Airtraq: Providing An Indirect Route To The Cords
Author: Jeffrey L Tong, Consultant Anaesthetist, Royal Centre for Defence Medicine, Birmingham, United Kingdom

Intensive Care Unit Tracheostomy: A Snapshot Of UK Practice
Authors: Tonny Veenith, Thomas Standley, Department of Anaesthetics, Addenbrooke’s Hospital, Cambridge
Sangeetha Ganeshamoorthy, Joseph Carter and Peter Young, Department of Anaesthetics, Queen Elizabeth Hospital, Norfolk

Minimising The Risks Of Retaining Throat Packs After Surgery
Author: Tracy Coates, Anaesthetic Lead at the National Patient Safety Agency (NPSA)

Airtraq: Providing An Indirect Route To The Cords
Author: Jeffrey L Tong, Consultant Anaesthetist, Royal Centre for Defence Medicine, Birmingham, United Kingdom

The Macintosh laryngoscope (ML) has been used world-wide to perform direct laryngoscopy and tracheal intubation in millions of patients, and is the device of choice for many clinicians. Whilst the aetiology of difficult direct laryngoscopy and intubation is multifactorial, the incidence of difficulty (1.5%) with the ML remains high¹. Numerous indirect laryngoscopes have been introduced which allow visualisation of the vocal cords without the need to align the oral, pharyngeal and laryngeal axes [Table 1]. These developments have provided clinicians with a significantly better view of the glottis and have improved the efficiency of routine and difficult intubation^{2, 3}.

Table 1. Indirect laryngoscopes.

The Airtraq® (Prodol Meditec SA., Vizcaya, Spain)
The Pentax-AWS® (Pentax Corp, Tokyo, Japan)
The McGrath® (Aircraft Medical Ltd, Edinburgh, UK)
The GlideScope® (Verathon Inc, Bothell, USA)

A common feature of clinical practice and one which is evident within the anaesthetic community is that opinions vary on almost every topic. Conflicting opinion may lead to confusion, which is a significant concern when difficult intubation continues to contribute to anaesthesia related morbidity and mortality⁴. The search for a disposable device that has a superior clinical performance to the ML has been an objective of several companies specialising in medical equipment. The results of clinical studies comparing the performance of laryngoscopes invariably show that indirect laryngoscopes are superior to the ML. However, in a recent editorial the scientific value and conclusions from several of these studies has been questioned5. Conducting studies which adequately evaluate these newer indirect laryngoscopes are essential if we are to provide clinicians with the evidence to reliably choose the most effective product.

Figure 1. The range of Airtraq laryngoscopes.

In recent years the range of Airtraq optical laryngoscopes (Prodol Meditec SA., Vizcaya, Spain) has expanded to seven [Figure 1 and Table 2], and it has become an increasingly popular device in clinical practice⁵. Although it is used for routine laryngoscopy, its use is particularly suited to difficult airway management and the pre-hospital environment.

Table 2. The range of Airtraq laryngoscopes, colour coding and corresponding tracheal tube sizes.

Regular adult	Blue	7.0 – 8.5 mm
Small adult	Green	6.0 – 7.5 mm
Paediatric	Purple	4.0 – 5.5 mm
Neonatal	Grey	2.5 – 3.5 mm
Nasotracheal adult	Orange	-
Nasotracheal paediatric	White	-
Double lumen	Yellow	35 – 41 F

Difficult airway management
The Airtraq has been shown to be effective during both routine and difficult laryngoscopy^{3, 6, 7}, and competency with its use can be quickly achieved. Following unanticipated failure of direct laryngoscopy (primary intubation plan), the Airtraq has been identified as a popular choice of secondary laryngoscope⁸. This has led to many departments supplementing their difficult intubation equipment with the Airtraq. When mask ventilation is sub-optimal, some clinicians are advocating a quick look with the Airtraq before following the Difficult Airway Society guidelines. In patients known to have a poor view of the glottis or when difficult laryngoscopy is anticipated, the incidence of failure of the primary intubation plan may be reduced if the first attempt to intubate is performed with an indirect laryngoscope, in preference to the ML.

