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Renew JR, Fouda EA, Mordecai DM, Huxhold AN, Logvinov II, Heckman MG, Torp KD. Early supraglottic airway versus facemask ventilation before tracheal intubation to facilitate ventilation in high-risk patients: A prospective randomised trial. Eur J Anaesthesiol 2024; 41:707-711. [PMID: 38953177 DOI: 10.1097/eja.0000000000002030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Affiliation(s)
- J Ross Renew
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, Florida, USA (JRR, EAF, DMM, ANH, IIL, KDT), Health Science Research, Mayo Clinic, Jacksonville, Florida, Mayo Clinic, Rochester, Minnesota, USA (MGH)
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Wong P, Sleigh JW. Airway management of lingual tonsillar hypertrophy: A narrative review. Anaesth Intensive Care 2024; 52:16-27. [PMID: 38006611 DOI: 10.1177/0310057x231196910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
Lingual tonsillar hypertrophy is rarely identified on routine airway assessment but may cause difficulties in airway management. We conducted a narrative review of case reports of lingual tonsillar hypertrophy to examine associated patient factors, success rates of airway management techniques and complications. We searched the literature for anaesthetic management of cases with lingual tonsillar hypertrophy. We found 89 patients in various case reports, from which we derived 92 cases to analyse. 64% of cases were assessed as having a normal airway. Difficult and impossible face mask ventilation occurred in 29.6% and 1.4% of cases, respectively. Difficult intubation and failed intubation occurred in 89.1% and 21.7% of cases, respectively. Multiple attempts (up to six) at intubation were performed, with no successful intubation after the third attempt with direct laryngoscopy. Some 16.5% of patients were woken up and 4.3% required emergency front of neck access. Complications included oesophageal intubation (10.9%), bleeding (9.8%) and severe hypoxia (3.2%). Our findings show that severe cases of lingual hypertrophy may cause an unanticipated difficult airway and serious complications, including hypoxic brain damage and death. A robust airway strategy is required which includes limiting the number of attempts at laryngoscopy, and early priming and performance of emergency front of neck access if required. In patients with known severe lingual tonsillar hypertrophy, awake intubation should be considered.
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Affiliation(s)
- Patrick Wong
- Department of Anaesthesia and Pain Medicine, Te Whatu Ora Health New Zealand Waikato, Hamilton, New Zealand
| | - Jamie W Sleigh
- Waikato Clinical Campus, University of Auckland, Hamilton, New Zealand
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Lenhardt R, Akca O, Obal D, Businger J, Cooke E. Nasopharyngeal Ventilation Compared to Facemask Ventilation: A Prospective, Randomized, Crossover Trial in Two Different Elective Cohorts. Cureus 2023; 15:e39049. [PMID: 37323341 PMCID: PMC10266899 DOI: 10.7759/cureus.39049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Facemask ventilation is routinely used to preoxygenate patients before endotracheal intubation during anesthesia induction or to secure ventilation in patients with respiratory insufficiency. Occasionally, facemask ventilation cannot be performed adequately. The placement of a regular endotracheal tube through the nose into the hypopharynx may be a valid alternative to improve ventilation and oxygenation before endotracheal intubation (nasopharyngeal ventilation). We tested the hypothesis that nasopharyngeal ventilation is superior in its efficacy compared to traditional facemask ventilation. METHODS In this prospective, randomized, crossover trial, we enrolled surgical patients requiring either nasal intubation (cohort #1, n = 20) or patients who met "difficult to mask ventilate" criteria (cohort #2, n = 20). Patients in each cohort were randomly assigned to receive pressure-controlled facemask ventilation followed by nasopharyngeal ventilation or vice versa. The ventilation settings were kept constant. The primary outcome was tidal volume. The secondary outcome was the difficulty of ventilation, measured using the Warters grading scale. RESULTS Tidal volume was significantly increased by nasopharyngeal ventilation in cohort #1 (597 ± 156 ml vs.462 ± 220 ml, p = 0.019) and cohort #2 (525 ± 157 ml vs.259 ± 151 ml, p < 0.01). Warters grading scale for mask ventilation was 0.6 ± 1.4 in cohort #1, and 2.6 ± 1.5 in cohort #2. CONCLUSION Patients at risk for difficult facemask ventilation may benefit from nasopharyngeal ventilation to maintain adequate ventilation and oxygenation before endotracheal intubation. This ventilation mode may offer another option for ventilation at induction of anesthesia and during the management of respiratory insufficiency, especially in the setting of "unexpected" ventilation difficulty.
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Affiliation(s)
| | - Ozan Akca
- Anesthesiology, Johns Hopkins University, Baltimore, USA
| | - Detlef Obal
- Anesthesiology, Stanford University, Stanford, USA
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Laferrière-Langlois P, Dion A, Guimond É, Nadeau F, Gagnon V, D'Aragon F, Sansoucy Y, Colas MJ. A randomized controlled trial comparing three supraglottic airway devices used as a conduit to facilitate tracheal intubation with flexible bronchoscopy. Can J Anaesth 2023; 70:851-860. [PMID: 37055702 DOI: 10.1007/s12630-023-02444-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 11/02/2022] [Accepted: 11/02/2022] [Indexed: 04/15/2023] Open
Abstract
PURPOSE Once difficult ventilation and intubation are declared, guidelines suggest the use of a supraglottic airway (SGA) as a rescue device to ventilate and, if oxygenation is restored, subsequently as an intubation conduit. Nevertheless, few trials have formally studied recent SGA devices in patients. Our objective was to compare the efficacy of three second-generation SGA devices as conduits for bronchoscopy-guided endotracheal intubation. METHODS In this prospective, single-blinded three-arm randomized controlled trial, patients with an American Society of Anesthesiologists Physical Status of I-III undergoing general anesthesia were randomized to bronchoscopy-guided endotracheal intubation using AuraGain™, Air-Q® Blocker, or i-gel® devices. We excluded patients with contraindications to an SGA or drugs and who were pregnant or had a neck, spine, or respiratory anomaly. The primary outcome was intubation time, measured from SGA circuit disconnection to CO2 measurement. Secondary outcomes included ease, time, and success of SGA insertion; success of intubation on first attempt; overall intubation success; number of attempts to intubate; ease of intubation; and ease of SGA removals. RESULTS One hundred and fifty patients were enrolled from March 2017 to January 2018. Median intubation times were similar across the three groups (Air-Q Blocker, 44 sec; AuraGain, 45 sec; i-gel, 36 sec; P = 0.08). The i-gel was faster to insert (i-gel: 10 sec; Air-Q Blocker, 16 sec; AuraGain, 16 sec; P < 0.001) and easier to insert (Air-Q Blocker vs i-gel, P = 0.001; AuraGain vs i-gel, P = 0.002). Success of SGA insertion, success of intubation, and number of attempts were similar. The Air-Q Blocker was easier to remove than the i-gel (P < 0.001). CONCLUSION All three second-generation SGA devices performed similarly regarding intubation. Despite minor benefits of the i-gel, clinicians should select their SGA based on clinical experience. STUDY REGISTRATION ClinicalTrials.gov (NCT02975466); registered on 29 November 2016.
