1. Intensive Care NAP4 Major complications of airway management in the UK Royal College of Anaesthetists, 13 July 2011

2. NAP4 in ICUs 47% of ICUs had reporters 36 incidents reported (<20% of all incidents) – 18 deaths (50%) – 4 persistent neurological injury – 3 partial recovery – 9 full recovery Deaths and brain damage: Anaesthesia 14%, ED: 33%

3. If there were 48,000 patients ventilated during this time…

4. Relative rates: oversimplifying a complex issue…… Anaesthesia ICU ED Death 16 18 4 Death +BD 18 22 1 Denominator 2.9m* 48,000** 20,000*** Incidence 1:180,000 1:2,700 1:50,000 Relative death rate 1 x67 x36 RR death +BD 1 x70 x38 *NAP4 Census **HES ICU data 2008/9 *** Hopkinson/Benger EMJ 2010

5. Events Accidental extubation: – Tracheal tube: 5, 1 death Obese (BMI > 30): 3 On movement: 2 Known difficult airway: 2 – Tracheostomy displacement: 14, 7 deaths Obese patients (BMI > 30): 8 On movement: 5 Known difficult airway: 3 Previous difficulties with tracheostomy: 3

6. Events Failed intubation: 10 (+ 2 tracheostomies) – 3 in patients with recognised difficult airways Unrecognised oesophageal intubation: 4 Transfer: 3 Haemorrhage: 3 Miscellaneous: 3 Failed cricothyroidotomy: 3/5

7. Contributory factors: patients 19 were receiving invasive mechanical ventilation, 8 non-invasive 94% supplemental O 2 ; 35% had FiO 2 > 0.6 13 had other organ failure, 9 vasoactive drugs or RRT 47% occurred in patients with BMI > 30 kg/m 2

8. Contributory factors: equipment Capnography Tracheostomy design Difficult airway trolleys

9. Contributory factors: planning Time delay to intubation Unanticipated difficult intubation, re-intubation Unanticipated airway displacement/ extubation Unanticipated difficulty post extubation

10. Contributory factors: staff 46% of events took place out of hours Consultants were present for 58% of events (36% out of hours) Lack of advanced airway skills: increasing number of non-anaesthetists staffing ICUs Lack of experienced assistants e.g. ODPs

11. Recommendations Right practitioner Right training Right equipment Right preparation Right assistance Right location

12. Recommendations: capnography Capnography should be used for intubation of all critically ill patients Continuous capnography should be used in all ICU patients with tracheal tubes (including tracheostomy) who are intubated and ventilator dependent. Where this is not done the clinical reason for not using it should be documented and reviewed regularly.

13. Recommendations: capnography: letter to CEs Continuous capnography monitoring is used in all patients with tracheal tubes (including tracheostomy) that are intubated and ventilator dependent in all critical care areas. Trainee medical staff who are immediately responsible for management of patients on ICU need to be proficient in simple airway management. They need to have access to senior medical staff with advanced airway skills at all hours Has you Chief Executive received this letter? Has the risk manager acted on it? What changes are being made as a result?

14. Recommendations: teaching and training Training of all clinical staff who work in ICU should include interpretation of capnography. Teaching should focus on identification of airway obstruction or displacement. In addition, recognition of the abnormal (but not flat) capnography trace during CPR should be emphasised.

15. Recommendations: checklists An intubation checklist should be developed and used for all intubations of critically ill patients. A checklist might usefully identify preparation of patient, equipment, drugs and team.

16. Recommendations: algorithms Every ICU should have algorithms for management of intubation, extubation and reintubation. National efforts should be made to develop evidence-based algorithms. There should also be plans for management of inadvertent tracheal tube or tracheostomy displacement or obstruction.

17. Recommendations: planning Patients at risk of airway should be identified and clearly identifiable to those caring for them. A plan for such patients should be made and documented. The planning should identify primary and back-up plans.

18. Recommendations: obese patients Obese patients on ICU should be recognised as being at increased risk of airway complications. Responsible bodies should work with other stakeholders and manufacturers to explore design of tracheostomies for obese patients: – Can tracheostomy design be improved to reduce risk ofdisplacement? – Can the optimal mode of fixation be determined?

19. Recommendations Every ICU should have immediate access to a difficult airway trolley. This should have the same content and layout as the one used in that hospital’s theatre department and be checked regularly. A fibrescope should be immediately available for use on ICU.

20. Recommendations: failure of direct tracheal access Training of those engaged in advanced airway management should include regular, manikin- based practice in the performance of cricothyroidotomy. Research is actively needed to identify the equipment and techniques most likely to be successful for direct tracheal access in critically ill patients.

21. Recommendations: access to advanced airway skills Junior medical staff who are to be immediately responsible for management of patients on ICU need airway training. This should include – basic airway management, – algorithms for management of predictable airway complications – use and interpretation of capnography. Training should identify the point at which trainees reach the limit of their expertise,and mechanisms for calling for more senior help.

22. Recommendations: audit Regular audit should take place of airway management problems or critical events in the ICU.