What, in your opinion, have been the recent advances, both technical and non-technical, that have improved the safety of airway management? OK, that’s a big question to start with. I think safety is improving. And I think there’s been increased attention to airway management. And I think NAP4, the Fourth National Audit Project, has played a part in that. Has been, perhaps, a sounding board or a stimulus for that. The greatest improvement has been– is brought about, and will continue to be brought about by non-technical skills. By factors such as improved preparation from an organisational point of view, preparation from an individual point of view, and preparation in the every day’s setting.
So ensuring that everybody understands what’s going on, and everybody’s doing the right thing. So three things I talk about, organisational preparedness, personal preparedness, and situational preparedness. In terms of equipment or technical aspects, factors such as videolaryngoscopy, safer supraglottic airway devices, novel ways of giving oxygen such as high flow nasal oxygen and a focus on those things have been important. And I would also include, in technical aspects, things such as our algorithms, which are more widely used and checklists. And those things all improve the potential for reliability of health care. And then, it’s dependent on the team delivering that health to make that potential reliability in actuality.
Do you think that the non-technical element, the method to control the human factors involved in airway management, are more important than the technological advances or that they just have to marry together for one– they’re complementary? I think they complement each other. So Atul Gawande, the doyen of quality improvement, I’m paraphrasing him, he said something along the lines of in his book Better- he said, the major advances in medical care will be made not through new technology, but by using existing technology and doing what we currently do better. A lot of technical advances in the last two decades have improved our potential for airway safety.
And one of my colleagues, Fiona Kelly, says that the improved human factors give space for good technical skills. Do you think that there’s been a recent step change in how we are viewing airway management, in terms of it shouldn’t necessarily just be complications from airway management or not just an accepted risk that, actually, we can really make strides forward to mitigate? I’ve always been interested in safety, and I’ve always been interested in airway management. So I was involved in full in the NAP4 project in the last decade. That has led to an increased focus on the safety of air management. Unfortunately, we still see high profile deaths or harm coming to patients.
You don’t have a very good way of collating that data. I think, throughout the world, we don’t have a good way of identifying those cases. Strength of NAP4 was bringing all those cases together from four countries in the UK, and over a whole period of a year. So that instead of looking at individual cases, which were often reported flamboyantly or adversarial, we were able to systematically look at– in fact, there’s 184 cases that occurred in a year where there was actual or potential harm to patients, and examine the themes that emerged from that large body of cases.
And why do you think, despite the major advances that have been made that we’ve mentioned earlier in safe airway management, the patients still are suffering complications? We don’t all learn the lessons that are known. And they’re not just from NAP4, but we’re not all organizationally prepared. We’re not necessarily individually prepared as best we might be. And of course, some patients are extraordinarily difficult. About half the patients who came to harm in that full report and reported in NAP4 probably had genuinely difficult airways, and probably about half of them didn’t. Became harmed because of circumstance rather than intrinsic difficulty.
The pressures of more frenetic health service, which is dependent on costs and individual staff who are working at, perhaps, the limits of their ability both in terms of tiredness, fatigue, stress, and maybe experience. And you put those together, and it’s a rather heady situation. There will always be cases which don’t go as the airway manager expected them to go. And I think in all those cases, there will be opportunities to rescue the situation. And safe airway management, I think, is about the ability to seize those opportunities through that step of preparation.
But actually, most of the cases where airway harm comes are not those cases which are considered to be extraordinarily difficult where a huge amount of planning has gone into it, and there’s this strategy of A- B- C- D- E, maybe, and then that fails. Most of them are, actually, more run of the day cases which have been managed the way I normally do it, which perhaps wasn’t the right thing on that occasion. So for the clinician listening now, he’s wanting to prove airway management safety within their department. What would you advise them are the key elements, or the key methods they can employ to do that?
One of the main outputs of the NAP4 for project was the recommendation by the college in DAS that every hospital should have an airway lead. So that is an individual, usually an anaesthetist, who would be responsible for ensuring that teaching in the department on airway matters was appropriate. And when I say the department, I mean the organisation. So the anaesthetic department, intensive care, and liaising with the emergency department and other areas where airway management takes place. So the teaching is appropriate, the equipment is both rationalised and standardised across the organisation. And that there is communication between those three organisations.
