Universal use of Storz C-MAC® videolaryngoscopes was implemented for adult tracheal intubations in the operating theatres, intensive care unit and emergency department at Royal United Hospitals Bath NHS Foundation Trust in 2017. We report data from 1099 intubations from March 2020 to March 2022, collected contemporaneously and anonymously using a smartphone app, representing an estimated 18% of intubations in operating theatres and 30% of intubations in other locations during this period. Intubation success was 100%. The first-pass success rate was 87.3% overall: 87% with a Macintosh videolaryngoscope, 92% with a hyperangulated videolaryngoscope and 81% for users with ≤ 20 previous uses. First-pass success without complications was 87% overall: 87% in operating theatres (836/962), 93% in the emergency department (38/41) and 83% in the intensive care unit (73/88). Complications occurred during 0.6% of intubations: 0/962 in operating theatres and 7/137 in non-theatre locations. The rate of complications was unaltered by blade type (Macintosh 5/994 vs. hyperangulated 2/105, p = 0.14); intubator experience with the device (≤ 20 previous clinical uses 2/260 vs. > 20 previous uses 5/832, p = 0.67) and use of airborne personal protective equipment (PPE 6/683 vs. no-PPE 1/410, p = 0.27). Complication rates increased outside theatres (theatres 0/963 vs. non-theatre 7/136, p < 0.001) and during rapid sequence induction (RSI 6/379 (1.6%) vs. non-RSI 1/720 (0.1%), p = 0.008).

Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker well-being. The implementation of human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. To encourage the adoption of human factors science in anaesthesia, the Difficult Airway Society and the Association of Anaesthetists established a Working Party, including anaesthetists and operating theatre team members with human factors expertise and/or interest, plus a human factors scientist, an industrial psychologist and an experimental psychologist/implementation scientist. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a 'hierarchy of controls' model and classified into design, barriers, mitigations and education and training strategies. Although most anaesthetic knowledge of human factors concerns non-technical skills, such as teamwork and communication, human factors is a broad-based scientific discipline with many other additional aspects that are just as important. Indeed, the human factors strategies most likely to have the greatest impact are those related to the design of safe working environments, equipment and systems. While our recommendations are primarily provided for anaesthetists and the teams they work with, there are likely to be lessons for others working in healthcare beyond the speciality of anaesthesia.

We read with interest Whitaker's letter regarding red-barrelled syringes [1]. We agree that prefilled syringes are an opportunity to improve the safety of neuromuscular blocking (NMB) drug administration, along with the delivery of many other anaesthetic drugs [1, 2], and indeed their use was recommended in the recently published human factors in anaesthesia guidelines [3]. We hope that the use of prefilled syringes will become more widespread in anaesthesia in the next few years, with their use for emergency anaesthetic drugs and NMB drugs being priorities. We also agree that the use of empty red-barrelled syringes for NMB drug administration is potentially hazardous. A number of issues can be foreseen: some staff using red-barrelled syringes for drugs other than NMB drugs if there is a shortage of standard 5 ml syringes; standard 5 ml syringes being used if no red-barrelled syringes are available; four different sizes of red-barrelled syringes would be needed should it be decided to always use these for NMB drug administration (5 ml syringes, as is common for NMB drug administration, 10 ml syringes for rapid sequence induction using rocuronium, 2 ml syringes for rapid sequence induction using suxamethonium and 1 ml syringes for paediatrics), meaning that four more storage locations would be needed in every operating theatre and central store, intensive care unit and emergency department; and it is still possible to accidentally draw up the wrong drug into a syringe, red barrelled or not [1]. In addition, the use of purple syringes for administering oral medication has not prevented oral medicines being accidentally given intravenously (although they have reduced the frequency with which this happens) and specifically designed syringes for drawing up insulin have not prevented insulin overdose. So, while intuitively plausible, there is no evidence that empty red-barrelled syringes would improve safety and there are possible unintended consequences. Human factors professionals should investigate this proposed change in the context of real work before clinicians recommend it [4]; we would fully support this, along with widespread use of red-barrelled prefilled syringes containing NMB drugs.

embraced in aneffort toprevent it. Airway management is generally reliable and safe, but when techniques fail it rapidly becomes highly dangerous. I have reviewed several hundred cases of patient harm due to airway management difficulties. Many involve both technical failures (failure to have or use optimal equipment, failure to be trained in or to use it correctly) and non-technical failures. While, quite rightly, there has recently been increased focus on human factors in such cases, it is essential we embrace technological advances and do not abandon technical excellence. It is almost inconceivable that other safety industries would not by now have adopted widespread VL. Those uncertain as to whether they should use VL or DL as a default technique for tracheal intubation might wish to present the above data to patients and, through shared decision-making, let them choose.

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date.

We thank Lomax et al. for their letter [1] and are hopeful that this will be a step towards healthcare and human factors professionals working together more closely. We agree that safety cannot be reduced to education, checklists, technologies and recipes, and we expand on this in the human factors narrative review paper that accompanies our guidelines [2, 3]. Feedback from human factors professionals from around the world has been positive and supportive, and we are particularly pleased that the guidelines are supported by the Chartered Institute of Ergonomics and Human Factors (CIEHF), the professional body for human factors scientists in the UK. However, we strongly disagree with what they describe as ‘insufficient representation of human factors professionals’ within our guideline group. Our group includes the Chair of the Healthcare Sector of the CIEHF; an industrial psychologist; expertise in high-risk industries, implementation science and patient safety; the chair of the Clinical Human Factors Group; and extensive clinical human factors experience. Lomax et al. question the use of the hierarchy of controls model, suggesting the Systems Engineering Initiative in Patient Safety (SEIPS) model instead. We agree that SEIPS is excellent; it is used by many members of the guideline group and indeed forms the basis of the new Patient Safety Incident Response Framework [4]. However, we believe that the hierarchy of controls model is useful in shifting mindsets away from the behavioural aspects of human factors. Part of our goal was to support understanding away from safety through non-technical skills and towards safety through design, and we believe that the hierarchy of controls model has a good contribution to make here. We did indeed use a three-stage Delphi process to formulate our 12 main recommendations. The Delphi process is not a pure ‘one group member = one vote’ process, but instead involves structured review and discussion at each stage, with opportunities for group members to suggest additional recommendations to be considered in the next round [3]. The clinicians within the group listened to the human factors experts and vice versa. Lomax et al. also question why we did not recommend employing professionally qualified human factors experts in each hospital. This was, in fact, one of our 47 initial recommendations that unfortunately did not make it through the Delphi process, and we fully agree with the advantages of such a strategy – indeed, Dr Lang works as an human factors specialist at Nottingham University Hospitals NHS Trust. The Royal Surrey County Hospital, Guildford is very fortunate to have qualified human factors specialists within its team. However, we believe that relying solely on human factors experts to implement human factors will be problematic and inevitably result in slow progress: there are inadequate NHS financial resources to employ human factors experts in every hospital; there are insufficient qualified human factors professionals to fill the need, with a recent advert receiving no applicants (S. Deakin, personal communication); and a human factors professional would be unable to bring about change unless clinicians, managers and their colleagues appreciate the importance of human factors and the reasons to implement their suggested actions. One alternative approach is the use of ‘train the trainer’ models: when applied well, these can help address the need and cascade the use of human factors methods within healthcare settings. Our guidelines were primarily designed for anaesthetists and their teams, with a focus on how they can draw on accessible aspects of human factors science to enhance patient safety and efficiency. We have created guidelines that clinicians can relate to and are relevant to their everyday work. We were not attempting to produce fully comprehensive guidelines for human factors practitioners working in clinical settings. A complete review of ‘many years of clinical human factors research’ and anything more than ‘scratching the surface of human factors’ would not have resulted in two relatively short and palatable articles that anaesthetists would have the time to read. Guidelines are only as effective as their uptake and implementation. We are thrilled that our guidelines have kickstarted a conversation about the importance, requisite investment in and scaled implementation of human factors within healthcare organisations, and hope that they will prompt much more work in this area. To deliver the dramatic shift in culture and knowledge necessary will require great effort and strong collaborative partnerships between human factors professionals and clinicians. We stand by our guidelines and hope that readers will be able to see them in that context and that they ‘herald the start of the specialty's transition to a more comprehensive understanding of performance based on features beyond the performance of clinicians’ [5].

