Airway management behaviour, experience and knowledge among Danish anaesthesiologists--room for improvement

Awake Tracheal Intubation: An Update

Awake tracheal intubation (ATI) remains the "gold standard" technique in securing a definitive airway in conscious, self-ventilating patients with predicted or known difficult airways and the procedure is associated with a low failure rate. Since its inception a variety of techniques to achieve ATI have emerged and there have been accompanying advancements in pharmaceuticals and technology to support the procedure. In recent years there has been a growing focus on the planning, training and human factors involved in performing the procedure. The practice of ATI, does however, remain low around 1% to 2% of all intubations despite an increase in those with head and neck pathology. ATI, therefore, presents a skill that is key for the safety of patients but may not be practised with regularity by many anesthetists. In this article we therefore aim to highlight relevant guidance, recent literature and provide an update on the practical methods fundamental for successful ATI. We also discuss the crucial aspects of a safe airway culture and how this can help to embed training and maintenance of skills.

The evolution of a national, advanced airway management simulation-based course for anaesthesia trainees

BACKGROUND

Needs analyses involving patient complaints and anaesthesiologists' confidence levels in difficult airway management procedures in Denmark have shown a need for training in both technical and non-technical skills.

OBJECTIVE

To provide an example of how to design, implement and evaluate a national simulation-based course in advanced airway management for trainees within a compulsory, national specialist training programme.

DESIGN AND RESULTS

A national working group, established by the Danish Society for Anaesthesiology and Intensive Care Medicine, designed a standardised simulation course in advanced airway management for anaesthesiology trainees based on the six-step approach. Learning objectives are grounded in the curriculum and analyses-of-needs (in terms of knowledge, skills and attitudes, including non-technical skills, which encompass the cognitive skills and social skills, necessary for safe and effective performance). A total of 28 courses for 800 trainees have been conducted. Evaluation has been positive and pre and posttests have indicated a positive effect on learning.

CONCLUSION

The course was successfully designed and implemented within the national training programme for trainees. Important factors for success were involvement of all stakeholders, thorough planning, selection of the most important learning objectives, the use of interactive educational methods and training of the facilitators.

Survey of Current Difficult Airway Management Practice

BACKGROUND

Even for the most experienced anesthesiologists "can't ventilate can't intubate" scenario in difficult airway management is challenging, and although rare it is life-threatening.

AIM

The aim of this survey was to analyse the current practice of difficult airway management at our University teaching hospital.

MATERIAL AND METHODS

A ten-question-survey was conducted in the Tertiary University Teaching Hospital "Mother Theresa", Clinic for Anesthesia, Reanimation and Intensive Care. The survey included demographic data, experience in training anaesthesia, practice in management of anticipated and non-anticipated difficult airway scenario, preferable equipment and knowledge of guidelines and protocols. Responses were noted, evaluated and analysed with the SPSS statistical program.

RESULTS

The overall response rate was very good; 94.5% answered the survey. During the assessment of the level of comfort with diverse airway equipment, there was diversity of answers due the experience of anaesthesia training, although the most frequent technique among all responders for anticipated difficult intubation was video laryngoscopy (48%). As for non-anticipated difficult intubation when conventional techniques failed to secure the airway most of the responders answered that they used supra-gothic airway device - laryngeal mask (38%) as a rescue measure.

CONCLUSION

Airway assessment, adequate training, experience, and availability of essential equipment are the pillars of successful airway management.

Difficult airway management algorithms: a directed review

The primary aim of this study was to identify, describe and compare the content of existing difficult airway management algorithms. Secondly, we aimed to describe the literature reporting the implementation of these algorithms. A directed search across three databases (MEDLINE, Embase and Scopus) was performed. All articles were screened for relevance to the research aims and according to pre-determined exclusion criteria. We identified 38 published airway management algorithms. Our results show that most facemask employ a four-step process as represented by a flow chart, with progression from tracheal intubation, facemask ventilation and supraglottic airway device use, to a rescue emergency surgical airway. The identified algorithms are overwhelmingly similar, yet many use differing terminology. The frequency of algorithm publication has increased recently, yet adherence and implementation outcome data remain limited. Our results highlight the lack of a single algorithm that is universally endorsed, recognised and applicable to all difficult airway management situations.

