British Journal of Anaesthesia, 117 (S1): i75i82 (2016)

doi: 10.1093/bja/aew190
Advance Access Publication Date: 28 July 2016
Special Issue

Emergency surgical airway management in Denmark:

a cohort study of 452 461 patients registered in the
Danish Anaesthesia Database
C. V. Rosenstock1, *, A. K. Nrskov1,2, J. Wetterslev2, L. H. Lundstrm1 and
the Danish Anaesthesia Database
1
Department of Anaesthesiology, Copenhagen University Hospital, Capital region of Denmark, Nordsjllands
Hospital, Dyrehavevej 29, 3400 Hillerd, Denmark, and 2Copenhagen Trial Unit, Centre for Clinical Intervention
Research, Copenhagen University Hospital, Capital region of Denmark, Rigshospitalet, 2100 Copenhagen,
Denmark
*Corresponding author. E-mail: charlotte.rosenstock@regionh.dk

Abstract
Background: The emergency surgical airway (ESA) is the nal option in difcult airway management. We identied ESA
procedures registered in the Danish Anaesthesia Database (DAD) and described the performed airway management.
Methods: We extracted a cohort of 452 461 adult patients undergoing general anaesthesia and tracheal intubation from the DAD
from June 1, 2008 to March 15, 2014. Difcult airway management involving an ESA was retrieved for analysis and compared
with hospitals les. Two independent reviewers evaluated airway management according to the ASAs2003 practice guideline
for difcult airway management.
Results: In the DAD cohort 27 out of 452 461 patients had an ESA representing an incidence of 0.06 events per thousand (95% CI;
0.04 to 0.08). A total of 12 149/452 461 patients underwent Ear-Nose and Throat (ENT) surgery, giving an ESA incidence among
ENT patients of 1.6 events per thousand (95% CI; 1.02.4). A Supraglottic Airway Device and/or the administration of a
neuromuscular blocking agent before ESA were used as a rescue in 6/27 and 13/27 of the patients, respectively. In 19/27 patients
ENT surgeons performed the ESAs and anaesthetists attempted 6/27 of the ESAs of which three failed. Reviewers evaluated
airway management as satisfactory in 10/27 patients.
Conclusions: The incidence of ESA in the DAD cohort was 0.06 events per thousand. Among ENT patients, the ESA Incidence
was 1.6 events per thousand. Airway management was evaluated as satisfactory for 10/27 of the patients. ESA performed by
anaesthetists failed in half of the patients.

Key words: airway management; complications; general anaesthesia; intubation; otorhinolaryngologic surgical procedures;
tracheostomy

