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Airway management in anaesthesia care: professional and patient perspectives
University of Gävle, Faculty of Health and Occupational Studies, Department of Health and Caring Sciences. Uppsala universitet, Institutionen för folkhälso- och vårdvetenskap.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Resource type
Text
Abstract [en]

Background: Careful airway management, including tracheal intubation, is important when performing anaesthesia in order to achieve safe tracheal intubation. Aim: To study airway management in anaesthesia care from both the professional and patient perspectives. Methods: 11 RNAs performed three airway tests in 87 patients, monitored in a study-specific questionnaire. The tests usefulness for predicting an easy intubation was analysed (Study I). 68 of 74 anaesthesia departments in Sweden answered a self-reported questionnaire about the presence of airway guidelines (Study II). 20 anaesthesiologists were interviewed; a phenomenographic analysis was performed to describe how anaesthesiologists' understand algorithms for management of the difficult airway (Study III). 13 patients were interviewed; content analysis was performed to describe patients' experiences of being awake fiberoptic intubated (Study IV). Results: The Mallampati classification is a good screening test for predicting easy intubation and intubation can be safely performed by RNAs (Study I). The presence of airway guidelines in Swedish anaesthesia departments is poorly implemented (Study II). Algorithms can be understood as law-like rules, a succinct plan to follow in difficult airway situations, an action plan kept in the back of one's mind while creating flexible and versatile personal algorithms, or as consensus guidelines based on expert opinion in order to be followed in clinical practice (Study III). One theme emerged describing experiences of being awake intubated; feelings of being in a vulnerable situation but cared for in safe hands, described in five categories: a need for tailored information, distress and fear of the intubation, acceptance and trust of the staff's competence, professional caring and support, and no hesitation about new awake intubation (Study IV). Conclusions: The Mallampati classification is a good screening test for predicting easy intubation, when the airway assessment is performed in a structured manner by RNAs. The presence of airway guidelines in Swedish anaesthesia departments was poorly implemented and should receive higher priority. Algorithms need to be simple and easy to follow and based on the best available scientific evidence. Tailored information about what to expect, ensuring eye contact, and giving breathing instructions during the procedure may reduce patients' feeling distress.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2016. , 56 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1205
Keyword [en]
Airway management, algorithm, awake intubation, professional and patient perspective
National Category
Nursing Anesthesiology and Intensive Care
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:hig:diva-21451ISBN: 978-91-554-9534-3 (print)OAI: oai:DiVA.org:hig-21451DiVA: diva2:924922
Public defence
2016-05-20, Brömssalen, Gävle sjukhus, Lasarettsvägen 1, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2016-04-29 Created: 2016-04-29 Last updated: 2016-04-29Bibliographically approved
List of papers
1. The best method to predict easy intubation: a quasi-experimental pilot study
Open this publication in new window or tab >>The best method to predict easy intubation: a quasi-experimental pilot study
2014 (English)In: Journal of Perianesthesia Nursing, ISSN 1089-9472, E-ISSN 1532-8473, Vol. 29, no 4, 292-297 p.Article in journal (Refereed) Published
Abstract [en]

PURPOSE:

To facilitate evaluation of the airway before endotracheal intubation, different scores have been developed, mainly to predict difficult airways. However, in anesthesia clinical practice in Sweden, scores would be more useful if they could also predict an easy airway, so that the correct category of anesthesia personnel can be allocated. Therefore, we evaluated whether scoring systems commonly used to predict difficult airways could also predict easy endotracheal intubation.

DESIGN:

This prospective observational study included patients who were scheduled for general anesthesia and required endotracheal intubation.

METHODS:

Airways were evaluated preoperatively by two independent variables, namely Mallampati classification and thyromental distance. After anesthesia induction, the Cormack and Lehane grade was assessed.

FINDING:

Mallampati scores yielded the highest specificity in predicting easy intubation, and Cormack and Lehane grades yielded the highest positive predictive value for predicting easy intubation.

CONCLUSIONS:

Mallampati classification is an appropriate screening test for predicting easy intubation.

Keyword
intubation, Mallampati classification, Cormack and Lehane grade, airway management
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:hig:diva-17345 (URN)10.1016/j.jopan.2013.05.015 (DOI)000340344000005 ()25062573 (PubMedID)2-s2.0-84904664939 (ScopusID)
Projects
Patientsäkerhet och omvårdnad i samband med anestesi med fokus på luftvägen
Available from: 2014-08-13 Created: 2014-08-13 Last updated: 2016-04-29Bibliographically approved
2. A nationwide postal questionnaire survey: The presence of airway guidelines in anaesthesia department in Sweden
Open this publication in new window or tab >>A nationwide postal questionnaire survey: The presence of airway guidelines in anaesthesia department in Sweden
Show others...
2014 (English)In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 14, no 25, 25- p.Article in journal (Refereed) Published
Abstract [en]

Background

In Sweden, airway guidelines aimed toward improving patient safety have been recommended by the Swedish Society of Anaesthesia and Intensive Care Medicine. Adherence to evidence-based airway guidelines is known to be generally poor in Sweden. The aim of this study was to determine whether airway guidelines are present in Swedish anaesthesia departments.

