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Practice patterns for predicted difficult airway management and access to airway equipment by anaesthetists in Queensland, Australia.

There have been a number of surveys conducted in various countries (1-5) assessing difficult airway management, training and equipment availability. These international surveys have revealed regional differences in selection of technique and equipment. Several professional societies have published airway algorithms with the aim of decreasing critical airway incidents. While Australia has not published its own algorithm as yet, its anaesthetic specialists have informally adopted both the American Society of Anesthesiologists' (ASA) Difficult Airway Management (6) and the Difficult Airway Society's (UK) (7) algorithms through its training programs.

We surveyed Fellows of the Australian and New Zealand College of Anaesthetists (FANZCA) living in Queensland. Our questionnaire assessed their current practice patterns for predicted difficult airway management, with the aim of assessing how new techniques and equipment have been integrated into both metropolitan and rural practice. We also surveyed the availability of airway equipment to gauge access and differences in equipment availability in different working environments.


The project was approved by the Human Research Ethics Committee of the Royal Brisbane and Women's Hospital. A survey of predicted difficult airway management was sent to all Fellows registered with the Australian and New Zealand College of Anaesthetists (ANZCA); non-practising members being excluded. Secretarial staff from the Queensland branch of ANZCA facilitated the mailing process with coded questionnaires ensuring confidentiality and anonymity, with a stamped self-addressed envelope included. To enhance response rate, a 'scratch and win' ticket was included with each questionnaire and a second mail-out was performed after eight weeks to non-responders using an identical anonymous process.

The survey consisted of a brief cover letter and was divided into three sections. The first section collected demographic information including work practice (location and full-time equivalent percentage), age, duration of practice, anaesthesia qualifications and Maintenance of Professional Standards activities (this was prior to the transition to the current ANZCA Continuing Professional Development Program). The second part consisted of five case scenarios describing patients requiring tracheal intubation, as outlined in the Appendix. In all cases the airway was predicted to be difficult. There was one elective and four emergency scenarios. Of the emergency cases, there was one case of suspected supraglottic pathology, one involved periglottic pathology, another subglottic pathology and the fourth emergency scenario was a trauma patient in a hard collar. Practitioners were asked to select a method of induction, method of intubation and preferred adjunct device for each scenario. The third part covered availability of difficult airway equipment and was based on the ASA's suggested contents of a portable storage unit for difficult airway management.

Received data was entered into an Excel[TM] (Microsoft Office 2003) spreadsheet by two independent operators and cross-checked. Surveys that were returned to sender unopened were excluded from analysis, but partially incomplete forms were included with blank responses coded as missing data. If two options were selected, then data was coded as missing. Data were analysed using SPSS version 15.0 (SPSS Inc., Chicago, IL, USA). Frequencies and cross-tabulations were used to describe the data. Descriptive statistics were used to present demographic data and to present the results of workplace scenarios and available equipment.

For location of practice, private facilities were classified depending on ability for admitting patients (data taken from the Queensland Health licensing of private health facilities, May 2008). The public hospitals were classified based on clinical services capability framework rating, which classifies public hospitals as level 1, 2, 3 or super-specialist, as detailed in Table 1. (This rating takes into account several factors including expertise of anaesthetic staff [general practitioner, senior medical officer or FANZCA specialist], the complexity of surgery performed at the facility, age of patients and the availability of auxiliary services including intensive care, radiology [diagnostic and interventional], endoscopy, pharmacy and pathology). Classifications used were from ratings assigned from 2005 to 2008 (K. Favaloro, Clinical Governance Unit, Queensland Health, personal communication).


Of the 454 surveys sent out 250 were returned (response rate 55%). Table 1 summarises the practice locations. Table 2 summarises the demographic data. Of the respondents, the majority were less than than 50 years old (64%). Twenty-one percent held another fellowship in addition to the ANZCA fellowships, with Fellowship of the Royal College of Anaesthetists the most common. Full-time private practice was the most common type of practice (44%), with full-time public (staff) anaesthetists representing 30% of the group. Of the public practitioners, the majority worked in level 3 or super-specialist level hospitals, with only four respondents from level 2 and none from level 1. A private hospital (not limited to day surgery) was the most common practice location (45%). Eighty-one percent of practitioners had under taken an airway management Maintenance of Professional Standards activity within the previous year and 31% had participated in a simulator or skills workshop.