Fibreoptic endoscopy and intubation has often been described as the recommended or gold standard approach for dealing with many types of difficult intubation⁹, but endoscopy skills fade, which may restrict operator performance and success. It should be possible to maintain the skills required to use the Airtraq through regular monthly use of the device, so skill fade is unlikely to be a significant issue. Having an alternative intubation plan is important for the occasional fibreoptic endoscopist and it is encouraging to note that following topical anaesthesia to the airway, awake intubation has been successful using the Airtraq^{10, 11.}

Temporomandibular joint disease and oropharyngeal infections commonly restrict mouth opening, and awake fibreoptic intubation is normally used to facilitate tracheal intubation in patients with reduced inter-incisor distance. In anaesthetised patients an alternative technique of intubation has been described that involves a paediatric Airtraq and bougie: this low profile Airtraq (12.5mm) is passed between the teeth until an indirect view of the glottis is obtained. A bougie is inserted through the guiding channel into the trachea; the tube is then railroaded over the bougie in the traditional manner. This technique may not provide a view of the glottis if the length of the Airtraq is less than the distance from the patients’ lower incisors to the angle of the mandible.

Pre-hospital use
The versatility of indirect laryngoscopes has led to significant interest from pre-hospital practitioners and by the armed forces of several nations^{12, 13}. At the road-side, tracheal intubation may be necessary prior to patient extrication and the Airtraq has been shown to be an efficient device for intubating sitting casualties. Intubation at floor level is also significantly easier with the Airtraq than with the ML12.

Following cervical spine immobilisation, mouth opening may be restricted by the collar and direct laryngoscopy is usually more difficult. Whilst maintaining manual in-line stabilisation, tracheal intubation may be accomplished by releasing the front of the collar, which often improves intubating conditions. Maintaining a neutral alignment between the head and neck provides optimal intubating conditions for Airtraq intubation¹⁴; and releasing the collar is rarely necessary. Continuous fluoroscopic studies have been used to assess cervical spine movement during tracheal intubation, and fibreoptic endoscopy has been shown to produce less cervical movement than indirect or Macintosh laryngoscopy.

Published data on the performance of the Airtraq during rapid sequence induction (RSI) either in or out of hospital is limited, but in feedback from other clinicians and from my own experience, the technique has been quick, smooth and uncomplicated.

Intubation using the Glidescope requires a rigid stylet, over which the tracheal tube is pre-loaded. Whilst the device provides an excellent view of the glottis, difficulty may be encountered introducing the stylet into the proximal trachea. An assistant may be required to hold and then remove the stylet during railroading of the tracheal tube, which may restrict its usefulness in environments where manpower is limited.

Improving intubation success
Although intubation using an Airtraq may be accomplished quickly in patients with normal and difficult airways, it may not always be successful on the first attempt. Despite providing a full indirect view of the glottis, the tracheal tube may be directed towards the oesophagus or impinge on the right arytenoid^{12, 15}. Manipulating and lifting the Airtraq (back and up manoeuvre), so that the glottis is lower in the view finder or video screen, usually allows intubation to be accomplished^{15, 16}. Regular use of the device should provide clinicians with an understanding of the subtleties associated with Airtraq intubation.

Tearing the tracheal tube cuff during intubation may be avoided by fully deflating it prior to loading the tube into the guiding channel on the Airtraq. The risk of cuff damage may be further reduced by lubricating the tube and guiding channel, which should decrease the inertia and limit any resistance to tube advancement during intubation.

Occasionally the tongue can obstruct the space required to insert the Airtraq into the mouth. A similar problem may occur in adults when inserting a Guedel airway and this problem may be resolved using a rotational or ‘flip manoeuvre’. It should be performed carefully to avoid trauma to the palate and teeth, but an adequate inter-incisor distance is needed, due to the wider profile of the Airtraq along its length.

The teaching of airway management has been shown to be improved when video-assisted laryngoscopic techniques are used¹⁷. A video screen is a common feature of indirect laryngoscopes, but with the Airtraq an optional video monitor or camera can also be connected using a wired or wireless method [Figure 2].

Figure 2. The Airtraq wireless monitor (AWM).

Minimising trauma
Airway instrumentation and laryngoscopy should always be performed with care and gently to minimise the risk of trauma to the airway. A recent study showed that video-assisted laryngoscopy exerted less force to the maxillary incisors than a Macintosh blade [¹⁸]. Whether this could reduce the incidence of litigation associated with anaesthetic-related dental trauma remains to be established.

