Friday, January 29, 2016
By Matthew Wiles MD.
Airway management is the foundation upon which anaesthesia is built. Fibreoptic intubation (FOI) has traditionally been a key method of securing the airway, both in elective and emergent situations1, although increasingly there are suggestions that FOI is being superseded by alternative techniques, most notably video laryngoscopy2, 3. This may reflect a general decline in the willingness of anaesthetists to undertake FOI as a routine part of their daily practice.
Airway management is the foundation upon which anaesthesia is built. Fibreoptic intubation (FOI) has traditionally been a key method of securing the airway, both in elective and emergent situations1, although increasingly there are suggestions that FOI is being superseded by alternative techniques, most notably video laryngoscopy2,3. This may reflect a general decline in the willingness of anaesthetists to undertake FOI as a routine part of their daily practice. An audit of the use of FOI in a large United Kingdom teaching hospital that was a tertiary centre for spinal, ENT and maxillofacial surgery, demonstrated that only 141 FOIs (61% awake, 39% asleep) were performed in a 12-month period4. This equates to around 1.2% of all tracheal intubations in that institution, and only 11% of the FOIs undertaken were done primarily for training purposes.
There are a number of potential reasons as to why anaesthetists may avoid performing FOI, especially when video laryngoscopes are now widely available. These include anxiety regarding the extra time needed to undertake the procedure, the potential to cause distress to the patient, fear of failure and/or complications and lack of operator confidence3. Concerns regarding failure and low confidence in the skill of FOI contribute to a vicious circle, as these are further compounded by a lack of practice. In addition, it has been shown that awake FOI can be done in between 3 to 7 minutes (although additional time is required for airway preparation)5, rates of vocal cord damage are comparable with direct laryngoscopy6 and patients questioned after undergoing awake FOI consistently report high levels of satisfaction7.
As experts in airway management, anaesthetists should be wary of allowing FOI to become a lost art. The fourth National Audit Project (NAP4) that examined the complications of airway management in the United Kingdom, identified a number of cases where awake FOI may have been advantageous over the selected technique of securing the airway under general anaesthesia8. Fibreoptic intubation is a difficult skill to acquire with a minimum of 10 required to gain basic competence9; however, extension of these learning curves suggest that true expertise may only be achieved after 45 FOIs10. This is of great interest, as anaesthetic trainees at the completion of their training have been shown to have done only a fraction of these numbers. Within the United Kingdom the majority of anaesthetic trainees do less than 10 FOIs prior to gaining consultant posts11. Similar results have been found in the United States of America with 65% of critical care fellows having undertaken less than 10 FOIs during their training; this was despite more than 50% of the training programs having a dedicated airway training rotation and 70% utilising simulation-based airway education12. This lack of exposure is probably a direct sequelae of the low rates of FOI undertaken in these countries, with both the United Kingdom and North America only undertaking FOI in around 1% of cases4,13. By way of comparison, a Swiss centre has incorporated FOI into daily anaesthetic practice resulting in a 12% FOI rate, with a significant number done primarily for training purposes14.
There will always be cases where FOI will be required in order to safely secure an airway, and as such, anaesthetists should be wary of allowing FOI to become a forgotten or occasional skill as has happened with other technical procedures. For example, since the advent of ultrasound guidance, there has been a deterioration in the ability of anaesthetists to use a landmark technique for placement of central venous catheters15. I am in full agreement with the conclusions of the FOI study completed by Heidegger et al.: “Only methods that are practised daily can be used successfully in emergencies”14.
Dr Matthew Wiles
Consultant in Neuroanaesthesia and Neuro Critical Care
Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, United Kingdom.
1. Apfelbaum JL, Hagberg CA, Caplan RA, et al. 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. Anesthesiology 2013; 118: 251-70.
2. Ahmad I, Bailey CR Time to abandon awake fibreoptic intubation? Anaesthesia 2016; 71: 12-6.
3. Fitzgerald E, Hodzovic I, Smith AF ‘From darkness into light’: time to make awake intubation with videolaryngoscopy the primary technique for an anticipated difficult airway? Anaesthesia 2015; 70: 387-92.
4. Wiles MD, McCahon RA, Armstrong JAM An Audit of Fibreoptic Intubation Training Opportunities in a UK Teaching Hospital. Journal of Anesthesiology 2014; 2014: 4.
5. Rai MR, Parry TM, Dombrovskis A, Warner OJ Remifentanil target-controlled infusion vs propofol target-controlled infusion for conscious sedation for awake fibreoptic intubation: a double-blinded randomized controlled trial. British Journal of Anaesthesia 2008; 100: 125-30.
6. Heidegger T, Starzyk L, Villiger CR, et al. Fiberoptic intubation and laryngeal morbidity: a randomized controlled trial. Anesthesiology 2007; 107: 585-90.
7. Sidhu VS, Whitehead EM, Ainsworth QP, Smith M, Calder I A technique of awake fibreoptic intubation. Experience in patients with cervical spine disease. Anaesthesia 1993; 48: 910-3.
8. Cook TM, Woodall N, Frerk C, Project obotFNA Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. British Journal of Anaesthesia 2011; 106: 617-31.
9. Johnson C, Roberts JT Clinical competence in the performance of fiberopt laryngoscopy and endotracheal intubation: A study of resident instruction. Journal of Clinical Anesthesia 1989; 1: 344-9.
10. Smith JE, Jackson APF, Hurdley J, Clifton PJM Learning curves for fibreoptic nasotracheal intubation when using the endoscopic video camera. Anaesthesia 1997; 52: 101-6.
11. McNarry AF, Dovell T, Dancey FML, Pead ME Perception of training needs and opportunities in advanced airway skills: a survey of British and Irish trainees. Eur J Anaesthesiol 2007; 24: 498-504.
12. Joffe AM, Liew EC, Olivar H, et al. A national survey of airway management training in United States internal medicine-based critical care fellowship programs. Respir Care 2012; 57: 1084-8.
13. Rose DK, Cohen MM The airway: problems and predictions in 18,500 patients. Can J Anaesth 1994; 41: 372-83.
14. Heidegger T, Gerig HJ, Ulrich B, Kreienbuhl G Validation of a simple algorithm for tracheal intubation: daily practice is the key to success in emergencies--an analysis of 13,248 intubations. Anesth Analg 2001; 92: 517-22.
15. Harber CR, Harvey DJR, Wiles MD, Bogod DG The ability of anaesthetists to identify the position of the right internal jugular vein correctly using anatomical landmarks. Anaesthesia 2010; 65: 885-8.
Competence in fibreoptic intubation: an essential skill or a dying art?