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

National survey on the current status of airway management in China

Apparently, understanding airway management status may help to reduce risk and improve clinical practice. Given these facts, our team conducted a second survey on the current status of airway management for mainland China following our 2016 national airway survey. The national survey was conducted from November 7 to November 28, 2022. An electronic survey was sent to the New Youth Anesthesia Forum, where Chinese anesthesiologists completed the questionnaire via WeChat. A total of 3783 respondents completed the survey, with a response rate of 72.14%. So far, in 2022, 34.84% of anesthesiologists canceled or delayed surgery at least once due to difficult airway. For the anticipated difficult airway management, 66.11% of physicians would choose awake intubation under sedation and topical anesthesia, while the percentage seeking help has decreased compared to the 2016 survey. When encountering an emergency, 74.20% of respondents prefer to use the needle cricothyrotomy, albeit less than a quarter have actually performed it. Anesthesiologists with difficult airway training experience reached 72.96%, with a significant difference in participation between participants in Tier 3 hospitals and those in other levels of hospitals (P < 0.001). The videolaryngoscope, laryngeal mask, and flexible intubation scope were equipped at 97.18%, 95.96%, and 62.89%, respectively. Additionally, the percentage of brain damage or death caused by difficult airways was significantly decreased. The study may be the best reference for understanding the current status of airway management in China, revealing the current advancements and deficiencies. The future focus of airway management remains on training and education.

Designing and implementing a new icon-based difficult airway cart: a two-phase prospective qualitative improvement project

PURPOSE

The difficult airway cart is essential for difficult airway management. Recognition of the importance of human factors in critical scenarios promoted the evolution of the difficult airway cart. Limitation to essential equipment, a structured layout, and proper labelling should be observed. We sought to redesign the difficult airway cart accordingly and analyze how perioperative professionals reacted to it.

METHODS

We conducted a two-phase prospective qualitative improvement project involving a multidisciplinary team. In phase 1, we reconfigured our difficult airway cart, including developing icons for labelling the drawers and discussing the equipment content. In phase 2, we delivered a multidisciplinary educational program and pre- and postsession questionnaires were administered to the professionals involved and compared.

RESULTS

Phase 1 of the project encompassed 21 participants. We presented the final layout and content of the difficult airway cart. In phase 2, 44 participants responded the presession questionnaires, and 30 participants answered the postsession questionnaires. The results showed that the new design and the implementation program increased the comfort level of professionals involved in a potential airway crisis (presession mean [standard deviation (SD)]: anesthesiologists, 8.0 [1.9]; anesthesia assistants/respiratory therapists [AAs/RTs], 9.3 [0.8]; operating room registered nurses [OR RNs], 6.3 [2.7]; P = 0.001; postsession: anesthesiologists, 8.5 [2.0]; AAs/RTs, 9.6 [0.5]; OR RN, 7.9 [2.0]; P = 0.10). Nevertheless, the improvement was only statistically significant among the OR RNs (presession mean [SD]: 6.3 [2.7]; postsession: 7.9 [2.0]; P = 0.01). Additionally, the program facilitated the recognition of the location of airway equipment in the airway cart (positive responses ranging from 97% to 100%).

CONCLUSION

Our quality improvement project successfully designed and implemented a new visual-based difficult airway cart at our institution. We believe this report enables other institutions to reproduce our project.

Impact of airway devices and emergency airway techniques characteristics on airway adverse events in mainland China: a cross-sectional study

BACKGROUND

Novel airway devices are becoming widely available, yet it is unclear whether the techniques or preferences of airway practitioners for airway management have been impacted. Given these facts, a cross-sectional study of the current status of airway management in mainland China was conducted and compared with previous survey findings.

METHODS

The national survey was conducted from November 7th to November 28th, 2022. An electronic survey was sent to the New Youth Anesthesia Forum to examine the availability of airway devices, preference for front-of-neck access (FONA) techniques, the incidence of adverse airway events, and the status of airway management training.

RESULTS

Questionnaires were completed by 3783 respondents, with a response rate of 72.14%. So far, the availability of optical airway devices has improved dramatically, with the availability of videolaryngoscopes reaching 97.18%. When encountering "cannot intubate, cannot ventilate" (CICV) scenarios, the majority of respondents would prefer needle cricothyrotomy to establish FONA. However, less than a quarter of respondents had actually performed it. Moreover, the incidence of airway adverse events from 2016 to 2022 was 11.48%, of which 5.13% were brain damage or death. Multivariate logistic regression analysis revealed that the ability to perform FONA techniques (odds ratio [OR] 0.23, 95% CI: 0.16, 0.32; P<0.001) and the availability of difficult airway management carts or kits (OR 0.59, 95% CI 0.41, 0.85; P=0.005) were associated with a lower incidence of airway adverse events.

