Anesthesia providers have access to numerous valuable airway devices, but their effectiveness is limited by a lack of training. The problem of lack of training is compounded by an absence of institutional support and prevailing teaching theories.
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One of the anesthesia professional’s greatest concerns is a difficult airway. For this reason, the American Society of Anesthesiologists has developed and updated its difficult airway algorithm.1 Over the years, numerous devices have been developed to assist with the difficult airway, ranging from video laryngoscopy to optical stylets to intubation catheters. However, despite an array of techniques and device options, the incidence of difficult airway cases has not decreased. Based on a cross-sectional study published in 2017, the incidence of difficult laryngoscopy (obtaining a view of the vocal cords and glottis) remains at 12.3% and difficult intubation (successfully inserting a tube into the airway) at 9%.2 We suspect that the “difficult intubation” incidence may not only reflect the truly difficult anatomical airway, but also improper technique. For example, some anesthesia professionals may not be using new devices in an appropriate manner and this may lead to difficulties with securing the airway. Institutions should request tutorials from industry on training providers with the right technique of the new device. Without appropriate instruction and education regarding proper technique, some airway operators using these devices may transform a manageable airway into a difficult one.
Based on studies showing the superiority of new device options, anesthesia providers are eager to use this equipment, without necessarily the knowledge of proper technique or even reading the instruction manual.3–6 In 2016, the British Journal of Anaesthesia published an article referencing a hospital death after improper use of medical device equipment, which they said was associated with new equipment being used without sufficient instruction and training.7 Supporting this concept, a qualitative observational study identified errors and common difficulties in intubation by inexperienced providers and, unsurprisingly, one of the primary factors affecting failure was unfamiliarity with the equipment.7 Another review focused on advanced airway technology and highlighted the importance of an operator being experienced with the equipment to ensure success.8 Nevertheless, we suspect that complications and the failure rate associated with the use of variable airway devices may be underreported.
The primary documented airway device issues have been associated with the use of video laryngoscopes and exchange catheters.3 For example, many cases have been published regarding anatomic dislodgement with the use of video laryngoscopy causing vocal cord damage, tracheal injury, and hoarseness.9–11 Video laryngoscopy is a highly valuable method, but its design, especially regarding certain models, requires training for proper use. This need for thorough, hands-on education is at odds, however, with the prevailing apprenticeship teaching concept “see one, do one, teach one,” which emphasizes observation without adequate practice on manikins.”12 This instructional approach may also prevent improvement in the incidence of difficult airways by discouraging sufficient product education, resulting in providers who are not sufficiently trained to use devices.4,5 Similarly, in a large prospective study in 2011, the difficult airway algorithm was modified to include modern optical devices for use when conventional management fails; however, the authors noted that a limitation of their study was that the positive recorded outcomes associated with these instruments were dependent on complete device training.13
As anesthesia professionals, we have many valuable devices in our arsenal. However, we are still missing the mark. Adequate simulation training and device manufacturing service support are necessary to appropriately apply new devices to patient care. It is imperative that we focus on improved use of the advanced techniques already at our disposal.
Dr. Looper is a PGY-3/CA-2 Resident in the Department of Anesthesiology at the University of Florida College of Medicine, Gainesville, FL.
Dr. Peng is a Professor of Anesthesiology and Chief of the Cardiothoracic Anesthesia Division in the Department of Anesthesiology and Associate Professor of Surgery, University of Florida College of Medicine, Gainesville, FL.
Drs. Looper and Peng have no conflicts of interest to declare.
- Nickinovich D, Ovassapian A. Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. 2013;118:251–270.
- Workeneh SA, Gebregzi AH, Denu ZA. Magnitude and predisposing factors of difficult airway during induction of general anaesthesia. Anesthesiol Res Pract.2017;2017:5836397.
- Baker PA, Feinleib J, O’Sullivan EP. Is it time for airway management education to be mandatory? Br J Anaesth. 2016;117:i13–i16.
- Driver BE, Prekker ME, Klein LR, et al. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial. 2018;319:2179–2189.
- Kaji AH, Shover C, Lee J, et al. Video versus direct and augmented direct laryngoscopy in pediatric tracheal intubations. Acad Emerg Med.2019 Oct 16.
- Liu DX, Ye Y, Zhu YH, et al.Intubation of non-difficult airways using video laryngoscope versus direct laryngoscope: a randomized, parallel-group study. BMC Anesthesiol. 2019;19:75.
- Satyapal VM, Rout CC, Sommerville TE. Errors and clinical supervision of intubation attempts by the inexperienced.Southern African Journal of Anaesthesia and Analgesia. 2018;24:47–53.
- Healy DW, Maties O, Hovord D. Kheterpal S.A systematic review of the role of videolaryngoscopy in successful orotracheal intubation. BMC Anesthesiol. 2012;12:32.
- Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. 2011;114:34–41.
- Thong SY, Goh SY. Reported complications associated with the use of GlideScope® video laryngoscope – How can they be prevented? OA Anaesthetics. 2013;1:1.
- Curran C. Case report: oropharyngeal injuries with GlideScope® usage in two obese patients.Southern African Journal of Anaesthesia and Analgesia. 2016;22:30–32.
- Kotsis SV, Chung KC. Application of the “see one, do one, teach one” concept in surgical training. Plast Reconstr Surg.2013;131:1194–1201.
- Amathieu R, Combes X, Abdi W, et al. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrach™): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. 2011;114:25–33.