Digital Comprehensive Summaries of Uppsala Dissertations

from the Faculty of Medicine 1205

Airway management in anaesthesia

care
– professional and patient perspectives

KATI KNUDSEN

ACTA
UNIVERSITATIS
UPSALIENSIS ISSN 1651-6206
ISBN 978-91-554-9534-3
UPPSALA urn:nbn:se:uu:diva-281905
2016
Dissertation presented at Uppsala University to be publicly examined in Brömssalen, Gävle
sjukhus, Lasaretsleden 1, Gävle, Friday, 20 May 2016 at 13:00 for the degree of Doctor
of Philosophy (Faculty of Medicine). The examination will be conducted in Swedish.
Faculty examiner: Ingegerd Bergbom (Institutionen för vårdvetenskap och hälsa, Göteborgs
Universitet).

Abstract
Knudsen, K. 2016. Airway management in anaesthesia care. – professional and patient
perspectives. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of
Medicine 1205. 56 pp. Uppsala: Acta Universitatis Upsaliensis. ISBN 978-91-554-9534-3.

Background: Careful airway management, including tracheal intubation, is important when

performing anaesthesia in order to achieve safe tracheal intubation. Aim: To study airway
management in anaesthesia care from both the professional and patient perspectives. Methods:
11 RNAs performed three airway tests in 87 patients, monitored in a study-specific
questionnaire. The tests usefulness for predicting an easy intubation was analysed (Study I).
68 of 74 anaesthesia departments in Sweden answered a self-reported questionnaire about
the presence of airway guidelines (Study II). 20 anaesthesiologists were interviewed; a
phenomenographic analysis was performed to describe how anaesthesiologists' understand
algorithms for management of the difficult airway (Study III). 13 patients were interviewed;
content analysis was performed to describe patients' experiences of being awake fiberoptic
intubated (Study IV). Results: The Mallampati classification is a good screening test for
predicting easy intubation and intubation can be safely performed by RNAs (Study I). The
presence of airway guidelines in Swedish anaesthesia departments is poorly implemented (Study
II). Algorithms can be understood as law-like rules, a succinct plan to follow in difficult airway
situations, an action plan kept in the back of one's mind while creating flexible and versatile
personal algorithms, or as consensus guidelines based on expert opinion in order to be followed
in clinical practice (Study III). One theme emerged describing experiences of being awake
intubated; feelings of being in a vulnerable situation but cared for in safe hands, described in
five categories: a need for tailored information, distress and fear of the intubation, acceptance
and trust of the staff's competence, professional caring and support, and no hesitation about new
awake intubation (Study IV). Conclusions: The Mallampati classification is a good screening
test for predicting easy intubation, when the airway assessment is performed in a structured
manner by RNAs. The presence of airway guidelines in Swedish anaesthesia departments was
poorly implemented and should receive higher priority. Algorithms need to be simple and easy
to follow and based on the best available scientific evidence. Tailored information about what to
expect, ensuring eye contact, and giving breathing instructions during the procedure may reduce
patients' feeling distress.

Keywords: Airway management, algorithm, awake intubation, professional and patient

perspective

Kati Knudsen, Department of Public Health and Caring Sciences, Box 564, Uppsala
University, SE-75122 Uppsala, Sweden.

© Kati Knudsen 2016

ISSN 1651-6206
ISBN 978-91-554-9534-3
urn:nbn:se:uu:diva-281905 (http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-281905)
To my family Bent & Olivia
4
List of Papers

This thesis is based on the following papers, which are referred to in the text
by their Roman numerals.

I Knudsen, K., Högman, M., Larsson, A., Nilsson, U. The best

method to predict easy intubation: a quasi-experimental pilot
study. J Perianesth Nurs. 2014; 29: 292-297.
II Knudsen, K., Pöder, U., Högman, M., Larsson, A., Nilsson, U.
A nationwide postal questionnaire survey: The presence of air-
way guidelines in anaesthesia department in Sweden. BMC
Anesthesiol. 2014; 14:25. Epub 2014 Apr 7.
III Knudsen, K., Pöder, U., Nilsson, U., Högman, M., Larsson A.,
Larsson J. Anaesthesiologists’ understanding of algorithms for
management of the difficult airway – a qualitative interview
study. Submitted.
IV Knudsen, K., Nilsson, U., Högman, M., Pöder, U. Awake intu-
bation creates feelings of being in a vulnerable situation but
cared for in safe hands. Submitted.

Reprints were made with permission from the respective publishers.

5
6
Contents

Preface .......................................................................................................... 11 

Introduction ................................................................................................... 13 
Preoperative airway assessment ............................................................... 14 
Managing a difficult airway ..................................................................... 17 
Airway guidelines and algorithms ....................................................... 17 
Airway management from a professional perspective ............................. 18 
Anaesthesia and intubation from a patient perspective ............................ 19 
Rationale for the thesis.................................................................................. 21 
Aims .............................................................................................................. 22 
Study I ...................................................................................................... 22 
Study II ..................................................................................................... 22 
Study III ................................................................................................... 22 
Study IV ................................................................................................... 22 
Methods ........................................................................................................ 23 
Design ...................................................................................................... 23 
Sample and setting ................................................................................... 24 
Study I.................................................................................................. 24 
Study II ................................................................................................ 24 
Study III ............................................................................................... 24 
Study IV ............................................................................................... 24 
Procedures ................................................................................................ 25 
Study I.................................................................................................. 25 
Study II ................................................................................................ 25 
Study III ............................................................................................... 25 
Study IV ............................................................................................... 25 
Data collection.......................................................................................... 26 
Study I.................................................................................................. 26 
Study II ................................................................................................ 27 
Studies III and IV ................................................................................ 27 
Data analysis ............................................................................................ 28 
Study I.................................................................................................. 28 
Study II ................................................................................................ 29 
Study III ............................................................................................... 29 

7
 Study IV ............................................................................................... 30 
Ethical considerations ................................................................................... 31 
Results ........................................................................................................... 33 
Study I ...................................................................................................... 33 
Study II ..................................................................................................... 34 
Study III ................................................................................................... 35 
Study IV ................................................................................................... 35 
Discussion ..................................................................................................... 37 
Summary of findings ................................................................................ 37 
Airway management and guidelines from a professional perspective ..... 37 
Anaesthesia and intubation from a patient perspective ............................ 41 
Methodological considerations................................................................. 42 
Clinical implications ..................................................................................... 45 
Conclusions ................................................................................................... 46 
Svensk sammanfattning (Swedish summary) ............................................... 47 
Acknowledgements ....................................................................................... 50 
References ..................................................................................................... 51 

8
Abbreviations

ASA American Society of

Anesthesiologists
RNA Registered Nurse Anaesthetist
SFAI Svensk förening för Anestesi och
Intensivvård
WHO World Health Organisation
DAS Difficult Airway Society

9
Preface

During my 20 years of working experience as a registered nurse anaesthetist

(RNA) in anaesthesiology, I have observed the different ways a patient’s
airway can be assessed before undergoing anaesthesia. I especially remem-
ber a situation in which an overweight middle-aged patient went into the
operating room for emergency abdominal surgery. My intuition told me that
he would probably be difficult to ventilate and intubate due to his beard,
obesity, and short neck. Despite being at high risk for difficult intubation I
felt that we did not do anything to prepare him or ourselves for a difficult
airway, such as shaving his beard in advance or having an alternative plan
available on how to secure the airway. At that point I began to think of how
we could prepare patients and ourselves when performing endotracheal intu-
bations so we do not jeopardise patient safety. The inability to secure a free
airway is not only an emotionally stressful situation for the patients, but
challenging for the anaesthesia professional. The present studies will help us
gain a deeper understanding and new knowledge about how these situations
could be experienced, from both professional and patient perspectives.

11
Introduction

Careful airway management, including endotracheal intubation, is important

when performing anaesthesia in order to achieve safe endotracheal intuba-
tion [1]. Endotracheal intubation is usually performed after the induction of
general anaesthesia when the patients are asleep. When a difficult airway is
expected, fiberoptic intubation is the recommended option to secure the air-
way and is performed before the induction of general anaesthesia when the
patient is still awake [2]. Depending on whether the intubation is performed
in an asleep or awake state, the patient experiences varying degrees of anxi-
ety when undergoing intubation [3]. In general, women are more anxious
than men [4], and patients who have experienced awake fiberoptic intubation
report more discomfort and suffocation than patients who have undergone
traditional endotracheal intubation [5]. To alleviate feelings of anxiety, it is
important that patients are well-informed about the procedures, which in-
creases their feelings of calm and security when undergoing anaesthesia.
Psychologically preparing the patient for an awake intubation is essential, as
this can be highly discomforting for the patient [6].
In Sweden, with a population of more than nine million people, approxi-
mately 500 000 general anaesthesia procedures are performed annually [7].
There is wide variation in estimations of the incidence of difficult intubation
and depends on differences in study design, assessment tools [8], and how
difficult airways are defined [9]. On the basis of a report written by a re-
searcher in the US, difficult face mask ventilation combined with difficult
intubation occurs in approximately 1 of every 250 cases annually [10],
whereas in a review by Cook & MacDougall-Davis [11], the incidence of
difficult intubation was estimated to be approximately 1 in 2000 in the elec-
tive setting and approximately 1 in 300 during rapid sequence induction.
However, in the literature it is unclear how many of those anaesthetic proce-
dures are performed in the awake state.

13
Preoperative airway assessment
Preoperative airway assessment is important when planning anaesthesia in
order to achieve safe endotracheal intubation [1]. Whether the intubation is
performed in an anaesthetised or awake state, the patients should undergo
preoperative airway assessment before inducing general anaesthesia. The
purpose of this assessment is to psychologically preparing patients for anaes-
thesia and to make anaesthesia professional aware of those patients who are
likely to be easy or difficult to intubate. Studies have shown that pre-
operative airway assessment before surgery helps identify patients at risk of
difficult ventilation and intubation [12, 13], improving patient safety. Ac-
cording to the fourth national audit project in the UK, the majority of airway
problems occur during elective surgery in seemingly healthy patients [14].
Individual patient characteristics, such as the presence of a beard, short neck,
limited mouth opening, poor dental status, male sex, increased Mallampati
classification, and obesity, are associated with intubation difficulties [15,
16].
In 1983, Mallampati [17] developed a simple bedside test for assessing
the patient’s airway before inducing anaesthesia. Using this test, adult pa-
tients can be divided into four classes according to the individual anatomical
structures observed in their mouth while they are sitting in an upright posi-
tion with the mouth opened wide and the tongue hanging out without phona-
tion. Figure 1 describes Mallampati classification I–IV.

Class I Class II Class III Class IV

Figure 1. Mallampati classification I–IV. Class I: soft palate, uvula, and faucial pillars can be
seen. Class II: soft palate, faucial pillars, and portion of the uvula can be seen. Class III: soft
palate and base of the uvula can be seen. Class IV: only the hard palate can be seen. "Illus-
trated by O. Wall, University of Gävle"

The Mallampati test revealed a significant relationship between the ease of

intubation and individual anatomical structures seen in the mouths of adult
patients [17]. However, the test has been criticised as not being specific
enough when used alone [18] due to variability from one person to another.
For example, patients who were expected to have a difficult airway had an

14
easy intubation, and vice versa, when the test was used alone. Khan et al.
[19] compared the Mallampati classification with the upper lip bite test, ster-
nomental distance, thyromental distance, and interincisor distance in 309
patients. Nineteen patients were difficult to intubate and no significant dif-
ference was found based on gender. However, significant differences were
found between the Mallampati test and laryngeal view [19]. Other studies
[20, 21] comparing the Mallampati test and the patient’s position (sitting and
supine) have found that the Mallampati test in a supine position is a better
predictor of difficult endotracheal intubation than the test in a sitting posi-
tion. On the other hand, the Mallampati test with the patient in a sitting posi-
tion is associated with a higher percentage of easy intubations compared to
the supine position [20]. Therefore, Bindra et al. [20] recommended per-
forming the Mallampati test in both the supine and sitting positions to obtain
a better assessment.
Another commonly used bedside test to predict difficult intubation is
measuring the thyromental distance [22], the space from the bony point of
the mentum to the thyroid notch. However, this test has been criticised as a
bedside test for predicting difficult intubation due to its lack of accuracy [23]
depending on how the thyromental distance is measured (i.e., with or with-
out a ruler). In a meta-analysis, Baker et al. [24] showed that the accuracy of
the test increased three-fold if the staff used a ruler when measuring the thy-
romental distance compared to the anaesthetist’s own finger width. Figure 2
describes how the thyromental distance is measured.