CONCLUSIONS

Optical airway devices can overcome some of the challenges posed by difficult airways, yet the CICV scenario remains a major obstacle. The future focus of airway management should be training, particularly for complicated emergency airway techniques.

Influence of airway trolley organization on efficiency and team performance: A randomized, crossover simulation study

BACKGROUND

Failed management of unanticipated difficult airway situations contributes to significant anesthesia-related morbidity and mortality. Optimization of design and layout of difficult airway trolleys (DATs) may influence outcomes during airway emergencies. The main objective of the current study was to evaluate whether a difficult airway algorithm-based DAT with integrated cognitive aids improves efficiency and team performance in difficult airway scenarios.

METHODS

In a crossover design, 16 teams (anesthetist, nurse anesthetist, assistant nurse) completed two high-fidelity simulated unanticipated difficult airway scenarios. Teams used both an algorithm-based DAT and a comparison, standard DAT, in the scenarios and were randomized to order of trolley type. Outcome measures included objective efficiency parameters, team performance assessment and subjective user-ratings. Linear mixed models ANOVA, including DAT type and order of condition as main factors, was utilized for the primary analyses of the team results.

RESULTS

Usage of the algorithm-based DAT was associated with fewer departures from the difficult airway algorithm (p = .010), and reduced number of unnecessary drawer openings (p = .002), but no significant differences in time to retrieval of airway devices or time to first effective ventilation, compared to the standard DAT. There were no significant differences in team performance, although participants expressed strong preference for the algorithm-based DAT (all user-rated measures p < .0001). Higher percentage of female members of the team improved adherence to the difficult airway algorithm (p = .043).

CONCLUSIONS

Algorithm-based DATs with integrated cognitive aids may improve efficiency in difficult airway situations, compared to traditional DATs. These findings have implications for improvement of anesthetic practice.

Improving emergency airway cart efficiency in compliance with Joint Commission standards

BACKGROUND AND OBJECTIVE

Emergency Airway Carts (EAC) are essential for pediatric otolaryngologists to provide rapid bedside care for emergent airway scenarios. At many institutions, EAC bronchoscopy equipment is individually peal-packaged due to Joint Commission (JC) standards, creating significant inefficiency in equipment assembly during time sensitive clinical settings. The objective of this quality improvement initiative was to improve the efficiency of use of our emergency airway cart equipment.

METHODS

Individually peel-packaged bronchoscope equipment was replaced with JC compliant sets. Otolaryngology trainees (N = 8) and pediatric otolaryngology attending physicians (N = 11) were tested in a simulated airway emergency scenario, requiring bronchoscope assembly. Complete bronchoscope assembly and time to tracheal visualization (TTV) was measured for each participant, which started with initial clinical scenario presentation and ended with successful visualization of the trachea using the rigid bronchoscope.

RESULTS

Pre-airway cart interventions, 68.4% of participants built a complete bronchoscope with no missing pieces, which improved to 100% with the new cart organization. Post-EAC interventions, all 19 participants reduced TTV significantly by a mean of 177.7 s (p < 0.001). Trainees reduced TTV by a mean of 251.2 s (46.2%, p < 0.0001) and attendings by 124.2 s (31.5%, p < 0.0022). All participants found the new airway cart sets easier to use and improved equipment setup efficiency.

CONCLUSIONS

Compiling bronchoscope equipment into sterile sets allowed for improved TTV and bronchoscope quality for trainees and attending physicians while maintaining JC standards. Simulation improved confidence among both trainees and attending surgeons in providing optimal patient care in airway emergencies.

George J. A prospective randomised simulation trial comparing our novel AIR-BOX to standard airway equipment storage modalities

Background

There is little evidence guiding equipment handling during emergency endotracheal intubations (EEI). Available evidence and current practice are either outdated, anecdotal or focused on difficult—not emergency—intubation. In this study, we describe and evaluate our equipment handling unit: the AIR-BOX.

Methods

This is a proof-of-concept, prospective, randomised simulation trial. A convenience sample of 50 airway course participants voluntarily underwent randomisation: 21 to the AIR-BOX group, 14 to the intubation box group, and 15 to the crash cart group. The volunteers were asked to intubate a manikin using the equipment from the storage unit of their randomisation. Outcome measures included time-to-readiness, time-to-intubation, first-pass success, and subjective operator experience.

