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Can’t Intubate, Can’t Oxygenate

The patient was being prepared for thoracic surgery and had a lesion in his lung, which we were looking to biopsy. He also had some cervical lymphadenopathy, some nodes in his neck. And there was an amount of swelling, called lymphoedema in the neck. In preparation for the procedure, my anaesthetic colleague was putting the patient off to sleep. And at the time of induction was going to intubate the patient. So before we started, I felt that there may be a problem with this patient. I knew that he had a difficult airway I had considered whether to do an awake fiberoptic intubation on this patient. But he did have adequate mouth opening, and the patient was quite breathless. He was needing emergency operation.
So he didn’t want an awake fibreoptic, and I thought it would be difficult anyway. So we proceeded, but the surgeons were aware of my concerns. So I had many other staff available. And well, the video laryngoscope, laryngoscopic equipment that I needed at hand. And as soon as I was aware that I couldn’t intubate, or couldn’t ventilate, and then couldn’t intubate him, there was no recognisable anatomy, I very quickly called for David. When I approached, she asked that I prepare for a front of neck access, because she wasn’t certain that she would be able to get control of this airway. I must admit that we had been trained in it, not more than about 10 days previously.
So I had actually done the UCLH course on front of neck access. And I was, therefore, quite relaxed and confident about it. We went through the protocol very quickly. And as soon as the anaesthetist let me know that she did want me to proceed, I proceeded fairly quickly. And we were able to put in a size 6 ET tube very safely into the patient and re-oxygenate him. Don’t hesitate to ask for further help if there are other experienced people in the department. The more hands, the better. And I felt confident that he’d be able to do it.
The first time of me being involved in a front of neck access, We had a male patient coming in for thoracic surgery, expected a difficult airway. My anaesthetist had gone through the plan with me. The whole experience was not so bad, because of the entire plan that was put into place, everyone was so calm. And I don’t think anyone was stressful, like I think everything was– because everything was dealt with in such a calm manner and we had everything ready, that made it a lot better. Just to go through the patients with the anaesthetists that you’re working with, because they’ve got far more bigger picture than when you see the patient coming in for a surgery.
Because they’ve obviously seen the patient, they know everything about the patient, really. So when they go through the history with you, you know what to prepare. And especially when you interact with them, they let you know what is to be expected. So you have all the equipment ready. So you’re not running around in an emergency situation, even though if you don’t use all the equipment, it’s fine. At least you have it ready if it needs to be used.
I remember two cases where we had to do front of neck access. One of them was in the hospital, a perfect setting, of a patient after ENT surgery, who was starting to bleed. We just couldn’t intubate anymore. So we had to do front of neck access. The second one was in a pre-hospital setting, on the floor in the living room, where a patient after radiation, due to a hypopharynx cancer, got into cardiac arrest. And I could just not intubate him with our video laryngoscope in the living room. So we had to do front of neck access. Surely, this is a very scary situation. And the feelings were completely different. In this hospital setting, it was very hectic.
It was very– everyone was scared and the atmosphere was very much under tension. What I realised, it was really interesting comparing these two cases. I worked with paramedics on one case, and with a whole team of nurses, anaesthetists, anaesthetic nurses, ENT surgeons in the other setting. And the real challenge is the communication between the disciplines, the multidisciplinary communication, which needs to be trained, actually. Because it doesn’t come naturally. I think since these situations are so rarely happening, it’s important to prepare yourself, train the team and decide exactly what you’re going to do. Decide beforehand which equipment you’re going to use and which technique, and to train it. Train it on a model.
Train it on a cadaver or wherever you have the chance to train.
So if I think of airway, I think about my patient who died at induction. We did a front of neck access, but it was too late. She arrested and never came back, despite CPR. Safe airway to me bring back this memory every single time. And so it brings back the fear that no matter how attentive you are in your pre-assessment or the assessment of your airway, there is still something that you might not know. And this is where the drill comes of help, because it’s what can take you out of– might be able to take you out of trouble. And if it doesn’t take you out of trouble, at least you stick to what is recognised being the correct plan.
And this is, I think, in the worst case scenario, the best case scenario that you might have. So at least you have tried what is recognised as the best possible way. So you can go home and still look at yourself in the mirror, and say, I’ve really done my best, and it’s the recognised best way to proceed.

In the last few steps, you have learnt about the Difficult Airway Society (DAS) Guidelines and the Vortex Approach. In a “Can’t Intubate, Can’t Oxygenate” situation, both of these culminate in airway rescue with an emergency front of neck airway (eFONA) when all other options to oxygenate have failed. In this video several health professionals will recount their harrowing experience of performing or assisting to eFONA.

The clinicians in the video refer to several cases involving patients, their families, colleagues and the hospital in which they were working. Please treat this information with respect.

The NAP4 report stresses​ the importance of a structured response to airway emergencies and to “Plan for failure”. The actual technique recommended by DAS will be covered in detail later this week. First, Dr Kirstie McPherson, Consultant Anaesthetist at University College London Hospital, will look at some of the challenges of performing eFONA and how they can be overcome.

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Airway Matters

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