DAS E-Zine May 2024

DIFFICULT AIRWAY SOCIETY MEMBERS EZINE May 2024 Edition

May 2024

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

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

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

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

@dasairway @dastrainees

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CONTENTS Executive Updates

#JanuAIRWAY - The Compilation

Editorial

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DAS Executive Update

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DAS Scienti c Of cer Report

9

DAS Professorship Applications

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Education

33

Trainees Q&A with DAS Professor

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Journal Club - Recommended Reads

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Trainee Report: Global Anaesthesia OOPE 34

Miscellaneous

Clinical Dilemma

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Post extubation laryngotracheal stenosis and more: Insights from a major airway service

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NAP7 Key Findings: Airway and 25 respiratory complications and perioperative cardiac arrest 2024 DAS Webinars

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HSSIB Report: Commentary

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Dif cult Airway Database

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Events DAS ASM 2024.

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GAMC 2024

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WAMM 2025

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

Straight to your inbox is our Spring edition of

emergency front of neck access – when did

the Dif cult Airway Society e-zine! We hope

you last receive training and is it time you had

you are looking forward to the sunshine as

a refresher?

much as we are. Whilst we wait, we have lots to share with you…

We also hear from a current trainee, who has recently completed a global anaesthesia and The education articles this month include

education fellowship abroad, dealing with

insights from the largest adult airway service

advanced airway pathology in a limited

in Europe managing laryngotracheal

resource setting. If you’d like to tell us about

stenosis, and a summary of the key ndings

your airway fellowship or similar training

related to airway and breathing complications

experience, we’d love to hear from you.

and associated peri-operative cardiac arrest from the recently published NAP7 report.

Please get in touch with our editorial team with your comments, feedback or We urge you to add the HSSIB report from

contributions by emailing ezine@das.uk.com

January 2024 to your reading list, see more

or tag us on X / Twitter @dasairway or

on page 30, as well as the recommended

@dastrainees.

reads from our journal club!

We thank all of the authors for their Our 2023 DAS Professor, Professor Andy

contributions to this edition.

Higgs joins us for a Q&A where he talks to us about his career highlights and inspirations.

We would also like to thank everyone who submitted an infographic to our recent trainee competition. The committee are set to pick a

This month’s clinical dilemma about epiglottitis prompts you to think about

winner, and we will announce the results soon!

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Don’t forget that we have some fantastic

We hope you enjoy this month’s jam-packed

events planned for your diary including the

read!

2024 DAS ASM in London and the 2025 World Airway Management Meeting (WAMM) in Florence. Register your interest

Nisha Abraham-Thomas

online now!

Moon-Moon Majumdar DAS Trainee Representatives

There’s also still time to book this month’s joint webinar with Anaesthesia journal, where we are set to discuss top publications and celebrate airway excellence.

New guidance: recommended rst-line agent for airway anaesthetists!

Image submission by: Dr Jane Orrock Advanced Airway Fellow Dr Patrick Ward Consultant Anaesthetist St John's Hospital, NHS Lothian Scotland, UK

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

Recent Welcome to our Spring edition of the DAS e-

patient safety concerns where safety learning

zine. There’s been much activity on the

could also help to improve NHS care. In

Airway front and plenty of content for you to

January they published a report of a death of

peruse, both news and education. Firstly,

a 12-year-old patient with Hunter syndrome.

what has been going on since your last

This report may have lasting rami cations

January edition.

and the RCoA-DAS Airway Lead, writes more about it in this edition.

In March we had our online DAS-RCoA Airway Leads day organised by Sandy

Our most recent webinar was on the RCoA

Sudan. A number of topics were presented

NAP7: perioperative cardiac arrest. This was

and discussed; an analysis of airway safety

presented by the College’s NAP Lead,

from SALG, a review of NAP7, the most

Professor Tim Cook and as ever very popular.

recent HSSIB report (more later) as well as

DAS members get 4 webinars a year for free

topics on best practice and updates on

and further ones are planned for May,

training and the ever-popular soapbox. A well

September and December.

received day by the airway leads who will have an opportunity to meet at the London ASM in November as well as at a face-to-face

Current

meeting at the RCoA next March.

So that’s what’s happened in the last busy quarter: ongoing projects continue however,

The Health Services Safety Investigations Body (HSSIB) are a newly formed (Oct 2023) independent body of the Department of Health and Social Care. They investigate

including the development of the new DAS website. This started at the beginning of last year and hopefully will come to fruition by the time Winter London ASM comes around and

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you’ll receive more updates in the month

Wales and the web-based database collection

ahead.

tool remains on track to be launched later in the year.

The Dif cult Airway Database is now supported by 236 hospitals and our

Further DAS guidelines continue apace. The

indefatigable lead on this Achuthan Sajayan

guidelines on Ethics in Airway Management

maintains his persistence on attaining

are in the nal tidying-up process and are

recognition by ACSA. More than 1600 cases

scheduled for launch at the London ASM with

of known dif cult airways have been uploaded

a whole session dedicated to discussing their

with several thousand clinicians signed up.

implications on the practice and training in

We are currently looking at strengthening our

anaesthesia.

IT governance for the database which will encourage yet more UK hospitals to join. Look

Looking ahead

out for a user survey on the DAD website soon.

So, looking ahead. If you like the idea of changing your letterhead to include Professor in your title look no further. Applications for the

Our membership numbers continue to grow,

DAS Professor of Anaesthesia and Airway

both full members as well as associate and overseas. Our Annual Members Meetings and webinars continuing to entice new members.

We’re currently at 2285 UK members and 327 overseas members, a continuing increase.

Management have now opened with a closing date of 26 May. Details are on the current website but do also contact the Scienti c Of cer for guidance (scienti cof cer@das.uk.com).

Our rolling 5-year Constitution review has

The DAS Committee are hard at work on our

started, and we welcome any members to

latest ASM which I hope you all know now is in

offer their opinion via

London on the 28-29 November https://

constitution@DAS.uk.com This will be completed and hopefully rati ed at the Annual Members Meeting in November.

www.das2024.co.uk/ It’s to be held at the stunning Guildhall, near St. Paul’s Cathedral and the City of London’s civic and ceremonial centre. It was originally the site of London’s

The eFONA Project (a joint project with the

amphitheatre in AD70 with the rst references

RCoA) is progressing well with much hard

to a guildhall from the 13th Century where

work by the eFONA fellow Parineeta Ghosh

citizens would come to pay their taxes

and Alistair McNarry. The Delphi process was

(hopefully not required at this meeting).

completed last month coinciding with the successful ethical approval in England and

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The 13th Century is also the time that our ASM dining venue also began to evolve, the House of Commons, the lower house of Parliament.

