Airway Management Instrumentation & Techniques · 2019-07-02 · NBCRNA Core Modules Supplemental...
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NBCRNA Core Modules Supplemental Part 2 Airway Management Instrumentation & Techniques Amy Sheppard, CRNA, MSNA
Transcript of Airway Management Instrumentation & Techniques · 2019-07-02 · NBCRNA Core Modules Supplemental...
NBCRNA Core Modules Supplemental Part 2
Airway Management Instrumentation & Techniques
Amy Sheppard, CRNA, MSNA
Presenter
Presentation Notes
My name is Jay Tydlaska and I’ve created this presentation with my business partner and colleague, Amy Sheppard. We are both graduates of Texas Wesleyan university in Fort Worth, Texas and practice in the Dallas/Fort Worth metroplex primarily doing plastics. Airway wasn't always a specific interest we shared but that changed in 2008 when I experienced my first “cant intubate, can't ventilate.” I was at a large surgery center in Dallas; a facility that I didn't normally practice at. Although the surgery center has 10 OR’s and there were other anesthesia providers in the building, I was essentially on my own. I was not there practicing as part of a group. So I was responsible for my own anesthetic (and any problems that might arise). And boy did I have a big problem arise that day. My difficult airway was completely unexpected. I thought I was prepared to manage that scenario but I wasn’t. My training failed me that day. The airway was eventually secured and my patient did fine without any problems but I left the facility that day questioning everything I thought I knew about airway management. That event altered the course of my career.
Getting your credits
❖ NBCRNA Core Module #1: Airway
❖ Series of 3 Airway lectures online: INCLUDED in conference fee
❖ CRNA Today is a recognized vendor for NBCRNA & Prior Approve by the AANA
Getting your credits
❖ FIRST – Visit and Register at CRNAToday.com❖ Enroll in the Airway: NBCRNA Core Module #1….At check out utilize your Coupon
Code “1FL” followed by your AANA number. NO Leading zero. Click Update❖ Online lecture
❖ Can be viewed on-demand…. ❖ 3 attempts to pass Post Test
❖ To get Class A Credit- A Post Test grade of 80% is required❖ 3 Attempts ❖ Certificate is only available after passing❖ All records submitted to the AANA monthly
Presenter
Presentation Notes
We do have a conflict of interest to disclose. Amy and I founded and operate a medical device company called Magaw Medical. We manufacture and sell a video laryngoscope called the CoPilot VL.
Objectives
❖ The Learner will demonstrate the appropriate steps in assessing an airway to develop the appropriate patient-specific plan that ensures safe management of the airway and facilitates continuity of care
❖ The Learner will identify the indications and contraindications associated with the use of airway equipment.
❖ The Learner will understand the associated malpractice claims arising from the management of the airway, using a closed claims analysis.
❖ The Learner will identify the complications associated with airway equipment
Presenter
Presentation Notes
The goal of this presentation is to enhance knowledge and skills in basic and advanced airway management instrumentation and techniques. Upon successful completion of the program, the Learner will ……………………
History of Airway Management
Morton Inhaler
Dräger “Pulmonator”
Alfred KirsteinAutoscope
1943 1941
Murphy Endotracheal Tube
“Airway Management” A broad term used to describe the tools, techniques and procedures used to support and control oxygenation and ventilation as well as
delivery of anesthetics.
Presenter
Presentation Notes
In anesthesia, “airway management” is a broad term used to describe the tools, techniques and procedures used to support and control oxygenation and ventilation as well as delivery of anesthetics. So lets have a look at some of the historical devices used in airway management 1846: Morton inhaler: used to administer ether 1895: Alfred Kirstein first described direct visualization of the vocal cords using his “autoscope.” 1907: Dräger Pulmonator: first commercially available intermittent PPV device. It was marketed as a device capable of resuscitating individuals who have lost consciousness from lack of oxygen. This product led the way for future development of new anesthesia and oxygen delivery systems. 1931: Cuffed endotracheal tubes are introduced into clinical practice 1940’s: Saw the introduction of the Mac and Miller laryngoscopes. These “modern” devices are still the primary tools used to perform intubation.
Getting started
❖ What factors need to be considered? • NPO status
• Risk of aspiration
• Patient factors
• Surgeon factors
• Type and length of surgery
• Regional anesthesia
• Provider competencies
Presenter
Presentation Notes
Alright, so what are some of the things the clinician needs to consider when developing an airway management strategy for their patient? What are current preoperative fasting guidelines? Is your patient at risk for aspiration? What are Patient factors: co-morbidities, size of patient, What are Surgeon Needs: Does surgeon need or insist on paralysis? Procedure Factors? Length of surgery, position needed for surgery, type of surgery (open bowel vs carpal tunnel) Is regional anesthesia an option? What are your own competencies? What are you comfortable with? Are you able to competently perform the techniques needed?
Preoperative Fasting Guidelines
❖ 2017: ASA updated recommendations for pre-operative fasting1
• 2 hours clear liquids
• 4 hours breast milk
• 6 hours solid foods, infant formula & non-human milk
• 8 hours fried or fatty foods
Presenter
Presentation Notes
After identifying our patient, one of the first things we will then try to ascertain is how long the patient has been NPO because the prevention of aspiration remains a cornerstone of anesthesia practice. 1999: ASA published original guidelines for pre-operative fasting.
