Helen L. Smith

Development of a guideline for the management of the unanticipated difficult airway in pediatric practice

Most airway problems in children are identified in advance; however, unanticipated difficulties can arise and may result in serious complications. Training for these sporadic events can be difficult. We identified the need for a structured guideline to improve clinical decision making in the acute situation and also to provide a guide for teaching.

Awake insertion of the laryngeal mask airway using topical lidocaine and intravenous remifentanil.

We assessed the use of intravenous remifentanil for the insertion of the laryngeal mask airway in 10 healthy awake volunteers, a technique primarily developed to facilitate functional magnetic resonance imaging studies of anaesthesia. Each volunteer received 200 μg glycopyrronium intravenously. Topical airway anaesthesia was effected by 4 ml nebulised lidocaine 4%, followed by 12 sprays of lidocaine 10%. Remifentanil was subsequently infused to achieve an initial target effect‐site concentration of 2 ng.ml−1; increments of 1 ng.ml−1 were allowed with the maximum effect‐site concentration limited to 6 ng.ml−1. Insertion of the laryngeal mask airway was successful on the first attempt in all cases. The median (IQR [range]) target effect‐site remifentanil concentration at insertion was 2.5 (2–3 [2–4]) ng.ml−1. All volunteers were co‐operative during the procedure and only one reported discomfort. Sore throat was a complication in all volunteers. We conclude that the technique allows successful insertion of the laryngeal mask airway in healthy awake volunteers under conditions that were safe and reproducible.

Integrated approaches to academic anaesthesia – the Cambridge experience

There is mounting concern about the pressures experienced by University Departments of Anaesthesia, which, if lost, could threaten undergraduate peri‐operative medicine teaching, development of critical appraisal skills among anaesthetists, and the future of coherent research programs. We have addressed these problems by establishing a foundation course in scientific methods and research techniques (the Cambridge SMART Course), complemented by competitive, fully funded, 12‐month academic trainee attachments. Research conducted during academic attachments has been published and used to underpin substantive grant applications allowing work towards higher degrees. Following the attachment, a flexible scheme ensures safe reintroduction to clinical training. Research at consultant level is facilitated by encouraging applications for Clinician Scientist Fellowships, and by ensuring that the University Department champions, legitimises and validates the allocation of research time within the new consultant contract. We believe that these are important steps in safeguarding research and teaching in anaesthesia, critical care and peri‐operative medicine.

Problems encountered with a pilot online attendance record and feedback scheme for medical students.

Lectures were traditionally optional for students in higher education with noregisters or records of attendance. This flexible approach was tolerated ifperformance in end of year or final examinations was satisfactory (Vinceneuxet al., 2000).This approach may still be possible in some subjects but in medicine muchhas changed. Students are increasingly required to verify attendance andparticipation as validation, appraisal and competence-based assessment areintroduced. Collecting and organizing written evidence is also becoming animportant part of postgraduate medical life.Resentment is caused by the ‘‘sign-up’’ system (Hrabak et al., 2004) becausestudents dislike being treated like school children when they are learning theattributes of a profession and some students can even resort to forgery(Beemsterboer et al., 2000). Signature sheets are easily lost and are rarelyinspected by faculty members while collecting signatures takes a dispropor-tionate amount of time. The acquisition of a signature only establishes astudent’s attendance, not whether they have learned anything.We perceive pressure from university authorities to account for students’attendance. Previously, students could choose to do something else if they

Response to Dr A Snoek - 'Useful as a point-of-care algorithm?'.

SIR—I read with interest the paper containing guidelines for management of the unanticipated difficult airway (1) and commend the authors for tackling a difficult task. There are three points worth adding. First, though the paper does contain the Delphi group (DG) results for many guideline steps, inconsistent use of terminology, employing phrases such as ‘favored’ or ‘recommended’, rather than the predefined Delphi levels of consensus terms, means that not all DG results are clearly presented. In addition, it is unclear if some statements in the text were considered by the DG, and whether these were subsequently included in the guideline (e.g., adjusting cricoid pressure) or not (e.g., use of the lateral position if tonsils are enlarged). The reader would have benefited from a summary table of each guidelineconsidered step with its respective DG result. This would clarify which parts of the final guideline had been more rigorously tested via the larger 27-person DG rather than those that only went through the smaller sixperson Working Group (WG). Second, the complex deliberations of the WG on what ultimately to include or exclude in the final guidelines have not been presented. Some statements appear in the guidelines without having achieved DG consensus agreement (e.g., use of a nasopharyngeal airway) and other statements that did achieve DG consensus were not incorporated (e.g., use of cuffed tubes). Filtering of guideline steps by the WG weakens the DG contribution and ultimately compromises the validity of the method. The discussion section in the paper could have been better utilized to elucidate reasons for such decisions. Third, the aim was to produce simple guidelines in keeping with a ‘less is more’ principle. In the setting of a rapidly deteriorating situation of downward spiraling saturations, it may be that these guidelines are too prolix to follow, for example when compared to the vortex approach (2). On the flip side, there are aspects of the guideline where the goal for simplicity has excessively dominated detail, for example in the omission of intramuscular suxamethonium for laryngospasm without intravenous access. Consequently, the guideline is not comprehensive enough without having read the background text in the paper. In a state of panic it is questionable whether the target group for these guidelines will think of such steps without a detailed directive. Not only that but the use of the word ‘consider’ implies a necessity to weigh up risks and benefits. In the heat of the moment, when it says ‘consider a nasopharyngeal airway’, will some do so even if mouth opening is adequate and at best waste time, or at worst cause a nosebleed with resultant worsening of airway conditions? In its use as a point-of-care algorithm I fear that many will fall short in appreciating such complexities, especially without having conscientiously developed a deeper understanding for all relevant factors. As with any other emergency algorithm, an overarching comprehension of the foundations from which the algorithm has been developed, underpins its effective use. We should caution against solely relying on these guidelines without having wrestled with the accompanying background.