If a department can implement all the recommendations from NAP4, that are relevant to that particular organisation, then they will have improved airway management in their hospital, undoubtedly. And what do you think are the implications for training and education in terms of improving airway management? So training is all. I think one of the key factors is that we need to be really good at what we do routinely, but we also need to be very good at what we’re going to do to rescue difficult situations. So unlike in some branches of medicine, the techniques we will use when airway management is difficult are traditionally different from those techniques we will use when it’s been straightforward.
There’s some specific teaching that needs to be done to learn those skills out with the normal. And that probably involves an element of simulation, for those hospitals that have access to that, or workshop training. So to make some of those interventions that we only do in extreme circumstances more routine, such that we’re more capable of managing them in those scenarios, is that– Absolutely, yes. So I’ll use our hospital in Bath as an illustration of that. We’ve taken that quite a long way. So whereas the DAS 2015 guidelines would say, if you’re having difficult intubation, use a videolaryngoscope. We use a videolaryngoscope for every intubation. Even if you’ve no concern about the difficulty? Absolutely. We don’t have non-video laryngoscopes.
We only have videolaryngoscopes. So throughout the hospital, in anaesthesia, for adults, in intensive care, the emergency department and moving to on the wards for cardiac arrests, we only have videolaryngoscopy. We’ve removed some of those initial barriers. So we’re not going, use a direct laryngoscope, have a couple of goes, fail with that, use A videolaryngoscope, we’re optimising our chances of success with a videolaryngoscope right from the start. One of the huge advantages of using that advanced technology, so bringing that advanced technology into routine use, is that the DAS guidelines say that every anaesthetist, every airway manager, should have availability of videolaryngoscopy, should be experienced and expert in videolaryngoscopy.
By using it all the time, not only do we reduce the likelihood of problems, but also we increase the skill of the individuals using it, and then also of those people in the environment who are involved or assisting us, so that our emergency care becomes our routine. And can I ask you if you have any stories of airway emergencies that have influenced your everyday practise? So having looked at 184 cases that reported to NAP4, and then various cases I’ve looked at when we review the litigation from the UK. I think one of the key themes is that the structured approach to the airway is rarely used in those circumstances, and communication fails within the team quite often.
The second thing is that– so in NAP4, about 40% of cases the primary event in anaesthesia was a failed or delayed or difficult intubation. And that failed intubation usually involves almost seeing the larynx and almost being able to intubate, and repeated attempts to intubate, most often with the same device. And we know that if you fail with intubation on one occasion, you have an 80% chance of failure the next time and the next time. So there’s little benefit in doing– The same– Probably doing it twice. Certainly, there’s no benefit in doing it three times.
These events usually take about 45 minutes to an hour from induction to either declaration of a failed airway, the need for front of neck airway, or indeed of the patient dying. And they start with a can’t intubate can oxygenate situation, and they deteriorate to can’t intubate cannot oxygenate situation. And it’s those multiple episodes of airway manipulation which, inevitably, lead to minor airway trauma. But put together over perhaps five or six different interventions, lead to significant trauma and deterioration. And I think we see people’s performance deteriorating during that time as well. So decision making becomes disordered. And the DAS guidelines are fabulous in many respects in that they simplify processes– A, B, C, D.
And they, and the Australian guidance, are very good at saying you should declare when you’ve had your three attempts. Perhaps, if you’re using a videolaryngoscope, your one optimal attempt, you declare I can’t intubate. And that declares not only to everybody around you that we’ve changed the situation or where we’re trying to intubate, but to one where we can’t intubate, but it also declares it to the airway operator as well and say, I’m now free to move on to the next stage. Try and rescue the airway with a supraglottic airwary device, this is now a failed intubation, and I can’t rescue with a superglottic airway device.
And at that stage, you’ll be getting ready for front of neck airway, and soon be transitioning to that. So I think having that structured approach in the mind of all the individuals is very important. And because our performance does deteriorate as stress rises, I think every anaesthetist has been in the circumstance where airway management is not going well, and their mind starts to spin forward and saying, if I don’t get this right in the next couple of attempts, we’re going to be in real trouble. And that can either focus the attention to do what you’re doing as best you can, or it can lead to unravelling. Professor Tim Cook, thank you very much.