A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre

Contemporary data are lacking for procedural practice, training provision and outcomes for awake fibreoptic intubation in the UK. We performed a prospective cohort study of awake fibreoptic intubations at a tertiary centre to assess current practice. Data from 600 elective or emergency awake fibreoptic intubations were collected to include information on patient and operator demographics, technical performance and complications. This comprised 1.71% of patients presenting for surgery requiring a general anaesthetic, with the majority occurring in patients presenting for head and neck surgery. The most common indication was reduced mouth opening (26.8%), followed by previous airway surgery or head and neck radiotherapy (22.5% each). Only five awake fibreoptic intubations were performed with no sedation, but the most common sedative technique was combined target-controlled infusions of remifentanil and propofol. Oxygenation was achieved with high-flow, heated and humidified oxygen via nasal cannula in 49.0% of patients. Most operators had performed awake fibreoptic intubation more than 20 times previously, but trainees were the primary operator in 78.6% of awake fibreoptic intubations, of which 86.8% were directly supervised by a consultant. The failure rate was 1.0%, and 11.0% of awake fibreoptic intubations were complicated, most commonly by multiple attempts (4.2%), over-sedation (2.2%) or desaturation (1.5%). The only significant association with complications was the number of previous awake fibreoptic intubations performed, with fewer complications occurring in the hands of operators with more awake fibreoptic intubation experience. Our data demonstrate that awake fibreoptic intubation is a safe procedure with a high success rate. Institutional awake fibreoptic intubation training can both develop and maintain trainee competence in performing awake fibreoptic intubation, with a similar incidence of complications and success compared with consultants.

Management of the airway in maxillofacial surgery: part 1

In part 1 of this review of management of the airway in maxillofacial surgery we discuss preoperative assessment of the airway, and the practical means to deal with difficulties. We review the evidence for videolaryngoscopy and flexible indirect laryngoscopy, together with surgical access to the airway including tracheostomy, cricothyroidotomy, and submental intubation.

Early Assessment of the Likely Cost Effectiveness of Single-Use Flexible Video Bronchoscopes

BACKGROUND

Bronchoscopic procedures are common in the clinical setting, with estimates indicating 500,000 are undertaken per year in the USA alone. These procedures are generally regarded as safe. Unfortunately, a risk of cross-contamination between patients, with possible subsequent infection, is associated with the re-usable technology typically used in these procedures.

OBJECTIVE

Our objective was to conduct an early cost-effectiveness analysis (CEA) of single-use flexible video bronchoscope technology compared with the current reusable technology in a US hospital intensive care setting.

METHODS

We conducted a CEA to determine an incremental cost-effectiveness ratio (ICER), and constructed a decision analytic model based on the best available evidence from a literature search and a Delphi panel. We also conducted several one- and two-way sensitivity analyses and a probabilistic sensitivity analysis to illuminate the uncertainty associated with the estimates.

RESULTS

The literature search showed ample evidence of risk, albeit little of it was quantifiable. Estimates from the Delphi method found approximately a 3% risk of cross-contamination and approximately a 21% risk of subsequent infection. Pneumonia was estimated as the most likely manifestation of infection. The CEA showed a saving of $US118 per procedure and elimination of 0.7% of the risk of infection with the single-use technology. Relevant sensitivity analyses generally validated this result.

CONCLUSION

This study suggests that implementation of the single-use technology in the intensive care unit is cost effective in most scenarios. However, this result should be interpreted with caution because of the lack of certain knowledge on this particular topic.

Early Assessment of the Likely Cost Effectiveness of Single-Use Flexible Video Bronchoscopes

BACKGROUND

Bronchoscopic procedures are common in the clinical setting, with estimates indicating 500,000 are undertaken per year in the USA alone. These procedures are generally regarded as safe. Unfortunately, a risk of cross-contamination between patients, with possible subsequent infection, is associated with the re-usable technology typically used in these procedures.

OBJECTIVE

Our objective was to conduct an early cost-effectiveness analysis (CEA) of single-use flexible video bronchoscope technology compared with the current reusable technology in a US hospital intensive care setting.

METHODS

We conducted a CEA to determine an incremental cost-effectiveness ratio (ICER), and constructed a decision analytic model based on the best available evidence from a literature search and a Delphi panel. We also conducted several one- and two-way sensitivity analyses and a probabilistic sensitivity analysis to illuminate the uncertainty associated with the estimates.

RESULTS

The literature search showed ample evidence of risk, albeit little of it was quantifiable. Estimates from the Delphi method found approximately a 3% risk of cross-contamination and approximately a 21% risk of subsequent infection. Pneumonia was estimated as the most likely manifestation of infection. The CEA showed a saving of $US118 per procedure and elimination of 0.7% of the risk of infection with the single-use technology. Relevant sensitivity analyses generally validated this result.

