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Sharing the Airways

Sharing the airways
Before the list we obviously see the patients, that patient’s assessed in pre-assessment, including a detailed airway assessment, if we’re unhappy with anything in that assessment, then a consultant anaesthetist will review the patient pre-operatively. And then on the day, the patient will be reviewed again. And the patient will be discussed in a team brief at the beginning of the day. So hopefully, any problems during the day will be highlighted at the team meeting at the beginning of the day. Yes, the team brief is a valuable period in the day, when we will all relax, and just without other commitments talk about the patients, and look to address the issues that are going to come up during the day.
And what we usually do then is to try and preempt most of these things before they happen. So I’m a chest physician, we do bronschoscopy and interventional bronschoscopy here at UCLH. So we run 8 lists on bronschoscopy, where we have an anaesthetist with us doing the sedation. So most of these patients require either a general anaesthetic or sedation in order to facilitate whatever procedure Ricky is doing, be it biopsies, cryotherapy, stent insertion. And our major challenge is trying to make sure that the patients remain oxygenated, cardiovascularly stable, and preferably asleep throughout all of it. We always start with a WHO checklist, where we confirm which patients we’re doing the procedure on and what we’re doing.
And as part of that, we run through any critical steps that we might encounter during the procedure. So the whole team, not just anaesthetists and the person performing the bronschoscopy, but the nursing team and everyone else in the room. So if any problems do come up, we know exactly what to do. Yeah, I completely agree with what Ricky is saying. I think the really important key elements are knowing the patient and also communicate with the whole team. A lot of Ricky’s patients are very complex and very sick. And it’s really important that we know enough about their airway anatomy and their comorbidities, so we can make a safe plan together.
And we need to communicate that plan to the whole team, so they know when potentially things might go wrong, and what our backup plan is if they do go wrong. Extremely relevant in complex head and neck surgery, because the anatomy could be challenging for intubation, and it’s protracted long hours surgery. And there may be changes to the anatomy as a result of the surgery. So it’s important to have a dialogue at the beginning and throughout the course of the surgery. And certainly, at the end, when surgery is complete. Yeah, I agree we always have really good discussions to plan the cases, what airway we’re planning to use, what are our anticipated difficulties.
And to a certain extent, when the patients are very complex, it’s a bit easier, because we’re always anticipating difficulty and problems and make lots of plans. It’s when you run into unexpected difficulty, in a more straightforward case, in a scenario that you may have not discussed or anticipated, that I think it’s harder to manage. And that’s when communication with the anaesthetist, the surgeon and the whole theatre team, the anaesthetic practitioner, about what your plan is, what your strategy is, what kit you need. If you need help, who specifically you want to come and join you. That’s when the communication is really key, and obviously, time critical.
So the first thing I want to say about things going wrong is knowing who you’re working with. So Abbie and I have worked together for a very long time. And I think that’s really important to have someone, one anaesthetist, or one team that you’re working with, who already may know exactly what you’re looking for– not just about the patient being asleep, or when something is starting to go wrong. For example, if there’s bleeding, they know exactly what I’m thinking, and i know what they’re thinking as well, so that’s really important.
And when things do go wrong in bronschoscopy, it’s actually quite rare for something catastrophic to happen. But when it does, really it requires the whole team to get involved to straighten it out. Communication is really, really important. And having experienced this before, I know that everyone sort of heads straight to the airway, the natural point of the problem. So my approach to this would still always be ABC. For a bronschoscopy within UCH, we have an emergency bronschoscopy box. We’ve developed it a proper in after action review, actually. So within there is the setting up of equipment to do emergency cricothyroidotomy.
If we need to put in a chest drain for a pneumothorax or block the airway when it comes to bleeding. Yeah, and I agree with everything that Ricky says. And I agree that that sort of team communication is really, really important. By emphasising the fact that we’re having a problem, so the entire team can focus, and extra help can be called. I think that Ricky is very good to responding to changes, for example desaturation. He knows the point at which he has to stop, and which point oxygenation becomes a priority. And that comes, again, with working with somebody for quite a long time.
