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 Table of Contents  
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 1-3

Creating the Indian airway guidelines and beyond

1 Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Former Professor and Head of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India

Date of Web Publication11-Jan-2019

Correspondence Address:
Prof. Sheila Nainan Myatra
Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Dr. Ernest Borges Road, Parel, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ARWY.ARWY_15_18

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How to cite this article:
Myatra SN, Ramkumar V. Creating the Indian airway guidelines and beyond. Airway 2018;1:1-3

How to cite this URL:
Myatra SN, Ramkumar V. Creating the Indian airway guidelines and beyond. Airway [serial online] 2018 [cited 2023 Feb 1];1:1-3. Available from: https://www.arwy.org/text.asp?2018/1/1/1/250026

Airway management is a vital skill that is relevant to the practice of almost all medical specialities, especially anaesthesiology, critical care, emergency medicine, paediatrics and general medicine to name a few. The last two decades have witnessed a significant change in the availability of airway equipment and techniques, along with a paradigm shift in our approach to airway management. In a country as large as India, with wide variation in the availability of equipment and also in the clinical practice of airway management, a focus on teaching and training and the use of standard guidelines is the way forward.[1] In the year 2010, the All India Difficult Airway Association (AIDAA) was formed to fulfil some of these needs. By getting airway interest groups onto a common platform, the AIDAA made it possible to share ideas and promote teaching and training in airway management with the goal of improving safety during airway management.

It has been common practice in India to follow difficult airway management guidelines from Western societies such as the American Society of Anesthesiologists (ASA) and the Difficult Airway Society (DAS).[2],[3] There was a long-felt need to create Indian guidelines to cater to the specific needs and situations in India. In addition, it was noticed that there were no available guidelines for the management of tracheal intubation in the context of the intensive care unit (ICU). Against this background, the AIDAA brought together a group of airway experts to create the difficult airway management guidelines for India. This lead to the publication by AIDAA of five guidelines in the December 2016 issue of the Indian Journal of Anaesthesia (IJA). This included unanticipated difficult tracheal intubation in the adult, obstetric and paediatric patients,[4],[5],[6] guidelines for tracheal intubation in ICU[7] and guidelines for the management of difficult extubation.[8]

The simultaneous publication of these five guidelines attracted global attention. Both appreciation and criticism followed from all quarters. Within the country, some were happy to finally have local guidelines that they embraced readily as they found them not only simple to understand but also easy to use. However, many Indian anaesthesiologists had initial apprehensions to use these guidelines. Several questions and concerns arose, including questions such as 'Should I be following these guidelines when ASA and DAS guidelines are available?' or 'Will they be as good as those brought out by international bodies?' Others asked 'Now that we have Indian guidelines, will I be sued if I have an airway problem and do not follow the guidelines?' The student community asked 'In the exams, will I be expected to know the Indian guidelines as well?' Senior fraternity members remarked 'I am not happy to follow these guidelines as despite being an airway expert, I was not involved in formulating these guidelines'. However, with the passage of time, most of these concerns were put to rest. As is clearly stated in the publications, these guidelines were made to assist clinicians manage unanticipated difficult intubation in patients using evidence-based recommendations. Neither do they represent the minimum standard of practice nor are they a substitute for good clinical judgment.[4]

The next big challenge was the dissemination of the newly formulated guidelines. Senior members of the AIDAA left no stone unturned in this endeavour. All members of the guideline committee and other leaders in airway management were actively involved in the dissemination of these guidelines among clinicians working in different clinical settings. This was done through presentations at national and regional meetings including those of AIDAA and academic programmes at teaching institutes. In addition, the AIDAA website was used to disseminate information. Small pocket cards bearing the five algorithms which served as a handy reference guide for clinicians were distributed at many meetings. Several members of the guideline committee were invited to speak on the guidelines at various international meetings. Following in the wake of the publication of guidelines in a widely read journal, the IJA, focused presentations by our guideline committee members lead to global attention being drawn to these five important airway management guidelines. The ICU guideline, being the first one on the management of tracheal intubation in ICU, got significant attention from the critical care community across the world.

What are the strengths of the AIDAA guidelines? We believe that they provide a comprehensive structured approach to clinicians for decision-making when encountered with a difficult airway in most of the clinical situations that we encounter in daily practice, irrespective of their level of experience or the resources available. AIDAA is the first society that simultaneously published guidelines to deal with five different patient groups or scenarios. The strength of this approach is in having a complete evidence-based package for difficult airway management in the majority of patient groups or scenarios that the clinician is likely to encounter in his usual practice setting in India. The algorithms have a vertical flow pattern with different colour coding for different patient groups, common text boxes among algorithms and new ones for the specific patient population, making it easy for the clinician to remember the algorithm, including the subtle difference between different patient groups and scenarios.

