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Survey of airway skills of surgeons in Western Australia.

During general anaesthesia, control of the patient's airway is a major responsibility of the anaesthetist. Ventilation of the lungs is achieved via tracheal tube, laryngeal mask airway, face-mask or, occasionally, tubes, needles or catheters passed via the trachea. Inability to pass a tracheal tube (failed intubation) is not in itself catastrophic, but loss of airway control (failed ventilation) is a life-threatening crisis that has been reported to occur in about one in seven difficult intubations reported to the Australian Incident Monitoring Study1. Preparing for an airway crisis has been the subject of numerous publications and traditional teaching has been that when airway control is lost, a surgical (or 'invasive') airway is secured urgently. Unless the anaesthetist has undergone training and is confident to perform a surgical airway, it is the surgeon who is most likely to be requested to perform this life-saving emergency procedure.

It is unknown whether surgeons generally have assisted, or are capable of assisting, anaesthetists during an airway crisis. It is accepted that surgeons in certain subspecialties, such as ear, nose and throat (ENT) or trauma surgeons, have expertise in the provision of surgical airways. However, airway crises may occur in any surgical setting. We therefore surveyed all surgeons registered in the State of Western Australia to determine their experiences and training relating to emergency airway management.


With approval from the Royal Perth Hospital Ethics Committee, the Royal Australian College of Surgeons and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 445 survey questionnaires were mailed to all specialists who practise surgery of any type within the State of Western Australia. A reply paid envelope was included with each form. The questionnaire is shown in the Appendix (see Appendix on the online version).


The survey was closed six months after the questionnaire mail-out. A total of 238 replies were received (53% response). Seventy-eight percent of respondents were in full-time practice and the remainder practised part-time. The types of surgical practice are listed in Table 1.

Respondents reported that they had last performed an elective surgical airway within various intervals: three months (8%), three to six months (2%), six to 12 months (5%) or longer than 12 months (59%) and 26% had never performed a surgical airway.

An emergency surgical airway had been performed by 60% of respondents; all ENT surgeons had performed one and 56% of non-ENT surgeons had done so. Of all surgeons who responded that they had performed at least one emergency surgical airway, only 5% had not previously performed an elective surgical airway. Of those respondents who reported having performed emergency airway surgery, the proportion of performing such airways is summarised in Figure 1. For example, 47 surgeons had each performed at least six surgical airways.


Surgeons may assist in difficult airway management with nonsurgical skills and 40% responded that they had done so; 94% of ENT surgeons and 36% of non-ENT surgeons had provided technical assistance. Figure 1 lists the number of respondents who had provided assistance once, twice and more often. Nine respondents had witnessed 20 or more difficult airways.

A 'failed airway' was defined as a clinical situation where the anaesthetist awakened the patient or required an emergency surgical airway. Fifty-seven percent of respondents had witnessed such a crisis and proportions of respondents who witnessed one, two or more events are also listed in Figure 1. Three respondents had witnessed 12 or more failed airways.

Confidence in performance of an urgent surgical airway was felt by 63% of respondents, with all ENT surgeons and 60% of non-ENT surgeons expressing this view.

Sixteen surgeons (7%) reported having witnessed a failed airway that resulted in death or neurological damage to a patient. One surgeon reported experiencing two such crises.

Formal training in tracheostomy was reported by 70% of surgeons and 26% had attended an advanced trauma life support or early management of severe trauma (EMST) course. Forty-six surgeons had undertaken tracheostomy and EMST/advanced trauma life support training and 58 had received no such training. We did not survey in which countries the respondents had received their training.


There have been few studies that have examined the role of surgeons in real or simulated airway emergencies. Our survey relied on respondents recalling their involvement in real airway emergencies where an anaesthetist was the initial airway specialist. Such crises are likely to be remembered, although the number of times this event occurred might not be exact. In certain settings, such as ENT surgery and trauma, surgical intervention in airway management is often planned when an anaesthetic airway is not achievable. The frequency of the worst case 'can't intubate, can't ventilate' scenario has been estimated to be approximately 1 in 10,000 patients (2) and cannot always be predicted prior to induction of anaesthesia (3). This survey includes those times when the surgeon was available to assist an anaesthetist to manage an airway crisis. These low-frequency events are difficult to study in the clinical setting.

Several authors have assessed technical competence by surgeons in the absence of airway specialists in simulations. Lowenstein et al (4) assessed junior medical and surgical staff at a university teaching hospital. Only 29% of those tested were able to ventilate an advanced cardiac life support manikin and only one-third could perform tracheal intubation in 35 seconds or less. Shannon et al (5) tested 59 surgeons at a testing station in an American College of Surgeons meeting. Overall, 51% of surgeons successfully performed tracheal intubation within one minute.

In general, difficult airways should be managed by the specialist with the greatest skill. in specific clinical scenarios anaesthetists may not always be the most appropriate practitioner to secure airway control (6) although such assertions continue to be debated (7). Schwartz (8) argues that "It is prudent to have a surgeon skilled in performing a tracheotomy and a cricothyroidotomy standby" in the situation where intubation may not be achievable. However, even skilled surgeons who have undergone training in surgical airway techniques may, in time, lose their ability to provide an emergency surgical airway. Furthermore, patients with unusual airway anatomy may present special difficulties even to an experienced surgeon during an airway crisis, resulting in a poor outcome.

