Equipment for the difficult airway in obstetric units in Germany

Current practice of German anesthesiologists in airway management : Results of a national online survey

BACKGROUND

There is a worldwide consensus among experts that guidelines and algorithms on airway management contribute to improved patient safety in anesthesia. The present study aimed to determine the current practice of airway management of German anesthesiologists and assess the safety gap, defined as the difference between observed and recommended practice, amongst these practitioners.

OBJECTIVE

To determine the effect of implementing the guidelines on airway management practice in Germany amongst anesthesiologists and identify potential safety gaps.

METHODS

A survey was conducted in September 2019 by contacting all registered members of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) via email. The participants were asked about their personal and institutional background, adherence to recommendations of the current German S1 guidelines and availability of airway devices.

RESULTS

A total of 1862 DGAI members completed the questionnaire (response rate 17%). The main outcome was that anesthesiologists mostly adhered to the guidelines, yet certain recommendations, particularly pertaining to specifics of preoxygenation and training, showed a safety gap. More than 90% of participants had a video laryngoscope and half had performed more than 25 awake intubations using a flexible endoscope; however, only 81% had a video laryngoscope with a hyperangulated blade. An estimated 16% of all intubations were performed with a video laryngoscope, and 1 in 4 participants had performed awake intubation with it. Nearly all participants had cared for patients with suspected difficult airways. Half of the participants had already faced a "cannot intubate, cannot oxygenate" (CICO) situation and one in five had to perform an emergency front of neck access (eFONA) at least once. In this case, almost two thirds used puncture-based techniques and one third scalpel-based techniques.

CONCLUSION

Current practice of airway management showed overall adherence to the current German guidelines on airway management, yet certain areas need to be improved.

Rescue supraglottic airway devices at caesarean delivery: What are the options to consider?

Tracheal intubation is considered the gold standard means of securing the airway in obstetric general anaesthesia because of the increased risk of aspiration. Obstetric failed intubation is relatively rare. Difficult airway guidelines recommend the use of a supraglottic airway device to maintain the airway and to allow rescue ventilation. Failed intubation is associated with a further increased risk of aspiration, therefore there is an argument for performing supraglottic airway-guided flexible bronchoscopic intubation (SAGFBI). The technique of SAGFBI has a high success rate in the non-obstetric population, it protects the airway and it minimises task fixation on repeated attempts at laryngoscopic tracheal intubation. However, after failed intubation via laryngoscopy, there is a lack of specific recommendations or indications for SAGFBI in current obstetric difficult airway guidelines in relation to achieving tracheal intubation. Our narrative review explores the issues pertaining to airway management in these cases: the use of supraglottic airway devices and the techniques of, and technical issues related to, SAGFBI. We also discuss the factors involved in the decision-making process as to whether to proceed with surgery with the airway maintained only with a supraglottic airway device, or to proceed only after SAGFBI.

Difficult airway management resources and capnography use in Japanese intensive care units: a nationwide cross-sectional study

Purpose

The availability of difficult airway management (DAM) resources and the extent of capnometry use in Japanese intensive care units (ICUs) remained unclear. The purpose of this study was to clarify whether: (1) DAM resources were adequate, and (2) capnometry was routinely applied in Japanese ICUs.

Methods

This nationwide cross-sectional study was conducted from September 2015 to February 2016. All ICUs received a mailed questionnaire about their DAM resources and use of capnometry. Outcome measures were availability of: (1) 24-h in-house backup coverage; (2) a supraglottic airway device (SGA); (3) a dedicated DAM cart; and (4) surgical airway devices, and (5) routine use of capnometry to verify tube placement and for continuous monitoring of ventilator-dependent patients. The association between these outcomes and ICU type (academic, high-volume, closed, surgical) was also analyzed.

Results

Of the 289 ICUs, 196 (67.8 %) returned completed questionnaires. In-house backup coverage and surgical airway devices were highly available (89.3 and 95.9 %), but SGAs and dedicated DAM carts were not (60.2 and 60.7 %). The routine use of capnometry to confirm tube placement was reported by 55.6 % of the ICUs and was highest in closed ICUs (67.2 %, p = 0.03). The rate of continuous capnography monitoring was also 55.6 % and was highest in academic ICUs (64.5 %, p = 0.04).

Conclusion

In Japanese ICUs, SGAs and dedicated DAM carts were less available, and capnometry was not universally applied either to confirm tube placement, or for continuous monitoring of ventilated patients. Our study revealed areas in need of improvement.

