iPhoneIcon_BigThe outcomes from a Canadian questionnaire study of anaesthetists preferences in difficult airway management is disappointing. When faced with establishing an airway in cannot-intubate-cannot-ventilate scenarios, the majority would go for  seldinger- or needle-techniques ie one of the ready-made kits.

The study
A simple questionnaire study divided into three parts where 997 canadian anaesthetists are questioned about their practices in unanticipated difficult intubations and cannot- intubate-cannot-ventilate scenarios. Finally there are some questions about familiarity with the Difficult Airway Society Alogrithm.

In the section about unexpected difficult intubations the respondents are asked what airway devices they would use in an unexpected difficult intubation and what airway devices they have trained with or used. Finally they are asked to score their level of comfort in using alternative devices.

Im glad to see that 90% went for a video laryngoscope as their first-choice device. Only 4% would use a flexible bronchoscope and even fewer would go for an intubating laryngeal mask or an optical stylet. The majority had used or were comfortable with flexible bronchoscopes, video laryngoscopes and intubating laryngeal masks. Fewer were familiar with optical stylets and retrograde wire intubations.

In the CICV section respondents are asked how many CICVs they have encountered and in what situations. Then they are asked for what method of surgical airway they would use, if they have used any of the methods or devices for creating a surgical airway and their level of familiarity.

52% percent had encountered a CICV scenario at once or twice and 17% at least three times. Mostly in electives anesthesia. That is what we do most of the time after all. Then comes the scary part…

39% would use a wire guided cricothyroidotomy for a first-choice technique.
28% would use an intravenous catheter cricothryoidotomy
22,5% would ´defer to tracheostomy by surgeon´.
Only 9,9% would, themselves, perform an open surgical or scalpel-bougie surgical cricothyroidotomy….

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Between 20 and 13% of anaesthetists had used any of the techniques in real CICV scenarios.

Finally, only 78% were familiar with the 2003 ASA difficult airway guidelines while 66% where familiar the 2004 Difficult Airway Society Guidelines.

Take-home message
This is disappointing and surprising. Only 10% of anaesthetists say they would establish a surgical airway in a failed airway situation. It’s a Canadian study but I’m sure scandinavian anaesthetists wouldn’t fare any better.

The gold standard for securing a surgical airway in a CICV setting is to perform a scalpel cricothyroidotomy. While the numbers were low, NAP4 showed us how the percutaneous techniques i.e. the commercial ready-made kits had alarmingly high failure rates.

I am also concerned about the significant percentage that would defer the airway to a surgeon to perform a tracheostomy. I have seen that happen a couple of times. I have interviewed colleagues involved in those situations. The results have been disastrous.

Airway management, including establishing the surgical airway, is the airway doctor’s responsibility. Only she/he is likely to have a full understanding of what is at stake and what needs to be done. In a CICV situation we often have about 30 seconds to secure the airway. At least from the Scandinavian perspective, very few surgeons I know of are trained to establish an airway that fast. Few will grasp the seriousness of the situation. Besides, there sure aren’t any surgeons around everywhere airways are being managed.

Study lives here:
A survey of Canadian anesthesiologists’ preferences in difficult intubation and “cannot intubate, cannot ventilate” situations. Wong DT, Mehta A, Tam AD, Yau B, Wong J.
Can J Anaesth. 2014 May 28.  PMID: 24866377




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  1. nfkb0 says:


    i’ve to admitt that i do not know these guidelines but my first choice would be be a wire guided crico. I’ve already done it and it went well but i guess that’s not always straight forward… My second choice would go for a surgical access, i would start myself and call a colleague.

  2. My first was wire-guided

    Never again! The sympathetic surge made threading a wire almost impossible…

    Since then, its scalpel – finger – bougie – ETT all the way, baby…

    Having fiddled w Levitans cric-kife/key in cadaver lab, this will probably be the go to device when on market…although scalpel-finger-ETT is superbly tactile

    As for relying on the surgeon to ‘do a tracheostomy’! Ha! Would you let the obstetric reg ‘cut the throat’ in a CICO for your crash section? Hell, it’s all they can do not to cut the ureters….


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