Imran Ahmad, DAS President Ravi Bhagrath, DAS Secretary Fauzia Mir, DAS Treasurer

When we were last in the Stranger’s Dining Room in 2017 there was a prior tour of the Palace of Westminster where one of our DAS Professors was nearly excommunicated for a breach of etiquette! We hope to again to have a tour so book the dinner early as soon as we open bookings (and be on your best behaviour).

Lastly, we have opened the call for the Annual Society Meeting in 2026, contact the Secretary for details and what this exciting prospect may entail (secretary@das.uk.com).

Enjoy this issue and as ever continue to get involved, we remain the world’s largest anaesthesia airway society!

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SCIENTIFIC OFFICER REPORT | Kariem El-Boghdadly | DAS aims to be a global leader in

£5,000 for studies broadly related

safety in airway management. To

to airway management will be

maintain and elevate this, we

peer-reviewed. Further details are

provide several academic

available on the DAS website or by

opportunities to members. It is

contacting me directly. We have

down to you, the DAS

already funded one application,

Membership, to take advantage of

and we are always open to receive

these opportunities, develop

more. Reach out for more

yourselves professionally, get

information on this today!

engaged in academia, and, importantly, harness the chance to improve patient care.

Importantly, the DAS Professor of Anaesthesia and Airway Management 2024 applications

2.

DAS Grants via the NIAA. DAS funds up

to £20,000, split between large Project Grants (up to £15,000) and Small Grants (up to

are open until 26/05/2024!

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

More information below!

round, with one application of £15,000 being received. Keep your eye on the second round later this year.

A CALL TO APPLY FOR OPPORTUNITIES 1.

Direct DAS Grants. To ensure continuity

and sustainability of grass-roots airway

3.

management research, we have a rolling

gives support to researchers who have a list of

process of grant funding via direct application

publications that may be suitable to put

to DAS. Applications for funding of up to

together as a PhD. DAS will support

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DAS PhD Programme. This Programme

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May 2024

applicants throughout the process of a PhD

Find out more here: https://das.uk.com/

by publication, including funding support.

das_professor_2024

4.

Our vision remains to take continue to

DAS Faculty of Professors. This is an

untapped resource that is open to any DAS

cultivate academia through DAS and airway

Member to reach out to for guidance, support

management, and begin to support, design

or advice on any academic matters,

and develop our own projects with our

including grant applications and study

enthusiastic, creative and brilliant

design.

membership. Don’t hesitate to reach out and get involved!

5.

DAS Professor of Anaesthesia and

Airway Management for 2024. This is an award conferred in recognition of a member’s national/international standing in the eld of

Kariem El-Boghdadly DAS Scienti c Of cer

airway management as established by

scienti c-of cer@das.uk.com

outstanding contributions through publications, creative work or other appropriate forms of scholarship, and through teaching and administration.

Following an extremely competitive series of previous rounds, the application is now open!

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

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

Please follow the links for the criteria and application form.

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

https://das.uk.com/das_professor_2024

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Dif cult Airway Society E-Zine

May 2024

Q&A WITH DAS PROFESSOR 2023 ANDY HIGGS | Moon-Moon Majumdar |

Why/when did you rst become interested

As a junior, I would do breoptic intubations

in dif cult airway management?

on straightforward lists. As long as I didn’t use the suction, the ODPs agreed they

I rst became interested in airway management as a junior – I quali ed in 1989 & went into anaesthetics in 1992. There was a lot of variation of practice, back in the day there were no guidelines or standards and it was oftentimes the wild west of anaesthetic practice. People had their pet techniques – some of which were good and some bad.

wouldn’t [formally] clean the scope (they would just run it under the tap and we would use it on the next one). What is acceptable has changed a bit since then! As a result, as a junior I did about 150 breoptic intubations – all on asleep patients. A lot of this was at Aintree hospital, Liverpool, a big head & neck centre.

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I did my rst awake one as a Senior Registrar

then take the intubated patient into theatres

in Melbourne doing ICU. It was about 4am, a

for surgery. I was intubating 15+ patients/day

big guy after a cervical fusion deteriorated

as a novice. I remember saying I was a bit

with a post-op pneumonia. I called the boss

upset to be spending all my time intubating

and they asked if I had done an awake

when I wanted to be getting experience with

intubation before. I said I hadn’t. He asked

these new LMAs! Things are the other way

“are you happy to crack on?”, and I said yes –

round for novices now…

because I was con dent: I had done so many asleep. He started on his way in, but by the time he had arrived I had already tubed the

I would also say – airway management being

patient.

‘a thing’ in itself – has evolved massively over the course of my career as well. Taking airways seriously is relatively new in anaesthesia, ICU & ED. Airway management

What do you think the biggest development

wasn’t actually taught as a subject – you just

in airway management has been during

picked it up as you trained . As long as there

your career?

wasn’t a trail of dead bodies out of your theatre on a regular basis it was assumed you

I may be biased - I have done a lot of guidelines, but the development and adoption of practical guidelines. I think that newer anaesthetists may not appreciate the massive historical variation in practice, and to be

knew vaguely how to do it. There wasn’t an airway chapter in my FRCA textbook (a bit about anaesthetising for ENT, yes, but it focused on hypotensive anaesthesia and Moffat’s solution). Back in the day 1 or 2

honest a lot of weird stuff going on.

hospitals in a region would have one person who was an enthusiast with a breoptic scope

Secondly I have to say [supraglottic devices]: when I started in anaesthesia, I did hour long cases on a facemask with a Clausen harness…things have changed a lot. The year

and most of the rest of the department would nd them amusing. Initially when I trained quite a few hospitals had no consultants who could do a breoptic intubation.

