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Leadership and teaching in airway management

In this issue of the Journal, Howard et al. report on a survey on the use of guidelines for the management of the unanticipated difficult airway in Southwestern Ontario. Their results raise important questions and draw attention to organisational and educational factors related to airway emergencies preparedness. Failed airways do happen in our country. The true incidence is uncertain as retrospective data do not account for ‘‘near miss’’ situations and potentially underreported complications. Closed claims analyses in Canada and the United States have shown that, although adverse events did occur among patients without obvious predictors for a difficult airway, pre-induction airway assessment was often incompletely recorded. In many cases, algorithms were not planned and front of neck airway access (FONA) was implemented too late. The large-scale 4 National Audit Project (NAP4) had already drawn the same conclusions ten years ago in the United Kingdom (UK). There is still room for improvement in our capacity to prevent airway-related brain injury and death. Airway management is one of the few moments in anesthesia where our actions will directly impact the outcome. This is one contributing factor to the stress imposed during an airway emergency. Having clear, pre-emptive, and proactive strategies for difficult airways is one measure to mitigate stress and maintain performance under such pressure. Various organizations such as the Canadian Airway Focus Group (CAFG), the American Society of Anesthesiologists (ASA) and the Difficult Airway Society (DAS) have published difficult airway algorithms to address this need. Guidelines from other organizations and/or addressing specific situations on the same topic have flourished in recent years. That may have contributed not only to the awareness of the necessity for an airway strategy but also to some confusion among airway practitioners. Howard et al. found that among consultant and trainee anesthesiologists of the London (Ontario) academic centre, the CAFG recommendations were the most popular. Yet, these did not reach the network of smaller community-affiliated hospitals where only the ASA guideline had been formally adopted. Limited translation of clinical guidelines into practice is a known challenge highlighted by Howard et al. They suggest that, as opposed to the ASA and the DAS guidelines, that a lack of formal endorsement by a society contributed to the limited dissemination and adoption of the CAFG recommendations in Southwestern Ontario. We suspect that the same could be observed in the rest of Canada. The eventual endorsement of airway guidelines by a national organization such as the Canadian Anesthesiologists Society (CAS) would certainly weigh on their implementation among its members and other airway practitioners. The CAS has a definitive clout in anesthetic practice across our country. Over 45 years ago, in 1975, it adopted the very first Guidelines for Standards of Practice—the first guidelines by any anesthesia society. Today, through frequent updates, the CAS’ Guidelines to F. Lemay, MD (&) Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11 Côte du Palais, Quebec City, QC G1R 2J6, Canada e-mail: francois.lemay.5@ulaval.ca

In this issue of the Journal, Howard et al. report on a survey on the use of guidelines for the management of the unanticipated difficult airway in Southwestern Ontario. 1 Their results raise important questions and draw attention to organisational and educational factors related to airway emergencies preparedness.
Failed airways do happen in our country. The true incidence is uncertain as retrospective data do not account for ''near miss'' situations and potentially underreported complications. Closed claims analyses in Canada and the United States have shown that, although adverse events did occur among patients without obvious predictors for a difficult airway, pre-induction airway assessment was often incompletely recorded. 2,3 In many cases, algorithms were not planned and front of neck airway access (FONA) was implemented too late. The large-scale 4 th National Audit Project (NAP4) had already drawn the same conclusions ten years ago in the United Kingdom (UK). 4 There is still room for improvement in our capacity to prevent airway-related brain injury and death. Airway management is one of the few moments in anesthesia where our actions will directly impact the outcome. This is one contributing factor to the stress imposed during an airway emergency. Having clear, pre-emptive, and proactive strategies for difficult airways is one measure to mitigate stress and maintain performance under such pressure. Various organizations such as the Canadian Airway Focus Group (CAFG), the American Society of Anesthesiologists (ASA) and the Difficult Airway Society (DAS) have published difficult airway algorithms to address this need. [5][6][7][8] Guidelines from other organizations and/or addressing specific situations on the same topic have flourished in recent years. 9 That may have contributed not only to the awareness of the necessity for an airway strategy but also to some confusion among airway practitioners. Howard et al. found that among consultant and trainee anesthesiologists of the London (Ontario) academic centre, the CAFG recommendations were the most popular. Yet, these did not reach the network of smaller community-affiliated hospitals where only the ASA guideline had been formally adopted.
Limited translation of clinical guidelines into practice is a known challenge highlighted by Howard et al. They suggest that, as opposed to the ASA and the DAS guidelines, that a lack of formal endorsement by a society contributed to the limited dissemination and adoption of the CAFG recommendations in Southwestern Ontario. We suspect that the same could be observed in the rest of Canada. The eventual endorsement of airway guidelines by a national organization such as the Canadian Anesthesiologists Society (CAS) would certainly weigh on their implementation among its members and other airway practitioners. The CAS has a definitive clout in anesthetic practice across our country. Over 45 years ago, in 1975, it adopted the very first Guidelines for Standards of Practice-the first guidelines by any anesthesia society. 10 Today, through frequent updates, the CAS' Guidelines to the Practice of Anesthesia still support anesthesiologists in promoting and providing safe patient care in their own institutions. 11 Airway guidelines certainly adhere to those same goals.