Power pack
Whilst the Airtraq is a single use device, the limited battery duration may restrict the shelf-life of the sealed product. A recent modification to the power pack has simplified the process of battery removal and disposal following use. Since alkaline batteries are classed by the military as dangerous air cargo, it also means that batteries could be reinserted into the device following air transport.

As the introduction and acceptance of indirect laryngoscopes disseminates, many more articles are likely to be published which will contribute to our collective knowledge and increase the evidence base with these products. Indirect laryngoscopes have provided us with the technology to improve the efficiency and success of tracheal intubation; all we need to do is to choose the best product.

References

1. Williams KN, Carli F, Cormack RS. Unexpected, difficult laryngoscopy: a prospective survey in routine general surgery. British Journal of Anaesthesia 1991; 66: 38-44.
2. Savoldelli GL, Schiffer E, Abegg C, et al. Comparison of the Glidescope, the McGrath, the Airtraq and the Macintosh laryngoscopes in simulated difficult airways. Anaesthesia 2008; 63: 1358-64.
3. Maharaj CH, Costello JF, Harte BH, et al. Evaluation of the Airtraq and Macintosh laryngoscopes in patients at risk for difficult tracheal intubation. Anaesthesia 2008; 63: 182-8.
4. Asai T, Koga K, Vaughan RS. Respiratory complications with tracheal intubation and extubation. British Journal of Anaesthesia 1998; 80: 767-75.
5. Frerk CM, Lee G. Laryngoscopy: time to change our view. Anaesthesia 2009; 64: 351-4.
6. Lange M, Frommer M, Redel A, et al. Comparison of the Glidescope and Airtraq optical laryngoscopes in patients undergoing direct microlaryngoscopy. Anaesthesia 2009; 64: 323-8.
7. Krasser K, Missaghi S, Lackner-Asserhofer H, et al. The Airtraq Optical Laryngoscope: experiences with a new disposable device for orotracheal intubation. Anaesthesia 2008, 63: 1387.
8. Gnanaseakaran S, Masters O, Gait AJ, et al. The role of newer intubation devices in difficult intubation protocols: A Pan Birmingham survey. Difficult Airway Society Annual Scientific Meeting, Liverpool, November 2008.
9. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675-94.
10. Suzuki A, Toyama Y, Iwasaki H, Henderson J. Airtraq for awake tracheal intubation. Anaesthesia 2007; 62: 746-7.
11. Tong JL. The Airtraq – the ideal indirect device for the Defence Medical Services. Journal of the Royal Army Medical Corps 2008; 154: 78.
12. Tong JL, Gait AJ, Woollard M, Nightingale PG, Sharma MR. Airway management at floor level: A comparison of tracheal intubation using the Macintosh and Airtraq laryngoscopes. Journal of the Royal Army Medical Corps 2008; 154: 21-5.
13. Hampton MS, Gonzalez MG, Adams BD. A comparative study of endotracheal intubation by Airtraq, Glidescope Ranger and direct laryngoscopy in a closed space environment. Annals of Emergency Medicine 2008; 52: S113.
14. Maharaj CH, Buckley E, Harte BH, et al. Endotracheal intubation in patients with cervical spine immobilisation: a comparison of Macintosh and Airtraq laryngoscopes. Anesthesiology 2007; 107: 53-9.
15. Dhonneur G, Abdi W, Amathieu R, et al. Optimising tracheal intubation success rate using the Airtraq laryngoscope. Anaesthesia 2009; 64: 315-19.
16. Beckmann LA, Edwards MJ, Greenland KB. Differences in two new rigid indirect laryngoscopes. Anaesthesia 2008; 63: 1385-6.
17. Low D, Healy D, Rasburn N. The use of the BERCI DCI laryngoscope for teaching novices direct laryngoscopy and tracheal intubation. Anaesthesia 2008; 63: 195-201.
18. Lee RA, Van Zundert AAJ, Maassen RLJG, et al. Forces applied to the maxillary incisors during video-assisted intubation. Anesthesia and Analgesia 2009; 108: 187-91.

