PROVISION OF DIFFICULT AIRWAY EQUIPMENT AND TRAINEES

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PROVISION OF DIFFICULT AIRWAY EQUIPMENT AND
TRAINEES EXPERIENCE IN ITS USE in the theatre
suites and ITUsof the Northwest rotation

• Brendan McGrath
• Bhaskar Saha, Ken Peckett, Sophie Bishop

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Background

• Trainees rotate are exposed to a variety of
  difficult airway equipment.
• Familiarity in an emergency is an essential part
  of ITU anaesthetic training.
• The Difficult Airway Society guidelines.
• Techniques
• Equipment
• Various difficult airway situations

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DAS Guidelines 2004

• Recommended equipment for management of
  unanticipated difficult intubation.
• Adult, non obstetric.
• Equipment list compiled to facilitate techniques
  recommended.
• Includes equipment that should be available for
  routine airway management.

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DAS Recommendations

• The equipment immediately available in all
  areas where anaesthesia is administered.
• stocked in dedicated trolleys.
• All anaesthetists should be familiar with the
  contents and location of the trolley.
• Training should be provided in the use of
  equipment selected by each department.

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The list - essentials

• At least one alternative blade (e.g. straight,
  McCoy)
• Intubating Laryngeal Mask Airway
• ETT reinforced and microlaryngeal size 5 6mm
• Flexible fibreoptic laryngoscope
• Proseal LMA
• Cricothyroid cannula
• Surgical cricothyroidotomy kit

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The list alternative techniques of proven value

• Bullard type laryngoscope
• Trachlight
• Aintree Intubation Catheter
• Combitube

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DAS Guidelines for unanticipated difficult
intubation
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Cant intubate, Cant ventilate.
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The survey
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Methods

• We contacted the 18 hospitals throughout the
  Northwest rotation which trainees attend.
• Ascertained what difficult airway equipment was
  immediately available.
• Main theatre suite.
• ITU.
• Visited or telephoned clinical areas directly.

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What about the people using the kit?

• We also surveyed 60 of the regions trainees
• SHO year 2 and above
• Training received
• Experience acquired

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Results of equipment survey
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Theatre
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ITU
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Results of equipment survey

• Not all hospitals had a full compliment of
  difficult airway equipment.
• No trolleys, cricothyroidotomy kits, capnography
• Wide variety of equipment was available
  throughout the region.
• The provision of equipment was generally even
  sparser in the ITUs.

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Equipment feedback

• Often different theatre suites in same hospitals
  have different kit
• Usually sterile packaged single use

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Results of surveys of trainees experience
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Who we asked
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How many times had you ever used these various
laryngoscope blades?
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How many times have you ever used specialist
LMAs?
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Are you confident to use these LMAs
unsupervised?
Yes
Yes
No
No
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How many times have you been involved in
cricothyroidotomy?
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Are you confident to perform a cricothyroidotomy
unsupervised?
Yes
No
No
Yes
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What is your experience in performing an ITU
bronchoscopy?Have you ever been to a bronch list?
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Are you confident to perform an unsupervised ITU
bronchoscopy?
Yes
No
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How many times have you been involved in a
fibre-optic intubation?
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Are you confident to fibre-optically intubate?
No
Yes
No
Yes
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Summary of findings

• Most SpRs surveyed were experienced in core
  techniques
• Exposure to fibre-optic intubation and
  cricothyroidotomy training was very limited.
• Exposure to bronchoscopy and fibre-optic skills
  were limited.

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Conclusions - equipment

• Provision of difficult airway equipment in the
  hospitals of this region is not standardised.
• Some theatre suites and especially ITUs lack
  basic equipment altogether.
• This makes training difficult.

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Conclusions - equipment

• Rotating trainees can be left exposed in
  emergency situations.
• Lack of equipment
• Lack of familiarity
• Lack of training opportunities
• Lack of experience

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Conclusions - training

• Equipment issues need addressing to allow
  training.
• ILMA experience and confidence poor.
• Not all clinical areas have them
• Cricothyroidotomy training, experience and
  confidence was poor.
• Perc trachy experience good grounding
• Formal training?
• Make most of opportunities to practice

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Conclusions - training

• Bronchoscopy experience poor
• F.O experience also poor (anaesthetic skill?)
• Maximise use of Medical bronchoscopy lists
• Maximise ITU bronchoscopy exposure
• Practical courses (esp. non anaes trainees)

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In an ideal world

• All hospitals on rotation would have standardised
  kit
• All trainees familiar with its use
• Each department would have demonstration models
• Photographic instructions for use of that
  specific equipment in clinical area?