Preoperative Fasting Guidelines
❖ Gum, smokeless tobacco, hard candy2
• Not specifically addressed by the ASA guidelines
• European Society of Anaesthesiology guidelines do NOT recommend delaying anesthesia
Presenter
Presentation Notes
What about gum, hard candy or mints? What about smokeless tobacco?
Aspiration Prophylaxis
❖ Overall incidence of aspiration remains very low
❖ Incidence of anesthesia related fatal aspiration was only 1:350,000 (.0003%)3
❖ In the NAP4 study, aspiration was responsible for 50% anesthetic deaths.3
❖ Risk of aspiration is greater with higher patient Physical Status (ASA status) and emergency surgery3
Presenter
Presentation Notes
Incidence of aspiration is low and fatal aspiration is pretty rare (1:350,000). Although it is rare, it is one of the primary causes of death in anesthesia. In the NAP4 report, which we will discuss later, aspiration was responsible for 50% of the anesthetic deaths. Risk of aspiration has been shown to be greater with higher patient Physical Status (ASA status) and emergency surgery
Aspiration Prophylaxis
❖ The intended goal of aspiration prophylaxis is to decrease gastric volume and pH.
❖ Sodium Citrate, Metoclopramide, Ranitidine (or other H2 antagonist)
The ASA guidelines do NOT recommend routineprophylaxis1
Presenter
Presentation Notes
So we do try and prevent aspiration whenever possible. The intended goal of aspiration prophylaxis is to decrease gastric volume and pH. Pharmacologically speaking, we do that with the administration of Sodium Citrate, Metoclopramide, Ranitidine (or other H2 agonists) The ASA guidelines do NOT recommend routine prophylaxis1
Aspiration Prophylaxis
❖ Full stomach
❖ Diabetic gastroparesis
❖ Symptomatic GERD
❖ Pregnancy
❖ Emergency surgery
❖ ESRD
❖ GI obstruction
❖ Hiatal hernia
❖ Active N/V
❖ NG tube
❖ Morbid obesity
Indications: 4, 5
Presenter
Presentation Notes
If the guidelines do not suggest ROUTINE prophylaxis, Who is a candidate for aspiration prophylaxis? If your pt has these conditions, you should consider administering prophylaxis. Indications would include………
Aspiration Prophylaxis in Pregnancy
Updated report from ASA task force on Obstetric Anesthesia & the Society for Obstetric Anesthesia and Perinatology6
For clear liquids: “The uncomplicated patient undergoing elective surgery (e.g. scheduled C/S, post partum tubal ligation) may have moderate amounts of clear liquids before induction of anesthesia.”
For solids: “The patient undergoing elective surgery (e.g. scheduled C/S, post partum tubal ligation) should undergo a fasting period of 6-8 hours depending on the type of food ingested (e.g. fat content).”
Before surgical procedures (e.g., cesarean delivery or post- partum tubal ligation) “The clinician should consider the timely administration of nonparticulate antacids, H2 antagonists, and/or metoclopramide for aspiration prophylaxis.”
After 20 weeks gestation, extra caution should be exercised with the unprotected airway to prevent aspiration29
Presenter
Presentation Notes
The pregnant patient is known to be at higher risk for aspiration after 20 weeks gestation.
Aspiration ProphylaxisStrategies for reducing aspiration risk3
Reducing gastric volume
Preoperative fasting, nasogastric aspiration, pro kinetic premedication
Avoidance of general anesthesia Is regional anesthesia an option?
Reducing pH of gastric contents Antacids, H2 antagonists, proton pump inhibitors
Airway protection Tracheal intubation, 2nd generation supra-glottic airway devices
Prevent regurgitation Rapid sequence induction
Extubation Extubate only after awake and airway reflexes have returned
Presenter
Presentation Notes
Global strategies for reducing the risk of aspiration include
Cricoid Pressure & Preventing Aspiration
Is it time to LET GO of cricoid pressure?
Presenter
Presentation Notes
Over the past 2 decades, the use and effectiveness of cricoid pressure during intubation has been frequently called into question. Popularized by Dr Brian Sellick in a study published in the Lancet in 1961, CP is believed to prevent regurgitation of gastric contents by occluding the upper end of the esophagus between the cricoid cartilage and the cervical vertebral bodies. But the original report would not pass modern scientific standards. His small study was a non randomized, uncontrolled case series that had each patient in a head down position during induction of anesthesia. Even though the maneuver was lacking any sort of scientific merit, it has essentially become a “standard of care” when management the airway of the patient at risk for aspiration.
Cricoid Pressure & Preventing Aspiration
❖ Does cricoid pressure (CP) reduce the risk of aspiration?• Evidence to support that CP is effective is based almost exclusively on cadaver studies and
case reports of regurgitation occurring after CP has been released. There is no evidence for or against the use of CP and there are no published randomized controlled trials comparing the incident of regurgitation on induction, with or without the use of CP. Additionally, CP has been shown to decrease LES tone thus potentially increasing the risk of aspiration.3
❖ Is cricoid pressure properly applied?• Who is applying the CP? Have they been trained? Do YOU even know how to properly apply?
