Qualitative analysis of unanticipated difficult airway management

Unanticipated difficult airway management (DAM) is a major challenge for the anaesthesiologist and is associated with a risk of severe patient damage. We analysed 24 cases of unanticipated DAM for actual case management and anaesthesiologists knowledge, technical and non-technical skills. Anaesthesiologists' opinions, as well as environmental factors of importance for DAM proficiency, were also assessed.

Departments of Anaesthesiology in three Copenhagen University Hospitals participated in a prospective study of unanticipated DAM. Anaesthesiologists recorded the details of the cases on a data sheet. Qualitative data were collected in a semi-structured interview if the value of the Intubation Difficulty Score (IDS) was more than five, if the value of the visual analogue scale score for mask ventilation was more than five or in the case of a registered complication. Transcripts were theme analysed independently by two analysts. Data sheets and interviews were used in the final evaluation.

All 24 cases concerned difficult tracheal intubation, and this was associated with difficult mask ventilation on four occasions. Management in three cases demonstrated strict adherence to a DAM practice guideline. Anaesthesiologists lacked standards for DAM. Inadequate knowledge, training and training facilities were documented. Sudden re-allocation of personnel and change of anaesthetic technique were potential risk factors for DAM. Insufficient airway assessment, insufficient patient information and registration of difficulties were demonstrated. Ethical issues were raised concerning the use of patients for skills practice.

Both personal and system failures resulted in unanticipated DAM. There was insufficient knowledge of DAM and anaesthesiologists lacked DAM training. Standards for DAM and curricula for continuing education in DAM are needed.