Results

The mean time-to-readiness was 67.2 s with the AIR-BOX, 84.6 s with the intubation box, and 115 s with the crash cart. The mean time-to-intubation was 105 s with the AIR-BOX, 127 s with the intubation box and 167 s with the crash cart. A statistically significant difference was achieved between the AIR-BOX and the crash cart. No statistically significant difference was found between the three groups with regard to first-pass success or the time between intubation readiness and intubation.

Conclusions

This study supports the AIR-BOX as a viable tool that can improve and simplify access to emergency intubating equipment. It also opens doors for multiple future innovations that can positively impact equipment handling practices. Future studies can focus on assessing whether applying the AIR-BOX will yield a clinically significant impact on patient outcomes.

Availability and organization of difficult airway equipment in Swedish hospitals: A national survey of anaesthesiologists

BACKGROUND

Airway complications account for almost one third of anaesthesia-related brain damage and death. Immediate access to equipment enabling rescue airway strategies is crucial for successful management of unanticipated difficult airway situations.

METHODS

We conducted a nationwide survey of Swedish anaesthesiologists to analyse availability and organization of difficult airway trolleys (DATs), and multiple factors pertaining to difficult airway management, to highlight areas of potential improvement.

RESULTS

Six hundred and thirty-nine anaesthesiologists completed the 14-item survey. Whereas DATs were almost ubiquitous (95%) in main operating departments of hospitals, prevalence was low in remote anaesthetizing locations (20.3%) and electroconvulsive therapy units (26.6%). Approximately 60% of emergency departments had a DAT. Immediate (within 60 seconds) access to videolaryngoscopes in all units where general anaesthesia is conducted was reported by 56.8%. Almost half of anaesthesiologists reported that all DATs at their workplace were standardized. Forty-six per cent reported that the DATs were organized according to a difficult airway algorithm; almost 90% believe that such an organization can impact the outcome of a difficult airway situation positively. Only 36.2% of DATs contained second-generation supraglottic airway devices exclusively. Most Swedish anaesthesiologists use the Swedish Society of Anaesthesiology and Intensive care Medicine difficult airway algorithm, but almost one fifth prefer the Difficult Airway Society algorithm. Less than half of respondents underwent formal difficult airway training annually.

CONCLUSION

Our results motivate efforts to (a) increase availability of DATs in remote anaesthetizing locations, (b) increasingly standardize DATs and organize DATs according to airway algorithms, and (c) increase the frequency of difficult airway training.

A national survey of videolaryngoscopes and alternative intubation devices in Hungary

INTRODUCTION

Videolaryngoscopy (VL) as a new airway management technique has evolved in recent decades, and a large number of videolaryngoscopes are now available on the market. Most recent major guidelines already recommend the immediate availability and use of VL in difficult airway management scenarios. However, national data on the availability of VL, introduction into practice and patterns of use are rarely published. Therefore, the current study aimed to provide data on VL in Hungary.

MATERIALS AND METHODS

An electronic survey was designed and popularized with the help of the Hungarian Society of Anaesthesiology and Intensive Therapy to explore the availability, use, and practice of and attitudes toward VL among Hungarian anesthesiologists. The survey was conducted between 01.01.2018 and 31.12.2018.

RESULTS

In total, 324 duly completed forms were returned and analyzed. Responders were mainly males (58%), specialists (80%) and those involved mainly in anesthesia practice (68%) in the public sector. Two hundred and ten (65%) responders had access to various videolaryngoscopes and were mainly from surgery, intensive care and traumatology units. No responders reported the availability of eight videolaryngoscopes out of the eighteen listed devices, and 32% of the responders had never used any videolaryngoscope in clinical settings. The most commonly available devices were KingVision, MacGrath Mac and Airtraq. Most of the responders reported using videolaryngoscopes mainly for difficult airway management and reported using a fiberscope as the first alternative device. Popular methods for selecting videolaryngoscopes included the following: short clinical trial (n = 67/324), decision of the departmental lead (n = 65/324) and price (n = 54/324). The majority of responders had some training prior to clinical application, but training was mainly voluntary. Overall, 98% of the responders considered videolaryngoscopes beneficial.