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Affiliation(s)
- Pascal Laferrière-Langlois
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Centre intégré universitaire de santé et services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Sherbrooke, QC, Canada.
- Department of Anesthesiology and Pain Medecine, Hôpital Maisonneuve-Rosemont, Centre hospitalier universitaire de Montréal, Montreal, QC, Canada.
| | - Alexandre Dion
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Centre intégré universitaire de santé et services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Sherbrooke, QC, Canada
| | - Éric Guimond
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Centre intégré universitaire de santé et services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Sherbrooke, QC, Canada
| | - Fannie Nadeau
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Centre intégré universitaire de santé et services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Sherbrooke, QC, Canada
| | - Véronique Gagnon
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Centre intégré universitaire de santé et services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Sherbrooke, QC, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Centre intégré universitaire de santé et services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Sherbrooke, QC, Canada
- Department of Anesthesiology and Pain Medecine, Hôpital Maisonneuve-Rosemont, Centre hospitalier universitaire de Montréal, Montreal, QC, Canada
- Centre de recherche clinique du CHUS, Sherbrooke, QC, Canada
| | - Yanick Sansoucy
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Centre intégré universitaire de santé et services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Sherbrooke, QC, Canada
| | - Marie-José Colas
- Department of Anesthesiology, Faculty of Medicine and Health Sciences, Centre intégré universitaire de santé et services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie-CHUS), Sherbrooke, QC, Canada
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Garcia-Marcinkiewicz AG, Lee LK, Haydar B, Fiadjoe JE, Matava CT, Kovatsis PG, Peyton J, Stein ML, Park R, Taicher BM, Templeton TW. Difficult or impossible facemask ventilation in children with difficult tracheal intubation: a retrospective analysis of the PeDI registry. Br J Anaesth 2023:S0007-0912(23)00122-8. [PMID: 37076335 DOI: 10.1016/j.bja.2023.02.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Difficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation. METHODS We queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed. RESULTS The incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening. CONCLUSIONS Certain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.
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Affiliation(s)
| | - Lisa K Lee
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
| | - Bishr Haydar
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - John E Fiadjoe
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Clyde T Matava
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - James Peyton
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Mary L Stein
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Raymond Park
- Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital of Boston, Boston, MA, USA; Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
| | - Brad M Taicher
- Department of Anesthesiology, Duke Children's Hospital & Health Center, Durham, NC, USA
| | - Thomas W Templeton
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Lim KS, Nielsen JR, Piekarski F, Gerth AM, Zhong G. What airway management information do anaesthetic charts prompt for? An audit of charts from 132 hospitals across Australia and New Zealand. Anaesth Intensive Care 2023; 51:43-50. [PMID: 36217287 DOI: 10.1177/0310057x221099033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Anaesthetists can make safer airway plans if they know which airway techniques worked previously and which ones did not. Anaesthetic charts do not always capture this information, however, and guidelines from the Australian and New Zealand College of Anaesthetists do not specify what details on airway management they should include. To assess how anaesthetic charts support airway documentation, we audited the airway management section of blank charts from 132 hospitals accredited for training by the Australian and New Zealand College of Anaesthetists. We evaluated charts for the presence of 17 clinically important data fields describing tracheal intubation, supraglottic airway use and bag-mask ventilation. Our audit revealed that data fields on anaesthetic charts focus more on tracheal intubation than bag-mask ventilation or supraglottic airway use. Nearly all charts (99%) had prompts for intubation and most had prompts for both operator technique and patient outcome. For supraglottic airway use, 95% of charts had at least one data field, but few had prompts for difficulty or outcome. For bag-mask ventilation, 58% of charts had a data field for difficulty but most of these were subjective; few (1.5%) included any outcome measures. Data fields describing bag-mask ventilation and supraglottic airway use were also inconsistent. In summary, data fields on Australian and New Zealand anaesthetic charts focus on tracheal intubation with consistent prompts for both operator method and outcome. The inclusion of fields for outcome and difficulty of bag-mask ventilation and supraglottic airway use could help clinicians make better records of airway management.
