and facebook, and >2500 signed up to watch it in their own time.

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DAS WEBINARS 2022 | Gunjeet Dua |

MORE 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.

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January 2022

VIDEOLARYNGOSCOPY IN PAEDIATRICS | Jamie Peyton | Direct laryngoscopy (DL) has been

complications are best described

the standard technique used to

using large scale registries and they

perform tracheal intubation in

have shown that severe oxygen

paediatric practice for many

desaturation is common, occurring

decades. It is a safe and (usually)

in nearly 50% of NICU intubations1,

successful technique, demonstrated

15% of PICU intubations8, and in

by the frequency it is used across all

around 9% of cases when dif culty

the specialties who regularly

was encountered in the operating

intubate children and infants. In

theatre7. Cardiac arrest occurred in

recent multi-centre studies DL was the

nearly 2% of cases in the Pediatric Dif cult

technique of choice in 79% of intubations in

Intubation Registry (PeDIR)7 and 6% of

the neonatal intensive care units (NICU)1, 97%

intubations described as dif cult in the PICU8.

of intubations performed in paediatric

Data have also repeatedly shown that

intensive care units (PICU)2, and 98% of

complications relating to tracheal intubation

intubations performed in children undergoing

are directly associated with the number of

surgery in Europe3. Given that so many

attempts at laryngoscopy8-10. These

children are intubated successfully by using

show that we can do better, but the question

traditional DL it is reasonable to ask the

remains how can we do better? One

question whether anything needs to change,

suggestion is that using video laryngoscopy

can we do any better?

(VL) instead of DL will improve intubation

Data regarding complications during tracheal

gures

success and decrease complications.

intubation in children is not as extensive as

Data from the PeDIR has been used to look at

those in adults, but what data we do have

the different success rates of techniques used

show that there is room for improvement.

for tracheal intubation. Importantly it has

Dif culties with tracheal intubation are

shown that DL has a poor success rate in

estimated to occur in 0.5-1% of children3 4,

children who are dif cult to intubate. A 2016

and may be higher in children less than a year

paper compared DL with Glidescope Video

In approximately 20%

Laryngoscopy (GVL) and showed that the

of cases dif culty with tracheal intubation was

success rates seen with DL were much lower

not anticipated7. When dif culty does occur,

(4% vs 53% 1st attempt success, and 21% vs

the complications can be severe and

82% eventual success)10 [Fig 1].

of age and

neonates5 6.

potentially life-threatening. These

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January 2022

The PeDIR data has also shown that different

infants and neonates who weighed <5kg in

video laryngoscopes have different success

the PeDIR standard blade VL use was

rates, particularly in smaller children. An

associated with signi cantly higher success

important characteristic of video

rates and fewer complications than non-

laryngoscopes that is often overlooked is the

standard hyperangulated VL blades9 [Fig 2].

design of the laryngoscope blade. Many

This concept is important because it means

people, and a signi cant portion of the

that with the correct equipment, DL and VL

literature, think of all video laryngoscopes as

are not mutually exclusive techniques.

being the same in terms of function and performance. Video laryngoscopes can be shaped at a more acute angle than traditional DL blades that effectively allow them to look around the natural curve of the airway to allow the video camera to see the larynx without having to create an almost straight direct line of sight to the user. Some VL systems have both angulated blades and the traditional standard Macintosh and/or Miller DL blades. There is no agreed upon nomenclature for the different types of VL blade, but it can help to think of them as standard blades (where DL can be performed, as well as indirect VL) and non-standard, hyperangulated blades (where usually only indirect VL can be performed). In

A consistent feature of the data we have is that smaller children are more likely to be dif cult to intubate and to have more complications, as well as having lower success rates when advanced techniques are used to intubate them than is commonly seen in adults. Infants and neonates were identi ed as a particularly vulnerable group, hence the PeDIR collaborative designed a multinational, randomized clinical trial designed to compare traditional direct laryngoscopy with standard blade indirect video laryngoscopy in infants (the VISI trial)11. This study looked speci cally at patients who were not anticipated to be dif cult to intubate and was designed to be re ective of anaesthetic practice in infants

Fig 1: From Park R, Peyton JM, Fiadjoe JE, et al. The ef cacy of GlideScope(R) videolaryngoscopy compared with direct laryngoscopy in children who are dif cult to intubate: an analysis from the paediatric dif cult intubation registry. Br J Anaesth

