CLINICAL AUDIT GUIDE

Adequacy of difficult airway requirement audit

Please check with your local ethics service or governing body as to the process requirements for conducting an audit of your own practice.

Difficult airway (DA) scenarios and airway complications are a leading cause
Background
of anaesthetic morbidity and mortality.1,2,3
The UK’s NAP4 results and the review from the American Society of
Anesthesiologists closed claims database analysis suggest many of these
cases are preventable.1
Expertise in airway management, including that of a difficult airway, is an
essential skill for anaesthetists. In the event of an unanticipated difficult
airway or airway complication, the effective management of a difficult airway
depends on essential equipment being rapidly available.
Airway complications can occur during all phases of the anaesthetic
process. NAP4 demonstrated that while induction was the phase when most
events occur, a significant minority occurred during emergence and in (or
during transfer to) the recovery area. This illustrates the need for a DA
trolley to be easily accessible in all areas of a complex that provides
anaesthesia and recovery/ post anaesthesia care.
Several algorithms and flowcharts have been formulated by various bodies
such as the American Society of Anesthesiologists (ASA), the UK’s Difficult
Airway Society (DAS) and more recently in Australia, the “Vortex Approach”,
to effectively manage the difficult airway as well as the “can’t intubate and
cant ventilate” situation.4,5,6
The Australian Incident Monitoring Study (AIMS) identified equipment
deficiencies, which were mainly due to failure to check, as responsible for a
third of the contributing factors identified in the difficult intubation reports.7
An audit in New Zealand identified inconsistencies and deficiencies in the
airway equipment available in a major metropolitan area and the UK, there
is evidence that the location and contents of DA equipment is poor.8
In 2012 ANZCA developed evidence based guidelines on equipment to
manage a difficult airway during anaesthesia (PS56) which specifies
essential equipment for management of a difficult airway as well as its
storage and location.9
Essential equipment should include simple airway adjuncts, intubation
equipment, supraglottic ventilation devices and an emergency
cricothyrotomy oxygenation system.9,10,11

Aim and objectives To identify areas of potential deficiency in the existence of, locations for,
labelling and/ or contents of Difficult Airway (DA) Trolleys in various
departments where general anaesthesia occurs.
To improve, where possible, the contents of and access to difficult airway
equipment.
Improvement in the speed of access to and ease of locating equipment
within a DA trolley in an emergency could reduce morbidity and mortality
relating to difficult airway management.

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Research evidence/ ANZCA background paper on PS56 recommends that a carefully selected
best practice range of equipment is essential for successful and safe patient outcomes.
This equipment needs to be checked, in good working order and readily
available to hand. There is no magical device or technique that will be
suitable for all airway problems, so therefore a range of equipment is
required.12
The DAS website has recommended equipment lists to
go with its algorithms.5
The UK’s Royal College of Anaesthetists ‘Guidelines for the provision of
anaesthetic services’ refer to a need for specialist airway equipment and
state ‘within each theatre suite, there must be at least one portable storage
unit with specialised equipment for managing the difficult airway.’13
The NAP4 Executive Summary recommended that national standardisation
of Advanced Airway trolleys should be given consideration and that each
hospital should ensure a minimum level of airway equipment for all sites
where airway management may be performed.1

Suggested indicators  Existence of a named consultant responsible for the DA set.

 Immediate availability of a DA set in all areas where anaesthesia is
administered, which includes a list of contents and an algorithm
flowchart of advanced airway management.
 Each cart is laid out in a simple, structured manner with labelled
drawers and including airway adjuncts, intubation kit, supraglottic
ventilation devices and emergency cricothyrotomy kit (including
oxygen delivery).
 There is documentation of regular maintenance and stocking of each
DA set.

Standards and  A named consultant should be responsible for the DA set.

criteria for best  100% DA trolley should have a simple layout with labelled drawers, a
practice list of contents and an algorithm flowchart of advanced airway
management.
 100% DA trolleys should include all equipment included on the trolley
contents list.
 100% DA trolleys should include evidence of regular maintenance.

Method Each hospital or practice determines the suitable contents of the DA trolley
and creates a list of contents.
Each trolley should be assessed as to whether it contains the equipment as
detailed on the contents list, that essential equipment is on the trolley and
that there is evidence of regular maintenance. A consultant should be
responsible for ensuring DA trolleys are suitably stocked and equipment
replaced when used.

1. NAP4: Major complications of airway management in the UK. Report

References
and findings of the 4th National Audit Project of The Royal College of
Anaesthetists. RCoA, London March 2011
(http://www.rcoa.ac.uk/nap4).
2. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory
events in anesthesia: a closed claims analysis. Anesthesiology
1990;72(5):828-33.
3. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney
FW. Management of the difficult airway: a closed claims analysis.
Anesthesiology 2005;103(1):33-9.

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 4. 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 2003;98(5):1269-77.
5. Henderson JJ et al. Difficult Airway Society guidelines for the
management of the unanticipated difficult intubation. Anaesthesia
2004;59:675–684.
6. The Vortex Approach: Management of the Unanticipated Difficult
Airway, by Nicholas Chrimes and Peter Fritz, 2013 , Ebook
7. Williamson JA, Webb RK, Szekely S, Gillies ER, Dreosti AV. The
Australian Incident Monitoring Study. Difficult intubation: an analysis
of 2000 incident reports. Anaesth Intensive Care 1993;21(5):602-7.
8. Baker PA, Hounsell GL, Futter ME, Anderson BJ. Airway
management equipment in a metropolitan region: an audit. Anaesth
Intensive Care 2007;35(4):563-9.
9. Australian and New Zealand College of Anaesthetists (ANZCA)
Professional Document PS56: Guidelines on Equipment to Manage a
Difficult Airway During Anaesthesia
10. Cook TM, MacDougall-Davis. Complications and failure of Airway
Management. British Journal of Anaesthesia 109 (s1):i68-i85 (2012)
11. Heard AMB, Green RJ, Eakins P. The formulation and introduction of
a ‘can't intubate, cant ventilate” algorithm into clinical practice.
Anaesthesia; 2009, 64: 601-608
12. Australian and New Zealand College of Anaesthetists (ANZCA)
Guidelines on Equipment to Manage a Difficult Airway During
Anaesthesia :Background Paper PS56BP
13. Guidance on the provision of anaesthesia services for intra-operative
care. RCoA, London 2009.

Acknowledgement This audit guide is adapted from Macguire, B. ‘Adequacy and location of
advanced airway equipment’ In: Royal College of Anaesthetists. Raising the
Standard: a compendium of audit recipes, 2012; p.92-93.
The Royal College has kindly granted ANZCA permission to use this
material.
Author: Dr Helen Ward, FANZCA. July 2015.

Associated documents:

Adequacy of Difficult Airway Equipment Data Collection Form

Adequacy of Difficult Airway Equipment Results Summary & Conclusions Form

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