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Affiliation(s)
- Kar-Soon Lim
- Department of Anaesthesia and Pain Management, 2659Concord Repatriation General Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - James R Nielsen
- Department of Anaesthesia and Pain Management, 2659Concord Repatriation General Hospital, Sydney, Australia
| | - Florian Piekarski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Alice M Gerth
- Department of Anaesthesia, Cambridge University Hospital, Cambridge, UK
| | - George Zhong
- Department of Anaesthesia and Pain Management, 2659Concord Repatriation General Hospital, Sydney, Australia
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Diagnostic Efficacy and Clinical Value of Ultrasonography in Difficult Airway Assessment: Based on a Prospective Cohort Study. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4706438. [PMID: 36082062 PMCID: PMC9433204 DOI: 10.1155/2022/4706438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/06/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022]
Abstract
Objective. A case-control study was conducted to explore the diagnostic efficacy and clinical value of ultrasound in difficult airway assessment. Methods. A total of 220 patients undergoing elective surgery under general anesthesia were prospectively enrolled in our hospital from April 2018 to April 2021. General data were collected one day before operation, including sex, age, height, weight, body mass index (BMI), modified Mallampati test (MMT), inter-incisor distance (IID) and thyromental distance (TMD), the upper lip bite test (ULBT), and thyromental height (TMH). DSH, DSE, DSV, HMD, and tongue width and thickness were measured by ultrasound in the supine position before anesthesia induction on the day of operation. The above data were measured by the same anesthesiologist. After anesthesia, the patients were exposed to laryngoscope by the same senior doctor who did not participate in the data analysis, and the Cormack–Lehane (CL) grade was recorded and endotracheal intubation was completed. The relationship between DSE, DSH, DSV, HMD, and tongue width and thickness and laryngoscope exposure difficulty and tracheal intubation difficulty was analyzed. The critical value of each index for predicting laryngoscope exposure difficulty and tracheal intubation difficulty was obtained by the receiver operating characteristic curve (ROC) and Jordan index. According to the critical value, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of each index were calculated. Results. On comparing the general conditions of the four groups, this study prospectively included 220 patients undergoing elective surgery under general anesthesia for tracheal intubation in our hospital from April 2018 to April 2021, of which 8 cases were excluded from the study because of loss of incisors, 5 cases were excluded from the study due to unclear development of the anterior vocal cords under ultrasound, 7 cases were excluded from the study, and finally 200 patients were included in the study, including 104 males and 96 females. Among the 200 patients, difficult laryngoscope exposure was found in 26 cases (13.00%) and difficult tracheal intubation in 17 cases (8.50%). Tracheal intubation was performed in 17 patients with a visual laryngoscope and light rod, respectively. The weight and BMI of patients in the DL group were higher than in the NDL group, and the difference was statistically significant (
); the weight and BMI of patients in the DI group were higher than in the NDI group, and the difference was statistically significant (
); there was no significant difference in sex, age, and height between the DL group and the NDL group and the DI group and the NDI group (
). Compared with the NDL group, IID, TMD, and TMH in the DL group were lower, and the difference was statistically significant (
); there was no significant difference in ULBT (
). DSE, DSH, and DSV were higher than in the NDL group, and the difference was statistically significant (
), the HMD was lower than in the NDL group, and the difference was statistically significant (
);the width and thickness of tongue were higher than in the NDL group, and the difference was statistically significant (
). On comparing the DI NDI groups, the IID, TMD, and TMH in group DI were lower than in group NDI, and the difference was statistically significant (
), but there was no significant difference in ULBT (
); DSE, DSH, and DSV were higher than in the NDI group, and the difference was statistically significant (
); the HMD was lower than in the NDI group, and the difference was statistically significant (
); the width and thickness of tongue were higher than in the NDL group, and the difference was statistically significant (
). The AUC of BMI, TMH, DSE, DSV, HMD, and tongue width and thickness all ranged from 0.70 to 0.9. Laryngoscope exposure difficulty diagnostic value was medium. The AUC of TMD, MMT, ULBT, IID, and DSH ranged from 0.5 to 0.7. The diagnostic value of laryngoscope exposure difficulty was low. According to the ROC curve, the AUC value of HMD, DSE, and tongue thickness in ultrasonic indicators was higher than that of traditional indicators and the AUC value of TMH was the highest in traditional indicators. When the HMD cutoff value was 5.29 cm; the accuracy, sensitivity, specificity, PPV, and NPV were 73.6%, 96.7%, 71.6%, 31.8%, and 97.4%, respectively. Compared with tongue width, tongue thickness has a better predictive performance. The accuracy of DSH, DSV, DSE, and tongue width and thickness in predicting difficult laryngoscope exposure was lower than HMD and the difference was statistically significant (
). The patients in the DI and NDI groups indicated that the AUC of ULBT, TMD, and IID was between 0.5 and 0.7, the diagnostic values of BMI, MMT, TMH, DSE, DSH, DSV, HMD, and tongue width and thickness were between 0.7 and0.9, and the diagnostic value for tracheal intubation difficulty was moderate. According to the ROC curve, HMD, DSE, and tongue thickness in ultrasonic indexes were higher compared to traditional indexes. Among the traditional indexes, the AUC value of TMH is the largest. In ultrasonic indexes, when the critical value of HMD DSE is 4.85 cm, the AUC value is 0.893, and its accuracy, sensitivity, specificity, PPV, and NPV are 81.6%, 93.8%, 80.6%, 30.2%, and 99.5%, respectively. In ultrasonic indexes, the prediction performance is better, followed by the tongue thickness prediction performance. The accuracy of DSH, DSV, DSE, and tongue width and thickness in predicting difficult tracheal intubation was lower than in HMD, and the difference was statistically significant (
). Conclusion. Ultrasonic measurements such as DSH, DSE, DSV, HMD, and tongue width and thickness have predictive value for difficult airway;when the ultrasonic measurement of HMD is ˂5.29 cm, we should pay attention to the difficulty of laryngoscope exposure, and when DSE is ˂4.85 cm, we should watch out for difficult tracheal intubation. In terms of other ultrasound indexes, HMD is more valuable in predicting difficult airway.
