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J R Soc Med. 2005 June; 98(6): 293–294.
PMCID: PMC1142250

Emergency airway management in the UK

Colin Graham, in his review article (March 2005 JRSM1), revisits the suggestion that all airway interventions in UK emergency departments could be managed by emergency physicians. If training of emergency physicians is standardized to six months in anaesthesia and six months in critical care, they would acquire only rudimentary skills in basic airway management and the conduct of anaesthesia. There is widespread use of the laryngeal mask airway, considerable decrease in working hours, and the need to concurrently teach anaesthesia trainees, paramedics, etc. In only six months trainees would participate in approximately 350 cases, on average performing less than 2 endotracheal intubations per week. Few of these will be in emergency circumstances.2-4

If anaesthesia experience mainly continues in emergency departments where 2 trauma patients will require rapid sequence intubation per month5 trainees cannot maintain their skills. How indeed are their consultants to revalidate as trainers? They must be able to predict and act immediately whenever there is difficulty. How will they recognize the difficult airway and call an anaesthetist early when even the most thorough examination is only 71% sensitive?6

It is one thing to intubate a patient following cardiac arrest and another to anaesthetize and intubate a patient on the brink of an arrest. Currently there is an inappropriate degree of self-confidence amongst emergency department trainees, despite their experience in emergency anaesthesia.7 So how can we best develop and maintain their skills despite infrequent exposure?

I believe the answer is to regularly repeat anaesthesia training blocks, perhaps one training list per month. In addition, written, practical, and simulator testing for recertification ensures maintenance of skills.8,9 Anaesthesia emergencies are uncommon. Therefore knowledge or clinical experience, lacking in those not formally trained, could only become apparent in very large outcome studies.10,11


1. Graham CA. Emergency department airway management in the UK. J R Soc Med 2005;98: 107-10 [PMC free article] [PubMed]
2. Abdalla S, Thompson KD. Away with the LMA? Anaesthesia 1999;54: 1116-17 [PubMed]
3. Sim DJ, Wrigley SR, Harris D. Effects of the European Working Time Directive on anaesthetic training in the United Kingdom. Anaesthesia 2004;59: 781-4 [PubMed]
4. Tomlinson A. Effects of the EWTD on anaesthetic training in the UK. Anaesthesia 2005;60: 96-7 [PubMed]
5. Butler JM, Lecky F, Townend WJ, Bouamra O, Woodford M. Intubations in trauma patients in UK emergency departments [Abstract]. Annual Scientific Meeting of the Faculty of Accident and Emergency Medicine, London, November 2001: A11
6. Wilson ME. Predicting difficult intubation. Br J Anaesth 1993;71: 333-4 [PubMed]
7. Graham CA, Thakore SB, Mattick AP, Docherty E, Wares GM. Rapid sequence intubation: a survey of senior and middle grade staff in Scotland [Abstract]. J Accid Emerg Med 2000;17: 71
8. Thalman JL, Rinaldo-Gallo S, MacIntyre NR. Analysis of an endotracheal intubation service provided by respiratory care practitioners. An experience of 10 years at Duke University Medical Center, SC. Respiratory Care 1993;38: 469-73 [PubMed]
9. Bishop MJ, Michalowski P, Hussey JD, Massey L, Lakshminarayan S. Recertification of respiratory therapists' intubation skills every year after initial training: analysis of skill retention and retraining. Respiratory Care 2001;46: 234-7 [PubMed]
10. Graham CA, Beard D, Oglesby A, et al. Rapid sequence intubation in Scottish urban emergency departments. Emerg Med J 2003;20: 3-5 [PMC free article] [PubMed]
11. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology 1995;82: 367-76 [PubMed]

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