CONCLUSION

This study suggests that implementation of the single-use technology in the intensive care unit is cost effective in most scenarios. However, this result should be interpreted with caution because of the lack of certain knowledge on this particular topic.

Effect of 90° counterclockwise rotation of the endotracheal tube on its advancement through the larynx during nasal fiberoptic intubation in children: a randomized and blinded study

BACKGROUND

Resistance to the passage of the endotracheal tube (ETT) is frequently encountered in children as it is advanced over the fiberoptic scope for placement into the trachea because it gets hung up at the laryngeal inlet. Literature in adults indicates that a 90° counterclockwise rotation (CCR) of the ETT before advancing results in smooth passage. We found no literature in children.

OBJECTIVES

Our aim was to study if a 90° counterclockwise rotation (CCR) of the ETT before advancement leads to smooth passage of the ETT into the larynx in children.

METHODS

Following IRB approval, we performed this study in two parts: Part 1: An unblinded, observational, pilot study on 20 children scheduled for oral rehabilitation where we concurrently used a fiberoptic scope nasally and GlideScope orally. We visualized the ETT path and observed that 90° CCR allowed smooth passage without hang up. Part 2: A blinded and randomized study on 40 children to confirm if 90° CCR from the outset would improve passage of the ETT during nasal intubation with a fiberoptic scope in children. All children were divided into two groups: group S, ETT bevel facing left; group R, ETT bevel facing down.

RESULTS

In Part 1, we observed that the ETT got hung up in 57% of children with standard bevel direction (facing left) and in 0% of children when prerotated. In Part 2, efficacy of prerotation was confirmed; the ETT got hung up in 50% of children in group S but in only 10.5% of children in group R.

CONCLUSION

A change in ETT tip orientation from bevel facing left to facing down by 90° CCR, leads to a significantly higher first-attempt success rate by nasal approach in children. We believe the ETT should be rotated before insertion into the nostril to ensure that full 90° CCR of the tip has been accomplished.

[A randomised crossover trial comparing the Airtraq(®) NT, McGrath(®) MAC and Macintosh laryngoscopes for nasotracheal intubation of simulated easy and difficult airways in a manikin]

OBJECTIVE

Several devices can aid nasotracheal intubation when managing difficult airways. The McGrath MAC and Airtraq NT were compared with a Macintosh laryngoscope when studying the performance of anaesthetists with different levels of experience, in a manikin model of easy or difficult airway scenarios.

METHODS

Sixty-three anaesthetists were recruited into a randomised trial in which each performed nasotracheal intubation with all laryngoscopes, in both scenarios. The main endpoint was intubation time. Additional endpoints included laryngoscopic view, intubation success, number of optimisation manoeuvres, audible dental clicks and the force applied to the upper airway.

RESULTS

Intubation time was significantly shorter using the McGrath MAC in both scenarios and using the Airtraq in the difficult scenario, when compared with the Macintosh laryngoscope. Both devices gave more Cormack and Lehane grade 1 or 2 views than the Macintosh in the difficult scenario (p<0.001). The McGrath MAC had the best first-attempt success rate (98.4% vs. 96.8% and 95.8%, p<0.001 for the Airtraq NT and Macintosh laryngoscopes respectively). The number of optimisation manoeuvres, audible dental clicks and subjective assessment of the degree of force applied were significantly lower for indirect laryngoscopes versus the Macintosh laryngoscope (p<0.001).

CONCLUSION

In a manikin, the Airtraq and the McGrath laryngoscopes appeared superior to the Macintosh laryngoscope when dealing with simulated airway scenarios. Both devices were associated with better views, intubation times and rates of success, especially in a simulated "difficult airway". Overall satisfaction was highest with the McGrath laryngoscope. Similar clinical studies are needed.

Current practice of difficult airway management: A survey

BACKGROUND AND AIMS

Difficult airway (DA) management depends on both training and actual usage of the various approaches in the event of difficulty. The aim of the study was to assess how well the anaesthesiologists are equipped to deal with DA situations. The current practice preference of DA management was also assessed.

METHODS

A questionnaire was distributed in a continuing medical education (CME) programme dedicated to DA and responses were noted and analysed, using Statistical Package for Social Sciences (SPSS) version 18.

