Each year we have asked a trainee anaesthetist to compile a report of the meeting. Read on to hear what they had to say about our past meetings……
Scottish Airway Group Annual Meeting Report 2016
Dr Andrew J Dalton, ST7 Anaesthesia, Tayside
The sixth annual Scottish Airway Group meeting took place at the Royal Concert Hall, Glasgow on Friday 4th March 2016. The meeting was very well attended, with delegates from throughout Scotland amongst the audience. The meeting this year was organised by Dr Craig Urquhart and Dr Kevin Fitzpatrick from Glasgow.
The first talk was entitled “Tongue, Teeth and the Airway” by Dr Brian Stickle, who is a Consultant Anaesthetist in Aberdeen. He reviewed the anatomy and function of the oropharyngeal cavity, whilst emphasising the difference between airway function and patency in an awake patient versus that after anaesthesia/paralysis. This should always be a consideration when planning an airway strategy. He reviewed potential problems with the tongue; ranging from increased size (e.g. after trauma, flap surgery or due to angioedema), loss of function (including a wooden, fixed tongue post radiotherapy) to bleeding (often due to tumour or trauma). During this he emphasised that assessment is paramount, and we should have a low threshold for nasendoscopy assessment; and, if in doubt, consider performing an awake fibreoptic intubation as most tongue problems will worsen with loss of consciousness. He then reviewed the management of abscesses, stating that warning signs are voice changes, dysphasia, dysphonia, dyspnoea and stridor. The key parts of this assessment are tongue protrusion and mouth opening: if you can open your mouth sufficiently for laryngoscope access, and protrude your tonguethen it will likely be safe to perform a standard general anaesthetic. However, if these features are absent then an awake fibreoptic intubation should be performed.
This was followed by Dr Ben Ulyatt, a Consultant Anaesthetist at Ninewells Hospital, who spoke about “Laryngeal issues: Airway obstruction”. After reviewing the potential causes of airway obstruction, he then focused on how to adapt an airway management strategy, with the focus being that even the best laid plans can fail! He did this with the aid of a very interesting case report of a patient he had recently anaesthetised, that the rest of the audience were pleased had not come during their own on-call! During the discussion around AFOI, awake tracheostomy, pre-emptive cannula cricothyroidotomy, he showed how in his case each had been considered/performed and each had failed, demonstrating that “no plan is always successful, and experience … determines outcome when the initial strategy is unsuccessful” as stated by NAP4. He viewed non-technical skills to be the key to management and a successful outcome, with the importance of planning, prioritising, teamwork, anticipation, and successful communication the key to achieve this.
The morning session was concluded by Dr Malcolm Watson, a Consultant Anaesthetist from Glasgow with an interest in Regional anaesthesia. His talk encompassed “Regional Anaesthesia and Ultrasound of the Airway”. An initial discussion of performing a superficial cervical plexus block was then followed with examples of other ultrasound guided airway blocks -however, the caveat was that these do not seem to be any more successful techniques for airway topicalisation than using a mucosal atomisation device (MAD) which is less invasive! He then discussed ultrasound of the airway, with some very clear ultrasound images demonstrating what information can be obtained and how this can guide the placement of tracheostomies and cricothyroidotomies when in expert hands. However, in the emergency situation of a ‘can’t intubate, can’t oxygenate’, there was debate as to how useful it would be given the time factor required to perform it in an already time pressurised, stressful environment.
After coffee, we recommenced with the trainee oral presentations. Dr Rachel Harvey opened by giving an update on her SAG sponsored project entitled “Distraction cards improve the number of successful steps undertaken during simulated ‘can’t intubate/oxygenate’ scenarios”. Her project posed the question of whether prompt cards could help the performance of complex emergency tasks, and the findings have been very positive, with the randomised ‘no card’ group performing 10 critical steps from 17, compared with the card group performing 16 or 17 of the 17 identified critical steps for cannula cricothyroidotomy, which had statistical significance following T-test analysis. She plans to continue the project by restudying it for surgical cricothyroidotomy after the revised DAS guidelines. Competing for the oral prize were Dr Karen Pearson, Dr Dima Nassif and Dr Jennifer Service. Dr Pearson spoke about her education project regarding the Airway Rescue Trolleys in Ninewells Hospital, and that after the identification of poor knowledge of both trolley contents and location, she undertook teaching of both medical and nursing staff, and then reaudited showing a marked improvement in knowledge and understanding of the concept. Dr Nassif spoke about “Sugammadex -4 years of clinical experience” in NHS Tayside and how the Sugammadex use has increased each year, with residual neuromuscular blockage remaining a worryingly high reason for requiring Sugammadex. She spoke about how increased vigilance to monitoring the NMB with quantitative monitoring devices may reduce this incidence and therefore potentially reduce the requirements for Sugammadex rescue. Dr Service concluded the presentations with her talk on “High flow nasal cannulae for outpatient bronchoscopy” in St Johns Hospital, Livingston. She demonstrated that after an initial trial period the bronchoscopy service has now switched to undertaking their sedation lists using high flow nasal cannulae as the method of oxygenation based on less desaturation episodes and higher satisfaction ratings from both the anaesthetists and bronchoscopists. All the talks were very well presented and received, and after a close vote the judges awarded the first prize to Dr Pearson.
