Difficult airways: how can we mitigate risks in theatre?

Airway management is fundamental to anaesthetic care. Most of the time this is routine and all goes well, but in the rare cases it fails the consequences can be severe. A difficult airway is broadly defined as a situation in which we encounter difficulties managing a patient's airway with recognised techniques. Ideally, we can identify patients with difficult airways early. With proper assessment, communication and planning, we can mitigate the risks of airway problems prior to surgery. However, despite best efforts, unanticipated problems can arise, and, in those cases, time is critical and we may need to perform lifesaving procedures.

You may have heard of NAP4, a large-scale study of major complications of airway management published by the Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) in 2011, which has done much to help drive improvements in the last decade.1 More recent National Audit Projects (NAPs), in particular NAP7, and an HSSIB report about anticipated difficult airway care, have informed further improvements in airway management.² A big part of that is through education and sharing best practice, which is central to my role as National Airway Lead for the RCoA/DAS.

Firstly, we must remember that management starts with preoperative care. There are many risk factors that, if identified early, can be mitigated through appropriate, individualised care for each patient. Too often, after an event, we look only at what went wrong in the moment of crisis and not at the opportunities we may have had to prevent problems. For this reason, preoperative assessments and airway assessments are essential steps before planned surgery to inform us how we may make airway management safe.