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Written on 26th January 2024 by Susan Brown

Healthcare safety watchdog, Health Services Safety Investigations Body (HSSIB) have published the findings of their national investigation into the safety risks to patients with ‘difficult airways’.

HSSIB’s report, Advanced airway management in patients with a known complex disease, finds that gaps in national guidance and staff training increases the risk of severe injury during anaesthetic and emergency procedures for people whose mouth, throat or windpipe make it difficult to manage their airway.

What is airway management?

Airway management is the process by which healthcare professionals ensure that a patient is able to breathe oxygen into their lungs. It is a critical component of safe anaesthetic, surgical and emergency care. The airway is the medical term for the passage through which air flows from the nose and mouth through the throat and trachea (windpipe) to the lungs.

Airway management may involve non-invasive manoeuvres, such as tilting the patient’s head and lifting their chin, or lifting the jaw forward (jaw thrust) to allow air to flow through the airway unobstructed. Airway devices may be used to keep the airway open, inserted into the pharynx (in the throat) via the mouth to prevent the tongue from blocking the airway, or via the nose, or by ‘bag and mask’ ventilation in which air is manually squeezed into and out of a patient’s lungs.  If these basic techniques are not enough to maintain the patient’s airway and oxygenation, then more advanced techniques may be needed. These include supraglottic airway devices (SGAs), such as laryngeal mask airways, or intubation.

Where all other ways of providing oxygen for a patient are not possible or have failed, surgical techniques such as scalpel cricothyroidotomy or tracheostomy may be used to create an airway through the neck directly into the trachea, by an ‘emergency front of neck airway’ (eFONA) procedure. These procedures may be needed in an emergency where the patient has extensive facial injuries or their airways are swollen or narrow, causing an obstruction in their airway.

What is intubation?

Tracheal intubation may be needed when a person’s airway is blocked or damaged or if they can’t breathe on their own, such as when they are anaesthetised during surgery. It is also the most commonly used way to maintain patients’ airways in emergency situations, in higher risk patients and where there is a risk of pulmonary aspiration (breathing stomach contents into the lungs). Intubation involves inserting a tracheal tube into a patient’s mouth or nose and then into their airway (trachea) to hold it open. The tube is then connected to an air bag that is squeezed, or a ventilator machine which pushes air in and out of the lungs. An anaesthetist or doctor may use a laryngoscope to push aside the tongue and gain a clearer view of the patient’s larynx and vocal cords whilst inserting the tracheal tube into the trachea.

Videolaryngoscopes have cameras enabling the anaesthetist to view the patient’s mouth and throat on a screen during the process of intubation. This helps reduce the risks of traumatic injury to the patient’s throat and larynx (voicebox) and life-threatening harm from oesophageal intubation, a dangerous mistake in which the tracheal tube is inserted into the passageway through which food passes from the mouth into the stomach. HSSIB emphasise that intubation should only be carried out by appropriately trained staff.

What is a difficult airway?

The Royal College of Anaesthetists (RCoA) and The Difficult Airway Society (DAS) have published guidelines for how a patient’s airway should be managed during anaesthesia, including for patients with a difficult airway.

HSSIB’s report makes clear that when a patient is said to have a ‘difficult airway’ this refers more to the challenges that will be faced by the clinician in managing the patient’s airway, rather than any specific feature of the patient’s anatomy. Those challenges may include features of the patient’s anatomy, such as injuries, growths, swelling or stiffness in the patient’s mouth, neck or airway, difficulty with the jaw or opening the patient’s mouth, or previous radiotherapy to their mouth or neck. They may also refer to the clinical situation, the clinician’s own level of expertise and the available airway equipment resources.

Anaesthetists are required to assess patients before any procedure involving an anaesthetic to determine (using a score test) whether their airway is likely to be difficult. HSSIB point out that, although rare, difficult airway scenarios are stressful for the anaesthetist involved and are potentially life-threatening for the patient.

Failure to provide an adequate airway for a patient who cannot maintain their own airway can result in severe injury, including respiratory and cardiac arrest, brain injury and long-term disability or death. If the patient’s injury was caused by negligent treatment, such as incorrect or delayed airway management, incorrect risk assessment, equipment failure or unrecognised oesophageal intubation, they may be entitled to claim substantial compensation.

A patient’s experience

HSSIB’s national investigation followed the tragic death in hospital of a 12-year-old boy with Hunter syndrome (a genetic condition that often affects the anatomy of the airway). He was admitted to the hospital’s A&E after having a seizure (fit) at home which the emergency department staff believed was caused by lack of oxygen to his brain. He was given medication to control his seizures and his airway was managed with additional oxygen and manoeuvres to best position his head, neck and jaw. Intubation was considered but predicted to be difficult owing to his Hunter syndrome and severe obstructive sleep apnoea (a sleep disorder where the airway becomes blocked). After several hours of monitoring and basic airway management, and discussions with his care team at a specialist (tertiary) hospital and the  patient retrieval service  that would transfer him to the hospital’s paediatric intensive care unit (PICU), his condition deteriorated. He was taken to the operating theatre but he died after attempted videolaryngoscopy intubation and surgical efforts to create an airway failed.  

HSSIB’s investigation found that there was no individualised airway management plan for the boy that formed part of a wider care plan addressing all his care needs. His known difficult airway had not been shared between his primary (GP), secondary (local hospital), and tertiary (specialist) care. The clinicians who assessed him at the local hospital identified that he was at risk of having a difficult airway, but there was no guidance for managing an anticipated difficult airway. The local hospital did not have a PICU or an on-site ENT (ear, nose and throat) specialist available at the time of the incident.

HSSIB’s findings and recommendations to improve care for patients with difficult airways

HSSIB’s national investigation focused on the national policies and guidance that govern the care of patients who are known to have a difficult airway. They considered the communication, preparation and planning for cases where a patient needs advanced airway management by healthcare professionals.

HSSIB’s findings included:

  • There is no nationally recognised system for sharing clinical information about patients who are known to have a difficult airway between those involved in their primary, secondary, and tertiary care.
  • There is no standard process for documenting and sharing an individualised airway management plan for people with a complex disease to all health care professionals and services involved in their care.
  • Multidisciplinary team (MDT) meetings to discuss the care of patients who have a complex disease and a known difficult airway don’t happen consistently between primary, secondary, and tertiary care.
  • They found lack of coordination and consistency in the existing guidance for healthcare professionals about how to care for patients with a complex disease who may have a difficult airway.  
  • There is no national standard for treating patients with a known, potentially life-threatening, difficult airway who need advanced airway management.
  • They found that it is ‘challenging’ for hospitals to provide the additional skills needed for advanced airway management of patients in emergency situations, as 24-hour on-site ENT specialists are not available in every hospital.
  • They highlighted variability and lack of standardisation in the use, training and competency assessments for videolaryngoscopy.  
  • Training and competency assessment for anaesthetists on emergency airway techniques, such as emergency front of neck airway (eFONA) is variable.
  • They identified at national level a lack of robust user testing in the design of advanced airway management equipment, to help identify and understand risks.

HSSIB’s recommendations included carrying out further work to improve clinical information-sharing, guidance, standardised procedures and training in relation to advanced airway management for people known to have difficult airways, to increase the chances of survival in life-threatening emergency situations.

If you or a family member have suffered severe injury as a result of medical negligence or have been contacted by HSSIB/MNSI or NHS Resolution you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.