The airway and the anaesthetist

Safe and effective anaesthesia depends crucially upon airway management. Our speciality urgently needs to prepare, provide and promote guidelines for this core skill. There has been an enormous increase in interest and activity in airway management, with more publications in the last decade than in the previous 50 years [1], many describing uses for new equipment [2]. We need a national strategy linked to the production of clinical guidelines to address these developments, putting them in context and providing our speciality with a firm foundation upon which to build. We live in an era of guidelines, systematically developed statements that assist in decision making about appropriate health care for specific conditions [3]. The Royal College of Anaesthetists has endorsed this principle, encouraging individuals and departments to develop protocols and standards based on recommendations within guidelines. The Association of Anaesthetists has produced a number of booklets over the years that approximate to guidelines on many issues. ‘Every department should have an agreed set of clinical guidelines to cover unexpected or unusual situations, e.g. failed intubation’[4]. But airway management has not received the attention it rightly deserves. In the College's recently published Guidelines for Service Provision [5], one has to look hard for guidance on this subject – there are brief mentions in training for resuscitation (one line, p. 35) and in obstetric anaesthesia (one sentence, p. 63), and that is all. It is 25 years since Tunstall first advocated reasoned approaches to airway management with his difficult airway drill [6]. The American Society of Anesthesiologists developed its Practice Guidelines for the management of the difficult airway with its algorithm in 1993 [7]. This comprehensive approach has not found great favour or acceptance in the United Kingdom, the guidelines considered by many to be too didactic and the algorithm so complicated as to be confusing. The Canadian Airway Focus Group has more recently contributed to the subject [8], but again this has the format of a review. We need a new approach with a set of reasoned and reasonable guidelines that are relevant to our clinical culture. The Difficult Airway Society is taking on this task. The case for guideline development was debated at their last annual meeting and more recently presented at the Winter Scientific Meeting of the Association of Anaesthetists in January 2001. We call upon our national bodies, College and Association, to work collaboratively with the Difficult Airway Society in the production of these guidelines. They should concisely and accurately define terms, promote a set of core competencies in planning, preparation and procedures for airway management relevant to all practising anaesthetists. Clinical, manikin and perhaps simulator skills can be specified. We advocate that each department has designated personnel for developing and promoting these guidelines in the same way that the position of designated paediatric or obstetric anaesthetist is now endorsed. The anaesthesia profession in the United Kingdom faces unprecedented demands. We have largely developed and provide critical care, with calls for further expansion into Critical Care Delivery Groups [9]. Now the anaesthetist is considered by many to be a ‘peri-operative physician’[10]. In responding to and coping with these demands, we are in danger of losing our way. Meanwhile, others, notably the recently christened (by some) speciality of ‘Emergency Medicine’, are busily developing strategies and tactics for airway management independent of anaesthetic involvement [11]. As anaesthetists, one of our main priorities remains airway management. We have a formidable reputation for innovative approaches to the airway, with a distinguished past. We can learn from the past, but we must not dwell on it. Rather, we must look to the future, deciding on what is truly important for our patients. We urgently need nationally agreed and endorsed guidelines on this most important subject, the airway and its' management.

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