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Rosenblatt WH, Yanez ND. A Decision Tree Approach to Airway Management Pathways in the 2022 Difficult Airway Algorithm of the American Society of Anesthesiologists. Anesth Analg 2022; 134:910-915. [PMID: 35171880 PMCID: PMC8986631 DOI: 10.1213/ane.0000000000005930] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The American Society of Anesthesiologists’ (ASA) Task Force on Management of the Difficult Airway has developed a decision tree tool that uses inductive assessments to guide the anesthesiologist’s choice of pathway in the ASA’s Difficult Airway Algorithm. The tool prompts the anesthesiologist to consider the risk of difficulty with laryngoscopy (direct or indirect) and tracheal intubation, facemask or supraglottic ventilation, gastric contents aspiration, and rapid oxyhemoglobin desaturation. For every airway management event, the approach integrates the anesthesiologist’s unique combination of experience, expertise, patient anatomy and disease, equipment availability, and other contextual conditions into the decision process. Entry into the awake intubation pathway is encouraged when the patient is judged at risk of difficult tracheal intubation and one or more of the following: difficult ventilation, significant aspiration risk, and/or rapid oxyhemoglobin desaturation. The decision tree tool is anticipated to improve communication between anesthesiologists and others by clearly identifying those factors of concern and how decision-making is affected by those concerns.
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Affiliation(s)
- William H Rosenblatt
- From the Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
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9
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Reardon RF, Robinson AE, Kornas R, Ho JD, Anzalone B, Carlson J, Levy M, Driver B. Prehospital Surgical Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:96-101. [PMID: 35001821 DOI: 10.1080/10903127.2021.1995552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Bag-valve-mask ventilation and endotracheal intubation have been the mainstay of prehospital airway management for over four decades. Recently, supraglottic device use has risen due to various factors. The combination of bag-valve-mask ventilation, endotracheal intubation, and supraglottic devices allows for successful airway management in a majority of patients. However, there exists a small portion of patients who are unable to be intubated and cannot be adequately ventilated with either a facemask or a supraglottic airway. These patients require an emergent surgical airway. A surgical airway is an important component of all airway algorithms, and in some cases may be the only viable approach; therefore, it is imperative that EMS agencies that are credentialed to manage airways have the capability to perform surgical airways when appropriate. The National Association of Emergency Medical Services Physicians (NAEMSP) recommends the following for emergency medical services (EMS) agencies that provide advanced airway management.A surgical airway is reasonable in the prehospital setting when the airway cannot be secured by less invasive means.When indicated, a surgical airway should be performed without delay.A surgical airway is not a substitute for other airway management tools and techniques. It should not be the only rescue option available.Success of an open surgical approach using a scalpel is higher than that of percutaneous Seldinger techniques or needle-jet ventilation in the emergency setting.
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10
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Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022; 136:31-81. [PMID: 34762729 DOI: 10.1097/aln.0000000000004002] [Citation(s) in RCA: 364] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.
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Duggan LV. In a forest of airway guidelines, it's time to make a shared path. Can J Anaesth 2021; 68:1324-1330. [PMID: 34231131 DOI: 10.1007/s12630-021-02058-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 05/18/2021] [Accepted: 05/25/2021] [Indexed: 12/19/2022] Open
Affiliation(s)
- Laura V Duggan
- Department of Anesthesiology and Pain Medicine, Ottawa Civic Hospital, University of Ottawa, Ottawa, ON, Canada.
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12
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Duggan LV, El-Boghdadly K. The importance of prospective observational studies in airway management: yet only the first step. Anaesthesia 2021; 76:1555-1558. [PMID: 34189730 DOI: 10.1111/anae.15538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 12/15/2022]
Affiliation(s)
- L V Duggan
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
| | - K El-Boghdadly
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
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13
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Abstract
Purpose of Review This paper will evaluate the recent literature and best practices in airway management in critically ill patients. Recent Findings Cardiac arrest remains a common complication of intubation in these high-risk patients. Patients with desaturation or peri-intubation hypotension are at high risk of cardiac arrest, and each of these complications have been reported in up to half of all intubations in critically ill patient populations. Summary There have been significant advances in preoxygenation and devices available for performing laryngoscopy and rescue oxygenation. However, the risk of cardiovascular collapse remains concerningly high with few studies to guide therapeutic maneuvers to reduce this risk.
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Wang M, Argalious M. Laryngeal Mask Airway-SupremeTM (LMAS) in elective non-cardiac surgery: towards a more accurate quantification of difficult placement. Minerva Anestesiol 2021; 87:502-504. [PMID: 33853275 DOI: 10.23736/s0375-9393.21.15633-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Mi Wang
- Department of General Anesthesiology, Anesthesiology Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Maged Argalious
- Department of General Anesthesiology, Anesthesiology Institute, The Cleveland Clinic, Cleveland, OH, USA -
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15
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Cho HY, Shin S, Lee S, Yoon S, Lee HJ. Analysis of endotracheal intubation-related judicial precedents in South Korea. Korean J Anesthesiol 2021; 74:506-513. [PMID: 33761583 PMCID: PMC8648513 DOI: 10.4097/kja.21020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/21/2021] [Indexed: 02/07/2023] Open
Abstract
Background Medical malpractice during endotracheal intubation can result in catastrophic complications. However, there are no reports on these severe complications in South Korea. We aimed to investigate the severe complications associated with endotracheal intubation occurring in South Korea, via medicolegal analysis. Methods We retrospectively analyzed the closed judicial precedents regarding complications related to endotracheal intubation lodged between January 1994 and June 2020, using the database of the Supreme Court of Korea. We collected clinical and judicial characteristics from the judgments and analyzed the medical malpractices related to endotracheal intubation. Results Of 220 potential cases, 63 were included in the final analysis. The most common event location was the operating room (n = 20, 31.7%). All but 3 cases were associated with significant permanent or more severe injury, including 31 deaths. The most common problems were failed or delayed intubation (n = 56, 88.9%). Supraglottic airway device was used in 5.2% (n = 3) cases of delayed or failed intubation. Fifty-one (81%) cases were ruled in favor of the plaintiff in the claims for damages, with a median payment of Korean Won 133,897,845 (38,000,000, 308,538,274). The most common malpractice recognized by the court was that of not attempting an alternative airway technique (n = 32, 50.8%), followed by violation of the duty of explanation (n = 10, 15.9%). Conclusions Our results could increase physicians’ awareness of the major complications related to endotracheal intubation and help ensure patient safety.