Figure 2. The thyromental distance is the space between the bony point of the mentum and
the thyroid notch, and is measured with the head fully extended and the mouth closed. The
measurement should be performed with a ruler. "Illustrated by O. Wall, University of Gävle"

Shiga et al. [25] conducted a meta-analysis that included 50 760 patients

from 35 different studies to determine the accuracy of bedside tests for pre-
dicting difficult intubation. They found that a combination of the Mallampati
test and thyromental distance was the most reliable method for predicting

15
difficult intubation. On the other hand, Rosenstock et al. [26] conducted a
qualitative interview study to explore how anaesthesiologists manage an
unanticipated difficult airway, finding that only five of 24 patients were ex-
amined using more than two airway tests before endotracheal intubation, as
recommended by the American Society of Anesthesiologists (ASA) guide-
lines [1].
Difficult endotracheal intubation is usually associated with a poor laryn-
geal view. One of the more widely accepted airway tests for predicting diffi-
cult intubation was described by Cormack & Lehane in 1984 [27]. This test
consists of four grades describing the best laryngeal view depending on the
visualisation of the glottis in the patient’s mouth during direct laryngoscopy.
However, this test has the disadvantage that it can only be used after the
patient has been anaesthetised. Figure 3 describes how Cormack & Lehane
grades I–IV are assessed.

Grade I Grade II Grade III Grade IV

Figure 3. Cormack & Lehane’s grading system. Grade I: all of the vocal cords can be seen.
Grade II: the anterior glottis is not seen. Grade III: only the epiglottis is seen. Grade IV: none
of the above can be seen. Adopted from the SIAARTI guidelines for a difficult intubation and
difficult airway management.

Traditionally, endotracheal intubation is performed after successful mask

ventilation, when the patient is anaesthetised [28]. When difficult mask ven-
tilation or intubation is expected based on the patient’s preoperative evalua-
tion, intubation should be performed while the patient is still awake [2].
To perform intubation in the awake state, it is important that patients are
informed of the procedure in order to increase the patient’s psychological
comfort and cooperation during the procedure [6, 29].

16
Managing a difficult airway
Managing a difficult airway when inducing anaesthesia is one of the most
challenging tasks for anaesthesia professionals. Failure to secure the airway,
even for a few minutes, may increase the risk of hypoxic brain damage and
harm the patients, causing stress for the professionals caring for them [1,14,
30]. When presented with a difficult airway in clinical practice, such as dur-
ing an emergency, there is no time to think about what has gone wrong. In-
stead, the airway must be prioritised and a plan B considered for securing the
airway [1, 31]. Therefore, in such critical situations, anaesthesia profession-
als must not only be technically skilled, but also have communicative, cogni-
tive, and behavioural competence in making decisions [32, 33]. Furthermore,
when a difficult airway is expected, there is a strong consensus among ex-
perts that specific strategies can improve patient outcomes when performing
anaesthesia [14].

Airway guidelines and algorithms

In order to promote safer airway procedures, airway guidelines have been
published to help anaesthesia professionals manage patient airways when
they fail. One of the first published guidelines for the management of a diffi-
cult airway was developed by the American Society of Anesthesologists
(ASA) in 1993 [34] and updated in 2003 [35] and 2013 [1]. As a lack of
consensus exists in the literature regarding the definition of a difficult air-
way, the ASA [1] defined a difficult airway as:

“…the clinical situation in which the conventionally trained anesthesi-

ologist experiences difficulty with face mask ventilation of the upper airway,
difficulty with tracheal intubation, or both” (page 251, ASA 2013).

Since then, various forms of clinical guidelines and algorithms that describe
procedures for managing a difficult airway have been published in Canada
[31] and the UK [36], followed by the European [37] and Scandinavian
countries [38]. Despite their purpose to enable safer procedures, there is an
ongoing debate regarding their relevance and usefulness in clinical practice
[39]. Regarding the differences between clinical guidelines and algorithms,
guidelines are systematically developed recommendations in the form of
standardised guidance that one ought to take into account when making deci-
sions. According to the World Health Organisation (WHO) [40], clinical
guidelines are defined as:

“…systematically developed evidence-based statements which should

assist the anaesthesia personnel, recipients and other stakeholders to secure
optimal treatment for all patients, regardless of by whom or where the pa-
tients are treated” (page 2, WHO 2003).

17
International and national guidelines can be modified and local guidelines
can be developed, but they cannot guarantee any specific outcomes and,
therefore, following them is not absolutely required. However, clinical
guidelines should summarise good practices and side steps from such proto-
cols to benefit the individual patient should be encouraged [41]. The advan-
tage of using guidelines in clinical practice is that they can remind anaesthe-
sia professionals of problems that could occur in daily practice. Deciding to
follow clinical guidelines may come down to the fact that these are standard
regimens for the average patient and sometimes lack scientific evidence to
support their recommendations [42].
In contrast, according to the ASA [1], an algorithm is defined as a form of
decision tree that describes step by step how to safely manage difficult air-
ways. The use of cognitive aids such as algorithms improves patient safety
only if they are well-designed and accompanied by training [43]. Marshall &
Mehra [44], who video-observed anaesthesia providers’ skills during a
“can´t intubate can’t ventilate scenario”, found that a cognitive aid presented
as algorithms improved the anaesthesia providers’ skills during the simula-
tion.
Despite airway guidelines being developed and recommended to achieve
safer airway procedures [1, 45], adherence to clinical guidelines and algo-
rithms is generally described as poor [46] and being influenced by the anaes-
thesia professionals’ individual experiences, beliefs, and attitudes when
making decisions in clinical practice [47]. Even if the purpose of using algo-
rithms is safer practice [1], there is no strong evidence of benefits for any
specific guidelines for the management of a difficult airway; there is, how-
ever, strong agreement that a pre-planned approach may lead to improved
patient outcomes [1, 44].

Airway management from a professional perspective

The anaesthesiologist has the primary responsibility of assessing the pa-
tient’s airway prior to anaesthesia and planning for their anaesthetic proce-
dure [37]. In Sweden, RNAs have a graduate diploma in specialist nursing in
anaesthesia care, with or without a master’s degree [48]. The RNAs’ clinical
work and education differ between European countries and the rest of the
world [49]. In Sweden, RNAs are allowed to start, maintain, and end general
anaesthesia in healthy patients (i.e., ASA physical status I-II) after prescrip-
tion by an anaesthesiologist [48]. In contrast, in some states in the US [50],
certified RNAs are allowed to independently administer anaesthesia to pa-
tients without the supervision of anaesthesiologists and under their own au-
thority [51].
The management of a difficult airway during anaesthesia is a challenging
and stressful situation [52] that anaesthesia professionals may sometimes be

18
involved in during their clinical work. In daily practice, RNAs and anaesthe-
siologists work closely as a team and have many overlapping skills that pro-
vide safer care for the patient during their anaesthesia [53]. In Sweden, an-
aesthesiologists are usually responsible for several operating rooms at the
same time and serve as support for RNAs, who do much of the work around
the patients during and after anaesthesia. The RNA is often the first person
the patient meets when they arrive in the operating room. When the patient is
in a state of unconsciousness or anaesthetised and cannot make their own
voice or choices heard, the RNA is professionally responsible for their care,
needs, and well-being. The RNAs act as the patients’ advocate to protect
them from harm [54], observing and evaluating the patient’s responses to the
anaesthesia and ensuring that the patient’s individual needs are met. When a
difficult airway is expected or the anaesthesia does not proceed as planned,
the RNAs and anaesthesiologists work together in the best interest of the
patient [48].

Anaesthesia and intubation from a patient perspective

For both awake and asleep intubation, patients worry about being anaesthe-
tised and intubated [3]. Patients undergoing anaesthesia worry about being
anaesthetised and intubated [55, 56] more as the date of the surgery ap-
proaches [4]. Those with previous anaesthesia experience are less anxious
than those who have never undergone anaesthesia [55, 56]. Patients who
perceive stress and worry about the anaesthesia and surgery preoperatively
report more postoperative anxiety and discomfort [55]. In addition, patients
experience more anxiety regarding general anaesthesia than local anaesthesia
[56], and women generally exhibit more anxiety about having anaesthesia
than men [4, 55, 56]. Patients who have experienced an awake endotracheal
intubation report more feelings of discomfort, sensation of suffocation, and
hoarseness than those who undergo a traditional endotracheal intubation
[56].
According to Burkle et al. [57], it is important to inform patients about
their planned anaesthesia so they can weigh their own individual risks and
benefits before undergoing anaesthesia. A systematic review [58] showed
that preoperative communication and dialogue between patients and health-
care professionals is important for improving the quality of care. It has also
been found that if patients discuss their thoughts and feelings with a nurse
anaesthetist and if a harmonious atmosphere in the operating room can be
created, patients feel secure and cared for [59]. If patients are informed and
know what will happen to them, it can reduce their fear of the unknown [60]
and calm them preoperatively [61]. Patients have concerns about having
anaesthesia and this cannot be overlooked or underestimated. The need for

19
more individualised information and support are of importance for the pa-
tient and may allay anxiety [62].

20
Rationale for the thesis

In clinical practice, careful airway assessment is important when performing

endotracheal intubation and to the quality of care. The aim of preoperative
airway assessment is to identify patients who will probably be easy or diffi-
cult to intubate in order to improve patient safety [1]. This is important be-
cause, in Sweden, RNAs are allowed to induce and maintain general anaes-
thesia without the direct supervision of an anaesthesiologist, in accordance
with specified protocols and agreements [48]. In addition, in clinical prac-
tice, it is not always the same anaesthesia professional that preoperatively
assesses the patient’s airway and then performs the endotracheal intubation.
Therefore, systematic and detailed documentation of the patient’s airway is
important for improving patient safety. Several anaesthesia societies, both
national and international [1, 36-38, 63], have published guidelines and algo-
rithms to assist anaesthesia professional in managing a difficult airway. Even
if the purpose is to provide safer practices, there is wide variability in the
adherence to guidelines and algorithms in anaesthesia practice [47]. Thus,
the use of guidelines and algorithms is influenced by human factors, such as
personality, individual experience, scientific beliefs, and attitudes, when
making decisions in clinical practice [47]. In addition, how a difficult airway
should be managed depends on the anaesthesia providers’ individual techni-
cal and non-technical skills and on the specific situation [64]. Studies have
also been published on how to support anaesthesia professionals when as-
sessing the patient’s airway prior to anaesthesia and how to safely perform
an endotracheal intubation [13, 65], but no nationwide studies have de-
scribed the presence of airway management guidelines or variations in the
ways anaesthesiologists understand the phenomenon ´airway algorithm´
when acting in and handling critical airway situations. When a difficult intu-
bation is expected, the recommended option for securing the airway is awake
fiberoptic intubation [2, 28], but little is known in the available literature on
how patients experience this procedure. To the best of my knowledge, no
study has explored patients’ experiences of being awake intubated. Preopera-
tive experiences, such as anxiety and worries about anaesthesia and surgery,
have been explored [55, 56]. From the patients’ perspective, feedback about
their experiences with awake fiberoptic intubation is useful information that
may contribute to changes in caring for patients, thereby improving the qual-
ity of care.

21
Aims

The overall aim of the present thesis was to study airway management in
anaesthesia care from both professional and patient perspectives.

Study I
The specific aim was to investigate whether the Mallampati classification,
thyromental, and Cormack & Lehane grades are useful tests for predicting an
easy intubation.

Study II
The specific aim was to explore the presence of airway guidelines in Swed-
ish anaesthesia departments.

Study III
The specific aim was to deepen our knowledge about how anaesthesiologists
comprehend algorithms for the management of difficult airways.

Study IV
The specific aim was to describe patient experiences of being awake fiber-
optic intubated.

22
Methods

Design
An overview of the included studies is presented in Table 1. Studies I and II
were quantitative, whereas studies III and IV were qualitative.

