Management of the difficult airway: alternative airway techniques and adjuncts

Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study

INTRODUCTION

Airway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients.

METHODS

The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters.

RESULTS

Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1-2.5, range 1-31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways.

CONCLUSIONS

EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.

Rapid Intubation Sequence: 4-Year Experience in an Emergency Department

Background

The rapid intubation sequence is advanced airway management that effectively ensures an adequate supply of oxygen in critically ill patients. The medical personnel in the emergency department performed this procedure.

Objective

To describe the main characteristics of the rapid intubation sequence in an emergency department of a high complexity hospital.

Methods

This is a descriptive, cross-sectional, retrospective study. We included all older patients with a rapid intubation sequence requirement in the emergency department from 2014 to 2017. We used central tendency measures for numerical variables and proportions for categorical variables.

Results

A total of 401 patients were eligible for this analysis. The main indication for intubation was the Glasgow Coma Scale = <8 in 170 patients (42.4%), followed by hypoxemia in 142 patients (35.4%). In 36 patients, at least one complication occurred. RSI was performed in 54.4% by emergency physician. RSI was successful on the first attempt in 90.5%. Only 36 patients (9%) presented complications.

Conclusion

In this study, we found that the rapid intubation sequence was not related to a high proportion of complications. Perhaps, this is attributed to the degree of medical training and the use of emergency department protocols in our hospital.

Managing the difficult airway: A survey of doctors with different seniority in China

ABSTRACT

Although equipment and human resources are vital elements of difficult airway management (DAM). But the approach and practice of DAM are more important. So, we conducted the present survey to address anesthesiologists of different working years in this knowledge gap.This nationwide cross-sectional study was conducted from October 27, 2016 to November 27, 2016. The survey was completed online in New Youth Anesthesia Forum including DAM assessment, anticipated and unanticipated DAM, difficult airway algorithm, use of the front of neck access (FONA) technique and training, DAM outside the operation room, and difficult extubation management.We received 1935 replies (44%). Mouth opening and Mallampati classification were the most common methods to evaluate difficult airways. When suffering from unanticipated difficult airway 63% less than 10 years anesthesiologists (LA) and 65% more than 10 years anesthesiologists (MA) would ask for help after trying 1 to 2 times (P = .000). More than 70% of LA and MA respondents reported preferring cannula cricothyrotomy to deal with emergency airway, 507 (41.6%) MA respondents reported that they used FONA techniques to save patients' lives (P = .000). Nearly 70% respondents worried full stomach when intubated outside operation room and more than 80% respondents selected auscultation to identify the placement. More than 80% respondents had not used Bougie to assist extubation. A 73.2% respondents know ABS algorithm and 96.4% know Chinese airway expert consensus among MA respondents, this was significant to LA respondents (P = .000).The respondents in the LA and MA have a training gap in their evaluation of difficult airways, trained and used FONA emergency skills, facilitated of the airway guidelines at home and abroad. Also, we should provide more airway theory and skill training to our young doctors to advanced airway skills.

The relationship between the intramuscular bleeding of the tongue and cause of death

Intramuscular bleeding of the tongue (ImBT) is occasionally found during post mortem examination. Despite its frequent reports, its cause has not yet been clarified. In this study, forensic autopsy data of 799 cadavers were examined and the relationship between ImBT and cause of death was investigated. A total of 74 cases showed ImBT (16 of 66 cases of fire fatality, 17 of 108 cases of drowning, 23 of 74 cases of asphyxiation, and 18 of 551 cases of other causes of death). The frequency of bleeding was significantly greater in cases with causes of death including fire fatality, drowning, and asphyxiation compared to those with other causes of death (p < 0.01). Among asphyxiation cases, ImBT was confirmed in two of five cases of typical hanging, three of 16 cases of atypical hanging, six of six cases of ligature strangulation, two of two cases of manual strangulation, eight of 38 cases of airway obstruction, and two of seven cases of oxygen deficiency. Among fire fatalities, the carboxyhemoglobin (CO-Hb) concentration of cases with ImBT was significantly lower than that in cases without ImBT (p < 0.01). In addition, the frequency of bleeding was significantly higher (p < 0.05) in cases where the blood cyanide concentration was 0.05 ppm or less. These observations suggested that ImBT during fire fatality occurs in a manner similar to that of ligature or manual strangulation, in which the flames cause the contraction and decrease in elasticity of the skin. Past reports indicated that bleeding frequency in cases of drowning did not significantly differ from that in cases with other causes of death. However, our cases showed a statistically higher incidence of bleeding compared to that in the other causes of death (p < 0.01). These results suggested that ImBT is a characteristic finding in cases of asphyxia and is an important evaluation for the diagnosis of death. When the relationship between ImBT and petechial hemorrhage was examined in three of the causes of death, no significant difference was observed between fire fatality and asphyxiation, but drowning was significantly different (p < 0.05). In cases without ImBT, the secretion of noradrenaline and adrenaline was significantly higher (p < 0.01). This finding suggests that it is unlikely that excessive secretion of catecholamine causes ImBT.