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Affiliation(s)
- Hye-Yeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - SuHwan Shin
- Department of Medical Law and Ethics, Graduate School, Yonsei University, Seoul, Korea
| | - SangJin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
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16
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DI Filippo A, Adembri C, Paparella L, Esposito C, Tofani L, Perez Y, DI Giacinto I, Micaglio M, Sorbello M. Risk factors for difficult Laryngeal Mask Airway LMA-Supreme™ (LMAS) placement in adults: a multicentric prospective observational study in an Italian population. Minerva Anestesiol 2021; 87:533-540. [PMID: 33591142 DOI: 10.23736/s0375-9393.20.15001-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Supraglottic airway devices (SADs) are precious tools for airway management in both routine and rescue situations; few studies have analyzed the risk factors for their difficult insertion. METHODS The aim of this study was to identify the risk factors for difficult insertion for a specific SAD, the Laryngeal Mask Airway LMA-Supreme™ (LMAS). This was a prospective multicentric observational study on a cohort of Italian adult patients receiving general anesthesia for elective surgery. The possible causes of difficulty in LMAS placement (difficulty in insertion or unsatisfactory ventilation) were identified based on literature and on the opinion of international airway management experts. A dedicated datasheet was prepared to collect patients' data, including anthropometric-parameters and parameters for the prediction of difficult airway management, as well as technical choices for the use of LMAS. Data were analyzed to discover the risk factors for difficult LMAS placement and the association between each risk factor and the proportion of incorrect positioning was evaluated through the relative risk and its confidence interval. RESULTS Four hundred thirty-two patients were enrolled; seventy required two or more attempts to insert the LMAS; nine required a change of strategy. At multivariate analysis, the following factors were significantly associated with difficult LMAS placement: Mallampati III-IV with either phonation or not; inter-incisor distance < 3 cm; reduced neck mobility; no administration of neuromuscular blocking agents (NMBAs). CONCLUSIONS The alignment of the laryngeal and pharyngeal axes seems to facilitate the procedure, together with NMBA administration; on the contrary, Mallampati grade III-IV are associated with difficult LMAS placement.
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Affiliation(s)
- Alessandro DI Filippo
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy.,Careggi University Hospital, Florence, Italy
| | - Chiara Adembri
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy - .,Careggi University Hospital, Florence, Italy
| | | | - Clelia Esposito
- Department of Anesthesiology, Resuscitation and Postoperative Intensive Care, AORN Ospedali dei Colli, Naples, Italy
| | - Lorenzo Tofani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Ylenia Perez
- Section of Anesthesiology and Intensive Care, Department of Health Sciences, University of Florence, Florence, Italy
| | - Ida DI Giacinto
- Department of Organ Failure and Transplantation, St.Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Massimiliano Sorbello
- Anestesiology and Intensive Care Unit, Vittorio Emanuele San Marco University Hospital, Catania, Italy
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17
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18
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Wong P, Lim WY. Aligning difficult airway guidelines with the anesthetic COVID-19 guidelines to develop a COVID-19 difficult airway strategy: a narrative review. J Anesth 2020; 34:924-943. [PMID: 32642840 PMCID: PMC7341705 DOI: 10.1007/s00540-020-02819-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 06/20/2020] [Indexed: 12/17/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is caused by a coronavirus that is transmitted primarily via aerosol, droplets or direct contact. This may place anesthetists at higher risk of infection due to their frequent involvement in aerosol-generating airway interventions. Many anesthethetic COVID-19 guidelines have emerged, whose underlying management principles include minimizing aerosol contamination and protecting healthcare workers. These guidelines originate from Australia and New Zealand, Canada, China, India, Italy, Korea, Singapore, the United States and the United Kingdom. Hospitalized COVID-19 patients may require airway interventions, and difficult tracheal intubation secondary to laryngeal edema has been reported. Pre-pandemic difficult airway guidelines include those from Canada, France, Germany, India, Japan, Scandinavia, the United States and the United Kingdom. These difficult airway guidelines require modifications in order to align with the principles of the anesthetic COVID-19 guidelines. In turn, most of the anesthetic COVID-19 guidelines do not, or only briefly, discuss an airway strategy after failed tracheal intubation. Our article identifies and compares pre-pandemic difficult airway guidelines with the recent anesthetic COVID-19 guidelines. We combine the principles from both sets of guidelines and explain the necessary modifications to the airway guidelines, to form a failed tracheal intubation airway strategy in the COVID-19 patient. Valuing, and a greater understanding of, these differences and modifications may lead to greater adherence to the new COVID-19 guidelines.
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Affiliation(s)
- Patrick Wong
- Duke-National University of Singapore Medical School, Yong Loo Lin School of Medicine (National University of Singapore), Singapore, Singapore
- Division of Anesthesiology and Perioperative Sciences, Sengkang General Hospital, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Wan Yen Lim
- Division of Anesthesiology and Perioperative Sciences, Sengkang General Hospital, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
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19
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Chow YM, Tan Z, Soh CR, Ong S, Zhang J, Ying H, Wong P. A Prospective Audit of Airway Code Activations and Adverse Events in Two Tertiary Hospitals. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2020; 49:876-884. [PMID: 33381781 DOI: 10.47102/annals-acadmedsg.2020242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Airway management outside the operating room can be challenging, with an increased risk of difficult intubation, failed intubation and complications. We aim to examine airway practices, incidence of difficult airway and complications associated with airway code (AC) activation. METHODS We conducted a prospective audit of AC activations and adverse events in two tertiary hospitals in Singapore. We included all adult patients outside the operating room who underwent emergency intubation by the AC team after AC activation. Adult patients who underwent emergency intubation without AC activation or before the arrival of the AC team were excluded. Data were collected and documented by the attending anaesthetists in a standardised survey form shortly after their responsibilities were completed. RESULTS The audit was conducted over a 20-month period from July 2016 to March 2018, during which a total of 224 airway activations occurred. Intubation was successful in 218 of 224 AC activations, giving a success rate of 97.3%. Overall, 48 patients (21.4%) suffered an adverse event. Thirteen patients (5.8%) had complications when intubation was carried out by the AC team compared with 35 (21.5%) by the non-AC team. CONCLUSION Dedicated AC team offers better success rate for emergency tracheal intubation. Non-AC team attempted intubation in the majority of the cases before the arrival of the AC team. Increased intubation attempts are associated with increased incidence of adverse events. Equipment and patient factors also contributed to the adverse events. A multidisciplinary programme including the use of supraglottic devices may be helpful to improve the rate of success and minimise complications.