Table 1. Description of the design, sample, data collection, and data analyses used in
study I - IV.
Study Design Sample Data collection Data analysis
I Descriptive, All RNAs, n=11, A study-specific Sensitivity and
comparative at 1 day surgery questionnaire specificity,
department was used to positive predic-
performed air- collect data tive value (PPV),
way assessment before, during, and negative
in 87 patients and after anaes- predictive value
thesia, in spring (NPV), receiver
2006 operating char-
acteristic (ROC)
curve analysis
II Descriptive, 68 of 74 anaes- A structured Pearson chi2 tests
comparative thesia depart- self-reported Fishers’ exact
ments in Sweden questionnaire test
were included was sent out by
postal mail in
March 2011
III Descriptive Strategic sam- Individual face- Phenomenograp
pling procedure, to-face inter- hic
n= 20 anaesthe- views were analysis
siologists conducted be-
tween December
2014 and Febru-
ary 2015
IV Descriptive Consecutive Individual face- Qualitative,
sampling pro- to-face inter- content
cedure, views were analysis
n= 13 patients conducted to
collect data
between autumn
2013 and spring
2015

23
Sample and setting

Study I
All RNAs in one department were recruited over a 4-month period in 2006.
The airways of 100 patients were assessed by RNAs who were directly in-
volved in the patients’ routine care. Inclusion criteria were adult patients
> 17 years of age who were scheduled to undergo general anaesthesia re-
quiring endotracheal intubation and were ASA physical status I or II. Pa-
tients undergoing emergency anaesthesia and patients who were pregnant or
had a body mass index > 35 kg/m2 were excluded from the study. This hospi-
tal provides anaesthesia services for both inpatient and outpatient surgery
and was organised as part of a larger county hospital in the County Council
of Gävleborg, which had 275 000 inhabitants at the time of the study. The
day surgery department served approximately 3300 patients annually and
was chosen as the research setting because the RNAs routinely conduct pre-
operative airway evaluations and intubate all patients as part of their routine
work.

Study II
A structured self-reported questionnaire concerning the presence of guide-
lines for airway management was sent out in March 2011 to directors or
assistant directors of Swedish anaesthesia departments (n = 74). The anaes-
thesia departments were identified by the Swedish Association of Local Au-
thorities and Regions [66].

Study III
A strategic sampling procedure was used to maximise the variation in which
anaesthesiologists understand algorithms. According to Bowden & Green
[67], 20-30 interview participants is enough to ensure sufficient variation.
Twenty anaesthesiologists from one university and three county hospitals in
Sweden were invited to participate in the study. The study was conducted
between December 2014 and February 2015. The inclusion criteria were a
minimum 2 years of working clinical experience in anaesthesiology. Anaes-
thesiologists not involved in direct patient care were excluded.

Study IV
A consecutive sampling procedure was used and participants recruited from
one university hospital and three county hospitals in the middle part of Swe-
den. The study was conducted between autumn 2013 and spring 2015. Inclu-

24
sion criteria were patients > 18 years of age admitted to the anaesthesia de-
partment for planned or unplanned awake fiberoptic intubation who were
able to speak and understand the Swedish language. Patients planned to un-
dergo regional anaesthesia or who had undergone planned or unplanned
awake fiberoptic intubation in the past were excluded from the study.

Procedures
Study I
Information and educational instruction regarding the study aim and proce-
dures were provided by Kati Knudsen (KK) 2 weeks before the study started.
All patients underwent airway evaluation at the time of the preoperative
visit, and after the anaesthesia were finished. The airway was evaluated by
the same RNA who then performed the anaesthesia to reduce assessment
error. The patients’ airways were evaluated during the daytime, Monday
through Friday. All patients received general anaesthesia according to the
hospital’s local standard and were intubated with a 7-mm (for women) or 8-
mm (for men) endotracheal tube using a Macintosh laryngoscope.

Study II
The directors received written information about the purpose of the study
and were asked to fill out the questionnaire and return in a prepaid and ad-
dressed envelope. Informed consent was given by returning the question-
naire. Reminders were sent out twice. Those who did not respond within 3
months of the second reminder were reminded a third time by telephone.

Study III
The head of each anaesthesia department was contacted via e-mail and asked
to distribute written invitation letters about the study purpose and procedures
to all anaesthesiologists who worked in their departments. Two weeks later,
during a workplace meeting, the anaesthesiologists were verbally informed
about the study by KK in person and an appointment for the interview set up.
Anaesthesiologists who volunteered for the study provided written informed
consent before the interview started. All interviews were conducted by KK
in the daytime in a quiet room over the course of 1 week at each workplace.

Study IV
Before the study started, patients received written and verbal information
about the study purpose and procedure from the anaesthesiologists during

25
their preoperative meeting. A consecutive sampling procedure was used and
individual face-to-face interviews performed. Each participant was inter-
viewed twice. The first interview was conducted at a place chosen by the
patient, such as the hospital or their own home. The second, follow-up inter-
view was conducted over the telephone 4 weeks after the first interview in
order to give the patient an opportunity to clarify and verify what had been
said. Written informed consent was obtained before the interviews started.

Data collection
Study I
A study-specific questionnaire was developed by KK based on clinical ex-
perience assessing and performing endotracheal intubations independently,
as well as on a brief review of existing airway tests in the literature [34, 63].
The questions were then evaluated and revised by a health care worker as an
expert in the field to ensure face validity. The next step was to discuss the
specific questions within the research group experienced in quantitative
methods in order to improve their clarity and establish content validity. The
questionnaire was developed in three parts: before, during, and after anaes-
thesia. Part one consisted of Mallampati classification scores I–IV (See Fig-
ure 1) and the thyromental distance. The thyromental distance (i.e., the dis-
tance between the bony point of the mentum to the thyroid notch with the
head fully extended) was measured with a 25-cm ruler while the patient’s
mouth was closed (See Figure 2). Part two consisted of Cormack & Lehane
grades I–IV (See Figure 3) and documentation of the number of intubation
attempts according to the ASA recommendations [34]. These airway tests
have been used and validated in multiple studies as “golden standards” for
predicting a difficult intubation [68, 69]. Part three consisted of the RNA’s
judgement of the intubation conditions being experienced as easy or diffi-
cult. These were documented and categorised using a four-grade scale as
follows: quite easy, easy, somewhat difficult, or difficult. In addition, sex,
age, weight, and height were documented, as well as data regarding the
RNA’s years of experience.
The following scores were considered to be predictors of easy endotra-
cheal intubation: Mallampati classification I–II, thyromental distance ≥ 10
cm, Cormack & Lehane grade I–II, and less than two intubation attempts.
Mallampati classification III–IV and Cormack & Lehane grade III–IV were
categorised as difficult intubations, as well as a thyromental distance ≤ 10
cm and two or more intubation attempts. RNA scores of “quite easy” and
“easy” were considered easy intubations, whereas “somewhat difficult” and
“difficult” were considered difficult intubations.

26
Study II
The questions in study II concerned the presence of airway management
guidelines in anaesthesia departments in Sweden. The eight questions con-
cerned whether the department had 1) an airway algorithm, 2) written patient
information in the case of a difficult airway, 3) guidelines for difficult air-
ways, 4) guidelines for preoperative airway assessment, 5) guidelines for
rapid sequence intubation, 6) guidelines for criteria on when to perform an
awake intubation, 7) instructions for awake fiberoptic intubation, and 8) a
prescription for when an RNA or anaesthesiologist should perform an en-
dotracheal intubation. In addition, two background questions were included
about hospital type and the number of general anaesthesia procedures per-
formed per year.
All responses to the questions were dichotomised (yes or no), and if the
respondent answered “yes” to any question they were asked to attach and
return copies of their current guidelines. Guidelines for regional anaesthesia
or other commonly used guidelines, such as preoperative fasting, were ex-
cluded. The director was also asked to attach the department’s anaesthetic
record form in order to review whether a fill-out “box” of airway elements
was pre-printed as a checklist. The questionnaires were returned by postal
mail in pre-addressed return envelopes.

Studies III and IV

As interviews are a common method of collecting data in qualitative re-
search, semi- structured individual face-to-face interviews were conducted in
both studies III and IV [70]. Interview guides were developed. To test the
interview guides and interview technique, pilot interviews were conducted
with some adjustments to the questions and not included in the studies. In
study III, the interview guide focused on variations in the ways how anaes-
thesiologists understand algorithms for the management of difficult airways.
The anaesthesiologists were asked three main questions (Table 2) to maxi-
mise the focus on airway algorithms. All interviews were conducted by KK.

27
Table 2. Interview guide for questions used in Study III on anaesthesiologists views on
algorithms, including probing questions.

1. Can you give a concrete example of an event when you observed a difficult airway?
2. What do you think about algorithms, which might also be referred to as guidelines, proto-
cols, or decision aids?
3. Can you describe a situation where you felt that you were successful or not successful in
managing a difficult airway?

Probing questions were:

“Did you use an algorithm that helped you manage the situation?”
“What do you mean”?
“Can you give more examples”?
“What did you think would happen”?
“Is there anything else you would like to add”?

In study IV, the questions concerned how patients experienced awake fiber-
optic intubation using open-ended questions (Table 3). The data were con-
sidered saturated after nine of the 13 interviews [71].

Table 3. Interview guide for questions used in Study IV on how patients experience being
awake intubated, including probing questions.

1. What is your experience with general anaesthesia in the past?

2. What information was given to you before your awake fiberoptic intubation was per-
formed?
3. What is your experience of being awake fiberoptic intubated?
4. Did any anaesthesia staff, postoperatively in the recovery room, ask about your experi-
ences with the anaesthesia?
5. What is your view of undergoing awake fiberoptic intubation again in the future?

Probing questions were:

“Please could you tell me more”
“How did you mean”
“How did you feel about that”

Data analysis
All quantitative data were analysed by PASW Statistics version 19.0 and
20.0 for Windows (SPSS Inc. an IBM Company, Chicago, IL USA) [72].

Study I
Data collected before, during and after anaesthesia were analysed. Cross
tabulation was used to determine correlations between the Mallampati classi-
fication and Cormack & Lehane grade. Results were also calculated on the

28
basis of sensitivity and specificity for the Mallampati classification, thy-
romental distance, and Cormack & Lehane grade used to predict the ease of
intubation. Sensitivity was defined in terms of the percentage of correctly -
predicted easy intubations as a proportion of all intubations that were truly
easy: [true easy intubations/(true easy intubations + false difficult intuba-
tions)]. Specificity was defined in terms of the percentage of correctly pre-
dicted difficult intubations as a proportion of all intubations that were truly
difficult: [true difficult intubations/(false easy intubations + true difficult
intubations)]. In addition, the positive predictive value (PPV) and negative
predictive value (NPV) were calculated if the test was clinically useful. The
PPV was defined in terms of the percentage of correctly predicted easy intu-
bations as a proportion of all predicted easy intubations: [true easy/(true easy
+ false easy)]. The NPV was defined in terms of the percentage of correctly
identified difficult intubations as a proportion of all predicted difficult intu-
bations: [true difficult/false difficult + true difficult]. The thyromental dis-
tance was measured and the results divided into two levels: >10 cm or < 10
cm. A receiver operating characteristic (ROC) curve [72] was applied to de-
termine the optimal cut-off level. Each cut-off value was plotted against
sensitivity on the vertical axis and 1-specificity on the horizontal axis. The
optimal cut-off value was the value in the upper leftmost position. In addi-
tion, continuous variables were described using means and standard devia-
tions (SDs), and categorical variables as frequencies and percentages [72].

Study II
Descriptive statistics were used to describe each hospital type (university,
county, and private). For comparisons between hospital type and the avail-
ability of written airway guidelines, cross tabulation was used and analysed
by Pearson's chi-square tests. Data are expressed as mean and SD, number,
or percentage. A p-value < 0.05 was considered significant [72].

Study III
The interviews were transcribed verbatim by a professional transcript com-
pany. The audio-recorded interviews were listened to by KK and checked
against the transcribed text. Qualitative phenomenographic analysis was
performed in five steps [73]:
1. The printouts were read and re-read several times to achieve overall com-
prehension of the interview.
2. In each interview, the parts of the texts where the anaesthesiologists de-
scribed experiences using algorithms in difficult airway situations or re-
flected on such experiences were marked.