We thank Dr Hambly for their letter in response to our human factors guidelines [1, 2], for their positive comments about our work and for raising the issue of prefilled syringes within anaesthetic practice. We would like to emphasise that just because a human factors intervention does not appear in our guidance does not mean it is not worthy of attention. Indeed 35 of our 47 initial ideas were lost through the Delphi process, even though the guideline group recognised they all had value. We are aware of and fully support the ongoing work of Drs Hambly, Whitaker and colleagues that focuses on drug safety, particularly the value of prefilled syringes as a design solution to improve drug safety, and thank them for their lobbying of national and international bodies. Meanwhile, we hope that our recommendation that colleagues consider joining their local medication safety committees will enable them to push for prefilled syringes wherever they are available and that this will influence drug companies to provide more through market forces while the regulatory work continues. Prefilled syringes have multiple human factors benefits, reducing the reliance on human performance to maintain medication safety for many reasons: they reduce the number of steps required for an anaesthetist to prepare intravenous drugs from 20 to 8 (D. Whitaker, personal communication); they enable anaesthetic emergency drugs to be immediately available in time-critical situations and, in doing so, reduce cognitive load of the anaesthetic team [3]; and by avoiding routine drawing up of emergency anaesthetic drugs, discarded at the end of the day if not used, they save money and reduce wastage (L. Jordan, personal communication). In addition, good packaging design, including the use of a larger font for the generic drug name than the company logo and colour coding, which matches internationally recognised drug labels, has been used by some manufacturers to improve safety further. We completely agree with Dr Hambly that failure to reference the use of prefilled syringes by anaesthetists in the Carter report was a significant lost opportunity [4]. We hope that the updated Association of Anaesthetists' guidelines for handling of injectable drugs in anaesthesia, due to be published soon, will have found a way to include the routine use of prefilled syringes within its recommendations.

We read with interest the editorial by Pandit et al. [1] regarding unrecognised oesophageal intubation [2]. We understand Glenda Logsdail’s case involved ‘misinterpretation’ of capnography without ‘sustained exhaled carbon dioxide’ soon becoming flat, with the anaesthetist focusing instead on a Grade 1 laryngoscopy view, loss of situation awareness and fixation on one diagnosis (here, anaphylaxis). We would like to add to the authors’ solutions included in the editorial. Considering ‘engineered solutions’, we suggest industry alters the capnograph trace on monitors to shade the area under the curve as already seen on some monitors (Fig. 1). This helps distinguish the capnograph trace from the ventilator airway pressure waveform (Fig. 2), reportedly an issue in Glenda Logsdail’s case [2]. We advocate ‘universal videolaryngoscopy’, which has benefits for skill acquisition, teamwork, communication, non-technical skills and teaching [3, 4]. Since implementing universal videolaryngoscopy in Bath in 2015, our culture has changed: all the intubating team see the view at laryngoscopy, with subsequent knowledge acquisition and increased active involvement in airway management. Our patient airways are now ‘shared’, intubation changed from ‘me to we’, our team hierarchy is flatter and teamwork and trust enhanced. The authors noted the crowded anaesthetic room described by the coroner [1, 2]. Consistent with NAP4

It is inevitable that anaesthetic, theatre and ICU staff will encounter critical incidents, deaths in theatre and other potentially traumatic events during their working lives [1]. Despite introducing trauma risk management (TRiM) at our hospital, a peer support tool that helps staff prepare for and recover from potentially traumatic events [1, 2], we identified four issues which we believed were negatively affecting staff well-being following such events: firstly, staff were not always aware of the normal reactions they might experience after a potentially traumatic event and the steps they could take to mitigate these; secondly, senior staff often found it difficult to carry out short team debriefs immediately after such traumatic cases, especially if they were affected themselves, adding to their anxiety; thirdly, our hospital TRiM system was not being utilised to its maximal potential, with TRiM assessments not always requested following potentially traumatic events; and fourthly, incomplete lists of staff involved in a potentially traumatic event resulted in some staff missing TRiM assessments and the subsequent support available to them. We therefore worked closely with our clinical psychologists to develop a cognitive aid that could be used by frontline clinicians immediately after a potentially traumatic event, a team immediate debrief (TID) tool, with information about ‘psychological first aid’ printed on the back (Fig. 1). This was designed to be displayed on the wall in operating theatres and ICU and used immediately after a potentially traumatic event, to enable a simple, short, fast and effective immediate debrief, and encourage a complete list of staff involved to be recorded immediately, TRiM referrals to bemade and staff well-being promoted. We designed and delivered a TID tool awareness campaign to familiarise the operating theatre and ICU multidisciplinary team with the purpose of the TID, its objectives and method of use, and sought feedback for further improvement. Multidisciplinary staff were invited to take part in small group ‘tea trolley’ training sessions [3], modified in order to be COVID-19 secure, and to complete feedback forms immediately afterwards. Seventy staff received training and 37 completed feedback forms (a response rate of 53%). Before training, 5 (13%) reported they felt very, or quite, confident to use the TID and 28 (78%) had never used it. Following training, 30 (81%) reported they felt very, or quite, confident to use the TID. Free comments included the need to simplify the TID further, to consider whether any staff member (and not just senior staff) could lead an immediate debrief and to clarify situations in which it could be used. Twenty-three staff (62%) reported specific situations they had been involved with when the TID would have been useful, including blocked tracheal tubes in ICU; difficult tracheal intubations; difficult paediatric cases; cardiac arrests; deaths in theatre; and ICU cases during the COVID-19 pandemic first wave. Thirty-six (97%) participants reported that they would recommend the use of the TID to other hospitals. In conclusion, the TID proved to be a popular tool for promoting and standardising immediate multidisciplinary team debriefs following potentially traumatic events. Staff reported that the tool improved confidence in leading an Figure 1 Bath team incident debrief tool.

they apparently fulfil standard BS EN ISO 5362:2019, Anaesthetic reservoir bags. It is worrying that a product which is so different from the original can comply with industry standards and be widely distributed for use in patients without formal clinical assessment. Levin identified that clinical performance needs to be recognised when manufacturing medical equipment and that adherence to industrial standards in isolation may compromise safety [5]. Studies by both Tan and Schilly clearly show that experienced paediatric anaesthetists can detect over 80% of tracheal occlusions by the feel of the bag alone [2,3]. Certainly it would be difficult to describe within a standard how a device feels after years of clinical experience. We would therefore advocate greater engagement between clinician and manufacturer to deliver a product that addresses manufacturing constraints yet maintains clinical performance.

The need to evacuate an ICU or operating theatre complex during a fire or other emergency is a rare event but one potentially fraught with difficulty: Not only is there a risk that patients may come to harm but also that staff may be injured and unable to work. Designing newly-built or refurbished ICUs and operating theatre suites is an opportunity to incorporate mandatory fire safety features and improve the management and outcomes of such emergencies: These include well-marked manual fire call points and oxygen shut off valves (area valve service units); the ability to isolate individual zones; multiple clear exit routes; small bays or side rooms; preference for ground floor ICU location and interconnecting routes with operating theatres; separate clinical and non-clinical areas. ICUs and operating theatre suites should have a bespoke emergency evacuation plan and route map that is readily available. Staff should receive practical fire and evacuation training in their clinical area of work on induction and annually as part of mandatory training, including 'walk-through practice' or simulation training and location of manual fire call points and fire extinguishers, evacuation routes and location and operation of area valve service units. The staff member in charge of each shift should be able to select and operate fire extinguishers and lead an evacuation. Following an emergency evacuation, a network-wide response should be activated, including retrieval and transport of patients to other ICUs if needed. A full investigation should take place and ongoing support and follow-up of staff provided.

