Front of neck access: whose responsibility is it?

Published Date: 21st February 2019

Publication Authors: Jain N, Kainth R, Kennedy T

Background

Management of an airway is a vital skill for many specialties. Front of neck access (FONA) is often a feared and unexpected event in a ‘can’t intubate, can’t oxygenate’ (CICO) scenario. Unless a clear plan is formed, further clinical difficulties could arise [1]. The Difficult Airway Society (DAS) has endeavoured to produce clear succinct standardised guidelines on how to manage unexpected difficult airways. Although these guidelines are primarily disseminated amongst anaesthetists, it is known that FONA often involves multiple disciplines. Our goal was to promote knowledge of the DAS guidelines and allow practice of the ‘scalpel, bougie and tube’ technique [2] for FONA amongst our anaesthetic, critical care, ear–nose–throat (ENT) and emergency medicine colleagues.

Methods

A series of surveys and educational teaching sessions were carried out to review knowledge and opinions about the multidisciplinary team (MDT) approach to DAS guidelines, and to allow each individual practise with FONA. Data were collected from anaesthetists, ENT surgeons, critical care and emergency medicine doctors.

Results

Fifty-seven responses were collected across all four departments in Whiston Hospital, the majority of which were anaesthetists (54.4%). All anaesthetic trainees (n = 12) were aware of current DAS guidelines and correctly described the steps involved. However, 84% of anaesthetic consultants (n = 19) were aware of guidelines and only 47% described the steps correctly. Twenty-three per cent of anaesthetic consultants had clinically performed cricothyroidotomies compared to 66% of ENT surgeons and 43% of critical care doctors. Amongst anaesthetic consultants (58%), anaesthetic trainees (75%), ENT surgeons (88%) and emergency medicine doctors (90%) confidence in performing emergency FONA was little to none. The majority of participants felt that emergency FONA was a shared role and that teaching should be delivered regularly.

Discussion

FONA is a vital and challenging skill, required at a critical point in airway management. Our review has found that anaesthetic trainees are most familiar with DAS guidance. However, it appears that doctors with the best knowledge of guidelines are not the most confident with FONA, and those with high confidence are not up to date with current DAS guidance. Almost all specialties agreed that FONA was a MDT skill, with shared responsibility [1, 2]. We intend to provide frequent teaching and updates on guidance for all emergency specialties to improve competence and confidence.

 

Kainth, R; Kennedy, T; Jain, N. (2019). Front of neck access: whose responsibility is it? . Anaesthesia. 74 (Sup 2), p70

« Back