Intensive Care Unit Tracheostomy: A Snapshot Of UK Practice
Authors: Tonny Veenith, Thomas Standley, Department of Anaesthetics, Addenbrooke’s Hospital, Cambridge
Sangeetha Ganeshamoorthy, Joseph Carter and Peter Young, Department of Anaesthetics, Queen Elizabeth Hospital, Norfolk

Background
The cost of hospital care is under increasing financial pressure in the developed world, with some estimates placing the cost of critical care services alone at approximately 1% of a nation's Gross Domestic Product (GDP)¹. One of the commonest management strategies in intensive care units is mechanical ventilation and tracheostomy in intensive care is usually performed for patients requiring prolonged mechanical ventilation². Over the last 10 years the number of tracheostomies performed has increased rapidly and tracheostomy has been shown to reduce the duration of ICU stay³.

Shelden (1957) first introduced percutaneous tracheostomy many years after the technique of modern surgical tracheostomy was described by Jackson in 1909^4,5. The percutaneous technique was further refined by Ciaglia (a general thoracic surgeon) in 1985⁶. The practice of ICU tracheostomy has constantly been evolving since, with the introduction of new equipment as well as the widespread use of fibre-optic bronchoscopic technology. Percutaneous tracheostomy is currently regarded as a cost-effective, safe alternative to the open surgical technique and carries the advantage of being widely practised as a bedside procedure⁷.

Two major meta-analyses comparing surgical versus percutaneous tracheostomy (both limited by heterogeneity) arrived at different conclusions as to which approach was superior. Dulguerov et al⁸ concluded that percutaneous tracheostomies were inferior their surgical equivalent whereas Freeman et al⁹ found percutaneous tracheostomies easier to perform with fewer associated complications. Many techniques exist for performing percutaneous tracheostomy, the previous preferred practice being serial dilatation which was further simplified by a two stage dilatation technique^6,10. The work of Polderman et al suggests that percutaneous tracheostomy with a kit (Portex; Hythe, Kent, UK) with curved dilating forceps and bronchoscopic guidance is as effective as surgical tracheostomy^11,12.

However, uncertainty still surrounds tracheostomy as an ICU procedure. There is doubt as to the benefit of tracheostomy for prolonged mechanical ventilation in unselected patients and the issue of timing remains contentious. Clec’h et al suggests that tracheostomy does not reduce intensive care unit mortality when performed in unselected patients and may represent a burden after intensive care unit discharge¹³. However, good quality prospective studies by Rumback and Moller show that tracheostomy reduces the incidence of ventilator associated pneumonia in intensive care^11,14. There have been valuable surveys in the past evaluating United Kingdom (UK) ICU tracheostomy practice^15-17. The aim of this study was to capture the current practice of tracheostomy in the UK in the context of current thinking about the procedure and previously documented practice.

Materials And Methods
A questionnaire was developed in our ICU and sent to the lead clinicians in all general intensive care units across the UK, with a covering letter and a prepaid envelope. This survey specifically aimed to identify variations in current tracheostomy practice including timing of insertion, equipment used, post-operative care and how patients were followed up. For the purpose of comparing with previous surveys all general ICUs across the UK were sent questionnaires (addresses sourced from The Directory of Critical Care 2003’ – CMA Medical Data, Loughborough, UK). All specialist ICUs (paediatric, neurosurgical, cardiothoracic and liver units) were excluded like previous surveys, to allow a fair comparison.

Results
From the 228 units we posted the questionnaire to, we received a prompt response from 197 units, achieving a response rate of 86.84%. Of the 197 responders, 3 units did not have a general intensive care unit, and were therefore excluded. 56% of units carried out less than 50 tracheostomies per year with only 4.1% performing more than 200.

Timing of tracheostomy in the UK Our survey revealed that 21% of responders carry out tracheostomy early (between 0 – 5 days), 71% between 6 to 10 days, and 8% of the units > 10 days (see Figure 1).

Figure 1. Timing of UK ICU tracheostomy.

Method of insertion
Surgical versus percutaneous tracheostomy

Percutaneous tracheostomy is preferred over the surgical technique. In 43% of units, tracheostomies are performed percutaneously > 95% of the time. In 32.4% of units, 75–95% of the tracheostomies are carried out via the percutaneous route and 16.6% of units perform between 50 to 75% of their tracheostomies percutaneously. 8% of units prefer the surgical technique performing fewer than 50% of their tracheostomies percutaneously.

Number of doctors required for the procedure

The majority of units (89.4%) performed the procedure with two doctors, 8.3% of units performed the procedure with 3 doctors, and the remaining 2.3% carried out the procedure with a single doctor. All the hospitals practicing a one-doctor tracheostomy technique were performing less than 60 tracheostomies per year.