I started anaesthesia was more or less the year that laryngeal mask airways (LMAs) became widely available in the UK…That makes me sound really old – I don’t think I am

Of which aspects of your career are you

that old! I’m 58…For my rst two months as a

most proud/what has been the highlight of

rst year SHO in Anaesthesia I was based 3-4

your career?

days a week at the eye hospital in Liverpool.

The highlight of my career has been writing

The new Anaesthetic SHO spent their whole

guidelines for the management of tracheal

day in the Anaesthetic Room inducing and

intubation in critically ill adults https://

intubating patients, and the consultants would

www.bjanaesthesia.org/article/

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S0007-0912(17)54060-X/fulltext . What NAP 4

from the guideline, which in turn follows on

showed (I wasn’t involved in NAP4) – was that

from NAP4.

there were two main danger areas for airway management – ENT/maxfax and ICU/critically ill patients. There was a lot of airway morbidity

I was also part of the 2012 DAS extubation

and mortality outside of theatres that was

guidelines group – still the most cited

really not recognised. NAP 4 actually

extubation guidelines. Again - NAP 4 showed

quanti ed this. I used to do a theatre list on a

1/3 of issues occurred at extubation. In recent

Monday – if the ODP said the capnograph

years I have become involved with PUMA

wasn’t working we simply wouldn’t go near the

(Project for the Universal Management of the

patient to anaesthetise them. I then did a 20

Airway). There was a problem with the DAS

bed ICU ward round on Tuesday – our sickest

extubation guideline in that we never fully

patients – and NONE of them had a

worked out how you might decide if an

capnograph – this just demonstrates the

extubation was high risk– it doesn’t describe

disparity. The guidelines have been widely

in speci c detail how to make a diagnosis of

adopted around the world. It’s the rst

‘high risk’. We haven’t published the PUMA

guideline with all the non-doctor groups e.g.

guidance yet (although it has been released

patients, ICU/ED/Theatre nurses and ODPs

at conferences), but we have now come up

represented in their production. It’s the rst

with a practical approach to decide what

national airway guideline endorsed by the

constitutes high risk and I hope takes

RCoA. I’m proud that we were able to bring

extubation to the next stage.

together the RCoA, the faculty of ICM, ICS and DAS. RCEM also had a named representative who reviewed the drafts before publication .

PUMA’s main work so far has been the Prevention of Unrecognised Oesophageal Intubation (PUOI) guideline, which I think is very important. Particularly the concept of

The timing was in a way fortuitous as the

sustained exhaled CO2 (rather than no trace

guidelines were published in 2018, then in late

wrong place – as many of the patients who die

2019 when the pandemic struck¬ – we had an

as a result of UOI have some etCO2 trace, but

ICU intubation guideline ready to go (the

it is abnormal). That’s been a big success. In

algorithm only needed slight modi cation for

the next year to 18 months – we will publish all

COVID – and therefore able to be written very

the PUMA documents (7 guidelines) – each

quickly). The initial Critically ill adult guideline

one takes 3 years to write, but we are writing

was still the most downloaded article from

them in parallel. They will be released in

BJA website last year – very unusual for a

(hopefully) rapid succession.

paper which is 5 years old. We have now written the rst ever GPIC (Guidelines for the Provision of Intensive Care Services) standard for airway management in ICU – this is fallout

All of these things I have set out to do because I think they needed to be done –

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responding to patient safety and trying to

Any nal things you want to convey?

improve our approach to avoiding them or managing them.

I am a DGH consultant. You can still have an impact as a DGH consultant!

What's the best tip you have learned from a trainee?

One nal thing I think is quite exciting – we have started work on a project with a

A long time ago I was taught by a then trainee

Warrington company to develop a

how to do ultrasound – then I started

biodegradable videolaryngoscope. I do feel a

ultrasounding all my percutaneous

bit guilty going around the world saying

tracheostomies!

everyone should use VL as it isn’t very sustainable. We will probably have to compromise and have plant-based plastic which is a step forward but not as revolutionary as the reason I originally joined

Who is an inspiration to you?

I have been lucky enough to work with the rst

the project.

two DAS professors – they were appointed in the same year: Mansukh Popat (Oxford) &

But the eventual end goal is to have VL blades

Pete Charters (Liverpool).

that are totally biodegradable. One that you can take from your list and (if the laws of the land allowed) you could then put in your garden compost heap and it would disappear

What is the biggest issue facing the

in 9 months time. We haven’t got degrading

anaesthesia workforce now?

facilities in the UK yet (they have them in the

The general chaos that the NHS is

Netherlands & Germany) – but at some point

descending into unfortunately. I think

in the future that will become the industry

healthcare in this country is not working as

standard. And I think that will be massive.

well as in the past and I worry that you’ll start to see loss of standardisation and loss of oversight by the royal colleges. One thing that the UK is good at is setting standards and enforcing adherence. We can do that because of the NHS. I think that what we will see is a breakdown in the NHS, and anaesthesia (as well as lot of a lot of other specialties) seeking local answers to the problems that arise. This will result in loss of standardisation.

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CLINICAL DILEMMA | What Would You Do? | A 50 year old gentleman presents to A&E with a 48 hour history of feeling generally unwell with worsening sore throat and intermittent fevers. He complains of new onset dif culty swallowing and dif culty in breathing over the last few hours. He has no signi cant past medical history.

On clinical examination the patient looks uncomfortable. He has a respiratory rate of 22, saturating 98% on room air. There is no audible stridor at present. His voice is hoarse and he has recurrent pooling of saliva in his mouth. Flexible nasendoscopy reveals a grossly swollen and erythematous supraglottis. True cords are visualised.

ADULT ACUTE EPIGLOTTITIS / SUPRAGLOTTITIS - What criteria or clinical predictors do you consider in deciding when to perform airway intervention in these patients?

Repeat

exible nasendoscopy shows worsening supraglottic swelling, with dif culty

clearly visualising vocal cords.

- What would be your primary or preferred technique for airway management in this patient?

Rate of failed intubation has been reported as high as ~4% in adult epiglottitis, with some cases requiring emergency front of neck access - In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best

delivered?

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

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WHATWOULDYOUDO? DAS Expert Corner Airway Expert 1:

What criteria or clinical predictors do you consider in deciding when to perform air intervention in these patients?