Accepted: May 29, 2016

The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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i75
i76 | Rosenstock et al.
Editors key points
The incidence of requiring emergency surgical airway was
assessed in patients undergoing general anaesthesia in
Denmark during June 1, 2008 to March 15, 2014.
The incidence was 27 of 452 461 patients (0.06 events per
thousand), and was higher in ear-throat and nose patients.
Airway management was judged satisfactory in 10 of 27
patients.
Since 1990 tremendous efforts have been made to reduce adverse
events resulting from difcult airway management. The problem
has been approached from different angles such as multiple
research projects including the systematic use of an airway
assessment score,1 evidence based guidelines developed by the
scientic societies, local departmental algorithms, skill- and
team- training and the development of new technical advanced
and/or improved equipment. Despite of these actions the ultim-
ate difcult airway, the cannot intubate, cannot ventilate (CICV)
situation, still occurs in 0.02% of general anaesthesia proce-
dures.2 The emergency surgical airway (ESA) is the nal option
in managing CICV in difcult airway management algorithms,
but is a rarely practiced procedure and may be difcult to perform
in an emergency high-risk situation. All Danish anaesthetists
attend a mandatory national course in difcult airway manage-
ment, including training in front of neck access procedures
during their specialist training. However, it is left to the discretion
of the individual departments of anaesthesia to offer recurrent
ESA training and it is unknown if such training is actually offered.
Current guidelines advocate that anaesthetists should master
necessary techniques for airway management failure. 3 In the
NAP 4 study an ESA incidence of 0.02 events per thousand (95%
CI; 0.0160.026) was found in conjunction with general anaesthe-
sia. The authors acknowledged the possibility of underreporting,
statistical analysis of data was, however, inconclusive with either
all patients being captured or three of every four patients being
missed.4 In the same study anaesthetists had a high failure rate
when performing ESA and the procedure was associated with a
poor patient outcome as previously documented. Out of 58
anaesthetic patients where ESA was the ultimate option, 74%
were head- and neck- patients. Contributing factors for an ESA
were poor planning, poor judgment, deviation from recognized
algorithms and failure of technical skills. Kheterpal and collea-
gues5 found an ESA incidence of 0.006 events per thousand
(95% CI; 0.0010.03) in connection with general anaesthesia,
however, having only one event in the dataset. As a result of
the infrequent nature of severe difcult airway management,
more studies are required elucidating cause and effect.
The aim of our study was to determine the incidence of
ESA registered in the Danish Anaesthesia Database (DAD), and
secondly to describe the performed airway management. We
speculated that we might be able to contribute to future recom-
mendations in order to improve difcult airway management
and reduce the number of ESAs.
Methods
The Danish Data Protection Agency, Copenhagen, Denmark
approved the registration and data extraction from the DAD. As
this is a retrospective register-based study, the Ethics Commit-
tees for Biomedical Research, Capital Region of Denmark waived
the need for approval. Access to the data was granted by the
steering Committee of the DAD. Eleven living patients gave
individual informed consent for access to all hospital les regard-
ing difcult airway management including the ESA. The National
Board of Health approved access to relevant hospital les regard-
ing the remaining 16 patients.
Data registration in the Danish Anaesthesia
Database
The DAD is a well-integrated national quality assurance database
including indicators that cover the perioperative period.6 Approxi-
mately 70% of all departments of anaesthesia in Denmark report
data to the DAD. Preoperatively, the anaesthetist ticks a manda-
tory Yes/No box to state whether difcult airway management is
anticipated or not. In addition, a plan for the scheduled airway
management is recorded preoperatively for all patients. The
DAD page regarding the actual anaesthesia is not displayed before
entering these data. Immediately after induction of anaesthesia
the actual airway management is registered. An intubation score
adhering to the Canadian Airway Focus Group denition of dif-
cult intubation is an integrated part of the DAD.7 It is based on
the number of intubation attempts and the type of intubation
equipment used. A difcult intubation is dened as using three in-
tubation attempts or more, or shifting technique using advanced
intubation equipment (e.g. a videolaryngoscope). We have previ-
ously found an incidence of 0.92% of anticipated difcult intub-
ation, in patients undergoing general anaesthesia including
airway management. Three hundred and fourteen out of 3511 pa-
tients with a difcult intubation were correctly anticipated as dif-
cult, giving a sensitivity of 8.9%.6 Mask ventilation is categorized
into easy, difcult or impossible, which is a simplication of the
grading scale originally proposed by Han and colleagues.8 In the
DAD, grade 1 and 2 from the Han grading scale is merged into
grade 1 (easy), whereas Hans grades 3 and 4 are identical with
the DAD grade 2 (difcult) and 3 (impossible).
Eligible patients
Documented airway management for all adult patients >15 yr re-
gistered in the DAD, with an ESA in the period of June 2008
to March 2014, was compared with relevant hospitals les in
order to describe the provided patient treatment in details.
Case review process
Two authors (C.V.R. and L.H.L.) independently evaluated patient
management according to the ASAs 2003 practice guideline for
difcult airway management.9 A predened structured data-
extraction sheet was used when evaluating the performed
patient treatment. In patients where the reviewers disagreed,
consensus was reached by involving a third reviewer. Patients
and healthcare personnels data were anonymized before enter-
ing in to the study database.
Outcomes
The incidence of ESA and a structured evaluation of the
performed airway management in patients with an ESA.
This manuscript was prepared according to the Strengthen-
ing the Reporting of Observational Studies in Epidemiology
(STROBE) statement.
Statistics
Data are expressed as means with a range, medians with a range
and incidences as events per thousand with 95% CI or other rele-
vant fractions.
 Emergency surgical airway management | i77

