A major project of the Scottish Airway Group to date has been the recommendation of standardised “difficult airway trolleys” within each anaesthetic, critical care and emergency department across Scotland. Several departments have already installed their Airway Rescue Trolleys (ARTs), with many others proposing to do so.
Recommendations for delivery of an Airway Rescue Trolley (ART):
A trolley specifically for airway management during unexpected, potentially life-threatening, difficulty. Equipment for the management of the predicted difficult airway can be kept separately.
IT MUST BE ABUNDANTLY CLEAR TO EVERYBODY THAT THIS IS THE TROLLEY REQUIRED DURING AN EMERGENCY (unless the Difficult Intubation Trolley is requested).
The ART should be sited in every location throughout the hospital where interventional airway management takes place. All staff must be familiar with its location and purpose.
The ART should be identical in layout and presentation in all sites throughout the hospital. The precise contents may differ very slightly, such as the presence or absence of a videolaryngoscope. The location of the ART must be explicit with signage (available on DAS website or via SAG) and communication to all relevant staff. Training in use of the trolley and its equipment is paramount.
The trolley should be mobile and uncluttered, with a minimum of 4 drawers and as few of each device as possible.
The trolley should be labelled very clearly, checked regularly, using the attached inventory, and have this recorded. Examples of drawer stickers are on SAG website.
A copy of the Difficult Airway Society (DAS) algorithms should also be attached.
The layout should follow the DAS Guidelines for the management of the unpredicted difficult intubation, namely the 4 drawers corresponding to Plans A-D of algorithms. The rationale should encourage staff to ensure oxygenation once any attempts at intubation during Plans A and B have been completed. The precise content of each drawer can be agreed locally, but we recommend using the following guide:-
Drawer A – Primary Intubation. [Max 4 attempts; 3 in RSI]
Kit should include conventional laryngoscopes, such as Macintosh and McCoy, bougies and stylets. A stubby handle is recommended. Videolaryngoscopes may be included here. However, the drawer should have as few devices as is necessary.
Drawer B – Secondary Intubation. [NOT IN RSI]
The DAS-named ‘low-skill fibreoptic intubation’. Options here are ILMA (3-5) and ETTs (6-8) and /or a supraglottic airway device (SAD) of choice (such as a cLMA, PLMA or iGel) and a Cook Aintree Catheter and size 7 ETT. A swivel connector for the latter technique is preferable as it facilitates optimal oxygenation during the procedure.
Drawer C – Oxygenation + Ventilation. [Consider ‘wake-up’ and reversal of paralysis]
Facemasks, OPAs, NPAs, SAD of choice (such as cLMA, PLMA, LMA-Unique)
Drawer D – CICO or CICV [Consider paralysing patient]
Narrow bore cricothyrotomy cannula, such as Ravussin, with oxygenation device, such as Enk Oxygen Flow Modulator or Manujet Ventilator.
Surgical Cricothyrotomy Kit. The Cook Universal Kit has the benefit of containing everything required for a surgical airway, bar an ETT, as well as narrow and wide bore cannulae. It is recommended that a bougie and an ETT (eg size 6) are included in this drawer.
Consider a wide-bore cannula kit, such as a Cook Melker, VBM Quicktrach or Smith’s PCK, but again there are benefits of keeping choice to a minimum.
Notes
1. A flexible fibrescope should be used for Plan B. this can be kept elsewhere in the theatre suite. We recommend a maximum of 2 attempts to effectively site SAD, before moving to plan C and just 1 attempt at passing ETT via SAD.
2. Sugammadex may have a role to play in Plan C depending on muscle relaxant used. Some trusts may choose to keep this on the trolley.
3. There is the option of having just one or both of the ILMA or Aintree / SAD options in Drawer B. Hospitals can make an individual choice, but opting for just one choice makes training and stocking easier. NAP4 recommends the Aintree catheter technique as this technique has some benefits in terms of familiarity, less complexity and the maintenance of oxygenation during the procedure.
4. Choice of SADs should again be made at a departmental or trust level. The published evidence would support the use of the PLMA, but issues remain re insertion technique, training, availability, processing etc. Familiarity with the SAD is key and so a single-use device such as the LMA-Unique may be the preferred option if that is what staff are using routinely. SAG would recommend the use of a ‘second generation’ SAD if it is used regularly in the department, as NAP4 demonstrated that aspiration remains a critical issue. This is particularly true for Plan C.
5. Choice of cricothyrotomy kits for Drawer D should again be made at a departmental or trust level. Narrow bore cannulae techniques require a high-flow oxygen delivery system.
6. Regarding Plan D, it is a NAP4 recommendation that the patient, in whom ‘wake up’ is not deemed an option, is paralysedbefore determining the need to proceed to cricothyrotomy.
7. Individual departments wishing to acquire stickers and signage for their trolley can do so via SAG by emailing b.mcguire@nhs.net.
Barry McGuire
SAG Chairman 2010-2013
The following documents can be downloaded here (as PDFs):
Recommended content for ART (NHS Tayside)
ART flowchart (NHS Lanarkshire)
Further examples of signage are available on the DAS website under Anaesthetic Emergency Signage (courtesy of Mark Barley)