The AIDAA guidelines focus on safe airway practices. An emphasis on the importance of adequate preoxygenation and oxygenation during intubation (apnoeic oxygenation using nasal oxygen continuously at a flow rate of at least 15 L/min in adults) forms one major cornerstone. The guidelines also emphasise the use of an oxygen saturation (SpO2) threshold of ≥95% as dictated by a pulse oximeter to restrict the number of attempts at intubation or insertion of a supraglottic airway device (SAD). Considering that human factors can cloud logical airway management during a crisis, a 'call for additional help' before performing cricothyroidotomy was added. It was believed that a person not involved in the airway crisis until then may be able to perform better and think more rationally in this situation. In addition, an extra pair of hands would always be welcome when the going gets tough. The technique of cricothyroidotomy, whether cannula, scalpel or using commercial cricothyroidotomy kits based on the familiarity and the availability of the equipment, makes it a universally acceptable step when immediate airway access becomes mandatory.

It is well known that human factors contribute to adverse outcomes during a crisis.[9] Thus, clear communication among team members using 'critical language', which refers to communication using specific terms or phrases having a clear, mutually agreed meaning, is essential in this situation.[10],[11],[12] Two terms – 'emergency cricothyroidotomy' and 'complete ventilation failure' – used in the AIDAA guidelines bear testimony to this crucial aspect of good communication. We believe that emergency cricothyroidotomy as a term is more appropriate than a term such as front of neck access[3] which is neither specific nor universally understood and could therefore be misunderstood in an emergency. The term 'emergency cricothyroidotomy' is free from confusion as it not only specifies what needs to be done but also addresses the urgency of the procedure and states the anatomical landmark to be used in an emergency (not tracheostomy). Complete ventilation failure is defined as 'a situation where intubation, ventilation using SAD and face mask have all failed after giving the best attempt, even if oxygenation is maintained (as evidenced by SpO2>95%)'.[4] Terms such as 'cannot intubate, cannot ventilate'[2],[13] and more recently 'cannot intubate, cannot oxygenate' (CICO)[3] have been used in other international guidelines to describe such a critical, potentially life-threatening juncture in airway management. There is a wide variation in what people understand by 'cannot oxygenate', especially in the era of apnoeic oxygenation, where the SpO2 may be preserved for a long time even after ventilation fails. To some, this term means the inability to ventilate; to others, it means a dropping saturation. As ventilation failure precedes oxygenation failure, it would be a more appropriate trigger to initiate cricothyroidotomy than waiting for the SpO2 to fall. In addition, intubation is not the only means of maintaining oxygenation as we commonly use SADs in the present day. This makes 'cannot intubate' in the context of CICO irrelevant in current practice. Considering this, we believe that the term complete ventilation failure will be a more appropriate terminology in comparison to CICO.

The AIDAA guidelines are well-thought-out, evidenced-based guidelines which are practical and simple to use in any clinical setting. Drawing a parallel to the management of sepsis where the surviving sepsis guidelines[14] are being universally used, the time has come to have a universal guideline for the management of the unanticipated difficult airway. In 2016, a multidisciplinary working group of airway specialists from across the world was formed to work on the Project for Universal Management of Airways (PUMA). This group will aim at producing a universal, evidence-based guideline that reflects as much as possible the consensus of existing published airway guidelines that can be applied to all patient ages and clinical settings across the world. It is a matter of great honour that a member of the AIDAA guidelines committee has been invited to be a part of this 13-member committee and represent the AIDAA guidelines. The set of five AIDAA guidelines with several unique features as described above has been discussed and considered by the PUMA group.

The publication of the five difficult airway management guidelines has without doubt been the proudest achievement of AIDAA in the last 10 years. These guidelines have given the AIDAA international recognition. However, several questions still remain unanswered. How many people are actually following the AIDAA guidelines in India? Has their implementation translated into improved patient care? We hope that these guidelines will help clinicians deal with an unanticipated difficult intubation and lead to safer airway management practices.

Our next big venture has been to have a journal completely dedicated to the airway. This will be the official publication of the AIDAA and has been most aptly titled 'Airway'. To the best of our knowledge, this is the first worldwide journal dedicated to airway issues. As we write this editorial, we stand on the threshold of releasing the Inaugural Issue of the 'Airway'. We sincerely hope that this journal will create the long-felt need of a platform for airway experts from all around the world to share their experiences and expertise with one common goal – making airway management safe for the patient.

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