This is an airway emergency and always makes me nervous as any delays in the management of these patients can make the clinical situation worse. I would take into consideration a global, overall view of the clinical situation when deciding how and when to manage the airway in this scenario. Is the patient distressed and what is the posture like, is there stridor, is the patient working hard to breathe, is the patient tiring and is the respiratory rate increasing? If the answer to all of these questions is yes, then I would want to secure the airway as soon as possible as the patient is struggling and airway obstruction is imminent. If I feel that I have time, then I would closely monitor the patient and start some conservative measures such as adrenaline nebulisers, supplemental O2, intravenous steroids and be prepared for intubation if the situation does not improve.

For this case, I feel that we can start conservative measures, but I would closely monitor the patient for any signs of deterioration, in which case I would plan for intubation.

What would be your primary or preferred technique for airway management in this patient?

My preferred technique would be an awake tracheal intubation using a

exible bronchoscope

in theatre with the surgical and scrub team immediately available. I would modify my standard ATI technique by minimising sedation, and downsizing the ETT to the smallest possible size. One could also consider ATI using a VL, but this would be challenging and should only be done in experienced hands. The third option would be to perform an asleep VL intubation, this has the advantage of familiarity with the technique, but the disadvantages of not knowing whether BMV is possible once asleep or whether the view of the glottis will be adequate to enable intubation, therefore additional back up to perform eFONA should be planned for.

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In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best delivered? eFONA is a life saving procedure that is rarely performed by anaesthetists and therefore training to gain and maintain competency in this procedure is important. Currently this is dependant on individual anaesthetists taking the responsibility to do so, but I am not sure of the uptake of this.

Airway Leads can facilitate this by providing local training and national bodies such as DAS and RCOA can provide training courses, the more accessible this is the more likely the uptake will be better. However, there are early discussions as to whether this requirement should be mandatory or not and if so who mandates it and how. We must also remember that it is not just anaesthetists that need this training but also anaesthetist assistants and other airway managers (eg in the Emergency department and critical care).

Airway Expert 2: What criteria or clinical predictors do you consider in deciding when to perform airway intervention in these patients?

It is a dif cult situation as the course of the disease is very unpredictable and decision making can be exceptionally hard specially deciding when to intervene. Understanding the progression of disease and regularly reviewing the patient to see the early signs of disease progression and airway compromise area good guide to decide when to actively intervene. Any signs of progressive airway compromise eg swelling, swallowing dif culty, pooling of saliva, tachypnoea, stridor are indicative of airway compromise. Oxygen saturation levels can be a late sign and may not be a suitable indicator for early airway compromise. I will tend to secure the airway in a timely manner when patients condition is indicative of early airway compromise and disease progression.

What would be your primary or preferred technique for airway management in this patient?

Adult epiglottitis patients requiring airway intervention can be done using awake or asleep techniques depending on the experience of the operator, skills of the team and patient compliance.

My preferred technique will be to perform an awake Tracheal intubation using a breoptic technique if the patient is compliant. This patient has had 2

exible nasendoscopies and therefore the

anaesthetist will have an idea of the airway and potential technical dif culties.

In cases where there is very obvious airway compromise or the patient is noncompliant or compromised, I will consider a GA and video laryngoscope to secure the airway. This technique in my view will be useful as a VL will give a wider angle of view compared with a exible scope and in the presence of severe airway swelling may give better working conditions and view to secure the airway. In both scenarios I will ensure the presence of a skilled ENT surgeon to perform an eFONA if needed in an emergency situation.

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In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best delivered? eFONA training is an essential component of regular airway training to be undertaken by all anaesthetists. Fading of skills after training/ teaching sessions is recognised and needs to be kept in mind when planning training sessions. In my view eFONA training should be delivered at least twice a year either using simulation labs or in the form of tea trolley teaching or a combination. This should be made mandatory for all anaesthetists and ideally individual departments should plan and deliver the training locally.

Airway Expert 3: Acute epiglottis is a medical emergency (the exam answer!)

So HFNO, IV access (take bloods for cultures) and broad spectrum IV antibiotics immediately. No imaging or airway manipulation. Place the patient in an area of safety, ICU if stabilising or theatres if not. Inform senior ENT surgeon and anaesthetist.

What criteria or clinical predictors do you consider in deciding when to perform airway intervention in these patients?

Increasing fever, increasing dif culty in breathing with falling SpO2, dysphonia and stridor, needing to sit-up, further irritability and any reduction in level of consciousness.

What would be your primary or preferred technique for airway management in this patient?

For a start the FNE should not be repeated. The patient should be in theatre and a clear plan discussed with the team - a consultant ENT surgeon scrubbed and a tracheostomy tray open with the most experienced airway consultant anaesthetist as the operator.

Consider one best attempt at an ATI but with a low threshold for a surgical front of neck.

In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best delivered?

Once a year eFONA training and this is best done in a simulation suite but if not available part-task trainers in a dedicated teaching session.

This once a year training should be mandatory with other modules requiring to be repeated in a 3year period much akin to the Australian/NZ consultant CPD model.

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Airway Expert 4: This patient has predictors of disease that are concerning. I would take a full history and examination, including performing a full airway assessment. The patient needs intravenous access and will likely need antibiotics due to presumed sepsis. Wild also administer intensive steroids for oedema. I would urgently request the ENT consultant to attend, communicate with the theatre team early and transfer the patient to the operating theatres for de nitive airway management.

What criteria or clinical predictors do you consider in deciding when to perform airway intervention in these patients?

First, his systemic symptoms started 48 hours ago. Next, his airway symptoms have progressed rapidly over a few hours. Furthermore, his symptoms of hoarse voice, dif culty swallowing and dif culty in breathing suggest the involvement with his airway is now signi cant.

What would be your primary or preferred technique for airway management in this patient?

I would perform awake tracheal intubation with a exible bronchoscope and using an oral tube with glottic suction port to allow management on ICU. Oxygenation with HFNO, sedation with remifentanil, topicalisation with a mucosal atomising device with 10% lidocaine. I would scan the next with ultrasound and mark the cricothyroid membrane. I would ask the ENT surgeon to be scrubbed with a tracheostomy kit ready.

In your opinion, how often should anaesthetists and other healthcare professionals undertake eFONA training and how is this best delivered?

This should be done annually, and can be done with tea trolley training and in training courses or meetings (come to DAS ASM 2024 in London!)

