Cliff Reid of Resus.Me fame put out an incredible post on NAP4, the audit done on all of the airway complications in Great Britain. It was such a phenomenal post that I got in touch with Cliff and asked if he wanted to come on the podcast to speak about it. He did me one better and got an interview with one of the authors of the Emergency and Critical Care Section.
So in this podcast, we interview Dr. Jonathan Benger, professor of Emergency Medicine with a particular interest in the management of the airway.
Points that came out of the show
- Mortality is higher in the ED and ICU compared to the operating room. Our patients are sicker, so we must be more diligent in planning
- Quantitative wave-form ETCO2 should be the standard of care for EVERY ED and ICU intubation
- Needle cricothyrotomy seems to fail more often than surgical cricothyrotomy
- Awake intubation was not used when it was indicated
- Junior resident anesthesiologists were often responding to the ED and ICU
- There was a failure to plan for failure
- Obesity figured into a large percentage of the airway disasters
- Airway operators were not prepared or just did not properly progress to surgical airway
For more from the NAP4
Full Report (Skip to the EM/ICU Chapter)
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Great Conferences Coming Up
- Essentials of Emergency Medicine in San Francisco – November 9-12
- Emergency Medicine in the Developing World in Capetown – November 15-17
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Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Chief, Division of Emergency Critical Care
Director, Resuscitation and Acute Critical Care Unit
Stony Brook Medicine
Stony Brook, NY, USA
No conflicts of interest (coi).
Professor
Chief, Division of Emergency Critical Care
Director, Resuscitation and Acute Critical Care Unit
Stony Brook Medicine
Stony Brook, NY, USA
No conflicts of interest (coi).
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Thanks Scott and Cliff for the interview podcast. There are some good take home messages but I would suggest that you have to be careful drawing strong conclusions from an audit such as NAP4. Whilst it is a very praiseworthy effort in the field of airway management research, it does not compare standard techniques /procedures. If anything it compares different practitioners using a technique they call the same name. To conclude that needle cricothyroidotomy is inferior to surgical open cricothyroidotomy based on an audit of uncontrolled techniques by various levels of provider is a big assumption to make. What is… Read more »
Minh,
Some fantastic points. I would respond, but even more fun would be to tape a show where we debate the issue. Are you game? If not, then I will give written reply. I cannot comment on the peds issue. I never speak about peds, b/c I do not feel I am an expert on the issue. Any readers want to comment on that portion?
scott
Minh, Scott great points. I agree that you cannot conclude unequivocally that needle cric is inferior to surgical. I would argue, more importantly, that we will NEVER get that information. The only way to prove this is to complete a RCT comparing some standardized needle technique to surgical cric. With such a rare event and no realistic way to consent to treatment, NAP4 or versions of that study, will be the best we can get. This is even more pronounced in peds, as surgical airway is likely an even more infrequent event. I’m not sure I agree with the idea… Read more »
Hi Ram I know what you are trying to say. Perhaps in response I’d ask you review the following paper at http://www.scribd.com/doc/23508447/algorithm-for-cant-intubate-cant-ventilate This is published airway research and in Australia is the general approach that the anaesthetic community is increasingly adopting. IN fact it is as a result of similar airway related deaths mentioned in NAP4, within Australia that has led to such airway research and training within my country. You must have a simple strategy that gives you small range of options using simple gear and technique. Its true that if you have never trained to do a needle… Read more »
Minh,
Fantastic paper, but I read the conclusion very differently. We can discuss this during our debate, but it seems this paper is a ringing endorsement of bougie guided cricothyrotomy.
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Hi all I would say that every doc who does any sort of anesthesia – ED or OT should be drilled in a simple, reliable technique for surgical airway. Imagine a pilot who never trained to land off the normal runway! My bias, based on many brown-trouser situations is: scalpel, bougie then a smallish (6 – 6.5) cuffed tube. Use the equipment you know, keep it simple stupid ( the least neurons required the better) As for kids – very rare in “normal” kids – the anatomy is the same. Usually less fat. I would not change or have a… Read more »
Thanks Scott and Casey for your comments Kids laryngeal anatomy is not the same as an adult. the cricoid cartilage is only partly formed depending upon the age and the membrane is smaller. SOmetimes there is more fat in the neck. I agree with keeping things simple and using the gear you have. No argument there. However I think it is only half the story. Keeping things simple does not mean in stressful situations people will make the simple decision you hope they will. explain why in the Bromiley case three doctors including a surgeon in an elective anaesthetic case… Read more »
Hi Scott et al
I have managed to track down dr Heard and he is happy to answer some written Qs. I will post it at Broome Docs when I can.
I’ll let you know if he is up for an interview.
Interestingly he is a bit critical of some of the recommendations to come out of NAP4. Should make for a lively debate
Casey
I look forward to a debate on crichothyrotomy methods. I have seen several cases of medical personnel unfamiliar and/or uncomfortable with procedures hesitating, leading to less than ideal outcomes. I would expect this to be a problem with non-surgical crichothyrotomies, as well. Perhaps that is one of the reasons for the low success rate with the non-surgical crichothyrotomies. For capnography, I think that we need to stress that CONTINUOUS waveform capnography is essential. Too many people act as if there is no beneficial information to be obtained from continuing to monitor waveform capnography. I don’t believe that any of you… Read more »
great comments! especially regarding the absolute necessity of continuing waveform monitoring so long as the patient has the ET tube in.
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