Airway management is the foundation upon which anaesthesia is built, and fibreoptic intubation (FOI) is a key facet of this skill. Despite this, many trainee anaesthetists in the UK have been unable to perform sufficient FOIs to gain competence. We aimed to establish the incidence of FOI in adult patients, in a UK teaching hospital, in order to determine what FOI training opportunities actually exist. During the study period (from October 1st, 2008, to September 30th, 2009) an estimated 11？712 general anaesthetics were undertaken that necessitated tracheal intubation. In 141 of these cases FOIs were performed giving an incidence of FOI of 1.2% (95% confidence interval 1%–1.4%). Of these, 86 (61%) were in awake and 55 (39%) in anaesthetised patients. Only 16 (11%) of the FOIs were done solely for the purposes of training. We suggest that a greater number of FOIs should be undertaken to allow trainees to gain and consultants to maintain the FOI expertise necessary for the provision of safe anaesthesia. 1. Introduction Airway management is the foundation upon which anaesthesia is built. Fibreoptic intubation (FOI) is a key part of this skill and forms the basis of the management of many difficult intubations, both anticipated and unexpected [1–3]. Accordingly, the National Confidential Enquiry into Peri-operative Deaths (NCEPOD) [4] recommended that every hospital should have anaesthetists trained in FOI. Furthermore, competence in FOI is considered to be an essential part of the training of anaesthetists in the UK. Despite this, many trainee anaesthetists in the UK complete their training having been unable to perform enough FOIs in order to gain competence [5, 6]. The situation is likely to be compounded by the time constraints presented by Modernising Medical Careers and the European Working Time Directive. Training opportunities are likely to be reduced [7] which may make competence at FOI even more difficult to achieve and maintain. The incidence of FOI varies greatly between countries. In Canada, FOIs make up 1.4% of all tracheal intubations [8], whilst in Switzerland the rate is in excess of 12% [9, 10]. To our knowledge, the incidence of FOI within the UK has never been determined. Therefore, we aimed to establish the incidence of FOI in adult patients in a tertiary centre for maxillofacial, ENT, and spinal surgery in order to determine what FOI training opportunities actually exist. 2. Methods Guidance from the National Research Ethics Service (NRES) classified the project as service evaluation, meaning that formal ethical approval was
References
[1]
J. J. Henderson, M. T. Popat, I. P. Latto, and A. C. Pearce, “Difficult Airway Society guidelines for management of the unanticipated difficult intubation,” Anaesthesia, vol. 59, no. 7, pp. 675–694, 2004.
[2]
American Society of Anesthesiologists Task Force on Management of the Difficult Airway, “Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway,” Anesthesiology, vol. 98, no. 5, pp. 1269–1277, 2003.
[3]
E. T. Crosby, R. M. Cooper, M. J. Douglas et al., “The unanticipated difficult airway with recommendations for management,” Canadian Journal of Anaesthesia, vol. 45, no. 8, pp. 757–776, 1998.
[4]
A. J. G. Gray, G. S. Ingram, and K. M. Sherry, The Report of the National Confidential Enquiry Into Perioperative Deaths, NCEPOD, London, UK, 1998.
[5]
F. B. Ahmed, V. Mitchell, and A. Patel, “Advanced airway techniques—the North Thames Central experience,” Anaesthesia, vol. 59, pp. 1042–1046, 2004.
[6]
A. F. McNarry, T. Dovell, F. M. L. Dancey, and M. E. Pead, “Perception of training needs and opportunities in advanced airway skills: a survey of British and Irish trainees,” European Journal of Anaesthesiology, vol. 24, no. 6, pp. 498–504, 2007.
[7]
D. J. Sim, S. R. Wrigley, and S. Harris, “Effects of the European working time directive on anaesthetic training in the United Kingdom,” Anaesthesia, vol. 59, no. 8, pp. 781–784, 2004.
[8]
D. K. Rose and M. M. Cohen, “The airway: problems and predictions in 18,500 patients,” Canadian Journal of Anaesthesia, vol. 41, no. 5 I, pp. 372–383, 1994.
[9]
T. Heidegger, H. J. Gerig, B. Ulrich, and G. Kreienbühl, “Validation of a simple algorithm for tracheal intubation: daily practice is the key to success in emergencies—an analysis of 13,248 intubations,” Anesthesia and Analgesia, vol. 92, no. 2, pp. 517–522, 2001.