1Consultant, Royal UnitedHospitals BathNHS Foundation Trust, CombePark, Bath, UK 2Consultant, St. JamesHospital, James Street, Dublin, Ireland ............................................................................................................................................................................................................................................................................................................ Correspondence to: T. Cook Email: timcook007@gmail.com Accepted: 21April 2021

‘Cannot intubate, cannot oxygenate’ (CICO) situations occur when all efforts to oxygenate the patient using facemask, supraglottic airway device (SAD) and tracheal intubation have failed, the patient is consuming oxygen faster than it can be delivered and is at risk of imminent hypoxic brain injury, cardiac arrest and death. The quickest method of oxygenating a patient in this situation is to recognise the CICO emergency and perform an emergency front-of-neck airway (FONA) 1, usually in the form of a cricothyrotomy. ‘Cannot intubate, cannot oxygenate’ emergencies are rare and are associated with significant mortality and morbidity 1-3, especially if there is a delay in recognising the situation and/or performing cricothyrotomy 1, 3. In this issue of Anaesthesia 4, Rehak and Watterson obtained a 91% response rate in their survey investigating the institutional preparedness of anaesthesia teaching hospitals in Australia and New Zealand for CICO emergencies. This essentially establishes findings for an entire population of teaching hospitals, avoiding the need for inference statistics about a population from a smaller sample – a rare event in research. Establishing a protocol to manage CICO emergencies and removing barriers that prevent staff from performing a cricothyrotomy when one is needed, is every institution's responsibility. Although the Australian and New Zealand College of Anaesthetists (ANZCA) has highlighted CICO preparedness as one of its three teaching priorities, as Winston Churchill said ‘however beautiful the strategy, you should occasionally look at the results’ (https://www.wsj.com/articles/dont-quote-churchill-on-that-1514330569). Rehak and Watterson do this in detail, identifying and quantifying relevant issues in order to enable further improvements in CICO management 4. Rehak and Watterson investigated several equipment-related issues 4. These included the type of cricothyrotomy equipment available in each hospital, and whether point-of-care CICO equipment packs, used to perform a cricothyrotomy, were accessible and ready to use in each operating theatre or location where airway management occurs. The questionnaire also included human factors-related issues such as: the availability of cognitive aids; whether communication of a CICO emergency was clear and whether the language used to describe a CICO situation was simple and easy to understand; provision of staff training in CICO management and cricothyrotomy; and whether case-review systems were in place 4. Rehak and Watterson's survey highlights several points. Even though both countries follow the same difficult airway management guidelines 5, there were significant differences between cricothyrotomy equipment available in Australian hospitals compared with those in New Zealand. Australian hospitals were more likely to have point-of-care CICO equipment for both cannula and scalpel techniques rather than for scalpel techniques only (85% vs. 35%, p < 0.0001); in comparison, a greater proportion of New Zealand hospitals reported providing equipment for scalpel techniques only (59% vs. 4%, p < 0.0001). This disparity likely reflects the ongoing worldwide debate regarding cricothyrotomy technique 6, with an exception being the UK where a scalpel-only technique has been largely adopted 6, 7. Rehak and Watterson's survey suggests that there is also an inconsistent approach between teaching hospitals in Australia and New Zealand, with multiple equipment choices available to a clinician who has declared a CICO situation. Human factors and ergonomics can be defined as “making it easy to do the right thing” 8, 9: having more than one type of equipment available in a CICO emergency, when immediate action is required, appears to be the antithesis of human factors and ergonomics principles. This is a situation which an anaesthetist may face only once in their whole career 6. Simplifying the equipment available, and ideally standardising the technique, is likely to make it easier for staff to manage the situation well as a team 1, 4, 6, 7. A recent human factors and ergonomics study found that ‘providing enablers’ and ‘removing barriers’ were important aspects of system design, with equipment availability and location being the biggest enabler of good performance in difficult airway situations 10. Rehak and Watterson's survey found that 83% of operating theatres had a point-of-care CICO rescue kit, compared with 55% of satellite locations where airway management occurred. The American Society of Anesthesiologists’ 2019 publication, comparing airway closed-claims in the years 2000–2012 to those in the years 1993–1999, found an increase in medico-legal cases related to satellite locations 11. Point-of-care CICO packs are simple, inexpensive and avoid the need to fetch a difficult airway trolley or to gather equipment from various locations, thereby removing an ‘inaccessible equipment’ barrier 10, 12, reducing delays and diminishing potential psychological barriers to performing a cricothyrotomy 10, 11. Making the point-of-care CICO packs easily visible also provides an immediate prompt to perform a cricothyrotomy should one be needed 12. In a recent review of airway-related closed legal claims in the US, delay to initiating a cricothyrotomy in CICO situations was highlighted as a recurring issue leading to brain damage and death 11. We feel that hospitals around the world would do well to introduce point-of-care CICO packs in all areas where airway management occurs. We were pleased to see that 70% of hospitals in Rehak and Watterson's survey reported that one or more cognitive aids were routinely present in their operating theatres 4. Cognitive aids are prompts designed to help users complete a task or series of tasks 13, 14: they are likely to encourage transitioning from one stage of the failed intubation algorithm to another 13, 14 and may provide prompts to encourage staff to perform a cricothyrotomy in a timely fashion 9, 13, 14. In addition, they may help ‘flatten the hierarchy’ or ‘reduce the authority gradient’ within a team, encouraging more junior staff to speak up and suggest that a cricothyrotomy is necessary if they believe that one is required 1. Multiple cognitive aids are available for CICO emergencies, one example being the Vortex model 14, although of note most cognitive aids (including the Vortex model) have not been validated. Reporting and reviewing CICO emergencies, regardless of outcome, is essential for improving system design and team performance. Rehak and Watterson's survey revealed that reporting of CICO events took place in only 34% of responding hospitals, and review of cases involving difficult airway management occurred in only 56% 4. Use of the Airway App, a database accessed via a smart phone application and available to clinicians worldwide, provides an easily accessible method of recording such events and enables analysis of cases, looking for common themes and learning points 15. There are two important issues that we believe could have been addressed by Rehak and Watterson's survey. Their survey focuses solely on the endpoint of the failed intubation algorithm 7, that of cricothyrotomy during a CICO event, and concentrates on issues surrounding performance of the cricothyrotomy. Systems to prevent CICO emergencies from occurring were not investigated. If every patient underwent a thorough documented airway assessment 16 and creation of an airway management strategy 1, including awake tracheal intubation or tracheostomy when required and if there is enough time to do so 1, it is possible that a failed intubation or complication of airway management may be avoided altogether. Strategies to optimise laryngoscopy, including the use of videolaryngoscopes as first choice devices 17, proficiency and skill with videolaryngoscope hyperangulated blades 17, high flow nasal oxygen when difficult laryngoscopy is anticipated and optimising patient positioning before laryngoscopy 7, increase the chance of a successful first intubation attempt 17, 18. This is vital because, if the first attempt at tracheal intubation fails, the chance of successful intubation declines with each subsequent attempt at laryngoscopy 2, 17, 18, and the risk of hypoxia and hypotension increases. More than half of the incidents reported to the 4th National Audit Project in the UK (NAP4) involved problems with intubation as the incident progressed 1. Emphasis during airway training, regardless of clinical specialty or patient location, to ‘make the first attempt at tracheal intubation your best attempt’ is a strategy which is likely to reduce the chance of a failed intubation and its complications, potentially preventing a CICO situation. Likewise, using a second-generation SAD for all patients, when tracheal intubation and/or facemask ventilation has failed, may improve oxygenation more rapidly while decreasing the risk of aspiration of gastric contents compared with first-generation SADs 19. It would have been beneficial if Rehak and Watterson's survey had also investigated the availability of equipment for Plans A and B of the DAS 2015 guidelines for the management of unanticipated difficult intubation in adults 7. The second issue that could have been addressed in more detail is airway training 20. Although 89% of hospitals reported providing CICO rescue training, only 13% reported that this training was mandatory. Although CICO is one of three compulsory emergency response activities in the current ANZCA Continuing Professional Development program, which must be completed every 3 years 21, anaesthetists do not have to attend CICO training and can instead choose training in massive transfusion or anaphylaxis management. Is it now time for ANZCA to make CICO training mandatory for all anaesthetists every 3 years, and for other national bodies, such as the Royal College of Anaesthetists, to follow suit? Could this be taken even further, with national bodies mandating regular airway training for all anaesthetists of all grades, and indeed all who manage airways, covering airway rescue techniques as well as CICO training 6, 7, 20, 22? We believe that it is time to do so. Airway management is often learned as a solo development of skills and decision making. However, airway management is very much a team sport, especially during emergency situations. As airway managers, we have an obligation to train with our anaesthetic assistants, intensive care and emergency department colleagues in order to obtain and retain the necessary mutual skills to be effective team players. This may include mandatory out-of-theatre airway workshops 22, plus in-situ simulation training to provide staff with good technical skills, strategies to improve their non-technical skills 23 and reveal any potential deficits and system errors during such drills (https://chfg.org). Importantly, however well-trained a team is in both technical and non-technical skills, if that team is then placed back into a poorly designed work environment, it is highly likely that an error will occur. Consistent patient safety should not depend on the skills of individual clinicians but instead should be the result of incorporation of human factors and ergonomics expertise into the design of safe working systems in order to reduce the risk of an error occurring 9. In summary, Rehak and Watterson are to be commended for their assessment of CICO equipment preparedness in nearly all Australia and New Zealand anaesthesia teaching hospitals. Clinicians worldwide would be advised to examine the design of their working environment to ensure that the relevant equipment is immediately available, is simplified and standardised as much as possible, and that staff are familiar with its location and skilled in its use. As the next step, it would be advisable for hospitals to look at airway techniques and equipment used earlier in the failed tracheal intubation algorithm: assessing all patients with a thorough airway examination, creation of an individualised airway strategy, use of awake techniques when indicated, using advanced airway equipment as first choice devices, all coupled with appropriate training in these techniques and skills. Rehak and Watterson have shown that Australia and New Zealand are prepared for CICO emergencies in the operating theatre, but less so in out-of-theatre locations. No clinician should have to manage a CICO event because equipment was not available to prevent a difficult airway situation degenerating into a CICO emergency, or because they were insufficiently trained to use the available equipment. Prevention of a CICO emergency is perhaps the best means of managing one. FK's department has received equipment for evaluation, research and training at cost price, for free or on loan. LD is an editor of Anaesthesia. No other external funding or competing interests declared.