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Affiliation(s)
- Yuen Mei Chow
- Department of Anaesthesiology, Division of Anaesthesiology and Perioperative Sciences, Singapore General Hospital, Singapore
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20
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Lim WY, Fook-Chong S, Wong P. Comparison of glottic visualisation through supraglottic airway device (SAD) using bronchoscope in the ramped versus supine 'sniffing air' position: A pilot feasibility study. Indian J Anaesth 2020; 64:681-687. [PMID: 32934402 PMCID: PMC7457982 DOI: 10.4103/ija.ija_320_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/21/2020] [Accepted: 06/03/2020] [Indexed: 01/03/2023] Open
Abstract
Background and Aims: Airway management in obese patients is associated with increased risk of difficult airway and intubation. After failed intubation, supraglottic airway-guided flexible bronchoscopic intubation (SAGFBI) may be required. It is uncertain whether SAGFBI is best performed in the ramped versus conventional supine “sniffing air” position. We conducted a feasibility study to evaluate the logistics of positioning, compared glottic views, and evaluated SAGFBI success rates. Methods: We conducted a prospective, pilot study in patients with a body mass index (BMI) 30–40 kg/m2 undergoing elective operations requiring tracheal intubation. All patients were placed in a ramped position. After induction, a supraglottic airway device (SAD) was inserted. A flexible bronchoscope was inserted into the SAD and a photograph of the glottic view taken. The patient was repositioned to the supine position. A second photograph was taken. SAGFBI was performed. Images were randomised and assessed by two independent anesthetists. Results: Of 17 patients recruited, 15 patients were repositioned successfully. There were no differences in glottic views observed in the two positions. SAGFBI was successful in 92.9% of patients (median time 91.5 s). Haemodynamic changes were noted in 42.7% of patients which resolved spontaneously. Conclusion: Our pilot study was completed within 5 months, achieved low dropout rate and protocol feasibility was established. SAGFBI was successfully and safely performed in obese patients, with a median time of 91.5 s. The time taken for SAGFBI was similar to awake intubation using FBI and videolaryngoscopy. Our study provided preliminary data supporting future, larger-scale studies to evaluate glottic views in the ramped versus supine positions.
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Affiliation(s)
- Wan Yen Lim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | | | - Patrick Wong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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21
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Bessmann EL, Rasmussen LS, Konge L, Kristensen MS, Rewers M, Østergaard D, Kotinis A, Mitchell AU, Munksgaard ABF, Schousboe BMB, Rosenstock CV, Nielsen J, Frederiksen H, Graeser K, Larsen PB, Pfeiffer P, Lauritsen T. Maintaining competence in airway management. Acta Anaesthesiol Scand 2020; 64:751-758. [PMID: 32034955 DOI: 10.1111/aas.13558] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/31/2020] [Accepted: 02/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Airway management is a defining skill for anaesthesiologists. Anaesthesiologists must maintain and update these crucial skills throughout their career, but how this is best achieved remains unclear. This study aimed to clarify anaesthesiologists' procedural volume, confidence in airway management and their current and preferred future educational strategies. METHODS A questionnaire was developed consisting of 28 items exploring essential skills in airway management. All anaesthesiologists in the Capital Region of Denmark were invited to participate. RESULTS The response rate was 84% (240/285). Most anaesthesiologists felt competent to a high or very high degree in basic airway management. Anaesthesiologists from anaesthesia felt confident to a significantly higher degree than those working in the intensive care unit (ICU) regarding the practical aspects of airway management in both the anticipated difficult airway (93% vs 73%, P < .001) and the unanticipated difficult airway (81% vs 61%, P = .002). Both groups performed most of the key advanced techniques ≤4 times yearly, whereas anaesthesiologists from the ICU had a lower and less diverse procedural volume than those working in anaesthesia. The anaesthesiologists preferred training through their daily clinical work, hands-on workshops, and scenario-based simulation training. However, a large discrepancy was identified between the current and the desired level of training. CONCLUSION The anaesthesiologists felt competent to a high or very high degree in basic airway management but the current procedural volume in advanced airway management causes concern for skill maintenance. Furthermore, we found a gap between the current and the desired level of supplemental training.
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Affiliation(s)
- Ebbe L. Bessmann
- Copenhagen Academy for Medical Education and Simulation Capital Region of Denmark Denmark
- Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia Centre of Head and Orthopaedics Rigshospitalet Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation Capital Region of Denmark Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | | | - Mikael Rewers
- Copenhagen Academy for Medical Education and Simulation Capital Region of Denmark Denmark
| | - Doris Østergaard
- Copenhagen Academy for Medical Education and Simulation Capital Region of Denmark Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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22
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Lentz S, Grossman A, Koyfman A, Long B. High-Risk Airway Management in the Emergency Department: Diseases and Approaches, Part II. J Emerg Med 2020; 59:573-585. [PMID: 32591298 DOI: 10.1016/j.jemermed.2020.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Successful airway management is critical to the practice of emergency medicine. Thus, emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this second part of a 2-part series. OBJECTIVE This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases commonly encountered in the emergency department. DISCUSSION Adverse events during emergent airway management are common with postintubation cardiac arrest, reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided by proper identification and understanding the underlying physiology, preparation, and postintubation management. Those with high-risk features including trauma, elevated intracranial pressure, upper gastrointestinal bleed, cardiac tamponade, aortic stenosis, morbid obesity, and pregnancy must be managed with airway expertise. CONCLUSIONS This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician.