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with normal airways. The VISI trial showed that

other advantages include allowing a

when standard (Miller) blade video

t r a i n e r t o s e e w h e re t h e t i p o f t h e

laryngoscopy was used in children who weigh

laryngoscope blade is, and to identify

<6.5kg there were higher success rates and

anatomical structures that an inexperienced

fewer complications associated with

trainee may not recognize. It also allows an

intubation.

objective view of the tracheal tube passing

In older children the data is less clear cut with multiple meta-analyses failing to show any superiority of VL over DL in older children. However, the major weaknesses of these m e t a - a n a l y s e s a re t h a t t h e y c a n n o t differentiate between different age groups, different intubating conditions, and different types of VL devices – all of which have an impact on the results of the studies within the

through the vocal cords rather than relying on the intubating clinicians view. This does not replace capnography for con rming tube placement, but it adds another layer of safety to the process. It is also important to realise that regular use of VL devices in elective settings will increase experience with them and allow users to be familiar with them before they reach for them in an emergency.

meta-analyses. They also tend to ignore the

It should also be noted that although VL

other bene ts of using VL, which are more

systems are associated with much higher

dif cult to quantify and measure12. These

success rates than traditional DL in children

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January 2022

who are dif cult to intubate, they are not a

of writing the Verathon system lacks a Mac 0,

panacea. The success rates we see in the

1, 2, or Miller 2 blade and the Storz system

PeDIR data make it clear that there are still a

lacks a non-standard hyperangulated blade

signi cant number of children, particularly

that is appropriate for use in infants. The

infants where VL fails. It is incumbent upon

exible bronchoscopes from both

intubating clinicians to avoid the mistakes of

manufacturers are also too large to be used in

xating on intubation, or on a particular piece

infants requiring size 3.5 or smaller tracheal

of equipment. The standard dif cult airway

tubes, so a third system is required if a smaller

advice to focus on oxygenation, ensure

exible bronchoscope is needed. This creates

meticulous preparation and planning, avoid

issues of expense and training, further

persisting with failing techniques and

highlighting the differences between adult and

providers, and calling for help remains

paediatric practice.

germane no matter what technique you are using13.

In summary, we know that when compared to DL, VL is associated with a higher intubation

From a practical standpoint this has led to a

success rate and fewer complications in

distinct change in practice amongst many of

children who are dif cult to intubate and in

us involved regularly in paediatric dif cult

infants with normal airways. With the correct

airway management. For example, within my

equipment DL and VL are not mutually

own institution (Boston Children’s Hospital,

exclusive techniques, and video assisted DL

Boston, MA, USA) we have a hospital-wide

can be used to improve teaching and

recommendation, in place since 2017, for VL

increase intubation success. Given that DL

systems to be used in children who weigh

remains an ef cient, safe technique in most

<5kg and older children who are suspected

children we should not abandon it completely.

to be dif cult to intubate. This has led to a

However, instead of using technology from the

m a s s i v e i n c re a s e i n u s e w i t h i n t h e

1930s we should increasingly be using VL

anaesthetic department and a plan to

systems to perform intubations by either DL,

eventually have a VL system located in every

video-assisted DL, or indirect VL.

operating theatre. The problem that this then creates for a tertiary paediatric centre where we regularly care for children at extremes ofVideo-Assisted Direct Laryngoscopy (VADL) weight (from <500g to >200kg) is that there are no fully comprehensive VL systems that allow for both standard and non-standard blades to be used across all our patients. The two systems that have the greatest market penetration and therefore most data available for use in children are the Verathon Glidescope system and Storz C-Mac system. Both also have exible bronchoscopy options for adults and children. However, at the time

Link to references

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JOURNAL CLUB | Recommended Reads | Welcome to the 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 Helen Iliff. We welcome members feedback and thoughts on the papers featured - please tweet us @dastrainees or @dasairway or email us at ezine@das.uk.com.

Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. ✦

Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database of Systematic Reviews. 2022; 4: CD011136. doi: 10.1002/14651858.CD011136.pub3. PMID: 35373840; PMCID: PMC8978307.

The debate over if videolaryngoscopy is superior to direct laryngoscopy was very much brought back into to the spotlight when this updated Cochrane Review was published in April. A fantastic piece of work for which the authors must be commended. First published in 2016 this updated review in looked at the growing body of evidence comparing videolaryngoscopy and direct laryngoscopy. The review collected data on the following outcomes: failed intubation; hyperaemia; successful

rst attempt at tracheal intubation;

oesophageal intubation; dental trauma; Cormack-Lehane grade; and time for tracheal intubation. It compares 3 types of videolaryngoscopy (Macintosh style, Hyperangulated and Channeled) versus direct laryngoscopy. The authors conclude that “videolaryngoscopy likely provides a safer risk pro le compared to direct laryngoscopy for all adults undergoing tracheal intubation.” While some on social media have been referring to this review as the end for direct laryngoscopy, the authors must also be commended for their balanced approach where they have been simultaneously advocating for a shift towards universal videolaryngoscopy (based on the evidence) and presenting the bene ts of direct laryngoscopy using videolaryngoscopes. We suspect the debate is now likely to shift towards comparing devices and the question of which device is best?