29
3. The marked parts of the text with descriptions of ‘what’ and ‘how’ the
anaesthesiologist thought about algorithms were summarised into one pre-
liminary ‘way of understanding’ for each interview.
4. The resulting 20 ‘ways of understanding’ were compared and, based on
similarities and differences, grouped into different categories.
5. Each category was discussed regarding its accuracy, going back to the
interview texts and revising the category description. In the final analysis,
four categories of understanding were revealed.
Three of the researchers conducted the analysis and reassessed the cate-
gories to enhance the rigour of the analysis [72]. After steps 1-4, the catego-
ries of descriptions that emerged were discussed with all fellow researchers
until a consensus was reached [73]. The research team has experience in
interviewing and qualitative methods, and one researcher had experience
specifically in the phenomenographic method. All researchers except one
had experience from working in anaesthesiology.

Study IV
The interviews were audio-recorded and transcribed verbatim by the first
author. Inductive qualitative content analysis was performed in several steps
as described by Graneheim & Lundman [74]. The goal of content analysis is
to gain an understanding of the phenomenon being studied [75]. This study
aimed to describe patients’ experiences with awake intubation. To get a
sense of the whole text, the analysis began by reading the interviews repeat-
edly. Meaning units from the interviews that corresponded with the aim of
the study were identified and marked with a number. The numbered meaning
units were then condensed and shortened into codes, which were compared
regarding differences and similarities for sorting into subcategories and cate-
gories in dialogue with the co-authors (manifest content analysis). After all
data were categorised, one theme was formulated. Verbatim quotations were
given to illustrate each category and to ensure credibility and transferability
[74]. During the analysis procedure, the categories were discussed and re-
evaluated in order for the researcher to confirm the outcome. The research
team had a pre-understanding of the phenomena being studied from work in
anaesthesiology and/or intensive care, which was actively reflected upon
during the analysis to minimise interpretive bias.

30
Ethical considerations

Formal approval from ethics committee was not required, according to

Swedish national legislation and directives [76, 77] at the time study I was
conducted, as no intervention was performed and no personal data were ob-
tained. To protect the interest of the people involved in the study I, the an-
aesthesia department involved reviewed the research protocol and approved
the study without any changes. Throughout the research, ethical issues were
considered carefully and in accordance with the Declaration of Helsinki [78].
Ethical consideration is important when conducting research involving
vulnerable participants [79], such as when there is a risk that a participant
may be affected by physical or mental discomfort or harm related to the re-
search procedures. The potential risks and benefits associated with the re-
search study were taken into account. As the study procedure included stan-
dardised care and were part of their routine airway assessments, and no addi-
tional or new intervention was implemented, there were no foreseeable risks
involved in the study. In study I, the primary focus was on how RNAs can
independently perform the airway assessment and intubation in patients. To
protect the patients’ rights, all were orally informed that the focus was on the
involved RNAs. The patients were also informed that their participation did
not change their usual care and that the obtained data would be coded in a
way that they would not be identified. Study II was a national survey of the
presence of written airway guidelines and did not involve sensitive personal
material or data. Therefore, this research is not subject to Swedish law and
no ethical approval was sought.
The Regional Ethical Review Board in Uppsala, Sweden, approved stud-
ies III-IV (Diary no. 2012/546 and 2014/491, respectively). All participants
received both oral and written information about the studies’ purpose and
procedures before the studies began. To protect the participants’ confidenti-
ality, they were informed that the obtained data were coded in a manner that
was not linked to the particular participants’ name or hospital. To protect all
of the involved participants, they were also informed that their participation
was strictly voluntary and that they could withdraw at any time, without
explanation, and that this withdrawal would not affect their employment or
care. The participants involved in studies III and IV were also informed that
the interviews should be audio-recorded, transcribed, coded, and stored so
that no one could be identified, neither in person nor in the workplace. Writ-
ten informed consent was obtained before the studies started. The partici-

31
pants were also informed that the collected data would be kept in a way that
access was limited to the research team only. Participants were also given
contact information for the researcher, should they have further questions or
want to discuss their concerns related to their involvement in the studies.

32
Results

Study I
A total of 11 RNAs performed airway assessments on 87 patients (68
women, 19 men). Most of the RNAs had worked for more than 10 years
(n=61 patients, 71%); 25% of patients were seen by RNAs who had worked
3-6 years (n=22) and 5% (n=4) by those who had worked less than 3 years.
The mean patient age was 42 (± 11) years, mean weight 71 (± 14) kg, and
mean height 168 (± 9) cm. Thirteen patients were excluded due to incom-
plete documentation of the data.
Preoperatively, 54 (62%) patients were classified as easy to intubate ac-
cording to the Mallampati classification and 55 (63%) patients with a thy-
romental distance ≥ 10 cm. After induction of anaesthesia, 72 (83%) patients
were graded as easy to intubate using the Cormack & Lehane grade (Table
3). The Mallampati classification had the highest specificity (91%) in pre-
dicting easy intubation, followed by the Cormack & Lehane grade (82%).
The thyromental distance had the poorest specificity (36%) and sensitivity
(65%) compared to the other tests.
Table 3. Distribution of the number of patients by thyromental distance, Mallampati
classification, Cormack & Lehane grade, and categorisation of intubation conditions
Intubation
Thyromental Mallampati classi- Cormack & Lehane Outcome of intu-
assess- distance (cm) fication classification bation conditions
ment
Easy
Class I n=24 Grade I n=55 n=19
intubation
Quite easy
Class II n=30 Grade II n=17 n=57
intubation
Easy
≥10 cm n=55
intubation n=54 n=72 n=76

Somewhat
Class III n=24 Grade III n=14 difficult n=7
intubation
Difficult
Class IV n=9 Grade IV n=1 n=4
Difficult intubation
<10 cm n=32
intubation
n=33 n=15 n=11

33
Sixty-two percent of the patients (54/33) were easy to intubate according to
the Mallampati classification (i.e., required less than two intubation at-
tempts). Seventeen percent (15/72) of the patients were difficult to intubate
according to the Cormack & Lehane grade and required two or more intuba-
tions attempts. The agreement between the number of intubation attempts
and the RNA scoring of intubation conditions was 86%. The agreement be-
tween the RNAs’ subjective assessments and the Mallampati classification
was 72%.

Study II
Of the 74 directors, 68 returned the questionnaire, a response rate of 92%.
These completed questionnaires were received from 53 county hospitals, 9
university hospitals, and 6 private hospitals. The highest number of general
anaesthesia procedures per year was performed by the university hospitals
(mean 14 389 ± 7674), followed by county hospitals (mean 5646 ± 4143),
and the private hospitals had the fewest anaesthesia procedures per year
(mean 4063 ± 1837). No significant difference was found between the hospi-
tals regarding the percentage of written guidelines for airway management,
except for guidelines on difficult airways (p = 0.049). Eight of the nine uni-
versity hospitals reported having guidelines for difficult airways, compared
to only 25 of the 53 county hospitals and 2 of the 6 private hospitals.
A total of 214 guidelines were reported by the anaesthesia departments,
67% of which (n=132) were not verified by an attachment. Of the attached
guidelines, 21% (n=46) were followed as recommendations of the SFAI [63]
and 17% (n=36) of the attached guidelines were developed by the local an-
aesthesia department. Twenty-nine of the 68 departments (43%) had guide-
lines for preoperative airway assessment. Forty-six departments (68%) had a
pre-planned intubation plan, in the form of an airway algorithm, in the case
of failed intubation. Thirty-five departments (52%) had guidelines for a dif-
ficult airway, and 35 departments (52%) had an anaesthesia problem card
that they gave to the patient in the case of a difficult airway. Guidelines for
how to perform awake fiberoptic intubation were available in 14 (21%) of
the departments, whereas criteria for when to perform an awake intubation
were available in 18 (26%) of the departments. In total, 21 (31%) of the de-
partments attached guidelines for emergency rapid sequence intubation. A
prescription for when the RNA could carry out the endotracheal intubation
was reported by 16 (24%) of the departments.
Fifty-one (75%) departments sent their anaesthesia record form for re-
viewing pre-printed airway tests. In 35 (69%) of these records, tooth status
was the most common pre-printed preoperative airway test, followed by the
thyromental distance (25%); sternomental distance (8%) was the least com-
mon pre-printed airway test. In 23 (45%) departments, the Cormack & Le-

34
hane grade and evaluation of the extubation conditions were the most com-
mon pre-printed airway test after the anaesthesia was finished, whereas the
number of intubation attempts was pre-printed in only 6 (12%) of the at-
tached anaesthesia records.

Study III
Twenty anaesthesiologists volunteered to participate in the study (5 women,
15 men). Their age ranged from 29 to 68 years (median 39 years), and their
clinical experience as anaesthesiologists ranged from 2 to 39 years (median
3.5 years).
Four categories of how an algorithm could be understood were identified:
1) a normative plan for procedures to be followed in difficult airway situa-
tions, i.e., law-like rules that must be followed; 2) a succinct plan to follow
in difficult airway situations; i.e., a decisional or cognitive aid; 3) an action
plan adaptable to the needs of the individual patient and the clinical situa-
tion, to be kept in mind when creating a personal algorithm based on experi-
ence; 4) a set of guidelines collected by a consensus of experts for proce-
dures in managing the difficult airway based on scientific evidence and ex-
pert opinions.
In the first category, the algorithm could be understood as a normative
plan for procedures to be followed in difficult airway situations. For exam-
ple, when an incident happens, one must be able to defend one’s choices of
action. If one has diverted from the algorithm based on personal knowledge
and experience, the reasons for this diversion must be clearly declared to
avoid future critique. In the second category, an airway algorithm could be
understood as a plan to follow in a difficult airway situation. For example,
plans B and C are ready as back-ups in stressful situations and to avoid for-
getting any important steps in the procedure. In the third category, the algo-
rithm could be seen as an action plan adaptable to the needs of the individual
patient and the clinical situation that can be kept in mind when creating a
personal algorithm based on experience. In the last category, algorithms
derived from scientific knowledge provide guidance, ideas, and recommen-
dations for how to act.

Study IV
A total of 15 patients were invited to participate in the study, two of whom
declined (1 man, 1 woman) without any specific reason. Ten of the patients
had previous experience with general anaesthesia and three of the patients
were receiving anaesthesia for the first time. Of the 13 included patients (7
men, 6 women), eight were interviewed preoperatively and five postopera-

35
tively. The reasons for awake fiberoptic intubation were rheumatoid arthritis
(n=2), thyroidectomy (n=2), pharyngeal abscess (n=2), oropharynx cancer
(n=1), mandibular surgery (n=2), neck immobility (n=3), and acute throat
bleeding (n=1).
From the patient interviews, one main theme emerged: feelings of being
in a vulnerable situation but cared for in safe hands. This theme was revealed
in the following five categories with 15 subcategories: 1) a need for tailored
information, 2) distress and fear of the intubation, 3) acceptance and trust of
the staff’s competence, 4) professional caring and support, 5) no hesitation
about new awake intubation. Patients described different concerns about
how they wished to be involved and how much information was needed be-
fore the intubation was performed. A lack of information about what to ex-
pect was noted. Knowing that they should undergo awake fiberoptic intuba-
tion was emotionally stressful due to the fear of throwing up during the pro-
cedure, provocation of the gag reflex by the tube, and fear of the local anaes-
thetics. For some of the patients, their fears became reality during the
procedure when the local anaesthetic solution was sprayed into the throat
and the injection into the cricothyroid membrane evoked feelings of discom-
fort, coughing, and suffocation. The patients expressed that this was the most
unpleasant experience during the whole procedure. The fiberoptic intubation
was extremely painful for some patients when the tube was inserted, despite
local anaesthetics. On the other hand, patients who had experienced upper
intestinal gastroscopy procedures in the past stated that an awake intubation
was nearly the same phenomenon and nothing to fear. Patients described
feeling more involved when the anaesthetists made eye contact with them
and saw how they reacted during the procedure.
Some patients revealed that they felt overwhelmed by the information
they were given and wanted less specific information about the equipment
used. Instead, they wanted more information about how they would be cared
for in the operating room, including breathing instructions and eye contact.
Undergoing awake intubation was an acceptable experience for most pa-
tients, though some found it to be painful and terrifying because they felt
they could not breathe or communicate during the procedure itself.

