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Nagasaka A, Shimizu T, Minami T, Takenaka I. Anticipated difficult airway management using a model of the upper airway. Can J Anaesth 2020; 67:1078-1080. [PMID: 32034675 DOI: 10.1007/s12630-020-01590-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 01/17/2020] [Accepted: 01/21/2020] [Indexed: 10/25/2022] Open
Affiliation(s)
- Aiko Nagasaka
- Department of Anesthesiology, University of Occupational Environmental Health Japan, Yahatanishi, Kitakyushu, Japan.
| | - Takehiro Shimizu
- Department of Anesthesiology, Wakamatsu Hospital of the University of Occupational Environmental Health Japan, Wakamatsu, Kitakyushu, Japan
| | - Tomoko Minami
- Department of Anesthesia, Kyushu Rosai Hospital, Kokuraminami, Kitakyushu, Japan
| | - Ichiro Takenaka
- Department of Anesthesia, Kyushu Rosai Hospital, Kokuraminami, Kitakyushu, Japan
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Athanassoglou V, Hughes‐Jones H, Hadjipavlou G, Teoh WH, Kristensen MS, Vanner R. Depth to the airway lumen at the level of the cricothyroid membrane measured by ultrasound. Acta Anaesthesiol Scand 2020; 64:48-52. [PMID: 31436317 DOI: 10.1111/aas.13464] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/29/2019] [Accepted: 08/02/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Knowing the likely depth to the airway before emergency cricothyroidotomy may improve success in cases where it cannot be measured. Our aim was to measure the depth to the airway at the cricothyroid membrane by ultrasound in a large group of adult patients. METHOD Prospective, observational study in two centres, Oxford and Gloucester. Patients presenting for a large variety of surgical operations were studied. Patients under 18 years; pregnant; critically ill; had a history of neck surgery were not included. Ultrasound examination was performed pre-operatively while participants lay supine with their head and neck extended, with light transducer pressure. We measured depth to the airway lumen in mm; age; weight; height and sex. RESULTS In total 352 patients were studied. We found that depth to the airway lumen strongly correlated with weight (r = 0.855, P < 0.001) and to a lesser extent body mass index (r = 0.781, P < 0.001). Statistical analysis produced an equation to predict upper 95% CI of depth to the airway from the patient's weight: Depth to the airway lumen in mm = (0.13 × weight in kg) + 0.86. CONCLUSIONS If ultrasound measurement is not possible before emergency cricothyroidotomy, the clinician could use our results to predict the depth to the airway by using the patient's weight. If the upper 95% CI were used as the depth of incision, it would enter the airway in 39 out of 40 patients of that weight, without damage to posterior structures in those with a shallower airway.
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Affiliation(s)
- Vassilis Athanassoglou
- Nuffield Department of Anaesthesia Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - Hannah Hughes‐Jones
- Department of Anaesthesia Gloucestershire Hospitals NHS Foundation Trust Gloucester UK
| | - George Hadjipavlou
- Nuffield Department of Anaesthesia Oxford University Hospitals NHS Foundation Trust Oxford UK
| | | | - Michael S. Kristensen
- Department of Anaesthesia, Center of Head and Orthopaedics Rigshospitalet University Hospital of Copenhagen Copenhagen Denmark
| | - Richard Vanner
- Department of Anaesthesia Gloucestershire Hospitals NHS Foundation Trust Gloucester UK
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Kumar A, Verma S, Tiwari T, Dhasmana S, Singh V, Singh GP. A comparison of two doses of ketamine with dexmedetomidine for fiberoptic nasotracheal intubation. Natl J Maxillofac Surg 2019; 10:212-216. [PMID: 31798258 PMCID: PMC6883880 DOI: 10.4103/njms.njms_86_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/03/2019] [Accepted: 01/15/2019] [Indexed: 01/01/2023] Open
Abstract
Background and Aims: Flexible fiber-optic intubation is considered to be the gold standard for management of difficult airway. Fiber-optic intubation does require effective sedation and blunting of airway reflexes for which various drug regimens have been utilized in the past. In a quest to find the noble drug combination, we combined ketamine and dexmedetomidine in two different doses, to evaluate the clinical efficacy and safety profile of ketamine and dexmedetomidine for fiber-optic intubation. Materials and Methods: This prospective randomized study was conducted in 72 patients of 20–50 years’ age group of either sex with the American Society of Anesthesiologists Physical Status I and II with difficult airway. We compared two doses of ketamine 20 mg (Group I) and 40 mg (Group II) with a common dose of dexmedetomidine at 1 μg/kg body weight, given as an infusion over 10 min (a solution of 50 ml with normal saline). Sedation scores, hemodynamic variables in terms of blood pressure, heart rate (HR), and oxygen saturation were studied along with 24-h postoperative patient discomfort and recall of procedure. Results: Group II patients showed less variation from their baseline values in terms of HR (ranged between 0.73% and 4.75%) and mean arterial pressure (ranged between 0% and 3.97%) in comparison to Group I HR (ranged between 0.09% and 9.81%) and mean pressures (ranged between 0.3% and 10.38%). Discomfort during procedure (P < 0.001) and recall of procedure scale (P = <0.001) were found significantly better/lower in Group II as compared to Group I. Conclusion: Ketamine 40 mg in comparison to 20 mg with dexmedetomidine provides better hemodynamic conditions with better tolerance and lower recall to the fiber-optic intubation.
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Affiliation(s)
- Arun Kumar
- Department of Anaesthesiology, KGMU, Lucknow, Uttar Pradesh, India
| | - Sateesh Verma
- Department of Anaesthesiology, KGMU, Lucknow, Uttar Pradesh, India
| | - Tanmay Tiwari
- Department of Anaesthesiology, KGMU, Lucknow, Uttar Pradesh, India
| | - Satish Dhasmana
- Department of Anaesthesiology, KGMU, Lucknow, Uttar Pradesh, India
| | - Vinita Singh
- Department of Anaesthesiology, KGMU, Lucknow, Uttar Pradesh, India
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Acute Awake Fiberoptic Intubation in the ICU in a Patient with Limited Mouth Opening and Hypoxemic Acute Respiratory Failure. Case Rep Anesthesiol 2019; 2019:6421910. [PMID: 31772778 PMCID: PMC6854940 DOI: 10.1155/2019/6421910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/31/2019] [Accepted: 08/19/2019] [Indexed: 12/17/2022] Open
Abstract
The incidence and survival of patients with head-and-neck cancer have been on the increase for decades. Following surgery or radiation therapy, complications such as difficult airways may evolve. These difficult airways may be unique and not manageable with conventional intubation methods as well as video laryngoscopes. Acute awake fiberoptic intubation may be a feasible option also for urgent emergency airway management of known difficult airways. The “cannot intubate–cannot oxygenate” (CI–CO) situation has to be avoided at all costs, since emergency cricothyrotomy has a fail ratio of more than 50% when performed by an anesthesiologist.