RESULTS

The response rate was 73%. Airway assessment was performed by majority. Sixty eight percent consultants and 47% residents were well aware of the American Society of Anesthesiologists' DA algorithm. 67% consultants and 65% residents attended at least one CME on DA in the previous 5 years. There was an overall deficiency of video laryngoscopes, retrograde intubation and cricothyrotomy sets. Most of the respondents were comfortable in using supraglottic airway devices (SGADs). In anticipated DA, the preferred choice of management for junior doctors was attempting conventional method once and awake fibreoptic bronchoscopy (FOB) for the experienced. In unanticipated DA, most of the residents and consultants opted for SGAD. Extubation strategy was similar for both. Thirty four percent of respondents experienced a 'cannot intubate-cannot ventilate' situation at least once.

CONCLUSION

Our survey showed that most respondents performed routine pre-operative airway assessment. A good armamentarium of airway gadgets should be made available in hospitals. Further training in techniques like video laryngoscopy, FOB or cricothyrotomy are essential.

A randomised crossover trial comparing the Airtraq(®) NT, McGrath(®) MAC and Macintosh laryngoscopes for nasotracheal intubation of simulated easy and difficult airways in a manikin

OBJECTIVE

Several devices can aid nasotracheal intubation when managing difficult airways. The McGrath MAC and Airtraq NT were compared with a Macintosh laryngoscope when studying the performance of anaesthetists with different levels of experience, in a manikin model of easy or difficult airway scenarios.

METHODS

Sixty-three anaesthetists were recruited into a randomised trial in which each performed nasotracheal intubation with all laryngoscopes, in both scenarios. The main endpoint was intubation time. Additional endpoints included laryngoscopic view, intubation success, number of optimisation manoeuvres, audible dental clicks and the force applied to the upper airway.

RESULTS

Intubation time was significantly shorter using the McGrath MAC in both scenarios and using the Airtraq in the difficult scenario, when compared with the Macintosh laryngoscope. Both devices gave more Cormack and Lehane grade 1 or 2 views than the Macintosh in the difficult scenario (p<0.001). The McGrath MAC had the best first-attempt success rate (98.4% vs. 96.8% and 95.8%, p<0.001 for the Airtraq NT and Macintosh laryngoscopes respectively). The number of optimisation manoeuvres, audible dental clicks and subjective assessment of the degree of force applied were significantly lower for indirect laryngoscopes versus the Macintosh laryngoscope (p<0.001).

CONCLUSION

In a manikin, the Airtraq and the McGrath laryngoscopes appeared superior to the Macintosh laryngoscope when dealing with simulated airway scenarios. Both devices were associated with better views, intubation times and rates of success, especially in a simulated "difficult airway". Overall satisfaction was highest with the McGrath laryngoscope. Similar clinical studies are needed.

Video-laryngoscopy introduction in a Sub-Saharan national teaching hospital: luxury or necessity?

Tracheal intubation using Macintosh blade is the technique of choice for the liberation of airways. It can turn out to be difficult, causing severe complications which can entail the prognosis for survival or the adjournment of the surgical operation. The video-laryngoscope allows a better display of the larynx and a good exposure of the glottis and then making tracheal intubation simpler compared with a conventional laryngoscope. It is little spread in sub-Saharan Africa and more particularly in Burkina Faso because of its high cost. We report our first experiences of use of the video-laryngoscope through two cases of difficult tracheal intubation which had required the adjournment of the interventions. It results that the video-laryngoscope makes tracheal intubation easier even in it's the first use because of the good glottal display which it gives and because its allows apprenticeship easy. Therefore, it is not a luxury to have it in our therapeutic arsenal.

The disposable Ambu aScope vs. a conventional flexible videoscope for awake intubation -- a randomised study

BACKGROUND

A new disposable flexible videoscope, the Ambu® aScope, has several potential advantages compared with reusable devices, but it is a prerequisite for its widespread use that it functions sufficiently well in the management of patients in whom difficulty with airway management is anticipated and awake intubation is indicated.

METHODS

In a pilot study, 20 patients with normal airways were intubated with the aScope. Subsequently, 40 patients with predicted difficult tracheal intubation were randomly assigned to be intubated awake with either the aScope or the reusable Olympus BF videobronchoscope.

RESULTS

All patients were successfully intubated awake. The median total intubation time, including the administration of local anaesthesia, was 278 vs. 234 s in the aScope and Olympus groups, respectively (P = 0.03). In two cases in the aScope group, the image became blurred immediately after the first injection of lidocaine via the injection channel, and the time that it took to replace the scopes was included in the intubation times.

CONCLUSION

Both the disposable aScope and the reusable Olympus videoscope allowed safe awake intubation in our elective patients with severely difficult, but uncompromised, airways. The occasional need to employ a spare scope because of malfunctioning would make the disposable aScope less suitable in patients with acutely compromised airways.