Sterility

All units observed sterile hand wash precautions and wore sterile gloves during tracheostomy insertion. The majority of operators (98%) wore sterile gowns; masks by 60%. Only 1% of units failed to use any sterile drapes during the insertion of percutaneous tracheostomies.

Bronchoscopic guidance during tracheostomy

Most units (80%) perform all percutaneous tracheostomies under bronchoscopic guidance whereas 20% don't use bronchoscopic guidance routinely. Of the latter 20%, 10% of units use the bronchoscope if a difficult tracheostomy is anticipated. 7% use more bronchoscope more than 50% time and 3% of units never utilise a bronchoscope during insertion of a percutaneous tracheostomy; the final category do more than 100 tracheostomies per year.

Maintenance of airway during percutaneous tracheostomy

Of the respondents 92% of units used the original cuffed endotracheal tube for the maintenance of the airway on insertion of a percutaneous tracheostomy. The vast majority of units (168) pull the original endotracheal tube back, and a minority (7 units) pushed the endotracheal tube further into the trachea during the procedure. Other infrequently used airways in addition to endotracheal tubes were supraglottic airways (7%) and a microlaryngeal tube (2%). Units where microlaryngeal tubes were used for airway maintenance carried out the procedure without bronchoscopic guidance.

Use of vasoconstrictors in local anaesthetics for insertion

Local anaesthetic with adrenaline was a common choice as the local anaesthetic during the procedure (95%). Only a minority used local anaesthetic without a vasoconstrictor (5%).

Favoured tracheostomy technique

Single stage dilatation was commonly used to perform tracheostomy. The favoured techniques were Blue Rhino (55%) and Ultraperc (28%). Griggs forceps (8%) and multiple dilator technique (5%) were used occasionally. 4% of the intensive care units used more than one technique for their percutaneous tracheostomies (Figure 2).

Figure 2. Favoured tracheostomy technique.

Post Insertion Care
Normal frequency of tracheostomy tube change

A quarter of the units changed their tubes routinely within 14 days; another quarter changed it routinely within 28 days. Half of the units did not change their tracheostomy tube before 28 days or changed only when the tube was blocked.

Use of inner liners

More than half (51%) of the intensive care units routinely used inner liners for the tracheostomy tubes. 31% of them used inner liners occasionally whereas 18% never used them at all.

Decannulation and follow-up

Decannulation is performed mainly by the intensive care nurses in 43% of units, by a combination of clinicians in 31%, doctors alone in 23%, and physiotherapist alone in 2%.

Follow-up was performed mainly by ICU review clinics (29%) and ENT and Outreach teams (12%). However, 59% of patients who had an ICU tracheostomy did not receive any follow up once they had left the unit.

Discussion
In our survey percutaneous tracheostomy is the widely used ICU tracheostomy method, which coincides well with the trend in current literature^15-18. The percutaneous technique seems to have gained universal acceptance in the hands of intensivists. There is wide variation in the complication rates following percutaneous tracheostomy; ranging from 7 – 19%^18,19. The randomised controlled trial by Silvester et al demonstrated no significant difference in complication rate between percutaneous dilatational and surgical tracheostomy, on long term follow-up to 20 months, albeit for a higher incidence of infection at day 7 following surgical tracheostomy¹⁹. The fact that complication rates for the percutaneous technique in the hands of doctors whose primary training is often not surgical, is surely a major factor in the generalised acceptance of the technique demonstrated in this and other surveys.

Taking a historical view with the other notable surveys of UK ICU tracheostomy in the last decade, there is a tangible increase in the number of hospitals providing a percutaneous tracheostomy service^15-17 (Figure 3).

Figure 3. Progression of percutaneous tracheostomy (numbers in%).

This increase may also be attributed to increasing experience and confidence with the percutaneous technique in addition to the widespread provision of fibre-optic bronchoscopes. Fibre-optic bronchoscopy is now much more accepted as an adjunct for percutaneous tracheostomy. Over a decade ago in the survey by Paw et al [15] only 49% of ICUs used routine fibre-optic bronchoscopy for percutaneous tracheostomy. In our survey over 80% of ICUs use routine fibre-optic bronchoscopy. The preference for a single stage dilatation technique is likely due to ease of use and decreased operative times compared to the serial-dilatation technique, without the risk of increased complications [20].