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Mao Z, Zhang N, Cui Y. A clinical prediction rule to identify difficult intubation in children with Robin sequence requiring mandibular distraction osteogenesis based on craniofacial CT measures. BMC Anesthesiol 2019; 19:215. [PMID: 31752712 PMCID: PMC6868728 DOI: 10.1186/s12871-019-0889-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Airway management is challenging in children with Robin sequence (RS) requiring mandibular distraction osteogenesis (MDO). We derived and validated a prediction rule to identify difficult intubation before MDO for children with RS based on craniofacial computed tomography (CT) images. METHOD This was a retrospective study of 69 children with RS requiring MDO from November 2016 to June 2018. Multiple CT imaging parameters and baseline characteristic (sex, age, gestational age, body mass index [BMI]) were compared between children with normal and difficult intubation according to Cormack-Lehane classification. A clinical prediction rule was established to identify difficult intubation using group differences in CT parameters (eleven distances, six angles, one section cross-sectional area, and three segment volumes) and clinicodemographic characteristics. Predictive accuracy was evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS The overall incidence of difficult intubation was 56.52%, and there was no significant difference in sex ratio, age, weight, height, BMI, or gestational age between groups. The distance between the root of the tongue and posterior pharyngeal wall was significantly shorter, the bilateral mandibular angle shallower, and the cross-sectional area at the epiglottis tip smaller in the difficult intubation group. A clinical prediction rule based on airway cross-sectional area at the tip of the epiglottis was established. Area > 36.97 mm2 predicted difficult intubation while area < 36.97 mm2 predicted normal intubation with 100% sensitivity, 62.5% specificity, 78.6% positive predictive value, and 100% negative predictive value (area under the ROC curve = 0.8125). CONCLUSION Computed tomography measures can objectively evaluate upper airway morphology in patients with RS for prediction of difficult intubation. If validated in a larger series, the measures identified could be incorporated into airway assessment tools to guide treatment decisions. This was a retrospective study and was granted permission to access and use these medical records by the ethics committee of Guangzhou Women and Children's Medical Center. TRIALS REGISTRATION Registration No. ChiCTR1800018252, NaZhang, Sept 7 2018.
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Affiliation(s)
- Zhe Mao
- Guangzhou Women and Children's Medical Center, No 9, Jinsui Road, Guangzhou, 510623, Guangdong, China
| | - Na Zhang
- Guangzhou Women and Children's Medical Center, No 9, Jinsui Road, Guangzhou, 510623, Guangdong, China
| | - Yingqiu Cui
- Guangzhou Women and Children's Medical Center, No 9, Jinsui Road, Guangzhou, 510623, Guangdong, China.
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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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Grange K, Mushambi M, Jaladi S, Athanassoglou V. Techniques and complications of awake fibre-optic intubation – A Survey of Difficult Airway Society members. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Managing and securing the bleeding upper airway: a narrative review. Can J Anaesth 2019; 67:128-140. [DOI: 10.1007/s12630-019-01479-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 06/12/2019] [Accepted: 06/14/2019] [Indexed: 12/11/2022] Open
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Walas W, Aleksandrowicz D, Kornacka M, Gaszyński T, Helwich E, Migdał M, Piotrowski A, Siejka G, Szczapa T, Bartkowska-Śniatkowska A, Halaba ZP. The management of unanticipated difficult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel. Scand J Trauma Resusc Emerg Med 2019; 27:87. [PMID: 31533787 PMCID: PMC6751579 DOI: 10.1186/s13049-019-0666-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/09/2019] [Indexed: 12/22/2022] Open
Abstract
Children form a specific group of patients, as there are significant differences between children and adults in both anatomy and physiology. Difficult airway may be unanticipated or anticipated. Difficulties encountered during intubation may cause hypoxia, hypoxic brain injury and, in extreme situations, may result in the patient’s death. There are few paediatric difficult-airway guidelines available in the current literature, and some of these have significant limitations. This position paper, intended for unanticipated difficult airway, was elaborated by the panel of specialists representing the Polish Society of Anaesthesiology and Intensive Care as well as the Polish Neonatal Society. It covers both elective intubation and emergency situations in children in all age groups. An integral part of the paper is an algorithm. The paper describes in detail all stages of the algorithm considering some modification in specific age groups, i.e. neonates.
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Affiliation(s)
- Wojciech Walas
- Paediatric and Neonatal Intensive Care Unit, University Hospital in Opole, Opole, Poland
| | | | - Maria Kornacka
- Neonatal and Intensive Care Department, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Gaszyński
- Department of Anaesthesiology and Intensive Therapy, Medical University of Lodz, Lodz, Poland
| | - Ewa Helwich
- Clinic of Neonatology and Intensive Neonatal Care, Institute of Mother and Child Care, Warsaw, Poland
| | - Marek Migdał
- Paediatric Intensive Care Unit, Children's Memorial Health Institute, Warsaw, Poland
| | - Andrzej Piotrowski
- Department of Anaesthesia and Intensive Care, Children's Memorial Health Institute, Warsaw, Poland
| | - Grażyna Siejka
- Department of Paediatric Anaesthesiology and Intensive Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Szczapa
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Alicja Bartkowska-Śniatkowska
- Department of Paediatric Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | - Zenon P Halaba
- Institute of Medicine, University of Opole, 48 Oleska Str, 45-052, Opole, Poland.