Universal videolaryngoscopy has been used in our hospital since 2017.1 Optimising videolaryngoscope (VL) use has involved disseminating Video-Assisted Flexible-Optical Intubation (VAFI)1 and a specific technique for using the CMAC® D blade (KarlStorz, Slough, UK) using a rigid KarlStorz stylet.2 VAFI is a two-person intubation technique that can be used when the larynx is visualised using a hyperangulated VL but a tracheal tube cannot be passed despite using a stylet: intubator one optimises the laryngeal view using a hyperangulated VL blade; intubator two (standing next to and to the right of intubator one) preloads a tracheal tube onto a flexible bronchoscope, guides the bronchoscope into the trachea, and then railroads the tracheal tube over the bronchoscope into place. This technique can be used electively for an anticipated difficult intubation or as a rescue technique in a ‘can’t intubate, can oxygenate’ situation. We designed and delivered a VAFI and CMAC® D blade training programme for our department: a CMAC® D-blade/VAFI guide was disseminated by e-mail; VAFI and CMAC® D blade stations were included in out-of-theatre airway workshops; a ‘Bath Tea Trolley’ training programme provided multidisciplinary VAFI and CMAC® D blade training in the workplace during the normal working day, using a previously described teaching method.3 Participants were given hand-outs to facilitate reflective learning and completed a feedback form. Fifty-four staff members received training: 17 consultants, five associate specialists, eight registrars, nine core trainees/clinical fellows, and 15 anaesthetic assistants/students. Results showed that before training, 31 of 54 (57%) participants reported that they were quite/very confident in CMAC® D-blade use and 16 (30%) for VAFI; after training, 44 (82%) of participants reported an increase in confidence of ≥1 on a 5-point Likert scale for CMAC® D blade use and 48 (89%) for VAFI; 94% of participants reported that their ability to manage a difficult airway would be improved after this training; 100% of participants requested that this training be repeated in Bath; 100% recommended this training to other hospitals. Confidence scores before or after training are shown in Figure 3. In summary, optimising videolaryngoscopy has involved dissemination of VAFI and CMAC® D blade techniques using a multimodal approach. ‘Tea trolley’ training proved very effective for teaching both techniques. Only 57% of staff felt quite/very confident in CMAC® D blade use before training despite multiple previous teaching programmes, showing the high frequency of skill decay and the need for regular training; continued training is planned to address this. 1.Hagberg CA, Artime CA, Daily WH. The Difficult Airway: A Practical Guide. Oxford University Press USA, 2013.2.Cook TM, Boniface NJ, Seller C, et al. Br J Anaesth 2018; 120: 173–803.O’Farrell G, McDonald M, Kelly FE. Anaesthesia 2015; 70: 104

