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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 1-3

Back to the drawing board – The culture of reflective practice

Former Professor and Head of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India

Date of Submission05-Apr-2021
Date of Acceptance06-Apr-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. Venkateswaran Ramkumar
‘Prakrithi’, D/95A, Ananthnagar 2nd Stage, Manipal - 576 104, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_19_21

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How to cite this article:
Ramkumar V. Back to the drawing board – The culture of reflective practice. Airway 2021;4:1-3

How to cite this URL:
Ramkumar V. Back to the drawing board – The culture of reflective practice. Airway [serial online] 2021 [cited 2021 Sep 27];4:1-3. Available from: https://www.arwy.org/text.asp?2021/4/1/1/315160

Good judgment comes from experience.

Experience comes from bad judgment.

Dr Kerr L White

Clinical medicine is initially learnt from books and by the patient's bedside. The knowledge and skills thus accumulated gradually shape future clinicians into becoming excellent clinical practitioners. Personal experiences go a long way in fine-tuning the way we practice any branch of medicine. It is always said that one should learn from one's experiences. A smart individual learns from one's own decisions which turned out to be ‘bad'. The smarter individual is one who internalises a fellow colleague's misadventures and tries not to repeat the same mistake. History should repeat itself only for good events. One does not need to make every ‘mistake’ that is possible before one becomes ‘wise'. That would be the most illogical way of learning. Besides, one can never live long enough to commit all the mistakes that one possibly can before saying 'Now I have seen it all’ !

The principle of debriefing that is emphasised in simulation-based training can be very easily practiced in a real-life clinical setting as well. It comes as no surprise that all of us are happy to wax eloquent on our success stories. We like to publish our successful clinical experiences. It is my belief that one needs an honest individual to report what went wrong in his or her practice. Discussing one's failures, though difficult, may be more useful for the future generations of clinicians. A debrief, by definition, discusses any clinical scenario threadbare with the idea of understanding not only what went wrong but also exactly where one went wrong. This principle is no different when analysing airway-related incidents and accidents. Which brings us to the question, what do we do when things do not go as expected?

Let us imagine that a team consisting of a trainee and a consultant anaesthesiologist have failed to secure a definitive airway despite their experience and the availability of all indicated advanced airway equipment. The situation is salvaged by safely awakening the patient. A decision is taken to postpone the elective surgery to a later date, giving the team enough time to think, re-group and plan a safer course of action. This is the time to go back to the basics of airway management and assess in a systematic manner what could have been done differently that might have resulted in a better outcome.

If one were to examine the various phases when airway examination and management can go wrong, one will need to start from the very beginning. At the very first meeting, a detailed history of past anaesthetics that the patient might have undergone should be enquired about, with special focus on any specific problems, airway-related or otherwise, that the earlier anaesthesiologist might have thought fit to convey to the patient or guardian. In most institutions running postgraduate training programmes, the anaesthesia resident will be the first person to perform a preanaesthetic evaluation including a complete airway examination. This is the first link in the chain which by its very nature could be ‘weak’ as the residents are still learning the art and science of anaesthesiology. With modern technology at our fingertips, residents could discuss any doubts with their consultant over a video-call. Besides helping the consultant to be better prepared mentally and physically for a possible difficulty the next day, such action also ensures that a proper management strategy is already in place well in advance. A ‘second-look’ airway examination in the preoperative waiting area of the operation theatre complex by the consultant along with the resident could prove to be an invaluable learning opportunity and also make airway management much safer.

Another mistake that often happens is performing an airway examination only in the sitting position. While most of the airway examination is conveniently conducted in the sitting position, examining the airway in the supine position provides added benefits. Many amongst us have been fooled by a ‘false range of extension of the cervical spine’ created by the patient arching the shoulder backward when asked to extend the head while in the seated position. Examining the patient in the supine position while standing at the head end and gently pressing down on both shoulders can assist in evaluating true movement that is happening only at the cervical spine (including the atlanto-occipital joint) and not a false impression created by an arching backwards of the shoulders. Even in an emergency situation, one can perform a ‘quick 1-2-3’ airway examination within 15–20 s. This consists of the following 3 steps. Ability to insinuate 1 finger placed in front of the tragus into the temporomandibular joint (TMJ) space as the patient opens the mouth confirms adequate TMJ mobility. A 2-finger-breadth interincisor space indicates sufficient gap available for introduction of a laryngoscope blade or a supraglottic airway device while a thyromental distance that is 3-finger-breadths indicates adequate space in the submandibular region for displacing the tongue during laryngoscopy.

Positioning of the patient's head is crucial for allowing easy introduction of a laryngoscope blade without the chest coming in the way of the handle. While using a firm pillow that is around 7–9 cm high seems appropriate for most adults, the relatively large head of an infant often needs elevation of the chest to ensure that the head does not flex onto the chest and create difficulty during laryngoscopy. Older children may do well with no pillow at all. A lateral profile view of the patient often provides an indication whether the head has been positioned optimally allowing sufficient space for unhindered introduction of the laryngoscope. It also gives an idea about retrognathia which could sometimes be missed if the frontal profile alone is taken into account. Special positions such as the head-elevated laryngoscopy position[1] and the use of the rapid airway management positioner[2] have been described for positioning obese patients such that the tragus is in line with the suprasternal notch (a position that ensures optimal conditions for successful laryngoscopy and intubation). Lee and colleagues have described the influence of table height and posture of the intubator on the ease of face mask ventilation, laryngoscopy and intubation.[3] While face mask ventilation was most comfortable with the patient's head at the level of the umbilicus of the intubator, elevating the table such that the patient's head was at the level of the xiphoid process of the intubator facilitated laryngoscopy.