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Jimbo I, Uzawa K, Tokumine J, Mitsuda S, Watanabe K, Yorozu T. Ultrasonographic identification of the cricothyroid membrane in a patient with a difficult airway as a result of cervical hematoma caused by hemophilia: a case report. BMC Anesthesiol 2019; 19:124. [PMID: 31288737 PMCID: PMC6617830 DOI: 10.1186/s12871-019-0798-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/30/2019] [Indexed: 02/08/2023] Open
Abstract
Background Surgical cricothyroidotomy is a last resort in patients with an anticipated difficult airway, but without any guarantee of success. Identification of the cricothyroid membrane may be the key to successful cricothyrotomy. Ultrasonographic identification of the cricothyroid membrane has been reported to be more useful than the conventional palpation technique. However, ultrasonographic identification techniques are not yet fully characterized. Case presentation A 28-year-old man with hemophilia and poor adherence to medication. He was brought to the emergency department with a large cervical hematoma and respiratory difficulty. An otolaryngologist decided to insert a tracheal tube to maintain his airway. However, emergent laryngoscopy indicated an anticipated difficult airway. A backup plan that included awake intubation by the anesthesiologists and surgical cricothyroidotomy by an otolaryngologist was devised. The cricothyroid membrane could not be identified by palpation but was detected by ultrasonographic identification with a longitudinal approach. Awake fiberoptic intubation was successfully performed. Conclusions In this case, the cricothyroid membrane could be identified using the longitudinal approach but not the transverse approach. It may be ideal to know which ultrasound technique can be applied for each patient.
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Affiliation(s)
- Ippei Jimbo
- Department of Anesthesiology , Kyorin University, School of Medicine 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-0004, Japan
| | - Kohji Uzawa
- Department of Anesthesiology , Kyorin University, School of Medicine 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-0004, Japan.
| | - Joho Tokumine
- Department of Anesthesiology , Kyorin University, School of Medicine 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-0004, Japan
| | - Shingo Mitsuda
- Department of Anesthesiology , Kyorin University, School of Medicine 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-0004, Japan
| | - Kunitaro Watanabe
- Department of Anesthesiology , Kyorin University, School of Medicine 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-0004, Japan
| | - Tomoko Yorozu
- Department of Anesthesiology , Kyorin University, School of Medicine 6-20-2 Shinkawa, Mitaka City, Tokyo, 181-0004, Japan
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Hung O, Malpas GA, Wong C. In reply: Concern regarding the use of extracorporeal membrane oxygenation in the anticipated difficult airway. Can J Anaesth 2019; 66:1117-1118. [PMID: 31172364 DOI: 10.1007/s12630-019-01417-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 05/14/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Orlando Hung
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada.
| | - Gemma A Malpas
- Department of Adult and Emergency Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Chrison Wong
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
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The article of month: A way to communicate with airway enthusiasts. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2019.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Abstract
An airway manager’s primary objective is to provide a path to oxygenation. This can be achieved by means of a facemask, a supraglottic airway, or a tracheal tube. If one method fails, an alternative approach may avert hypoxia. We cannot always predict the difficulties with each of the methods, but these difficulties may be overcome by an alternative technique. Each unsuccessful attempt to maintain oxygenation is time lost and may incrementally increase the risk of hypoxia, trauma, and airway obstruction necessitating a surgical airway. We should strive to optimize each effort. Differentiation between failed laryngoscopy and failed intubation is important because the solutions differ. Failed facemask ventilation may be easily managed with an supraglottic airway or alternatively tracheal intubation. When alveolar ventilation cannot be achieved by facemask, supraglottic airway, or tracheal intubation, every anesthesiologist should be prepared to perform an emergency surgical airway to avert disaster.
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Affiliation(s)
- Richard M. Cooper
- From the Department of Anesthesia, Faculty of Medicine, University of Toronto and University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
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Cabrini L, Baiardo Redaelli M, Ball L, Filippini M, Fominskiy E, Pintaudi M, Putzu A, Votta CD, Sorbello M, Antonelli M, Landoni G, Pelosi P, Zangrillo A. Awake Fiberoptic Intubation Protocols in the Operating Room for Anticipated Difficult Airway. Anesth Analg 2019; 128:971-980. [DOI: 10.1213/ane.0000000000004087] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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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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Baillard C, Boubaya M, Statescu E, Collet M, Solis A, Guezennec J, Levy V, Langeron O. Incidence and risk factors of hypoxaemia after preoxygenation at induction of anaesthesia. Br J Anaesth 2019; 122:388-394. [DOI: 10.1016/j.bja.2018.11.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/12/2018] [Accepted: 11/17/2018] [Indexed: 12/20/2022] Open
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Detsky ME, Jivraj N, Adhikari NK, Friedrich JO, Pinto R, Simel DL, Wijeysundera DN, Scales DC. Will This Patient Be Difficult to Intubate?: The Rational Clinical Examination Systematic Review. JAMA 2019; 321:493-503. [PMID: 30721300 DOI: 10.1001/jama.2018.21413] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available. OBJECTIVE To identify risk factors and physical findings that predict difficult intubation. DATA SOURCES The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies. STUDY SELECTION Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed. DATA EXTRACTION AND SYNTHESIS Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge. RESULTS Among the 62 high-quality studies involving 33 559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of <3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring <9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]). CONCLUSIONS AND RELEVANCE Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient.
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Affiliation(s)
- Michael E Detsky
- Department of Medicine, Sinai Health System, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Naheed Jivraj
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Neill K Adhikari
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Departments of Critical Care Medicine and Medicine, St Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David L Simel
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Duminda N Wijeysundera
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Prospective validation of a new airway management algorithm and predictive features of intubation difficulty. Br J Anaesth 2019; 122:245-254. [DOI: 10.1016/j.bja.2018.09.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 09/28/2018] [Accepted: 09/29/2018] [Indexed: 12/20/2022] Open
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71
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The Difficult Airway Trolley: A Narrative Review and Practical Guide. Anesthesiol Res Pract 2019; 2019:6780254. [PMID: 30833967 PMCID: PMC6369510 DOI: 10.1155/2019/6780254] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 12/06/2018] [Accepted: 01/01/2019] [Indexed: 01/14/2023] Open
Abstract
Death and severe morbidity attributable to anesthesia are commonly associated with failed difficult airway management. When an airway emergency develops, immediate access to difficult airway equipment is critical for implementation of rescue strategies. Previously, national expert consensus guidelines have provided only limited guidance for the design and setup of a difficult airway trolley. The overarching aim of the current work was to create a dedicated difficult airway trolley (for patients>12 years old) for use in anesthesia theatres, intensive care units, and emergency departments. A systematic literature search was performed, using the PubMed, Embase, and Google Scholar search engines. Based on evidence presented in 11 national or international guidelines, and peer-reviewed journals, we present and outline a difficult airway trolley organized to accommodate sequential progression through a four-step difficult airway algorithm. The contents of the top four drawers correspond to specific steps in the airway algorithm (A = intubation, B = oxygenation via a supraglottic airway device, C = facemask ventilation, and D = emergency invasive airway access). Additionally, specialized airway equipment may be included in the fifth drawer of the proposed difficult airway trolley, thus enabling widespread use. A logically designed, guideline-based difficult airway trolley is a vital resource for any clinician involved in airway management and may aid the adherence to difficult airway algorithms during evolving airway emergencies. Future research examining the availability of rescue airway devices in various clinical settings, and simulation studies comparing different types of difficult airway trolleys, are encouraged.