A cost analysis of reusable and disposable flexible optical scopes for intubation

BACKGROUND

Intubation using a flexible optical scope (FOS) is a cornerstone technique for managing the predicted and unpredicted difficult airway. The term FOS covers both fibre-optic scopes and videoscopes. The total costs of using flexible scopes for intubation are unknown. The recent introduction of a disposable flexible scope for intubation merits closer scrutiny of the total costs associated with both modalities.

METHODS

The costs incurred during intubations using FOSs at a large anaesthesia department were identified, and a series of intubations using a disposable scope were analyzed for comparison. Recognized health-economic methodology was applied.

RESULTS

During a 1-year period, 360 FOS intubations were performed. In this clinical setting, the average cost of an intubation using a reusable FOS was €177.7. When using the disposable Ambu(®) aScope (Ambu A/S, Ballerup, Denmark), the cost was €204.4. The break-even point, i.e. the number of intubations per month where the cost of using disposable and non-disposable equipment is identical, was 22.5/month. A subgroup analysis looking solely at intubations performed with flexible videoscopes revealed that the cost per intubation was equal for disposable and reusable videoscopes.

CONCLUSION

At our institution, the total cost of an intubation is greater when using disposable compared with reusable equipment (€204.4 vs. €177.7). If video equipment with an external monitor is considered mandatory, the expenses are of equal magnitude. The cost analysis is particularly sensitive to the actual number of flexible optic intubations performed; with fewer intubations, the total cost will begin to favour disposable equipment.

Education in airway management

In airway management, poor judgment, education and training are leading causes of patient morbidity and mortality. The traditional model of medical education, which relies on experiential learning in the clinical environment, is inconsistent and often inadequate. Curriculum change is underway in many medical organisations in an effort to correct these problems, and airway management is likely to be explicitly addressed as a clinical fundamental within any new anaesthetic curriculum. Competency-based medical education with regular assessment of clinical ability is likely to be introduced for all anaesthetists engaged in airway management. Essential clinical competencies need to be defined and improvements in training techniques can be expected based on medical education research. Practitioners need to understand their equipment and diversify their airway skills to cope with a variety of clinical presentations. Expertise stems from deliberate practice and a desire constantly to improve performance with a career-long commitment to education.

A comparison of bonfils fiberscope-assisted laryngoscopy and standard direct laryngoscopy in simulated difficult pediatric intubation: a manikin study

INTRODUCTION

Difficult airway management in children is challenging. One alternative device to the gold standard of direct laryngoscopy is the STORZ Bonfils fiberscope (Karl Storz Endoscopy, Tuttlingen, Germany), a rigid fiberoptic stylette-like scope with a curved tip. Although results in adults have been encouraging, reports regarding its use in children have been conflicting. We compared the effectiveness of a standard laryngoscope to the Bonfils fiberscope in a simulated difficult infant airway.

METHODS

Ten pediatric anesthesiologists were recruited for this study and asked to perform three sets of tasks. For the first task, each participant intubated an unaltered manikin (SimBaby (TM), Laerdal, Puchheim, Germany) five times using a styletted 3.5 endotracheal tube (ETT) and a Miller 1 blade (group DL-Normal). For the second task, a difficult airway configuration simulating a Cormack-Lehane grade 3B view was created by fixing a Miller-1 blade into position in the manikin using a laboratory stand. Each participant then intubated the manikin five times with a styletted 3.5 ETT using conventional technique but without touching the laryngoscope (group DL-Difficult). In the third task, the manikin was kept in the same difficult airway configuration, and each participant intubated the manikin five times using a 3.5-mm ETT mounted on the Bonfils fiberscope as an adjunct to direct laryngoscopy with the Miller-1 blade (group BF-Difficult). Primary outcomes were time to intubate and success rate.

RESULTS

A total of 150 intubations were performed. Correct ETT placement was achieved in 100% of attempts in group DL-Normal, 90% of attempts in group DL-Difficult and 98% of attempts in BF-Difficult. Time to intubate averaged 14 s (interquartile range 12-16) in group DL-Normal; 12 s (10-15) in group DL-Difficult; and 11 s (10-18) in group BF-Difficult. The percentage of glottic opening seen (POGO score) was 70% (70-80) in group DL-Normal; 0% (0-0) in group DL-Difficult; and 100% (100-100) in group BF-Difficult.