Following airway assessment, the anaesthesiology team should have an airway management strategy in place and all airway equipment that may be needed must be checked and in working condition. While one may still be unsuccessful in securing a definitive airway, the possibility that a supraglottic airway device can be placed as a rescue device may give the team some degree of confidence.

No patient ever dies because of inability on the part of the anaesthesiologist to intubate. On the other hand, patients can die or suffer irreversible brain damage if the anaesthesiologist fails to oxygenate. Thus, anaesthesiologists should never miss an opportunity to oxygenate. Preoxygenation prior to inducing unconsciousness is the first step that ensures adequate oxygen reserves in the lungs to cover periods of intended apnoea. Completeness of oxygenation is estimated by monitoring the fraction of expired oxygen which should be at least 90% (FEO2 >0.9). Should any undue delay occur in securing a definitive airway, re-oxygenation should be performed with 100% oxygen administered by face mask ventilation. Continuous administration of oxygen at 10–15 L/min through a binasal cannula while the anaesthesiologist is performing laryngoscopy and intubation can and should be practiced for all patients. This procedure replenishes oxygen stores in the lungs by a process of apnoeic oxygenation.[4] The recent availability of high flow nasal oxygen devices that can administer up to 70 L/min of humidified oxygen is a further refinement of the apnoeic oxygenation technique that provides an even longer duration of safe apnoea.[5]

While communication is of paramount importance for good team dynamics, its importance cannot be overemphasised during airway management. Many of us who supervise anaesthesia residents would have faced situations (before the era of videolaryngoscopes) where the superviser was not aware of the laryngoscopic view being obtained by the trainee. Even now, videolaryngoscopes are not freely available in all operating locations. If the primary operator verbalises the best laryngeal view obtained, the assistant/superviser can be ready to intervene at the correct moment with the appropriate assistance or device. As a teacher of anaesthesiology, I have always asked the trainee to state loudly the best laryngeal view obtained. I personally prefer using Cook's modification of the Cormack-Lehane grading of laryngeal view as it essentially provides a functional grading that can be used to predict the best course of action to successfully secure the airway.[6] Grade 1 and 2A where cords are visible either entirely or almost so, fall into an ‘easy’ category wherein most airway managers can intubate with conventional airway equipment. Grade 2B where only the arytenoids are visible and Grade 3A where only epiglottis is visible and liftable fall into the ‘restricted’ category wherein even experienced airway managers need airway adjuncts to secure the airway. Grade 3B where epiglottis is seen but not liftable and grade 4 where no laryngeal structures are seen constitute the ‘difficult’ category that needs skilled airway managers who are not only adept at using advanced airway gadgets but who can also perform an emergency cricothyrotomy should the need arise.

No airway can be classified as an easy airway until it is safely secured. Despite several methods to identify a difficult airway, one comes across an unanticipated difficult airway ever so often in one's practice. Most often, these are unexpected. As long as the anaesthesiologist is able to oxygenate the patient and the surgery is not of an emergent nature, the most logical step would be to terminate the anaesthetic and postpone surgery. This course of action gives sufficient time for the team to think, re-group and go back to the basics so that the next time around, they come back with a better-formulated airway management strategy. As anaesthesiologists acquire better skill sets and advanced airway equipment is no longer considered a ‘dead investment’ by hospital administrators, fewer surgical patients will die because of the inability to secure a definitive airway. Let us all aim higher and make the practice of anaesthesiology even safer than it already is today.

  References Top

Rich JM. Use of an elevation pillow to produce the head-elevated laryngoscopy position for airway management in morbidly obese and large-framed patients. Anesth Analg 2004;98:264-5.  Back to cited text no. 1
Cattano D, Melnikov V, Khalil Y, Sridhar S, Hagberg CA. An evaluation of the rapid airway management positioner in obese patients undergoing gastric bypass or laparoscopic gastric banding surgery. Obes Surg 2010;20:1436-41.  Back to cited text no. 2
Lee HC, Yun MJ, Hwang JW, Na HS, Kim DH, Park JY. Higher operating tables provide better laryngeal views for tracheal intubation. Br J Anaesth 2014;112:749-55.  Back to cited text no. 3
Frumin MJ, Epstein RM, Cohen G. Apneic oxygenation in man. Anesthesiology 1959;20:789-98.  Back to cited text no. 4
Patel A, Nouraei AR. Transnasal humidified rapid insufflation ventilator exchange (THRIVE): A physiologic method of increasing apnoea time in patients with difficult airways. Anaesthesia 2015;70:323-9.  Back to cited text no. 5
Cook TM. A new practical classification of laryngeal view. Anaesthesia 2000;55:274-9.  Back to cited text no. 6


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