Electronic supplementary material

The online version of this article (doi:10.1007/s00540-016-2176-3) contains supplementary material, which is available to authorized users.

Are prehospital airway management resources compatible with difficult airway algorithms? A nationwide cross-sectional study of helicopter emergency medical services in Japan

Purpose

Immediate access to the equipment required for difficult airway management (DAM) is vital. However, in Japan, data are scarce regarding the availability of DAM resources in prehospital settings. The purpose of this study was to determine whether Japanese helicopter emergency medical services (HEMS) are adequately equipped to comply with the DAM algorithms of Japanese and American professional anesthesiology societies.

Methods

This nationwide cross-sectional study was conducted in May 2015. Base hospitals of HEMS were mailed a questionnaire about their airway management equipment and back-up personnel. Outcome measures were (1) call for help, (2) supraglottic airway device (SGA) insertion, (3) verification of tube placement using capnometry, and (4) the establishment of surgical airways, all of which have been endorsed in various airway management guidelines. The criteria defining feasibility were the availability of (1) more than one physician, (2) SGA, (3) capnometry, and (4) a surgical airway device in the prehospital setting.

Results

Of the 45 HEMS base hospitals questioned, 42 (93.3 %) returned completed questionnaires. A surgical airway was practicable by all HEMS. However, in the prehospital setting, back-up assistance was available in 14.3 %, SGA in 16.7 %, and capnometry in 66.7 %. No HEMS was capable of all four steps.

Conclusion

In Japan, compliance with standard airway management algorithms in prehospital settings remains difficult because of the limited availability of alternative ventilation equipment and back-up personnel. Prehospital health care providers need to consider the risks and benefits of performing endotracheal intubation in environments not conducive to the success of this procedure.

Electronic supplementary material

The online version of this article (doi:10.1007/s00540-015-2124-7) contains supplementary material, which is available to authorized users.

Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new?

The purpose of this article is to review the fundamental aspects of obesity, pregnancy and a combination of both. The scientific aim is to understand the physiological changes, pathological clinical presentations and application of technical skills and pharmacological knowledge on this unique clinical condition. The goal of this presentation is to define the difficult airway, highlight the main reasons for difficult or failed intubation and propose a practical approach to management Throughout the review, an important component is the necessity for team work between the anaesthesiologist and the obstetrician. Certain protocols are recommended to meet the anaesthetic challenges and finally concluding with “what is new?” in obstetric anaesthesia.

National survey to assess the content and availability of difficult-airway carts in critical-care units in the United States

We have surveyed the availability of equipment, content of difficult-airway carts (DAC), and training in the use of such equipment in intensive-care units (ICU). We devised a set of proposals regarding what constitutes the ideal DAC. We surveyed 300 ICU in the United States. The survey was conducted to inquire about the presence and content of a DAC. Only 70% of respondents had a DAC in their unit. 82% of units surveyed checked the contents of the cart daily. 80% of directors were aware of its location. 80% of units had an attached list of contents and 51% had an attached algorithm for management of a difficult airway. LMA was present in 80% followed by 35 and 30% for Combitube and pre-assembled needle cricothyroidotomy set. Under non-invasive airway devices, video laryngoscope with 48% was ahead of fibreoptic bronchoscope (38%) and lighted stylet (15%). 80% of units had a CO₂-detection device immediately available. Limited data are available on the impact of DAC in airway management in the ICU. It is strongly recommended that a DAC be present. What constitutes the ideal contents of a DAC is open to questions. We hope discussion will lead to consensus of what should or should not be included on the cart.

Need for emergency surgical airway reduced by a comprehensive difficult airway program

BACKGROUND

Inability to intubate and ventilate patients with respiratory failure is associated with significant morbidity and mortality. A patient is considered to have a difficult airway if an anesthesiologist or other health care provider experienced in airway management is unable to ventilate the patient's lungs using bag-mask ventilation and/or is unable to intubate the trachea using direct laryngoscopy.

METHODS

We performed a retrospective review of a departmental database to determine whether a comprehensive program to manage difficult airways was associated with a reduced need to secure the airway surgically via cricothyrotomy or tracheostomy. The annual number of unplanned, emergency surgical airway procedures for inability to intubate and ventilate reported for the 4 yr before the program (January 1992 through December 1995) was compared with the annual number reported for the 11 yr after the program was initiated (January 1996 through December 2006).