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POST-INTUBATION LARYNGOTRACHEAL STENOSIS AND MORE: INSIGHTS FROM A MAJOR AIRWAY SERVICE | Annabel Lim | Guri Sandhu | John Myatt |

Prof Guri Sandhu, Consultant Airway and Head and Neck Surgeon, leads the airway service at Charing Cross Hospital in London, the largest adult airway service in Europe managing laryngotracheal stenosis. In this article we explore some insights from our clinical practice.

cervical spine surgery. Consent for tracheostomy as a risk of these operations should therefore be gained. The increased risk with second side surgery occurs in the instance that there has been vocal cord paralysis from the rst surgery which the patient had compensated for. If this is undetected preoperatively, subsequent damage to the vocal cord on the second side

Tracheostomy Indications: Expected and

leads to stridor and unanticipated

Unexpected Surgical Scenarios

requirement for tracheostomy. In order to

Tracheostomy may be expected as a planned airway technique during surgery, most commonly for major head and neck cancer resections. However, situations may arise where a tracheostomy is required due

reduce this risk, patients should have a preoperative outpatient exible nasal endoscopy, including saying “eee” followed by a sniff, as a check for abduction of the vocal cords.

to complications during surgery, despite not being part of the primary airway plan. From

Laryngotracheal stenosis: High rates of

our experience, surgical procedures where

acquired pathology

this can occur include thyroid goitre/tumour (especially second side), thyroglossal duct/ cyst surgery, squamous neck cancer resection, carotid endarterectomy (especially second side), and anterior approaches to

Laryngotracheal stenosis is a long term condition which often requires serial surgical treatment for symptom management.

Endoscopic procedures such as balloon

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dilatation, intralesional steroid injections and

take care in preventing post-intubation

CO2 laser treatment, are used to increase

injury as much as possible. Acquired

tracheal diameter and may be repeated at

laryngotracheal stenosis can occur in the

intervals ranging from every few months to a

subglottic (66%) or tracheal (34%) areas,

year or two. While laryngotracheal stenosis

and can also be accompanied by vocal cord

can occur in the setting of cancer, our patient

mobility impairment. A national database of

population has demonstrated the wide range

over 600 000 patients in the USA1 recorded

of pathology that can lead to benign

adult patients who were readmitted to ICU for

laryngotracheal stenosis. Signi cantly, a high

mechanical ventilation within 45 days of an

proportion of stenosis is acquired following

original admission where mechanical

prolonged ventilatory support in ICU, through

ventilation was used. It showed the incidence

an endotracheal tube or tracheostomy. While

of new laryngeal or tracheal stenosis was

tracheostomy provides bene ts in long term

1.98 per 1000 discharges. While this is a low

(over 7-10 days) ventilatory support such as

percentage of all ICU patients, it still results

improved increased patient mobility and

in a signi cant number of patients requiring

comfort, facilitating decreased sedation,

long term follow up and surgical treatment,

allowing oral nutrition and limited speech,

with a substantial impact on the patients’

and avoiding glottic injury, there is actually a

lives. Long term evidence from patients

similar incidence of laryngotracheal stenosis

requiring tracheostomy in ICU have shown

compared to the use endotracheal tubes.

that the change from use of low volume,

Post-intubation stenosis and risk factors

high-pressure cuffs to high volume, lowpressure cuffs has helped to signi cantly

As a large proportion of benign

reduce laryngotracheal stenosis, and

laryngotracheal stenosis is secondary to

therefore should be routinely chosen.

iatrogenic causes, this highlights the need to

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tension dysphonia, prolonged laryngitis, Post-intubation stenosis in the COVID-19 population

glottic oedema and unilateral vocal cord paresis, suggesting that there may be additional effects from the virus and

The COVID-19 pandemic caused an

in ammatory response, themselves

unprecedented surge in need for

contributing to risk of airway injury. Patients

mechanical ventilation, with many patients

who were intubated were signi cantly more

undergoing prolonged intubation in ICU,

likely to develop glottic injury (oedema,

often in a prone position to aid respiratory

erosion or granuloma), laryngotracheal

mechanics. Compared to pathology where

stenosis, and posterior glottic diastasis.

more knowledge was widespread about the

Modi able risk factors associated with

natural progression of disease, in the earlier

increased injury were increased

period of COVID-19 patients, tracheostomy

endotracheal tube size and longer duration

was often relatively delayed. This was due to

of intubation, while patient factors included

a range of aspects such as lack of hospital

type 2 diabetes mellitus, obesity,

resources, unfamiliarity with best

hypertension, cardiovascular disease, and

management for long-term outcomes due to

smoking. However, the data currently

the novel nature of the disease, and

published has only come from small case

protocols to reduce aerosol transmission. It

series. We therefore look forward to gaining

was therefore hypothesised that there may

more information in the near future in order

be a higher incidence of laryngotracheal

better characterise the patient cohort, and

injury in this cohort of patients, forming a

optimise both prevention and treatment of

new group of patients in the coming years

post-intubation airway injury.

who require long term care and follow up in airway services. Recently published case series reports2-4 have started to characterise

Link to references

the laryngotracheal complications and sequelae of COVID-19. Interestingly, some COVID-19 patients who were not intubated still developed issues such as muscle

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AIRWAY AND RESPIRATORY COMPLICATIONS AND PERI-OPERATIVE CARDIAC ARREST: KEY FINDINGS FROM THE 7TH NATIONAL AUDIT PROJECT OF THE ROYAL COLLEGE OF ANAESTHETISTS (NAP7) | Jasmeet Soar | Fiona Oglesby | Tim Cook |

The NAP7 report was published in

the second (2% incidence and 22% of all

November 2023 and included a section on

complications) and fourth (1% incidence and

airway and respiratory complications and

14% of all complications) most common

associated peri-operative cardiac arrest.

complications, respectively. The most

The key ndings included:

common airway complications were laryngospasm (38% of airway complications),

•

In the last 10 years the surgical

airway failure (30%) and aspiration (6.4%).

population are likely to have become more

The incidence of a cannot intubate and

complex from an airway perspective. The

cannot oxygenate (CICO) situation or the

NAP7 Activity Survey which assesses overall

need for an emergency front of neck airway

anaesthetic activity showed the population is

(eFONA) was 1 in 8370 (95% con dence

older, more obese and more comorbid in

interval, CI, 1 in 2296 to 1 in 30,519). The

comparison to previous NAPs.

most common respiratory complications were

•

severe ventilation dif culty (37% of all

In the Activity Survey, since NAP4,

supraglottic airway (SGA) use has decreased

respiratory complications), hyper- or

(56% to 45% of general anaesthetics) but

hypocapnia (24%) and hypoxaemia (23%).

second generation SGA use has increased

•

(from 10% to 65%). As body mass index

operative cardiac arrest reported to NAP7

(BMI) increased, when a SGA was used, the

over a one year period, airway and

proportion of rst to second generation

respiratory complications were a leading

devices changed minimally. Use of a

cause of cardiac arrest, accounting for 13%

tracheal tube only rose notably at or above a

of all cardiac arrests and 9% of deaths.