Dr Alistair May concluded the morning with a very interesting talk entitled “Let’s think how we train”. He spoke about changing the focus of teaching/learning from the traditional apprenticeship model to a more modern approach of mastery learning, whereby tasks are broken down into lots of small steps to develop the overall skill. He highlighted several studies showing that mastery learning helps learn tasks quicker and produce better performance, with significant retention of the skills even when retested after a prolonged time period. He described his experience of implementing this teaching in his unit for new starts learning airway skills with very promising results from both the trainees and the trainers (including some sceptical members!). His talk challenged all trainers present to ensure they make the most of opportunities to teach and how they go about maximising the learning experience for trainees. The lunch break followed, which allowed the opportunity to review the excellent poster presentations and visit the trade displays.
Dr Anil Patel, a Consultant at the Royal National Throat Nose and Ear Hospital, current DAS president and much respected international speaker, followed with two talks; firstly “DAS updated guidelines”. He spoke about the development of the guidelines, and the main changes from the previous 2004 version. There is no longer a separation between unexpected difficult intubation in a ‘routine’ induction vs rapid sequence; instead these have been combined into a single algorithm. Videolaryngoscopy has been included to reflect the changing practice across the UK, but no specific type of video scope has been recommended as there is insufficient evidence to do so. After 3 laryngoscopy attempts, the focus is now much more on oxygenation via a second generation SAD and wake up from here as the primary mindset, rather than the more focused secondary intubation plan of the previous guidelines. The other main shifts are regarding paralysis and front of neck access. The theme is that “nobody should get to can’t intubate/oxygenate without being fully paralysed”. Therefore, after failed intubation, SAD and face mask ventilation, ensure paralysis for one final attempt at face mask ventilation prior to undertaken emergency cricothyroidotomy. Regarding emergency cricothyroidotomy, surgical ‘scalpal, bougie, tube’ is now the recommended technique. It is recognised that there is thankfully limited evidence to draw on for this, but Dr Patel stated there “is not enough evidence to choose any particular technique, but enough evidence to choose one!” which has led to the shift in the guidance. Dr Patel then spoke about his landmark research and publication regarding THRIVE (transnasal, humidified, rapid insufflation ventilatory exchange) oxygenation. He discussed the process of undertaking THRIVE and the THRIVE triangle of ‘CPAP, apnoeic ventilation and apnoeic oxygenation’. THRIVE has been shown to be suitable for pre-oxygenation (with no additional face mask required), and at maintaining oxygenation even after the onset of apnoea as long as a patent airway is maintained. Stridulous patients also feel more comfortable with THRIVE on as it reduces the work of breathing by increasing tidal volume, reducing respiratory rate, increasing expiration time and therefore allowing re- recruitment of greater lung areas (while awake). Classical apnoeic oxygenation does not clear carbon dioxide and can give rise to acid-base disturbance, whereas THRIVE blunts the rise of CO2 during apnoeic periods. It is important to remember that THRIVE should not be considered a substitute for a definitive airway, and that it does not work with total airway obstruction, nor is it a rescue for desaturation in an anaesthetised patient. While the initial work has been done using THRIVE for transglottic surgery as the sole method of oxygenation, it is recognised that this forms a very small part of the general anaesthesia workload. Instead, the role it can play in preventing desaturation during airway management and the positive impact this could have in human factors/nontechnical skills is a very exciting development towards safer anaesthesia delivery.
Mr Omar Hilmi an ENT Consultant working at Glasgow Royal Infirmary, concluded the session with a talk entitled “Imaging of the Airway”. He started by emphasising that imaging should always be considered alongside clinical assessment and nasendoscopy, not in isolation. It is essential to have CT imaging when assessing the level and the extent of the tumour. It is also useful for establishing if there is a ‘straight line’ from mouth to larynx (as this will determine both laryngoscopy for anaesthesia and surgical access), if there is any tracheal displacement/tracheal narrowing, as well as when there is a clinically significant neck mass. Imaging performed acutely can also be very useful for diagnosing and planning purposes if it is agreed that it is safe for the patient to undergo a CT scan.
After coffee, the final session opened with Dr Ross Moy, an Emergency Medicine Consultant and Army doctor. He talked about “Tactical Aeromedical Evacuation”, and opened by stating the army medical aims that “no one should exsanguinate from compressible bleeding” and “no one should asphyxiate if they do not have a crushed airway”. He discussed the capabilities of the aeromedical evacuation unit: assessment and resuscitation, control of catastrophic bleeding, airway management including surgical airway, chest decompression, giving blood products, dynamic triage and dealing with multiple casualties. During resuscitation they aim for haemostatic resuscitation, give tranexamic acid early, control temperature actively, and use damage control surgery as part of the resuscitation when indicated. They have a 94% intubation success despite the challenging conditions -he attributed this to having a consistent team very familiar with their roles, all of whom undertake regular team moulage training, use of high dose muscle relaxant, no cricoid pressure and no in-line stabilisation regardless of injury, alongside routine debriefing and then clinical governance meetings.
The final speakers of the day were Drs Simon Crawley and Barry McGuire, both Anaesthetists at Ninewells Hospital. They engaged in a lively debate around “Scalp, bougie, tube will cause more problems than it will solve!” with Dr McGuire defending the motion and Dr Crawley opposing it. Several good points were made on both sides, with the highlight being Dr Crawley using a video of his 5 year old daughter performing the technique to show that with adequate training anyone should be able to carry out the task! The vote was very close, with Dr Crawley just shading it (that’s a white lie as I have to work with Barry). Finally, Dr Urquhart closed what was a very enjoyable and successful meeting. Thanks again to him and everyone else involved for all the hard work that went into organising the day.
He announced that next year the 7th annual meeting will be organised by Dr Crawley and a team from Ninewells Hospital in Dundee. It will be held at the Royal College of Surgeons in Edinburgh on the 10th of March 2017. Look forward to seeing you all there.
