This investigation looks into patient safety issues associated with airway management – the techniques used by healthcare professionals to help patients to get enough oxygen into their lungs, for example during surgery or a medical emergency. The reports findings, safety recommendations and safety observations are intended to help healthcare professionals quickly recognise whether someone has a potentially difficult airway and may need advanced airway management techniques to keep their airway open.
The investigation used as a reference event the case of Ethan who was taken to an emergency department (ED) by ambulance after his sister found him struggling to breathe and moving in a strange way. The ED staff thought that he was fitting and that this was likely caused by a lack of oxygen to his brain.
It was thought that Ethan may need to be intubated to help keep his airway open, but the procedure was predicted to be difficult because of his Hunter syndrome and severe obstructive sleep apnoea (a sleep disorder where the airway becomes blocked). Ethan was monitored for several hours and the risks of intubation versus managing his airway using basic airway management techniques were continually assessed.
To ensure the best possible conditions for a potentially difficult intubation, Ethan was taken to one of the hospital’s operating theatres. Intubation using a camera (videolaryngoscopy) was attempted but was unsuccessful. Ethan was given oxygen between consecutive
attempts at intubation. The difficult airway guidance was followed, and an emergency opening was created at the front of his neck so a tube could be inserted into his windpipe.
This was also unsuccessful. An on-call ear, nose and throat (ENT) consultant was contacted as the team was unable to intubate Ethan. Attempts at creating an airway using surgical techniques were unsuccessful and Ethan died.
Key findings from the investigation included:
- There is no nationally recognised system for sharing clinical information about people with a known difficult airway between primary, secondary, and tertiary care.
- There is no standard process for documenting and sharing an individualised airway management plan for people with a complex disease to all health care professionals and services involved in their care.
- Multidisciplinary team meetings to discuss the care of people with a complex disease and who have a known difficult airway are not happening consistently between primary, secondary, and tertiary care.
- Existing guidance for healthcare professionals on how to care for people who have a complex disease and may have a difficult airway is not always co-ordinated and consistent.
- There is currently no national standard for treating people with a known potentially ‘life threatening’ difficult airway who require advanced airway management.
- The requirement for additional skills, for example a head and neck specialist or ENT specialist, in emergency situations where a patient requires advanced airway management is challenging as 24-hour on-site ENT provision is not available in every hospital.
- Training and competency assessment in videolaryngoscopy is not standardised and there is variability in how and when videolaryngoscopy is used.
- Training and competency assessment for anaesthetists on airway rescue techniques such as emergency front of neck airway (eFONA) is variable.
- The design of equipment to support advanced airway management does not consistently include robust user testing at a national level to help identify and understand risks.
HSSIB made the following recommendations:
- NHS England identifies and implements a system for sharing clinical information about people with a known difficult airway. This is to improve access to this information for healthcare professionals and reduce the risk of a person’s known difficult airway not being recognised.
- The Royal College of Anaesthetists works with the Difficult Airway Society and other key stakeholders to produce a framework on the management of a potentially ‘life threatening’ difficult airway for people with a known difficult airway who require advanced airway management. This work should consider the adoption of a common language which defines and explains principles for treating people with a known potentially ‘life threatening’ difficult airway who require advanced airway management. This could optimise the chances of survival for people who experience a life-threatening airway emergency.
- The Royal College of Anaesthetists makes changes to its Guidelines for the Provision of Anaesthetic Services (GPAS) requirements for all anaesthetists, to include guidance on: requirements for anaesthetists to have access to videolaryngoscopes in all locations where anaesthesia is delivered and airway management takes place, requirements for all anaesthetists to be competent and skilled in the use of videolaryngoscopes; requirements for anaesthetists to be regularly updated on airway rescue techniques, such as emergency front of neck airway; requirements for anaesthetists and anaesthetic assistants to be regularly updated on other equipment that may be used in airway emergencies.
- The Royal College of Anaesthetists works with the Association of Anaesthetists and relevant key stakeholders to implement critical incident training for all anaesthetists and anaesthetic assistants. This should include consideration of scenario-based training and include the principles for the management of an expected or unexpected difficult airway using advanced airway techniques, including videolaryngoscopy and emergency front of neck airway.
HSSIB made the following observations:
- Healthcare organisations that commission elective (planned) surgical services for people with mucopolysaccharidoses (MPS) can improve safety by involving healthcare professionals from different disciplines who are experienced in airway evaluation and management, before, during and after a person’s surgery.
- Healthcare organisations could improve safety of the management of difficult airways by procuring equipment that has evidence of safety by design and robust user testing and assessment.
- Healthcare providers can improve patient safety by supporting and encouraging anaesthetic staff, anaesthetic assistants and operating department practitioners to become familiar with and experienced in the use of airway rescue equipment and techniques available locally, including videolaryngoscopy.