36
Discussion

Summary of findings
The aim of this thesis was to study airway management in anaesthesia care
from both professional and patient perspectives. Study I pointed out that the
Mallampati classification is a good screening test for predicting easy intuba-
tion and that intubation can be safely performed by RNAs. Despite the rec-
ommendations of locally adopted airway guidelines, study II affirmed that
the presence of airway guidelines in Swedish anaesthesia departments is
poorly implemented. According to the findings from study III, algorithms
can be understood in four different ways: as law-like rules, as a succinct plan
to follow in difficult airway situations, as an action plan kept in the back of
one’s mind while creating flexible and versatile personal algorithms, or as
consensus guidelines based on expert opinion in order to be followed in
clinical practice. Study IV revealed one main theme; feelings of being in a
vulnerable situation but cared for in safe hands, which is described in five
categories as follows: a need for tailored information, distress and fear of the
intubation, acceptance and trust of the staff’s competence, professional car-
ing and support, and no hesitation about new awake intubation.

Airway management and guidelines from a professional

perspective
Study I pointed out that the Mallampati classification is a good screening test
to predict an easy intubation. Of the 87 included patients, most patient were
easy to intubate according to the Mallampati classification I-II, and required
less than two intubations attempts and by definition classified as easy intuba-
tion by the ASA [1].
According to the ASA [1], all patients scheduled for general anaesthesia
and tracheal intubation should be considered for preoperative airway as-
sessment. However, these assessments have been reported to often be in-
completely documented or lacking [14]. The results from study II agree with
this, as the presence of guidelines for airway management in our depart-
ments could be improved. For instance, surprisingly few departments re-
ported have guidelines for preoperative airway assessment. Adequate airway
assessments and detailed documentation of patient airways are important,

37
especially when the endotracheal intubation is not always carried out by the
same anaesthesia professional that performed the preoperative airway as-
sessment. From a professional safety perspective, it is important to perform
a preoperative airway assessment in advance, when the patient is still awake,
to give the anaesthetists enough time to be prepared for alternative airway
approaches. Research has shown that a previous history of difficult endotra-
cheal intubation is a strong risk factor for intubation problems in the future
[80].
In study II, few departments reported they have prescriptions for when
RNAs can carry out endotracheal intubation, despite RNAs being allowed to
maintain and intubate patient airways independently. In Sweden, they are
allowed to induce and perform general anaesthesia independently in healthy
adult patients with ASA physical status I and II according to specified proto-
cols and agreements [48]. Standardised, structured documentation of the
patients’ airway assessment, as recommended by the ASA [1], may make the
anaesthesia professionals aware and prepared for using the right competence
at the right time to ensure patient safety, that adequate airway devices are
readily available, and that there is supervision from a more experienced an-
aesthesiologist who is able to assist the RNA and secure the airway if
needed. Based on the preoperative airway evaluation, a test that can predict
easy intubation beforehand, such as the Mallampati classification, is a valu-
able tool in clinical practice. This test facilitates the decision about who
should carry out the intubation, the RNA or the anaesthesiologist, when there
is still time to plan for an alternative airway approach.
Airway guidelines and algorithms for managing patients’ airways within
anaesthesia care have been recommended by several anaesthesia societies
and by the Swedish National Board of Health and Welfare [1, 36-38, 80].
Despite these recommendations, study II demonstrated that the presence of
airway management guidelines is generally poorly implemented in Swedish
anaesthesia departments. One reason for a lack of local adopted airway
guidelines in Swedish anaesthesia departments could be a lack of time and,
perhaps, knowledge about how to create evidence-based guidelines. A lack
of knowledge and practical skills in handling a difficult airway and adher-
ence to guidelines have also been found in Danish [81], German [82], and
Canadian anaesthesia departments [83]. The ASA recommends practice
guidelines being adopted and modified according to the department's own
needs and constraints. As airway guidelines are not an absolute requirement,
the development of such guidelines may not be a priority for departments.
The results from study III are consistent with previous studies, which affirm
that human factors, such as the professional’s knowledge and beliefs, influ-
ence compliance with or deviation from the guidelines [47].
Some researchers have argued that algorithms are a useful cognitive aid to
achieve safer airway procedures [44]. However, the results from study III
argue that, before airway algorithms can be used, it must be ensured that

38
they are easy to follow, without too many steps, because in a stressful situa-
tion too many steps would be difficult to memorise. As stated by Smith &
Alderson [41], guidelines should be as short and concise as possible; if they
are too descriptive they appear to limit professionals’ judgement. The au-
thors further advocated that guidelines need to be based on the best available
scientific evidence and a broad consensus to improve patient outcomes.
Study III showed that algorithms for the management of difficult airways
can be understood in four ways: as law-like rules, as a succinct plan to fol-
low in difficult airway situations, as an action plan kept in the back of one’s
mind while creating flexible and versatile personal algorithms, or as consen-
sus guidelines based on expert opinion. One barrier against using guidelines
such as algorithms is that they do not take the individual anatomical charac-
teristics of a patient (e.g., a tonsil tumour) or a specific situation into ac-
count. For instance, it was explained that algorithms are developed for the
“average” patient and are not applicable to all kinds of patients and situa-
tions:

“An algorithm is a useful tool, but you need to tailor it for each individual
patient… a useful support, like a crutch... but patients are also different; they
have various conditions and anatomy, and one must take these factors into
account... “(Study III)

Thus, algorithms may be more useful in clinical practice if they could be

designed in a more efficient and practical manner. In addition, algorithms
need to be based on a simple principle and easy to follow in order to be im-
plemented. A systematic review by Ebben et al. [84] highlighted that there is
a gap between guidelines and clinical practice. One reason for this gap is that
guidelines contain too many recommendations to adhere to when making
choices. They emphasised that if guidelines could be translated into more
efficient, practical and feasible algorithms, it would be easier to adhere to
them. Goldhaber-Fiebert & Howard [85] recently reported that cognitive
aids, such as algorithms, cannot be implemented powerfully if they are not
developed from evidence-based practice. A study on the use of evidence-
based guidelines for mechanical ventilation in a Swedish intensive care set-
ting reported similar findings [86]. However, anaesthesia professionals’
manage difficult airways on their own during critical situations based on
their own knowledge and beliefs [47]. According to Polanyi [87], knowledge
can be divided into two different categories, namely tacit knowledge and
explicit knowledge, and can be used to explain how individuals handle spe-
cific situations. He described tacit knowledge as an individual’s intuitively
acquired knowledge that is developed through experiences and difficult to
verbalise, whereas explicit knowledge is knowledge acquired by reading the
medical literature and sharing specific information. However, he argued that
individuals need both tacit and explicit knowledge when acting in and han-

39
dling specific situations. In other words, knowing how to adopt and use, for
example, guidelines and algorithms in clinical practice requires both tacit
knowledge and the support of explicit knowledge.
A common opinion among anaesthesiologists in study III was that you
must have experienced a real situation before you are able to use algorithms,
and this requires training and clinical experience. This is consistent with the
findings of a systematic review of 13 studies examining the number of en-
dotracheal intubations a novice intubator must perform using direct laryngo-
scopy to achieve expertise with the procedure [88]. In elective circum-
stances, a novice intubator needed to perform at least 50 endotracheal intu-
bations on patients before successfully mastering the airway procedures.
Dreyfus & Dreyfus [89] described practitioners going through five different
levels of experience, from novice to expert, before they master work-related
skills. As a novice without previous experience, they make decisions using
clear rules and instructions, which they follow strictly until they have gained
experience, whereas an expert, who has developed a lot of clinical experi-
ence over time, may see situations differently and identify and handle prob-
lems more intuitively. Thus, skills such as face-mask ventilation and per-
forming endotracheal intubation are mastered by working bedside on a daily
basis (“learning by doing”) and by being exposed to patients with various
individual anatomies and situations, especially in time-pressure emergency
situations. Perhaps, after a couple years of clinical experience, you can cre-
ate your own strategies for how to use airway algorithms, modified by your
own clinical experiences to fit the patients and situations. Therefore, it seems
evident that clinical experience is required, along with theoretical knowl-
edge, to master skills such as handling a difficult airway in critical situations.
The professional’s ability to communicate calmly and clearly is also impor-
tant when acting in and handling critical situations [53]. Hands-on training is
needed to improve procedural skills in critical airway situations [90]. Simu-
lator training, together with education and reflection, contributes to improv-
ing procedural skills and performance in critical situations [33,44]. However,
the simulation training in anaesthesiology is still under development and it is
not yet known how efficient such approach will be [91]. Part of the problem
is that algorithms are developed for the "average" patient and do not account
patient individual factors or the skill of the intubator. Simulation training for
management of a difficult airway may well improve both knowledge and
skills but perhaps not the professionals’ behaviour in critical situation.
The ability to maintain a free airway through face-mask ventilation and
intubation is a craft that requires routine practice to master. Once a difficult
airway appears, it is an emotionally stressful situation for the professionals
[52]. In my experience, difficult intubation is less problematic than difficult
mask ventilation because you can still ventilate and oxygenate the patient’s
lungs. Problems may occur when it is difficult to ventilate the patient, espe-
cially during time-pressure critical situations. Securing the patient's airway is

40
a team effort [92], and it is hard to work entirely on your own in a critical
situation. When facing difficult mask ventilation, one may need to use a two-
handed technique to oxygenate the patient’s lungs. However, study III re-
vealed that the ASA algorithm is too descriptive, and it is hard to memorise
all the steps and remember them in a critical situation:

“Algorithms are there in the back of your mind... so that you have a plan
to follow and know what to do next… but they´ve got to be simple and easy to
follow - no more than 3-4 steps - to help avoid becoming blocked in critical
situations… once you are in a difficult airway situation, you may not be able
to think of every step in the algorithm…” (Study III)

In my opinion, more attention should be given to the development of an al-

gorithm in the form of an illustrated picture showing, step by step, how to
handle the situation when the airway fails. In a critical airway situation in
which, the airway needs to be managed immediately, it is easier to look at an
illustrated algorithm for instructions on what to do next than read a lot of
text. The key is to make it easier when acting and handling difficult airways
in critical situations. When an airway needs to be managed immediately,
patients become extra vulnerable because there is no or little time to ade-
quately prepare them.

Anaesthesia and intubation from a patient perspective

Study IV revealed that careful emotional support before and during the an-
aesthesia procedure is important when the intubation is performed in the
awake state. Patients want tailored information about the procedure without
technical details about the equipment used. Support, such as breathing in-
structions, along with eye contact from the anaesthesia professional, helps
patients cope and feel more safe and confident during the procedure. Ac-
cording to Lazarus & Folkman [93], coping is a natural response when indi-
viduals face a stressful situation, such as anaesthesia. How patients deal with
stress depends on the situation and the patient´s own individual coping
strategies. Patients can use several types of coping strategies [94]. Study IV
revealed that patients use emotion-focused coping strategies, such as medi-
tating and accepting the situation, when they feel that they have little control
over their own situation. Also, patients use problem-focused coping before
the procedure. Not knowing what should happen evoked feelings of being in
a vulnerable situation. The patients expressed a need for tailored information
about what to expect, which helped them master and control the situation.
This finding is supported by the study by Mitchell [4], who highlighted that

41
patients undergoing general anaesthesia are more anxious and want more
information than patients scheduled for local anaesthesia.

“It was just to realise that I must leave myself in other people’s hands. I
had full confidence, I meditated and calmed down... There is nothing I can do
now, so I have to trust you and your colleagues, those who are going to do
this, I must resign myself to it.” (Study IV)

Even if the study by Mitchell did not focus on awake intubation per se, the
patients experienced greater feelings of emotional support when they felt
informed. From the patients’ perspective, it is important to be well-informed
[4] about what to expect and how the procedures could be experienced, as
local anaesthetic is a common part of the anaesthetic procedure. Several
patients in study IV described the most unpleasant experience during the
whole procedure to be feelings of discomfort after the local anaesthetic solu-
tion was sprayed into the throat and the injection was made in the back of the
trachea, including pain, coughing, and feelings of suffocation.

“It felt like I could not swallow, like I would suffocate on the fluid, like as
I cough and throw up at the same time…” (Study IV)

This is a dilemma during an awake intubation, when patients need to be se-

dated enough to make the procedure more tolerable and alleviate unpleas-
antness, but still need to be able to follow instructions and commands.