Timing
Although tracheostomies are routinely performed in intensive care units there is yet no clear evidence regarding the optimal time of insertion for this technique. Rumback et al demonstrated in a sound prospective double blind controlled trial that there is significant reduction in ICU mortality and length of stay after an early tracheostomy¹¹. The TracMan trial run by the Intensive Care Society of the UK has recruited 788 patients at the time of preparation of this manuscript and when completed may give a more definitive answer to the timing of tracheostomy in UK ICU’s²¹.

Our survey demonstrates mixed practice with regard to the timing of ICU tracheostomy. Whilst, early tracheostomy undoubtedly benefits some patients, too proactive an approach to tracheostomy based purely on anticipated length of ventilation may not be in every patient's best interest, particularly where underlying cardiorespiratory physiological function is good and the underlying condition that has resulted in ICU admission is readily reversible. We did not take any specific details of the casemix of the units surveyed – to have done would have increased the data collected enormously – and so, cannot make any comment as to the appropriateness of the mixed practice seen. Nonetheless, it is likely that opinions on this issue do vary.

Post tracheostomy care and follow-up
Routine post insertion change of the tracheostomy tube every two weeks helps to reduce granulation tissue, incidence of tracheal stenosis and bacterial contamination of the stoma²². In our survey half the units changed the tube after 28 days or only when it was blocked. Perhaps more alarming is the lack of follow up to identify longer term complications following ICU tracheostomy. Compared to previous surveys^15-17, follow-up after ICU discharge has marginally increased to 41%. Lack of solid data on the consequences of ICU tracheostomy is surely needed on each and every unit in order to allow a fuller risk/benefit assessment for each patient where tracheostomy is being considered, especially if significant morbidity is being missed from the procedure. Knowledge of the complications that occur may also help to inform which patients should receive a tracheostomy and when.

Conclusion
This survey has created a snapshot of the current practice of ICU tracheostomy in the UK. Percutaneous tracheostomy is the preferred technique in the majority of units when compared to surgical tracheostomy, with a single dilatation technique being favoured by the majority. There is mixed practice with regards to the timing of ICU tracheostomy, which suggests heterogeneous opinions. There is still a fairly low level of routine follow-up after ICU discharge, which may mean significant morbidity is being missed, representing a major omission in our attempt to fully understand the risks and benefits to individual ICU patients.

Competing interests
The authors declare that they have no competing interests.

Authors’ contributions
TV, SG, PY conceived the study, and participated in its design and coordination. JC, TS revised the manuscript after peer review with full access to survey data. All authors read and approved the final manuscript.

Acknowledgements
The Critical Care Unit (QEH Kings Lynn) funded the overhead costs for this study