and no associated surgical procedure (Fig. 1). Thus, the incidence

452 461
patients in general anaesthesia
31 patients
with an ESA
27 patients 4 patients erro-
with an ESA neously registered
Fig 1 Flow chart for patients reported to the DAD undergoing general
anaesthesia, attempted tracheal intubated and registered with an
emergency surgical airway.
Table 1 Patients characteristics. DAD cohort, 452 434 patients
from the Danish Anaesthesia Database undergoing general
anaesthesia and airway management; ESA, emergency surgical
airway; N, the number of patients within categories; Comparing
ESA patients with other than ESA patients within categories, Out of the DAD cohort consisting of 452 461 patients, a total of
demonstrated a signicant difference for gender (P = 0.001). The
Mean (range) age of the ESA-patients was 57 (2985) and the
Mean (range) age of the Non-ESA patients was 55 (15109),
respectively
of ESA was 27/452 461, 0.06 events per thousand (95% CI; 0.04
0.08).
Patient characteristics
Mean (range) age of the patients was 57 (2985). ASAs physical
classication system I to IV was 6/10/9/1 and unknown for one
patient. Male to female ratio was 21/6 and median (range) BMI
was 25 (1842). Table 1 shows ESA patients characteristics com-
pared with the rest of the DAD population. Table 2 demonstrates
the summary of ndings.
Type of surgery
A total of 20/27 (74%, 95% CI; 5587%) patients underwent ear-
nose and throat (ENT) surgery. In addition, 3/27 patients under-
going other than ENT surgery had a hematoma on the neck, a val-
lecular cyst and a malignant laryngeal tumour, respectively. For
these three patients the planned procedure was neuro-surgery,
breast-surgery and urology, respectively. The remaining 4/27 pa-
tients had no apparent internal/external airway pathology, but
one patient undergoing spine surgery was registered with a re-
strictive pulmonary disease using a CPAP-mask during sleep.
12 149 patients underwent ENT surgery. Thus, the incidence of
ESA among ENT patients was 1.6 events per thousand (95% CI;
1.02.4).

ESA patients DAD cohort Anticipation of airway management difculties

N % other than ESA
patients % Nine out of 27 patients were registered in the DAD with an
anticipated difcult tracheal intubation. Of these nine patients,
Gender
ve were anticipated difcult to both mask ventilate and tracheal
Female 6 22.2 54.6
intubate. However, hospital les demonstrated a discrepancy
Male 21 77.8 45.4
compared with the DAD registration, so that difcult airway
Age
management was in fact, anticipated in 14/27 patients. The dif-
15 yr < 40 5 18.5 23.4
40 yr < 60 11 40.7 31.3
cult airway management was experienced at induction of the
60 yr < 80 8 29.6 36.7 anaesthesia for 26/27 patients. A supraglottic airway device
yr 80 3 11.1 8.6 (SAD) was used for oxygenation before ESA in 6/27 patients and
BMI in 13/27 patients a neuromuscular blocking agent (NMBA) was
BMI < 18.5 1 3.7 4.4 administered before ESA. Anaesthetists were unable to oxygen-
18.5 BMI < 25 14 51.9 43.3 ate 19/27 patients and the median (range) lowest saturation,
25 BMI < 35 10 37.0 44.2 SATpO2 for all 27 patients was 60% (2798%). ENT- surgeons per-
BMI 35 2 7.4 7.2 formed 19/27 ESAs, and in 1/27 patients a surgeon other than an
Unknown 1.0 ENT surgeon performed the ESA. Anaesthetists attempted 6/27
ASA-classication ESA, of which three failed. In one of these patients an anaesthe-
I 6 22.2 32.2 tist and a surgeon both failed the ESA procedure and the patient
II 10 37.0 44.1 awoke during the course of the airway management. In the
III 9 33.3 20.5 second case of failed ESA performed by an anaesthetist the
IV-VI 1 3.7 2.4 patient also awoke. An ENT surgeon rescued the third failed
Unknown 1 3.7 0.7 ESA attempted by an anaesthetist. Finally, in 2/27 patients
it was impossible to determine who had performed the ESA.
Tables 3 and 4 give detailed characteristics of the ESA of the indi-
vidual patients.
Results
A total of 452 461 patients had a general anaesthesia including
airway management and 31 of these patients were registered
Complications
with an ESA. When comparing DAD registration with associated On the grounds of the available les, reviewers evaluated if the
hospital records misclassication was found regarding four patients were in a truly life-threatening situation in relation to
patients. In two patients information from associated hospital the difcult airway management, these patients ESA priority
les excluded an ESA. Another patient had an apparently uncom- was dened as emergency. One patient died of hemodynamic
plicated difcult airway management and nally one patient was shock as a result of rupture of an aneurysm of the abdominal
a DAD test patient with imaginary difcult airway management part of the aorta. One patient suffered cardiac arrest secondary
i78 | Rosenstock et al.