❖ Does properly applied cricoid pressure actually compress the esophagus?• The esophagus is laterally displaced relative to the midline of the vertebral body in 49%-53% of
subjects without cricoid pressure being applied. When CP was applied, lateral displacement increased by 53%- 91%.7
❖ Does cricoid pressure increase or decrease the quality of the laryngeal view?• Numerous articles have been published with contradictory results. However, it has been found
that application of > 40N of force can compromise airway patency and cause difficulty with tracheal intubation.7
❖ Is CP harmful?• Difficult laryngoscopy, esophageal rupture, cricoid fracture8
❖ Are there any contraindications to use of CP?• Trauma to anterior neck, unstable C-spine, obstructing mass, active vomiting8
Presenter
Presentation Notes
Read from slide
Cricoid Pressure & Preventing Aspiration
Is it time to LET GO of cricoid pressure?
Cochrane Anaesthesia, Critical and Emergency Care Group9
There is currently NO information available from published RCTs (randomized controlled trials) on clinically relevant outcome measures with respect to the application of cricoid pressure during RSI.
Presenter
Presentation Notes
READ above, then There is no science to back up the use of CP as a tool to prevent aspiration during endotracheal intubation. We do it because its what we were taught and we never questioned it. On the other hand, there is solid evidence that CP is applied inconsistently and incorrectly by a majority of the clinicians. And If we are not able to perform the technique as recommended, whether or not it is a useful becomes a secondary argument. In other words, if you are going to do it, do it right
Cricoid Pressure & Preventing Aspiration
To correctly apply cricoid pressure, 30 - 40N (3 - 4 Kg)
of force should be applied downward onto the cricoid cartilage.10
If you are going to do it, you should at least do it correctly.
Presenter
Presentation Notes
So what is the “right” way to do it? 30N of force would be like compressing a tennis ball with a finger In the study referenced on this slide, 61 participants (including anesthesiologists, nurse anesthetists, pre op, intra op, post op and ICU nurses) where asked about their knowledge of CP and asked to demonstrate their CP technique on a model of the larynx that was able to measure the amount of force applied. Only 26% of participants were able to provide the proper amount of force and only 20% of participants were even able to identify the correct anatomy. There was some dialog from this study that I found interesting. Who are you asking to provide your CP? Have they been properly trained? Are you properly trained?
Just how good is your cricoid?
Investigator
Ok, please proceed with the application of cricoid pressure to the test fixture
Just how good is your cricoid?
Participant
OK!
Just how good is your cricoid?
Investigator
Are you applying cricoid pressure to the test fixture?
Just how good is your cricoid?
Participant
Yes, of course
Just how good is your cricoid?
Investigator
Something must be wrong. We’re not registering any pressure? You are pressing
down on the cricoid, right?
Just how good is your cricoid?
Participant
Oh no, I would never do that. I always “squeeze” the sides of the throat. Pushing down
would obstruct the view of the person intubating.
Just how good is your cricoid?
Investigator
And how long have you been applying cricoid pressure in this manner?
Just how good is your cricoid?
ParticipantFor 38 years!
Airway Assessment
Presenter
Presentation Notes
Next we’re going to talk about airway assessment. We all learned a standardized way to conduct a machine check and set up for an anesthetic? But what about an airway exam? Is there a standardized procedure for conducting an airway exam? Does your facility have a standardized form for documenting a complete and thorough airway exam? What specific exams are your performing and why? Are they even relevant? Do you know the science behind the exams you are performing?
Airway Assessment
No single test has been devised that can predict a difficult airway 100% of the time; especially when tests are done by themselves.
Evaluating the Airway
Presenter
Presentation Notes
Most of the time, difficult airways catch us off guard. Ideally, we would always be able to predict which patients might have a difficult airway. Unfortunately, studies have show that no single test has been devised that can predict a difficult airway 100% of the time; especially when tests are done by themselves. Does that mean we should abandon the practice altogether? No. A thorough airway exam and understanding the factors that point to a difficult airway can alert the clinician to the potential for difficulty and allow for appropriate planning. Also, when several different measures are used together, the accuracy improves. Lets talk about a few of the exams you might perform.
Modified Mallampati Classification
• Originally described in 1983, Mallampati is an easy to perform, commonly used airway assessment tool. As a stand alone tool however, it is insufficient to predict the difficult airway.11
• In a meta analysis of over 177,000 patients, only 35% of patients with a difficult intubation were identified as Mallampati III or IV.11
• May be useful clinically when used in combination with other airway predictors11
• To properly perform, the neck should be neutral (not extended) and the patient should not phonate4
Presenter
Presentation Notes
As a stand alone tool however, it is insufficient to predict the difficult airway and yet how many of us utilize the MP test as the backbone of our airway evaluation?
LEMON
Test15 Evaluation
Look externallyAre there any physical attributes that stand out?
Evaluate 3-3-2 3-3-2 rule
Mallampati
Obstruction/Obesity
Facial trauma, edema, foreign body, obesity, large breasts?
Neck mobility RA? Radiation? Burns?
*Adapted with permission from The Difficult Airway Site (TheAirwaySite.com) & Walls RM & Murphy, MF:Manual of Emergency Airway Management, 4th ed
Philadelphia, Lippincott, Williams and Wilkins, 2012
Presenter
Presentation Notes
Look : What does the lay of the land look like? Loose teeth or jewelry in the mouth? Dentures. Beard. Evaluate (3:3:2) 3 FB mouth opening; 3 FB from the hyoid to mentum (hyomental distance), 2 FB from thyroid to hyoid (thyrohyoid distance) MP Obstruction Neck
El-Ganzouri Multivariate Risk Index
Abdel Raouf Sayed Ahmed El-Ganzouri, M.D.
