Abstract:
Any quest to improve the quality and safety of airway management must start with an understanding and recognition of the problems, before addressing the solutions. I include in this thesis case reports, audits, clinical studies and bench studies which help to define some of the problems associated with airway management. Emphasis is placed on assessment, equipment, education and documentation. The studies, combined with two review articles, provide a platform for improvement. The successful delivery by an EXIT procedure of a newborn child with severe micrognathia was attributed to meticulous preoperative assessment of the airway, planning, provision of expertise and equipment. Preoperative airway assessment, however, has limitations. In our study of the dissemination of critical airway information, in only half of the patients with a difficult airway was this anticipated preoperatively. Poor technique in the assessment of airways is partly to blame. In a survey and meta-analysis of the thyromental distance test, ruler measurement, rather than finger breadth, increased test sensitivity three fold when predicting difficult intubation. While assessment and planning are important, the loop must be closed by robust dissemination of information concerning critical airways. Airway management equipment should be fit for purpose; practitioners should be knowledgeable in the correct use of that equipment; manufacturers’ instructions should be followed and equipment should comply with performance standards. These fundamental requirements were examined and important data concerning performance was discovered. An audit of airway management equipment in Auckland identified missing emergency equipment, expired and faulty equipment and poor quality control mechanisms such as inadequate checking of equipment. In this study I recommended the establishment of detailed equipment guidelines. The Australian and New Zealand College of Anaesthetists then published a guideline for equipment to manage the difficult airway during anaesthesia. The guideline was founded on principles such as standardisation, redundancy and a culture of safety. Finally, I include a review article in which I discuss the importance of education in airway management. This review highlights key components of simulation training, both in procedural skills and human factors. In the future, the trend is likely to be towards a greater emphasis on competency in medical education. It is likely that anaesthetists will be required to demonstrate competency in the management of difficult airways, not only during training, but throughout their entire professional lives. Improvements in the quality and safety of airway management are multifaceted. At the local level, improvements can be made by identifying problems such as faulty laryngoscopes and applying quality standards to effect change. Equally, improvements can be achieved globally by adding to the evidence that is required to establish practice guidelines. The findings presented in this thesis exemplify the impact of research on the safety of airway management.