Acute airway management

Acute airway management has challenged clinicians for nearly four millennia. History underscores the discoveries of surgeons and anesthesiologists, whose advances in technology and surgical technique have transformed management algorithms from primarily surgical tracheostomy, to transoral endotracheal intubation under direct laryngoscopy. Despite this progress and a better understanding of airway anatomy, physiology and pathogenesis of disease, the acute airway, whether obstructed, traumatically disrupted, or externally compressed, remains a life-threatening challenge. The role of all clinicians in acute airway management is patient stability and emergent control of the airway to ensure patency as well as adequate oxygenation and ventilation. The standard of care remains transoral intubation under direct laryngoscopy with use of indirect laryngoscopy as a first adjunct. If unsuccessful, surgical intubation of the trachea via cricothyroidotomy with subsequent conversion to open tracheostomy is the procedure of choice. While there is growing support for the use of percutaneous tracheostomy as an alternative to surgical intubation of the trachea after failed transoral intubation, the potential for damage to critical neck structures and longer time-to-intubation must be considered. In this perspective, we provide a history of acute airway management, highlighting milestones in the fields of airway surgery and anesthesia. We present a review of current medical and surgical approaches to managing the acute airway, including the risks, benefits and appropriateness of each approach with respect to patient stability, available equipment, clinician training and patient outcomes. We conclude with an emphasis on the role of the thoracic surgeon in prevention and the critical nature of regular surveillance of patients with chronic, partial tracheal obstruction.

Comparison of three tracheal intubation techniques in thyroid tumor patients with a difficult airway: a randomized controlled trial

OBJECTIVE

To investigate the effectiveness of the Shikani optical stylet (SOS) and GlideScope video laryngoscope (GVL) for tracheal intubation of thyroid tumor patients with a difficult airway.

SUBJECTS AND METHODS

One hundred and twenty thyroid tumor patients with a difficult airway, who were undergoing elective surgery requiring general anesthesia, were enrolled in the study. They were randomly allocated to 3 groups (n = 40 each) who underwent direct laryngoscopy (DL), SOS or GVL. The outcomes recorded were time to intubation, first-attempt success rate, mean artery pressure (MAP), heart rate (HR) and incidence of complications.

RESULTS

The mean time to intubation in the SOS group (group S; 42.4 ± 24.1 s) and the GLV group (group G; 29.8 ± 22.3 s) was significantly less than that in the DL group (group D) (68.8 ± 26.6 s). The first-attempt success rate in group S (90.0%) and group G (97.5%) was significantly higher than that in group D (75.0%; all p < 0.05). The HR and MAP at 1 min after intubation were lowest in group S (76.4 ± 9.2 beats/min and 12.9 ± 1.1 kPa), followed by group G (79.9 ± 9.3 beats/min and 13.0 ± 0.9 kPa) and then group D (90.4 ± 8.1 beats/min and 16.6 ± 1.2 kPa). The difference was statistically significant (all p < 0.05). The incidence of lip or mucosal trauma was lowest in group S, followed by group G and then group D.

CONCLUSION

The SOS and the GLV had advantages over the DL in the management of thyroid tumor patients with a difficult airway in terms of a shorter time to intubation, a higher first-attempt success rate and a reduced incidence of complications. Thus, a rational choice of one of these techniques may be better for the perioperative safety of thyroid tumor patients with a difficult airway.

[Analysis of 208 flexible bronchoscopies performed in an intensive care unit]

OBJECTIVE

To describe the main indications, clinical results and complications associated with fibrobronchoscopy in the Intensive Care Unit (ICU).

DESIGN

A retrospective, single-center observational study was carried out. Setting. Seventeen beds in a medical/surgical ICU. Patients. Consecutive patients undergoing fibrobronchoscopy during their stay in the ICU over a period of 5 years.

INTERVENTIONS

Flexible bronchoscopy performed by an intensivist. Main variables of interest. Flexible bronchoscopy indications and complications derived from the procedure.

RESULTS

A total of 208 flexible bronchoscopies were carried out in 192 patients admitted to the ICU. Most of the procedures (193 [92.8%]) were performed in mechanically ventilated patients. The average patient age was 58 ± 16 years, with an APACHE II score at admission of 19 ± 7. The most frequent indication for flexible bronchoscopy was diagnostic confirmation of initially suspected pneumonia (148 procedures), with positive bronchoalveolar lavage findings in 46%. The most frequent therapeutic indication was the resolution of atelectasis (28 procedures). Other indications were the diagnosis and treatment of pulmonary hemorrhage, the aspiration of secretions, control of percutaneous tracheotomy, and difficult airway management. The complications described during the procedures were supraventricular tachycardia (3.8%), transient hypoxemia (6.7%), and slight bleeding of the bronchial mucosal membrane (2.4%).