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Affiliation(s)
- Skyler Lentz
- Division of Emergency Medicine, Department of Surgery, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Alexandra Grossman
- Department of Emergency Medicine, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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23
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Mosier JM, Sakles JC, Law JA, Brown CA, Brindley PG. Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go. Am J Respir Crit Care Med 2020; 201:775-788. [DOI: 10.1164/rccm.201908-1636ci] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jarrod M. Mosier
- Department of Emergency Medicine and
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, University of Arizona, Tucson, Arizona
| | | | - J. Adam Law
- Department of Anesthesiology and Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Calvin A. Brown
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Peter G. Brindley
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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24
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Tips and tricks: Supraglottic airway device insertion using a tongue depressor. Eur J Anaesthesiol 2020; 37:154-155. [PMID: 31913942 DOI: 10.1097/eja.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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25
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Zhang JJ, Qu ZY, Hua Z, Zuo MZ, Zhang HY. Effect of different types of laryngeal mask airway placement on the right internal jugular vein: A prospective randomized controlled trial. World J Clin Cases 2019; 7:4245-4253. [PMID: 31911905 PMCID: PMC6940344 DOI: 10.12998/wjcc.v7.i24.4245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/27/2019] [Accepted: 11/30/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND In recent years, with the popularity of laryngeal mask airway (LMA) for the management of clinical anesthesia, the influence of the LMA on the position and blood flow of the internal jugular vein (IJV) has attracted an increasing amount of attention.
AIM To investigate the effect of placement of different types of LMA (Supreme LMA, Guardian LMA, I-gel LMA) on the position and blood flow of the right IJV.
METHODS This was a prospective randomized controlled trial. A total of 102 patients aged 18-75 years who were scheduled to undergo laparoscopic abdominal surgery with general anesthesia were randomly assigned to three groups: Supreme LMA (group 1), Guardian LMA (group 2), and I-gel LMA (group 3) groups. The main indicator was the overlap index (OI) of IJV and the common carotid artery (CCA) at the high, middle, and low points before and after the placement of the LMA. The second indicators were the proportion of ultrasound-simulated needle crossing the IJV and CCA, and the cross-sectional area and blood flow velocity of the IJV before and after placement of the LMA at the middle point.
RESULTS Data from 100 patients were included in the statistical analysis. The OI increased significantly after placement of the LMA in the three groups at the three points (P < 0.01), except group 2 at the low point. In group 2 and group 3, the OI was lower than that in group 1 after LMA insertion at the high point (P < 0.0167). At the middle point, after LMA insertion, the proportion of simulated needle crossing the IJV significantly decreased in all three groups (P < 0.05), and the proportion in group 2 was higher than that in group 3 (P < 0.0167). The proportion of simulated needle crossing the CCA or both the IJV and CCA significantly increased in group 1 and group 2 (P < 0.05), which increased with no statistical significance in group 3. After LMA insertion, the cross-sectional area of the IJV significantly increased, while the blood flow velocity significantly decreased (P < 0.01). There was no significant difference among the three groups.
CONCLUSION The placement of Supreme, Guardian, and I-gel LMA can increase the OI, reduce the success rate of IJV puncture, increase the incidence of arterial puncture, and cause congestion of IJV. Type of LMA did not influence the difficulty of IJV puncture. Therefore when LMA is used, ultrasound is recommended to guide the IJV puncture.
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Affiliation(s)
- Jing-Jing Zhang
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Zong-Yang Qu
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Zhen Hua
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Ming-Zhang Zuo
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Hong-Ye Zhang
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
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26
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Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia 2019; 75:509-528. [PMID: 31729018 PMCID: PMC7078877 DOI: 10.1111/anae.14904] [Citation(s) in RCA: 189] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2019] [Indexed: 12/13/2022]
Abstract
Awake tracheal intubation has a high success rate and a favourable safety profile but is underused in cases of anticipated difficult airway management. These guidelines are a comprehensive document to support decision making, preparation and practical performance of awake tracheal intubation. We performed a systematic review of the literature seeking all of the available evidence for each element of awake tracheal intubation in order to make recommendations. In the absence of high‐quality evidence, expert consensus and a Delphi study were used to formulate recommendations. We highlight key areas of awake tracheal intubation in which specific recommendations were made, which included: indications; procedural setup; checklists; oxygenation; airway topicalisation; sedation; verification of tracheal tube position; complications; management of unsuccessful awake tracheal intubation; post‐tracheal intubation management; consent; and training. We recognise that there are a range of techniques and regimens that may be effective and one such example technique is included. Breaking down the key practical elements of awake tracheal intubation into sedation, topicalisation, oxygenation and performance might help practitioners to plan, perform and address complications. These guidelines aim to support clinical practice and help lower the threshold for performing awake tracheal intubation when indicated.
