IN this issue of Anesthesiology, investigators from different parts of the globe, Kitamura et al.1
from Japan and LeGrand et al.2
from the United States, assess the biomechanics of direct laryngoscopy in anesthetized patients. Regardless of their results, the mere presence of these articles is welcomed, in large measure because, directly or tangentially, both address one of the most disturbing problems in the delivery of anesthesia: managing the difficult airway. Indeed, airway loss is the basis of some of the most tragic patient outcomes in the entire practice of anesthesiology, and lawsuits related to airway loss yield some of the greatest payouts by defendants.3
Despite the focus of modern medicine to reduce the number of mishaps and improve outcomes, and the desire of organized anesthesiology to lessen the number of airway catastrophes, one can only wonder why we anesthesiologists, in the words of Kitamura et al.
still “lack fundamental knowledge of the mechanics of difficult laryngoscopy despite its clinical significance.”
In the past quarter of a century, we anesthesiologists have seen the introduction into clinical practice of fiberoptic scopes, laryngeal mask airways, intubating stylettes, light wands, a host of new laryngoscope designs, and percutaneous tracheotomy devices. Elsewhere, we have seen progressive efforts to improve practitioners’ application of those devices. Algorithms have been introduced to guide practitioners of all levels of experience in their assessment and care of difficult airway patients.4
Amusingly, these algorithms share with other treatment algorithms the quality of training
one to act properly, regardless of whether the practitioner is educated
as to the foundation reasons for the action.
If there is a major oversight in our ability to advance the science and practice of difficult airway management today, it rests largely with our failure to develop an appropriate, anesthesia-relevant language for the problem, amass the knowledge behind that language, and exercise both daily. Highly developed language allows us to more effectively describe, interpret, and store information, and develop solutions to problems. The more knowledge we gain, the more the language becomes nuanced and informative. Further, the relation between language development and knowledge is bidirectional: New language helps to describe new observations, but also new knowledge is sought when existing language proves inadequate. One need only examine the history of modern physics or the study of human immunodeficiency virus/acquired immunodeficiency syndrome or prion-related diseases to see that this is true.
Unfortunately, these concepts of language development are currently underused as we anesthesiologists study and clinically manage difficult airways. Instead, many of us remain locked in the crude language of “bag the patient,” “anterior larynx,” “small mandible,” and “big tongue,” and this coarse, undiscriminating language is costing us. Ask the typical laryngoscopist to discuss the effect of head positioning on Kitamura et al.
’s “submandibular space”1
or the meaning of LeGrand et al.
’s “maximal segment craniocervical motion,”2
and the expected response will be, “What?” But these failures of language unfortunately do not begin with the complex terminology of biomechanics. Hand a beginning or intermediate student of laryngoscopy a stack of pillows and ask her to place the supine patient in a “classic sniffing position,” and all too often one will be amazed at the results. Or read an anesthesia record describing a difficult or failed orotracheal intubation, and the description is often so lacking that the reader is left wondering whether the failure was the result of challenging patient anatomy, a less-than-ideal performance by the laryngoscopist, or both. Such deficient descriptions provide little guidance when preparing a more appropriate plan for the next intubation.
The language used to characterize and analyze problems directs us toward the language of problem resolution, and this can work to our favor or detriment. Indiscriminate, inaccurate language leads to miscommunication of core ideas from one practitioner to another, and—in medical care—miscommunication leads to inefficiencies and errors.5*
Despite this, we anesthesiologists have done little to develop utilitarian airway language, and, further compounding the problem, we have insufficiently borrowed from the language and knowledge of other specialties. However, we must recognize that borrowing language and concepts from others will not entirely solve our predicament, because other specialists do not place the same demands on that knowledge (and its language) that we anesthesiologists do. Our need to manipulate the human anatomy to safely secure an airway, and to do so in a manner that achieves secondary clinical goals (e.g.
, achieving ingress to the trachea through a passage other than the mouth; minimizing alterations in systemic physiology while performing airway management), are somewhat unique to the anesthesiology perspective. As such, our perception and understanding of airway anatomy and function will differ from that of the surgical oncologist asked to resect a head-and-neck cancer. Hence, we must conduct our own research (as Kitamura et al.1
and LeGrand et al.2
have done) so that the results address our special needs.