When the coronavirus 2019 (COVID-19) pandemic struck much of the world in late February 2020, this editorial was in final draft form. Now in early June, as the worst of the first epidemic surge wanes in the UK, we have reflected and updated its content accordingly below. Ensuring success when managing unexpected airway difficulty relies on being adequately prepared. A 'prepared airway practitioner' has been described as one who 'performs safe airway management, displaying skill, knowledge and a full awareness of human factors, within a culture of safety … ', and such practitioners 'should aim for expertise rather than mere competence'.1Baker P. Preparedness and education in airway management.Anesthesiol Clin. 2015; 33: 381-395Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar This statement highlights the three main components of preparedness: the culture of safety relating to institutional preparedness, human factors relating to team preparedness, and skill, knowledge, and expertise relating to personal preparedness. Without all of these, an airway practitioner's ability to achieve reliable success when managing unexpected airway difficulty will be impaired. One important facet of preparedness is optimising equipment and its use. The 4th National Audit Project (NAP4) highlighted equipment issues—the appropriate range of equipment, its immediate availability, and the skills and experience to use it—as significant contributors to adverse outcomes in airway management.2Cook T.M. Woodall N. Frerk C. Major complications of airway management in the UK: results of the 4th national Audit Project of the royal College of anaesthetists and the difficult airway society. Part 1 anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1374) Google Scholar Whilst in most countries there is broad consensus around the types of equipment that should be available when encountering airway difficulty, there is less clarity about availability and preparation to ensure it can be skilfully deployed. We explore here how we can use airway equipment, and importantly its routine availability, to optimise our institutional, team, and personal preparedness. Competence in using the equipment required for managing unexpected airway difficulty is an expected minimum of a prepared airway practitioner, and expertise is the goal. For trainees, the route to competence may be obvious, with detailed and specific curricula to follow.3Annex D. Royal College of anaesthetists 2010 curriculum. Available from: https://www.rcoa.ac.uk/sites/default/files/documents/2019-08/TRG-CCT-ANNEXD.pdf (accessed 22 May 2020).Google Scholar Even then, trainees are often exposed to equipment with little or no official training.1Baker P. Preparedness and education in airway management.Anesthesiol Clin. 2015; 33: 381-395Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar However, for those who are no longer in training, who form the majority of practitioners, the task may be more challenging, with limited guidance on how to maintain competence with existing equipment or to achieve it when new equipment is introduced. To address this, the Australian and New Zealand College of Anaesthetists have made some strides towards mandating triennial airway rescue training,4Emergency response ActivitiesAustralian and New Zealand College of anaesthetists.2020http://www.anzca.edu.au/fellows/continuing-professional-development/emergency-response-activitiesDate accessed: May 18, 2020Google Scholar but in practice this can be avoided by choosing other educational options and there is a strong argument that, in focusing only on the front-of-neck airway techniques, the wrong skill set is being emphasised.5Kelly F.E. Duggan L.V. Preparing for, and more importantly preventing, 'cannot intubate, cannot oxygenate' events.Anaesthesia. 2020; 75: 707-710Crossref PubMed Scopus (6) Google Scholar In many other counties there is no process for mandating skills retention or acquisition whatsoever. In the UK barely half of trained anaesthetists get any locally delivered skills training.6Lindkær-Jensen N.H. Cook T.M. Kelly F. A national survey of practical airway training in UK anaesthetic departments. Time for a national strategy?.Anaesthesia. 2016; 71: 1273-1279Crossref PubMed Scopus (31) Google Scholar The adage 'practice makes perfect' is relevant here: 'reinforcement learning' has been studied by neurobiologists in some detail. In simple terms, neuronal circuits are either 'actors' (those that produce an action/behaviour) or 'critics' (those that relay feedback on the outcome of that action/behaviour) to fine tune motor skills and behaviours.7Charlesworth J.D. Warren T.L. Brainard M.S. Covert skill learning in a cortical-basal ganglia circuit.Nature. 2012; 486: 251-255Crossref PubMed Scopus (78) Google Scholar These interactions reinforce adjustments that bring the action or behaviour closer to the desired outcome until it is honed. Consequently, in addition to other benefits such as knowledge and familiarity, using advanced or rescue airway equipment during our normal practice, rather than only during difficulty, will hone those motor skills we need to acquire for both competence and expertise. The essence of Plan A as outlined in the 2015 Difficulty Airway Society (DAS) guidelines for management of the difficult airway is to maximise the likelihood of successful intubation at the first attempt.8Frerk C. Mitchell V.S. McNarry A.F. et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Difficult Airway Society intubation guidelines working group.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1388) Google Scholar Videolaryngoscopy has transformed the management of difficult airways with numerous benefits widely reported. Videolaryngoscopy enables a better view at laryngoscopy with greater operator ease and less force.9Lewis S.R. Butler A.R. Parker J. Cook T.M. Schofield-Robinson O.J. Smith A.F. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review.Br J Anaesth. 2017; 119: 369-383Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar It leads to fewer Grade 3–4 views and fewer intubation failures. Benefits are particularly evident in higher risk patients.9Lewis S.R. Butler A.R. Parker J. Cook T.M. Schofield-Robinson O.J. Smith A.F. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review.Br J Anaesth. 2017; 119: 369-383Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar However, benefits of videolaryngoscopy are limited to those practitioners experienced in its use; direct laryngoscopy skills do not translate into skill with videolaryngoscopy, especially devices with hyperangulated blades.9Lewis S.R. Butler A.R. Parker J. Cook T.M. Schofield-Robinson O.J. Smith A.F. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review.Br J Anaesth. 2017; 119: 369-383Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar Gill and colleagues10Gill R.L. Jeffrey A.S.J. McNarry A.F. Liew G.H.C. The availability of advanced airway equipment and experience with videolaryngoscopy in the UK: two UK Surveys.Anesthesiol Res Pract. 2015; 2015: 152014https://doi.org/10.1155/2015/152014Crossref PubMed Scopus (28) Google Scholar reported that more UK anaesthetists with an interest in advanced airway management believed they were competent to teach videolaryngoscopy than had used the devices more than 10 times. For many anaesthetic procedures there is a steep learning curve for the first 30 cases, but with the learning curve not flattening off beyond at least 100 cases.11Greaves J.D. Training time and consultant practice.Br J Anaesth. 2005; 95: 581-583Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Regarding hyperangulated videolaryngoscopy, 76 uses were reported to be required to achieve reliable performance.12Cortellazzi P. Caldiroli D. Byrne A. Sommariva A. Orena E.F. Tramacere I. Defining and developing expertise in tracheal intubation using a GlideScope® for anaesthetists with expertise in Macintosh laryngoscopy: an in-vivo longitudinal study.Anaesthesia. 2015; 70: 290-295Crossref PubMed Scopus (98) Google Scholar This sustained acquisition of expertise chimes with our own local experience where, after 5 yr of universal videolaryngoscopy, we are still gaining in expertise.13Cook T.M. Boniface N.J. Seller C. et al.Universal videolaryngoscopy: a structured approach to conversion to videolaryngoscopy for all intubations in an anaesthetic and intensive care department.Br J Anaesth. 2018; 120: 173-180Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar The 2015 DAS guidelines state that anaesthetists should be 'trained to use, and have immediate access to, a videolaryngoscope', and that they should be 'experts'.8Frerk C. Mitchell V.S. McNarry A.F. et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Difficult Airway Society intubation guidelines working group.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1388) Google Scholar This begs the question as to whether videolaryngoscopy should be used solely as a rescue device or routinely. A 2012 UK survey reported that only 57% had access to videolaryngoscopes.10Gill R.L. Jeffrey A.S.J. McNarry A.F. Liew G.H.C. The availability of advanced airway equipment and experience with videolaryngoscopy in the UK: two UK Surveys.Anesthesiol Res Pract. 2015; 2015: 152014https://doi.org/10.1155/2015/152014Crossref PubMed Scopus (28) Google Scholar By 2017, the vast majority of UK hospitals had videolaryngoscopes, but access was often restricted to the main operating theatre suite and absent in many clinical settings.14Cook T.M. Kelly F.E. A national survey of videolaryngoscopy in the United Kingdom.Br J Anaesth. 2017; 118: 593-600Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar Critically, routine use was reported in fewer than one-third of hospitals and was sometimes restricted to specified individuals, training was often inadequate, and attitudes to use of videolaryngoscopy were inconsistent. Having videolaryngoscopes immediately available to all practitioners and adopting them into routine practice benefits the patient and facilitates acquisition of competence and expertise. Education is facilitated, in real time and through recorded images, and airway team communication and teamwork are improved.15Howard-Quijano K.J. Huang Y.M. Matevosian R. Kaplan M.B. Steadman R.H. Video-assisted instruction improves the success rate for tracheal intubation by novices.Br J Anaesth. 2008; 101: 568-572Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar,16Zaouter C. Calderon J. Hemmerling T.M. Videolaryngoscopy as a new standard of care.Br J Anaesth. 2015; 114: 181-183Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar Routine use of videolaryngoscopy therefore improves institutional, team, and individual preparedness for managing intubation difficulty. The relationship between choice and outcome/decision-making is a complex one. Counterintuitively, higher levels of information and more choice do not always result in better outcomes.17Marewski J.N. Gigerenzer G. Heuristic decision making in medicine.Dialogues Clin Neurosci. 2012; 14: 77-89Crossref PubMed Google Scholar 'Choice overload' is a term used outside medicine to describe situations where an increase in choice can result in delay in decision-making or the inability to decide or take action at all,18Scheibehenne B. Greifeneder R. Todd P. et al.Can there ever be too many options? A Meta-analytic review of choice overload.J Consum Res. 2010; 37: 409-425Crossref Scopus (643) Google Scholar and which may be more profound when time is limited.19Jessup R.K. Ritchie L.E. Homer J. Hurry up and decide: empirical tests of the choice overload effect using cognitive process models.Decision. 2020; 7: 137-152Crossref Scopus (3) Google Scholar The concept of 'fast-and-frugal' decision-making within medicine has been studied in some detail.17Marewski J.N. Gigerenzer G. Heuristic decision making in medicine.Dialogues Clin Neurosci. 2012; 14: 77-89Crossref PubMed Google Scholar Using problem-focused decision-making tools, clinicians can make decisions rapidly, based on very little information (or choice), producing results comparable to those made by complex models with multiple variables.17Marewski J.N. Gigerenzer G. Heuristic decision making in medicine.Dialogues Clin Neurosci. 2012; 14: 77-89Crossref PubMed Google Scholar These concepts could usefully be extended to the equipment we use. By limiting available airway equipment—and therefore choice—to that known to be most likely to achieve success in a crisis, we can improve decision-making and 'algorithm transitioning'. In addition to this technical benefit, the whole team will be more likely to be aware of and familiar with the equipment required for transitioning to the next step. The emphasis of Plan B in the 2015 DAS guidelines is on maintaining oxygenation using a supraglottic airway (SGA) device.8Frerk C. Mitchell V.S. McNarry A.F. et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Difficult Airway Society intubation guidelines working group.