The Airway Ally

By Krstin Bantug, Chris Groombridge & Amit Maini

Currently, there is no specific credentialing required to act as an airway assistant outside of anaesthesia, yet the challenges faced outside of the operating theatres in relation to airway management are significantly increased. Some of these challenges include environmental factors, availability of equipment, varied and rotating teams and generally critically ill patients.

NAP4, published in 2011, highlighted that 1 in 4 major airway events occurred in ICU or ED and the importance of human factors and team training within airway management, yet little has been done around the inclusion of airway assistant in existing medical airway training programs nor the advocacy and recognition of the crucial role airway assistants play during an airway management event.

We have seen a shift in anaesthesia owning the airway, to now ICU and ED owning their own airways, though that shift has not translated on the nursing front. Airway assistants have distinct skills from that of the airway operator, thus, cannot just be replaced by anyone – not even a second airway operator. 

What we need is a cultural shift! There needs to be more advocacy for team training that incorporates the airway assistant and credentialing for anyone that is expected to step into the role of an airway assistant. Credentialing needs to involve more than just going through a checklist and handing equipment but including components to encompass technical and non-technical expertise required for the entire airway management event.

Advocacy, not just for airway assistants…but for Airway Allies!

Foundational skills of an Airway Ally:

Equipment expertise: the airway ally should have knowledge of all the equipment and adjuncts required to encourage a best effort at all three upper airway lifelines (FM, SGA, ETT) and knowledge of both cannula and scalpel neck rescue equipment.

 

Strategy development and preparation: the airway ally should play a role during the development of the airway strategy, not just be told of it after the fact. Such initiatives as communicating problems or issues that the airway operator may have overlooked or suggesting certain people or equipment that should be available may potentially validate concerns that the airway operator may have but not necessarily had vocalised.

 

Facilitating implementation: this skill involves not just being able to provide the necessary equipment, but also to have the ability to anticipate the needs of the airway operator and take initiative to prompt options or optimisations. The airway ally must also have situation awareness to reduce airway operator task fixation; a common occurrence during stressful situations, as well as having an awareness of the patient physiology and resource availability during the entire airway management event. The airway ally would also play a crucial role in keeping the airway operator accountable to implementing the strategy.

 

Communication: strong communication in an airway event requires critical language that the whole team has been trained on, the ability to close the loop and implement graded assertiveness techniques to be able to move any situation forward. This requires the airway ally to feel empowered and confident enough in the value that they add to the situation and the team and in their own ability and knowledge.

 

How can we start to instil change?

  • Team training with a focus on both non-technical and technical skills to optimise implementation during stressful situations: often team training focuses on communication and ignores the importance of training/simulation during technical skills training so the entire team appreciates their individual roles within that situation.  

  • CICO training to include airway allies: most CICO courses currently do not include airway assistants, yet their role is critical in a CICO situation.

  • Airway algorithms consistently taught to the whole team, inclusive of the airway ally, not just airway operators: many airway assistants are not familiar with airway algorithms used by airway operators, making it difficult to have a holistic approach to the entire airway management event.