Scottish Airway Group Annual Meeting Report 2015
Dr Andrew J Dalton, ST6 Anaesthesia, Tayside
The fifth annual Scottish Airway Group meeting took place at the Royal College of Physicians of Edinburgh on Friday 6th March 2015. The meeting was very well-attended, with trainees and consultants in Anaesthesia, Emergency medicine, and Intensive Care from throughout Scotland, as well as anaesthetic nursing colleagues amongst the audience.The meeting this year was organised by Dr Barry McGuire and Dr Simon Crawley from Ninewells, Dundee.
The initial talk was entitled “The Trauma Airway” by Mr Jan Jansen, who is a Consultant General/Trauma Surgeon and Intensivist based at Aberdeen Royal Infirmary. He emphasised the importance of preparation, familiarisation and teamwork, stating that if these are optimised, most trauma airways are not any more difficult to manage. However, it is essential that you anticipate and plan for failure, as requiring implementation of Plan D of the DAS intubation guidelines will happen at some stage. He stated a preference for a surgical cricothyroidotomy approach in an emergency airway, but that insertion of a cricothyroid cannula prior to induction in a threatened airway has its place to allow a back-up oxygenation to be already established. From a practical perspective, he suggested that if a patient does not have any neurological signs then a cervical spine collar should be removed prior to induction to enhance the chances of intubation success.
This was followed by Dr Dean Kerslake, an Emergency Medicine Consultant at the Royal Infirmary of Edinburgh (RIE) who spoke about “Emergency Department Airways”. Further emphasis on the importance of teamwork, communication and preparation in the potentially unfamiliar environment/team was made. He described walking through the plan including the plan for failure in your head prior to starting, and that the checklist should be ensuring everything is ready, not a prompt to get it ready. The published intubation register in the RIE ED department was also discussed, which shows that 99% of their intubations were successful within 2 attempts. They have a default position of contacting the senior anaesthetist on-call in the hospital prior to induction, but that actually the majority of the intubations were undertaken by ED staff with supervision. While surgical airways are very rare, they should not necessarily be considered as a failed airway in the Emergency Department, rather an option that can be considered for every patient.
The morning session was concluded by Dr Robbie Thorpe, a Consultant Anaesthetist who until recently was working at the Institute for Neurological Sciences, Glasgow. His talk encompassed “The Awake Craniotomy”. He spoke about the challenges of managing the airway when the head is fixed, inaccessible, and the patient needs to be taken from a state of awake to anaesthetised to awake to anaesthetised again! A thorough pre-operative patient assessment is essential, both in assessing the patient and also in preparing them for what the process entails. The case requires 2 anaesthetists due to the complexities involved. The initial airway management (prior to the head being immobilised) should be undertaken in the same way as you will do it intra-operatively, to establish the feasibility of this. Therefore no bag-mask ventilation and the laryngeal mask airway (which is the preferred airway option as it is most feasible for reinsertion intra-operatively) should be inserted from in front of the patient. Neurophysiological monitoring is interfered with by inhalational agents; therefore TIVA should be used for anaesthesia.
Dr Elizabeth McGrady, Consultant Anaesthetist at Glasgow Royal Infirmary restarted proceedings after coffee with a talk entitled “The Obstetric Airway – is it really that difficult?” She emphasised that the failed intubation rate in the obstetric population has remained relatively constant in the UK at approximately 1:300, which is approximately ten times that of the general population. She highlighted that although the vast majority of Caesarean sections are performed under regional anaesthesia, the marked increase in Caesarean section rates mean that a similar number of General Anaesthesia sections are still being undertaken. While highlighting all the physiological/anatomical differences of an obstetric patient, she suggested that a main contributor to the higher failed intubation rate is human factors related, with the high pressure, stressful environment in which anaesthetic trainees may be undertaking distant supervision cases for the first time hindering performance.
Dr Rob Walker, a Paediatric Anaesthetist from Manchester Children’s Hospital, then spoke about “The management of Upper Airway Obstruction in Children”. He started by highlighting the anatomical differences between children and adults, and why these are important adaptations, such as the high position of the epiglottis being necessary to allow an infant to breath and swallow simultaneously during feeding. This was then followed by an excellent selection of videos demonstrating differing signs of respiratory distress caused by various pathologies, and how these clinically correlate to further management and investigative decisions. For the management of airway obstruction, maintaining spontaneous ventilation and avoiding positive pressure ventilation is a key principle. This can either be done by inhalational or TIVA techniques, with local anaesthetic airway topicalisation complementing both techniques.
The lunch break followed, which allowed the opportunity to review the excellent poster presentations and visit the trade displays.
The trainee oral presentations followed the lunch break. Dr David Falzon presented “Improving tracheostomy emergency management in a tertiary Head and Neck centre”, which was followed by Dr Lynsey Foulds presenting “Monitoring and reversal of neuromuscular block – a Scotland survey”, and then finally Dr Pamela Farquharson presenting “Tea trolley teaching of the TOF watch”. All the talks were very well presented and received, and after a close vote the judges awarded the first prize to Dr Foulds.
Dr Brendan McGrath, a Consultant at the University Hospital of South Manchester and respected international speaker, followed with the talk “Is your hospital on the right trach?” He spoke about the common tracheostomy related problems, and the significant morbidity and mortality that result from these. He emphasised that most of these problems are recurring, and are therefore predictable and amenable to system-wide quality improvement strategies. He highlighted the 2014 NCEPOD report into tracheostomy care as a valuable resource for identifying these problems (where around 20% of tracheostomies were reported as having an ‘incident’ of some variety), and also regarding the recommendations that were made for improving care, such as mandatory capnography, emergency drills, ongoing education, appropriate tubes and replacements immediately available, and an appropriate location for managing patients with tracheostomies. The use of bed head tracheostomy signs, readily available guidelines, and a multidisciplinary team approach to tracheostomy management were the immediately implementable take home points.