RESULTS

The number of emergency surgical airways decreased from 6.5 +/- 0.5 per year for 4 yr before program initiation to 2.2 +/- 0.89 per year for the 11-yr period after program initiation (P < 0.0001). During the 4-yr period from January 1992 through December 1995, 26 surgical airways were reported, whereas only 24 surgical airways were performed in the subsequent 11-yr period (January 1996 through December 2006).

CONCLUSIONS

A comprehensive difficult airway program was associated with a reduction in the number of emergency surgical airway procedures performed for the inability of an anesthesiologist to intubate and ventilate, a reduction that was sustained over an 11-yr period. This decrease occurred despite an increase in the number of patients reported to have a difficult airway and an overall increase in the total number of patients receiving anesthesia per year.

Complications of obstetric anaesthesia

The present review addresses common and rare, but potentially severe complications of obstetric anaesthesia. Although several recent randomized and controlled studies on the prevention of spinal hypotension have been reported, the incidence of neurological complications caused by neuraxial blocks is estimated primarily from the results of retrospective investigations and case reports. In order to avoid potential risks in obstetrics, however, vigilance and close monitoring of the patient are critical. The adoption of published recommendations (e.g. those regarding regional techniques and coagulopathy, and difficult airway management) may help to improve the outcome for mother and child.

Airway management practices at German university and university-affiliated teaching hospitals--equipment, techniques and training: results of a nationwide survey

BACKGROUND

Until recently, Germany did not have national airway management guidelines. This survey collected comprehensive data on departmental airway management practices from German teaching institutions to identify weaknesses, and the results are presented here. German national airway guidelines were formulated by an expert group on the basis of these data and the current evidence in the literature.

METHODS

Questionnaires were mailed to the directors of 452 university and university-affiliated anaesthesia departments. They were asked to respond to 39 questions on the use of particular equipment and techniques, management of the difficult airway and training in airway management.

RESULTS

Two hundred and twelve questionnaires were returned. Many alternative devices for endotracheal intubation, such as the Bullard laryngoscope, the Bonfils laryngoscope and the Trachlight, are not used in the majority (80%) of departments. Thirty-six per cent of departments do not have difficult airway carts. No departmental difficult airway management plan is used in 22% of departments. Patients are not provided with written information on their personal airway management difficulties in 14% of departments. Structured training in the form of block rotation is offered in only 29-40% of departments. Although trainees perform fibreoptic intubation (FOI) in most departments, appropriate training in FOI is not available in some departments (8%).

CONCLUSION

There are deficits in various areas of airway management, in particular training and the use of algorithms. International guidelines and recommendations are not followed by a large number of German teaching institutions. The provision of German national airway guidelines should improve this situation.

Airway problems in pregnancy

OBJECTIVES

To provide a current review of the literature regarding airway problems in pregnancy and management.

BACKGROUND

Obstetrical anesthesia is considered to be a high-risk practice that exposes the anesthesiologist to increased medicolegal liability. Anesthetic management of a parturient is a challenge because it involves simultaneous care of both mother and baby. Failure to appropriately manage a difficult or failed intubation increases the risk of hypoxemic cardiopulmonary arrest and/or pulmonary aspiration, resulting in a high probability of maternal morbidity and mortality.

DATA

Anesthesia is the seventh leading cause of maternal mortality in the United States. Anatomic and physiologic changes during pregnancy place the parturient at increased risk for airway management problems. It is essential to perform a thorough preanesthetic evaluation and identify the factors predictive of difficult intubation. Airway devices such as the laryngeal mask airway, ProSeal, intubating laryngeal mask airway, Combitube, and laryngeal tube are described and have been used during failed intubation in pregnant patients.

CONCLUSION

Teamwork between an anesthesiologist and an obstetrician is absolutely essential for the safety of both the mother and baby. Most of us tend to agree that airway emergencies have a way of occurring at the worst possible times. It is essential that all anesthesia care practitioners must have a preconceived and well thought-out algorithm and emergency airway equipment to deal with airway emergencies during difficult or failed intubation of a parturient.

Airway problems in pregnancy

Obstetric anesthesia is considered to be a difficult, high-risk practice that exposes the anesthesiologist to increased medicolegal liability. Anesthetic management of parturient patients is a challenge, as it involves simultaneous care of two lives. The anesthesia practitioner has a duty to provide safe anesthetic care, including effective airway management when providing regional or general anesthesia. The potential need to manipulate the airway is perhaps the leading cause of concern among obstetric anesthesiologists.

Anaesthesiological airway management in Denmark: assessment, equipment and documentation

BACKGROUND

Failed intubation remains one cause of anaesthesia-related morbidity and mortality. In a recent survey in Denmark, 20% of respondents reported preventable mishaps in airway management.