Table 2 Summary of ndings. DAM, difcult airway management; Daytime, 8 am to 4 pm; ENT, ear, nose, throat; ESA, emergency surgical
airway; Night shift, 4 pm to 8 am; N, the number of patients within categories; NMBA, neuromuscular blocking agent; SAD, supraglottic
airway device

N N N

Time of surgery Type of surgery Priority of surgery

Daytime 18 ENT 20 Elective 11
Night shift 9 Other than ENT 7 Emergency 16
Preoperative airway assessment Use of NMBA Consultant present
Anticipated DAM 14 Yes 13 Yes 25
Unanticipated DAM 13 No 27 No 2
Primary attempted airway management Laryngeal mask attempted Cannot ventilatecannot intubate
Sevourane inhalation. 3 Yes 6 Yes 19
SAD 2 No 21 No 8
Direct laryngoscopy 11
Flexible optic intub. 7
Video laryngoscopy 3
ESA in local anaest. 1
Lowest saturation Time of ESA ESA performed by
80100% 5 Induction 26 Anaesthetist 3
6079% 7 After induction 1 ENT-surgeon 19
Below 60% 9 Other surgeon 1
Unknown 6 Failed 2
Unknown 2
ASA -algorithm followed
Yes 10
No 17

to respiratory insufciency. Chest compressions were provided
with the return of spontaneous circulation. The patient could
be mask ventilated, whereas intubation was impossible, there-
fore she was moved to the operating theatre for a denitive air-
way ( patient ID 22). Thirteen patients died a median (range) of
7 (042) months after the procedure. However, none of the pa-
tients died in immediate relation to, or as a result of the provided
airway management and no patient suffered from brain damage
as a consequence of ESA. Type of ESA procedure according to
managing specialty, degree of urgency, non-fatal complications
and presence/absence of cardiac arrest is depicted in Table 4. Six-
teen out of 27 patients underwent emergency surgery. A consult-
ant in anaesthesia was present in 25/27 patients; no les
documented the call for assistance of another consultant in
anaesthesiology.
Primary airway management technique
The rst scheduled, but failed airway management was: exible
optic intubation with preserved spontaneous respiration (7/27
patients); I.V. anaesthesia induction followed by direct laryngos-
copy (11/27 patients); Sevourane inhalation followed by direct or
videolaryngoscopy (3/27 patients); I.V. anaesthesia induction fol-
lowed by videolaryngoscopy (3/27 patients); I.V. anaesthesia in-
duction followed by placement of a SAD (2/27 patients); and
nally tracheostomy in local anaesthesia (1/27 patients).
Patients with subsequent anaesthetics
After the episodes of ESA, eight patients were registered with
subsequent general anaesthetics, including airway management
(Patient ID 2, 6, 13, 14, 18, 20, 21 and 27), Tables 3 and 4. Patient ID
13 was registered with two subsequent anaesthetics and was in-
tubated using another method than direct laryngoscopy,
preferably videolaryngoscopy on both occasions. Patient ID 14
and 27 were registered with one subsequent anaesthetic and
both were intubated using a exible optic scope. Patient ID 18
was intubated with a exible optic scope on one occasion and
on the second anaesthetic intubated using another method
than direct laryngoscopy, most likely videolaryngoscopy. The re-
maining four patients were tracheal intubated without complica-
tions by direct laryngoscopy on subsequent anaesthetics and all
had reversible reasons for difcult airway management on the
occasion of the ESA.
Reviewers evaluation of airway management
Reviewers evaluated the provided airway management as
satisfactory in 10/27 (37%) patients. Reasons for reviewers evalu-
ating the provided airway management as adequate, were re-
cords documenting that the difcult airway algorithm had been
adhered to, after the anticipation of difcult airway management
in 8/10 patients. These patients were undergoing intubation with
preserved spontaneous respiration and when this procedure
failed the next step was an ESA. In the remaining 2/10 patients
where reviewers evaluated airway management to be satisfac-
tory airway management difculties could not have been antici-
pated. These two patients were handled appropriately according
to the ASAs 2003 practice guideline for unanticipated difcult
airway management.
Reviewers reasons for assessing airway management as poor
were: overlooking a history of difcult airway management,
abstaining from using information from preoperative nasophar-
yngoscopy, failure to plan for awake intubation also through the
cricothyroid membrane, lack of rescue plans, using SADs as a
solution for nal airway management in patients with a high
risk of failure with this device, lack of relevant equipment, airway
management initiated in remote locations, insufcient skills for
Table 3 Characteristics of the emergency surgical airways of the 27 individual patients. CV-CI, cannot ventilate cannot intubate; DAM, difcult airway management; Dir lar, direct laryngoscopy;
ESA, emergency surgical airway; Flex. Optic, exible optic intubation; I-LMA, intubation laryngeal mask airway; SAD, supraglottic airway device; Sevo, sevourane; NMBA, neuromuscular
blocking agent; NS, not specied; Retrogr., Retrograde intubation; Video lar, videolaryngoscopy