Mr Pete Ross, an ENT surgeon from Ninewells Hospital, Dundee, opened the final session with the talk entitled “ENT/Anaesthesia Interface: current and future challenges”. He first discussed robotic surgery, from the initial prototypes to the robots now available, and their application to head and neck surgery. Limited anaesthetist access, difficulty moving the robot in case of emergency and the potential for extubation or haemorrhage/oedema were all potential issues that were highlighted, with the conclusion being that there needs to be significant advances before robots are preferable to humans for these procedures! The second half of his talk concerned the centralisation of ENT services, and the impact this has on care/the delivery of services. There is no current data to say centralisation is detrimental, perhaps surprisingly given the potential for a rapidly developing airway issue with no ENT surgeon close by. However, sites may be exposed when there are multiple emergencies and practical issues like availability of specific equipment, site specific protocols and staff familiarisation all must be considered.
The final speaker of the day was Dr Grant Rodney, a Consultant Anaesthetist from Ninewells Hospital, Dundee, with his talk “Twitching, blocking and reversing – doing it better”. He demonstrated that residual neuromuscular blockage is underestimated, and that a train-of-four (TOF) ratio < 0.9 impairs respiratory muscle function and ventilatory drive, and risks awareness both at extubation and emergence. He highlighted the NAP5 recommendation that the use of a peripheral nerve stimulator should be considered essential when using a muscle relaxant. He then discussed the more advanced quantative monitoring such as the TOF watch, which can reliably demonstrate the return of the TOF ratio > 0.9. The increased use of these would then allow a more scientific based approach to the need for reversal agent, and if so which one is most appropriate.
During the meeting it was announced that the first SAG national audit is going to be undertaken in the coming year. The topic of this will be concerning neuromuscular blockage and the use of reversal agents. Further details will follow in due course, so please look out for the audit over the coming months!
Finally, Dr McGuire closed what was a very enjoyable and successful meeting. Thanks again to him and everyone else involved for all the hard work that went into organising the day. He also announced that next year the 6th annual meeting will be returning to Glasgow on Friday 4th March 2016, so get your study leave in early!
SAG Annual Meeting 2014
Trainee Report by Vanessa Vallance, Anaesthetic ST6, West of Scotland
Following an excellent turnout in a new venue last year, the fourth annual Scottish Airway Society meeting took place again in the Royal College of Physicians of Edinburgh on Friday 7th March. There were more than 160 delegates from all over Scotland at the meeting and from both anaesthetic and non-anaesthetic backgrounds.
The meeting’s organiser Dr Caroline Brookman from NHS Lothian chaired the first session, which began with a talk by Dr Barry McGuire from Ninewells Hospital in Dundee, entitled “Rigid Sticks in Dark Holes – friends or foes?”. We were enlightened as to the differences between bougies, introducers and stylets and also the complications that such devices can carry if used incorrectly. Dr McGuire also discussed the role of the new extubation catheters that are making their way into clinical practice for use in “at risk” extubations.
The second talk of the morning was by Dr David Ray, a Consultant Anaesthetist from Edinburgh Royal Infirmary (ERI). The talk was entitled “Out of our Comfort Zone – airway management out of theatre” and highlighted the risks and complications of rapid sequence inductions (RSIs) out with the “safe” environment of the operating theatre that we are all accustomed to. NAP4 revealed that 25% of major airway events occurred in ICU or emergency departments with most events being complications of rapid sequence inductions. Dr Ray also drew our attention to the ongoing problem of using propofol during RSIs in patients with major physiological derangement. Despite being a drug that the vast majority of anaesthetists use on a daily basis, his data from ERI showed that when used at emergency inductions, we are still using large doses in critically unwell patients, leading to adverse events of hypotension.
The last talk of the first session was by Dr Suzie Thomson who works both as a Consultant Anaesthetist at the Institute for Neurological Sciences and as part of the Emergency Medical Retrieval Service (EMRS). Dr Thomson’s talk was about “Airways in Unusual Locations” and discussed her interesting and varied role as a consultant in the EMRS. Situational awareness and various job/person factors play key roles during her retrievals and she and her team use checklists and standard operating procedures to very good effect. Dr Thomson’s talk ended with attention-grabbing footage of an American military team having to undertake an emergency cricothyroidotomy in the back of a helicopter at altitude!
Following an excellent first set of talks, coffee and cookies were available for all, and a chance to sneak a peek at the posters and also the 21 trade exhibitors who were there with all their new technology.
The second session of the day was chaired by Dr Valerie Cunningham, Consultant Anaesthetist at the Institute for Neurological Sciences in Glasgow. She introduced her fellow colleague from the Neuro Institute, Dr Michael Murray who gave us a highly entertaining and very well received talk on “Connecting Tissues and the Airway”. His talk challenged the theory behind what we routinely do in anaesthesia and made us think twice about using cricoid pressure, manual in-line stabilization and a head down tilt during our next RSI. The key points from Dr Murray’s lecture were to embrace new technology, manage our stress effectively and skill share.
Following on from that was an excellent lecture from Dr Anil Patel, who had travelled up to talk to us from the Royal National Throat, Nose & Ear Hospital in London where he works. His talk entitled “My Airway Disasters – what have I learnt?” was highly educational. Dr Patel has undertaken more than 4000 airway procedures during his long career as an anaesthetist. He shared with us his knowledge and expertise in managing difficult airways and showed us some interesting (if somewhat scary) footage of various airway pathologies he has encountered in the ENT operating theatres.