Management choices for each of the five scenarios are summarised in Table 3. Awake intubation was the most commonly selected technique for cases 1 to 4. In case 5, an intravenous induction was selected by 89% of respondents. Flexible fibreoptic intubation was preferred by more respondents in cases 1 and 4, whereas direct laryngoscopy was preferred in cases 2, 3 and 5. The option for a surgical airway was selected by 10 and 12% of respondents for cases 2 and 4, respectively. A gum elastic bougie was the most popular adjunct device in all cases (when taking into account that "none" was the most selected in case 4).

The availability of equipment (according to ASA recommendations) was surveyed. A difficult intubation trolley was available to 98% of respondents, with only one respondent indicating that they did not have access to one. Of note, this anaesthetist practised mostly in a private stand-alone day surgery facility. Ninety-four percent of respondents indicated that they had access to appropriate difficult airway equipment. Ninety percent of respondents indicated that no additional equipment was desired. Inadequate access to fibreoptic bronchoscopes and rigid video-aided laryngoscopy devices (Glidescope[TM] and C-Trach[TM], LMA PacMed Pty Ltd, Richmond, Vic.) was documented by 2%. Two respondents stated inadequate access to cricothyroidotomy equipment and both worked predominantly in private institutions. Of interest, nine of the eleven respondents who indicated that additional equipment was required worked in private institutions.


We surveyed FANZCA-qualified anaesthetists working in Queensland regarding their practice patterns for predicted difficult airway management to ascertain how new equipment and techniques have been integrated into practice. The response rate was 55% which is comparable with surveys conducted in other countries, such as 42% in the Netherlands (1), 49% in Canada (3) and 47% in the USA (2). Our results showed that flexible fibreoptic and direct laryngoscopic techniques were preferred for a range of predicted airway difficulties, which is consistent with other surveys performed overseas. The next most frequently selected techniques were surgical airway followed by the intubating LMA. It is notable that newer devices (rigid fibreoptic devices, light wand) and alternative techniques, such as blind nasal intubation, were infrequently selected. This suggests that anaesthetists may prefer using a limited range of familiar equipment and techniques during management of a difficult airway.

The presence of difficult intubation trolleys/boxes was almost universal and 94% of respondents felt that they contained adequate equipment. This was similar to some previously published studies (3), but higher than others studies internationally (5) and local results from rural and remote Queensland centres (8). An error in data collection (the questionnaire stated rigid, not flexible fibreoptic scope) led to inaccurate numbers for flexible fibreoptic intubation equipment. However it remained a popular selection in the scenarios. Items of equipment less frequently available at private facilities were the retrograde wire set, Combitube[TM], Cook tube exchanger[TM], short laryngoscope handles and lighted stylet. While not commonly selected as adjuncts, a complete difficult intubation trolley may prove to be even more important in private hospitals where assistance during crises may be limited. Our findings are consistent with recent data regarding airway management equipment in metropolitan anaesthesia sites that indicated that availability of designated difficult airway equipment may be lacking, with deficiencies more common in private standalone facilities (9). Expenditure on infrequently used equipment such as that found in the ASA list may be prohibitive in the private sector. Formalising Australian recommendations for difficult airway equipment availability could empower private practitioners to improve the range of adjuncts and universal coverage of difficult airway containers to aid them in airway emergencies.

There are several limitations with this survey. Our response rate of 55% excludes a significant portion of the target group. Public hospitals with a clinical services capability framework of level 1 and 2 were represented by only four respondents. These centres may be largely serviced by non-FANZCA members (i.e. general practitioners and senior medical officers) and hence were not surveyed. Reliance on responder recall with equipment availability may also introduce error. The five case scenarios were selected carefully to provide an elective case, a case of manual in-line stabilisation of the neck and sub-, peri- and supraglottic pathology. The selection of cases may not be appropriate to certain professionals if they perform less emergency anaesthesia. Obstetric and paediatric patients were also excluded.