Test 12, 13 Score
Mouth Opening 0 - 1
Mallampati 0 - 2
TM Distance 0 - 2
Neck Movement 0 - 2
Hx difficult intubation 0 - 2
Ability to prognath 0 - 1
Weight 0 - 2
TOTAL 0 - 12
A score ≥ 4 indicates potential difficulty when performing direct laryngoscopy
Presenter
Presentation Notes
The EGMVRI is one of the most thorough tools available to us because it looks at so many different variables. Originally described in 1996 Mouth opening > 4cm = 0 < 4cm = 1 Mallampati 0, 1 (for MP 2) or 2 (for MP 3 or 4) TM distance > 6.5cm = 0 6.0 - 6.5cm = 1 < 6.0cm = 2 Neck movement > 90 = 0 80-90 = 1 < 80 = 2 Hx of difficult intubation None = 0 Questionable = 1 Definite = 2 Ability to prognath (ability to protrude the lower jaw) Yes = 0 No = 1 Body weight < 90 kg = 0 90-110 kg = 1 > 110 kg = 2
Documenting EGRI
A score ≥ 4 indicates potential difficulty when performing direct laryngoscopy
0 1 2Mouth Opening ≥ 4 cm < 4 cm
Mallampati 1 2 3, 4
TM Distance > 6.5 cm 6 - 6.5 cm < 6 cm
Neck Movement > 90 80 - 90 < 80
Hx difficult intubation No Questionable Yes
Ability to prognath Yes No
Weight < 90 kg 90 - 110 kg > 110 kg
Total =_______
Presenter
Presentation Notes
The EGMVRI is one of the most thorough tools available to us because it looks at so many different variables. Originally described in 1996 Mouth opening > 4cm = 0 < 4cm = 1 Mallampati 0, 1 (for MP 2) or 2 (for MP 3 or 4) TM distance > 6.5cm = 0 6.0 - 6.5cm = 1 < 6.0cm = 2 Neck movement > 90 = 0 80-90 = 1 < 80 = 2 Hx of difficult intubation None = 0 Questionable = 1 Definite = 2 Ability to prognath (ability to protrude the lower jaw) Yes = 0 No = 1 Body weight < 90 kg = 0 90-110 kg = 1 > 110 kg = 2
Deciding How to Manage the Airway
vs
vs
vsvs
vs
Presenter
Presentation Notes
We have lots of options when deciding upon how we are going to manage our patients airways. So now we’ll talk about some of those.
Positioning
7-9cm
“Sniffing Position”: Neck flexion and head extension14
Presenter
Presentation Notes
Proper patient positioning is an important tool that is often over looked. Sometimes, your airway plan changes, so you might as well position your patient for ANY airway intervention. Placing your patient in the sniffing position is a good place to start The position we often talk about is the Sniffing position. Properly positioned, the patients head and neck will not only be flexed but also extended. Proper sniffing position can be defined as 35° neck flexion and 15° head extension To do this, you need to elevate the occiput 7-9cm from the normal plane of the bed. This is easiest to do before the start of the surgical procedure when access to the head of the patient may have become obscured.
Positioning
Ideally, the external auditory meatus should be in horizontal alignment with the sternal notch.
Positioning of the obese patient14
Presenter
Presentation Notes
Proper positioning is even more important when managing the airway of the obese patient. This is Ed, one of the nurses that we work with. He probably wouldn't be to happy to know that I put his photo on a slide that includes the word “obese” “Ramping” will help properly position the obese patient. Can be done with the use of pillows, blankets or commercially available ramping devices. Ideally, the external auditory meatus should be in horizontal alignment with the sternal notch.
Capnography
❖ Continuously monitor ETC02 during controlled or assisted ventilation and any anesthesia or sedation technique requiring artificial airway support. During moderate or deep sedation, continuously monitor for the presence of expired C02.16
Presenter
Presentation Notes
I’d like to briefly discuss capnography. We are all accustomed to monitoring ETC02 when the airway is being maintained via a SGA or ETT. But what about when the anesthetic technique is MAC or TIVA and only supplemental O2 is being provided by N/C? What about an EGD or colonoscopy? What about a patient receiving IV sedation on top of a spinal anesthetic? Are you monitoring ETCO2? Since 2011?, the standards for Nurse Anesthesia Practice require that we monitor for the presence of expired CO2 continuously throughout the anesthetic. You aren't required to document and actual #, but you are required to continuously monitor for the presence of expired CO2.
Preoxygenation
❖ Optimal is 3 mins Vt, but 8 Vc may be acceptable.4
❖ ET O2 should be > 90% to maximize apnea time.4
❖ What’s the purpose?Denitrogenation: increase the time a patients will stay oxygenated during apnea
Presenter
Presentation Notes
The O2 mask is usually one of the first items placed on a patient before inducing general anesthesia; sometimes even before monitors.