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Noll E, Shodhan S, Varshney A, Gallagher C, Diemunsch P, Florence FB, Romeiser J, Bennett-Guerrero E. Trainability of Cricoid Pressure Force Application. Anesth Analg 2019; 128:109-116. [DOI: 10.1213/ane.0000000000003385] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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73
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Langeron O, Bourgain JL, Francon D, Amour J, Baillard C, Bouroche G, Chollet Rivier M, Lenfant F, Plaud B, Schoettker P, Fletcher D, Velly L, Nouette-Gaulain K. Difficult intubation and extubation in adult anaesthesia. Anaesth Crit Care Pain Med 2018; 37:639-651. [DOI: 10.1016/j.accpm.2018.03.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 12/17/2022]
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74
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You-Ten KE, Wong DT, Ye XY, Arzola C, Zand A, Siddiqui N. Practice of Ultrasound-Guided Palpation of Neck Landmarks Improves Accuracy of External Palpation of the Cricothyroid Membrane. Anesth Analg 2018; 127:1377-1382. [DOI: 10.1213/ane.0000000000003604] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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75
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Hayashida K, Matsumoto S, Kitano M, Sasaki J. Predictive value of quick surgical airway assessment for trauma (qSAT) score for identifying trauma patients requiring surgical airway in emergency room. BMC Emerg Med 2018; 18:48. [PMID: 30497393 PMCID: PMC6267875 DOI: 10.1186/s12873-018-0203-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 11/20/2018] [Indexed: 12/23/2022] Open
Abstract
Background A surgical airway is usually unpredictable in trauma patients. The aim of this study was to develop a predictable scoring system to determine the need for a surgical airway by using a database from a large multicenter trauma registry. Methods We obtained data from the nationwide trauma registry in Japan for adult blunt trauma patients who were intubated in the emergency department. Based on a multivariate logistic regression analysis in the development cohort, the Quick Surgical Airway Assessment for Trauma (qSAT) score was defined to predict the need for a surgical airway. The association of the qSAT with surgical airway was validated in the validation cohort. Results Between 2004 and 2014, 17,036 trauma patients were eligible. In the development phase (n = 8129), the qSAT score was defined as the sum of the three binary components, including male sex, presence of a facial injury, and presence of a cervical area injury, for a total score ranging from 0 to 3. In the validation cohort (n = 8907), the proportion of patients with a surgical airway markedly increased with increasing qSAT score (0 points, 0.5%; 1 point, 0.9%; 2 points, 3.5%; 3 points, 25.0%; P < 0.001). Multivariate analysis revealed that qSAT score was an independent predictor of surgical airway (adjusted OR, 3.19 per 1 point increase; 95% CI, 2.47–4.12; P < 0.0001). The qSAT score of ≥1 had a had a good sensitivity of 86.8% for predicting the requirement for surgical airway; while qSAT score of 3 had a good specificity of 99.9% in ruling out the need for surgical airway. Conclusions The qSAT score could be assessed simply using only information present upon hospital arrival to identify patients who may need a surgical airway. The utilize of qSAT score in combination with repeated evaluations on physical finding could improve outcomes in trauma patients.
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Affiliation(s)
- Kei Hayashida
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, 230-8765, Kanagawa, Japan
| | - Mitsuhide Kitano
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama, 230-8765, Kanagawa, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Bruijstens L, Titulaer I, Scheffer GJ, Steegers M, van den Hoogen F. Emergency front-of-neck airway by ENT surgeons and residents: A dutch national survey. Laryngoscope Investig Otolaryngol 2018; 3:356-363. [PMID: 30410989 PMCID: PMC6209617 DOI: 10.1002/lio2.183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 04/20/2018] [Accepted: 05/25/2018] [Indexed: 12/19/2022] Open
Abstract
Objectives ENT surgeons and anesthesiologists work closely together in managing challenging airway cases. Sharing knowledge, experiences, and expectations interdisciplinary is essential in order to facilitate decision‐making and adequate management in emergency front‐of‐neck airway cases. Methods A survey was performed, to analyze level of experience, technique of preference, training, knowledge of material and protocols, and self‐efficacy scores of Dutch ENT surgeons and residents in performing an urgent or emergency front‐of‐neck airway. Results Within one year (January 2014–2015), 25.7% of the 257 respondents had performed an urgent or emergency front‐of‐neck airway. Of all reported emergency front‐of‐neck airways (N = 30), 80% were managed by tracheotomy. In future emergency front‐of‐neck airway cases, 74% stated cricothyrotomy would be their technique of preference. The majority would choose an uncuffed large‐bore cannula technique. Post‐academic hands‐on training was attended by 42% of respondents. Self‐efficacy scores were highest for surgical tracheotomy, and higher when trained or experienced. In case of an emergency scenario, 8.6% would not perform a front‐of‐neck airway themselves. The main reasons for reluctance to start in general were lack of experience and lack of training. Reported items for improvement were mainly the development of a protocol and training. Conclusion The chance of encountering an airway emergency scenario requiring front‐of‐neck airway is realistic. There is inconsistency between advised technique, technique of preference and technique actually performed by ENT surgeons. This study shows that there is both a need and desire for improvement in training and organization of care. Interdisciplinary guidelines and education is needed and could eventually safe lives. Level of evidence 5
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Affiliation(s)
- Loes Bruijstens
- Department of Anesthesiology Pain Medicine and Palliative Care, Radboud University Medical Center Nijmegen the Netherlands
| | - Imke Titulaer
- Department of Emergency Medicine Maxima Medical Center Veldhoven the Netherlands
| | - Gert Jan Scheffer
- Department of Anesthesiology Pain Medicine and Palliative Care, Radboud University Medical Center Nijmegen the Netherlands
| | - Monique Steegers
- Department of Anesthesiology Pain Medicine and Palliative Care, Radboud University Medical Center Nijmegen the Netherlands
| | - Frank van den Hoogen
- Department of Otorhinolaryngology and Head and Neck Surgery Radboud University Medical Center Nijmegen the Netherlands
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Xue FS, Liu QJ. Tracheal Intubation Awake or Under Anesthesia for Potential Difficult Airway: Look Before You Leap. Chin Med J (Engl) 2018. [PMID: 29521305 PMCID: PMC5865328 DOI: 10.4103/0366-6999.226891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Fu-Shan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Qian-Jin Liu