References

1. Chalfin , Donald B MD: MS Assessing the Cost-Effectiveness of Emerging Therapies in the ICU. Seminars in Respiratory & Critical Care Medicine 1999, 20(3):263-270.
2. MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S: Management of Patients Requiring Prolonged Mechanical Ventilation. Chest 2005, 128:3937-3954.
3. Cox CE, Carson SS, Holmes GM, Howard ABS, Carey TS: Increase in tracheostomy for prolonged mechanical ventilation in North Carolina, 1993–2002. Critical Care Medicine 2004, 32(11):2219-2226.
4. Jackson C: Tracheostomy. Laryngoscope 1909, 19:285-290.
5. Sheldon CH, Pudenz RH, Tichy FY: Percutaneous tracheostomy. JAMA 1957, 165:2068-2070.
6. Ciaglia P, Frisching R, Syniec C: Elective percutaneous dilatational tracheostomy, a new simple bedside procedure: Preliminary report. Chest 1985, 87:715-9.
7. Heikkinen M, Aarnio P, Hannukainen J: Percutaneous dilational tracheostomy or conventional surgical tracheostomy? Critical Care Medicine 2000, 28(5):1399-1402.
8. Dulguerov P, Gysin C, Perneger TV, Chevrolet JC: Percutaneous or surgical tracheostomy: a metaanalysis. Crit Care Med 1999, 27:161725.
9. Freeman BD, Isabella K, Lin N, Buchman TG: A metaanalysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 2000, 118:14128.
10. Susanto I: Comparing percutaneous tracheostomy with open surgical tracheostomy. BMJ 2002, 324:3-4.
11. Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB: A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004, 32(8):1689-94.
12. Polderman KH, Spijkstra JJ, de Bree R, Christiaans HM, Gelissen HP, Wester JP, Girbes AR: Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication. Chest 2003, 123(5):1595-602.
13. Clec’h C, Alberti C, Vincent F, Garrouste-Orgeas M, De Lassence A, Toledano D, Azoulay E, Adrie C, Jamali S, Zaccaria I, Cohen Y, Timsit J, On behalf of the OUTCOMEREA study group: Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: A propensity analysis. Critical Care Medicine 2007, 35(1):132-138.
14. Moller MG, Slaikeu JD, Bonelli P, Davis AT, Hoogeboom JE, Bonnell BW: Early tracheostomy versus late tracheostomy in the surgical intensive care unit. Am J Surg 2005, 189:293-296.
15. Cooper RM: Use and safety of percutaneous tracheostomy in intensive care Report of a postal survey of ICU practice. Anaesthesia 1998, 53:1209-1227.
16. Krishnan K, Elliot SC, Mallick A: The current practice of tracheostomy in the United Kingdom: a postal survey. Anaesthesia 2005, 60:360-364.
17. Paw HGW, Turner S: the current state of percutaneous tracheostomy in intensive care: A postal survey. Clinical Intensive Care 2002, 13(2):95-101.
18. Yuca K, Kati I, Tekin M, Yilmaz N, Tomak Y, Cankaya H: Fibre-optic bronchoscopy-assisted percutaneous dilatational tracheostomy by guidewire dilating forceps in intensive care unit patients. J Otolaryngol Head Neck Surg 2008, 37(1):76-80.
19. Silvester W, Goldsmith D, Uchino S, Bellomo R, Knight S, Seevanayagam S, Brazzale D, McMahon M, Buckmaster J, Hart GK, Opdam H, Pierce RJ, Gutteridge GA: Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up. Crit Care Med 2006, 34(8):2145-52.
20. Johnson JL, Cheatham ML, Sagraves SG, Block EFJ, Nelson LD: Percutaneous dilational tracheostomy: a comparison of single versus multiple-dilatator techniques. Crit Care Med 2001, 29:1251-1254.
21. <@l>www.tracman.org.uk/
22. Yaremchuk K: Regular Tracheostomy Tube Changes to Prevent Formation of Granulation Tissue. 2003, 113(1):1-10.

International Archives of Medicine 2008, 1:21doi:10.1186/1755-7682-1-21

© 2008 Veenith et al; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons. org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Minimising The Risks Of Retaining Throat Packs After Surgery
Author: Tracy Coates, Anaesthetic Lead at the National Patient Safety Agency (NPSA)

Summary
In April the National Patient Safety Agency (NPSA) issued guidance to all NHS Trusts on the risks of retaining throat packs after surgery.

Throat packs are often used by anaesthetists or surgeons during surgery to absorb saliva in the patient’s mouth, prevent other materials/fluids entering the patient’s oesophagus or lungs as well as to stabilise their artificial airways.

The guidance follows an analysis of the NPSA’s Reporting and Learning System – the national database in which healthcare staff are advised to report all incidents that could have or did lead to patient harm – revealing that theatre teams were occasionally forgetting to remove these devices from patients after surgery. Although only one of the 38 reported incidents caused moderate harm the clinical risks, such as airway obstruction and pulmonary oedema could have been much higher.

This prompted the Anaesthesia: Improvement through Partnership project (a two-year initiative led by the NPSA, Royal College of Anaesthetists and other associated bodies) to commission a work stream to review existing policies both locally and nationally and develop recommendations to minimise future risk to patients.

These recommendations are detailed in the NPSA guidance and designed for all theatre teams and clinical risk managers to implement.

Background
Ways to minimise the risk of retaining throat packs after surgery have been known for several decades; however the application of these precautions nationally is inconsistent, as local organisations have their own policies dependent on the structure of their surgical teams. The NPSA guidance is the first time that a standardised list of recommendations have been developed for anaesthetists, surgeons and other theatre staff in the England and Wales.