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Videolaryngoscopy vs. direct Macintosh laryngoscopy in tracheal intubation in adults: a ranking systematic review and network meta-analysis. ✦

de Carvalho CC, da Silva DM, Lemos VM, Dos Santos TGB, Agra IC, Pinto GM, Ramos IB, Costa YSC, Santos Neto JM. Videolaryngoscopy vs. direct Macintosh laryngoscopy in tracheal intubation in adults: a ranking systematic review and network meta-analysis. Anaesthesia. 2022; 77: 326-38. doi: 10.1111/anae.15626. Epub 2021 Dec 1. PMID: 34855986.

There are a number of different video laryngoscopes available for use today. Most manufacturers offer a range of blades in different sizes including hyperangulated and paediatric blades. Departments may have either a single option or multiple options available for use and there has been no clear evidence of superiority of a single device or manufacturer. In this recently published paper, the authors carried out a systematic review with network metaanalyses to rank video laryngoscopes for orotracheal intubation performance compared with the Macintosh direct laryngoscope in adults. The primary outcome was the risk of failed intubation with the devices, with the secondary outcomes being: failed rst intubation attempt; failed intubation within 2 attempts; dif culty of intubation; percentage of glottic opening seen; dif cult laryngoscopy; and time to intubation. This was a well thought out and conducted piece of work looking at a question clinicians are seeking the answer to. Although the authors found statistical and clinical evidence of the bene ts of videolaryngoscopy over direct laryngoscopy they were unable to identify statistically signi cant differences between the various videolaryngoscopes assessed. An interesting read to see the comparative scores of different devices. Worth a look to see how did the device you are most familiar with/prefer faired.

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DIFFICULT AIRWAY DATABASE - AN UPDATE | Achuthan Sajayan | DAS Dif cult airway database is continuing its expansion across the country and several national organisations have con rmed their of cial support to the project in the last few months. The following is the list of organisations supporting us: • Society for Obesity and Bariatric Anaesthesia (SOBA) • Association of Anaesthetists (AoA) • Obstetric Anaesthetists Association (OAA) • Royal College of Anaesthetists (RCoA) • Safe Anaesthesia Liaison Group (SALG)

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

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.

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.

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.

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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GP letter

January 2022

• Association for Perioperative Practice (AfPP)

which is already a part of the project, please encourage your colleagues to

• College of Operating Depar tment Practitioners (CODP)

submit the data promptly and let us know if you have any feedback about the project or the process of submission.

• Society for Education in Anaesthesia (SEA-UK) Here is the comparison of current

gures

Some useful links are given below:

with those from September 2021:

DAS Database main page

Sept 21

The list of Trusts currently taking part in the

Current Status

150 Hospital sites

175

820+ submissions

900+

1935 Access logins

2200+

project Other project related documents can be found here

The analysis of the data collected over the rst

ve years is in the process of being

Dr Achuthan Sajayan

published. Please watch the space!

Co-Lead, DAS Dif cult Airway Database

If your hospital is not yet part of this project

dad@das.uk.com

and you are interested in taking the lead role locally, please do get in touch with us via dad@das.uk.com . If you work in a hospital

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Dif cult Airway Society E-Zine

January 2022

WORLD AIRWAY MANAGEMENT MEETING 2023 | ANNOUNCEMENTS COMING SOON |

Following a competitive bidding process for host cities for the World Airway Management Meeting in 2023, the World Alliance of Airway Management is currently nalising details before con rming and announcing the winning bid to host WAMM 2023.

HOST CITY AND DATES ANNOUNCEMENT COMING SOON!!

@wamm2023 #WAMM2023

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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.

Provisional Programme Here Register now so as not to be disappointed. Spaces are limited!