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1388) Google Scholar SGAs have been in routine use for more than 30 yr. Whilst first-generation devices are effective in selected cases, they have limitations. Second-generation devices, such as the ProSeal laryngeal mask airways and i-gel, largely address these limitations with modifications that improve airway seal and reduce risk of pulmonary aspiration. Although definitive evidence of improved safety is lacking, this is likely because of the impracticality of such research, which would require several million patients to prove the point. Using weighted scores across several domains of safety and efficacy based on available 'all source' evidence, second-generation SGAs were calculated to outperform their predecessors in all areas of practice, and particularly for airway rescue.20Cook T.M. Kelly F.E. Time to abandon the 'vintage' laryngeal mask airway and adopt second-generation supraglottic airway devices as first choice.Br J Anaesth. 2015; 115: 497-499Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar The 2015 DAS guidelines recommend second-generation SGAs as rescue devices.8Frerk C. Mitchell V.S. McNarry A.F. et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Difficult Airway Society intubation guidelines working group.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1388) Google Scholar This was reinforced in the 2018 guidance for airway management of the critically ill.21Higgs A. McGrath B.A. Goddard C. et al.Guidelines for the management of tracheal intubation in critically ill adults.Br J Anaesth. 2018; 120: 323-352Abstract Full Text Full Text PDF PubMed Scopus (509) Google Scholar If both first- and second-generation SGAs are available when difficulty is encountered, the practitioner must actively weigh the benefits and limitations of each before choosing one device. A more inexperienced practitioner may make the incorrect choice or lose precious time while deciding. Even when the correct decision is made, this may not be anticipated by the assistant, adding further delay. If instead only one or two second-generation SGAs are available, both for routine use and as a rescue device, then in a crisis situation not only is the correct equipment immediately available but practitioners are practised and skilled in their use, delays in crisis decision-making are minimised, assistants are more likely to anticipate correctly, and algorithm transitioning is enhanced. Here again, by reducing the choice of available airway equipment, an organisation will not only improve institutional preparedness, but also the preparedness of the team and individual clinicians. Industry has applied standardisation of processes and equipment for many years to improve efficiency. More recently, human factors and ergonomic research in healthcare has highlighted the importance of standardisation of equipment in reducing human errors and improving safety.22Care Quality Commission. Supporting note: standardisation. Available from: https://www.cqc.org.uk/sites/default/files/documents/20110506_supporting_note_-_standardisation_updated_for_external_publication.pdf (accessed 25 February 2020).Google Scholar Standardisation may refer to any aspect of the equipment, from the model and functionality, to the location where it is kept and how it is cleaned or disposed of. Whilst it may initially be unrealistic to expect national standardisation, this should certainly be possible in an individual hospital, and regional networks may facilitate this more widely.23McNarry A. Cook T.M. O'Sullivan E.P. Baker P.A. The airway lead – opportunities to improve institutional and personal preparedness for airway management.Br J Anaesth. 2020; 125: e22-e24Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Because clinicians, especially trainees, move frequently between different hospitals and even between different departments within hospitals, such equipment standardisation has obvious potential to improve familiarity, confidence, and competence, and thereby engender a culture of safety. When attempts to manage the airway by tracheal intubation, mask ventilation, and SGA have failed, a cannot intubate-cannot oxygenate situation arises that necessitates an emergency front-of-neck airway (eFONA) according to Plan D of the DAS guidelines.8Frerk C. Mitchell V.S. McNarry A.F. et al.Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Difficult Airway Society intubation guidelines working group.Br J Anaesth. 2015; 115: 827-848Abstract Full Text Full Text PDF PubMed Scopus (1388) Google Scholar While the approach to the emergency front-of-neck airway (eFONA) has not been standardised across the UK, major steps in that direction have been taken. The NAP4 recommended that a surgical cricothyroidotomy approach be taught to all anaesthetists,2Cook T.M. Woodall N. Frerk C. Major complications of airway management in the UK: results of the 4th national Audit Project of the royal College of anaesthetists and the difficult airway society. Part 1 anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1374) Google Scholar and the 2015 DAS guidelines recommended a scalpel-bougie-tube approach as the default technique.13Cook T.M. Boniface N.J. Seller C. et al.Universal videolaryngoscopy: a structured approach to conversion to videolaryngoscopy for all intubations in an anaesthetic and intensive care department.Br J Anaesth. 2018; 120: 173-180Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Both emphasised universal training and a single approach within any one hospital. This has been further emphasised in cross-specialty documents.24Pracy J.P. Brennan L. Cook T.M. et al.Surgical intervention during a can't intubate can't oxygenate (CICO) event: emergency front-of-neck airway (FONA)?.Br J Anaesth. 2016; 117: 426-428Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Although rarely used, eFONA equipment, when needed, must be immediately available and the team familiar with and confident in its use in order to save a life in extremis.2Cook T.M. Woodall N. Frerk C. Major complications of airway management in the UK: results of the 4th national Audit Project of the royal College of anaesthetists and the difficult airway society. Part 1 anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1374) Google Scholar Delay in performing eFONA is likely to be a greater cause of harm than procedural complications. Despite this, a small UK survey reported that more than one in four anaesthetists could not confirm that an eFONA kit was available in their institution.25Mendonca C. Ahmad I. Sajayan A. et al.Front of neck access: a survey among anesthetists and surgeons.J Anaesthesiol Clin Pharmacol. 2017; 33: 462-466PubMed Google Scholar Conversely, a survey of Australasian anaesthetic departments reported immediate availability and visibility of point-of-care eFONA equipment in >80% of operating theatres, though this was the case in only around half of satellite locations.26Rehak A. Watterson L. Institutional preparedness to prevent and manage anaesthesia-related 'can't intubate, can't oxygenate' events in Australian and New Zealand teaching hospitals.Anaesthesia. 2019; 75: 767-774Crossref PubMed Scopus (17) Google Scholar Current UK practice is unknown. Following the evidence is possible. Reducing choice is possible. Standardisation is possible. Mandating training is possible. In our hospital we have done all these. Videolaryngoscopy is used universally and after 5 yr we believe that we are still learning new skills and benefitting our patients.27Saunders T.G. Gibbins M.L. Seller C.A. Kelly F.E. Cook T.M. Videolaryngoscope assisted fibreoptic intubation for tracheal tube exchange in a difficult airway.Anaesth Rep. 2019; 7: 22-25Crossref PubMed Scopus (9) Google Scholar We removed all first-generation SGAs from use 3 yr ago (except for flexible laryngeal masks for head and neck surgery) and have only two types of second-generation SGA available for routine (and rescue) use. Point-of-care eFONA kits (a scalpel, a bougie, and a tracheal tube) are boxed and available in every location where anaesthesia takes place. Workshop-based airway training, which includes training in use of all the equipment described in this editorial and all techniques necessary in the 2015 DAS algorithms, was made mandatory for all anaesthesia and intensive care department members 4 yr ago, with 100% compliance. When airway difficulty arises in clinical practice, the equipment deployed is instantly available, and is that which is in routine use and with which we and our assistants are trained, familiar, and skilled or expert. Introducing these changes in practice was not without barriers, but we firmly believe that it has improved the standard and reliability of airway management throughout the hospital and improved patient care. It has reduced the frequency of airway crises with no eFONA performed in 6 yr. We would not wish to return to previous non-standardised approaches. The COVID-19 pandemic has brought the reliability of airway management techniques into sharp focus, both to improve patient safety and to protect the health of the intubating team. Amongst four COVID-specific airway management guidelines from across the globe, institutional preparedness is emphasised and both universal use of videolaryngoscopy and second-generation SGAs are recommended by all.28Cook T.M. El-Boghdadly K. McGuire B. McNarry A.F. Patel A. Higgs A. Consensus guidelines for managing the airway in patients with COVID-19. Guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal College of anaesthetists.Anaesthesia. 2020; 75: 785-799Crossref PubMed Scopus (684) Google Scholar, 29Sorbello M. El-Boghdadly K. Di Giacinto I. et al.The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice.Anaesthesia. 2020; 75: 724-732Crossref PubMed Scopus (265) Google Scholar, 30Brewster D.J. Chrimes N. Do T.B. et al.Consensus statement: safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group.Med J Aust. 2020; 212: 472-481Crossref PubMed Scopus (291) Google Scholar, 31Yao W. Wang T. Jiang B. et al.Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.Br J Anaesth. 2020; 125: e28-e37Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar All emphasise limiting choices and use of techniques that are reliable and with which the operator is trained.28Cook T.M. El-Boghdadly K. McGuire B. McNarry A.F. Patel A. Higgs A. Consensus guidelines for managing the airway in patients with COVID-19. Guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal College of anaesthetists.Anaesthesia. 2020; 75: 785-799Crossref PubMed Scopus (684) Google Scholar, 29Sorbello M. El-Boghdadly K. Di Giacinto I. et al.The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice.Anaesthesia. 2020; 75: 724-732Crossref PubMed Scopus (265) Google Scholar, 30Brewster D.J. Chrimes N. Do T.B. et al.Consensus statement: safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group.Med J Aust. 2020; 212: 472-481Crossref PubMed Scopus (291) Google Scholar, 31Yao W. Wang T. Jiang B. et al.Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations.Br J Anaesth. 2020; 125: e28-e37Abstract Full Text Full Text PDF PubMed Scopus (249) Google Scholar Together the COVID-19 guidelines encapsulate the concepts discussed above. They advocate for safe, accurate, and swift airway management.28Cook T.M. El-Boghdadly K. McGuire B. McNarry A.F. Patel A. Higgs A. Consensus guidelines for managing the airway in patients with COVID-19. Guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal College of anaesthetists.Anaesthesia. 2020; 75: 785-799Crossref PubMed Scopus (684) Google Scholar This cannot be achieved without institutional, team, and individual preparedness. Equipment standardisation and routine use of equipment that will be used in an emergency is a logical central component of each of these goals. In the short term it is likely that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) will be an endemic infection and the need to ensure safe, accurate, and swift airway management with remain. It is quite possible airway management will have been changed forever. We will watch with interest to learn what lessons the airway community has learnt from the SARS-CoV-2 pandemic, but the above principles offer a template for safe practice now. Contributed to the ideas, drafting, and finalising of this editorial: all authors. TMC is an associate editor of the British Journal of Anaesthesia. MG and FEK have no conflicts to declare.