CONCLUSIONS

Approximately two-thirds of Hungarian anesthesiologists have immediate access to videolaryngoscopes, which are used mainly for difficult airway management. The overall attitude towards VL is positive, and many videolaryngoscopes are known and have been used by Hungarian anesthesiologists. However, only a few devices on the market are used commonly. Based on the results, further improvement might be recommended regarding VL training and availability.

Endotracheal catheter equipped with functional cuff produces clinically relevant positive end expiratory pressure: a bench study

Recently, we developed a novel endotracheal catheter with functional cuff (ECFC). Using such an ECFC and a regular ICU ventilator, we were able to generate clinically relevant tidal volume in a lung model and adult human sized animal. This ECFC allows co-axial ventilation without using a jet ventilator. The aim of this study was to determine if ECFC also could generate clinically relevant positive end expiratory pressure (PEEP). The experiment was conducted on a model lung and artificial trachea. Lung model respiratory mechanics were set to simulate those of an adult human being. The tip of the distal end of ECFC 14 or 19 Fr catheter was positioned in the artificial trachea 3 cm above the carina. The proximal end of ECFC was connected to an ordinary ICU ventilator. With 14 Fr catheter at respiratory rate 10 bpm, PEEP 0, 2.9, 8.2, 12.9 cmH₂O was generated at preset PEEP 0, 5, 10, 15 cmH₂O respectively and tidal volume was up to 393.4 ml. With 19 Fr catheter, PEEP was 0, 2.8, 7.6, 12.3 cmH₂O, at preset PEEP 0, 5, 10, 15 cmH₂O respectively and the tidal volume was up to 667.3 ml. With 14 Fr catheter at respiratory rate 20 bpm, PEEP was 0, 3.9, 9.6, 14.6 cmH₂O at preset PEEP 0, 5, 10, 15 cmH₂O respectively and tidal volume was up to 188.8 ml. With 19 Fr catheter, PEEP was 0, 3.6, 8.9, 13 cmH₂O, at preset PEEP 0, 5, 10, 15 cmH₂O respectively and tidal volume was up to 345.3 ml. ECFC enables clinicians to generate not only adequate tidal volume but also clinically relevant PEEP via co-axial ventilation using an ordinary ICU ventilator.

Management of the Difficult Airway in the Pediatric Patient

Loss of airway control in children, if not resolved quickly, will lead to devastating consequences. Successful management of the pediatric difficult airway, both anticipated and unanticipated, is facilitated by preprocedure assessment and preparation. Accessibility of and continued hands-on training with modern airway instruments, familiarization with difficult airway guidelines, and collaboration with multidisciplinary airway teams can aid in the management of the difficult pediatric airway. This review outlines the importance of airway assessment and advanced airway equipment for children. It also discusses difficult airway management techniques and algorithms for the management and rescue of the pediatric difficult airway.

A "Neurological Emergency Trolley" reduces turnaround time for high-risk medications in a general intensive care unit

OBJECTIVES

To reduce medication turnaround times during neurological emergencies, a multidisciplinary team developed a neurological emergency crash trolley in our intensive care unit. This trolley includes phenytoin, hypertonic saline and mannitol, as well as other equipment. The aim of this study was to assess whether the cart reduced turnaround times for these medications.

RESEARCH METHODOLOGY/DESIGN

In this retrospective cohort study, medication delivery times for two year epochs before and after its implementation were compared. Eligible patients were identified from our intensive care unit screening log. Adults who required emergent use of phenytoin, hypertonic saline or mannitol while in the intensive care unit were included. Groups were compared with nonparametric analyses.

SETTING

33-bed general medical-surgical intensive care unit in an academic teaching hospital.

MAIN OUTCOME MEASURES

Time to medication administration.

RESULTS

In the pre-intervention group, there were 43 patients with 66 events. In the post-intervention group, there were 45 patients with 80 events. The median medication turnaround time was significantly reduced after implementation of the neurological emergency trolley (25 vs. 10minutes, p=0.003). There was no statistically significant difference in intensive care or 30-day survival between the two cohorts.

CONCLUSION

The implementation of a novel neurological emergency crash trolley in our intensive care unit reduced medication turnaround times.

Human and equipment resources for difficult airway management, airway education programs, and capnometry use in Japanese emergency departments: a nationwide cross-sectional study

BACKGROUND

Although human and equipment resources, proper training, and the verification of endotracheal intubation are vital elements of difficult airway management (DAM), their availability in Japanese emergency departments (EDs) has not been determined. How ED type and patient volume affect DAM preparation is also unclear. We conducted the present survey to address this knowledge gaps.

