Comment from a senior American anesthesiologist about yesterday's post

The scenario sounds to me like the sinus infection had spread beyond the eye socket, perhaps downward into the pharynx (behind the tongue), making inserting a breathing tube more difficult, perhaps stirring up bleeding or pus, which would make visualizing the airway more difficult or impossible. If Ms Bromiley was overweight, the large tongue might make intubation difficult. With repeated attempts at intubation, the airway may become swollen. Awakening the patient before this point may have saved her; we have done this on occasion; inconvenient, but life-saving. Careful preoperative examination of the airway may have alerted the anesthesiologist to the precarious conditions present.

Actually, a tracheostomy is NOT the preferred treatment - this takes several minutes. A "cricothyrotomy" - a needle through a membrane, takes seconds, and the patient can be ventilated for a while before a better airway is established. We practice doing cricothyrotomy on dummies.

Of course, if the infection extends all the way to the throat, a tracheostomy or cricothyrotomy may not be possible. For such cases, a flexible fiberoptic device may enable the anesthesiologist to see around corners, and place the breatihing tube. Again, careful preoperative discussion between anesthesiologist and surgeons may make for better planning.

Here in the USA, we have a "difficult airway algorithm". See here

We drill our trainees (and ourselves) many times about these guidelines, on paper, with test questions, and on an electronic simulator (PC verson, and life size rubber dummy connected to a computer). This is standard practice here. This pilot would be stunned if he could see the level of our training on this issue. We have airway workshops where we can practice fiberoptic intubation on dummies, and we do it on patients as well. See here

Having a TV screen is a giant step forward (our institution is too cheap) - it allows the instructor to see what the trainee sees, and speeds up the teaching process.

ASA has close claims data, the best source of complications. I believe there has not been a case (or, more likely, too few to count) of airway disasters where a difficult airway has been diagnosed preoperatively; such cases alert the anesthesiologists to use more care or special methods (like fiberoptic). The most litigation is in emergency C-sections in (usually morbidly obese) where the airway is lost. This is why regional (spinal, epidural) anesthesia is so popular (but there are times and conditions where regional anesthesia is not possible. Hopefully, if intubation is abandoned after multiple attempts, the "cannot intubate cannot ventilate" scenario will never occur; if it does, surgical airway is a no brainer.

Pulse oximeters are a standard of care. When the oxygen in the skin drops, we are alerted that something must be done - NOW. One recently developed device is the Laryngeal Mask airway (LMA). This device allows maintaining an airway in a patient where the larynx cannot be visualized; it has been a lifesaver.

I had a recent emergency C-section in a fat lady where I couldn't intubate her. I could have maintained ventilation, but that would not protect her from vomiting and aspiration. All contraindications are relative; I used a LMA because I believed the small risk of vomiting and aspiration was less than the risk of airway obstruction from further attempts at intubation.

The anesthesiologist is normally in charge of the airway. If we must, WE request the surgeon to establish a surgical airway. The senior anesthesiologist is "in charge". Unfortunately, nervous surgeons may confuse the issue at times. I believe the British pilot would be pleasantly surprised at the level American doctors do such things. There is ACLS (advanced cardiac life support, both for adults and children); ATLS (advanced trauma life support) courses, exams, computer drills, ethc.

I am amused at nurses who claim an exclusive as "patient advocates". I am very proud what anesthesiologists have done to improbe patient safety. We are "patient advocates" as well. It was anesthesiologists who raised hell with hospital administrations to buy equipment to make anesthesia safer. Much of our improvement in safety has been with the initiatives of anesthesiologists, not Government mandates. When the Government demands better safety, then we must begin to worry.

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For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

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