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Jiang J, Ma DX, Li B, Wu AS, Xue FS. Videolaryngoscopy versus fiberoptic bronchoscope for awake intubation - a systematic review and meta-analysis of randomized controlled trials. Ther Clin Risk Manag 2018; 14:1955-1963. [PMID: 30410341 PMCID: PMC6197207 DOI: 10.2147/tcrm.s172783] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Background Awake intubation with videolaryngoscopy (VL) is a novel method that is drawing more and more attention as an alternative to awake intubation with fiberoptic bronchoscope (FOB). This meta-analysis is designed to determine the performance of VL compared to the FOB for awake intubation. Methods The Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web of science were searched from database inception until October 30, 2017. Randomized controlled trials comparing VL and FOB for awake intubation were selected. The primary outcome was the overall success rate. Rev-Man 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE system was used to assess the quality of evidence for all outcomes. Results Six studies (446 patients) were included in the review for data extraction. Pooled analysis did not show any difference in the overall success rate by using VL and FOB (relative risk [RR], 1.00; P=0.99; high-quality evidence). There was no heterogeneity among studies (I2=0). Subgroup analyses showed no differences between two groups through nasal (RR, 1.00; P=1.00; high-quality evidence) and oral intubations (RR, 1.00; P=0.98; high-quality evidence). The intubation time was shorter by using VL than by using FOB (mean difference, −40.4 seconds; P<0.01; low-quality evidence). There were no differences between groups for other outcomes (P>0.05). Conclusion For awake intubation, VL with a shorter intubation time is as effective and safe as FOB. VL may be a useful alternative to FOB.
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Affiliation(s)
- Jia Jiang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Da-Xu Ma
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Bo Li
- Beijing Hospital of Traditional Chinese Medicine, Affiliated to Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing 100010, China
| | - An-Shi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, China
| | - Fu-Shan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China,
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Schäuble JC, Heidegger T. [Management of the difficult airway : Overview of the current guidelines]. Anaesthesist 2018; 67:725-737. [PMID: 30291405 DOI: 10.1007/s00101-018-0492-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Several national airway task forces have recently updated their recommendations for the management of the difficult airway in adults. Routinely responding to airway difficulties with an algorithm-based strategy is consistently supported. The focus is increasingly not on tools and devices but more on good planning, preparation and communication. In the case of anticipated airway difficulties the airway should be secured when the patient is awake with maintenance of spontaneous ventilation. Unaltered a flexible bronchoscopic intubation technique is advised as a standard of care in such patients. The importance of maintenance of oxygenation is emphasized. Face mask ventilation and the use of supraglottic devices are recommended if unexpected airway difficulties occur. Face mask ventilation may be facilitated and optimised by early administration of neuromuscular blocking agents. If required, in not fastened patients threatened by acute hypoxia, carefully applied and pressure-controlled ventilation may ensure sufficient oxygenation until the airway is secured. Apnoeic oxygen techniques are recommended in high-risk patients and to relieve the time pressure of falling oxygen saturation during decision-making processes. The early use of video laryngoscopy is advised for endotracheal intubation in the case of failed direct laryngoscopy or if intubation is expected to be difficult. For the coverage of cannot intubate-cannot oxygenate scenarios, second generation supraglottic devices and invasive airway access are advocated. The discussion regarding the optimal technique for emergency invasive airway access is still in progress. In the case of uncontrollable respiratory deterioration and progressive hypoxia, the algorithm must be consistently executed and without delay due to ineffective activities (straightforward strategy). Although there is no evidence to support the selection of a particular approach, the importance and the need for a defined airway concept/algorithm in any anesthesia department is fostered. Simplicity and clarity are essential for recall under stressful and time-sensitive conditions. The algorithm should be adapted to local conditions and preferences and devices should be limited to a definite number. The acquisition and maintenance of expertise by education and training is demanded.
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Affiliation(s)
- J C Schäuble
- Institut für Anästhesiologie, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Schweiz.
| | - T Heidegger
- Departement für Anästhesie, Intensivmedizin und Reanimation, Spitalregion Rheintal, Werdenberg, Sarganserland, Schweiz.,Universität Bern, Bern, Schweiz
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Onrubia X, Frova G, Sorbello M. Front of neck access to the airway: A narrative review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.06.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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81
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Dixit A, Ramaswamy KK, Perera S, Sukumar V, Frerk C. Impact of change in head and neck position on ultrasound localisation of the cricothyroid membrane: an observational study. Anaesthesia 2018; 74:29-32. [DOI: 10.1111/anae.14445] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2018] [Indexed: 12/15/2022]
Affiliation(s)
- A. Dixit
- Northampton General Hospital; Northampton UK
| | | | - S. Perera
- Northampton General Hospital; Northampton UK
| | - V. Sukumar
- Northampton General Hospital; Northampton UK
| | - C. Frerk
- Northampton General Hospital; Northampton UK
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82
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Hannig KE, Jessen C, Hauritz RW, Grejs AM. Awake Fiberoptic Intubation in Fast Track Ambulatory Surgery: A Case Report. A A Pract 2018; 11:165-168. [PMID: 30130277 DOI: 10.1213/xaa.0000000000000863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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83
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Ieropoulos P, Tassoudis V, Ntafoulis N, Mimitou I, Vretzakis G, Tzovaras G, Zacharoulis D, Karanikolas M. Do Difficult Airway Techniques Predispose Obese Patients to Bronchospasm? Turk J Anaesthesiol Reanim 2018; 46:292-296. [PMID: 30140536 DOI: 10.5152/tjar.2018.02328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 02/06/2018] [Indexed: 02/03/2023] Open
Abstract
Objective The existing evidence separately correlates morbid obesity with difficult intubation and bronchospasm. However, there is a lack of data on whether anaesthesia provider manipulations during difficult intubation contribute to an increased ratio of bronchospasm in these patients. Methods This is a retrospective analysis of data prospectively taken from 50 morbidly obese patients involved in a previously published study. A possible difficult intubation was preoperatively investigated by recording the following specific physical examination indices: Mallampati and Cormack-Lehane (CL) classifications, cervical spine mobility (CSM), thyromental distance (Td) and patients' ability to open their mouth (mouth opening). Bronchospasm was clinically detected by auscultation and confirmed by measuring peak airway pressures during mechanical ventilation. The Kruskal-Wallis H test was used for data analysis, followed by the Mann-Whitney U test as applicable. Results Different physical examination prognostic indices, including Mallampati and CL scales (p<0.001; the CSM excluded -p=0.790), showed that they are related to difficult intubation. Bronchospasm not attributable to difficult intubation was observed in six obese patients. Conclusion Patients with morbid obesity constitute an increased relative risk group as far as difficult intubation is concerned, particularly if preoperative findings support a relationship between the two variables examined. In our study, difficult intubation and the concomitant use of special equipment and manipulations did not contribute to an increased rate of bronchospasm in obese patients, but in view of the lack of data, a large number of more sophisticated studies are required to elucidate such an assumption.