DISCUSSION

The Bonfils fiberscope-assisted laryngoscopy was easier to use and provided a better view of the larynx than simple direct laryngoscopy in the simulated difficult pediatric airway, but intubation success rate and time to intubate were not improved. Further studies of the Bonfils fibrescope as a pediatric airway adjunct are needed.

Awake tracheal intubation using the Airtraq laryngoscope: a case series

The Airtraq laryngoscope (AL) is a new single use indirect laryngoscope designed to facilitate tracheal intubation in anaesthetised patients either with normal or difficult airway anatomy. It is designed to provide a view of the glottis without alignment of the oral, pharyngeal and tracheal axes. We report four cases of successful awake tracheal intubation using the AL. The first case is a patient with severe ankylosing spondylitis and the other three cases with anticipated difficult airway. An awake intubation under sedation and topical airway anaesthesia was chosen. We consider that the AL can be used effectively to accomplish an awake intubation in patients with a suspected or known difficult airway and may be a useful alternative where other methods for awake intubation have failed or are not available.

Mortality related to anaesthesia in France: analysis of deaths related to airway complications

Death certificates from the French national mortality database for the calendar year 1999 were reviewed to analyse cases in which airway complications had contributed to peri-operative death. Respiratory deaths (and comas) found in a previous national 1978-82 French survey (1:7960; 95% CI 1:12,700 to 1:5400) were compared with the death rate found in the present one: 1:48,200 (95% CI 1:140,000 to 1:27,500). In 1999, deaths associated with failure of the breathing circuit and equipment were no longer encountered and no death was found to be related to undetected hypoxia in the recovery unit. Deaths related to difficult intubation also occurred at a lower rate than in the previous report (1:46,000; 95% CI 1:386,000 to 1:13,000) in 1978-82 vs 1:176,000 (95% CI 1:714,000 to 1:46,000) in 1999, a fourfold reduction. In most cases, there were both inadequate practice and systems failure (inappropriate communication between staff, inadequate supervision, poor organisation). This large French survey shows that deaths associated with respiratory complications during anaesthesia have been strikingly reduced during this 15-year period.

Pre-hospital advanced airway management by anaesthesiologists: is there still room for improvement?

Background

Endotracheal intubation is an important part of pre-hospital advanced life support that requires training and experience, and should only be performed by specially trained personnel. In Norway, anaesthesiologists serve as Helicopter Emergency Medical Service HEMS physicians. However, little is known about how they themselves evaluate the quality and safety of pre-hospital advanced airway management.

Method

Using a semi-structured questionnaire, we interviewed anaesthesiologists working in the three HEMS programs covering Western Norway. We compared answers from specialists and non-specialists as well as full- and part-time HEMS physicians.

Results

Of the 17 available respondents, most (88%) felt that their continuous exposure to intubations was not sufficient. Additional training was mainly acquired through other clinical practice and mannequin- or cadaver-based skills training. Of the respondents, 77% and 35% reported having experienced difficult and failed intubations, respectively. Further, 59% reported knowledge of airway management-related deaths in their HEMS program. Significantly more full- than part-time HEMS physicians had experienced these problems. All respondents had airway back-up equipment in their service, but 29% were not familiar with all the equipment.

Conclusion

The majority of anaesthesiologists working as HEMS physicians view pre-hospital advanced airway management as a high-risk procedure. Relevant airway management competencies for HEMS physicians in Norway seem to be insufficiently trained and maintained. A better-defined level of competence with better training methods and systems seems warranted.

Management of unexpected difficult airway at a teaching institution over a 7-year period

STUDY OBJECTIVE

To review an anesthesiology department's experience with managing unexpected difficult airways over a 7-year time span.

DESIGN

Retrospective review of unexpected difficult airway reporting forms.

SETTING

A tertiary care teaching hospital.

PATIENTS

447 patients who had an unanticipated difficult airway and had a difficult airway form filled out by their anesthesiologist.

MEASUREMENTS

Retrospective identification of pertinent physical features associated with difficult intubation was noted. The techniques chosen, their success, and the frequency with which the different advanced airway techniques were chosen was reviewed.

MAIN RESULTS

An anterior larynx was the most common anatomical feature associated with difficult laryngoscopy. When a laryngeal mask airway was placed in our patients, ventilation was possible in all patients. Intubation was successfully "blindly" achieved (ie, without the use of a fiberoptic bronchoscope) through the laryngeal mask airway in 52% of these patients. Fiberoptic intubation was unsuccessful in intubating approximately 10% of patients. The Bullard laryngoscope was the most common advanced airway technique chosen at our institution.

