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Provisional data from the 4th National Audit Project of the Royal College of Anaesthetists has identified that at least 20% of major airway events take place on the ICU and that these are more frequently fatal than events elsewhere (TM Cook, personal communication). Over 23% of these incidents relate to the instigation or maintenance of an artificial airway . Both the use of capnography and the immediate availability of airway rescue devices to avert or manage such incidents have been recommended. This study seeks to determine the adherence to these recommendations, the availability of such equipment on UK ICUs and to identify areas for safety improvement.
Every adult general, hepatobiliary and satellite ICU (grouped together as GICU), neurointensive care unit (NICU) and cardiac intensive care unit (CICU) in the UK was telephoned, thereby covering every area in the UK where ventilated adult patients are routinely cared for outside the operating theatre. Data were obtained from the nurse in charge over a 3-month period in 2009.
In total, 315 of 328 contacted units responded (96% response). Capnography during intubation: 32% units use always, 43% sometimes and 25% never. Capnography for continuous monitoring of intubated patients: 25% units use always, 35% sometimes and 40% never. Of note, 45% of NICUs never use capnography for continuous monitoring (where doing so may prove most beneficial). Basic airway equipment (oropharyngeal airways, laryngoscopes and bougies), alternative means of patient ventilation and equipment checking procedures are seen on 97 to 100% of ICUs. A standard laryngeal mask (LMA) is available on 97% of ICUs. More advanced airway rescue devices are seen less commonly: 71% have a McCoy laryngoscope and 55% have a bougie through which ventilation is possible. Forty-three per cent have an intubating LMA and 21% have supraglottic airway with a gastric port immediately available. Forty-nine per cent of units have a bronchoscope on the ICU. Seventy per cent of units have equipment for emergency trans-tracheal access. CICUs are least likely to use capnography or have airway rescue equipment immediately available.
Basic standards of airway safety are not being met on UK ICUs and are far from the standards being routinely employed in the operating theatre. The potential airway difficulties presented by the ICU patient, together with the lack of routine use of capnography, exposes these patients to significant risks that may be easily addressed.