[10]
T. Heidegger, H. J. Gerig, B. Ulrich, and T. W. Schnider, “Structure and process quality illustrated by fibreoptic intubation: analysis of 1612 cases,” Anaesthesia, vol. 58, no. 8, pp. 734–739, 2003.
[11]
R. C. Clarke and A. I. Gardner, “Anaesthesia trainees' exposure to airway management in an Australian tertiary adult teaching hospital,” Anaesthesia and Intensive Care, vol. 36, no. 4, pp. 513–515, 2008.
[12]
C. Johnson and J. T. Roberts, “Clinical competence in the performance of fiberopt laryngoscopy and endotracheal intubation: a study of resident instruction,” Journal of Clinical Anesthesia, vol. 1, no. 5, pp. 344–349, 1989.
[13]
H. G. Schaefer, S. C. U. Marsch, H. L. Keller, S. Strebel, L. Anselmi, and J. Drewe, “Teaching fibreoptic intubation in anaesthetised patients,” Anaesthesia, vol. 49, no. 4, pp. 331–334, 1994.
[14]
J. E. Smith, A. P. F. Jackson, J. Hurdley, and P. J. M. Clifton, “Learning curves for fibreoptic nasotracheal intubation when using the endoscopic video camera,” Anaesthesia, vol. 52, no. 2, pp. 101–106, 1997.
[15]
A. J. Dawson, C. Marsland, P. Baker, and B. J. Anderson, “Fibreoptic intubation skills among anaesthetists in New Zealand,” Anaesthesia and Intensive Care, vol. 33, no. 6, pp. 777–783, 2005.
[16]
C. Marsland, P. Larsen, R. Segal et al., “Proficient manipulation of fibreoptic bronchoscope to carina by novices on first clinical attempt after specialized bench practice,” British Journal of Anaesthesia, vol. 104, no. 3, pp. 375–381, 2010.
[17]
A. G. L. Allan, “Reluctance of anaesthetists to perform awake intubation,” Anaesthesia, vol. 59, no. 4, p. 413, 2004.
[18]
K. Jenkins, D. T. Wong, and R. Correa, “Management choices for the difficult airway by anesthesiologists in Canada,” Canadian Journal of Anesthesia, vol. 49, no. 8, pp. 850–856, 2002.
[19]
W. H. Rosenblatt, P. J. Wagner, A. Ovassapian, and Z. N. Kain, “Practice patterns in managing the difficult airway by anesthesiologists in the United States,” Anesthesia and Analgesia, vol. 87, no. 1, pp. 153–157, 1998.
[20]
H.-G. Schaefer and S. C. U. Marsch, “Comparison of orthodox with fibreoptic orotracheal intubation under total i.v. anaesthesia,” British Journal of Anaesthesia, vol. 66, no. 5, pp. 608–610, 1991.
[21]
M. Barak, A. Ziser, A. Greenberg, S. Lischinsky, and B. Rosenberg, “Hemodynamic and catecholamine response to tracheal intubation: direct laryngoscopy compared with fiberoptic intubation,” Journal of Clinical Anesthesia, vol. 15, no. 2, pp. 132–136, 2003.
[22]
M. R. Rai, T. M. Parry, A. Dombrovskis, and O. J. Warner, “Remifentanil target-controlled infusion vs propofol target-controlled infusion for conscious sedation for awake fibreoptic intubation: a double-blinded randomized controlled trial,” British Journal of Anaesthesia, vol. 100, no. 1, pp. 125–130, 2008.
[23]
T. Heidegger, L. Starzyk, C. R. Villiger et al., “Fiberoptic intubation and laryngeal morbidity: a randomized controlled trial,” Anesthesiology, vol. 107, no. 4, pp. 585–590, 2007.
[24]
V. S. Sidhu, E. M. Whitehead, Q. P. Ainsworth, M. Smith, and I. Calder, “A technique of awake fibreoptic intubation: experience in patients with cervical spine disease,” Anaesthesia, vol. 48, no. 10, pp. 910–913, 1993.
[25]
S. Yarrow, J. Hare, and K. N. Robinson, “Recent trends in tracheal intubation: a retrospective analysis of 97 904 cases,” Anaesthesia, vol. 58, no. 10, pp. 1019–1022, 2003.
