International Consensus Guidelines for Preventing Unrecognised Oesophageal Intubation. Free full text in @anaesjournal.bsky.social Supported by @dasairway.bsky.social @safeairwaysociety.org @asahq.bsky.social @rcoanews.bsky.social & many more… www.universalairway.org/puoi/support

The Safe Airway Liaison Group in the UK have released a statement on displaying the waveform capnography trace in line with the @universalairway.org recommendations. The CO2 trace should be: 1. The bottom trace 2. White 3. Shaded in www.salg.ac.uk/salg-publica...

The @universalairway.org guidelines for preventing unrecognised oesophageal intubation are supported by @safeairwaysociety.org, @anzca.bsky.social & @dasairway.bsky.social VL should be used routinely whenever feasible. Clinical signs should not be used to exclude oesophageal intubation.

🚨We have retired "no trace, wrong place" to align with PUMA guidelines. Instead, with @assocanaes.bsky.social and @dasairway.bsky.social, our message is that if sustained exhaled CO2 is not detected, then oesophageal intubation must be ruled out. See our dedicated webpage👉 ow.ly/vOZs50WA03r

3-step guide to mastering #HAVL from @cliffreid.bsky.social 1. Watch the video m.youtube.com/watch?v=aYo7... 2. Read the stepwise guide drive.google.com/file/d/14r_W... 3. Deliberate team practice (rinse & repeat)

International consensus guidelines for preventing unrecognised oesophageal intubation from @universalairway.org

The Project for Universal Management of Airways (PUMA) will no longer post on Twitter. Join us #Xodus

Airway assistant (ala airway ally) litfl.com/airway-assis... the forgotten role in airway management in ED, ICU, and the wards… but an important one! #foamed #foamcc

Unrecognised esophageal intubation litfl.com/unrecognised... Largely derived from the superb PUMA guidelines by @chrimesy.com et al #foamed #foamcc

Key points: 1. ALWAYS confirm criteria for sustained exhaled CO2 are satisfied. 2. NEVER use clinical signs to exclude oesophageal intubation 3. The fastest, simplest & most definitive way to exclude oesophageal intubation is to remove the tube AND ventilate with an alternate device.

Organisations supporting the 'Consensus guidelines for preventing unrecognised oesophageal intubation' incl both @anzca.bsky.social and @rcoanews.bsky.social. Guidelines free full text in @anaesjournal.bsky.social: associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/...

But do patients at risk of aspiration need “a tube stuck in quickly”? It’s unlikely there’s actually a proportional incr in asp risk the longer the airway is unprotected. I’d suggest that regurg/asp mainly occurs w change in m tone at induction or w instrumentation while inadeq anaesthetised/relaxed

Aren’t there already things we would do when extubating a patient at incr risk of aspiration? Rather than being ‘rapid’ they relate to ensuring return of airway reflexes prior to removing tube (awake), potentially decreasing risk of regurg (gastric suction) & aspiration (lat position).

But what are the elements of intubation technique you’d encourage to reduce aspiration risk & do any of them relate to the components of RSI? I’d suggest that it’s more important that a patient is deeply anaesthetised/paralysed before the airway is instrumented than anything relating to rapidity.

Background reading for this week’s debate - this excellent editorial by @sthjournalclub.bsky.social & Craig Lyons in @anaesjournal.bsky.social associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/epdf/10....

Should we use universal videolaryngoscopy in real-world operating theatre settings? YES! ↑ rate of easy intubation ↑ rate successful first-attempt intubation ↓ incidence of difficult laryngoscopy ↓ complications related to intubation #AnSky #AirwaySky #MedSky doi.org/10.1111/anae...

In adult patients undergoing tracheal intubation in real-world operating theatre settings, universal VL showed clear advantages over direct laryngoscopy. This is the largest comparative analysis conducted to date! #AnSky #AirwaySky #MedSky doi.org/10.1111/anae...

Brilliant, provocative editorial from @sthjournalclub.bsky.social & Craig Lyons. While cricoid has been vilified out of existence in some areas by the EBM zealots, there's no evidence for benefit of any other aspect of RSI. Conversely CV compromise & use of rapid-onset NMBAs may cause harm.

Important paper on Airway Leads and implementing comprehensive airway quality improvement process in the Emergency Department from @emcrit.bsky.social Whether or not you agree w the specific interventions, this should be the template for all airway management programs.

Thio sux is the only classic (but I've never seen it done one, hence all being mRSI). I think otherwise it ought to be fast acting hypnotic and 1/kg or more of sux or roc. Opioids seem reasonable but I'd be worried about that being your sole "relaxant" I love www.universalairway.org/rsi above

For exactly this reason the @universalairway.org guidelines have removed the term “modified RSI” in favour of a defined spectrum of variations that constitute RSI. Anything outside this is not RSI. www.universalairway.org/rsi

It’s extraordinary that this is a case report in 2025. It’s like publishing a case of a CVC wire being lost intravascularly in which the authors conclude that it might be a good idea to always hold onto the wire.

“At least seven respondents reported in the free text comments that UOI could not happen to a competent anaesthetist and that further training was therefore not warranted” In my experience, the greatest barrier to uptake of the PUOI guidelines is getting clinicians to recognise they need them.

But I'm sure you'd agree that's clearly outdated & something the majority of clinicians would disagree with. In the @universalairway.org guidelines we've defined RSI based on a spectrum of practice that adheres to specific principles. www.universalairway.org/rsi

The term "TIVA RSI" misrepresents the issue. All RSIs are IV. Whether it's a TIVA anaesthetic depends on whether the subseq maintenance agent is inhaled or IV (& irrelevant to the process of RSI). The question is whether IV induction agents should be administered by an infusion pump during RSI.

I underwent explainaesthesia this week and emerged knowing a LOT more about hyperangulated videolaryngoscopy thanks to @chrimesy.com youtu.be/aYo7kqu9QpA

Tim Cook heads up the charge to change from no trace=wrong place to sustained exhaled carbon dioxide as per Puma Guidelines @rcoanews.bsky.social #airwayleads

Some anaesthetists now documenting ET Co2 x 7 on our anaesthetic charts to demonstrate following of guidelines

@chrimesy.com @safeairwaysociety.org is the source of my teaching today. Great video on HAVL youtu.be/biHmn-q9HSw?... #ansky

The PUMA guidelines for prevention of oesophageal intubation are supported by -RCOA -AoA -FICM -ICS -CODP -DAS This is true of no other airway guidance I am aware of & make them the de facto UK National guidance associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/...

Seven breaths prevent death. A few months ago I did a grade 1, POGO 100% intubation with a VL. But on ventilation it didn’t feel right. Inflated the cuff a bit more. Still not right. Looked at ETCO2 trace, not right - low peaks. Tube out, reintubated. All good. 7 breaths prevent death.

Time to retire ‘no trace, wrong place’ @doctimcook.bsky.social Many UOI do have ‘a trace’ It is all about sustained exhaled carbon dioxide @universalairway.org

Standardising capnograph & other monitoring also recommended by PUMA. associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/... 3 important points re capnograph specified in SALG recommendations. www.salg.ac.uk/salg-publica...

Earlybird registration now open for #SAS2025Noosa the Safe Airway Society’s annual meeting Fri 12th Sep: PM workshops (optional) Sat 13th Sep: Full day interactive plenaries More info & registration: www.safeairwaysociety.org/eventdetails...