The High-Risk Airway

Perioxygenation During Advanced Airway Management

ABSTRACT

Advanced airway management is a skill that is used every day in patient care settings throughout the world. Albeit common, it is not benign. Advanced airway management may either be elective or urgent; in either case, it may result in significant patient morbiidity and mortality. The complications of difficult or failed endotracheal intubation can be severe and include death or permanent neurologic injury. Difficulty or failure with advanced airway management often coincides with the onset of hypoxia. The onset of hypoxia affects both the patient and the airway manager. While hypoxemia may result in dysrhythmias and ultimately cardiac arrest for the patient, it adds time pressure and stress to the airway manager, and thus may impact successful performance. In this review, we will discuss how to identify patients at risk for rapid desaturation during advanced airway management. Additionally, methods of peri-oxygenation throughout the performance of airway management will be discussed.

Tracheal tube introducer-associated airway trauma: a systematic review

BACKGROUND

Tracheal tube introducers are recommended in airway management guidelines and are used increasingly as videolaryngoscopy becomes more widespread. This systematic review aimed to summarise the published literature concerning tracheal tube introducer-associated airway trauma.

METHODS

PubMed, EMBASE and CINAHL databases were searched using pre-determined criteria. Two authors independently assessed search results and performed data extraction and risk of bias assessments.

RESULTS

We included 16 randomised controlled trials and five observational studies involving 10,797 patients. There was heterogeneity in patient characteristics, airway manipulation, and airway trauma definition and measurement. One study investigated hyperangulated videolaryngoscopy. The standard stylet was the most commonly reported introducer, followed by bougie and stylets with additional features such as video or lighted tip. Airway trauma resulted in low harm and most frequently involved injuries to the upper airway, followed by laryngeal and tracheobronchial injuries. Eighteen studies were comparative and reported a reduction in airway trauma incidence when an introducer was used, with the exception of the standard stylet. Median (IQR [range]) pooled incidence of airway trauma associated with standard stylets was 13.1% (4.2-31.4 [0.5-79.2])% and with bougies was 5.4% (0.4-49.9 [0.0-68.0])%. The risk of bias of included studies was variable and many randomised trials were found to be at high risk due to non-robust measurement of the outcome.

CONCLUSIONS

Stylets might be associated with an increased risk of airway trauma compared with other devices or when no stylet was used, though the quality of evidence is modest. However, other introducers appear to be safe and reduce the risk of airway trauma.

Executive Summary of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management

The Airway section of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) present the Guidelines for the integral management of difficult airway in adult patients. This document provides recommendations based on current scientific evidence, theoretical-educational tools and implementation tools, mainly cognitive aids, applicable to the treatment of the airway in the field of anesthesiology, critical care, emergencies and prehospital medicine. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations and optimization in the progression of the application of strategies to preserve adequate alveolar oxygenation in order to improve safety and quality of care.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Randomized controlled trial comparing an open surgical technique and a Seldinger technique for cricothyrotomy performed on a simulated airway

OBJECTIVES

Emergency cricothyrotomy is a lifesaving procedure performed when intubation fails and oxygenation cannot occur. There are multiple techniques and kits to perform this procedure. However, current evidence does not provide a definitive answer as to which method is superior. Two techniques in common use are a surgical technique and a percutaneous Seldinger-based cricothyrotomy kit. The objective was to determine which of these two methods was quickest to perform and to determine which was most preferred by participants.

METHODS

A prospective randomized controlled crossover trial was conducted involving emergency physicians and trainees. Each participant performed both cricothyrotomy techniques in succession on an airway model, with the technique performed first being randomized for each participant. The primary outcome was time to first insufflation of the artificial lung. A survey was completed by participants asking their comfort with each technique on a 5-point scale from 1 (not at all comfortable) to 5 (very comfortable) and which technique they preferred.

RESULTS

Twenty-one emergency physicians and nine emergency medicine trainees were recruited. The surgical technique was performed the fastest, with a mean (±SD) time of 51.6 (±16.3) s versus 66.6 (±14.9) s for the Seldinger technique, with a statistically significant difference of 15.0 s (95% confidence interval = 8.5 to 21.5, p < 0.001). The surgical technique was rated the most comfortable to perform, with a median rating of 5 (interquartile range [IQR] = 4-5) versus 4 (IQR = 3-5) for the Seldinger technique. The surgical technique was most preferred by participants (80% vs 20%).

CONCLUSION

The surgical technique was the fastest to perform and was rated the most comfortable to perform and the most preferred technique.