Once we develop appropriate language, we anesthesiologists and anesthesia educators need to be more active in teaching it to others. Here we have been horribly remiss. One of the greatest obstacles in teaching the language and concepts of airway management to our trainees results from the fact that we do not sufficiently exercise that language in daily scholarly discussions and, when the language has its greatest utility in addressing the high-risk airway, that teaching opportunity often finds the practitioner under considerable stress and focused on immediate technical success, not long-term understanding of the root cause of a problem. This, in turn, results from the fact that the greatest concerns about failed airway management do not envision the consequences of minor injury to a large number of patients, but instead a large amount of injury to a few patients.3
Because of the rarity of the best “teaching moments,” and the clinical exigencies that preclude one from actually stopping patient care to adequately teach, we cannot solely rely on the hit-or-miss experiences of patient encounters during a training program to optimally prepare our anesthesiology trainees. Instead, we need to expose them to the latest in education techniques, such as can be provided by instructional videos (using anatomical dissections, cinefluoroscopy, dynamic graphic illustrations, and so forth) and participation in simulation center instruction. If the costs of such resources prevent their development at all medical centers that have anesthesiology training programs, training program guidelines should encourage trainees to travel to resource centers where analytic, technical, and communication skills can be improved. Indeed, this model of having trainees travel is already used to more appropriately expose them to populations of special-needs patients (e.g.
, pediatric patients).
The concept of using language development and verbal communication to advance our specialty is nothing new. The American Board of Anesthesiology, in scoring candidates on oral examination performance, uses five criteria deemed “qualities and attributes which are fundamental to performance as a Board certified anesthesiologist.” One of these addresses the importance of communication: “Ability to communicate effectively about those issues of specific relevance to anesthesia care and also those topics of general medicine which are crucial to the care of patients with diverse diseases.”†
Indeed, the American Board of Anesthesiology has recognized that professionalism is not attained simply by being able to perform a task (e.g.
, anesthetic delivery, airway management); instead, we American Board of Anesthesiology diplomates must show some mastery of the language of the specialty, so that we can communicate effectively with other anesthesia providers, physicians from other specialties, and patients and their loved ones. Such mastery of language and effective communication help to distinguish the expert from the technician and are critical to the attainment of professional respect in the broader medical community.
In the context of anesthesiologists’ approach to dealing with the complex airway, we have all too often been accepting of the successes of the skilled technician, and we have often gotten away with this approach because—with proper preparation and the development of contingency plans—a technician’s approach has sufficed more often than not. This is largely because the failure of one approach to airway management typically does not preclude trying another and another from the operator’s “bag of tricks”6
until a solution is secured. However, such an approach is not ideal for advancing our understanding of the problems at hand or identifying broadly applicable solutions. Taking a more scholarly approach, whereby we are able to better verbalize our observations, analysis, and treatment plans, will provide many rewards, including improving our patients’ and other physicians’ faith in our abilities and professionalism.
In closing, we anesthesiologists need to demand that we and our trainees appropriately introduce and use the language of the difficult airway and understand its meaning, and we need to approach our educational mission as if life itself depended on our success. Because, in reality, for some complex patient at some future date, that will indeed be the case.
William L. Lanier, M.D.
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. firstname.lastname@example.org
1. Kitamura Y, Isono S, Suzuki N, Sato Y, Nishino T: Dynamic interactions of craniofacial structures during head positioning and direct laryngoscopy in anesthetized patients with and without difficult laryngoscopy. Anesthesiology 2007; 107:875–83
2. LeGrand SA, Hindman BJ, Dexter F, Weeks JB, Todd MM: Craniocervical motion during direct laryngoscopy and orotracheal intubation with the Macintosh and Miller blades: An in vivo
cinefluoroscopic study. Anesthesiology 2007; 107:884–91
3. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW: Management of the difficult airway: A closed claims analysis. Anesthesiology 2005; 103:33–9
4. American Society of Anesthesiologists Task Force on Management of the Difficult Airway: 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 2003; 98:1269–77
5. Shulman R, Singer M, Goldstone J, Bellingan G: Medication errors: A prospective cohort study of hand-written and computerized physician order entry in the intensive care unit. Crit Care 2005; 9:R516–21
6. Lanier WL: Improving anesthesia mask fit in edentulous patients. Anesth Analg 1987; 66:1053
* Computers may help fix doctors’ handwriting. USA Today. Available at: http://www.usatoday.com/tech/news/techinnovations/2003-09-23-dr-writing_x.htm
. Accessed September 10, 2007. Cited Here...
† The American Board of Anesthesiology: An overview of the certification process with emphasis on the oral examination. Available at: http://www.theaba.org/anes-initial.asp
. Accessed September 10, 2007. Cited Here...
© 2007 American Society of Anesthesiologists, Inc.