Airway management is a fundamental aspect of anaesthetic practice. The consequences of failed oxygenation are disastrous and we should strive to avoid, or manage (if necessary), that situation. Clinical circumstances and patient pathology are often impossible to change, but external factors can be controlled. Such factors include decision-making with respect to an anticipated difficult airway, availability of appropriate equipment, currency in the use of that equipment and access to assistance.

Standardisation is a concept well accepted in improving patient safety (10). Therefore we feel that standardising available difficult airway equipment would be a fundamental step in improving difficult airway management in both the public and private sectors. As this equipment is used infrequently, recommended equipment for difficult airway management should be user-friendly and require limited training for successful outcomes (11-13). Following standardisation of equipment, a uniform education curriculum focusing on this equipment and the associated airway techniques would assist trainees and consultants in planning for anticipated difficult airways and managing unexpected difficulties. At present, there is no formal structure to airway management training in the ANZCA training program. This may have led to the infrequent use of some techniques (e.g. blind nasal intubation) and explain less frequent use of newer equipment (e.g. rigid fibreoptic devices and the Intubating Laryngeal Mask[TM]). Following such standardisation, further analysis of practice patterns would be necessary to confirm the impact of this on anaesthetic management and on patient safety.

Clinical scenarios

Scenario number   Description

Case 1            A 44-year-old patient presents for an elective
                  laparoscopic cholecystectomy. Previous anaesthetic
                  records indicate difficult bag-mask ventilation,
                  grade III larynx, intubated blindly with bougie on
                  second attempt after 1x oesophageal intubation by
                  consultant anaesthetist.

Case 2            A 38-year-old male presents with possible adult
                  epiglottitis with dysphagia, dysphonia and drooling
                  saliva with increasing dyspnoea. His BMI is 40. He
                  has arrived in theatre for airway management and
                  exploration. Case 3 A 67-year-old man after carotid
                  endarterectomy with a postoperative bleed. Increasing
                  neck swelling and difficulty swallowing. Unable to
                  lie flat. Has arrived in operating theatre for

Case 4            A 28-year-old patient had motorbike vs fence
                  accident. He arrives in theatre with an expanding
                  anterior neck haematoma, dysphonic, increasing
                  dyspnoea, but still conscious and co-operative.

Case 5            A 25-year-old patient has been involved in a motor
                  vehicle accident while intoxicated. His gCS is 11
                  with hard collar in situ and C-spine uncleared. He
                  is haemodynamically unstable and requires intubation
                  for laparotomy.

BMI = body mass index, gCS = glasgow Coma score.


The authors would like to thank Heather Reynolds (Research Assistant), Fran Dwyer and Crystal Smith for their help preparing and processing the data. Thanks to Justin Scott for assistance in preliminary work on the statistics. Thanks also to Janelle Talty of ANZCA for assistance in access to the database and co-ordinating the anonymous mail-out.

Accepted for publication on September 3, 2009.


(1.) Borg PA, Stuart C, Dercksen B, Eindhoven GB. Anaesthetic management of the airway in The Netherlands: a postal survey. Eur J Anaesthesiol 2001; 18:730-738.

(2.) Rosenblatt WH, Wagner PJ, Ovassapian A, Kain ZN. Practice patterns in managing the difficult airway by anesthesiologists in the United States. Anesth Analg 1998; 87:153-157.

(3.) Jenkins K, Wong DT, Correa R. Management choices for the difficult airway by anesthesiologists in Canada. Can J Anaesth 2002; 49:850-856.

(4.) Bokhari A, Benham SW, Popat MT. Management of unanticipated difficult intubation: a survey of current practice in the Oxford region. Eur J Anaesthesiol 2004; 21:123-127.

(5.) Goldmann K, Braun U. Airway management practices at German university and university-affiliated teaching hospitals--equipment, techniques and training: results of a nationwide survey. Acta Anaesthesiol Scand 2006; 50:298-305.

(6.) 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 1269-1277.

(7.) Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59:675-694.

(8.) Eley V, Lloyd B, Scott J, Greenland K. Availability of difficult airway equipment to rural anaesthetists in Queensland, Australia. Rural Remote Health 2008; 8:1020.

(9.) Baker PA, Hounsell GL, Futter ME, Anderson BJ. Airway management equipment in a metropolitan region: an audit. Anaesth Intensive Care 2007; 35:563-569.