Multidisciplinary training in the operating theatre emphasises workload distribution and participation by all members of the operating team in all crises. For airway emergencies, surgeons have often been regarded as a valuable resource for provision of a surgical airway. Results from this survey indicate that these historical ideas need revision. While some surgeons who have undergone training outside of Australia, or those who have experienced a broad training within this country, may feel confident in performing emergency tracheostomy, current training is not so broad. in Australia, basic training of young surgeons overseen by the Royal Australasian College of Surgeons does not include tracheostomy. All Australian-trained surgeons are expected to complete an EMST course. However, EMST does not teach advanced surgical airway skills. The definitive surgical trauma care course program of the Royal Australasian College of Surgeons does teach advanced surgical airway skills, but is optional. Also, training for obstetrician/ gynaecologists administered by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists does not include tracheostomy.

Current guidelines and algorithms from the American Society of Anesthesiologists (9), the Difficult Airway Society (10) (UK) and the Australian and New Zealand College of Anaesthetists' Effective Management of Anaesthetic Crises (11) now include techniques for supraglottic airway devices (laryngeal mask airway, Combitube), transtracheal needle or catheter techniques and also surgical airway techniques. In general, advanced airway training for airway crises utilises synthetic models with commercial airway devices that are available locally. A more realistic 'wet lab' using anaesthetised sheep for teaching surgical airway management to anaesthetists at Royal Perth Hospital has recently been described (12). Both trainee and consultant grade anaesthetists are encouraged to undertake this supervised course and to undergo refresher training wherever possible. While there is no certainty that anaesthetists, who have been trained with needle and scalpel techniques for management of the surgical airway, will be successful in the event of a 'can't intubate, can't ventilate' scenario, it might be better that they attempt a surgical airway rather than persisting with non-invasive techniques that were unsuccessful initially. Following training, both anaesthetists and surgeons face the challenge of skill retention and refresher courses in advanced airway management should reflect this fact.

In conclusion, anaesthetists should discuss the potential for surgical airway management with their surgical colleagues whenever difficulty is anticipated. Even when routine airway management is planned, it is important for anaesthetists to know the surgical airway capabilities of their colleagues. If there is concern by an anaesthetist that his or her patient has a difficult airway that cannot be managed with non-invasive techniques, it remains their responsibility to ensure that such a patient is managed in a setting where advanced airway techniques are available. On occasion this will require transfer of such patients to another facility. Because airway crises can be catastrophic for the patient and devastating to those caring for them, we recommend that patients with identified difficult airways receive care by clinicians with advanced airway skills.


The authors thank all participants for their responses to this survey.

Accepted for publication on February 6, 2009.


(1.) 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 1994; 21:602-607.

(2.) Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology 1989; 71:769-778.

(3.) Turkan S, Ates y, Cuhruk H, Tekdemir i. Should we reevaluate the variables for predicting the difficult airway in anesthesiology? Anesth Analg 2002; 94:1340-1344.

(4.) Lowenstein SR, Hansbrough JF, Libby LS, Hill DM, Mountain RD, Scoggin CH. Cardiopulmonary resuscitation by medical and surgical house-officers. lancet 1981; 2:679-681.

(5.) Shannon Fl, Jurkovich GJ, Hansbrough JF. Assessment of the proficiency of the surgeon in providing basic and advanced cardiac life support. Surg Gynecol Obstet 1984; 159:9-12.

(6.) Gleeson MJ, Siodlak MZ, Wengraf Cl. Fibre optic guided nasal intubation--shouldn't we be the experts? J Laryngol Otol 1985; 99:775-778.

(7.) Desjardins G, Varon AJ. Do you really want the surgeon to take care of the airway? Can J Anaesth 1997; 43:1181-1182.

(8.) Schwartz DE, Wiener-Kronish JP. Management of the difficult airway. Clin Chest Med 1991; 12:483-495.

(9.) 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; 98:1269-1277.

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

(11.) Weller JM. Effective Management of Anaesthetic Emergencies. in: Riley RH, ed. Manual of Simulation in Healthcare. Oxford: Oxford university Press 2008.

(12.) Matzelle S, Heard A, Eakins P. Airway training program. The ANZCA Bulletin 2008; July:30-31.

R. H. RILEY *, T. STRANG [dagger], S. RAO [double dagger]

Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia

* F.A.N.Z.C.A., F.A.C.A., Anaesthetist.

[dagger] F.R.C.A., Senior Registrar.

[double dagger] F.R.A.C.S., Surgeon, Department of General Surgery, Royal Perth Hospital.

Address for reprints: Dr R. H. Riley, Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Box X2213 GPO, Perth, WA 6001.

Surgeons' areas of practise (n = 238)

Specialty %

General surgery 25
Obstetrics/gynaecology 24
Orthopaedic surgery 19
Ear, nose and throat surgery 8
Plastic surgery 8
Ophthalmology 6
All other specialties 10
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Article Details
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Author:Riley, R.H.; Strang, T.; Rao, S.
Publication:Anaesthesia and Intensive Care
Article Type:Survey
Geographic Code:8AUST
Date:Jul 1, 2009
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