Total intravenous anaesthesia (TIVA) use is becoming increasingly popular for a number of reasons, including quality of patient recovery, the possibility of an impact on cancer recurrence and environmental sustainability 1. However, the 5th UK National Audit Project NAP5 reported an association between TIVA and increased risk of accidental awareness during general anaesthesia (AAGA) 2. This risk occurs because pharmacological monitoring of drug delivery to the patient is not possible with TIVA, as it is for volatile anaesthetics. This means anaesthetists may be unaware of technical problems with drug delivery including accidental disconnection or displacement of the intravenous (i.v.) line. Three current guidelines recommend that the i.v. access site should be visible ‘where practical’ when TIVA is used; the Association of Anaesthetists minimum monitoring guidelines 3; the NAP5 report 2; and the Association of Anaesthetists/Society of Intravenous Anaesthesia TIVA guidelines 4. These publications also recommend processed EEG ‘depth of anaesthesia’ monitoring when TIVA is used with a neuromuscular blocking (NMB) drug and the TIVA guidelines recommend a lower threshold for its use when the i.v. access site is not continuously visible. We undertook a semi-blinded audit (i.e. the observed anaesthetists were not aware of the purpose of the audit) of 100 cases, across a range of surgical specialties and grades of anaesthetist. In 99 (99%) cases the cannula was in a vein in the hand and in one case it was in a vein in the foot. In 68% of cases, the patient's arms were at their sides. In 46% of cases the cannula being used for TIVA was not visible, in 11% it was also not accessible and in 43 (93%) of these cases it was judged to be not visible either out of necessity or due to surgical choice. Bispectral index (BIS) monitoring was used in 60% of cases: in 40 out of 41 (98%) when a NMB drug was used and in 20 out of 59 (34%) when no NMB drug was used. In 2 out of the 60 (4%) cases, BIS monitoring failed; in one the monitoring module failed and in one the BIS strip lost contact and was not accessible during surgery. In the one case where TIVA and NMB drugs were administered without BIS monitoring, this had been intended but was forgotten. In 16 cases, BIS was not used and the cannula was not visible. We noted no clear differences in practices between different grades of anaesthetist. We have shown low compliance with the recommendation to have the i.v. line visible and high but imperfect compliance with the recommendation to use BIS when TIVA and NMB drugs are used together. We do not know of any comparative data for visibility of i.v. access sites. Our rate of BIS use during TIVA is higher than that reported in NAP6 5 with NMB drug use (98% vs. 40%) and similar without NMB drugs (34% vs. 32%). In NAP6 6, TIVA was reported to be used in 9% of all general anaesthetics, a rise from below 6% in NAP5 7. It is likely that use is increasing further. In our hospital TIVA is used for 53% of all general anaesthetics and BIS monitoring is available in all theatres. For many surgical procedures, for example, laparoscopy, the patient's arms are routinely wrapped by their sides, therefore, the cannula is not visible and is often inaccessible. There is a balance to strike between visibility of the i.v. access site and the risk of other complications from repositioning the arm, such as impeding surgical access and risking compression neuropraxias. We are aware that some will place the hand in a sterile plastic bag to maintain visibility (Dr D. Mulvaney, Personal communication) but this is not routine in our hospital and we are not aware how widespread this practice is. After reflecting on our results, it is likely that our use of BIS monitoring will increase, whether or not NMB drugs are used. If almost half of venous access sites in other hospitals are also not visible it is likely that the use of processed EEG monitoring should increase generally in order to comply with the guidelines and to reduce the risk of AAGA.