(10.) Heidegger T, Gerig HJ, Ulrich B, Kreienbuhl G. Validation of a simple algorithm for tracheal intubation: daily practice is the key to success in emergencies--an analysis of 13,248 intubations. Anesth Analg 2001; 92:517-522.

(11.) Greenland KB, Edwards MJ, Beckmann L, Hutton N. Difficult airway management--a glass half empty. Anaesthesia 2009; 64:1024-1025.

(12.) Frerk CM, Lee G. Laryngoscopy: time to change our view. Anaesthesia 2009; 64:351-354.

(13.) Wilkes AR, Hodzovic I, Latto IP. Introducing new anaesthetic equipment into clinical practice. Anaesthesia 2008; 63:571-575.

Address for correspondence: Dr B. M. Zugai, Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, Qld 4029.

B. M. ZUGAI *, V. ELEY ([dagger]), K. A. MALLITT ([double dagger]), K. B. GREENLAND ([section])

Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland,


* B.Med.Sci. (Hons.), M.B., B.S., F.A.N.Z.C.A., Provisonal Fellow.

([dagger]) M.B., B.S., F.A.N.Z.C.A., Staff Specialist.

([double dagger]) B.Sc. (Hons.), Biostatistician, Queensland Institute of Medical Research.

([section]) M.B., B.S., F.A.N.Z.C.A., F.H.K.A.M, Deputy Director (Research).

Classification of practice location *

classification     Definition              Examples

Level 1 public     Adults and children     Kingaroy Hospital,
                   1-14 y                  Gympie Hospital

Level 2 public     Adults and children     Mackay Base
                   1 month-14 y/HDU        Hospital, Caboolture
                   available               Hospital

Level 3 public     Adults and children     Nambour General,
                   1 month-14 y/Level 1    Cairns Base Hospital
                   ICU available

Super-specialist   Provides services for   RBWH/RCH, PAH,
public             children <1 month       Townsville, Mater

Private (day       Provides day surgery    Short St day
surgery only)      services only           Hospital, Sunshine
                                           Coast Day Surgery

Private (not       Provides services       Wesley Hospital,
limited to day     other than day          Northwest Private
surgery)           surgery

HDU = high dependency unit, ICU = intensive care unit,
RBWH = Royal Brisbane and Women's Hospital, RCH = Royal
Children's Hospital, PAH = Princess Alexandra Hospital.
* Queensland Health Clinical Services Capability Framework
(Version 2.0 S8). From:


Demographic data (n = 454)

Data                             n (%)

Total number of questionnaires   454
Completed questionnaires         250 (55)
Age (y)
   Mean                          46.5
   < 50 y                        159 (63.6)
   [greater than or equal to]     87 (34.8)
   50 y
   Missing                         4 (1.6)

Type of practice
   Full-time staff                76 (30.4)
   Full-time private             110 (44.0)
   Part-time staff only           12 (4.8)
   Part-time private only         23 (9.2)
   Part-time staff and private    23 (9.2)
   Part-time and teaching          2 (0.8)
   Missing                         4 (1.6)

Location of practice
   Level 1 public                  0 (0)
   Level 2 public                  4 (1.6)
   Level 3 public                 50 (20.0)
   Super-specialty level          65 (26.0)
   Private (day surgery only)      9 (3.6)
   Private hospital (not day     112 (44.8)
   surgery only)
   Missing                        10 (4.0)

Length of time as a practising
   [less than or equal to] 4 y    50 (20.0)
   5-9 y                          54 (21.6)
   10-19 y                        65 (26.0)
   [greater than or equal to]     81 (32.4)
   20 y

Anaesthetic qualification held
   FANZCA                        250 (100)
      None                       198 (79.2)
      FRCA                        26 (10.4)
      FCA (SA)                     5 (2.0)
      FHKCA                        2 (0.8)
      Other College               19 (7.6)
   MOPS *
      None                        47 (18.8)
      CME                        133 (53.2)
         Teaching/training/       76 (30.4)
         Quality assurance        52 (20.8)
         Clinical attachment       5 (2.0)
         Simulator/skills         77 (30.8)
         Other                    14 (5.6)