BMI of 40 kg m-2.

Hypoxaemia was the primary cause of these

•

events. Although survival after cardiac arrest

Among 24,721 surveyed cases,

airway and respiratory complications were

Among the 881 cases of peri-

due to airway and respiratory events was

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higher than for other events, a

•

disproportionate number of survivors

during rapid sequence induction (RSI) for

experienced a severe outcome, indicating

acute abdominal surgery. There was a single

permanent harm or prolonged critical care

case of aspiration associated with supraglottic

stay.

airway (SGA) use. This is in contrast to NAP4.

•

Airway events were twice as common

•

Most cases of aspiration occurred

There were six cases of unrecognised

as respiratory events (63% vs 37%) prior to

oesophageal intubation with three resulting in

cardiac arrest, but mortality from airway-

cardiac arrest. Failure to correctly interpret

related cardiac arrest was much higher than

capnography was a recurrent theme in these

for respiratory-related cardiac arrest (45% vs

events.

18%).

•

• Patients with obesity (BMI ≥ 35 kg

m-2) were overrepresented, with extubation and recovery representing a particularly high-risk period for this group of patients.

•

Infants (age range 28 days to less

A lack of familiarity with or misuse of

airway and breathing equipment contributed to cardiac arrest in some cases.

•

Overall, the data, while distinct from

NAP4, suggest that airway management is likely to have become safer in the last decade,

than 1 year) were overrepresented, with

despite the surgical population having

cases occurring in theatres, in paediatric

become more anaesthetically challenging.

critical care and during preparation for retrieval.

•

Airway issues in cases of cardiac

arrest of the critically ill child were prominent.

•

Out-of-hours cases were

overrepresented in airway and respiratory related cardiac arrests.

•

examples of patients with a predictably higher-risk airway being inappropriately managed by junior anaesthetists.

•

Lack of monitoring during transfer to

recovery areas contributed to unrecognised hypoxaemia and cardiac arrest in several cases.

•

The full NAP7 report including the section 'Airway and respiratory complications associated with perioperative cardiac arrest' (Chapter 21) can be accessed here A publication in the journal Anaesthesia can be accessed here

While supervision of anaesthetists in

training was generally good, there were

Cases of emergency front of neck

airway (6, approximately 1 in 450,000) and pulmonary aspiration (11, approximately 1 in 25,000) leading to cardiac arrest were rare and notably less prominent than in NAP4.

Jasmeet Soar is NAP7 Clinical Lead and Consultant in Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK. Fiona C. Oglesby is a NAP7 Steering Group Member and Specialty Registrar, Bristol School of Anaesthesia, Severn Deanery, Bristol, UK. Tim M Cook is Director of National Audit Projects, Consultant in Anaesthesia and Intensive Care Medicine, Royal United Hospital Bath, and Honorary Professor of Anaesthesia, University of Bristol School of Medicine, UK.

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

Thank you for joining us at our NAP 7: Key Airway Messages webinar on 25th March 2024. We hope you enjoyed it! Recordings are still available to those who registered.

SIGN UP NOW FOR OUR NEXT WEBINAR 13th May 2024 Exploring Airway Excellence: Top airway publications by Anaesthesia Journal and Dif cult Airway Society

Still to come later in the year… webinars on: oxygenation, and patient information & consent

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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COMMENTARY ON HSSIB REPORT INVOLVING ADVANCED AIRWAY MANAGEMENT | Sandeep Sudan | ·

The Health Services Safety

A framework in managing

patients with an ANTICIPATED

Investigations Body (HSSIB) is an

dif cult airway

independent body, who investigate safety concerns (in a no blame

·

fashion) in both the NHS and

inclusive dif cult airway database

independent healthcare settings.

·

Their investigators of different

incident training

backgrounds (including healthcare ·

workers, military, aviation, law and

A more sustainable and

To implement MDT critical

An emphasis on training with

videolaryngoscopy and rescue techniques

human factors) work with patients/families and health professionals to make recommendations and safety observations.

There are similar themes within the recent NAP7 report, within the airway and breathing section: Airway and respiratory

As you may be aware, HSSIB recently published a report concerning the advanced airway management in a patient with known

Anaesthetists.

complex disease (hssib.org.uk).

Whilst any change on a national level will

It centres around the case of a 12-year-old

need due process and therefore take time,

boy, Ethan, who had Hunters syndrome

individual and institutional change (towards

(known dif cult airway). He presented to the emergency department having had a seizure intubation, attempts failed (including eFONA), and he sadly died.

Key stakeholders such as DAS, RCoA, AoA and NHSE are collaborating to discuss how they can implement the recommendations from the report which include:

associated with peri‐operative cardiac Project of the Royal College of

management in patients with a known

at home. Ultimately when it came to

complications during anaesthesia and arrest as reported to the 7th National Audit

complex disease (Advanced airway

‘airway preparedness’) can happen sooner.

Your AirWay Lead (AWL) is a key player in this but needs the support of the department. To remind us all:

1.

If your department hasn't already

signed up to the DAS dif cult airway database, please do have a look at DAS Airway Alert Card and Dif cult Airway Database | Dif cult Airway Society.