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Affiliation(s)
- I Ahmad
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - K El-Boghdadly
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - R Bhagrath
- Department of Anaesthesia, Barts Health NHS Trust, London, UK
| | - I Hodzovic
- Department of Anaesthesia, Cardiff University School of Medicine, Cardiff, UK.,Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, UK
| | - A F McNarry
- Department of Anaesthesia, NHS Lothian, Edinburgh, UK
| | - F Mir
- Department of Anaesthesia, St. George's University Hospital NHS Foundation Trust, London, UK
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, Dublin, Ireland
| | - A Patel
- Department of Anaesthesia, Royal National Throat Nose and Ear Hospital and University College London Hospitals NHS Foundation Trust, London, UK
| | - M Stacey
- Department of Anaesthesia, Cardiff and Vale NHS Trust (HEIW), Cardiff, UK
| | - D Vaughan
- Department of Anaesthesia, Northwick Park Hospital, London, UK
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27
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Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB. Management of Difficult Tracheal Intubation: A Closed Claims Analysis. Anesthesiology 2019; 131:818-829. [PMID: 31584884 PMCID: PMC6779339 DOI: 10.1097/aln.0000000000002815] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database. METHODS Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management. RESULTS Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A "can't intubate, can't oxygenate" emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80). CONCLUSIONS Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.
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Affiliation(s)
- Aaron M. Joffe
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA; United States
| | - Michael F. Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Karen L. Posner
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA; United States
| | - Laura V. Duggan
- Department of Anesthesiology, Pharmacology, & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shawn L. Mincer
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA; United States
| | - Karen B. Domino
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA; United States
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Lim WY, Wong P. Awake supraglottic airway guided flexible bronchoscopic intubation in patients with anticipated difficult airways: a case series and narrative review. Korean J Anesthesiol 2019; 72:548-557. [PMID: 31475506 PMCID: PMC6900415 DOI: 10.4097/kja.19318] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 08/27/2019] [Indexed: 12/26/2022] Open
Abstract
Awake intubation is indicated in difficult airways if attempts at securing the airway after induction of general anesthesia may lead to harm due to potential difficulties or failure in those attempts. Conventional awake flexible bronchoscopic intubation is performed via the nasal, or less commonly, oral route. Awake oral flexible bronchoscopic intubation (FBI) via a supraglottic airway device (SAD) is a less common technique; we refer to this as ‘supraglottic airway guided’ FBI (SAGFBI). We describe ten cases with anticipated difficult airways in which awake SAGFBI was performed. After sedation and adequate airway topicalization, an Ambu AuragainTM SAD was inserted. A flexible bronchoscope, preloaded with a tracheal tube, was then inserted through the SAD. Finally, the tracheal tube was railroaded over the bronchoscope, through the SAD and into the trachea. The bronchoscope and the SAD were carefully removed, whilst keeping the tracheal tube in-situ. The technique was successful and well tolerated by all patients, and associated complications were rare. It also offered the advantages of performing an ‘awake test insertion’ of the SAD, an ‘awake look’ at the periglottic region, and an ‘awake test ventilation.’ In certain patients, awake SAGFBI offers advantages over conventional awake FBI or awake videolaryngoscopy. More research is required to evaluate its success and failure rates, and identify associated complications. Its place in difficult airway algorithms may then be further established.
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Affiliation(s)
- Wan Yen Lim
- Department of Anesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Patrick Wong
- Department of Anesthesiology, Singapore General Hospital, Singapore, Singapore
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Edelman DA, Perkins EJ, Brewster DJ. Difficult airway management algorithms: a directed review. Anaesthesia 2019; 74:1175-1185. [PMID: 31328259 DOI: 10.1111/anae.14779] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2019] [Indexed: 12/18/2022]
Abstract
The primary aim of this study was to identify, describe and compare the content of existing difficult airway management algorithms. Secondly, we aimed to describe the literature reporting the implementation of these algorithms. A directed search across three databases (MEDLINE, Embase and Scopus) was performed. All articles were screened for relevance to the research aims and according to pre-determined exclusion criteria. We identified 38 published airway management algorithms. Our results show that most facemask employ a four-step process as represented by a flow chart, with progression from tracheal intubation, facemask ventilation and supraglottic airway device use, to a rescue emergency surgical airway. The identified algorithms are overwhelmingly similar, yet many use differing terminology. The frequency of algorithm publication has increased recently, yet adherence and implementation outcome data remain limited. Our results highlight the lack of a single algorithm that is universally endorsed, recognised and applicable to all difficult airway management situations.
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Affiliation(s)
- D A Edelman
- Central Clinical School, Monash University, Melbourne, Vic., Australia
| | - E J Perkins
- Central Clinical School, Monash University, Melbourne, Vic., Australia
| | - D J Brewster
- Central Clinical School, Monash University, Melbourne, Vic., Australia
- Cabrini Hospital, Melbourne, Vic., Australia
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Charlesworth M, van Zundert AAJ. Digital dystopias: will the electronic health record ever fulfil its potential? Anaesthesia 2019; 74:1361-1364. [DOI: 10.1111/anae.14683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2019] [Indexed: 12/17/2022]
Affiliation(s)
- M. Charlesworth
- Department of Cardiothoracic Anaesthesia Wythenshawe Hospital Manchester University Hospitals NHS Foundation Trust ManchesterUK
| | - A. A. J. van Zundert
- Discipline of Anaesthesiology Department of Anaesthesia and Peri‐operative Medicine Royal Brisbane and Women's Hospital The University of Queensland Brisbane QLD Australia
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Law JA, Duggan LV. The airway assessment has come of age—or has it? Anaesthesia 2019; 74:834-838. [DOI: 10.1111/anae.14658] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2019] [Indexed: 12/17/2022]
Affiliation(s)
- J. A. Law
- Department of Anesthesia, Pain Management and Peri‐operative Medicine Dalhousie University Halifax NSCanada
| | - L. V. Duggan
- Department of Anesthesiology University of British Columbia Vancouver BC Canada
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Ahmad I, El-Boghdadly K. From evidence based on practice to evidence-based practice: time for a difficult airway management research strategy. Anaesthesia 2018; 74:135-139. [DOI: 10.1111/anae.14452] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- I. Ahmad
- Guy's and St Thomas’ NHS Foundation Trust and Honorary Senior Lecturers; King's College London; London UK
| | - K. El-Boghdadly
- Guy's and St Thomas’ NHS Foundation Trust and Honorary Senior Lecturers; King's College London; London UK
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