Our investigation focused on situations where advanced airway management techniques are needed, for example intubation during planned surgical procedures or medical emergencies. We specifically looked at patients with a complex condition or diseases where it is recognised that they may have a difficult airway. In those cases, advanced airway management, for example tracheal intubation might be more difficult, and even the rescue strategies (should intubation fail) present more of a challenge.
The report highlights that risks to the patient are present during planned procedures but are further heightened if the patient requires advanced airway management in an emergency. Risks can range from injury or damage from the intubation (to teeth, lips, mouth, or nose) to airway trauma, brain injury and death if patients don’t get adequate oxygen.
Reference case
The report sets out the reference case of Ethan, a 12-year-old boy with Hunter Syndrome, a genetic condition that often affects the anatomy of the airway.
He was admitted to the emergency department (ED) after having a seizure at home. Staff had given him medication to control his fitting and had used basic techniques to manage his airway. They felt that he may need to be intubated to keep his airway open but predicted this would be challenging due to his Hunter Syndrome and severe obstructive sleep apnoea.
He was continually monitored and assessed in the ED and when his condition began to deteriorate, a decision was made to intubate him, and he was taken to an operating theatre to ensure the best possible conditions – more space and access to specialist equipment.
Attempts to intubate were made, including using a camera (videolaryngoscopy), emergency opening at the front of his neck to insert a tube into his windpipe and a surgical technique known as a tracheostomy by an ear, nose and throat (ENT) consultant. The attempts were not successful, and Ethan suffered a cardiac arrest and sadly died.
Themes for national learning
Analysis of Ethan’s case identified themes that were then explored in our wider investigation. His case highlighted where staff had followed available procedure and provided good care, and that there were opportunities for improvement and learning at a national level.
For example, staff had to follow guidance on an ‘unanticipated difficult airway’ and we identified that there is currently no national standard for treating people with a known potentially ‘life threatening’ difficult airway.
We also found that healthcare professionals working in primary, secondary and tertiary care may not have access to information that a patient may have a difficult airway.
Overall we made nine key findings under four themes:
- communication and information sharing
- airway guidance management, training, and competence in the use of advanced airway management
- workplace culture
- introduction of new technology.
Our report notes that advancement in treatments for complex disorders like Hunter Syndrome mean that people’s life expectancy is improving. As they live longer it is more likely they could require surgical procedures for complications of their disease. Therefore, the safety recommendations and safety observations are aimed at helping healthcare professionals quickly recognise whether someone has a potentially difficult airway and may need advanced airway management techniques to keep their airway open.
Nichola Crust, Senior Safety Investigator at the Health Services Safety Investigations Body (HSSIB), says: “Our investigation emphasises that in complex cases staff may not always have the system in place to support optimised care for advanced airway management. It is important that the right support is in place because often procedures that are normally routine become much more challenging.
“In Ethan’s case, the situation was life threatening and this was made more difficult because of his complex disease and the affect this had on the anatomy of his airway. We saw that this situation is incredibly distressing for patients, their families and staff involved in their care.
“Talking to and working with healthcare professionals, and national bodies that can influence change, we have developed safety recommendations and observations aimed at ensuring a robust system is in place to support effective communication and collaboration when it comes to more advanced airway management in people with an anticipated difficult airway.
“Specifically, there is a requirement for a robust 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. This will help to mitigate risks to any patient, but primarily for those who are most vulnerable when experiencing an airway emergency.”
Findings in full
- 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 ear, nose, and throat (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.