We are writing to share our experience of using name/ role stickers to improve team working and communication on our Intensive Care Unit (ICU) during the COVID-19 pandemic. Like all ICUs, we faced many challenges during the past months: working with large numbers of non-ICU staff (‘side skillers’); working while wearing personal protective equipment (PPE); communicating while caring for patients in isolation rooms; high levels of anxiety amongst staff associated with caring for patients with a previously unknown disease.

Malignant hyperthermia (MH) is an inherited disorder of the ryanodine receptors in skeletal muscle, triggered by inhalational anaesthetic agents and depolarising muscle relaxants. It is a rare and potentially fatal condition, which can be difficult to diagnose and complex to manage. The Association of Anaesthetists’ Guideline on MH management outlines key details in the recognition, treatment and monitoring 1, a key part of which is the preparation and administration of dantrolene. Dantrolene is prepared as a powder in vials containing 20 mg: each vial is mixed individually with 60 ml sterile water. Thus, in order to prepare the initial bolus of 2.5 mg.kg−1 for a 70 kg adult with MH, nine vials are required to be mixed as quickly as possible. Subsequent boluses may require a further 28 vials. Despite very few anaesthetists having experienced a case of MH during their career, it is well known that dantrolene can be time consuming to prepare, with the guidelines rightly recommending that one member of staff is designated purely to prepare dantrolene in an MH emergency. We noticed that our dantrolene supply in theatres was about to expire, and therefore designed and delivered a multidisciplinary ‘Bath Tea Trolley’ teaching session, run once the dantrolene had expired and using an education method previously described 2, to refresh knowledge of the Association of Anaesthetists’ MH guidance, to recap locating and calculating the correct loading dose of dantrolene and to practise actually making up the expired dantrolene. One key learning point from this training programme was that a Braun Mini-Spike® (B.Braun Medical Ltd., Sheffield. UK), or similar, designed for drawing up 50 ml or 100 ml vials of propofol, was a much quicker and easier alternative for preparing vials of dantrolene, rather than using a standard drawing up needle. Given the time-critical and multifaceted approach to managing these patients, this simple improvement to one of the most important elements of the treatment algorithm seems worthy of highlighting to the anaesthesia community.

We thank Dr Mactier and colleagues 1 and Drs Fawke and Wyllie 2 for their comments, which we have considered carefully. From the outset, we should make clear we are not seeking to undermine or criticise colleagues working in neonatology. On reflection, our use of the term 'major gaps in optimal airway care' 3 may have been injudicious and might better be phrased as 'significant areas worthy of examination and improvement where indicated'. Mactier et al. state that our survey, which took place in 2016, does not represent current practice, but our responses from 90% of all UK neonatal intensive care units (NICUs), are likely representative of the practices at that time. A survey from 2013 reported 34% of level-3 NICUs did not use capnometry to confirm successful tracheal intubation and 32% used it only if there were difficulties 4. These results are consistent with our findings. Mactier et al. cite a survey abstract by Charles et al., date unknown, which reported 'routine' use of capnography (likely capnometry) during intubation in 81–88% of delivery suites 5. This survey was far less extensive than ours and had a lower response rate (83%). Airway management practices in NICUs may have changed since our survey, but this survey does not provide robust evidence of that. We noted marked differences between practices in NICUs compared with paediatric ICUs (PICUs) and, perhaps more notably, variation in practice between NICUs. Before publication, our survey was presented at European and UK neonatal conferences 3, with both followed by animated discussions, which highlighted variations in practice and opinions, particularly concerning capnography. Mactier et al.'s letter focuses on capnography, but we examined considerably more than that. Compared with PICUs (whose practice mirrors adult ICU practice), NICUs were notably less likely to have a difficult airway policy and a difficult airway trolley, to use a pre-intubation checklist, and more likely to report airway-related death or serious harm. Airway management is challenging in all areas of critical care. In neonatology, challenges include high intubation failure rates, hypoxia, bradycardia and frequent accidental extubations. Hatch examined 273 neonatal intubations; first attempt success was 47%, adverse events (excluding bradycardia and hypoxia) occurred in 39%, and hypoxia (SpO2 < 60%) and bradycardia (< 60 bpm) in 44% and 24%, respectively 6. Emergency intubation was the most significant risk factor for serious complications at intubation and accounted for 62% of NICU intubations. A subsequent quality improvement programme, which included a pre-intubation checklist, significantly reduced adverse event rates, severe hypoxia and bradycardia 7. Capnography is a complex and perhaps vexed topic. Both groups list the difficulties of using waveform capnography in neonates: we also listed these explicitly in our paper and explained that this is an area meriting further research. However, it is notable that many NICUs do use waveform capnography, and both parties agree that it is widely used during transfer of small infants, suggesting it is feasible. This variation in practices merits exploration. The literature suggests waveform capnography may be effective and practical in babies as small as ~500 g 8. Our survey focused only on waveform capnography, so would have underestimated the use of 'capnometry' overall and at intubation in particular. Fawke and Wyllie note false positives with colorimetry can be caused by 'contamination with surfactant, epinephrine or atropine', and we would add stomach acid to that list: continuous waveform capnography has none of these pitfalls and would therefore seem less prone to erroneous results. Fawke and Wyllie discuss the clinical methods of confirmation of tracheal intubation but the American Society of Anesthesiologists' Closed Claims studies have shown that reliance on clinical techniques can lead to missed diagnoses of oesophageal intubation resulting in brain damage and death. Auscultation of the chest preceded 63% of such cases, in 90% this auscultation (wrongly) 'confirmed tracheal intubation' 9 and 91% of cases of oesophageal intubation were judged to represent sub-standard care 10. Safe airway management extends well beyond the period of intubation and it is unlikely that colorimetric capnometry will be as useful in detecting a displaced, obstructed or kinked tracheal tube as well as a waveform device. Using ventilator waveforms for this purpose is likely to be complicated by airway leak from uncuffed tubes and involves monitoring something 'at least one step distant' from the patient's physiology. Waveform capnography, on the other hand, gives a breath-by-breath indication of that physiology, and is the ideal monitor of airway position and patency 11, 12. Both correspondents comment on the limitations of capnography for monitoring 'trends in ETCO2'. For clarity, our paper focuses on the use of capnography for airway monitoring, not respiratory or ventilatory monitoring. Notwithstanding this, waveform capnography provides many other benefits and Kugelman et al. reported that continuous waveform capnography significantly improved ventilation accuracy and reduced intracranial bleeding complications in ventilated neonates 13. Fawke and Wyllie discuss the use of 'exhaled CO2 detection' during cardiac arrest. There is much confusion about this issue in adult medicine, with many practitioners believing that a lack of ETCO2, and/or a flat capnography trace, can be attributable to the patient having no cardiac output. However, an attenuated ETCO2 trace will be seen during a cardiac arrest if cardiopulmonary resuscitation is being performed with a patent tracheal tube in the trachea 11. Deaths still occur in adult practice because of this misunderstanding and this led the Royal College of Anaesthetists and the Difficult Airway Society to initiate the 'No trace wrong place' campaign 14. Waveform capnography has additional benefits at cardiac arrest including assessing the adequacy of chest compressions and identifying the return of spontaneous circulation. We note that several of the documents Fawke and Wyllie cite seem to imply that a low cardiac output is associated with absent CO2 detection in a neonate and we recommend this advice is urgently re-assessed. We, like many others, fully acknowledge and are grateful for the enormous amount of synthesis of evidence that ILCOR and its constituent bodies have done in recent decades. There is no doubt many lives have been saved as a result. However, guidance and evidence is of no value if it is not implemented. Our survey 'holds a mirror' up to current practices. A survey may confirm good practice, identify deficits in implementation of best practice or identify areas of variable practice. Ours has perhaps noted all three of these. Most notable perhaps is the wide variability of practices. There is an inevitable and perhaps unavoidable sense of 'confrontation' in letters criticising articles and the resulting responses, but we hope to avoid that. Both groups of correspondents mention that the British Association of Perinatal Medicine is conducting a review of difficult airway management in NICUs. We welcome this and would hope the Association does not restrict this review to the 'difficult airway' but also considers routine airway management and monitoring. The use of capnography for confirmation of tube position and patency at tracheal intubation and in patients reliant on artificial ventilation is not about difficult airways, but about the routine airway: about every airway and every breath. The NAP4 study in adults might serve as an equivalent 11: its findings were not welcomed by all, but 3 years after its publication, 80% of UK adult intensive care units had made practice changes, closing the safety gap between actual and optimal practice by 60% 15. It is challenging to determine whether new technology improves safety, and balancing the evidence requires considerable effort. Regarding rare and serious harm events, such as airway-related deaths, the answer rarely lies in randomised controlled trials 16. We hope the findings of our survey will be of use in the BAPM review and would encourage the specialty to repeat our in-depth survey if they wish to see how practices have changed.