A prospective, cohort evaluation of major and minor airway management complications during routine anaesthetic care at an academic medical centre

Postoperative sore throat negatively affects patient satisfaction and recovery. Numerous randomised trials have tested the efficacy of corticosteroids applied to tracheal tubes to prevent postoperative sore throat. We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Wanfang Database, and the China Academic Journal Network Publishing Database from inception to 7 December 2017. We included randomised controlled trials that assessed the efficacy and safety of corticosteroids applied to tracheal tubes, compared either with non-analgesic controls and analgesic agents, in adults undergoing elective surgery under general anaesthesia. We pooled the data using a random-effects model and assessed the risk of random error by applying trial sequential analysis. Our primary outcomes were postoperative sore throat 24 h after surgery/extubation, and adverse events. The evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. We included 20 randomised controlled trials involving 2200 patients. Compared with non-analgesic controls, corticosteroids applied to tracheal tubes were associated with a reduced incidence of postoperative sore throat, risk ratio (95%CI) 0.39 (0.32-0.49) (18 trials, 1506 patients). Two randomised trials reported no adverse events. Compared with lidocaine, corticosteroids applied to tracheal tubes were associated with reduced incidence of postoperative sore throat, risk ratio (95%CI) 0.42 (0.35-0.51) (nine trials, 706 patients). Trial sequential analyses suggested the presence of firm evidence that corticosteroids applied to tracheal tubes were superior both to non-analgesic controls and lidocaine, in preventing postoperative sore throat. Evidence for postoperative sore throat for both comparisons was assessed as high quality. Only two trials sought adverse events; none were recorded.

Section: Discussionmentioning

confidence: 87%

Topical application of corticosteroids to tracheal tubes to prevent postoperative sore throat in adults undergoing tracheal intubation: a systematic review and meta‐analysis

Kuriyama

Maeda²,

Sun

et al. 2018

“…In a prospective study, unanticipated difficulty in tracheal intubation occurred at a rate of 0.1% ; resolution of these difficulties was achieved with a videolaryngoscope in 52%, with fibreoptic intubation in 14% and with a combination technique in 10%. A Cochrane systematic review (64 RCTs, > 7000 patients, overall moderate quality evidence) reported numerous benefits of videolaryngoscopy vs. direct laryngoscopy for tracheal intubation .…”

Section: Avoiding Failed Tracheal Intubation and Its Sequalaementioning

confidence: 99%

“…Huitink et al. adopted a different approach, and attempted to capture all potential and actual significant airway events in a Dutch University hospital's operating theatre over a 60‐day period . Cases were identified by daily interviews with clinicians, being volunteered by clinicians and by triggered interviews when the anaesthesia information system detected an episode of oxygen desaturation (SpO 2 < 93%).…”

Section: Epidemiology Of Major and Minor Airway Eventsmentioning

confidence: 99%

Strategies for the prevention of airway complications – a narrative review

Cook

2017

132

SummaryDespite being infrequent, complications of airway management remain an important contributor to morbidity and mortality during anaesthesia and care of the critically ill. Developments in the last three decades have made anaesthesia safer, and this has been mirrored in the equipment and techniques available for airway management. Modern technology including novel oxygenation modalities, widespread availability of capnography, second-generation supraglottic airway devices and videolaryngoscopy provide the tools to make airway management safer still. However, technology will only take safety so far, and non-technical aspects of airway management are critically important for communication and decision making during airway crises, acknowledging a 'cannot intubate, cannot oxygenate' situation and transitioning to emergency front of neck airway. Randomised controlled trials provide little useful information about safety in this setting, and data from registries and databases are likely to be of more value. This narrative review focuses on recent evidence in this area.

“…In these cases, awake nasal fibreoptic intubation is still essential. However, awake videolaryngoscopy would be entirely appropriate in patients who were difficult to mask ventilate and in the obese, as complications are frequent in those with a higher body mass index . Indeed, one of the studies included in Alhomary et al.…”

Section: Making a Choicementioning

confidence: 99%

The emerging role of awake videolaryngoscopy in airway management

Wilson

Smith

2018

This editorial accompanies an article by Alhomary et al., Anaesthesia 2018; 73: 1151-61. Awake fibreoptic intubation has been considered the technique of choice when managing many types of predicted difficult airway. In principle, if a patient is maintaining the patency of their own airway, there is a margin of safety which is lost if general anaesthesia is induced before the trachea is intubated. Despite this, the Fourth National Audit Project of the Royal College of Anaesthetists (NAP4) reported that awake fibreoptic intubation was not used as the primary airway plan for many highrisk patients [1]. However, awake fibreoptic intubation is a complex skill requiring regular practice to maintain competence. It is easy to see how this potentially difficult task, performed on a high-risk patient group, in departments where numbers of awake fibreoptic intubations may be low, may pose a problem; and in consequence, it is understandable that an anaesthetist might opt for a more familiar, but less appropriate, technique [1]. It is of course also true that awake fibreoptic intubation is not suitable for tracheal intubation in all patients with airway problems, and it is not always successful; NAP4 demonstrated that it failed for a variety of reasons. Most commonly these were airway obstruction, lack of patient co-operation and difficulty recognising airway anatomy due to excess secretions, blood or suction failure [1]. Changing practiceThe NAP4 was published in 2011. However, anaesthetic practice is ever changing. In 2016, Ahmad and Bailey argued in this journal that awake fibreoptic intubation was becoming obsolete [2]. Later that year, reviewing the revised Difficulty Airway Society's (DAS) guidelines on difficulties in intubation, Marshall and Pandit suggested that "if it is essential to maximise the first attempt success rate, and if it is the case that videolaryngoscopes yield higher success in visualising the glottis, then it follows that these should become first-line devices in most if not all tracheal intubations" [3]. A Cochrane systematic review of videolaryngoscopy compared with direct laryngoscopy in adults concluded that "failed intubations were significantly fewer when videolaryngoscopy was used in participants with anticipated difficult airway." [4], although a similar review found no evidence of benefit in children [5]. In addition to this, the recent DAS guidelines on intubation in critically ill adults acknowledge the role of videolaryngoscopy [6], stating that "if difficult laryngoscopy is predicted then videolaryngoscopy should be considered from the outset". However, these publications deal largely with the management of intubation in patients who are anaesthetised. This month's issue of Anaesthesia presents a systematic review comparing awake videolaryngoscopy and awake fibreoptic intubation in patients with anticipated airway difficulty [7]. Using standard systematic review methodology, the authors included eight studies overall. One study could not be included in the quantitative meta-analysis,...