Mask Ventilation
❖ Indications: preoxygenation, short duration anesthetic, bridge to definitive airway4
❖ Relative contraindication: full stomach, facial trauma, unstable c-spine4
❖ Complications: hyper/hypo ventilation, aspiration4
Ideally, peak inspiratory pressure should be kept less than 20cm H2O4
Presenter
Presentation Notes
“Mask ventilation is a straight forward, non invasive technique for airway management that can be used as a primary mode of ventilation for an anesthetic of short duration or as a bridge to establishing a more definitive airway” MILLER SAYS Use of Oral and nasal airways can make MV easier
Prediction of Difficult Mask Ventilation
*Adapted with permission from The Difficult Airway Site (TheAirwaySite.com) & Walls RM & Murphy, MF:Manual of Emergency Airway Management, 4th ed Philadelphia, Lippincott, Williams and Wilkins, 2012
MOANS15
Difficult Mask Ventilation Mnemonic
Mask Seal Beard? Jowls?
Obese
Age > 55 y/o
No Teeth Is the patient edentulous
Stiff/Snoring Stiff neck/jaw? Sleep apnea?
Oral & Nasal AirwaysOral4 Nasal4
❖ Indications: airway obstruction, facilitate mask ventilation, facilitate suctioning
❖ Relative contraindication: intact gag reflex
❖ Complications: dental damage, soft tissue damage, bleeding, lingual nerve palsy
❖ Proper sizing: Corner of mouth to earlobe
❖ Indications: airway obstruction, facilitate mask ventilation, facilitate suctioning
❖ Relative contraindication: basilar skull fracture, coagulopathy
❖ Complications: bleeding, soft tissue damage
❖ Proper sizing: Nostril to earlobe
Presenter
Presentation Notes
Use of oral and nasal airways can make mask ventilation easier to perform Nasal is typically tolerated better in a patient with an intact gag reflex
Supraglottic Airway
❖ Indication: facilitate oxygenation and ventilation, delivery of anesthesia, conduit to intubation, bridge to extubation, failed intubation (rescue device)17
❖ Relative Contraindications: Active GERD, obesity, traumatic airway injury, intestinal obstruction, intoxication, restricted mouth opening, deformed airway anatomy17
❖ Complications: Inadequate ventilation, airway injury, sore throat, tongue edema, frenulum injury, aspiration17
Cuff pressure should be <60 cm H2O18
Presenter
Presentation Notes
Next, we’ll talk about the SGA ARE YOU MONITORING YOUR LMA CUFF PRESSURES?????????
Supraglottic Airways (SGA)
❖ 1st generation: LMA Classic and other manufacturers of laryngeal masks19
• Simple, low pressure
• Easy to place
❖ 2nd generation: i-gel, LMA ProSeal, LMA Supreme19
• Additional design features to reduce aspiration risk, allow for higher seal pressure to facilitate controlled ventilation, and may also have integrated bite block.
Presenter
Presentation Notes
LMA Classic: permits PPV ventilation at pressure up to 20 cm h20. The manufacturer of theLMA suggests placing the largest size LMA possible. Too small can result in overinflation of the cuff. LMA Proseal/Supreme: PPV up to 30 cm h20 Miller “Anecdotally, 2nd generation SGAs may reduce the risk of asp of gastric contents. These properties have enabled SGA devices to be used in various applications where the classic LMA would not be suitable: lateral, prone, laparoscopic surgery and obese patients. The successful routine use of the LMA Supreme in fasted, non obese patients for cesarean section has also been reported.”
Prediction of Difficult SGA Placement
RODS15
Difficult SGA Placement Mnemonic
Restricted Mouth opening
Obstruction
Distorted Airway
Stiff lungs/neck
*Adapted with permission from The Difficult Airway Site (TheAirwaySite.com) & Walls RM & Murphy, MF:Manual of Emergency Airway Management, 4th ed Philadelphia, Lippincott, Williams and Wilkins,
2012
LMA in the Prone Patient
❖ Review prone LMA insertion in 441 subjects in 1 RCT, 2 description studies, 1 case series and 2 case reports20
❖ Successful LMA placement: 100%
❖ Successful ventilation: 100%
❖ Risks: “Comparable to those when LMA’s are used in the supine patient.”
Presenter
Presentation Notes
LMA in the prone patient? Why might you want to do this? You prefer LMA over ETT Quicker operating room turnover: You can induce the patient prone after the patient positions themselves. LMA could also be used as a rescue device in the event of inadvertent extubation in the prone position.
Endotracheal Intubation
❖ Indications: General anesthesia, aspiration prevention, respiratory failure, inadequate oxygenation/ventilation4
❖ Contraindications: Penetrating or blunt force trauma to the upper airway anatomy, unstable c-spine4
❖ Complications: Sore throat, dental damage, soft tissue damage, vocal cord damage4
Presenter
Presentation Notes
There are few absolute contraindications to tracheal intubation.
Modified Cormack-Lehane
❖ The Cormack-Lehane classification, first described in 1984, is broadly used to describe the laryngeal view obtained during laryngoscopy4
❖ 4Yentis further defined this grading system in 1998 when he divided Grade 2 into 2A and 2B4
Presenter
Presentation Notes
The goal of laryngoscopy is to visual the vocal cords.
Direct Laryngoscopy
The goal of traditional direct laryngoscopy is to obtain direct line of sight with the glottic opening. To accomplish this task, the rigid laryngoscope is used to align the oral, pharyngeal and laryngeal axes.