In developing the guidance, a group of healthcare professionals was commissioned, including consultant anaesthetists, recovery and anaesthetic nurses and human factors experts and led by Dr John Curran, former Senior Vice President of the Royal College of Anaesthetists. One of the group’s key objectives was to test the existing professional networks and clinical forums used to disseminate national information alongside the more formal routes – such as the Department of Health’s Central Alert System (CAS), currently used by the NPSA and other Arms Length Bodies to issue healthcare-related guidance. The group reviewed the various outlets of communication and concluded that a Safer Practice Notice – an easily identifiable NPSA product – was the most appropriate vehicle to publish these recommendations, alongside stakeholder websites and bulletins. Uptake of the guidance will later be evaluated against these various methods to ascertain the most widely accessed resources, so as to improve learning and better engage with staff.

The recommendations are based on both analytical and practical evidence. Professional organisations such as the Association of Perioperative Practice, the Royal College of Nursing and the College of Operating Department Practitioners were contacted for examples of local solutions already in place, policies, and first-hand experiences from clinicians on using throat packs. A literature review was also undertaken to support this evidence, including a recent UK study by Knepil and Blackburn (2008) on when throat packs should be used in surgery and staff members involved.

Data
A search of the NPSA’s Reporting and Learning System (RLS) revealed that there were 38 reported incidents between 1 January 2006 and 31 December 2007 relating to surgical throat packs, 24 specifically to do with unintended retention. Of these only one incident was reported as causing moderate harm to the patient – this led to a “crash call” and the patient having to be re-intubated.

A key outcome of the RLS analysis was that although the reported incidents of retained throat packs rarely resulted in serious harm to the patient, theatre staff were occasionally forgetting to remove them following surgery and that the necessary checks by theatre staff were not being followed. There was no standard procedure and staff were often assuming that their peers had made these checks; resulting in patients being signed out of their theatre rooms with their throat pack still inside them.

In addition to the RLS data, the SPN group also consulted medical defence organisations and the NHS Litigation Authority (the body responsible for handling negligence claims) to inform them of any legal actions relating to the use of throat packs; this returned one alleged incident of a serious nature involving a patient undergoing surgery for a cleft lip whose throat pack was retained, resulting in respiratory distress and alleged brain damage.

Recommendations
Based on the aforementioned data, the NPSA is now advising all clinical risk managers responsible for anaesthesia and surgery to adapt their local policies to state that:

1. The decision to use a throat pack is justified by the anaesthetist or surgeon for each patient as appropriate. This person should also be responsible for ensuring that the chosen safety procedures (listed below) are undertaken.
2. At least one visually-based and one documentary-based procedure is applied wherever a throat pack is deemed necessary.
   1. Visual checks:
      1. Label or mark the patient – either on the head or in exceptional circumstances, on another visible part of the body with an adherent sticker or marker.
      2. Label the artificial airway (e.g. tracheal tube or supraglottic mask airway).
      3. Attach the throat pack securely to the artificial airway.
      4. Leave part of the throat pack protruding.
   2. Documentary checks:
      1. Formalised and recorded “two-person” check of insertion and removal of pack.
      2. Record insertion and removal on swab board.
3. All theatre staff are fully informed on the locally chosen procedures.
4. The World Health Organization’s Surgical Safety Checklist (as adapted by the NPSA for use in England and Wales) should be used alongside the above recommendations and theatre teams should consider adapting this locally to include the use and monitoring of throat packs, if appropriate.

NHS organisations have been given a deadline of October 2009 to complete these actions.

Next Steps
One of the key aims of the SPN group was to test the existing professional networks and clinical forums used to disseminate national information alongside the more formal routes such as the CAS.

The evaluation plan is in two stages:

1. Stage One - will take place in August 2009 and will involve questioning clinical staff on where they first saw the notice, e.g. NPSA website, clinical network website or notified through their departments.
2. Stage Two – will be undertaken next year with a similar methodological approach to determine whether the recommendations have been implemented and written in to their local policies.

The NPSA believes that the collaboration between clinical staff to develop this guidance has been a valuable exercise for learning for future work and hopes to build on the strengths and contributions of all stakeholders.

Further information
To view the NPSA’s Safer Practice Notice and the Supporting Information visit:

www.npsa.nhs.uk/nrls/alerts-and-directives/notices/throatpacks/

Clinical risk managers and all theatre staff are advised to report all incidents involving the misuse of throat packs as well as all other incidents which could have or did lead to patient harm, either to their local reporting mechanisms or anonymously to the NPSA’s Reporting and Learning System. This is done in the interests of openness and transparency in the NHS as well as to enhance the learning of current patient safety issues. To report visit: www.npsa.nhs.uk/nrls/reporting/