CONCLUSION

Mastery with a number of advanced airway techniques should be sought, as multiple modalities may be needed when faced with managing an unexpectedly difficult airway. Formal written communication to the patient of an unexpected difficult airway encounter may allow future anesthesiologists to formulate an appropriate plan for patient care.

Pre-anesthetic evaluation can play a crucial role in the determination of airway management in a child with oropharyngeal tumor

We experienced a case of a huge hemangioma occupying the oropharyngeal space in an 11-year-old child. Although urgent surgical tracheostomy under local anesthesia was suggested initially, medical interview and findings of computerized tomography and fiberoptic laryngoscopy revealed that the airway of the patient was relatively stable when she was in the semi-left decubitus position. General anesthetic induction would have had potential risks of airway obstruction. Thus, after placing the patient in the semi-left decubutus position, we chose semi-awake induction to secure the airway. With a small dose of fentanyl, we accomplished orotracheal intubation. In this report, we discuss the importance of referring to an airway management algorithm when encountering a difficult airway.

Acquisition of basic fiberoptic intubation skills with a virtual reality airway simulator

STUDY OBJECTIVE

To test the hypothesis that a virtual reality (VR) airway simulator (the AccuTouch Virtual Reality Bronchsocopy Simulator; Immersion Medical, Gaithersburg, MD) can be used to teach residents basic fiberoptic intubation (FOI) skills effectively.

DESIGN

Observational study.

SETTING

University anesthesiology department.

INTERVENTION

Supervised training was done using a VR airway simulator.

MEASUREMENTS

Time to intubation before and after a 4-day training period using an adult VR FOI scenario and time to intubation using a fresh human cadaver two weeks after the training experience were measured.

MAIN RESULTS

Residents were able to significantly improve time to intubation in the VR scenario (114 vs 75 seconds; P = 0.001). Novices differed from experienced attending anesthesiologists in time to intubation in the VR scenario, before but not after training (114 vs 79 seconds compared with 75 vs 72 seconds). Novices who had been trained with the simulator performed significantly faster in the cadaver than novices who had not (24 vs 86 seconds; P < 0.001). Furthermore, there was no difference in time to intubation in the cadaver between trained novices and experienced attending anesthesiologists (24 vs 23 seconds; P > 0.05).

CONCLUSION

Use of a VR airway simulator enables anesthesia residents to acquire basic FOI skills comparable to those of experienced anesthesiologists in a human cadaver.

Fibreoptic intubation skills among anaesthetists in New Zealand

The aim of this study was to investigate methods of practice, assess skill level, and evaluate attitudes towards fibreoptic intubation in the anaesthetic community of New Zealand. A postal survey questionnaire was sent to all vocationally registered anaesthetists in New Zealand and to all New Zealand anaesthetic trainees registered with the Australian and New Zealand College of Anaesthetists. There were 611 survey questionnaires posted and 386 (63%) respondents. Almost all respondents (98% of specialists, 100% of trainees) had access to fibreoptic equipment in public and 92% of respondents performed fibreoptic intubation. The median number of fibreoptic intubations performed per year was 3 for consultants and 4 for trainees. Respondents were either self taught or colleague taught (82%). Most learnt the technique on patients (92%). There were 14% who considered themselves experienced, 30% competent, 34% adequate and 20% novice. Skills were maintained by clinical patient mix in 73%. Fibreoptic intubation was considered a skill required by all anaesthetists in 87%, and 66% considered it the gold standard for expected difficult airways. Lack of clinical cases requiring the skill and lack of practice were identified as the primary barriers to skill development. Consultants had greater opportunity to learn fibreoptic intubation skills during daily practice than trainees. Only 18% of trainees had a formal airway management program available to them at their place of work. There appears to be a need to increase available opportunities to perform fibreoptic intubation to enable maintenance and improvement of fibreoptic skills in our community. A formalized program of teaching fibreoptic intubation may offer greater opportunity for learning and skill development.

Airway management practices at German university and university-affiliated teaching hospitals--equipment, techniques and training: results of a nationwide survey

BACKGROUND

Until recently, Germany did not have national airway management guidelines. This survey collected comprehensive data on departmental airway management practices from German teaching institutions to identify weaknesses, and the results are presented here. German national airway guidelines were formulated by an expert group on the basis of these data and the current evidence in the literature.

METHODS

Questionnaires were mailed to the directors of 452 university and university-affiliated anaesthesia departments. They were asked to respond to 39 questions on the use of particular equipment and techniques, management of the difficult airway and training in airway management.

