Patient safety
Managing patients with ‘difficult airways’
The Health Services Safety Investigations Body’s latest report shows improvement is needed at a national level in the communication, preparation and planning for patients who may have ‘a difficult airway’. CSJ provides an overview of the key findings.
The Health Services Safety Investigations Body (HSSIB) has warned that improvements need to be made to tackle the safety risks around patients with difficult airways. An HSSIB investigation recently focused on situations where advanced airway management techniques are needed, for example intubation during planned surgical procedures or medical emergencies. HSSIB 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. In a report, published earlier this year, the HSSIB highlighted 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. The report set 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 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 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
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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 ENT consultant. The attempts were not successful, and Ethan suffered a cardiac arrest and sadly died. Analysis of Ethan’s case identified themes
that were then explored in HSSIB’s 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 HSSIB identified that there is currently no national standard for treating people with a known potentially ‘life threatening’ difficult airway. HSSIB 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 HSSIB made nine key findings under the following themes: communication and information sharing, airway guidance management, training, and competence in the use of advanced airway management and workplace culture and introduction of new technology. HSSIB’s report notes that advancement
in treatments for complex disorders like Hunter Syndrome mean that life expectancy is improving and, 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,
said: “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
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