Background and Objectives: Airway management is the cornerstone of resuscitation. The adverse effects of mismanaged airway problems in emergency department can be catastrophic and include death and hypoxic brain injury. To date there has been no evaluation of the type of difficult airway equipment currently available in emergency departments in Wales. The objective of this survey was to identify the availability of difficult airway equipments. There are currently no accepted guidelines with respect to stocking of difficult airway equipment in emergency departments.

Methods: All emergency departments in Wales with at least one dedicated consultant were surveyed via telephone.

Results: All departments possessed equipments for basic airway management. All had at least one alternate device onsite for ventilation and intubation. The most common alternate ventilating device was laryngeal mask airway (83%). The most common alternate intubating device was surgical airway device (100%).

Conclusions: It is concluded that all Welsh emergency departments are well equipped for basic airway care and endotracheal intubation. It is recommended that rescue devices like laryngeal mask airway and intubating laryngeal mask airway should be readily available and training should be offered to use these equipments in failed intubation scenarios. Capnographic confirmation of tube placement is mandatory in emergency department. In this survey 78% of departments possessed an end tidal carbon dioxide detector.


airway management, resuscitation, endotracheal intubation, emergency department, capnography, difficult airway, failed intubation.


The need for endotracheal intubation in the emergency department is often unpredictable in nature. It is more likely to be difficult in the A&E setting when compared to operating room [1-3]. In severely traumatised or critically ill patient with airway compromise endotracheal intubation is the definitive airway management [4-5]. The adverse effects of mismanaged airway include death and hypoxic brain damage [6]. Closed malpractice claims have shown persistent and prolonged attempts at intubation to be the most common cause
leading to major respiratory events [7]. Survey of English emergency departments demonstrated considerable variation in the availability of difficult
airway equipments [8]. The American Society of Anaesthesiologists recommend that all operating rooms should have alternate devices for ventilation and intubation immediately available. But there are no such recommendations for the emergency departments. At the same time stipulation of ideal contents of difficult airway equipment is very difficult as evidence is limited [9-10]. To date there has been no evaluation of the type of difficult airway equipment available in Welsh emergency departments.
The purpose of this survey was to describe the difficult airway equipment available onsite in Welsh emergency departments.


All emergency departments in Wales listed in HOWIS with at least one dedicated consultant were surveyed. The survey was carried over a six-day period in December 2006. The questionnaire was completed based on responses given by the consultant or senior clinical nurse on duty. If the appropriate person was not available or did not have the information at hand a second call was given at a later date.

All respondents were asked whether the following basic airway equipment were located within the actual environment of the emergency department:

Curved and straight laryngoscope blades
Gum Elastic Bougie
Mccoy laryngoscope

Alternate ventilation equipment
Laryngeal mask airway
Needle Cricithyroidotomy kit

Alternative intubation equipment
Surgical Airway Device
Intubating LMA
Fibre optic bronchoscope

Availability of other equipments like
End tidal carbon dioxide monitor
Difficult airway trolley



All the 18 departments contacted responded eagerly to this survey. Annual attendance ranged from 18000 to 60000 cases. The results of the survey are summarised below

Table 1 Difficult airway equipments in Welsh emergency departments


Item of equipment

(n =18)

Number of departments possessing Item (%)

(n =18)

Basic Adjuncts

Curved laryngoscope blade

Gum elastic Bougie


18 (100%)

18 (100%)

18 (100%)


Alternative ventilation equipment

Laryngeal mask airway

Needle cricithyroidotomy kit


15 (83%)

18 (100%)


3 (16%)

Alternative Intubation equipment

Surgical quick Trach


Intubating laryngeal mask

18 (100%)

 0 (0%)


3 (16%)


End tidal CO2 monitor

Portable storage unit

Mccoy laryngoscope

14 (78%)

 7 (39%)




All the departments contacted had at least one alternative device for ventilation and intubation. The most common alternative device for ventilation was Laryngeal mask airway (83%). Of all the alternate intubating equipments surgical airway device was commonly available (100%). Only 3 departments possessed either an intubating LMA or combitube. Fourteen units (78%) possessed an end tidal co2 monitor device, while seven (39%) held their difficult airway equipments in a specific portable trolley.