Methods

A nationwide postal questionnaire inquiring about the presence of airway guidelines was sent out to directors of Swedish anaesthesia departments (n = 74). The structured questionnaire was based on a review of the Swedish Society of Anaesthesia and Intensive Care voluntary recommendations of guidelines for airway management. Mean, standard deviation, minimum/maximum, percentage (%) and number of general anaesthesia performed per year as frequency (n), were used to describe, each hospital type (university, county, private). For comparison between hospitals type and available written airway guidelines were cross tabulation used and analysed using Pearson’s Chi-Square tests. A p- value of less than 0 .05 was judged significant.

Results

In total 68 directors who were responsible for the anaesthesia departments returned the questionnaire, which give a response rate of 92% (n 68 of 74). The presence of guidelines showing an airway algorithm was reported by 68% of the departments; 52% reported having a written patient information card in case of a difficult airway and guidelines for difficult airways, respectively; 43% reported the presence of guidelines for preoperative assessment; 31% had guidelines for Rapid Sequence Intubation; 26% reported criteria for performing an awake intubation; and 21% reported guidelines for awake fibre-optic intubation. A prescription for the registered nurse anaesthetist for performing tracheal intubation was reported by 24%. The most frequently pre-printed preoperative elements in the anaesthesia record form were dental status and head and neck mobility.

Conclusions

Despite recommendations from the national anaesthesia society, the presence of airway guidelines in Swedish anaesthesia departments is low. From the perspective of safety for both patients and the anaesthesia staff, airway management guidelines should be considered a higher priority.

Keyword
Airway guidelines, Airway management, Patient safety
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:hig:diva-16945 (URN)10.1186/1471-2253-14-25 (DOI)000335076000001 ()24708670 (PubMedID)2-s2.0-84899477547 (ScopusID)
Projects
Patientsäkerhet och omvårdnad i samband med anestesi med fokus på luftvägen
Available from: 2014-06-16 Created: 2014-06-16 Last updated: 2016-04-29Bibliographically approved
3. Anaesthesiologists understanding of algorithms for management of the difficult airway: a qualitative interview study
Open this publication in new window or tab >>Anaesthesiologists understanding of algorithms for management of the difficult airway: a qualitative interview study
Show others...
2016 (English)Article in journal (Other academic) Submitted
Keyword
airway algorithm, qualitative study
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:hig:diva-21452 (URN)
Available from: 2016-03-30 Created: 2016-04-29 Last updated: 2016-04-29Bibliographically approved
4. Awake intubation creates feelings of being in a vulnerable situation but cared for in safe hands: a qualitative study
Open this publication in new window or tab >>Awake intubation creates feelings of being in a vulnerable situation but cared for in safe hands: a qualitative study
2016 (English)In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 16, no 1, 71Article in journal (Refereed) Published
Abstract [en]

Background

Awake fiberoptic intubation is an alternative procedure for securing the airway and is a recommended option when a difficult airway is expected. The aim of the present study was to describe patient experiences with this procedure.

Methods

A qualitative, descriptive design was used and patients were recruited from three county hospitals and one university hospital in Sweden. Data was collected by semi-structured interviews with 13 patients who underwent awake fiberoptic intubation. A qualitative content analysis extracted theme, categories, and subcategories.

Results

From the patient statements, one main theme emerged, feelings of being in a vulnerable situation but cared for in safe hands, which were described in five categories with 15 subcategories. The categories were: a need for tailored information, distress and fear of the intubation, acceptance and trust of the staff’s competence, professional caring and support, and no hesitation about new awake intubation. The patients felt they lacked information about what to expect and relied on the professionals’ expertise. Some patients felt overwhelmed by the information they were given and wanted less specific information about the equipment used but more information about how they would be cared for in the operating room. Undergoing awake intubation was an acceptable experience for most patients, whereas others experienced it as being painful and terrifying because they felt they could not breathe or communicate during the procedure itself.

Conclusions

Tailored information about what to expect, ensuring eye contact and breathing instruction during the procedure seems to reduce patient distress when undergoing awake fiberoptic intubation. Most of the patients would not hesitate to undergo awake intubation again in the future if needed.

Keyword
Awake fiberoptic intubation, Anaesthesia care, Qualitative study
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:hig:diva-21453 (URN)10.1186/s12871-016-0240-z (DOI)000382199100004 ()27576876 (PubMedID)2-s2.0-84984622328 (ScopusID)
Available from: 2016-03-30 Created: 2016-04-29 Last updated: 2016-11-11Bibliographically approved

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