METHODS

This nationwide cross-sectional study was conducted from April to September 2016. All EDs received a mailed questionnaire regarding their DAM resources, airway training methods, and capnometry use for tube placement. Outcome measures were the availability of: (1) 24-h in-house back-up; (2) key DAM resources, including a supraglottic airway device (SGA), a dedicated DAM cart, surgical airway devices, and neuromuscular blocking agents; (3) anesthesiology rotation as part of an airway training program; and (4) the routine use of capnometry to verify tube placement. EDs were classified as academic, tertiary, high-volume (upper quartile of annual ambulance visits), and urban.

RESULTS

Of the 530 EDs, 324 (61.1%) returned completed questionnaires. The availability of in-house back-up coverage, surgical airway devices, and neuromuscular blocking agents was 69.4, 95.7, and 68.5%, respectively. SGAs and dedicated DAM carts were present in 51.5 and 49.7% of the EDs. The rates of routine capnometry use (47.8%) and the availability of an anesthesiology rotation (38.6%) were low. The availability of 24-h back-up coverage was significantly higher in academic EDs and tertiary EDs in both the crude and adjusted analysis. Similarly, neuromuscular blocking agents were more likely to be present in academic EDs, high-volume EDs, and tertiary EDs; and the rate of routine use of capnometry was significantly higher in tertiary EDs in both the crude and adjusted analysis.

CONCLUSIONS

In Japanese EDs, the rates of both the availability of SGAs and DAM carts and the use of routine capnometry to confirm tube placement were approximately 50%. These data demonstrate the lack of standard operating procedures for rescue ventilation and post-intubation care. Academic, tertiary, and high-volume EDs were likely to be well prepared for DAM.

Use of a Novel Airway Kit and Simulation in Resident Training on Emergent Pediatric Airways

Objective Development of a novel pediatric airway kit and implementation with simulation to improve resident response to emergencies with the goal of improving patient safety. Methods Prospective study with 9 otolaryngology residents (postgraduate years 1-5) from our tertiary care institution. Nine simulated pediatric emergency airway drills were carried out with the existing system and a novel portable airway kit. Response times and time to successful airway control were noted with both the extant airway system and the new handheld kit. Results were analyzed to ensure parametric data and compared with t tests. A Bonferroni adjustment indicated that an alpha of 0.025 was needed for significance. Results Use of the airway kit significantly reduced the mean time of resident arrival by 47% ( P = .013) and mean time of successful intubation by 50% ( P = .007). Survey data indicated 100% improved resident comfort with emergent airway scenarios with use of the kit. Discussion Times to response and meaningful intervention were significantly reduced with implementation of the handheld airway kit. Use of simulation training to implement the new kit improved residents' comfort and airway skills. This study describes an affordable novel mobile airway kit and demonstrates its ability to improve response times. Implications for Practice The low cost of this airway kit makes it a tenable option even for smaller hospitals. Simulation provides a safe and effective way to familiarize oneself with novel equipment, and, when possible, realistic emergent airway simulations should be used to improve provider performance.

[Airway management in intensive care units in Rhineland-Palatinate : Evolution over five years]

BACKGROUND

Securing the airway in severely ill patients is associated with a high rate of complications. So far, no information exists about the equipment readily available for airway management in German intensive care units (ICUs). It is also unknown if the range of material has improved over time.

OBJECTIVES

In the present trial the availability of equipment for airway management in ICUs in Rhineland-Palatinate was evaluated at two different times.

MATERIALS AND METHODS

Using a structured questionnaire, all ICUs in the state were contacted in the years 2010 and 2015. The availability of different types of equipment for airway management, as well as the presence of a training program for airway management, was evaluated.

RESULTS

For 2010 data from 64 ICUs were evaluated and for 2015 data sets from 63 ICUs were collected. In 2010 indirect laryngoscopes were available in eight ICUs; in 2015 these devices were directly accessible in 43 units (p < 0.0001). Extraglottic devices were available in all but one ICU in 2010 and all ICUs in 2015. Equipment for emergency surgical airway procedures was available in nearly every ICU (n = 60). The availability of capnography increased significantly from 2010 (n = 12) to 2015 (n = 56; p < 0.0001). In 2010 and 2015, frequent training with a focus on airway management was performed in 23 and 32 units, respectively (p > 0.05).

CONCLUSION

Most ICUs in Rhineland-Palatinate have a broad range of equipment for airway management available, and the range has significantly improved over the time period evaluated. The availability of indirect laryngoscopes and capnometers improved significantly. However, it is remarkable that in some ICU's there is still a lack of equipment for advanced airway management.

Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review

Management of the difficult airway is an important, but as yet poorly-studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Techniques for the difficult airway

PURPOSE OF REVIEW

Management of the difficult airway is associated with significant morbidity and mortality in critically ill patients. An increasing array of advanced airway tools are available, but appropriate selection and application in the ICU remains poorly defined.

RECENT FINDINGS

Difficult airway incidence during emergent intubation is 10%, but complications of ICU airway management remain common. Training and equipment in many ICUs remain variable despite data that demonstrate that an 'intubation management bundle' and a systematic approach to teamwork and training can reduce life-threatening airway complications. A protocol employing an extraglottic airway (EGA) early in cases of inadequate ventilation has been associated with no episodes of prolonged hypoxemia in 12 225 consecutive intubations. Direct laryngoscopy with gum elastic bougie is the most commonly employed method to manage emergent difficult airways, and videolaryngoscopes also provide greater glottic visualization and a high rate of intubation success in patients with difficult airway risk factors or a failed airway.

SUMMARY

A systematic approach to intubation that emphasizes planning and teamwork can reduce intubation complications. Early use of an EGA or cricothyroidotomy may reduce complications when oxygenation is inadequate. Use of a gum elastic bougie or indirect optical device is also associated with a high rate of intubation success when oxygenation permits.

Jet or intensive care unit ventilator during simulated percutaneous transtracheal ventilation: a lung model study

BACKGROUND

Percutaneous transtracheal ventilation (PTV) via a jet ventilator (PTJV) is considered a rescue technique in difficult airway management. However, whether a conventional ventilator can generate adequate ventilation via PTV is not known. Our goal was to evaluate the tidal volume (V(T)) generated by a conventional ventilator during simulated PTV compared with PTJV in a lung model.

METHODS

A lung model simulating an adult lung was used. A catheter was inserted through the artificial trachea and connected to either a jet ventilator or a conventional ventilator. The direction of catheter insertion was perpendicular to the trachea, pointing towards the lung and away from the lung. The jet ventilator was operated at 344.7 kPa. The conventional ventilator was operated in the pressure mode at peak inspiratory pressures of 40-90 cm H(2)O.

RESULTS

The jet ventilator generated larger V(T) [817 (336) ml] when the catheter was pointing towards the lung than when pointing away from the lung or perpendicular to the trachea [121 (41) and 69 (24) ml, respectively, P<0.01]. With the conventional ventilator, changes in V(T) at different direction of catheter insertion were much less [222 (81) ml catheter pointing towards the lung, 229 (121) ml perpendicular to the trachea, and 187 (97) ml away from the lung].

CONCLUSIONS

Our result demonstrated that PTJV was effective only when the catheter was pointing towards the lung and requires high operating pressure. A conventional ventilator can generate reasonable minute ventilation through the transtracheal catheter less dependent on directions of catheter insertion and should be considered during emergent PTV.

Strategies to prevent airway complications: a survey of adult intensive care units in Australia and New Zealand

BACKGROUND

There is growing evidence that airway complications are relatively common in critical care. Strategies have been suggested to decrease their incidence.

METHODS

We conducted a telephone survey of all adult intensive care units (ICUs) in Australia and New Zealand to establish the current practice regarding strategies used to reduce airway complications in five key areas: (i) use of capnography; (ii) care of oral tracheal tubes; (iii) care of tracheostomy tubes; (iv) difficult and failed intubation; and (v) training and medical staffing.

RESULTS

Of 176 ICU meeting inclusion criteria, 171 agreed to participate. Capnography is used during tracheal intubation in 88% of ICUs and for continuous monitoring in 64%. Protocols for advancing or partially withdrawing malpositioned tracheal tubes are used by 54% of units, with most allowing repositioning by unaccredited nurses. A small minority of ICUs use bed head signs to identify patients with 'critical airways' or laryngectomy, while only 8% have specific protocols for the care of these high-risk patients. Tracheostomy emergency algorithms are available in 13% of ICUs. At night, a doctor is exclusively assigned to 73% of units, although in 72%, the night doctor is not required to have prior anaesthetic/airway training. In 97% of the institutions surveyed, the senior doctor relied upon for airway emergencies at night is either non-resident or working elsewhere in the hospital.

CONCLUSIONS

Our data suggest that several possible strategies for avoiding airway complications in ICU patients dependent on an artificial airway are poorly implemented. This may expose these patients to avoidable risk.