In the overall patient population, clinicians are unable to visualize the vocal cords when performing direct laryngoscopy up to 7.5% of
patients21
Presenter
Presentation Notes
In a meta analysis of over 50K patients, clinicians were unable to visualize the vocal cords in 7.5% of the general population and in up to 15% of obese patients.
Video Laryngoscopy
Presenter
Presentation Notes
More and more, it is the go to device for performing difficult and even routine intubation
Predictors of Difficult Video Laryngoscopy
❖ Usual clinical indicators of difficult direct laryngoscopy & intubation do not appear to predict difficult videolaryngoscopy.22
❖ In a study of 6,278 subjects, patients were divided into 2 groups base on their EGRI score21
• ≥ 7 and patient received awake FOB
• ≤ 6 and patients were intubated via video laryngoscope
❖ 6 patients received awake FOB based on protocol, 1 patients received awake FOB based on presence of large neck tumor and another an awake tracheostomy for the same reason (even though their score was less than 7). All other patient were intubated via video laryngoscope.
❖ The incidence of C/L grade III was only 0.14% when performing VL. Grade IV was not encountered. All patients in the study were successfully intubated.
Presenter
Presentation Notes
Whats interesting is that Usual clinical indicators of difficult direct laryngoscopy & intubation do not appear to predict difficult video laryngoscopy. Can difficult laryngoscopy be ELIMINATED when patients have received a thorough airway evaluation an VL is used as the primary intubating tool? Something to think about.
Regional anesthesia and the difficult airway
❖ Regional anesthesia is recommended in patients with potentially difficult airways who present for surgery23
❖ However incidents may occur after the initiation of regional anesthesia that would “force” the clinician to manage the airway. These incidents may include hemorrhage, high/total spinal, anaphylaxis, failed block23
❖ A successful regional anesthetic may help avoid the need to directly manage a difficult airway, it does not prevent it23
Even when utilizing regional anesthesia, an airway management strategy should always be discussed with the patient and planned in advance23
Apneic Oxygenation
❖ 15 L/min
❖ May prolong the time patient maintain adequate oxygen saturation during laryngoscopy/intubation
Use of high-flow nasal cannula oxygen therapy can prevent desaturation during tracheal intubation24
Presenter
Presentation Notes
Next, I want to talk about apneic oxygenation. Its something I learned about only a few years ago and feel is a very valuable tool to implement; especially when laryngoscopy might be expected to be difficult. “Apneic oxygenation is based on the principle that even when patient’s are apneic, alveoli can still absorb oxygen into the blood stream at a rate of approximately 250 ml/min To perform this technique, a nasal cannula can be placed under a face mask during pre-oxygenation. After induction, the flow rate can be increased to 15 l/mi and then left in place, administering oxygen through the nose throughout the intubation procedure. The end result is that the patient can remain saturated for a longer period of time even while apneic.
ETT Cuff Pressure❖ Complications associated with excessive ETT cuff
pressure can include25
• Sore throat• Recurrent laryngeal nerve palsy• Mucosal ischemia• Tracheal ulceration• Tracheal stenosis• Trachea-esophageal fistula• Death
❖ Studies have shown an inability to accurately identify ETT cuff pressure by palpating the pilot balloon.
❖ No correlation between years in practice or number of intubations performed and the ability to properly inflate the ETT cuff or detect over inflation.
❖ Current evidence suggests that a minimum volume of air to obviate air flow past the cuff, up to a maximum pressure of less than 25cm H20, is safest to minimize complications from high ETT cuff pressures.
Presenter
Presentation Notes
However, the ability to ventilate and the prevention of aspiration do take precedence over cuff pressure. If it is found that > 25cm H20 pressure is needed to prevent leak around the cuff, then that is what is needed. However, regular reassessment should be performed to identify changes in the minimum occlusive volume in order to allow subsequent reduction in ET tube cuff pressure.
Closed claims and the airway
Originally 223 cases (1989-1997) from the records of St. Paul Fire and Marine Insurance Company. Reviewed by 8 CRNA researchers
Updated recently looking at 245 claims (2003-2012 ) provided by CNA insurance company. Reviewed by 15 CRNA researchers
AANA Foundation Closed Claims Analysis26
Closed claims and the airway
❖ Years of experience do not appear to be a factor in terms of frequency of occurrence of adverse events.
❖ 69.8% of adverse events occurred in hospitals
❖ 68.2% of the events are confirmed to have occurred during the intra-anesthesia period but only 38.8% of the events became apparent to the provider during the intra-anesthesia period.
❖ 45.5% of negative outcomes were preventable
❖ In 32.7%, anesthesia management was deemed to have been inappropriate
❖ Respiratory events are responsible for the most common negative outcomes (31.8%).
❖ When there was a failure to meet AANA Practice Standards for Nurse Anesthetists, breach of standard #5 (includes continuous monitoring of oxygenation and ventilation) occurred 2nd most often behind breach of standard #4
AANA Foundation Closed Claims Analysis26
Presenter
Presentation Notes
*From the 2015 AANAF closed claims analysis Standard V Monitor, evaluate, and document the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs. When any physiological monitoring device is used, variable pitch and threshold alarms shall be turned on and audible. The CRNA should attend to the patient continuously until the responsibility of care has been accepted by another anesthesia professional. a. Oxygenation b. Ventilation Standard IV Implement and adjust the anesthesia care plan based on the patient’s physiologic status. Continuously assess the patient’s response to the anesthetic, surgical intervention, or procedure. Intervene as required to maintain the patient in optimal physiologic condition.