Next up was an excellent buffet lunch, a chance for a catch up with colleagues and another opportunity to peruse the line up of interesting posters and trade stands.
After lunch Dr Ben Shippey, a Consultant Anaesthetist based in Fife, ensured we were educated yet again, this time by five trainees from across Scotland who made oral presentations. The first was an audit of “The use of the McGrath MAC videolaryngoscope” by Dr Andrew Dalton, the next an audit of “Tracheal intubations by the EMRS” presented by Dr Mark Ross. Following on was an ingenious presentation by Dr Jenny Bain called “A sponge, a tube and a roll of sticky-backed plastic”, then Dr Rachel Harvey presented her work “Developing a multi-professional high-fidelity training programme” and last but not least was Dr David Hall who presented his audit on “The increasingly effective use of capnography in recovery”.
The next talk was by Dr Mark Stacey who had travelled up from Cardiff to give us an excellent presentation on “Airway Education – teaching under pressure”. This very well received presentation explained the importance of context-specific training in anaesthesia and how it is not only important to teach it right but also to train it right. Having not only impressed the audience with his passion for teaching, he also astounded us all by showing us a video that challenged the way we learn skills – it showed us that we have all been peeling bananas the wrong way all our lives!
Another break for a caffeine top-up and then we were into our final session of the day, chaired by Dr Grant Rodney from Dundee. First up were the expert panel made up of Dr Anil Patel, Dr Barry McGuire, Dr Alistair McNarry and Dr David Ball. “Front of Neck Access” (FONA) was the hot topic and Dr McNarry started the ball rolling with a brief update on NAP4’s findings with regards to FONA. The panel then discussed their opinions on their first choice of technique for FONA in an emergency, and answered questions from the audience on whether we should be using standard operating procedures for emergency FONA, and needle versus surgical cricothyroidotomy.
The final speaker of the day was Mr. Colin MacIver, an eminent Oral-Maxillofacial Surgeon with years of experience in both the military and the NHS. Mr. MacIver gave an excellent talk on facial transplantation, discussing the complications and controversies, and presenting some of his previous surgical cases from his year working in France. The audience was in awe of his life-changing surgeries, and he finished his talk discussing the potential future that facial transplantation surgery will hopefully have in Scotland.
The prizes for oral presentation and posters preceded the day’s AGM meeting, and rounded off another highly educational meeting.
Finally, a date for your diary…Friday 6th March 2015 will be the 5th annual SAG meeting. Look forward to seeing you then!
Annual Meeting 2013 Report
West of Scotland
Following last year’s successful meeting, the third annual Scottish Airway Group (SAG) meeting was held at a larger venue – the Royal College of Physicians of Edinburgh. Located centrally in the city, this impressive building was built between 1844 and 1846, with the statues of Aesculapius, Hygieia, and Hippocrates welcoming you at the entrance. The meeting was very well-attended with trainees and consultants in anaesthesia, emergency medicine, and intensive care medicine amongst the audience, as well as anaesthetic nursing colleagues.
The meeting organiser Dr. David Ball was the centre of attention, and deservedly so, as he kicked off the meeting with a welcome address delivered in his usual entertaining manner. He then proceeded to introduce the first session chair, Dr. Suzie Thomson from Glasgow.
Dr. Valerie Cunningham, Consultant Anaesthetist at the Institute of Neurosciences, was the first speaker, and educated the audience on the very interesting topic of neck compression. Acute versus chronic, and accidental versus non-accidental causes were discussed. The very well-presented case discussions compared the cases of a patient with chronic compression with a patient developing an expanding haematoma in recovery following carotid endarterectomy. The cases successfully highlighted the ‘time factor’ in management of these two patients. Where formulation of a plan and optimisation was a necessity in the first patient, it was not even a consideration in the second, despite the similarities in airway management. Complications of neck compression were also highlighted, and one that particularly captured the audience interest was carotid artery stenosis presenting as a late complication of non-accidental compression, for example hanging. A discussion of imaging concluded the talk: should we, as anaesthetists, be arranging for neck imaging in patients with suspected airway compromise due to an intrinsic mass or external compression? The speaker’s opinion was delivered confidently – yes to imaging IF it is likely to change our management.
Suzie then introduced the next speaker – requiring no introduction, the Chairman of SAG and Consultant Anaesthetist at Ninewells Hospital, Dr. Barry McGuire. His presentation was not a let-down for the standard set by the title – ‘Crikes, what happened to NAP4?’ Full of controversial issues, his talk provided a snapshot of NAP4 concerns regarding front-of-neck access. Why was surgical access almost always successful? Should we be training our trainees more on airway rescue procedures rather than how to hold a facemask in their limited training time? Should we be concentrating on surgical access rather than narrow-bore access? What can be improved – equipment, training, or both? Continuing the theme of ‘can’t intubate, can’t ventilate’, he proceeded to discuss the use of neuromuscular blockade and its reversal, making his opinion quite clear on the matter – only reverse paralysis in these situations if you CAN ventilate. Sugammadex: not a panacea!
