Lost in transition: the challenges of getting airway clinicians to move from the upper airway to the neck during an airway crisis

Abstract

Technical and psychological factors make performance of an emergency front-of-neck airway (eFONA) a challenging procedure for clinical teams involved in airway management. When 'cannot intubate, cannot oxygenate' (CICO) emergencies occur, eFONA is frequently performed too late or not at all. The concept of transition to eFONA comprises simultaneous efforts to prevent and prepare for eFONA before a declaration of CICO in an effort to facilitate its timely and effective implementation. Although such a transition represents an appealing idea, attention to many aspects of airway practice is required for it to become an effective intervention.

Data and debriefing observations on healthcare simulation to prepare for the COVID-19 pandemic

“…Next, two scenarios for known COVID-19 patients were run simultaneously for two different teams. One case required the team to transport an intubated patient to the operating room, and the other case was a difficult emergency airway where the patient cannot be intubated or oxygenated requiring an emergency surgical airway[ 9 , 24 , 25 ]. These cases were debriefed for CRM concepts[ 22 , 23 ] and then new protocols for patient transport and emergency airway management were discussed and suggestions made for revisions.…”

Lost in transition: use of SpO2 in the Australian and New Zealand College of Anaesthetists transition tool. Comment on Br J Anaesth 2020; 125: e38–46

“…EditordPrecapillary pulmonary hypertension (PH) is defined as a mean pulmonary artery pressure (mPAP) 25 mm Hg at rest coupled with a pulmonary capillary wedge pressure (PCWP) 15 mm Hg and an elevated pulmonary vascular resistance (PVR) >3 Wood units (WU). 1 A high risk of perioperative morbidity and mortality is observed after noncardiac and non-obstetric surgery. Retrospective studies including small samples have reported a complication rate of 6e42%, 2e7 and a mortality rate up to 18%.…”

“…EditordChrimes and colleagues 1 are to be congratulated for their article on transition emphasising the simultaneous attempts to avert and prime for an emergency front-of-neck airway (eFONA) in conjunction with technical and psychological factors. This should be mandatory reading for all airway providers.…”

“…Concern should be upgraded if at any point oxygen saturation falls below 90%'. Similarly, SpO 2 is included in the Vortex Approach CICO status tool (fig 3 in Chrimes and colleagues 1 ) for the same reason of emphasising that additional escalation is required.…”

Special Announcement – Guidelines to the Practice of Anesthesia – Revised Edition 2022

“…An improved approach and a shift of thinking related to earlier discussion of preparedness for the performance is eFONA is being strongly promoted. 11 Frequently, eFONA is only considered quite late in the difficult airway management sequence, ending in a “cannot ventilate, cannot oxygenate” (CVCO) scenario well beyond when significant hypoxia has occurred—reflective of a “sequential” approach. A newer approach uses the term “priming” to refer to a progressive escalation in open discussion and readiness to undertake eFONA that occurs much earlier.…”