Closed claims and the airway
❖ Established in 1985 in an attempt to improve patient safety and prevent anesthesia related injuries
❖ At the time, 11% of total dollars paid for anesthesia related patient injuries while Anesthesiologist accounted for only 3% of total physicians insured
❖ Data is derived from lawsuits regardless of the litigation outcome
ASA Closed Claims Database27
Presenter
Presentation Notes
Over 10K claims in database to date
Closed claims and the airway
❖ Respiratory system issues accounted for 17% of all claims
❖ The most common respiratory events leading to anesthesia claims were difficult intubation, inadequate oxygenation or ventilation and pulmonary aspiration
❖ Claims arising from esophageal intubation have largely disappeared with the adoption of capnography
ASA Closed Claims Database27
(1990-2007)
Closed claims and the airwayRespiratory events leading to claims27
(1990-2007)
Presenter
Presentation Notes
As you can see, difficult intubation is the primary cause of respiratory related claims
Closed claims and the airwayClaims related to the difficult airway27
(1990-2007)
Closed claims and the airwayLessons Learned27
❖During airway emergencies, persistent intubation attempts were associated with death or permanent brain damage
❖The LMA was not an effective rescue device in some claims in which multiple, prolonged intubation attempts had been made
❖Surgical airway should be instituted early in the management of the difficult airway
Closed claims and the airway❖ NAP4: National Audit Project of the
Royal College of Anesthetist and the Difficult Airway Society28
❖ Not a closed claims per se. Evaluated cases from 309 NHS hospitals in the UK over a year (2008-2009)
❖ Designed to evaluate what types of airway devices are used during anesthesia, how often complications resulting in serious harm occur and to see how this information be used to reduce the incidence of these events and complications.
Closed claims and the airway❖ NAP 4 Highlights28
• Poor airway assessment
• Poor planning: Plan vs Strategy
• Failure to plan for Failure
• Failed use of awake FOI
• Repeated intubation attempts
• Supraglottic devices were used inappropriately
• High failure rate of needle cricothyroidotomy
• Aspiration was the single most common cause of death
Poor judgment, as determined by both the reporters and the reviewers,
repeatedly appeared to be the most common cause of events
Presenter
Presentation Notes
Poor airway assessment: an airway assessment wasn't done, was done incompletely or the clinician failed to modify airway management plans based on assessment findings. Plan vs Strategy: Study authors found that all too often, clinicians had a simple airway plan that included only a single approach to management of the airway. The study authors suggest the implementation of an airway management strategy instead. In contrast to a “plan” a strategy is a coordinated, logical sequence of plans, which aim to achieve good gas exchange and prevention of aspiration. Failure to plan for Failure: Study authors found that clinicians rarely gave thought to what would happen if their plans failed. Unexpectedly difficult airways left the clinician in a panic trying to resolve the issue. In these cases, outcomes were generally poor. It is recommended that all anesthesia departments should have an explicit policy for management of difficult or failed intubation and for impossible mask ventilation. The project identified numerous cases where awake fibreoptic intubation was indicated but was not used. The project methods did not enable them to determine why AFOI was not used but there were cases suggesting, lack of skills, lack of confidence, poor judgement and in some cases lack of suitable equipment being immediately available. Problems arose when difficult intubation was managed by multiple repeat attempts at intubation. The airway problem regularly deteriorated to a can’t intubate can’t ventilate situation. It was recognized that a change of approach is required rather than repeated use of a technique that has already failed. Supraglottic devices were used inappropriately: Numerous cases of aspiration when SAD were used on patients with multiple risk factors for aspiration. SAD’s were used in an attempt to avoid tracheal intubation in a known difficult airway High failure rate of needle cricothyroidotomy: 60% failure rate. Clinicians should be taught how to perform surgical airways. Aspiration was the single most common cause of death: poor judgement and poor patient assessment were likely the root causes in most cases of aspiration
The Takeaway
❖ Chose the right tool for the right patient (proper preparation, strategy)
❖ Learn from other’s mistakes (closed claims)
Presenter
Presentation Notes
Proper preparation: do an airway assessment, document airway assessment, have plan A, B and C Be aware of the information that is gleamed from closed claims analysis and adjust your practice based on what you learn from them
