Adverse effects associated with difficult airway management can be catastrophic and include death, brain injury and myocardial injury . Closed-malpractice claims have shown persistent and prolonged attempts at endotracheal intubation to be the most common situation leading to disastrous respiratory events . Difficult endotracheal intubations are more common in the emergency department (3-5.3%) than the operating suite (1.15-3.8%) [3-5]. The American Society of Anesthesiologists (ASA) recommends that all anesthetizing locations should contain alternative devices for lung ventilation and intubation as well as an end-tidal CO2 detector . However, recent surveys of English and American hospitals demonstrated considerable variation in the availability of difficult air-way equipment in emergency medicine departments [6,7]. To date, there has been no evaluation of the types of difficult airway equipment available in Irish departments of emergency medicine. The purpose of our survey, therefore, was to describe the difficult airway equipment available on site in Irish departments of emergency medicine.
All departments of emergency medicine in the Republic of Ireland stated in the Irish Hospital Directory as employing at least one dedicated Emergency Medicine Consultant were surveyed. The survey was carried out over a 2 day period in July 2002. The questionnaire was completed based on responses provided by the consultant or senior clinical nurse manager on duty. If the appropriate person was unavailable or did not have the information immediately to hand, a second telephone call was made at a later date.
All respondents were initially asked the annual attendance rate at their institution and then whether the following basic items of airway equipment were located within the actual environment of the emergency department:
- curved and straight laryngoscope blades,
- gum-elastic bougie,
- McCoy laryngoscope.
Alternative ventilation equipment:
- laryngeal mask airway,
- needle cricothyroidotomy kit,
Alternative intubation equipment:
- surgical airway device,
- retrograde intubation kit,
- intubating laryngeal mask,
- fibreoptic bronchoscope,
- lighted stylet.
We also asked if any of the emergency departments held
(a) end-tidal CO2 monitor,
(b) difficult airway trolley,
(c) any other airway device not mentioned in the questionnaire.
Of the 19 departments of emergency medicine contacted, all but one responded to our survey. In the last case, we were unable to contact the hospital despite multiple telephone calls. The results of the survey are summarized in Table 1. Annual attendance ranged from 22 000 to 66 000 cases. All of the departments of emergency medicine contacted held at least one alternative device on site for both lung ventilation and intubation. The most common alternative ventilation device was the laryngeal mask airway (89%). Of possible alternative intubating devices, only the surgical airway device was commonly available (100%). Only four (22%) of the emergency departments held either a retrograde intubation kit, intubating laryngeal mask airway, fibreoptic bronchoscope or lighted stylet.
Fifteen (83%) units stated that they had an end-tidal CO2 monitor available on site, while six (33%) held their difficult airway equipment in a specific difficult airway trolley.
The most important finding of this survey is that all the departments of emergency medicine, who took part in this study, held at least one alternative device for both lung ventilation and intubation. This finding is particularly significant given that the incidence of both difficult (3-5.3% vs. 1.15-3.8%) and failed (0.5-1.1% vs. 0.05-0.35%) tracheal intubation is higher in the emergency department than in the operating suite [3-5,8,9].
The finding that 100% of Irish emergency departments hold alternative ventilation devices compares favourably to national surveys carried out in England and the USA [6,7]. In England, 11% of emergency departments, who responded to the survey, contained no alternative device for lung ventilation, while in the American survey 21% of emergency residency programs had no alternative ventilating device.
The most common alternative ventilating device was the laryngeal mask airway, which was shown to be available in 16 (89%) of the departments of emergency medicine surveyed. The laryngeal mask is now a well-established alternative to bag-valve-mask ventilation and both the ASA and European Resuscitation Council [1,18] have advocated its use in emergency airway management. Moreover, it has consistently been shown that even after a brief training period, inexperienced personnel can become proficient in its use [10-12]. This is particularly relevant to a country, such as Ireland, where doctors who are expert in tracheal intubation may not be immediately available in the department of emergency medicine.
At present any fully registered doctor can work in departments of emergency medicine in Ireland. The Faculty of Emergency Medicine of the Royal College of Surgeons in Ireland introduced a higher training scheme in emergency medicine in 2001. There are no specific requirements for nurses working in emergency medicine; however, a non-mandatory critical care course is available.
In contrast to other countries [4,5], it is the anaesthetists who most commonly carry out emergency airway management in Irish departments of emergency medicine. An ongoing audit of endotracheal intubation performed in the Department of Emergency Medicine at the authors' institution shows that 85% of these intubations were carried out by anaesthetists and the remainder by emergency physicians with anaesthetic training (personal communication). We believe that this represents a pattern of practice common in many Irish departments of emergency medicine.