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Dif cult Airway Society E-Zine

January 2022

PERIOPERATIVE MEDICINE: THE NATIONAL EMERGENCY LAPAROTOMY AUDIT PROJECT | References | 1. https://cpoc.org.uk 2. https://www.ncepod.org.uk/2011poc.html 3. https://www.nela.org.uk 4. https://www.gettingitright rsttime.co.uk 5. RCS Report The High Risk General Surgical Patient Raising the Standard December 2018 6. Shipway D et al. British Geriatric Society statement: older patients undergoing emergency laparotomy. Age ageing 2021;50(1) 268-269 7. https://data.nela.org.uk/riskcalculator/ 8. Shinall CM at al. Association of preoperative patient frailty and operative stress with postoperative mortality JAMA Surg 2020;155(1):e194620 doi: 10.1001/jamasurg.2019.4620 9. http://www.riskprediction.org.uk/index-pp.php 10. http://www.sortsurgery.com 11. Eliezer DD et al for the Hunter Emergency Laparotomy Collaborator Group. High-Risk Emergency Laparotomy in Australia: Comparing NELA, P-POSSUM, and ACS-NSQIP Calculators. J Surg Res.2020 Feb;246:300-304. Doi:10.1016/j.jss.2019.09.024 https://www.journalofsurgicalresearch.com/article/S0022-4804(19)30658-4/fulltext

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Dif cult Airway Society E-Zine

January 2022

VIDEOLARYNGOSCOPY IN PAEDIATRICS | References | 1. Foglia EE, Ades A, Sawyer T, et al. Neonatal Intubation Practice and Outcomes: An International Registry Study. Pediatrics 2019;143(1) doi: 10.1542/peds.2018-0902 [published Online First: 2018/12/13] 2. Nishisaki A, Turner DA, Brown CA, 3rd, et al. A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs. Critical care medicine 2013;41(3):874-85. doi: 10.1097/CCM.0b013e3182746736 [published Online First: 2013/01/19] 3. Engelhardt T, Virag K, Veyckemans F, et al. Airway management in paediatric anaesthesia in Europe-insights from APRICOT (Anaesthesia Practice In Children Observational Trial): a prospective multicentre observational study in 261 hospitals in Europe. Br J Anaesth 2018;121(1):66-75. doi: 10.1016/j.bja.2018.04.013 [published Online First: 2018/06/25] 4. Schmid K, Buehler PK, Schmitz A, et al. Frequency distribution of modi ed Cormack-Lehane views-A retrospective audit of tracheal intubation in children with normal airways. Acta Anaesthesiol Scand 2019;63(8):1001-08. doi: 10.1111/ aas.13387 [published Online First: 2019/06/05] 5. Disma N, Virag K, Riva T, et al. Dif cult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study. Br J Anaesth 2021;126(6):1173-81. doi: 10.1016/j.bja.2021.02.021 [published Online First: 2021/04/05] 6. Park RS, Peyton JM, Kovatsis PG. Neonatal Airway Management. Clin Perinatol 2019;46(4):745-63. doi: 10.1016/ j.clp.2019.08.008 [published Online First: 2019/10/28] 7. Fiadjoe JE, Nishisaki A, Jagannathan N, et al. Airway management complications in children with dif cult tracheal intubation from the Pediatric Dif cult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med 2016;4(1):37-48. doi: 10.1016/S2213-2600(15)00508-1 8. Graciano AL, Tamburro R, Thompson AE, et al. Incidence and associated factors of dif cult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS. Intensive Care Med 2014;40(11):1659-69. doi: 10.1007/s00134-014-3407-4 9. Peyton J, Park R, Staffa SJ, et al. A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Dif cult Intubation Registry. Br J Anaesth 2020 doi: 10.1016/j.bja.2020.08.010 [published Online First: 2020/09/21] 10. Park R, Peyton JM, Fiadjoe JE, et al. The ef cacy of GlideScope(R) videolaryngoscopy compared with direct laryngoscopy in children who are dif cult to intubate: an analysis from the paediatric dif cult intubation registry. Br J Anaesth 2017;119(5):984-92. doi: 10.1093/bja/aex344 11. Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, et al. First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet 2020;396(10266):1905-13. doi: 10.1016/ S0140-6736(20)32532-0 [published Online First: 2020/12/15] 12. Kelly FE, Cook TM, Boniface N, et al. Videolaryngoscopes confer bene ts in human factors in addition to technical skills. Br J Anaesth 2015;115(1):132-3. doi: 10.1093/bja/aev188 [published Online First: 2015/06/20] 13. Sohn L, Peyton J, von Ungern-Sternberg BS, et al. Error traps in pediatric dif cult airway management. Paediatr Anaesth 2021;31(12):1271-75. doi: 10.1111/pan.14289 [published Online First: 2021/09/04]

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Dif cult Airway Society Newsletter

Winter 2019

Dif cult Airway Society www.das.uk.com @dasairway @dastrainees