References1. Practice Guidelines for Preoperative Fasting & the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures. An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126(3):376-393.2. Smith I, Kranke P, Murat I, et al. Perioperative fasting in adults and children. European Journal of Anaesthesiology. 2011;28(8):556-569. doi:10.1097/eja.0b013e3283495ba1.3. Robinson M, Davidson A. Aspiration under anesthesia: Risk assessment and decision making. Continuing Education in Anaesthesia Critical Care and Pain.2014;14(4):171-175.4. Miller RM et al.,eds. Miller's Anesthesia. 8th ed. Philadelphia: Saunders; 2015: 1652-1680.5. Butterworth JF, Mackey DC, Wasnick JD, eds. Morgan & Mikhail’s Clinical Anesthesiology. 5th ed. McGraw Hill Companies. New York: 2013: 769.6. Practice Guidelines for Obstetric Anesthesia. An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology. 2016;124:00-00.7. Bhatia N, Bhagat H, Sen I. Cricoid pressure: Where do we stand? J Anaesthesiol Clin Pharmacol Journal of Anaesthesiology Clinical Pharmacology. 2014;30(1):3. doi:10.4103/0970-9185.125683. 8. Stewart JC, Bhananker S, Ramaiah R. Rapid-sequence intubation and cricoid pressure. International Journal Critical Illness and Injury Science. 2014;4(1):42–49. 9. Algie CM, Mahar RK, Tan HB, Wilson G, Mahar PD, Wasiak J. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database of Systematic Reviews. 2015. doi:10.1002/14651858.cd011656.10. Lefave M, Harrell B, Wright M. Analysis of Cricoid Pressure Force and Technique Among Anesthesiologists, Nurse Anesthetists, and Registered Nurses. Journal of PeriAnesthesia Nursing. 2016;31(3):237-244.11. Lundstrom LH, Vester-Andersen M, Moller AM, Charuluxananan S, L'hermite J, Wetterslev J. Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. British Journal of Anaesthesia. 2011;107(5):659-667.12. El-Ganzouri AR, Mccarthy RJ, Tuman KJ, Tanck EN, Ivankovich AD. Preoperative Airway Assessment. Anesthesia & Analgesia. 1996;82(6):1197-1204. doi:10.1213/00000539-199606000-00017. 13. Corso RM, Cattano D, Buccioli M, Carretta E, Maitan S. Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway. Brazilian Journal of Anesthesiology (English Edition). 2016;66(3):298-303. doi:10.1016/j.bjane.2014.09.003.14. El-Orbany M, Woehlc H, Salem M. Head and neck position for direct laryngoscopy. Anesthesia and Analgesia. 2011;133:103-109. doi:10.1213/ane.0b013e31821c7e9c.15. Walls RM, Murphy MF. Manual of Emergency Airway Management, 4th Ed Philadelphia: Lippincott Williams and Wilkins; 2012.
References16. Standards for Nurse Anesthesia Practice. American Association of Nurse Anesthetists website. http://www.aana.com/resources2/professionalpractice/Pages/Scope-of-Nurse-Anesthesia-Practice.aspx. Updated 2013. Accessed June 12, 2016. 17. Michalek P, Donaldson W, Vobrubova E, Hakl M. Complications Associated with the Use of Supraglottic Airway Devices in Perioperative Medicine. BioMed Research International. 2015;2015:1-13. doi:10.1155/2015/746560.18. Kang J-E, Oh C-S, Choi JW, Son IS, Kim S-H. Postoperative Pharyngolaryngeal Adverse Events with Laryngeal Mask Airway (LMA Supreme) in Laparoscopic Surgical Procedures with Cuff Pressure Limiting 25 : Prospective, Blind, and Randomised Study. The Scientific World Journal. 2014;2014:1-7. doi:10.1155/2014/709801.19. Cook T, Howes B. Supraglottic Airway devices: Recent Advances. Contin Educ Anaesth Crit Care Pain Continuing Education in Anaesthesia, Critical Care & Pain. 2011;11(2):56-61. 10.1093/bjaceaccp/mkq058.20. Whitacre W, Dieckmann L, Austin PN. An Update: Use of Laryngeal Mask Airway Devices in Patients in the Prone Position; AANA Journal. 2014:82(2).21. Caldiroli D, Cortellazi P. A new difficult airway management algorithm based upon the El Ganzouri Risk Index and GlideScope videolaryngoscope. A new look for intubation? Minerva Anestesiologica. 2011;77(10):1011-7. 22. Diaz-Gomez JL, Satyapirya A, Satyapriya SV et al. Standard clinical risk factors for difficult laryngoscopy are not independent predictors of intubation success with the GlideScope. Journal of Clinical Anesthesia. 2011; 23(8):603-610 doi:10.1016/j.jclinane.2011.03.006.23. Saxena, N. (2013). Airway management plan in patients with difficult airways having regional anesthesia. J Anaesthesiology Clin Pharmacol Journal of Anaesthesiology Clinical Pharmacology. 2013:29(4):558 doi.org/10.4103/0970-9185.119106.24. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Annals of Emergency Medicine.2012;59(3):165-175. doi:10.1016/j.annemergmed.2011.10.002.25. Sultan P, Carvalho B, Rose BO, Cregg R. Endotracheal tube cuff pressure monitoring: a review of the evidence. Journal of Perioperative Practice. 2011:21(11).26. Jordan LM, Quraishi. The AANA Foundation Malpractice Closed Claims Study: A Descriptive Analysis. AANA Journal. 2015;83(5); 318-323.27. Metzner J, Posner KL, Lam MS, Domino KB. Closed claims’ analysis. Best Practice & Research Clinical Anaesthesiology. 2011;25(2)263-276. doi:10.1016/j.bpa.2011.02.007.28. Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. British Journal of Anaesthesia. 2011;106(5):617–631. doi: 10.1093/bja/aer058.29. Reitman E, Flood P. Anaesthetic considerations for non-obstetric surgery during pregnancy. British Journal of Anaesthesia. 2011;107(suppl 1):i72-I78. doi:10.1093/bja/aer343.