The final talk before coffee saw introduction of Dr. Grant Rodney, Consultant Anaesthetist at Ninewells Hospital. There was no evidence of wilting in the audience as Dr. Rodney’s talk on African Airways instantly captured everyone’s interest. He gave a brief overview of ‘Facing Africa’, the charity that funds two teams of experienced surgeons, anaesthetists and nurses to perform extensive facial reconstruction surgery in Ethiopia. 35-45 surgeries are performed in each 2-week period, and 80% of these patients are victims of cancrum oris – a devastating gangrenous infection of the face, also known as noma. There are 140,000 cases of noma annually in Africa, with a staggering 90% mortality. The majority of the talk focused on the challenging airway issues these patients present with. The survivors are left with severe deformities and, unsurprisingly, direct laryngoscopy is a challenge in these individuals, although bag-valve-mask ventilation and fibreoptic intubation are usually manageable. A significant number of these patients have trismus, making front-of-neck access mandatory. Several interesting photographs reinforced the verbal content of the talk, as the extent of aid provided by Facing Africa became increasingly clear with each passing slide of the presentation.
The morning break provided the opportunity to both mingle and discuss the most recent airway kits with the representatives present, with a chance to play with their impressive gadgets and equipment. And, of course, coffee and biscuits!
Dr. Barry McGuire chaired the following session, the first presentation of which saw our first ‘visiting’ speaker continuing the theme of controversy surrounding suggamadex: ‘an update from a cynic’ indeed! Dr. Paul Jefferson from Warwick admitted upfront that yes, it is a good drug: recovery of T2 to train-of-four ratio to 0.9 takes 2 minutes. Compare that with the astonishing 10 to 27 minutes with neostigmine. What’s there to be cynical about? Giving the drug takes time. Add these 2 minutes to the time taken to reach the decision of cracking open those 9 vials kept under lock-and-key in most hospitals, and then there is the time that it takes to crack open the vials, whilst mentally calculating the correct dose for the patient. He continued to provide further fodder for thought, as he discussed the use of suggamadex in ‘can’t intubate, can’t ventilate’ scenarios, where it has the potential to make things worse by providing unfavourable conditions for front-of-neck access, and the possibility of pulmonary oedema if reversal leaves a partially obstructed airway! He concluded by highlighting the most concerning practice in the use of neuromuscular blockade: the use of, or lack of, monitoring the blockade. An interesting comment from the audience: should neuromuscular blockade monitoring be included in AAGBI standards of monitoring?
Dr. Ellen O’Sullivan, of course requiring no introduction, continued the morning’s events by discussing the key issues in education in airway management. NAP4 issues were again highlighted: poor assessment, poor planning, and poor judgement. Inappropriate use of the equipment and unavailability of the equipment also featured. The answer to these problems does not lie in video laryngoscopes or fibreoptic intubations or front-of-neck access. The problem is due to lack of training, therefore the solution unsurprisingly is standardisation of training and teaching. A piece of unfamiliar equipment is no use to us in a hurry!
Lunch provided a further chance to look at the trade exhibition and catch up with colleagues, whilst ensuring refreshment for the afternoon session. The judges discreetly judged the posters, all of which maintained the usual high standards, one being submitted by a nursing colleague for the first time in SAG history.
Oral presentations, chaired by Dr. Alasdair McNarry from Edinburgh, followed the break. There were six excellent presentations, the first an audit of suggamadex use in their hospital, followed by an audit of significant airway events in intensive care. The next was a study looking at which supraglottic airway performs the best at intubating through LMA using a fibrescope and Aintree catheter. McGrath series 5 video laryngoscope was compared with MacIntosh blade in the next study when intubating with cervical spine immobilisation. Video laryngoscope availability, experience and training skills were discussed in the following presentation, and the final talk delivered audit findings of laryngoscopy in a bariatric surgery population. Dr. Simon Chillingworth was the eventual winner, with his presentation on airway events in ICU.
Dr. Raj Padmanabhan from Lanarkshire then took to the stage to chair the fourth session of the day, which promised to be an interesting one with airway challenges in two very different patient groups. Dr. Tom Engelhardt from Aberdeen presented the much-awaited lecture on unexpected difficult paediatric airway. His message was loud and clear – it is never impossible to oxygenate! Children’s physiology equals high oxygen demand and low oxygen reserve. In addition, younger children are at a higher risk of functional airway problems. As a result, management of any functional or anatomical airway obstruction is time critical. He highlighted, however, that impossible bag valve mask ventilation in healthy children does not exist. Once again, though, training and prior experience with equipment are paramount when attending to these children.
From one group to the next, Dr. Simon Crawley from Dundee quickly followed with his presentation on airway in critical care. However, despite the differences, the focus of the presentation was the same. Sick patients have high oxygen requirements and low oxygen reserve. Airway management in these patients is time-critical. However, these patients have been shown to have more difficult intubations with higher rates of complications, whether in emergency department or ICU. What is the solution to these issues? He went on to provide a very helpful insight into the practice of EMRS – a team that has clear plans, clear roles and clear equipment layout. And in that moment, he brought us back to the theme that had been throughout the day – experience, training, familiarity with the equipment. He concluded this part of his talk by reinforcing that ‘repetition is the basis of all skill’. A very brief overview of ICU extubations then followed, which are based on the recent DAS guidelines.
Final break of the day followed, which brought us to the final session of the day, chaired by Dr. David Ball. This new and very entertaining session of ‘Expert Panel’ consisted of written questions from the audience, gathered throughout the day by Dr. Ball, being directed at the panel: Ellen O’Sullivan, Barry McGuire, Alasdair McNarry, and Ben Shippey.
- Should we be adopting second generation LMAs as a standard of care?
- What should we call ‘these airway carts’?
- Which video laryngoscope would you buy?
- Could it be considered negligent to use atracurium now that we have suggamadex?
- Do you use LMA exchange for extubation?