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Affiliation(s)
| | - Vassilios Tassoudis
- Department of Anesthesiology, University Hospital of Larissa, Larissa, Greece
| | - Nick Ntafoulis
- Department of Anesthesiology, General Hospital of Larissa, Larissa, Greece
| | - Ioanna Mimitou
- Department of Anesthesiology, "Gennimatas" General Hospital of Thessaloniki, Thessaloniki, Greece
| | - George Vretzakis
- Department of Anesthesiology, University Hospital of Larissa, Larissa, Greece
| | - George Tzovaras
- Department of Surgery, University Hospital of Larissa, Larissa, Greece
| | | | - Menelaos Karanikolas
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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84
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Zhang J, Ho DYM, Tan KH, Swe M. Success of blind tracheal intubation using the Auragain laryngeal airway compared with the Intubating Laryngeal Mask Airway (lma Fastrach) by novice users: A manikin study. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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85
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Teoh WH, Kristensen MS. Prediction in airway management: what is worthwhile, what is a waste of time and what about the future? Br J Anaesth 2018; 117:1-3. [PMID: 27317701 DOI: 10.1093/bja/aew148] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- W H Teoh
- Private Anaesthesia Practice, Wendy Teoh Pte. Ltd, Singapore
| | - M S Kristensen
- Rigshospitalet, Copenhagen University Hospital, Blegdamsvej, Copenhagen DK-2100, Denmark
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Kristensen M, Teoh W. Front of neck: continued discovery of this anatomy essential for airway management. Br J Anaesth 2018; 120:895-898. [DOI: 10.1016/j.bja.2018.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 02/12/2018] [Accepted: 02/14/2018] [Indexed: 12/20/2022] Open
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Ultrasound as an Assessment Method in Predicting Difficult Intubation: A Prospective Clinical Study. J Maxillofac Oral Surg 2018; 17:563-569. [PMID: 30344401 DOI: 10.1007/s12663-018-1088-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/22/2018] [Indexed: 12/19/2022] Open
Abstract
Objective Aim of the study is to predict the difficulty in intubation preoperatively using ultrasonography. Methods One hundred and thirty-seven patients underwent ultrasound followed by surgery under general anesthesia. A experienced radiologist examined the airway and performed measurements of specific airway parameters: visualization of hyoid bone, visualization of vocal cords through thyroid cartilage, visualization of epiglottis, distance from base of tongue to hyoid bone, distance of hyomental region distance of thyrohyoid region, distance between skin and fat pad thickness to thyroid cartilage, thickness of submental region, distance from epiglottis to skin (above hyoid), and visualization of cricothyroid membrane. After performing ultrasound, patient was presented for surgery. An experienced anesthesiologist who is associated with this study did all the laryngoscopy and intubation. Results We were able to visualize all relevant anatomical structures in all the participants using ultrasound. The receiver operating characteristic curve analysis results showed that hyomental is ≤ 1.09 (P value < 0.01) to classify difficult in intubation. Conclusion The study shows that ultrasound can reliably image all the airway structures. This study suggests that hyomental distance is a more valid criterion in predicting difficult intubation. Further, case control study is needed for assessing the ease of intubation.
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Temporal Trends in Difficult and Failed Tracheal Intubation in a Regional Community Anesthetic Practice. Anesthesiology 2018; 128:502-510. [DOI: 10.1097/aln.0000000000001974] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract
Background
When tracheal intubation is difficult or unachievable before surgery or during an emergent resuscitation, this is a critical safety event. Consensus algorithms and airway devices have been introduced in hopes of reducing such occurrences. However, evidence of improved safety in clinical practice related to their introduction is lacking. Therefore, we selected a large perioperative database spanning 2002 to 2015 to look for changes in annual rates of difficult and failed tracheal intubation.
Methods
Difficult (more than three attempts) and failed (unsuccessful, requiring awakening or surgical tracheostomy) intubation rates in patients 18 yr and older were compared between the early and late periods (pre- vs. post-January 2009) and by annual rate join-point analysis. Primary findings from a large, urban hospital were compared with combined observations from 15 smaller facilities.
Results
Analysis of 421,581 procedures identified fourfold reductions in both event rates between the early and late periods (difficult: 6.6 of 1,000 vs. 1.6 of 1,000, P < 0.0001; failed: 0.2 of 1,000 vs. 0.06 of 1,000, P < 0.0001), with join-point analysis identifying two significant change points (2006, P = 0.02; 2010, P = 0.03) including a pre-2006 stable period, a steep drop between 2006 and 2010, and gradual decline after 2010. Data from 15 affiliated practices (442,428 procedures) demonstrated similar reductions.
Conclusions
In this retrospective assessment spanning 14 yr (2002 to 2015), difficult and failed intubation rates by skilled providers declined significantly at both an urban hospital and a network of smaller affiliated practices. Further investigations are required to validate these findings in other data sets and more clearly identify factors associated with their occurrence as clues to future airway management advancements.