Patients experienced awake fiberoptic intubation as a feeling of being in a

vulnerable situation but cared for in safe hands. Several of the patients de-
scribed awake intubation as a quite acceptable experience, despite the emo-
tional stress, and that they would not hesitate to undergo awake intubation
again in the future if needed. Nevertheless, patients are vulnerable during the
procedure because it is difficult to vocally communicate due to the local
anaesthetic solution and when the tube is inserted. Therefore, it is important
for the staff to be aware of how to communicate with the patients via eye
contact during the procedures, as described by the patients in study IV. Simi-
lar findings have been reported by others [95, 96].

Methodological considerations
In studies I and II, quantitative study designs were chosen because of their
usefulness in gaining valuable information about current anaesthesia practice
and describing the presence of airway guidelines in our anaesthesia depart-
ments. In studies III and IV, qualitative study designs were chosen in order
to gain a deeper understanding of how algorithms can be understood and

42
how patients experience awake fiberoptic intubation. However, there are
some methodological strengths and limitations in the presented studies that
need to be taken into account [70]. In studies I and II, study-specific ques-
tionnaires were used as a data collection method, which must be taken into
consideration when assessing the validity and reliability [97]. Before the
start of the studies, the questionnaires were pilot tested and reviewed by
experienced researchers involved in the study and by RNAs and anaesthesi-
ologists working in the field in order to ensure that the questions were clear
and understandable and to establish face and content validity.
In addition, study I included relatively few patients, more women than
men, and only healthy adult ASA I-II patients undergoing elective day sur-
gery. Another limitation was that the study was conducted by RNAs who
worked at the same anaesthesia clinic. The reliability may have differed if
another group of RNAs with different experience or skills from different
clinics or if anaesthesiologists had assessed and carried out the intubation.
As in all quantitative research, the sample size is important for generalising
the findings to a larger population [98]. A sample size calculation was not
performed before starting study I. The findings cannot be generalised to
other patients or be said to be representative of all anaesthesia departments.
However, the result provided information that the Mallampati classification
is a useful test for predicting easy intubation when the airway assessment is
performed by RNAs in a standardised manner.
The main strength of Study II was that it was a nationwide survey with a
high response rate (92%) and included a large number of anaesthesia de-
partments. A limitation of study II was that the questions only addressed
specific airway management issues and did not explore how often the de-
partments evaluated their airway management guidelines. The generalisabil-
ity of the results is questionable, as the data are not necessarily based on
which guidelines really exist at these departments. Perhaps they had airway
guidelines but use different terms for their documents, such as standards,
protocols, checklists, algorithms, clinical pathways, and recommendations
for clinical practice [41, 84, 99, 100]. This makes it difficult to draw firm
conclusions when interpreting the results.
Individual interviews are a common data collection method in qualitative
research. According to Lincoln & Guba [75], to ensure trustworthiness in
qualitative research, the credibility, dependability, confirmability, and trans-
ferability need to be taken into considerations. In studies III and IV, semi-
structured face-to-face interviews were conducted by KK. An interview
guide was developed and used to collect data and strengthen the credibility,
minimising research bias (dependability). Pilot interviews were carried out
with both anaesthesiologists and patients not included in the studies to test
the interview guide and ensure that the questions that were asked closely
reflect the aim of the study [67]. As Larsson & Holmström [73] suggested in
a phenomenographic study, the data from 20 informants is usually enough to

43
discover variations in the ways people understand or perceive a specific phe-
nomenon. The phenomenographic approach is based on the theory that peo-
ple understand a specific phenomenon in a limited number of qualitatively
different ways [101]. The data analysis in study III started when all inter-
views had been conducted. In contrast to study IV, the data analysis was on-
going until saturation was reached and no additional information was ob-
tained [102]. To strengthen the confirmability, the data analyses began by
reading the text repeatedly and breaking down the data into smaller units and
codes, then grouping the coded material into categories and themes [73, 74].
In both studies, quotes from the interviews were extracted to exemplify the
categories and themes that emerged. The research team had a pre-
understanding of the phenomenon under study due to extensive experience
in anaesthesiology and/or intensive care, which were actively reflected upon
during the analysis to minimise interpretive bias [73]. During the whole
analysis process, consensus was reached between the researchers concerning
the emerging results through discussion to avoid influencing the authors’
pre-understanding of working in the field. The findings have been critically
debated and discussed with others with experience in qualitative methods
and different pre-understandings of the phenomenon during research semi-
nars. As with all qualitative studies [70], the findings from these two studies
cannot be generalised and the transferability of the results is up to the reader
to decide. The results from study III are valuable as they can be used to de-
velop a more applicable algorithm to follow in clinical practice. The results
from study IV are useful as no available study has explored patient experi-
ences with awake intubation. Such valuable information can improve the
quality of care. Whether the results from these studies are transferable to
other settings and patients requires further study.

44
Clinical implications

Preoperative airway assessment is important to identify patients who will be

easy or difficult to intubate. Most of the published literature has mainly fo-
cused on the prediction of difficult airways [25]. Mallampati classification
III-IV is also a predictor of difficult mask ventilation combined with difficult
laryngoscopy [103]. Therefore, it is important to use airway tests that can
clearly define easy airways to provide guidance for when RNAs can main-
tain and perform endotracheal intubation independently. In clinical practice,
airway tests are more useful if they also predict an easy airway, as endotra-
cheal intubations in Sweden are mostly performed by RNAs without the
direct supervision of anaesthesiologists.
In order to promote patient safety in clinical practice, the development of
evidence-based guidelines and algorithms for the management of difficult
airways should be considered a higher priority. Study III revealed that algo-
rithms are a valuable tool when presented with a difficult airway, but in
clinical practice, more attention should be given to developing algorithms
that are simple and easier to follow, as presented by the Difficult Airway
Society (DAS) [36]. It will be interesting to follow when the DAS guidelines
for the management of difficult airways become available in our anaesthesia
departments. From the professional perspective, dealing with a difficult air-
way is one of the most stressful events one will face, especially during an
emergency, and the approach takes time to learn and master. Therefore, a
well-designed algorithm that is easy to follow is essential. In critical situa-
tions, a visual algorithm can be helpful for the practitioner to communicate
effectively with the team, especially if one's own experience is governed.
Awake fiberoptic intubation is an alternative procedure for securing the
patient’s airway when a difficult airway is expected. From the patients’ per-
spective, tailored information about what to expect and how awake fiber-
optic intubation could be experienced is important to increase their feelings
of control and ability to cope during the procedure. To improve the quality
of care, it is important to take patients’ needs, feelings, and thoughts into
consideration. In addition, patients should be offered written and visual in-
formation about how they should be cared for in the operating room to en-
able patients to feel calm before the procedure is performed.

45
Conclusions

The overall aim of the present thesis was to study airway management in
anaesthesia care from both the professional and patient perspective.

- Airway management is of central importance when performing

anaesthesia. The Mallampati classification is a good screening
test for predicting easy intubation  when the airway assessment
is performed in a structured manner by RNAs.

- In anaesthesia care, airway guidelines and algorithms have

been developed and recommended to achieve safer airway
procedures, but airway guidelines are poorly implemented in
Swedish anaesthesia departments.

- Algorithms have been recommended in clinical practice to aid

in determining how to act and handle difficult airways. To be
used in daily practice, algorithms need to be simple and easy to
follow and based on the best available scientific evidence.

- From the patients’ perspective, the most unpleasant part of the

procedures is discomfort following the application of local an-
aesthetic. Tailored information about what to expect, ensuring
eye contact, and giving breathing instructions during the pro-
cedure may reduce patients’ feeling distress. Most of the pa-
tients would not hesitate to undergo awake intubation again if
needed, in the future.

46
Svensk sammanfattning (Swedish summary)

Preoperativ luftvägsbedömning är viktigt för att identifiera patienter som

sannolikt kommer att bli lätta eller svåra att intubera. Trakeal intubation är i
det flesta fall tekniskt okomplicerad och utförs vanligtvis efter en lyckad
maskventilation, när patienten är nersövd. De flesta luftvägsproblem i sam-
band med trakeal intubation har inträffat när adekvat luftvägsbedömning inte
har gjorts. Olika rutiner och riktlinjer, nationellt som internationellt, för hur
luftvägen ska bedömas har blivit beskrivna i syfte att öka patientsäkerheten
vad gäller luftvägsproblem i samband med anestesi. Trots detta dokumente-
ras viktiga förutsägande luftvägstester olika samt ibland inkonsekvent bland
anestesipersonal. För att öka patientsäkerheten vid anestesi rekommenderas
att evidensbaserade riktlinjer används och att en luftvägsalgoritm följs vid
svår luftväg. Dock visar studier att förekomst och följsamhet till luftvägsrikt-
linjer och algoritmer är bristfällig. Faktorer som personliga erfarenhet, ve-
tenskaplig övertygelse och den enskildes attityd påverkar beslutet att följa
eller frångå riktlinjerna.
Vakenintubation anses vara det säkraste sättet att erhålla fria luftvägar in-
för generell anestesi och rekommenderas för patienter som identifierats med
svår luftväg. En vakenintubation genomförs vanligtvis under lokalanestesi
och lätt sedering. Samarbete och kommunikation mellan patienten och den
som genomför vakenintubationen är av betydelse eftersom patientens möj-
ligheter till verbala kommunikation begränsas genom trakealtubens placer-
ing. För det flesta patienter är anestesi i samband med operation förknippat
med varierande grad av oro och ångest. Generellt upplever kvinnor mer oro
och ångest jämfört med män. Tidigare studier har kunnat påvisa ökad pati-
enttillfredsställelse och minskad ångest och oro i samband med anestesi om
patienten är välinformerad.

Det övergripande syftet med avhandlingen var att studera luftvägsbedöm-

ning inom anestesisjukvård från både anestesiprofessionens och patientens
perspektiv.

Syftet med studie I var att studera om Mallampatis klassifikation, thyromen-

tal avstånd och Cormack och Lehanes gradering var användbara luftvägstes-
ter för att predicera lätt intubation. Anestesisjuksköterskor vid en dagkirur-
gisk operationsavdelning fick under en fyra månaders period preoperativt
luftvägsbedöma 100 patienter inför planerad anestesi. Resultatet visade att

47
Mallampati klassifikation var ett användbart test för att predicera lätt luftväg
om bedömningen genomförs på ett strukturerat sätt samt att intubationen kan
genomföras självständigt och på ett patientsäkersätt av anestesisjuksköters-
kan.
Syftet med studie II var att genom en nationell studie granska förekoms-
ten av rutiner och riktlinjer för luftvägsbedömning. Ett strukturerat fråge-
formulär skickades ut till samtliga chefer inom anestesiavdelningar i Sveri-
ge. Resultatet visade att förekomst vad gäller riktlinjer för luftvägsbedöm-
ning var bristfälligt. Riktlinjer för preoperativ luftvägsbedömning rapporte-
rades tillgängliga hos 29 (43 %) av 68 anestesiavdelningar. Riktlinjer för hur
man ska genomföra en vakenintubation rapporterades tillgängligt hos 18 (26
%) av anestesiavdelningarna. Endast 16 (24 %) av anestesiavdelningarna
rapporterade riktlinjer för när anestesisjuksköterskans självständigt kunde
intubera patienter.
Syftet med studie III var att beskriva hur strategiskt utvalda anestesiolo-
ger tänker kring situationer med svår luftväg och vilka strategier de använder
för att hantera och lösa situationen. Individuella intervjuer med 20 anestesio-
loger spelades in och skrevs ut ordagrant och analyserades med hjälp av
fenomenografisk metod. Resultatet visade att algoritmer (kan också kallas
för riktlinjer, protokoll eller beslutsstöd) för att hantera svåra luftvägar kunde
uppfattas som en enkel plan att följa vid svåra luftvägssituationer, ett be-
slutsstöd, en handlingsplan anpassad efter patient och situation, en riktlinje
utarbetad av experter for hur man handlägger svåra luftvägar baserad på
evidens och expert kunnande.
Syftet med studie IV var att beskriva patienters upplevelser i samband
med en vakenintubation. Under ett besök på den preoperativa mottagningen
för sedvanlig anestesibedömning informeras patienten muntligt och skriftligt
om studien. Därefter genomfördes individuella intervjuer med 13 patienter.
Intervjuerna spelades in och analyserades med hjälp av kvalitativ innehålls-
analys. Av resultatet framkom ett huvudtema; känna sig i en utsatt situation
men vårdad i säkra händer och följande fem kategorier; behov av skräddar-
sydd information, oro och rädsla inför intubation, tillit till personalens kom-
petens, omtänksam och professionell vård och ingen tvekan att genomgå en
vakenintubation igen.
Sammanfattningsvis visar avhandlingsarbetet att Mallampati klassifika-
tion var ett användbart test för att predicera lätt luftväg när bedömningen
genomfördes på ett strukturerat sätt av anestesisjuksköterskan. Vidare visade
avhandlingen att nationella kliniska riktlinjer för luftvägshantering inför
anestesi behöver förbättras för att öka patientsäkerheten. Trots att algoritmer
för hur man ska hantera svåra luftvägar har utvecklats och publicerats, både
nationell och internationell, framkom att algoritmer för hur man hantera
svåra luftvägar är svåra att komma ihåg i en stressig luftvägssituation. Algo-
ritmer bör vara enkla och innehålla få steg för att implementeras i det dagliga
kliniska arbetet. Vakenintubation är en rekommenderad metod för att säk-

48
ra fria luftvägar hos patienter med misstänkt svår luftväg. Från patientens
perspektiv, skräddarsydd information, ögonkontakt och andningsinstruk-
tioner under själva förfarandet minskar oro och ångest inför anestesi.
Patientens upplevelser av vakenintubation är av klinisk betydelse för hur
den preoperativa informationen kan utformas samt hur patientens egen
delaktighet kan optimeras i samband med vakenintubation.