And to end this report on a pondering note, the final and my favourite question of the day:
- Which of these in your opinion would make history first: suxamethonium, cricoid pressure, McCoy blade, or first generation LMAs?
Prizes for oral presentation and posters preceded the AGM meeting, concluding the events of a very educational and interesting day.
More to come next year, I’m sure.
7th March 2014: exciting prospect with an exciting new committee!
Annual Meeting 2012 Report
ST 6 Anaesthesia
NHS Greater Glasgow and Clyde
The second meeting of the Scottish Airway Group took place in Glasgow in March 2012 with a packed venue, all available places having been snapped up by attendees from a good variety of Scottish hospitals.
What did I learn at this meeting?
- Consider ketamine as the induction agent of choice for all trauma patients.
- Communication of the strategy for airway management to the whole theatre team is vital.
- Anaesthetists still have a lot to learn about Human Factors and how to improve patient safety.
Dr Mike Donald began the day by presenting an informative talk on the Trauma Airway, giving examples of pre-hospital care scenarios to scare most of the audience. The management of emergencies in pre-hospital care is well structured and planned, with the use of Standard Operating Procedures (SOPs) and predetermined strategies. Daily scenario rehearsals ensure good communication and relationships within the team.
The Failed Paediatric Airway was presented next, by Dr Alastair Baxter. He dazzled us with snazzy graphics and kept the audience interested (?frightened) with his discussion on emergency / difficult paediatric airways. He mourned the demise of Halothane with its properties which allow smooth rapid inhalational induction and is a TIVA enthusiast in children, a relatively new concept in paediatrics.
Dr Chris Frerk spoke after the morning coffee break to summarise the findings from the NAP 4 project. The recommendations made by the panel were broken down into his Top 5 to make the large project more digestible. He reiterated the importance of making strategies for airway management, the importance of capnography use outside the theatre environment and the important role 2nd generations supraglottic airway devices play in airway management. Dr Frerk concluded by reminding us of the importance of patient safety at all times, and recommended looking at the large NAP 4 project piecemeal.
Dr Alistair McNarry spoke next on topic of extubation, which seems to be a topic ever-increasing in popularity. He admitted that this may be an unglamorous topic, but pointed out that what goes in usually has to come out, and many of us admit to making no plan for extubation. He stated that anaesthetists tend to like to be prepared for all scenarios, so we should naturally include difficulties in extubation in our strategies.
Rumbling tummies everywhere signalled lunchtime. In the interest of giving a full report I attempted to sample all of the food on offer, and can report that the high standard of last year’s food was maintained Lunchtime gave an opportunity for all to socialise, eat and drink, and peruse the trade stands and posters.
The notoriously difficult post-prandial slot was filled by the trainee oral presentations, with varying topics on discussion. Simon Crawley and Pravan Raju represented NHS Tayside, while Naveen Kirodian presented findings from Aberdeen Maternity Hospital. NHS GGC’s Robbie Thorpe won the prize for best oral presentation, from a study done during his time with the EMRS.
Professor Mark Bellamy from Leeds then presented on The Obese Airway. Among the important learning points he made, he recommended the RAMP position for mask ventilation and laryngoscopy, with the sternal notch in horizontal alignment with the tragus of the ear. This helps improve airway control in the obese patient, which can be more difficult than intubation.
This presentation was followed by Team Resource Management by Captain Andy Rooney, chief pilot from Bond Air Services. He impressed the audience with the obvious appetite for training and safety systems in aviation. He outlined the well recognised overlap between aviation and anaesthetics with regard to the human factors influence in critical incidents, stating the importance of safety systems and training in both of these disciplines.
The last session of the highly successful meeting was the lively debate between Dr Ben Shippey and Dr Chris Frerk, arguing for and against the statement “This house believes that routine preoperative airway assessment is pointless”. The majority of the assembled anaesthetists voted overwhelmingly in favour of Dr Frerk. Very few abstained, and Dr Shippey was able to convince only 6 members of the audience with his argument.
This concluded another successful meeting from SAG, which was attended by consultants and trainees alike. We look forward to the 2013 meeting, which will be organised by Dr David Ball from NHS Dumfries and Galloway, who will undoubtedly be up to the challenge of maintaining the high standards set thus far.
Annual Meeting 2011 Report
Ninewells Hospital, Dundee
The inaugural meeting of the newly formed Scottish Airway Group took place at the Teacher Building, St Enochs Square in Glasgow on the 25th Feb 2010. It was the culmination of many months of hard work by the organising committee (Valerie Cunningham, Kevin O’Hare, Suzie Thomson) and was a very well attended and well-received meeting with a good mix of trainees and consultants from all over the country.
As chair of the local organising committee, Dr Valerie Cunningham, of the Institute of Neurosciences, had the honour of introducing the first session. She, after all, had put great effort into the meeting itself and therefore deserved a bit of the limelight. She got us started with a very warm welcome to the meeting and the introduction of, the always entertaining, Dr Barry McGuire, Consultant Anaesthetist from Dundee and the Chairman of the Scottish Airway Group.
Dr McGuire spoke first about the development of SAG, the concepts behind its development and some general plans for the future in regards to collaboration with airway training, research, airway fellowships and evaluation of equipment. There has been an excellent response from all over Scotland to the planned first meeting and regional contacts have been made in most Scottish hospitals. After much preamble, Barry got started on his views on “Algorithms and Airway Drills”. The failings of airway management and thus need for clear management pathways was highlighted with a great video starring some well known “gasers” from the West. He told us that 20% of closed claim analyses in the USA have references made to ASA guidelines by the defence so we might see our own DAS algorithms become a “medicolegal standard”. Since the introduction of the ASA guidelines, there has been a fall in claims in the US surrounding the induction of anaesthesia but we still have not seen similar falls in maintenance and extubation incidents. More work is required to address this, through advancement of technical and non-technical skills, more algorithms and revision of our present ones (are 4 attempts at intubation too many?). To achieve improvement we will need funding time to practice but in the meantime we should aim to “be prepared and communicate”. Wise words.