METHODS

Assessment of the airway, and its documentation, as well as the availability of various equipment to manage a difficult airway, and the existence of a failed intubation plan were surveyed by mailing a questionnaire to the clinical directors of all 69 anaesthesia departments in Denmark.

RESULTS

Fifty-six departments (81%) returned the questionnaire. Pre-operative airway evaluation is performed in 90% of the departments. The tests included the mouth-opening test (77%), Mallampati score (48%), lower jaw protrusion (34%), neck mobility (63%), the measurement of the thyromental (11%) and sternomental distance (4%). The result of the tests are documented by 38% of the departments in the anaesthetic chart (96%), in the record (54%), on a card given to the patient (23%), in a letter sent to the patient's general practitioner (2%) or in a database (13%). The patients are personally informed in 82% of the departments. Only 54% of the departments have a failed intubation plan readily available.

CONCLUSION

The preoperative assessment of the airways and its documentation is still unsatisfactory, as is communicating with the patient after a case of a difficult/impossible intubation. The adoption of internationally recognized recommendations might improve airway management and teaching to the best standard possible in the already well-equipped Danish anaesthetic departments.

Difficult airway management practice patterns among anesthesiologists practicing in the United States: have we made any progress?

STUDY OBJECTIVE

To determine the extent instruction and practice in the use of airway devices and techniques varies among anesthesiologists practicing in the United States.

DESIGN

Survey questionnaire.

SETTING

University medical center.

MEASUREMENTS

Questionnaires were completed by American-trained anesthesiologists who attended the 1999 American Society of Anesthesiologists (ASA) Annual Meeting. Data collected included demographics, education, skills with airway devices/techniques, management of clinical difficult airway scenarios, and the use of the ASA Difficult Airway Algorithm.

MAIN RESULTS

1) DEMOGRAPHICS: 452 questionnaires were correctly completed; 62% attending anesthesiologists, 70% <50 years, 81% males, 44% from academic institutions, 63% >10 years of practice, 81% night duty, 77% board certified. 2) Education: 71% had at least one educational modality: difficult airway rotation, workshops, conferences, books, and simulators. 3) Skills: Miller blade 61%, Bullard laryngoscope 32%, LMA 86%, Combitube 43%, bougie 43%, exchangers 47%, cuffed oropharyngeal airway (COPA) 34%, retrograde 41%, transtracheal needle jet ventilation 34%, cricothyrotomy 21%, fiberoptics 59%, and blind nasal intubation 78%. The average reported use of special airway devices/techniques was 47.5%. 4) Management choices: failed intubation/ventilation: LMA (81%) and for all other situations: fiberoptic intubation. Use of ASA Difficult Airway Algorithm in clinical practice (86%).

CONCLUSION

Fiberoptic intubation and the LMA are most popular in management of the difficult airway.

Difficult airway management patterns among attending anaesthetists practising in Israel

BACKGROUND AND OBJECTIVE

In recent years, a large number of airway devices have been introduced into clinical practice as adjuncts to the management of the difficult airway. The purpose of this study was to evaluate the practices of Israeli anaesthetists in specific clinical situations and their familiarity with the use of a variety of airway devices and techniques.

METHODS

A survey developed in our institution was sent to 300 attending anaesthetists representing all board-certified anaesthetists practising in Israel.

RESULTS

Of the 153 respondents, 75% belonged to university hospitals. Ninety-six percent were skilled with laryngeal mask airways and 73% with fibreoptics. Seventy percent preferred regional anaesthesia with anticipated difficult intubation, continuation of anaesthesia with a laryngeal mask with failed intubation and a laryngeal mask for impossible mask ventilation. For the airway scenarios, awake fibreoptic, awake direct laryngoscopy, intubation under inhalation anaesthesia and tracheostomy were shared equally.

CONCLUSIONS

There is a high degree of adherence by Israeli anaesthetists to the American Society of Anesthesiologists' difficult airway algorithm. Current airway management practice patterns in Israel are presented.

Anaesthesia for non-scheduled caesarean delivery

In many countries there has been an increase in the number of women who deliver by caesarean section. This article reviews anaesthetic management of non-scheduled caesarean section. The choice of anaesthetic technique (regional anaesthesia versus general anaesthesia) is discussed and highlighted particularly from the viewpoint of urgency of operative delivery. A multidisciplinary approach is mandatory especially in emergency cases to prevent morbidity and mortality in mothers and neonates.