Pt. Sex Age ASA BMI Priority of Time of CV- Expected SAD NMBA Progression in airway management
Id surgery surgery CI DAM used used 1. technique 2. technique 3. technique 4. technique 5. technique
(attempts) (attempts) (attempts) (attempts) (attempts)

1 M 83 2 24 Elective 10:30 am No No Yes No SAD (1) Dir Lar (2) SAD (1) ESA
2 F 82 2 24 Emergency 04:00 am No No No Yes Dir Lar (2) ESA
3 M 54 1 26 Emergency 03:00 pm Yes Yes No No Flex. optic (1) ESA
4 M 54 3 27 Emergency 01:00 pm Yes Yes No Yes Video Lar (1) ESA
5 M 65 NS 26 Emergency 12:00 am Yes No Yes Yes Dir Lar (3) I-LMA (1) Retrogr.(1) ESA
6 F 32 2 24 Emergency 04:00 am Yes Yes No No Dir lar+Sevo (2) ESA
7 M 63 2 20 Elective 01:00 pm No No No No Dir lar (2) Video lar (1) ESA
8 M 45 1 36 Elective 04:00 pm Yes No No Yes Dir lar (1) Video lar (1) ESA
9 F 54 1 25 Elective 11:00 am Yes No Yes Yes Dir lar (?) I-LMA (?) SAD (?) Flex. optic (?) ESA
10 M 46 1 28 Elective 01:00 pm No No No No Video lar+Sevo ESA
(1)
11 M 61 2 29 Emergency 02:00 am No No No Yes Dir lar (5) Combitube (1) ESA (2) failed Flex. optic (1)
12 M 72 3 29 Emergency 05:15 pm Yes Yes No No Flex. optic (2) ESA
13 F 52 2 20 Elective 02:00 pm Yes Yes No Yes Flex. optic (1) Dir lar (1) Video lar (1) ESA
14 F 59 2 23 Elective 08:00 am Yes Yes Yes No Video lar (2) SAD (?) ESA
15 M 85 3 19 Elective 12:00 am Yes Yes No No Dir lar (1) Flex. optic (1) ESA
16 M 58 3 18 Emergency 06:15 pm Yes Yes No No Flex. optic (5) ESA