We also, because Ricky is very skilled with a bronschoscope, quite often we use his skills, for example, getting tube down into just one lung, which has gotten us out of several sticky situations. The patients usually have quite a lot of comorbidities. And they have frequently quite poor lung disease. So you don’t have as much time before the patient will deteriorate if things are going wrong with the airway, if you’re not ventilating adequately. Then the patient becomes more hypoxic faster. And if they’ve got coincidental cardiovascular disease, which frequently they do, they will then go on to have sequelae of cardiac problems.
So then in the operating theatre, during surgery, we obviously have a patient where we have to provide the surgeon with good operating conditions, which is a lung that’s not being ventilated, therefore, we’re ventilating on the other lung. And difficulties with tube placement or difficulties with the lung itself, with lung disease, lead it to being quite a problem sometimes, in order to provide adequate oxygenation for the patient. So throughout, we have good communication with the team. So the surgeon will be told– I’ll say that there is a pending problem. And the surgeon, because they’re operating on the airway and the lungs, they understand the problems.
And so they will usually stop what they’re doing or then be forewarned if I’m going to, for example, ventilate the lung they’re operating on at some point. And usually, they’ll say, OK, I’ll give you a couple of minutes. And then we get to a point where then I can ventilate. So we work together. During a very complicated tracheostomy in someone who’d had extensive head and neck surgery, and the surgical team was struggling to put the tracheostomy in, and couldn’t put it in the right place, and we weren’t getting in total CO2 to confirm it. But the patient had a big mid-face defect, and her mouth had been sutured here. And the whole side of her cheek was missing.
So face mask ventilation was very, very difficult. And so we called for help. Several surgeons turned up, including you. And in the meantime, I put an i-gel– an LMA through the side of the defect, to ventilate her from above, which was very difficult, and was a very poor seal, but was ventilating her enough to oxygenate her until the tracheostomy and definitive airway could be secured. But there were probably three consultant anaesthetists and three or four consultant surgeons while this was going on. And I think the key is about as much as you anticipate potential problems, I think it’s the availability of support, and dialogue, and planning beforehand scenarios.
If you were to come across a problem, then you have a plan B, C, D. And so, it’s like that and being versatile about using the airways, and this example of the i-gel typifies this. And possibly, being there for support in terms of bleeding and other acute surgical problems, that may be challenging for the anaesthetist to deal with. We try not to let things go wrong, by good preparation, but every now and again, something unpredictable will happen. We operate on heart and lungs. I think the most important thing is that the two consultants keep everybody in the theatre very calm and relaxed. The ambience must be one of harmony and team working, with communication being clear and concise.
And I think if the two consultants work closely together to maintain that ambience in theatre, then we can make sure that we get the best out of all the supporting staff that we have. And if we get them all working together, we approach things in a systematic manner and don’t let anybody panic.

As we discussed in the previous steps, good teamwork and communication are essential for safe airway management. In this video we will see examples from three clinical settings where the airways are shared: thoracic surgery with Dr Ruth Hurley, Consultant Anaesthetist and Mr David Lawrence, Consultant Cardiothoracic Surgeon, interventional bronchoscopy with Dr Abigail Whiteman, Consultant Anaesthetist and Dr Ricky Thakrar, Consultant Respiratory Physician, and head and neck surgery with Dr Irene Bouras, Consultant Anaesthetist and Mr Zaid Sadiq, Consultant Head and Neck Surgeon at University College London Hospitals.

We would also like to hear from you. Do you work in a shared airway setting? How do you work together to make sure the patient is safe? How do you prepare for and deal with difficulties when doing shared airway cases?

In the next activity we will learn about altered airways. We’ll start by reading about Jen Taylor’s experience of having a tracheostomy.

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Airway Matters

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