Howard et al. reported that only half of trainee anesthesiologists considered themselves adequately trained for difficult airways. This statement is difficult to interpret because, despite numerous options and tools mentioned in the National Curriculum Guide for Canadian Anesthesiology Residency from the Royal College of Physicians and Surgeons, 12 there is no other consensus, guidance, or discrete definition of what constitutes readiness for difficult airways. Trainees must not only learn how to perform FONA and rescue tracheal intubation through extraglottic devices but also have the capacity to handle a comprehensive array of options and adjuncts to maintain oxygenation while establishing priorities and being able to deal with human factors, contextual issues, and ethics during an airway crisis. This cannot be achieved simply by attending training courses. Trainees must be given the opportunity to practice and demonstrate their skills. 13 Simulation labs have substantially helped creating those opportunities and clinical airway rotations aim at enhancing those skills. The Entrustable Professional Activities for Anesthesiology recommends to collect observations from a large breadth of both anticipated and unanticipated difficult airway with the expectations not all will be achieved, with a minimum of six observations of achievement in a clinical setting. Those six observations do not confirm competency in awake intubation, for example, where the number required to achieve proficiency only with a flexible scope is considered more than three times higher. 14 Crosby and Lane have thoroughly shown the challenges in airway training in Canada back in 2009. 15 In the light of the results reported by Howard et al., many of the reflections and solutions Crosby and Lane had proposed continue to be relevant. This could serve as an opportunity for anesthesiologists involved in airway education to survey once again training across the country and discuss their airway curriculums. At our institution, we have recently revised our airway teaching program to ensure that essential airway techniques are taught to our residents. We have limited our references to recommendations to those from the CAFG and the DAS to ensure consistency. We have increased the accessibility to airway workshops to promote contextual learning and resource management training, while having a dedicated airway rotation and an otorhinolaryngology rotation. Residents from other programs such as Critical Care and Emergency Medicine have been included in our workshops. The Table lists, as an example, the airway workshops we offer to anesthesiology residents throughout their training. We still have to measure the long-term impact of this training on our graduates regarding their confidence in managing difficult airways.
Forty-three percent of respondents of the survey by Howard et al. never practiced FONA and only 13% did so within the last year. This potentially explains why only 18% of consultant and 7% of trainee anesthesiologists reported that they were confident with scalpel cricothyroidotomy. Emergency FONA is a rare event, happening only once in every 50,000 general anesthetics. 4 Therefore, the ability to timely and adequately perform FONA is mostly gained through training. Frequent learning opportunities are required to promote skill mastery and long-term retention. 16 This relies once again on hands-on workshops.
The National Curriculum asks anesthesiologists to demonstrate a working knowledge of surgical options for emergency airway management. The anesthesiologist must demonstrate knowledge of the use of at least one cricothyrotomy kit or approach (minitracheostomy, cricothyrotomy, jet ventilation). FONA should be feasible in any location where airway management occurs. Added to the risks of jet ventilation in ''can't intubate can't oxygenate'' emergencies and the benefits of standardizing such a procedure, 17 we have made the decision for our institution's airway curriculum to teach only the scalpel-bougie-tube technique promoted by the DAS. 7 In our most recent survey on our FONA workshop, residents from Anesthesiology and Emergency Medicine provided positive comments on its structure and its perceived impact to improve skills in surgical cricothyrotomy.
Narrative comments from the participants highlighted the importance of performing the procedure many times. Once again, we still have to measure the long-term impact of such training on residents; we intend to implement regular rehearsals of the FONA technique for consultants and operating room staff.
Finally, Howard et al. mention the fruitful implementation of an Airway Leads network in the UK following the publication of the NAP4. Airway Leads is endorsed by The Royal College of Anaesthetists and advocates for organizational strategies in airway management at local and national levels. 18 The Australian and New Zealand College of Anaesthetists, through its Airway Management Special Interest Group, does so with its Airway Leads network. In Canada, other than the CAFG, there is no national airway interest group or formal Airway Leads network. We have not heard of any at the provincial level either. This is unfortunate, and the ongoing COVID-19 pandemic illustrates a concrete example of the importance of networking and collaboration in airway management. Particularly at the beginning of the pandemic, there was a need to share protocols regarding personal protective equipment for airway management in COVID-19 patients. Early information sharing was mostly done through personal communication and social media without dedicated channels. At the same time, COVID-19 airway management protocols were being developed through local organizations, which were not necessarily consistent with the recommendations eventually published by the CAS. 19 Had it existed prior to the pandemic, a Canadian airway network could have promoted efficient leadership and expertise in airway management at both local and national levels during this time.
Anesthesiologists are considered airway experts by definition. Interestingly, in Canada, airway management has not been the specific focus of traditional interest groups such as those for regional and obstetric anesthesia, which, among others, are formerly hosted as distinct Sections within the framework of the CAS. Anesthesiologists must assume leadership in airway management organization and reach airway practitioners from other specialities. One step in this direction could be the networking of airway leaders in this country, formerly hosted within a section of the CAS which would welcome anesthesiologists with a particular interest in airway management. Such an Airway Management Section could nurture development, knowledge, and teaching of airway management strategy and techniques among its members. It could also link with other societies and the CAFG. This would contribute to and support the latter three-decadesold effort at promoting safe airway management in Canada.