Summary We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with ‘predicted easy’ airways were rare (approximately 1 in 14,200), but 45 times more common in those with ‘predicted difficult’ airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high‐flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.

Fibreoptic-guided tracheal intubation using a supraglottic airway device as a conduit is a technique that can be used in anticipated and unanticipated difficult airway management. Although the i-gel â supraglottic airway device has been examined for this purpose, the LMA â Protector TM , a recently introduced secondgeneration supraglottic airway device, has not been evaluated for this use in clinical trials. This prospective, randomised clinical trial compared fibreoptic-guided tracheal intubation via i-gel and LMA Protector supraglottic airway devices in two UK hospitals. Patients who were ASA physical status 1 or 2 and undergoing elective surgery requiring tracheal intubation were recruited to the study. A block randomisation list was generated for each study site. The primary outcome measure was time to successful tracheal intubation and secondary outcomes were tracheal intubation success rate, glottic view through flexible fibrescope, ease of tracheal intubation using operator visual analogue score, supraglottic airway device insertion time and insertion success rate. Ninety patients were randomly allocated to each device, and final data analysis was carried out for 92 patients in the i-gel group and 86 patients in the LMA Protector group. Mean (SD) tracheal intubation time in the i-gel and LMA Protector groups were 54.3 (13.8) s and 52.0 (13.0) s, respectively (p = 0.240). There were no significant differences in tracheal intubation success rate, glottic view and ease of tracheal intubation between the two groups. This study demonstrates that the LMA Protector supraglottic airway device is comparable to the i-gel supraglottic airway device as a conduit for fibreoptic-guided tracheal intubation.

To address the problem of lack of clinical evidence for airway devices introduced to the market, the Difficult Airway Society (UK) developed an approach (termed ADEPT; Airway Device Evaluation Project Team) to standardise the model for device evaluation. Under this framework we assessed the LMA Protector, a second generation laryngeal mask airway. A total of 111 sequential adult patients were recruited and the LMA Protector inserted after induction of general anaesthesia. Effective insertion was confirmed by resistance to further distal movement, manual ventilation, and listening for gas leakage at the mouth. The breathing circuit was connected to the airway channel and airway patency confirmed with manual test ventilation at 20 cm H20 (water) pressure for 3 s. Data was collected in relation to the time for placement, intraoperative performance and postoperative performance of the airway device. Additionally, investigators rated the ease of insertion and adequacy of lung ventilation on a 5-point scale. The median (interquartile range [range]) time taken to insertion of the device was 31 (26–40[14–780]) s with the ability to ventilate after device insertion 100 (95% CI 96.7- 100)%. Secondary endpoints included one or more manoeuvres 60.3 (95% CI 50.6—69.5)% cases requiring to assist insertion; a median ease of insertion score of 4 (2–5[3–5]), and a median adequacy of ventilation score of 5 (5–5[4–5]). However, the first time insertion rate failure was 9.9% (95% CI 5.1—17.0%). There were no episodes of patient harm recorded, particularly desaturation. The LMA Protector appears suitable for clinical use, but an accompanying article discusses our reflections on the ADEPT approach to studying airway devices from a strategic perspective.

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iFRCA is a new iPhone examination application which aims to prepare the user for the FRCA examinations. It functions as a large database of questions based on popular exam topics, written by those who have recently passed the relevant exam, and is applicable to both the primary and final written papers. iFRCA has useful applications throughout all phases of exam preparation, from identifying areas that require the most initial focus, to applying finishing touches in the days leading up to the exam. The database currently stands at over 500 questions; the largest resource of Single Best Answer (SBA) questions among all comparable applications. It was the first app in the Apple store specifically geared towards the FRCA and is currently the highest grossing FRCA app. Customer reviews of iFRCA in the Apple store are also uniformly positive, with over 90% of users giving the app a maximum rating of five stars.The home screen displays several basic options with a simple and professional layout. 'Untimed revision' allows the user to proceed at their own pace, setting the number of SBAs or Multiple Choice Questions (MCQ) in the session to between 5 and 40 along with a choice of three main topicspharmacology, physiology and physics, which may be taken together or individually. Clinical questions relevant to the three basic sciences are included under each heading. A 'customised exam' mode allows the user to toggle between seeing the answers at the end of each question, or at the end of the entire session.'Mock exam' mode consists of 90 questions picked at random, answerable within a period of three hours. They cover all 3 topics and are split between 30 SBAs and 60 MCQs, closely resembling the conditions of the primary FRCA written exam. This is an extremely useful tool for preparing the candidate for the rigours of the examination, and will be invaluable during the final weeks of preparation.Each question has an attached 'rationale', which can be reviewed either after each question or at the end of the mock examination depending on the mode chosen. Generally well written, these focus the user on the salient points of the question, improving both knowledge and exam technique. The transition between question and rationale is accessible and well designed, allowing a rapid transition from a state of ignorance to one of understanding.Overall I have found the application an essential tool in preparing for the primary FRCA. I would highly recommend it to anyone taking the primary FRCA written paper, and also to those taking the final FRCA who wish to test exactly how much of their basic science knowledge remains.