It is somewhat disturbing, therefore, to note that in 14 (79%) of the departments of emergency medicine surveyed, a surgical airway device was the only alternative ventilation device available. It is unlikely that anaesthetic personnel will be very experienced in the use of these devices. In contrast, only three (16.6%) emergency departments had an intubating laryngeal mask airway available. Studies have shown that the intubating laryngeal mask airway is a valid alternative device, for both lung ventilation and endotracheal intubation, with a high success rate - even for non-anaesthetic personnel [13,14] - and is associated with fewer adverse events than fibreoptic intubation . The intubating laryngeal mask airway has now begun to appear in recommendations for the contents of difficult airway trolleys . Due to their experience with the laryngeal mask, it is likely that Irish anaesthetists will be more successful in intubating a patient using an intubating laryngeal mask airway than with a surgical airway device. Furthermore, and because of the ease with which other healthcare personnel can be trained in the use of the intubating laryngeal mask airway [13-15], we feel that this is the best available option as an alternative intubating device in departments of emergency medicine. In light of new evidence regarding the intubating laryngeal mask airway, it is reasonable that older guidelines on difficult airway management, such as the ASA 1993 guidelines , should be updated.
It is not surprising that only one of the departments of emergency medicine surveyed had a bronchoscope on site as fibreoptic intubation is not recommended in an emergency. Quantitative data from capnometry are subject to misinterpretation , and capnometry may fail to confirm tracheal intubation during cardiac arrest as the end-tidal CO2 (ETCO2) may fall to zero . Nevertheless, end-tidal CO2 monitoring is recognized as an important tool in confirmation of correct tracheal tube placement, and it is widely recommended that an end-tidal CO2 detector is available wherever endotracheal intubation is likely to take place [1,16,18]. In our survey, ETCO2 monitors were available in 15 (83%) of the departments of emergency medicine surveyed. This is somewhat greater than recent surveys carried out in the UK, where availability ranged from 50% to 74% [6,19].
However, in the authors' experience these monitors are rarely pre-attached to monitoring equipment in Irish departments of emergency medicine. In an emergency, time may not be available to find and attach the monitors. We believe that prior placement of such devices in areas where emergency airway management is likely to occur would help to minimize any delay in identification of tracheal tube misplacement.
Only six (33%) of the emergency departments surveyed stated that they held difficult airway equipment in a portable storage unit. The storage of all necessary difficult airway equipment in such a unit has been advocated to ensure its rapid deployment to any area of the emergency department .
Irish departments of emergency medicine compare well with those of other countries as far as possession of difficult airway equipment is concerned. Nevertheless, we believe that this situation could be further improved by training inexperienced healthcare providers in the use of the laryngeal mask airway and intubating laryngeal mask airway, by placing greater emphasis on the ready availability of capnography and by the increased use of portable difficult airway storage units.
1. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology
2. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology
3. Crosby ET, Cooper RM, Douglas MJ, et al.
The unanticipated difficult airway with recommendations for management. Can J Anesth
4. Tayal VS, Riggs RW, Marx JA, Tomaszewski CA, Schneider RE. Rapid-sequence induction at an emergency medicine residency: success rates and adverse effects during a two-year period. Acad Emerg Med
5. Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med
6. Morton T, Brady S, Clancy M. Difficult airway equipment in English emergency departments. Anaesthesia
7. Levitan RM, Kush S, Hollander JE. Devices for difficult airway management in academic emergency departments: results of a national survey. Ann Emerg Med
8. Benumof JL. Management of the difficult adult airway. Anesthesiology
9. Rose DK, Cohen MM. The airway: problems and predictions in 18,500 patients. Can J Anesth
10. Davies PFR, Tighe SQM, Greenslade GL, Evans GH. Laryngeal mask airway and tracheal tube insertion by unskilled personnel. Lancet
11. Martin PD, Cyna AM, Hunter WAH, Henry J, Ramayya GP. Training nursing staff in airway management for resuscitation. A clinical comparison of the facemask and laryngeal mask. Anaesthesia
12. Yardy N, Hancox D, Strang T. A comparison of two airway aids for emergency use by unskilled personnel. The Combitube and laryngeal mask. Anaesthesia
13. Dörges V, Wenzel V, Neubert E, Schmucker P. Emergency airway management by intensive care unit nurses with the intubating laryngeal mask airway and the laryngeal tube. Crit Care
14. Baskett PJF, Parr MJA, Nolan JP. The intubating laryngeal mask. Results of a multicentre trial with experience of 500 cases. Anaesthesia
15. Langeron O, Semjen F, Bourgain JL, Marsac A, Cros AM. Comparison of the intubating laryngeal mask airway with fiberoptic intubation in anticipated difficult airway management. Anesthesiology
16. McGuire GP, Wong DT. Airway management: contents of a difficult intubation cart. Can J Anesth
17. Benumof JL. The American Society of Anesthesiologists' management of the difficult airway algorithm and explanation - analysis of the algorithm. In: Benumof JL, ed. Airway Management, Principles and Practice.
St. Louis, USA: Mosby - Year Book, 1996: 143-156.
18. de Latorre F, Nolan J, Robertson C, Chamberlain D, Baskett P, European Resuscitation Council. European Resuscitation Council Guidelines 2000 for Adult Advanced Life Support. A statement from the Advanced Life Support Working Group (1) and approved by the Executive Committee of the European Resuscitation Council. Resuscitation
19. Florance R, Griffiths R, Cope A. Capnography and 'major' accident and emergency departments in East Anglia. J Accid Emerg Med