Number of clinical sessions in
past four weeks
   0                              12 (4.8)
   1-14                           37 (14.8)
   15-24                          52 (20.8)
   25-34                          98 (39.2)
   [greater than or equal to]     51 (20.4)

FANZCA = Fellow of the Australian and New Zealand College
of Anaesthetists, FRCA = Fellow of the Royal College of
Anaesthetists, FCA (SA) = Fellow of the College of Anaesthetists
(South Africa), FHKCA = Fellow of the Hong Kong College
of Anaesthesiologists, MOPS = Maintenance of Professional
Standards, CME=continuing medical education. * Does not
summate to total because multiple MOPS undertaken.


Summary of difficult airway scenario results

                                                        Case 3
                            Case 1       Case 2         Post-carotid
                            Elective     Epiglottitis   bleed

Method of induction,
n (%)
   Asleep, intravenous       61 (24.4)    10 (4.0)       54 (21.6)
   Asleep, inhalational      36 (14.4)   110 (44.0)      79 (31.6)
   Awake [+ or -]           152 (60.8)   128 (51.2)     115 (46.0)
   Missing                    1 (0.4)      2 (0.8)        2 (0.8)

Method of intubation,
n (%)
   Direct laryngoscopy       74 (29.6)   117 (46.8)     133 (53.2)
   Blind tracheal tube        1 (0.4)      1 (0.4)        3 (1.2)
   Flexible fibreoptic      154 (61.6)   101 (40.4)     104 (41.6)
   Lighted stylet/light       1 (0.4)      0 (0.0)        0 (0.0)
   Intubating Laryngeal       9 (3.6)      1 (0.4)        5 (2.0)
   Surgical airway            0 (0.0)     25 (10.0)       2 (0.8)
   glidescope Mask[TM]        6 (2.4)      2 (0.8)        1 (0.4)
   Other                      4 (1.0)      1 (0.4)        1 (0.4)
   Missing                    1 (0.4)      2 (0.8)        1 (0.4)

Adjunct device,
n (%)
   Bougie                   117 (46.8)   115 (46.0)     130 (52.0)
   (or equivalent)
   Solid tracheal tube       16 (6.4)     14 (5.6)       18 (7.2)
   Cook's airway exchange    27 (10.8)    43 (17.2)      38 (15.2)
   None                      88 (35.2)    74 (29.6)      63 (25.2)
   Missing                    2 (0.8)      4 (1.0)        1 (0.4)

                            Case 4       Case 5
                            Laryngeal    C-spine
                            trauma       restriction

Method of induction,
n (%)
   Asleep, intravenous       20 (8.0)    222 (88.8)
   Asleep, inhalational      37 (14.8)     2 (0.8)
   Awake [+ or -]           191 (76.4)    24 (9.6)
   Missing                    2 (0.8)      2 (0.8)

Method of intubation,
n (%)
   Direct laryngoscopy       56 (22.4)   199 (79.6)
   Blind tracheal tube        0 (0.0)      0 (0.0)
   Flexible fibreoptic      156 (62.4)    23 (9.2)
   Lighted stylet/light       1 (0.4)      2 (0.8)
   Intubating Laryngeal       2 (0.8)     14 (5.6)
   Surgical airway           31 (12.4)     2 (0.8)
   glidescope Mask[TM]        0 (0.0)      6 (2.4)
   Other                      1 (0.4)      2 (0.8)
   Missing                    3 (1.2)      2 (0.8)

Adjunct device,
n (%)
   Bougie                    72 (28.8)   176 (70.4)
   (or equivalent)
   Solid tracheal tube        9 (3.6)     22 (8.8)
   Cook's airway exchange    44 (17.6)    23 (9.2)
   None                     122 (48.8)    26 (10.4)
   Missing                    3 (1.2)      3 (1.2)

(Appendix outlines the difficult airway scenarios).
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Article Details
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Title Annotation:Original Papers
Author:Zugai, B.M.; Eley, V.; Mallitt, K.A.; Greenland, K.B.
Publication:Anaesthesia and Intensive Care
Article Type:Survey
Geographic Code:8AUST
Date:Jan 1, 2010
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