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Tracheal Intubation Guidelines

We are used to lines that guide – from those that keep our words straight on the page to those that direct planes down runways or trains along tracks. Moving from lines that guide our direction to guidelines that direct our behaviour, particularly in clinical medicine, is a very exciting time.

The science of anaesthesia (from the Greek an– and aisthēsis meaning “without feeling”) has facilitated rapid advances in surgery that have allowed the treatment of disease and suffering from hip replacements to liver transplants. Anaesthetists are frequently compared to airline pilots. Pilots are responsible for guiding travellers safely from one place to another; anaesthetists are responsible for guiding their patients safely though surgical procedures. There are other similarities too; flying and administering anaesthesia are essentially very safe and both professions are known for their safety culture. Just as the general public has a right to expect that their pilots perpetually strive to make air travel safer, patients can rest assured that anaesthetists are always working to make anaesthesia safer.

This week, a working party of the Difficult Airway Society published guidelines in the British Journal of Anaesthesia to help anaesthetists deal with a rare event that can harm patients. When a patient is having a general anaesthetic, the anaesthetist must help the patient with their breathing by keeping their airway clear for the administration of oxygen. Whilst in most situations this is straight forward, there are certain unforeseeable situations which can make this challenging.

The guidelines are an update to the original version published 11 years ago and represent the bringing together of published science, a recent massive project looking at how well airways are managed across the UK, and an understanding by the group that a cohesive and deliverable strategy was required in the emergency setting to provide best patient care. The guidelines take into account the numerous ways by which an anaesthetic procedure can be performed and address how human factors might influence performance in a crisis- an impact that can affect everyone from the most senior member of staff to the most junior.

Illustration by Christopher Thompson (via BJA)

The science involved the review of over 7,000 abstracts related to tracheal intubation. That information was sifted and collated to generate a cohesive system of steps that assist the anaesthetist and direct the focus of care to the oxygenation of the patient. The guidelines even allow for the patient to be woken from anaesthesia without having had surgery should oxygenation prove challenging. Whilst this may seem strange or even unfair to some, think of it like the airline pilot who abandons take-off after starting the engines because of some previously unknown fault. I think the majority of us can see how a safety-first approach is so vitally important.

The author group is aware that there are perpetual advances in medicine and whilst they acknowledge that it is impossible to predict the future, the guidelines also provide questions to ask of new technologies that may just be becoming available or may have yet to be invented. This gives anaesthetists a way of considering how developments in anaesthetic practice and equipment provision might be adopted into the guidelines whilst maintaining the primacy of patient oxygenation.

What do the guidelines offer the non-anaesthetist? They take the complex subject of tracheal intubation and airway management and ask a simple question- what should I do if the plan I had made doesn’t work?

This series of plans (a strategy) all focused on achieving the same outcome but accepting that any part of the plan may fail can be applied to many areas of anaesthesia, medicine generally, and to complex procedures in many environments- although obviously the steps will be different!

When we take the train, we are confident that the lines (or tracks) will guide us safely to our destination. In the same regard, we hope that the updated guidelines for anaesthetists will make their patients’ journeys through surgery even safer and will provide reassurance to patients everywhere that should a difficulty occur with their breathing after the induction of anaesthesia, their anaesthetist will have a strategy to handle it.

Featured image: Track by Monsterkoi. CC0 Public Domain via Pixabay.

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