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May 2024

Use this HSSIB report, alongside the

requirement requires those on the specialist

RCoA GPAS document for head and neck

register to demonstrate one (out of 10)

surgery (Chapter 12: Guidelines for the

emergency response activity each year. Two

Provision of Anaesthesia Services for ENT,

of these are airway related (Can't intubate,

Oral Maxillofacial and Dental surgery 2024 |

can't oxygenate and COVID-19 airway

The Royal College of Anaesthetists), as

management). eFONA and unrecognised

evidence for why we must have access to

oesophageal intubation are probably the

videolaryngoscopy, High Flow Nasal

top two examples of what everyone needs

Oxygenation (HFNO) and emergency front of

to maintain skills in and understand.

neck kits - in addition to any other kit needed for advanced airway management.

It goes without saying that we are reliant on

A further safety observation within the report

working in teams, and as we know those

does also refer to supporting more routine use of videolaryngoscopy to increase clinical experience.

that work together must train together, including our surgeons.

The recommendations cited within the report do provide a real opportunity for us to

3.

Use this HSSIB report as evidence for

further improve airway safety at a local level.

the need to have the time to train everyone in

Nationally, alongside the stakeholders

advanced airway skills. This can be both

mentioned before, DAS has an integral and

task-based training (such as Tea Trolley

important part to play.

Training) but also critical incident training.

The discussion on whether this should be

Sandeep Sudan

MANDATED is once again up for debate.

RCoA / DAS Airway Lead Advisor

Perhaps it's time that we follow the example set by the Australian and New Zealand College of Anaesthetists (ANZCA). Their CPD

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

by Nisha Abraham-Thomas.

Use these papers to facilitate your journal club and let us know your thoughts and feedback.

Please get in touch @dastrainees or @dasairway or email us at ezine@das.uk.com.

✦ Ruetzler K, Bustamante S, Schmidt MT, et al. Video Laryngoscopy vs Direct Laryngoscopy

for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. JAMA. 2024;331(15):1279–1286. doi:10.1001/jama.2024.0762 This cluster randomised clinical trial sought to investigate the effect of initial video laryngoscopy or direct laryngoscopy on the number of intubation attempts for a variety of elective and emergent surgical procedures. Whilst video laryngoscopy has been reported to improve glottic view, does this reduce intubation attempts? The authors found that hyperangulated blade video laryngoscopy reduced the number of attempts compared with direct laryngoscopy.

What are your thoughts on on routine

rst-line use of video laryngoscopy for all surgical

procedures? When do you choose to use the hyperangulated blade video laryngoscope?

✦ Crístian de Carvalho C, Iliff HA, Santos Neto JM, Potter T, Alves MB, Blake L, El-Boghdadly K.

Effectiveness of preoxygenation strategies: a systematic review and network metaanalysis. Br J Anaesth. 2024 Apr 9:S0007-0912(24)00130-2. doi: 10.1016/j.bja.2024.02.028.

Epub ahead of print. PMID: 38599916.

This systematic review and meta-analysis included 52 studies of 3914 patients and found that pre-oxygenation with high- ow nasal oxygen in the head-up position prior to induction of general anaesthesia was the most effective strategy in prolonging safe apnoea time compared with other strategies.

Consider your strategy for pre-oxygenation. What technique do you use and how do you position your patients?

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

AVAILABLE HERE!

@dastrainees @vapourologist #DASeducation

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FROM LONDON TO LUSAKA: A JOURNEY IN AIRWAY MANAGEMENT | Mary Madden | infancy. Recruitment and training

In August 2023, after nishing my

of local physician anaesthetists

ST6 year of training, I packed up

are therefore fundamental to

my life in London and moved to

increasing and strengthening the

Lusaka for a 6 month Out of

workforce.

Programme Experience. I was delighted to nally be making this

One of the main areas of delivery

trip after initially applying for a

of the ZADP partnership is by the

fellowship with the Zambia Anaesthesia

visit of in-country fellows, who work

Development Programme (ZADP) three years

alongside local consultants to deliver the

prior, in February 2020. So now, after a global

anaesthesia and critical care training

pandemic and a FRCA out of the way, I was

program. As a fellow, time is mostly spent

arriving as a Senior ZADP Fellow, rather than

in the 1655-bedded tertiary referral centre of

the Junior Fellow role I had initially

Zambia (University Teaching Hospital,

envisioned.

Lusaka) which housed 6 theatre complexes.

ZADP is a partnership between the Global Anaesthesia Development Partnerships (GADP) and the Society of Anaesthetists of Zambia (SAZ), established in 2012. Like many countries in sub-Saharan Africa, Zambia has very few physician anaesthetic providers; 79 for a population of over 16 million1. This is far below what is needed to support the consistent, safe delivery of surgery and perioperative care. It is a medical specialty which is still largely in its

Outreach visits to Ndola Teaching Hospital, 300km north of Lusaka are also provided by fellows. Due to the scarcity of consultant anaesthetists, the residents and nonphysician anaesthesia providers largely work independently from a very junior level.

Therefore, a large component of the incountry fellow is to provide daily clinical and non-clinical support to residents. This is complemented by remote fellows from around the globe that facilitate multiple online weekly teaching sessions.

Being an in-country fellow is a truly immersive experience. Upon my arrival, I quickly became embedded in a busy clinical environment whilst being warmly welcomed by the local staff. I felt that my postponed arrival to Zambia was rather fortuitous as I had just nished a 6-month Specialist Interest Area rotation in Advanced

The University Teaching Hospital, Lusaka

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Airway Management at Guy's Hospital. I now

residents and adapting our limited

felt comfortable managing complex airways

armamentarium we were able to jointly

and navigating the breoptic bronchoscope.

manage some extremely challenging

However, from being a trainee in a well-

airways safely and successfully.

resourced system where clinical procedures are almost prescriptive, I now found myself not just being the trainer, but having to be very adaptive and innovative based on the equipment and resources available. Complex airway management in this setting was met with multiple new challenges - it was bidirectional learning, to say the least.

There

were

two

working

videolaryngoscopes available and a focus was to promote the role of its use, where possible. I encouraged and supervised trainees in its elective use, supporting recognition of its role when it came to dif cult airway management. Again, this is a resource that was not readily available

I was now in an environment where sourcing

throughout the whole hospital. However, by

a working direct laryngoscope could be a

the end of my time there, I was delighted to

challenge in itself and no capnography was

see it being requested by junior residents in

the norm. Supply chain issues and lack of

their plan when faced with a patient with a

consumables meant that basic drugs and

potentially dif cult airway. The development

equipment were not available, this could

of the residents’ experience and con dence

even include oxygen on some days.

was evident.