Intubation in the emergency department is a more hazardous and difficult procedure than that performed in the operating room. Crosby et al. defined difficult intubation as one which occurs ‘when an experienced laryngoscopist, using direct laryngoscope requires: 1) more than 2 attempts with the same blade or 2) change in the blade or an adjunct to a direct laryngoscope (bougie) or 3) use of an alternative device or technique following failed intubation with direct laryngoscope’. Using this definition, the incidence of difficult intubation in the operating room can be estimated at 1.15 - 3.8% [1]. This is when compared with an incidence of 3 - 5.3% in emergency department [1-3]. Failed intubation in the operating room is 0.05 – 0.35%, whereas in emergency department is 0.5 – 1.1% [2-3].

The finding that 100% of Welsh emergency departments possess an alternative ventilation device compares better to surveys carried out in England [8]. In England 11% of emergency departments who responded contained no alternative device for ventilation, while in the American survey it was 21%. All operating theatres should have a difficult airway trolley and appropriate contents have been suggested [12-13]. However little attention has been paid to keep dedicated difficult airway trolleys in places such as emergency departments where difficult intubations are more common.

This survey showed that majority of departments stacked a curved laryngoscope blade, gum elastic bougie and surgical airway device. However there was a large variation with the availability of other devices. The most common alternative ventilation device was LMA (83%). The Laryngeal Mask airway is now a well-established alternative to bag-valve-mask ventilation and both the American Society of Anaesthesiologists and European Resuscitation council [6-14] have advocated its usage in emergency situations. Moreover it has been shown that even inexperienced personnel can become proficient in its use even after a brief period of training.

Compared to other countries [2-3] it is the anaesthetists commonly carrying out airway management in Welsh emergency departments. It is surprising to note that intubating LMA is available only in 3(16%) departments even though it has proven to be a very good alternative ventilating and intubating device. Studies have shown that there is a high success rate even for non-anaesthetic personnel in its usage [15-16] and has fewer adverse effects than fibre optic intubation. The intubating LMA has now begun to appear in recommendations for contents of difficult airway trolleys [13]. Due to their experience with normal LMA, it is likely that welsh anaesthetists will be more successful in intubating using an intubating LMA than a surgical airway. Because of the ease with which other health care professionals can be trained in using an intubating LMA, this is considered the best option as an alternative intubating device in emergency departments [18]. In light of new evidence [14-18] regarding ILMA, the older guidelines on difficult airway management, such as ASA 1993 [6] needs updating.

It is not surprising that none of the departments possessed a bronchoscope onsite, as it is not recommended in an emergency situation. Even though the data from capnometry are subject to misinterpretation [7] and may fail to confirm endotracheal intubation in cardiac arrest as EtCO2 may fall to zero. However end tidal CO2 monitoring is required as an important tool in confirmation of correct tube placement. In the survey end tidal CO2 monitors were available in 14(78%) of the emergency departments surveyed. This is greater than surveys carried out in England, where availability ranged 50% to 74%. It is a common finding that these monitors are rarely pre attached to monitoring equipment and ready for use. It is highly recommended that prior placement of such devices in areas where emergency airway management is likely to occur would help minimise any delay in identification of tracheal tube placement. Only 7(39%) of the departments surveyed stated that they held difficult airway equipment in a portable storage unit. The storage of all such devices in a portable unit ensures its rapid deployment to any area of emergency department [13]. It was noted that most of the times it was the anaesthetist on his own doing the intubations in the emergency department without the presence of skilled assistant, which is again not compliant with current guidelines [19].

Welsh emergency departments compare well with those of other countries as far as difficult airway equipment are concerned. Nevertheless this situation could be further improved by training inexperienced health care professionals in usage of LMAs and ILMAs. Greater emphasis should be placed on ready availability of capnometry and increased usage of portable difficult airway storage units.


I take this opportunity to thank all the consultants and their colleagues who participated in this survey.


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Copyright Priory Lodge Education Ltd 2007

First Published October 2007

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