Emergency surgical airway management

17 M 72 3 25 Elective 02:00 pm Yes Yes No No ESA in LA (1) Flex. optic (>1) ESA
18 M 65 2 22 Emergency 10:30 am No No No Yes Dir lar (1) ESA
19 M 55 3 23 Elective 08:00 am No Yes No No Flex. optic (2) ESA
20 M 36 1 21 Emergency 02:00 am Yes Yes No Yes Flex. optic (>1) ESA (2) (failed) Video lar (1) Flex. optic (1)
21 M 39 3 41 Emergency 01:00 pm Yes Yes No No Dir lar (1) Flex. optic (2) ESA
22 F 29 3 24 Emergency 04:30 pm No No Yes Yes Dir lar (>1) Video lar (3) SAD (1) Flex. optic (2) ESA
23 M 70 2 26 Elective 01:15 pm Yes No Yes Yes SAD (2) Dir lar (1) Video lar (1) ESA (1) Failed
24 M 59 4 24 Emergency 08:15 am Yes Yes No No Flex. optic (>1) ESA
25 M 53 2 27 Emergency 06:30 pm Yes No No Yes Video lar (>1) ESA
26 M 39 1 29 Emergency 03:15 pm Yes Yes No No Dir Lar + Sevo ESA
(>1)
27 M 66 3 24 Emergency 00:00 am Yes No No Yes Dir lar (4) ESA

| i79
 i80
| Rosenstock et al.
Table 4 Characteristics of the emergency surgical airways of the 27 individual patients. Anaesth., anaesthetist; Cricothyr., Cricothyroidotomy; DAM, difcult airway management; Dil. Trach.,
dilatation tracheostomy; ENT, ear, nose, throat surgeon; ESA, emergency surgical airway; LA, local anaesthesia; Trach., tracheostomy

Pt. ESA performed Type of ESA Time of ESA Priority of Type of Surgical procedure/clinical conditions Complication related to ESA/surgery Cardiac
Id (attempted) by ESA surgery arrest

1 ENT Trach. Induction Urgency ENT Diagnostic multi-scopy for cancer No No

2 Anaesth. Dil. Trach. Induction Urgency ENT Bleeding after thyroidectomy No No
3 Surgeon Cricothyr. Induction Urgency Neuro Bleeding after cervical discus operation No No
4 ENT Trach. Induction Urgency ENT Bleeding after tongue bite No No
5 Unknown Unknown Induction Urgency Vascular Aneurysm of the abdominal aorta Mors in tabula, because of bleeding from Yes
surgery abdominal aorta aneurysm.
6 ENT Trach. Induction Urgency ENT Fixed fork in larynx No No
7 ENT Trach. Induction Urgency ENT Diagnostic laryngoscopy for cancer No No
8 ENT Cricothyr. Induction Urgency ENT Diagnostic laryngoscopy for cancer After extubation emphysema, requiring No
re-intubation.
9 Anaesth. Dil. trach Induction Urgency Breast Breast surgery, vallecula cyste. No No
10 ENT Trach. Induction Urgency ENT Diagnostic laryngoscopy for cancer No No
11 Anaesth. (1; failed) Cricothyr.(1) Induction Urgency Abdominal Appendicitis Awake after two failed attempts of ESA. No
Surgeon (2; failed) Trach.(2)
12 Unknown Chricothyr. Induction Urgency Unknown Excision of lymph node (location unknown) Unknown Unknown
13 ENT Trach. Induction Urgency ENT Diagnostic laryngoscopy for cancer No No
14 ENT Trach. Induction Urgency ENT Neck node excision No No
15 ENT Trach. Perioperative Emergency ENT Diagnostic laryngoscopy for cancer. Accidental SAT 27% No
extubation during anaesthesia
16 ENT Trach. Induction Urgency ENT Diagnostic laryngoscopy for cancer No No
17 ENT (1; failed) Trach in LA (1) Induction Emergency ENT Diagnostic laryngoscopy for cancer No No
ENT (2; success) Trach (2)
18 ENT Chricothyr Induction Unknown ENT Diagnostic laryngoscopy for cancer Unknown Unknown
19 ENT Chricothyr. Induction Urgency ENT Diagnostic laryngoscopy for cancer Bleeding from stoma No
20 Anaesth. (1; failed) Chricothyr.(1) Induction Emergency ENT Epiglottidis Pulmonary oedema No
Anaesth. (2; success) Chricothyr.(2)
21 ENT Chricothyr. Induction Emergency ENT Downs syndrome, peri-tonsillar abscess 2 days postoperative extubation neck- No
emphysema; Opening of stoma
22 Anaesth. (1; failed) Chricothyr.(1) Induction Urgency Spine Rigid spine. Urgency call to respiratory arrest in ward. Cardiac arrest, no neurological sequelae Yes, prior
ENT (2; success) Chricothyr.(2) Moved to operation theatre for DAM. DAM
23 Anaesth. (1; failed) Chricothyr. Induction Urgency Urology Transurethral resection of the prostate. Awoke after one failed ESA No
Unexpected malignant laryngeal tumour
24 ENT Chricothyr. Induction Emergency ENT Diagnostic laryngoscopy for cancer During induction convulsion2 No
25 ENT Chricothyr. Induction Urgency ENT Dental abscess No No
26 ENT Trach. Induction Urgency ENT Epiglottidis No No
27 ENT Chricothyr. Induction Urgency ENT Cancer lingua No No

