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What Makes Airway Management Safe?

Let's try to recap by answering again the Big Question
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I think the most important principle is that we know enough about airway management now that for an adult elective patient who does not have a known difficult airway problem or a suspected one, there should be a zero instance of mortality and morbidity. And that is achievable now. Having a sound plan of how we are going to manage the airway from start to the end– so that consists of communicating with the anaesthetists, asking her or he what the steps– what they’re planning for the airway management. That could be what kind of intervention– if is an LMA, ET tube that we’re going to be using for this patient, and how we’re going to do be extubating.
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So we have a step-by-step detailed plan of how we’re going to keep these patients safe. If we designed systems, systems that include the operators and their design and think through all the possible things that could go wrong. I think what has evolved and what is improving is patient preparation and planning. I think that’s very important. And then procedurally, people now have algorithms to follow. When I started, there were no difficulty airway guidelines. We’ve had two sets in 2004 and 2015. I think they’ve really helped the thought processes, where people are following guidelines. We have cognitive aids as well, like the Vortex. So people are working with these guidelines, and good teamwork and communication has improved dramatically.
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A plan in place– and couple that with communications. They’re communicating to the surgical team, especially in shared-airway cases to the theatre staff, and especially to our anaesthetic nurse, or ODP, essentially, following the best guidelines– so having a plan A, plan B, plan C. So we have all the eventualities worked out. Education, global initiatives, and communication. You need communication, you need an effective team, and you need to plan ahead. You need to anticipate problems and failures, and I think with all of the evidence from NAP and various other studies, we’ve always typically focused on airway management as induction and intubation.
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But actually, there’s more and more evidence suggesting that you can have airway catastrophes intraoperatively, postoperatively, extubation– so I think planning more for that whole of the case, particularly if it’s a shared-airway case. The real trick to successful airway management in the critically ill is the plan it well. And that means using a well-constructed checklist, which looks at preparing patients, preparing the equipment you’re going to use, preparing the team, and also, preparing for airway difficulty. In my unit, we get the nursing staff to prepare the patients according to a very rigorous checklist, and prepare the equipment. In terms of preparing the team and preparing for difficulty, the actual airway operator runs that part of the checklist.
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And that way, the whole team knows what the plan, shares the mental model, and is ready for problems. Being listened to, being spoken to, with having a connection between me and the people working with me, and being adaptable when people were treating me. A recognition that it’s a team sport and the fact that airway disasters generally happen when the team is not quite switched on, so it goes into that whole narrative around WHO checklists, the breaking down of barriers of– 30 years ago, you wouldn’t challenge a consultant– the breaking down of the hierarchies. All of that, I think, has made probably the most significant contribution to airway management in the sense that there is a questioning of what one does.
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Research is my last, it’s critical in improving . Safety is research. So if you’re a researcher, keep doing it.
We are now reaching the end of Airway Matters. Before we finish the course, we would like to summarise what we have learnt over the last five weeks by answering the “Big Question” we asked at the start:
What makes airway management safe?
In this video you will hear the answer given by health professionals, patients and experts and then we would really like to hear from you:
  • Think about your answers to this question at the start of the course. Has anything changed?
  • What is the most interesting or useful thing that you’ve learnt?
  • How important was reading other people’s comments and taking part in discussion?
  • How do you think you might use what you’ve learnt on this course in your practice?
You might also like to go back the the Padlet wall: Human Factors and Ergonomics in Airway Management we have created together in Week 1 and read about some of the many suggestions to improve Human Factors and Ergonomics.
For a final time please do discuss your thoughts on these questions in the forum.
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Airway Matters

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