49
Acknowledgements

First of all, I would like to thank my supervisor Ulrica Nilsson. Thank for
guiding me over the past five years as this thesis would not have been possi-
ble without your help. I would also like to thank Ulrika Pöder, my co-
supervisor for your valuable assistance, encouragement, critical comments
and editing of my numerous manuscripts. I would also like to thank
Marieann Högman, my co-supervisor for your ideas and input when devel-
oping my own algorithm and for your constructive comments and guidance
during my research. I would also like to thank Anders Larsson, my co-
supervisor for your constructive comments and valuable feedback and input
into my work. I would also like to thank Dr. Jan Larsson for your expertise
that contributed to this thesis.

Thanks to my friend and earlier colleagues, Ulla-Carin Blom-Ivarsson for

introducing me to my supervisor. To Ann-Marie Broqvist & Tarja Lidberg
for our many walking tours where you listened to my concerns, sharing my
tears and holding me up during these years.

Thanks to my earlier colleagues working, at the anaesthesia departments in

Gävle Hospital, Eva Åström & Miska Hibner for helping me when I needed
support.

I would also like to thank all of my doctoral colleagues, too many to name,
at the Department of Health and Caring Sciences at University of Gävle & at
the Department of Public Health and Caring Science at Uppsala University
who has helped me along my doctoral journey. Thank, especially for your
support in reviewing, critiquing and feedback of my research during semi-
nars and sharing my doctoral journey. Also, thanks to statistician Hans
Högberg for your support with my statistics.

Thanks to my friends, too numerous to mention all by name, who have been
there and supporting me. Thanks to my brother for your support with my
tables.

To my family, Bent and lovely daughter Olivia for always being there, trust-
ing and believing in me. I would not have been able to complete this thesis
without your help. You are my all happiness and pleasure, love you.

50
References

1. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich
DG, et al. American Society of Anesthesiologists Task Force on Management
of the Difficult Airway. Practice guidelines for management of the difficult air-
way: An updated report by the American Society of Anesthesiologists Task
Force on management of the difficult airway. Anesthesiology 2013; 118: 251-
270.
2. Benumof JL. Management of the difficult adult airway, with special emphasis
on awake tracheal intubation. Anesthesiology 1991;75:1087-1110.
3. Schnack DT, Kristensen MS, Rasmussen LS. Patients' experience of awake
versus anaesthetised orotracheal intubation: a controlled study. Eur J Anaesthe-
siol 2011; 28: 438-442.
4. Mitchell M. Influence of gender and anaesthesia type on day surgery anxiety. J
Adv Nurs 2012; 68: 1014-1025.
5. Mavridou P, Dimitriou V, Manataki A, Arnaoutoglou E, Papadopoulos G. Pa-
tient's anxiety and fear of anesthesia: effect of gender, age, education, and pre-
vious experience of anesthesia. A survey of 400 patients. J Anesth 2013; 27:
104-108.
6. Ramkumar V. Preparation of the patient and the airway for awake intubation.
Indian J Anaesth 2011; 55: 442-447.
7. The National Board of Health and Welfare (Socialstyrelsen). Statistical Data-
bases (Accessed 7 Mars 2016). Available from:
http://www.socialstyrelsen.se/statistics
8. Vannucci A, Cavallone LF. Bedside predictors of difficult intubation: a system-
atic review. Minerva Anestesiol 2016;82: 69-83.
9. Rose DK, Cohen MM. The incidence of airway problems depends on the defini-
tion used. Can J Anaesth 1996; 43: 30-34.
10. Kheterpal S, Healy D, Aziz MF, Shanks AM, Freundlich RE, Linton F, et al.
Incidence, predictors, and outcome of difficult mask ventilation combined with
difficult laryngoscopy: a report from the multicenter perioperative outcomes
group. Anesthesiology 2013; 119: 1360-1369.
11. Cook TM, MacDougall-Davis SR. Complications and failure of airway man-
agement. Br J Anaesth 2012;109 1:i68-i85
12. Eberhart LH, Arndt C, Aust HJ, Kranke P, Zoremba M, Morin A. A simplified
risk score to predict difficult intubation: Development and prospective evalua-
tion in 3763 patients. Eur J Anaesthesiol 2010; 27:935-940.
13. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of
impossible mask ventilation: A review of 50,000 anesthetics. Anesthesiology
2009; 110:891-897.
14. Cook TM, Woodall N, Frerk C, Fourth National Audit Project. Major complica-
tions of airway management in the UK: Results of the fourth national audit pro-
ject of the royal college of anaesthetists and the difficult airway society. Part 1:
Anaesthesia. Br J Anaesth 2011;106:617-631.

51
15. L'Hermite J, Nouvellon E, Cuvillon P, Fabbro-Peray P, Langeron O, Ripart J.
The simplified predictive intubation difficulty score: A new weighted score for
difficult airway assessment. Eur J Anaesthesiol 2009;26: 1003-1009.
16. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in
apparently normal patients: A meta-analysis of bedside screening test perfor-
mance. Anesthesiology 2005;103:429-437.
17. Mallampati SR. Clinical sign to predict difficult tracheal intubation (hy-
pothesis). Can Anaesth Soc J 1983; 30:316-317.
18. Lee A, Fan LT, Gin T, Karmakar MK, Ngan Kee WD. A systematic review
(meta-analysis) of the accuracy of the mallampati tests to predict the difficult
airway. Anesth Analg 2006;102:1867-1878.
19. Khan ZH, Mohammadi M, Rasouli MR, Farrokhnia F, Khan RH. The diagnos-
tic value of the upper lip bite test combined with sternomental distance,
thyromental distance, and interincisor distance for prediction of easy laryngos-
copy and intubation: A prospective study. Anesth Analg 2009;109:822-824.
20. Bindra A, Prabhakar H, Singh GP, Ali Z, Singhal V. Is the modified Mallampati
test performed in supine position a reliable predictor of difficult tracheal intuba-
tion? J Anesth 2010; 24:482-485.
21. Khan ZH, Eskandari S, Yekaninejad MS. A comparison of the Mallampati test
in supine and upright positions with and without phonation in predicting diffi-
cult laryngoscopy and intubation: A prospective study. J Anaesthesiol Clin
Pharmacol 2015;31:207-211.
22. Frerk CM. Predicting difficult intubation. Anaesthesia. 1991; 46:1005-1008.
23. Baker P. Assessment before airway management. Anesthesiol Clin
2015;33:257-278.
24. Baker PA, Depuydt A, Thompson JM. Thyromental distance measurement--
fingers don't rule. Anaesthesia 2009; 64:878-882.
25. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in
apparently normal patients: A meta-analysis of bedside screening test perfor-
mance. Anesthesiology 2005;103:429-437.
26. Rosenstock C, Hansen EG, Kristensen MS, Rasmussen LS, Skak C, Ostergaard
D. Qualitative analysis of unanticipated difficult airway management. Acta
Anaesthesiol Scand 2006; 50:290-297.
27. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia
1984;39:1105 -1111.
28. Smith T, Pinnock C, Lin T, editors. Fundamentals of Anaesthesia. 3 rd ed.
Cambridge Medicine: Lippincott Williams & Wilkins, 2009.
29. Corbanese U, Possamai C. Awake intubation with the Bonfils fibrescope in
patients with difficult airway. Eur J Anaesthesiol 2009; 26:837-841.
30. Larsson J, Rosenqvist U, Holmström I. Enjoying work or burdened by it? How
anaesthestists experience and handle difficulties at work: a qualitative study. Br
J Anaesth 2007: 99; 493-499.
31. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, et al.
Canadian Airway Focus Group. The difficult airway with recommendations for
management--part 1--difficult tracheal intubation encountered in an uncon-
scious/induced patient. Can J Anaesth. 2013; 60:1089-1118.
32. Gjeraa K, Jepsen RM, Rewers M, Østergaard D, Dieckmann P. Exploring the
relationship between anaesthesiologists' non-technical and technical skills. Acta
Anaesthesiol Scand 2016; 60: 36-37.
33. Flin R, Patey R, Glavin R, Maran N. Anaesthetists’ non-technical skills. Br J
Anaesth 2010; 105: 38-34.

52
34. American Society of Anesthesiologists. Practice guidelines for management of
the difficult airway. A report by the American Society of Anesthesiologists
Task Force on Management of the Difficult Airway. Anesthesiology 1993;
78:597-602.
35. Practice guidelines for management of the difficult airway: an updated report by
the American Society of Anesthesiologists Task Force on Management of the
Difficult Airway. American Society of Anesthesiologists Task Force on Man-
agement of the Difficult Airway. Anesthesiology 2003; 98:1269-1277.
36. Frerk CM, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015
guidelines for the management of unanticipated difficult intubation in adults
(DAS). Br J Anaesth 2015; 115: 827-848.
37. Petrini F, Solca M, De Robertis E, Peduto VA, Pasetto A, Conti G, et al.
SIAARTI-ESA Task Force. The Helsinki Declaration on Patient Safety in An-
esthesiology: a way forward with the European Board and the European Society
of Anesthesiology. Minerva Anestesiol 2010; 76:971-977.
38. Jensen AG, Callesen T, Hagemo JS, Hreinsson K, Lund V, Nordmark J. Scan-
dinavian clinical practice guidelines on general anesthesia for emergency situa-
tions. Acta Anasthesiol Scand 2010; 54: 922-950.
39. Crosby ET. An evidence-based approach to airway management: is there a role
for clinical practice guidelines? Anaesthesia 2011; 66 2:112-118
40. World Health Organisation. Guideline for WHO Guidelines EIP/
GPE/EQC/2003.1 2003. (Accessed 7 Mars 2016). Available from:
http://whqlibdoc.who.int/hq/2003/eip_gpe_eqc_2003_1.pdf
41. Smith A, Alderson P. Guidelines in anaesthesia: Support or constraint? Br J
Anaesth 2012; 109:1-4.
42. Mehlman MJ. Medical practice guidelines as malpractice safe harbors: Illusion
or deceit? J Law Med Ethics 2012; 40:286-300.
43. Marshall S. The use of Cognitive Aids During Emergencies in Anesthesia: A
Review of the Literature. Anesth Analg 2013; 117:1162-1171.
44. Marshall SD, Mehra R. The effects of a displayed cognitive aid on non-
technical skills in a simulated 'can't intubate, can't oxygenate' crisis. Anaesthesia
2014; 69: 669-677.
45. Heidegger T, Gerig HJ, Henderson JJ. Strategies and algorithms for manage-
ment of the difficult airway. Best Pract Res Clin Anaesthesiol 2005; 19:661-
674.
46. Petrini F. Airway management and guideline implementation: The gap from
research to daily practice. Minerva Anestesiol 2008; 74:449-450.
47. Phipps DL, Beatty PC, Parker D, Nsoedo C, Meakin GH. Motivational influ-
ences on anaesthetists' use of practice guidelines. Br J Anaesth 2009; 102: 768-
774.
48. National Association for Anaesthesia and Intensive Care & Swedish Society of
Nursing - SSF. Description of competence for Registered Nurse with Graduate
Diploma in Specialist Nursing – Anaesthesia Care. Stockholm. (Accessed Mars
7 2016). Available from: http://www.swenurse.se/globalassets/publikationer-
svensk-sjukskoterskeforening/kompetensbeskrivningar-
publikationer/anestesi.eng.komp.pdf
49. Meeusen V, van Zundert A, Hoekman J, Kumar C, Rawal N, Knape H. Compo-
sition of the anaesthesia team: A European survey. Eur J Anaesthesiol 2010;
27:773-779.
50. Matsusaki T, Sakai T. The role of certified registered nurse anesthetists in the
United States. J Anesth 2011; 25:734-740.