ESA access, and nally inadequate rescue methods when dealing
with uncooperative patients during attempts at awake intub-
ation. We performed a univariable logistic regression analysis
to determine if the incidence of ESA changed over the years of ob-
servation. We did not nd any statistically signicant association
with time.
Discussion
We found an ESA incidence of 0.06 events per thousand in con-
nection with general anaesthesia. This is 310 times higher
than reported in previous studies in the UK and USA.4 5 Among
ENT patients we found an ESA incidence of 1.6 events per thou-
sand. Underreporting was mentioned as an explanation of the
lower incidence found in the NAP4 study, but statistical data
analysis was inconclusive leaving no evidence of this. Excluding
patients undergoing rapid sequence induction, awake or asleep
exible optic intubation and awake tracheostomy is a likely ex-
planation for the lower ESA incidence found in the Kheterpal
and colleagues study.5 We cannot exclude the possibility of
underreporting in our study, so that the true ESA incidence in
Denmark might be even higher. In contrast to the NAP 4 study,
no patient died as an immediate consequence of the difcult
airway management. This raises the question whether patients
were exposed to an unnecessary ESA leaving other non-invasive
airway management options untried. We assessed airway man-
agement using the 2003 ASA difcult airway management
algorithm, because it would be unfair using the updated 2013
guideline as most cases were dated before 2014.9 10 Updated
guidelines now state that if not previously attempted, a SAD
and/or an NMBA should be administered before performing an
ESA.3 4 One of these options might have prevented some of the
surgical airways registered in our study. We have no national Da-
nish guideline for difcult airway management and no knowl-
edge of the content of individual local departmental guidelines.
Therefore variations in- or lack of- local algorithms may offer
some explanation of the infrequent use of SADs and NMBAs
in this study. Additionally, the use of NMBAs in association
with difcult airway management was previously discredited
and this historical controversy could also inuence our results.
Prospective studies dating from 2003 have now documented im-
proved mask ventilation after the administration of an NMBA.1114
The decision to perform a surgical airway relies on a subtle
balance between following a correct airway management strat-
egy and saving the life of a patient. Thought processes, the ability
to think creative and maintaining an overview over a situation is
impaired during stress, leading to potential bypasses or signi-
cant delays of important steps in an algorithm, endangering
the patient in question.15 On the other hand, no patients died
or suffered severe complications in relation to the ESA proce-
dures in this study, which could argue for a timely decision and
relevant action by the anaesthetist in relation to re-establishing
oxygenation.
Just as important as extracting learning from patients where
airway management was less optimal, is the information that
can be derived from patients with satisfactory performance. In
ten patients airway management were evaluated as satisfactory
with les documenting a correctly followed difcult airway man-
agement algorithm.
In all ENT patients the possibility of securing the airway by a
tracheostomy in local anaesthesia might not have jeopardized
patients and should always be carefully considered before
surgery. Twenty out of 27 (74%) patients with an ESA were ENT
patients, thereby conrming previous ndings of the NAP4
Emergency surgical airway management | i81
study.4 This implicates that all patients undergoing anaesthesia
should be questioned for prior ENT surgery. In case of present
ENT surgery a preoperatively, interdisciplinary evaluation by
both the anaesthetist and the ENT surgeon, also involving infor-
mation from nasopharyngoscopy and airway imaging, should be
performed in order to plan for optimal airway management.16 17
We were unable to evaluate from the written documentation
whether ENT patients in this study were properly interdisciplin-
ary discussed. Flexible optic intubation and sevourane inhal-
ation used as primary airway management techniques, in
awake or sedated patients, failed with apparently loss of the air-
way necessitating a surgical airway. The described techniques
can be highly challenging and has previously been documented
to result in severe complications.18 When preparing the airway
management strategy it is essential to include escape plans
