The Association of Anaesthetists has announced that new guidelines have been published which will help anaesthetists perform safer airway management for patients undergoing general anaesthesia.
The Association of Anaesthetists has announced that new guidelines have been published which will help anaesthetists perform safer airway management for patients undergoing general anaesthesia. In the UK, anaesthetists are responsible for delivering 3–5 million general anaesthetics each year. One of the primary goals of anaesthesia is to ensure an adequate supply of oxygen to vital organs, such as the brain. To do this, anaesthetists ‘manage the patient’s airway’ in a variety of ways – by holding on a face mask, placing a mask just over the opening to the lungs, or by passing a tube into the trachea (windpipe).
Some patients have airways that are difficult to manage for a range of reasons and in these situations managing the airway before being asleep (under general anaesthesia) is the safest thing to do. These new guidelines, the first of their kind worldwide, aim to encourage more anaesthetists to manage a patient’s airway before they have been anaesthetised. This technique, known as Awake Tracheal Intubation (ATI) is low risk and avoids the consequences of difficult airway management in an anaesthetised patient.
Difficult airway management is estimated to occur in 100,000 patients per year, and many patients are thought to die or suffer permanent brain damage because of complications in managing the airway. The ATI technique can reduce this risk. Despite the high success rate and safety profile of the ATI technique, it is often underused, often due to a lack of training, experience or confidence.
These new ATI guidelines aim to standardise the training and practice of this technique, benefitting thousands of patients a year who would otherwise be at risk of complications.
Published in the journal Anaesthesia, key recommendations of the guidelines include:
- Awake tracheal intubation must be considered in the presence of predictors of difficult airway management.
- A cognitive aid such as a checklist is recommended before and during performance of awake tracheal intubation.
- Supplemental oxygen should always be administered during awake tracheal intubation.
- Effective topicalisation must be established and tested. The maximum dose of lidocaine should not exceed 9 mg.kg−1 lean body weight.
- Cautious use of minimal sedation can be beneficial. This should ideally be administered by an independent practitioner. Sedation should not be used as a substitute for inadequate airway topicalisation.
- The number of attempts should be limited to three, with one further attempt by a more experienced operator (3 + 1).
- Anaesthesia should only be induced after a two-point check (visual confirmation and capnography) has confirmed correct tracheal tube position.
- All departments should support anaesthetists to attain competency and maintain skills in awake tracheal intubation.
Dr Kariem El-Boghdadly, Secretary of the guidelines group and Consultant Anaesthetist at Guy’s and St Thomas’ NHS Foundation Trust in London, said: “These new guidelines aim to make this important technique more available to all patients by providing direct guidance on how to safely manage at-risk patients. In the long-term we hope that this will improve the care of patients undergoing surgery anywhere in the world.”
Dr Imran Ahmad, Chairperson of the guidelines group, Consultant Anaesthetist at Guy’s and St Thomas’ NHS Foundation Trust and Honorary Secretary for the Difficult Airway Society said: “The Difficult Airway Society has a long tradition of producing guidelines that increase patient safety; we hope these guidelines will continue this tradition by encouraging anaesthetists to perform this technique when indicated and avoid potential complications in at-risk patients.”
To access the guidelines, visit: https://onlinelibrary.wiley.com/doi/10.1111/anae.14904
