Just breathe!

Breathing seems to be a major theme in the literature (and at meetings) at the moment, and there are a number of articles in this month’s edition of the journal that are relevant.

Apnoeic oxygenation and nasal oxygen administration are two concepts that are hardly new in anaesthesia, but are rapidly taking centre-stage for management in a wide variety of situations. Dr’s Patel and Nouraei coined the term THRIVE – Transnasal Humidified Rapid-Insufflation Ventilatory Exchange – and described a case series in Anaesthesia in 2015. This paper has just received the award for ‘Best paper in Anaesthesia of 2015’ at the AAGBI Annual Scientific Meeting in Birmingham.

The situation of rapid sequence induction of general anaesthesia is one in which we are poor at predicting airway management difficulty (see e.g. Norskov et al. Anaesthesia 2015; 70: 272 – number 2 ranked of the 2015 Anaesthesia articles), yet we produce an unstable situation of complete muscle paralysis before the definitive tracheal intubation procedure. In this edition of the journal, Pillai et al. using the Nottingham Physiology Simulator have  shown that, under ideal conditions, oxygen delivery during apnoea might increase the time to desaturation of a pregnant subject from 4.5 min to 58 min. This is incredible if true, and will be of great interest to all obstetric anaesthetists, but needs to be further investigated in pregnant patients – I believe such trials are ongoing.

There are likely to be more papers on this subject in Anaesthesia in the near future – watch this space for progress that may dramatically change how we do things in one of the high-risk areas of our practice.

This edition of the journal also includes a paper describing the current state of airway training in UK anaesthetic departments. The Fourth National Audit Project (NAP4) recommended routine and regular airway training for trainee and trained anaesthetists. However, in this survey from 206 hospitals (62%) covering all regions of the UK, 16% of hospitals did not provide airway workshops for staff at all, and 51% only for trainees. Of those providing workshops, more than half were being run less than annually. The authors concluded that workshop-based airway training is variable in provision, frequency and content, and is often not prioritised by departments or individual trainers. I agree that the provision of appropriate training identified in NAP4 is sadly lacking in many hospitals, and the reasons for this are many, but surely include resources as well as motivation. Getting Consultants out of the operating theatre into an hour or two-long airway workshop is what is needed, and regularly, but this isn’t easy, especially when getting any time out of theatre (or ICU) is getting harder and harder in the current climate. Should this be made part of mandatory training? And are workshops really the answer?

Finally, what about trainees challenging consultants? There is a perception that trainees should challenge their ‘seniors’ more frequently, especially when they are obviously wrong. This is borne out by this simulation study which explores the concept of ‘barriers to challenging seniors’ for anaesthetic trainees. The authors concluded that more senior trainees challenged their consultant supervisor quicker, allowed fewer intubation attempts, established quicker adequate rescue oxygenation and ventilation and less simulated patient desaturation was observed. This is not really surprising as experience and maturity should improve performance, especially in this sort of scenario, but the authors make some interesting observations about improving training to give trainees the confidence to challenge more effectively and with less hesitation. Take a deep breath and go for it!


Andrew Klein