Letter From the Chair
Christopher Beach, MD, FACEP
Having recently had the pleasant-and-cognitively non-taxing (not!) opportunity to perform awake fiberoptic intubation on a few patients, it seemed like a good time to review some of the history of airway management and discuss current training in advanced airway skills for EM.
Prior to 1878, the management of airway problems was predominantly performed through tracheostomy or blind intubation. Tracheostomy had been used for thousands of years to manage airway obstruction. In 1880, a Scottish physician, Sir William Macewen, described passing an oral tube into the trachea after having practiced digital intubation on cadavers. From 1885 to the early 1900s physicians like Joseph O’Dwyer, George Fell and Hans Kuhn modified flexible tubes to relieve airway obstruction in patients with diphtheria. During this time and through World War I, where many casualties required intubation, development of direct laryngoscopy and tracheal intubation occurred.
Alfred Kirstein developed the “autoscope” to view the airway and Chevalier Jackson built upon this tool by providing illumination with a tungsten light bulb to improve visualization of the glottis in the 1920s. In 1941, Robert Miller described the straight laryngoscope blade and in 1943 Sir Robert Macintosh described the curved blade, both of which are still in use, with modifications today. With the introduction of curare at the same time, tracheal intubation became routine. In the 1960s, electronic monitoring and the use of plastic further advanced airway management. However, failure to provide adequate glottic views prompted the innovation of fiberoptic bronchoscopes in the 1980s, the laryngeal mask airway and Bullard laryngoscope in the 1990s and video laryngoscopes in the 2000s. Currently, video laryngoscopes such as the Glidescope and C-mac, as well as hand held video laryngoscopes, are becoming increasingly popular as the first choice for intubation. Co-existent with many of these equipment advances were advances in sedative medications and paralytics, as well as monitoring tools such as pulse oximetry and capnography.
Increasingly, current efforts to improve advance airway management skills focus on the cognitive aspects of this task; simply “passing plastic” does not assure a safe and effective procedure. 95% of the work that goes into decision-making includes evaluating the necessity of the airway procedure, effectively preparing the environment for success, planning for contingencies, providing the most optimal medications, and assuring that the entire team understands the task at hand. These leadership skills are equally, if not more important, in assuring good patient outcomes. Colleagues of yours within QIPS, as well as many others within ACEP, are currently working on this effort to assure intubation is as safe as possible. Additionally, many residents have recognized that this skill is vital to career success. At my institution, Northwestern University, our residents have created their own Airway and Procedural Sedation Committee, which is a sub-committee of our Quality Management Committee. Nine resident physicians are part of this committee and work closely with physician leaders and nurses to: build better equipment platforms; further develop monitoring and documentation tools; advance educational efforts through quantifiable data; and strategize ways to change culture. One central effort of this work is the approach that every airway should be considered a ‘difficult airway’ and removing ‘difficult’ from the lexicon assures that providers are cognitively prepared and have the necessary equipment to manage any contingency.
The history of airway management is impressive and long. Currently, there are many intensive educational classes focused solely on airway skills and management for emergency medicine physicians taught by emergency medicine physicians. Emergency Medicine (EM), as a specialty, evolved in the 1960s and 1970s beginning with the “Alexandria Plan” in parallel to similar large advances with airway management. Fortunately, ACEP’s founders and the early residency programs of the 1970s recognized the need for advanced airway skills for EM clinicians and this became a key research and educational area in EM. It is the work of pioneers in EM which provided a trusting and fertile ground for those of us currently to explore new and exciting ways to safely and efficiently manage any emergent airway. Without those efforts, it would not have been possible for us to have contemplated awake fiberoptic intubation for those patients who prompted this short review and successfully save their lives. With deep and genuine gratitude I would like to thank them for those efforts and inform them that, every day, their work is saving lives.
On a personal note, I want to thank the members of QIPS, current and past leaders, and our ACEP Staff Liaisons, Stacie Jones and Dainsworth Chambers for your mentorship and leadership over the past year. It has been my distinct privilege to grow and learn from national experts in safety and quality as a clear focus on value has emerged for this generation of EM providers. QIPS is one of the finest sections within ACEP and it is blessed with ample talent, which helps advance the efforts of ACEP and EM as a specialty. I have appreciated the opportunity to serve as Chair and look forward to our exciting future as a Section dedicated to advancing quality and safety in Emergency Medicine.
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