CONCLUSIONS

A microbiological diagnosis of pneumonia and the resolution of atelectasis are the most frequent indications for flexible bronchoscopy in critically ill patients. Flexible bronchoscopy performed by an intensivist in ICU is a safe procedure.

Experienced Airway Management in Laryngotracheal Injuries: Series of Cases, Survey and Review of Literature

Definitive airway control of penetrating laryngotracheal injury can be an extremely difficult challenge for the emergency physician. We report three serious cases of penetrating neck trauma with laryngeal injury that were managed successfully using different techniques of airway control in the Emergency Department (ED) of Hamad General Hospital during the three years from January 2006 through December 2008. Individualized assessment, identification of type of injury and familiarity with airway control techniques and the available options assure timely, safe and proper airway control in such injuries. Choice of technique in penetrating laryngotracheal injury is multifactorial and depends upon case presentation, physician preference, skill, and clinical constraints. The incidence of neck injury during this period was lower than in other reports; being 0.07 % of total trauma cases, while the incidence of penetrating neck injuries represented 17.6% of total neck injuries with no deaths. Implications Statement: Familiarity and availability of variant airway management techniques and variant surgical interventions in penetrating laryngotracheal injuries, improve outcome and reduce mortality.

Retrograde intubation

Airway management in the emergency department is a critical skill that must be mastered by emergency physicians. When rapid-sequence induction with oral-tracheal intubation performed by way of direct laryngoscopy is difficult or impossible due to a variety of circumstances, an alternative method or device must be used for a rescue airway. Retrograde intubation requires little equipment and has few contraindications. This technique is easy to learn and has a high level of skill retention. Familiarity with this technique is a valuable addition to the airway-management armamentarium of emergency physicians caring for ill or injured patients. Variations of the technique have been described, and their use depends on the individual circumstances.

Rapid Sequence Airway (RSA)--a novel approach to prehospital airway management

This article presents a case in which an air medical flight crew encountered a potentially difficult airway when a trauma patient deteriorated in-flight. The crew elected to sedate and paralyze the patient and place a laryngeal mask airway without a prior attempt at direct laryngoscopy and endotracheal intubation. The term Rapid Sequence Airway (RSA) is coined for this novel approach. This article describes and supports this concept and provides definitions of alternative and failed airways.

Airway management in neurological emergencies

Several neurological conditions may present to the emergency department (ED) with airway compromise or respiratory failure. The severity of respiratory involvement in these patients may not always be obvious. Proper pulmonary management can significantly reduce the respiratory complications associated with the morbidity and mortality of these patients. Rapid sequence intubation (RSI) is the method of choice for definitive airway management in the ED and is used for the majority of intubations. The unique clinical circumstances of each patient dictates which pharmacological agents can be used for RSI. Several precautions must be taken when using these drugs to minimize potentially fatal complications. Noninvasive positive pressure ventilation may obviate the need for intubation in a select population of patients. This article reviews airway management, with a particular emphasis on the use of RSI for common neurological problems presenting to the ED.

Managing the difficult airway: A survey of residency directors and a call for change

This study examines airway management issues in Emergency Medicine residency programs (EMRP) including; airway adjunct availability and frequency of use, number of pediatric intubations, approach to trauma airways, and teaching methods. Surveys were distributed to all accredited EM program directors, who were asked about these issues. Availability of airway adjuncts among respondents included: cricothyrotomy kits (94.9%), fiberoptic scopes (76.3%), Bougies (69.5%), LMAs (66.1%), intubating LMAs (61.0%), lighted stylets (54.2%), retrograde intubation kits (49.2%), Combitube (45.8%), and esophageal obturator airways (15.3%). Responses indicated that 93.6% of airways were orotracheal intubations. A small percentage of intubations used airway adjuncts. Programs use didactics, mannequins, cadavers, direct care and operating rooms for airway training. Emergency Physicians (EPs) are responsible for trauma airways in 89.9% of programs. Most programs have multiple airway adjuncts available, but they are rarely utilized. EPs must become proficient with airway adjuncts. EMRPs must increase resident exposure by using airway adjuncts during routine intubations.

Algorithms for management of the difficult airway

PURPOSE OF REVIEW

The purpose of this review is to examine recent evidence for the management of the difficult airway.

RECENT FINDINGS

Recent findings still recommend the importance of a predefined, simple strategy for both the anticipated and unanticipated difficult airway. For the former, awake fiberoptic intubation is still the 'gold standard'. For management of the unanticipated difficult airway, the use of the laryngeal mask airway (LMA), intubating laryngeal mask airway (ILMA), the 'gum elastic bougie' and fiber-optics are recommended. If intubation and ventilation fails, cannula or surgical cricothyroidotomy should be an early consideration.

SUMMARY

This review of algorithms for management of the difficult airway strengthens several generally accepted crucial points. What is always needed is expertise, which one can only get and maintain by daily practice.