in case of failure of the primary technique.4 Flexible optic intub-
ation and inhalation techniques may be considered as fail proof,
with the implication that the need for back-up plans may be ne-
glected. Patients suffering from upper airway obstruction may be
uncooperative. However, ablation of spontaneous respiration or
rendering patients unconscious by anaesthesia induction may
be highly dangerous and the anaesthetists should master sed-
ation and local anaesthesia techniques that enable securing the
airway in the spontaneously breathing uncooperative patient.19
Anaesthetists performed few ESAs in this study, but in half of
the patients, the procedure failed. Guidelines state that the ESA
procedure is an essential skill for us as a specialty to master. So
even if the situations is rarely encountered, all anaesthesia
departments should offer necessary skill- and team- training
with suitable regular intervals.3 Causes of distorted airway anat-
omy are multifactorial and unfortunately no single device will
solve all possible airway management difculties encountered.
Studies have documented that simple algorithms and access to
adequate but limited types of equipment, associated with appro-
priate training, increases difcult airway management success.20
The recent updated Difcult Airway Society 2015 guidelines, for
management of unanticipated difcult intubation in adults,
should be commended for taking this into account with further
algorithm simplication and the encouragement of practitioners
to stop and think in case of sufcient oxygenation.3 It is left to the
departments to adjust guidelines to local conditions, including a
limited number of suitable difcult airway management devices,
in order to improve patient management.
Procient difcult airway management relies on knowledge,
experience, skills and behavioural factors. The results of this
study are based only on the written documentation from hospital
les and the DAD, with the obvious limitations in evaluating
the aforementioned factors. It would have been desirable to per-
form a contributory factor analysis, but that would have required
team member interview and case audit in immediate relation
to the event and that was unfortunately beyond the scope of
our study. We have only examined ESA in association with
patients undergoing general anaesthesia registered in the DAD.
Obviously, ESA also occurs in relation to intensive care- and
prehospital- management. Therefore the true ESA incidence in
Denmark is unknown and further research on this topic is
needed in relation to intensive- and prehospital- care. We were
unable to document whether registration of ESA in the DAD
was missing for some patients, as we based our cohort on pa-
tients registered in the DAD. But as false positive ESAs occurred
in the DAD, false negatives may occur as well. Questions in the
DAD regarding the anticipation of difcult airway management
were before 2012 defaulted as no. The anaesthetist had to
actively change this, if difcult airway management was in fact
i82 | Rosenstock et al.
anticipated. This may explain the discrepancy between the DAD
and the hospital les regarding anticipated difcult airway man-
agement.6 Therefore we have given the information on the an-
aesthetic le, regarding anticipation of difcult airway
management a higher weight compared with corresponding
data in the DAD. Finally, despite using a predened structured
scoring approach we cannot exclude the possibility of reviewer-
, hindsight- and outcome- bias when evaluating the provided pa-
tient management.
Conclusion
We found an incidence of ESA of 0.06 events per thousand among
patients undergoing general anaesthesia registered in the DAD.
Among ENT patients the ESA incidence was 1.6 events per
thousand. Seventy per cent of the ESA patients were registered
with a CICV. Airway management was evaluated as satisfactory
for 10 out of 27 patients. ESA performed by anaesthetists, failed
in three out of six patients. Supraglottic airway devices and
NMBAs were used infrequently in order to achieve oxygenation.
Procient difcult airway management relies on simple algo-
rithms and suitable equipment and knowledge, experience, skills
and behavioural factors.
Authors contributions
Study design/planning: C.V.R., A.K.N., L.H.L.
Study conduct: C.V.R., A.K.N., L.H.L.
Data analysis: C.V.R., A.K.N., J.W., L.H.L.
Writing paper: C.V.R., A.K.N., J.W., L.H.L.
Revising paper: all authors
Acknowledgements
The Danish Anaesthesia Database.
Declaration of interest
None declared.
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Handling editor: T. Asai