The

advanced airway armamentarium largely consisted of lidocaine, atropine, ketamine and a couple of re-used bronchoscopes and nasal tubes.

To supplement in-theatre supervision we ran biweekly simulation training sessions, covering common anaesthetic and critical care emergencies. This included scenarios

As a large component of the teaching and

to incorporate safe airway management,

hands-on support was in the clinical

embedding the DAS 2015 and recent PUMA

environment, I found I naturally placed myself

guidelines, adapted to the local setting. I

in various airway lists or cases where there

co-devised a 4-day novice induction

were potential airway challenges, whilst mentoring trainees in other theatres. The range of maxillofacial pathology was extremely diverse, often with late presentation of progressive disease. Large maxillofacial tumors, airway and facial burns with subsequent strictures and impending airway obstructions were frequently encountered.

Emergencies were most often managed with awake tracheostomy due to the lack of equipment availability and trained anaesthetic staff. However, with effective team working with surgeons, enthusiastic

Local faculty and ZADP members at the Society of Anaesthetists of Zambia annual scienti c meeting, November 2023.

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program for the newly recruited residents,

trolley was rolled out in the elective theatres

with 1 of the days based on airway

with much anticipation and support from the

assessment and management. We ran this to

wider theatre team. Work is undergoing to

align with the RCoA Novice Guide for Initial

roll this out in other theatre blocks, with a

Assessment of Competence including SIM

priority being obstetric theatres.

scenarios. This was the rst novice induction delivered in UTH with local faculty and ZADP support, and hopefully the

rst of many

more. I was also honoured to have the opportunity to present at the annual SAZ conference themed ‘Improving Peri-operative Obstetric Care in Zambia’. Here, I presented on the management of the obstetric airway, focusing on local, context-speci c practice aligning it with recommendations from the DAS obstetric guidelines and how to promote safety in this high-risk population, where unfortunately maternal mortality related to anaesthesia is still disproportionate.

Other non-clinical roles included exam support. This included setting up a weekly morning written nal exam club and running mock OSCE and VIVA exams. Although residents undergo FRCA-level exams, a lot of the material they learn is not available or routine in their clinical practice. Despite this, I was in awe of their depth of knowledge and clinical skills. Additionally, I increasingly recognised my mentoring role required providing pastoral and well-being support to the residents. This was a space I took great pride in providing, particularly after witnessing

rst-hand the demanding

Supporting leadership, management, and

conditions the residents so tirelessly and

academic activities including quality

resiliently work in daily and their

improvement is another aspect of the

commitment to advancing the specialty.

teaching role. Alongside another visiting fellow we supervised local residents’ airway Q I ’s p r o j e c t s . T h i s i n c l u d e d t h e implementation of eFONA ‘tea trolley’ teaching and packs as well as creating the rst Dif cult Airway Trolley at UTH. This initial

Novice trainees about to embark on their training after successfully completing the induction to anaesthesia course.

The ZADP teaching fellowship has so many facets and opportunities to focus on based on your individual interests. It was a privilege to have the opportunity to be so actively involved in promoting safe airway Introducing the Dif cult Airway Trolley to main elective theatres in UTH. A QIP led by Dr Katongo Mumba, 3rd year resident.

management not just to residents but all

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members of the theatre team. It offered a window of experience into the critical and challenging area of global health, highlighting the role of inter national collaboration working to support and embed sustainable practice.

Personally, this OOPE

was an experience that helped me develop in more ways than I could have ever imagined and one I'm sure will stay with me throughout my career. My only regret was not extending it for a longer time. Zambia is a beautiful country, and a lasting memory is just how friendly and welcoming the local people were. Getting ‘down-time’ was also a necessity during the busy program and one

The daily commute to UTH, under the majestic ame trees.

is truly spoilt with just so much spectacular wildlife and landscapes to explore, including one of the awe-inspiring natural wonders of the world, Victoria Falls.

I would highly recommend this experience to anyone interested in global anaesthesia and education. I can't wait to return someday!

——————————————————— If you would like to nd out more about Global Anaesthesia Partnerships please contact: Website: https://gadpartnerships.com/ Email: info@gadpartnerships.com

A quiet moment overlooking the Luangwa river valley in South Luangwa National Park

X: @gadpartnerships ——————————————————— Dr Mary Madden ST7 Anaesthetics, South West London School of Anaesthesia ——————————————————— References: 1.

Workforce Map - WFSA (wfsahq.org)

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

Register your interest today!

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POST-INTUBATION LARYNGOTRACHEAL STENOSIS AND MORE: INSIGHTS FROM A MAJOR AIRWAY SERVICE | References | 1. Johnson RF, Bradshaw S, Jaffal H, Chorney SR. Estimations of laryngotracheal stenosis after mechanical ventilation: a cross-sectional analysis. Laryngoscope 2022;132(9):1723-8 2. Neevel AJ, Smith JD, Morrison RJ, Hogikyan ND, Kupfer RA, Stein AP. Postacute COVID-19 Laryngeal Injury and Dysfunction. OTO Open. 2021 Aug 24;5(3):2473974X211041040. doi: 10.1177/2473974X211041040. PMID: 34458661; PMCID: PMC8392819.

3. Naunheim MR, Zhou AS, Puka E, Franco RA Jr, Carroll TL, Teng SE, Mallur PS, Song PC. Laryngeal complications of COVID-19. Laryngoscope Investig Otolaryngol. 2020 Oct 30;5(6):1117-1124. doi: 10.1002/lio2.484. PMID: 33364402; PMCID: PMC7752067.

4. Allisan-Arrighi AE, Rapoport SK, Laitman BM, Bahethi R, Mori M, Woo P, Genden E, Courey M, Kirke DN. Long-term upper aerodigestive sequelae as a result of infection with COVID-19. Laryngoscope Investig Otolaryngol. 2022 Mar 9;7(2):476-485. doi: 10.1002/lio2.763. PMID: 35434347; PMCID: PMC9008172.

Contents

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Dif cult Airway Society E-Zine

41

Winter 2019

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

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42

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Dif cult Airway Society Newsletter