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The use of extracorporeal membrane oxygenation in the anticipated difficult airway: a case report and systematic review. Can J Anaesth 2018; 65:685-697. [DOI: 10.1007/s12630-018-1099-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 12/18/2017] [Accepted: 12/20/2017] [Indexed: 12/15/2022] Open
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Okano H, Uzawa K, Watanabe K, Motoyasu A, Tokumine J, Lefor AK, Yorozu T. Ultrasound-guided identification of the cricothyroid membrane in a patient with a difficult airway: a case report. BMC Emerg Med 2018; 18:5. [PMID: 29422029 PMCID: PMC5806288 DOI: 10.1186/s12873-018-0156-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 01/31/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Surgical cricothyroidotomy is considered to be the last resort for management of the difficult airway. A major point for a successful surgical cricothyroidotomy is to identify the location of the cricothyroid membrane. CASE PRESENTATION We encountered a patient with progressive respiratory distress who was anticipated to have a difficult airway due to a large neck abscess. We prepared for both awake intubation and surgical cricothyroidotomy. The cricothyroid membrane could not be identified by palpation, but was readily identified using ultrasound. CONCLUSION Ultrasound-guided identification of the cricothyroid membrane may be useful in a patient with a difficult airway due to neck swelling.
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Affiliation(s)
- Hiromu Okano
- Department of Anesthesiology, Kyorin University School of Medicine, Mailing address: 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Kohji Uzawa
- Department of Anesthesiology, Kyorin University School of Medicine, Mailing address: 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan.
| | - Kunitaro Watanabe
- Department of Anesthesiology, Kyorin University School of Medicine, Mailing address: 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Akira Motoyasu
- Department of Anesthesiology, Kyorin University School of Medicine, Mailing address: 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Joho Tokumine
- Department of Anesthesiology, Kyorin University School of Medicine, Mailing address: 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, Mailing address: 3311-1 Yakushiji, Shimotsuke-shi, Tochigi-ken, 329-0498, Japan
| | - Tomoko Yorozu
- Department of Anesthesiology, Kyorin University School of Medicine, Mailing address: 6-20-2 Shinkawa, Mitaka-shi, Tokyo, 181-8611, Japan
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Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit. Ann Am Thorac Soc 2018; 14:368-375. [PMID: 27983871 DOI: 10.1513/annalsats.201606-472oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. OBJECTIVES To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). METHODS This is an observational study of 906 consecutive patients intubated in the ICU with a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. MEASUREMENTS AND MAIN RESULTS There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7-27.0% vs. 13.3%; 95% CI, 8.0-18.8%). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64-4.20), airway edema (OR, 2.85; 95% CI, 1.48-5.45), and obesity (OR, 1.59; 95% CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60-4.64), cervical immobility (OR, 3.34; 95% CI, 1.28-8.72), and airway edema (OR, 3.10; 95% CI, 1.42-6.70) were associated with first-attempt failure. CONCLUSIONS In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.
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94
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Obstructive sleep apnea as a risk factor associated with difficult airway management - A narrative review. J Clin Anesth 2018; 45:63-68. [PMID: 29291467 DOI: 10.1016/j.jclinane.2017.12.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 12/14/2017] [Accepted: 12/21/2017] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE The association between obstructive sleep apnea (OSA) and difficult airway had been studied in various clinical trials but the relationship between the two conditions has not been clearly established. The objective of this narrative review is to determine if OSA is a risk factor associated with difficult airway. DESIGN The OVID Medline in process, Medline (vis Pub Med), EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science and SCOPUS were searched up to April 2016 using specific keywords. Inclusion criteria were: [1] airway management in patients with a diagnosis of OSA, [2] comparison of airway management between OSA and non-OSA patients, [3] publications or abstracts in the English language. The incidence of difficult airway between OSA and non-OSA patients was compared using Chi-square analysis or Fisher's exact test. MAIN RESULTS Ten studies were included in the final review. Overall, the incidence of difficult tracheal intubation was higher in OSA patients versus non-OSA patients [56/386 (14.5%) vs. 69/897 (7.7%); P=0.0002]. OSA patients also have a higher incidence of difficult mask ventilation [115/4626 (2.5%) vs. 471/64,684 (0.7%); P<0.0001]. Compared to non-OSA patients, OSA was not associated with difficulty in the use of a supraglottic airway (SGA) device [10/663 (1.5%) vs. 162/15,171 (1.1%); P=0.38]. No studies compared difficult surgical airway in OSA and non-OSA patients. CONCLUSIONS OSA was found to be a risk factor associated with difficult tracheal intubation and difficult mask ventilation. There was no association between OSA and difficult SGA use.
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95
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Ruth N, Maryam B, Mawaddah A, Bee-See G. Novel tubeless supraglottic ventilation in a difficult paediatric airway. EGYPTIAN JOURNAL OF ANAESTHESIA 2018. [DOI: 10.1016/j.egja.2018.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ng Ruth
- Department of Otorhinolaryngology Head and Neck SurgeryUniversiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia
| | - Budiman Maryam
- Departmentof Anaesthesiology and Intensive Care, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia
| | - Azman Mawaddah
- Department of Otorhinolaryngology Head and Neck SurgeryUniversiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia
| | - Goh Bee-See
- Department of Otorhinolaryngology Head and Neck SurgeryUniversiti Kebangsaan Malaysia Medical Centre (UKMMC), Kuala Lumpur, Malaysia
- Institute of EarHearing and Speech (Institute-HEARS), Universiti Kebangsaan Malaysia (UKM), Kuala Lumpur, Malaysia
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96
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Chae JS, Woo JH, Kim CH, Chun EH, Baik HJ, Choi MH. Endotracheal Intubation Using McGrath Videolaryngoscope in Klippel-Feil Syndrome. THE EWHA MEDICAL JOURNAL 2018. [DOI: 10.12771/emj.2018.41.4.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Ji Seon Chae
- Department of Anesthesiology and Pain Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Chi Hyo Kim
- Department of Anesthesiology and Pain Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Eun Hee Chun
- Department of Anesthesiology and Pain Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Min Hee Choi
- Department of Anesthesiology and Pain Medicine, Ewha Womans University College of Medicine, Seoul, Korea
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97
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Kristensen MS, Fried E, Biro P. Infrared Red Intubation System (IRRIS) guided flexile videoscope assisted difficult airway management. Acta Anaesthesiol Scand 2018; 62:19-25. [PMID: 29063583 DOI: 10.1111/aas.13016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 09/26/2017] [Accepted: 09/30/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Tracheal intubation with a flexible scope is a cornerstone technique in patients with severely difficult airways, but may fail. We report on a technique, Infrared Red Intubation System (IRRIS), that seems to facilitate the identification of the glottis. METHODS The IRRIS is placed over the patient's cricothyroid membrane and emits blinking infrared light through the patient's skin into the subglottic space. When a flexible videoscope (one that does not filter infrared light) is introduced into the airway, it will display this as a blinking white light emerging from the glottis, retrograde transillumination, showing the pathway to the trachea. We have introduced this as an adjunct when managing our patients with difficult airways. We describe the technique and retrospectively report on the first ten patients where it was used. RESULTS All ten patients had significant pathology in the airway, radiation therapy, predictors for difficult intubation and/or morbid obesity. In all cases the blinking light was visible during the flexible endoscopy and provided unambiguous identification of the glottis, from a distance. The blinking nature of the light from the IRRIS helped to distinguish it from the reflections in the mucosa that inevitably arise when the mucosa is hit by the light from the flexible scope itself. CONCLUSION The addition of the IRRIS technique to intubation with flexible videoscopes may be a tool that will make intubation of the most difficult airways easier and may be of special help to the clinician who only rarely uses flexible videoscopes for tracheal intubation.