Barry was followed by the even more entertaining, Dr David Ball from Dumfries. He started by likening the management of the obstructed airway to “the art of war” and highlighted the size of the problem -1 death every 10 days. Not unusual for David, he took a philosophical approach to pre-oxygenation and suggested we do the same. He stressed the need for avoiding multiple attempts at airway intervention and discussed the many permutations of airway obstruction on the basis of site, severity, speed of onset, source and situation. The article Mason and Fielder on airway obstruction and the recent one by Patel et al on manual ventilation and neuromuscular blockade in tracheal stenosis (see on-line presentation for references) are worth a look. Other useful approaches are the use of the “awake look” with a fibrescope to assess the pathology and the increasing use of ultrasound guided pre-emptive cricothyroidotomy. It was a great lecture with many impressive photographs collected over the years.
The last talk before coffee had a trio of experts sharing their thoughts on tracheostomies. Barry McGuire was back again with an algorithmic approach to tackling the blocked or dislodged tracheostomy tube, Steven Cole then shared his knowledge on percutaenous tracheostomy in ICU and threw in some advertising for his locally run course (it is worth doing actually). Last of the three was Rodney “The Legend” Mountain, Consultant ENT surgeon with a wealth of experience, who gave us the surgical take on emergency awake tracheostomy and important surgical techniques that minimise complications. I am sure he could have talked for a lot longer on the subject than his allotted slot.
We broke for coffee and biscuits and had opportunity to speak to the representatives from the trade, Ambu, Cook and Intavent. It also allowed a great chance to catch up with old friends and colleagues and have a look at the array of posters presentations.
The second session was chaired by Dr Cole and kicked off with Dr Kevin O’Hare from Glasgow who showed us all his technique for an awake fibreoptic intubation using a recorded demonstration using one of his trainees. It was great to see another person’s technique as we all do these things differently and can always learn from others.
Dr Alasdair McNarry, an English Irishman from Edinburgh, followed with a high speed, enthusiastic and energetic talk on the new “trend” of videolaryngsocopy. It has been a tremendous development and has even got onto the new curriculum. However, is it the holy grail of intubation and is it as “safe as a Volvo”? He quickly showed us the vast array of optical stylets, channelled and non-channelled scopes and pointed out the very important point (and often criticism) that a great view does not always mean an easy intubation. There are many pieces of equipment available and a rapidly growing list of publications, but we still do not know which one is the best due to a disappointingly poor evidence base. This lecture also won the prize (not a real prize though) for what I thought was the quote of the day; “We are not laryngscopists, we are endotracheal tube inserters and airway maintainers”.
Dr Edgar from Glasgow tackled the subject of “Spinal Injuries”. He presented the evidence base on airway intervention and c-spine movement, stating that the former cannot happen without the later. There is minimal difference between the uses of various blades and even in-line stabilisation during intubation itself and the use supraglottic devices are associated with a degree of c-spine movement.
Lunch finally arrived and those travelling from Dundee were clearly the hungriest. Steve Cole had two cakes and Lynsey Foulds was the first to move on to the desserts.
Caroline Brookman chaired the first session with Willie Frame, an obstetric anaesthetist from Glasgow, beginning with a good story about sperm donation, despite this being an airway meeting! Obstetrics anaesthesia can be stressful and is becoming more difficult with the increasing size of the maternal population. The presence of “two patients” and the drive to meet delivery targets in Category 1 sections means anaesthetists can often feel pressured into administering general anaesthesia when there may potentially be airway difficulty. The airway is an ‘evolving beast’ and can not only change through the course of pregnancy (by up to two grades), but also through stages of labour. We should aim to communicate our concerns to our obstetric colleagues, assess patients early, institute early epidurals and have a plan for what we need to do if we need to intervene with the airway. The use of the ramped position, “stubby” handles and straight blades were all discussed.
Dr Gilmartin from the MDDUS followed up with a very informative and somewhat frightening talk on medico-legal implications of medical error. I think this made everyone a bit nervous so it was good to break away for a chat and another coffee break.
Trainee presentations took place after the break and everyone presented well. Dr Tanner from Stirling looked at LMA cuff pressures and inflation volumes comparing recommended values with a low volume alternative. Dr Ramanathan from the Southern General in Glasgow looked at Trucorp and Laerdal mannequins and their suitability for use in blind intubation via various supraglottic conduit devices. Dr Robertson, from the Western in Glasgow looked at airway assessment in bariatric surgery whilst Dr Gardner, the eventual prizewinner from Edinburgh, looked at improving communication with the primary care teams following difficult intubations. Well done to them all.
The last educational session of the day was led by Dr Al May and Dr Simon Edgar from the Scottish Simulator Centre. The increasing need for use of simulators as an adjunct to training is becoming clear and none more so than in airway management. The development of programmes looking at non-technical skills in anaesthesia looks to maximise learning opportunities making “everyday a learning day”. Well done to Matt Freer for letting us all give him feedback on his successful RSI (despite Suzie Thomson’s efforts to sabotage him).
The meeting closed with prizes for the best trainee presentations and an award for Dr John Henderson, a stalwart of Scottish airway management for many years, who has now retired. Lucky devil!! We wish him well.
Looking forward to seeing you all next March.