Current Difficult Airway Management

—Not Good Enough!
Takashi Asai, M.D., Ph.D.; David Hillman, M.D.
 Author Notes
From the Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan (T.A.); and the Faculty of Health and Medical Sciences, Surgery, University of Western Australia, Perth, Australia (D.H.).
Accepted for publication June 14, 2019.
Correspondence: Address correspondence to Dr. Asai: asaita@dokkyomed.ac.jp
Anesthesiology Newly Published on July 10, 2019. doi:10.1097/ALN.0000000000002885

In safety-critical pursuits, such as aviation and anesthesiology, analysis of critical incidents involving threatened or actual harm is vital in identifying deficiencies and eliminating them. Analyses of anesthesiology-related closed claims offer a distillation of this necessary self-examination as they are concerned with events where harm has occurred. Reflecting on the particularly compelling cases they often involve offers anesthesia care providers insights that are far better gained vicariously than by their own direct experience.
In this issue of Anesthesiology, Joffe et al.1  examine recent closed claims related to difficult tracheal intubation and compare them to older claims, in part to determine whether updated practice guidelines and improved airway management devices and techniques have influenced patient outcomes. Difficulty in tracheal intubation is a time-honored concern in anesthesia practice. A closed claim analysis of adverse respiratory events in 1990 highlighted that adverse outcomes involving the respiratory system were the single largest class of injury, and that the incidence of death or permanent brain damage associated with respiratory-related claims was much higher (85% of claims) than that associated with nonrespiratory claims (30% of claims).2  Since then, major efforts have been made to address difficult airway management issues with the first comprehensive practice guidelines formulated by an American Society of Anesthesiologists task force in 1993.3  These have been followed by updates4  and development of guidelines by other organizations.5  Monitoring has improved, with the wide availability and uptake of oximetry and capnography, and better airway management devices and techniques have been developed. Despite these advances, complications associated with airway management are still the largest cause of anesthesia-related death or permanent brain damage.6  Hence the analysis of Joffe et al.1  is timely as it provides a contemporary view of the characteristics of airway management problems that are now responsible for serious adverse outcomes and provides impetus for renewed efforts to prevent them.