53
51. Certification and regulation of advanced practice nurses. American association
of colleges of nursing. J Prof Nurs 1999; 15:130-132.
52. Larsson J, Rosenqvist U, Holmström I. Enjoying work or burdened by it? How
anaesthetists experience and handle difficulties at work: a qualitative study. Br J
Anaesth 2007; 99:493-499.
53. Larsson J, Holmstrom IK. How excellent anaesthetists perform in the operating
theatre: A qualitative study on non-technical skills. Br J Anaesth 2013; 110:115-
121.
54. Sundqvist AS, Carlsson AA. Holding the patient's life in my hands: Swedish
registered nurse anaesthetists' perspective of advocacy. Scand J Caring Sci
2013; 29: 281-288.
55. Matthias AT, Samarasekera DN. Preoperative anxiety in surgical patients -
experience of a single unit. Acta Anaesthesiol Taiwan 2012; 50:3-6.
56. Mavridou P, Dimitriou V, Manataki A, Arnaoutoglou E, Papadopoulos G. Pa-
tient's anxiety and fear of anesthesia: effect of gender, age, education, and pre-
vious experience of anesthesia. A survey of 400 patients. J Anesth 2013;
27:104-108.
57. Burkle CM, Pasternak JJ, Armstrong MH, Keegan MT. Patient perspectives on
informed consent for anaesthesia and surgery: American attitudes. Acta
Anaesthesiol Scand 2013; 57:342-349.
58. Chan Z, Kan C, Lee P, Chan I, Lam J. A systematic review of qualitative stud-
ies: patients' experiences of preoperative communication. J Clin Nurs 2012;
21:812-824.
59. Rudolfsson G, von Post I, Eriksson K. The expression of caring within the peri-
operative dialogue: a hermeneutic study. Int J Nurs Stud. 2007;44: 905-915.
60. Lindwall L, von Post I, Bergbom I. Patients' and nurses' experiences of periop-
erative dialogues. J Adv Nurs 2003; 43:246-253.
61. Rosén S, Svensson M, Nilsson U. Calm or not calm: the question of anxiety in
the perianesthesia patient. J Perianesth Nurs 2008; 23:237-246.
62. Burkle CM, Mann CE, Steege JR, Stokke JS, Jacob AK, Pasternak JJ. Patient
fear of anesthesia complications according to surgical type: potential impact on
informed consent for anesthesia. Acta Anaesthesiol Scand. 2014; 58:1249-1257.
63. SFAI, Svensk Förening för Anestesi och Intensivvård. Den svåra luftvägen.
Hallen K, Ullman J, Frykholm P, Nellgård P, Åkesson J. (Accessed 7 Mars
2016). Available from: http://sfai.se/riktlinje/medicinska-rad-och-
riktlinjer/anestesi/den-svara-luftvagen/
64. Flin R, Patey R, Glavin R, Maran N. Anaesthetists' non-technical skills. Br J
Anaesth 2010; 105:38-44.
65. Langeron O, Birenbaum A, Le Saché F, Raux M. Airway management in obese
patient. Minerva Anestesiol 2014; 80:382-392.
66. Swedish Association of Local Authorities and Regions. Municipalities, county
councils and regions. (Accessed 7 Mars 2016). Available from:
http://english.skl.se/municipalities_county_councils_and_regions
67. Bowden, J A., Green, P. Doing developmental phenomenography. Melbourne,
RMIT University Press. 2005.
68. Rosenstock C, Gillesberg I, Gatke MR, Levin D, Kristensen MS, Rasmussen
LS. Inter-observer agreement of tests used for prediction of difficult laryngo-
scopy/tracheal intubation. Acta Anaesthesiol Scand 2005; 49:1057-1062.
69. Naguib M, Scamman FL, O'Sullivan C, Aker J, Ross AF, Kosmach S, et al.
Predictive performance of three multivariate difficult tracheal intubation mod-
els: A double-blind, case-controlled study. Anesth Analg 2006; 102:818-824.

54
70. Polit, D.F. & Beck, C.T. Nursing research. Generating and Assessing Evidence
for Nursing Practice. 9th ed. Philadelphia: Lippincott Williams & Wilkins,
2012.
71. Krippendorff K. Content Analysis: An Introduction to its Methodology. 2nd ed.
Thousand Oaks, CA: Sage Publications, 2004.
72. Norman GR, Streiner DL. Biostatistic. The Bare Essentials, 3th ed. Canada: BC
Decker Inc., 2008.
73. Larsson J, Holmström I. Phenomenographic or phenomenological analysis: does
it matter? Examples from a study on anaesthesiologists’ work. Int J Qual Stud
Health Well-being 2007; 2: 55-64.
74. Graneheim UH, Lundman B. Qualitative content analysis in nursing research:
Concepts, procedures and measures to achieve trustworthiness. Nurse Educ
Today 2004; 24: 105-112.
75. Lincoln YS, Guba EG. Naturalistic Inquiry. Thousand Oaks, CA: Sage Publica-
tions Inc., 1985.
76. Swedish Codes of Statues (SFS). Law (2003:460). Ethical Review of Research
Involving Humans. (Accessed 7 Mars 2016) Available from:
http://www.riksdagen.se/sv/Dokument-
Lagar/Lagar/Svenskforfattningssamling/Lag-2003460-om-etikprovning_sfs-
2003-460/
77. Codex rules & guidelines for research. (Accessed 7 Mars 2016). Available
from: http://www.codex.vr.se/en/index.shtml
78. CODEX rules and guidelines for research. [Accessed 4 Mars 2016]. Available
from: http://www.wma.net/en/30publications/10policies/b3/
79. Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Gätke MR, Wetterslev J;
Danish Anaesthesia Database. A documented previous difficult tracheal intuba-
tion as a prognostic test for a subsequent difficult tracheal intubation in adults.
Anaesthesia 2009; 64:1081-1088.
80. The National Board of Health and Welfare. Socialstyrelsen. (Accessed 7 Mars
2016). Available from: http://www.socialstyrelsen.se/english
81. Rosenstock C, Østergaard D, Kristensen MS, Lippert A, Ruhnau B, Rasmussen
LS. Residents lack knowledge and practical skills in handling the difficult air-
way. Acta Anaesthesiol Scand 2004; 48:1014-1018.
82. Goldmann K, Braun U. Airway management practices at German university and
university-affiliated teaching hospitals-equipment, techniques and training: re-
sults of a nationwide survey. Acta Anaesthesiol Scand. 2006; 50:298-305.
83. Borges BC, Boet S, Siu LW, Bruppacher HR, Naik VN, Riem N, Joo HS. In-
complete adherence to the ASA difficult airway algorithm is unchanged after a
high-fidelity simulation session. Can J Anaesth 2010; 57:644-649.
84. Ebben RH, Vloet LC, Verhofstad MH, Meijer S, Mintjes-de Groot JA, van
Achterberg T. Adherence to guidelines and protocols in the prehospital and
emergency care setting: a systematic review. Scand J Trauma Resusc Emerg
Med. 2013 Feb 19; 21:9. doi: 10.1186/1757-7241-21-9.
85. Goldhaber-Fiebert SN, Howard SK. Implementing emergency manuals: can
cognitive aids help translate best practices for patient care during acute events?
Anesth Analg 2013; 117: 1149-1161.
86. Eldh AC, Vogel G, Söderberg A, Blomqvist H, Wengström Y. Use of evidence
in clinical guidelines and everyday practice for mechanical ventilation in Swed-
ish intensive care units. Worldviews Evid Based Nurs 2013; 10:198-207.
87. Polanyi M. The Tacit Dimension. London: Routledge & Kegan Paul, 1966

55
88. Buis ML, Maissan IM, Hoeks SE, Klimek M, Stolker RJ. Defining the learning
curve for endotracheal intubation using direct laryngoscopy: A systematic re-
view. Resuscitation 2016; 99: 63-71.
89. Dreyfus HL, Dreyfus SE. Mind over Machine: The Power of Human Intuition
and Expertise in the Era of the Computer. New York. 1986.
90. Boet S, Borges BC, Naik VN, Siu LW, Riem N, Chandra D, et al. Complex
procedural skills are retained for a minimum of 1 yr after a single high-fidelity
simulation training session. Br J Anaesth 2011; 107: 533-539.
91. Green M, Tariq R, Green P. Improving Patient Safety through Simulation Train-
ing in Anesthesiology: Where Are We? Anesthesiol Res Pract. 2016; doi:
10.1155/2016/4237523
92. Ford SR. Teamwork in anaesthetics and critical care is possible. Br J Anaesth
2015; 114:349.
93. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. Springer: New York,
1984.
94. Folkman S. Stress, coping and hope. Psychooncology 2010; 19:901-908.
95. Sundqvist AS, Carlsson AA. Holding the patient's life in my hands: Swedish
registered nurse anaesthetists' perspective of advocacy. Scand J Caring Sci
2014; 28: 281-288.
96. Karlsson AC, Ekebergh M, Mauléon AL, Almerud Österberg S."Is that my
leg?" patients' experiences of being awake during regional anesthesia and sur-
gery. J Perianesth Nurs 2012; 27:155-164.
97. Bolarinwa OA. Principles and methods of validity and reliability testing of
questionnaires used in social and health science researches. Niger Postgrad Med
J 2015; 22:195-201.
98. Tabachnick, B. G. & Fidell, L. S. Using multivariate statistics. 5th ed, Pearson
Education, Inc., 2007.
99. Lawal AK, Rotter T, Kinsman L, Machotta A, Ronellenfitsch U, Scott SD et al.
What is a clinical pathway? Refinement of an operational definition to identify
clinical pathway studies for a Cochrane systematic review. BMC Med. 2016;
doi: 10.1186/s12916-016-0580-z.
100. Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway?
Development of a definition to inform the debate. BMC Med. 2010. doi:
10.1186/1741-7015-8-31.
101. Marton F. Phenomenography- Describing conceptions of the world around us.
Instr Sci 1981; 10: 177-200.
102. Malterud K, Siersma VD, Guassora AD. Sample Size in Qualitative Interview
Studies: Guided by Information Power. Qual Health Res 2015:27; 1-8.
103. Kheterpal S, Healy D, Aziz MF, Shanks AM, Freundlich RE, Linton F et al.
Incidence, predictors, and outcome of difficult mask ventilation combined with
difficult laryngoscopy: a report from the multicentre perioperative outcomes
group. Anesthesiology 2013; 119:1360-1369.

56
Acta Universitatis Upsaliensis
Digital Comprehensive Summaries of Uppsala Dissertations
from the Faculty of Medicine 1205
Editor: The Dean of the Faculty of Medicine

A doctoral dissertation from the Faculty of Medicine, Uppsala

University, is usually a summary of a number of papers. A few
copies of the complete dissertation are kept at major Swedish
research libraries, while the summary alone is distributed
internationally through the series Digital Comprehensive
Summaries of Uppsala Dissertations from the Faculty of
Medicine. (Prior to January, 2005, the series was published
under the title “Comprehensive Summaries of Uppsala
Dissertations from the Faculty of Medicine”.)

ACTA
UNIVERSITATIS
UPSALIENSIS
Distribution: publications.uu.se UPPSALA
urn:nbn:se:uu:diva-281905 2016