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Affiliation(s)
- M. S. Kristensen
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University Hospital of Copenhagen; Copenhagen Denmark
| | - E. Fried
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University Hospital of Copenhagen; Copenhagen Denmark
| | - P. Biro
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University Hospital of Copenhagen; Copenhagen Denmark
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98
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Gómez-Ríos MA, Gaitini L, Matter I, Somri M. Guidelines and algorithms for managing the difficult airway. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2018; 65:41-48. [PMID: 29031661 DOI: 10.1016/j.redar.2017.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 07/03/2017] [Indexed: 06/07/2023]
Abstract
The difficult airway constitutes a continuous challenge for anesthesiologists. Guidelines and algorithms are key to preserving patient safety, by recommending specific plans and strategies that address predicted or unexpected difficult airway. However, there are currently no "gold standard" algorithms or universally accepted standards. The aim of this article is to present a synthesis of the recommendations of the main guidelines and difficult airway algorithms.
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Affiliation(s)
- M A Gómez-Ríos
- Departamento de Anestesiología y Medicina Perioperativa, Complejo Hospitalario Universitario de A Coruña , La Coruña (Galicia), España; Grupo de Anestesiología y Tratamiento del Dolor, Instituto de Investigación Biomédica de A Coruña (INIBIC), La Coruña (Galicia), España.
| | - L Gaitini
- Department of Anesthesiology, Bnai Zion Medical Center, Haifa, Israel; Faculty of Medicine, Technion, Institute of Technology, Haifa, Israel
| | - I Matter
- Department of Surgery, Bnai Zion Medical Center, Haifa, Israel; Faculty of Medicine, Technion, Institute of Technology, Haifa, Israel
| | - M Somri
- Department of Anesthesiology, Bnai Zion Medical Center, Haifa, Israel; Department of Surgery, Bnai Zion Medical Center, Haifa, Israel
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99
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Update on difficult airway management with a proposal of a simplified algorithm, unified and applied to our daily clinical practice. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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100
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Hirakawa M, Nishihara T, Nakanishi K, Kitamura S, Fujii S, Ikemune K, Dote K, Takasaki Y, Yorozuya T. Perioperative management of a patient with Coffin-Lowry syndrome complicated by severe obesity: A case report and literature review. Medicine (Baltimore) 2017; 96:e9026. [PMID: 29245289 PMCID: PMC5728904 DOI: 10.1097/md.0000000000009026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
RATIONALE Coffin-Lowry syndrome (CLS) is a rare inherited disease with specific clinical features, such as mental retardation, facial dysmorphism, and cardiac abnormality. In particular, the characteristic facial features of CLS, including retrognathia and large tongue, are associated with difficult ventilation and/or intubation, which is a serious problem of anesthesia management. However, case reports on anesthesia management of CLS are very limited as there are only two published English reports till date. In this case report, we discuss anesthetic and postoperative considerations in patients with CLS, focusing on difficult airway management, and summarize past reports including some Japanese articles. PATIENT CONCERNS A 25-year-old man with CLS was planning to undergo laminectomy because of progressive quadriplegia caused by calcification of the yellow ligament. We suspected difficulty in airway management because of several factors in his facial features, short thyromental and sternomental distances in computed tomography, severe obesity, and sleep apnea syndrome. DIAGNOSES Difficult airway was suspected. However, because of mental retardation, awake intubation was considered difficult. INTERVENTIONS We selected bronchofiberscope-guided nasotracheal intubation, maintaining spontaneous breathing under moderate sedation with a propofol target-controlled infusion. OUTCOMES Airway management was safely performed during anesthesia induction. LESSONS In many patients with CLS, difficult intubation was reported, and sedation or slow induction maintaining spontaneous breathing was mainly selected for anesthesia induction. Spontaneous breathing should be maintained during anesthesia induction in case of CLS patients.
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Affiliation(s)
- Mikako Hirakawa
- Department of Anesthesiology and Resuscitology, Ehime University Hospital, Shitsukawa, Toon
| | - Tasuku Nishihara
- Department of Anesthesiology and Resuscitology, Ehime University Hospital, Shitsukawa, Toon
| | - Kazuo Nakanishi
- Department of Anesthesiology and Resuscitology, Ehime University Hospital, Shitsukawa, Toon
| | - Sakiko Kitamura
- Department of Anesthesiology and Resuscitology, Ehime University Hospital, Shitsukawa, Toon
| | - Sonoko Fujii
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine
| | - Keizo Ikemune
- Intensive Care Unit, Ehime University Hospital, Shitsukawa, Toon, Ehime, Japan
| | - Kentaro Dote
- Intensive Care Unit, Ehime University Hospital, Shitsukawa, Toon, Ehime, Japan
| | - Yasushi Takasaki
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine
| | - Toshihiro Yorozuya
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine
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