Patient safety
Difficult airways: how can we mitigate risks in theatre?
Dr. Sandeep Sudan, Consultant Anaesthetist at the University Hospitals Sussex NHS Foundation Trust, and Royal College of Anaesthetists/Difficult Airway Society Airway Leads Advisor, writes on the importance of preparation for difficult airways.
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
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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.
Being prepared 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.
An assessment enables us to identify risks,
develop an airway strategy and personalise it to the risks of the patient for potential airway difficulty and, just as importantly, aspiration risk. This plan needs to include the steps that should
be taken in different scenarios to maintain good gas exchange and prevention of aspiration. Hospitals should have an explicit policy for management of difficult or failed intubation and other airway emergencies and that should be incorporated into patient specific strategy. The DAS difficult airway guidelines are a valuable resource for such planning.3
Continued education Surgery is a collaborative process involving many people and airway management is a team game. Anaesthetists often lead the way, but help may be needed from others in emergency situations to deliver lifesaving skills. Teamwork is needed and good communication is key. Recently, there have been discussions for
airway management education and training to be made mandatory, something I personally would fully support. Training cannot be taken as a ‘one and done’ but as a continuing development of competency. From the most junior to the most senior person in the room, we all need to take regular training and practice. Teams that work together should train together
in both technical and non-technical skills so they can help each other in emergency situations, including managing difficult airways. An example might be practising airway rescue techniques such as emergency front-of-neck airway (eFONA) during regular multidisciplinary out-of- theatre airway workshops. With high pressure, low frequency procedures, such as these, skill fade can occur within as little as three months. The RCoA runs a series of airway workshops
that provide anaesthetists with the opportunity to obtain, maintain and enhance difficult airway management skills within a small group teaching environment. Other such courses run locally, up and down the country. Other learning methods include online courses, high fidelity simulation, low fidelity simulation (part task trainer), flash card simulation and tea trolley training; a combination is needed to remain up to date.4
The importance of a departmental Airway Lead An important development in education and sharing best practice has been establishing a
May 2025 I
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