RESULTS

Two hundred and twelve questionnaires were returned. Many alternative devices for endotracheal intubation, such as the Bullard laryngoscope, the Bonfils laryngoscope and the Trachlight, are not used in the majority (80%) of departments. Thirty-six per cent of departments do not have difficult airway carts. No departmental difficult airway management plan is used in 22% of departments. Patients are not provided with written information on their personal airway management difficulties in 14% of departments. Structured training in the form of block rotation is offered in only 29-40% of departments. Although trainees perform fibreoptic intubation (FOI) in most departments, appropriate training in FOI is not available in some departments (8%).

CONCLUSION

There are deficits in various areas of airway management, in particular training and the use of algorithms. International guidelines and recommendations are not followed by a large number of German teaching institutions. The provision of German national airway guidelines should improve this situation.

Education and training in airway management

Despite the use of alternative training methods and efforts to structure training, it remains a challenge to ensure that every anaesthesia trainee gains sufficient experience in the use of core techniques of airway management. As less time is spent in the operating room during training, it becomes less likely that trainees will be exposed to an adequate number of challenging airway cases that enable them to practise advanced techniques of airway management under supervision. Nowadays the only way to overcome this deficit in anaesthesia training is to prepare trainees as well as possible outside the operating room so that clinical training opportunities can be used most effectively when they arise. Sufficient training can only be ensured when the required equipment and time are provided. Therefore, particularly in the light of increasing economic pressures, it is necessary to address the responsibilities of everyone involved in the training process. Here, we critically review traditional and recent modalities of anaesthesia training, assess their value, and describe a multi-modal approach to airway management education.

Evaluation of the airway of the SimMan full-scale patient simulator

BACKGROUND

SimMan is a full-scale patient simulator, capable of simulating normal and pathological airways. The performance of SimMan has never been critically evaluated.

METHODS

Sixty subjects (anesthesiologists, nurse anesthetists, and anesthesia residents) performed mask ventilation, laryngeal mask insertion and endotracheal intubation on SimMan. The simulator's airway was evaluated using visual analog scales (VAS) and by measuring the subject's performances.

RESULTS

The SimMan full-scale patient simulator's airway is generally acceptably realistic but it significantly differs from the human airway in important aspects. Mask seal was more difficult than in humans whereas Laryngeal mask (LMA) insertion and function was acceptable. The distance from the teeth to the vallecula was too short. Cervical spine mobility was significantly reduced in the 'reduced neck movement' mode but the intubation was only slightly more difficult than in the 'normal' mode.

CONCLUSION

The SimMan full-scale patient simulator's airway is generally acceptably realistic but it significantly differs from the human airway in important aspects. The user must be aware of these aspects in order to obtain maximum benefit from training and evaluation scenarios and when using the simulator for testing new equipment and techniques.

Tube tip in pharynx (TTIP) ventilation: simple establishment of ventilation in case of failed mask ventilation

BACKGROUND

Mask ventilation occasionally fails. Alternative readily available and simple methods to establish ventilation in these cases are needed.

METHODS

Retrospective description of cases in which a new technique, tube tip in pharynx (TTIP) ventilation, was employed for restoring ventilation in case of failed facemask ventilation during induction of anaesthesia. The technique involves a standard endotracheal tube and can be performed single-handed: A standard endotracheal tube was placed via the mouth with the tip in the pharynx and the cuff was inflated. By placing the fourth and fifth fingers below the ramus of the mandible, the third finger below the lower lip, the second finger above the upper lip and on one side of the nose and the first finger on the other side of the nose, an open airway is restored. Chin lift is inherent in the grip, thus contributing to opening of the airway.

RESULTS

In all four cases of failed mask ventilation the anaesthetist could establish an open airway and subsequent ventilation without the need for an assistant. There were no indications of gastric insufflation.

CONCLUSION

The TTIP technique established ventilation in all four patients after abandoned facemask ventilation. The technique only involves one person and an endotracheal tube and warrants to be included in the armamentarium of anaesthetists. Further prospective studies are needed to refine the technique and delimit its indications.

Airway problems in pregnancy

Obstetric anesthesia is considered to be a difficult, high-risk practice that exposes the anesthesiologist to increased medicolegal liability. Anesthetic management of parturient patients is a challenge, as it involves simultaneous care of two lives. The anesthesia practitioner has a duty to provide safe anesthetic care, including effective airway management when providing regional or general anesthesia. The potential need to manipulate the airway is perhaps the leading cause of concern among obstetric anesthesiologists.

Residents lack knowledge and practical skills in handling the difficult airway

BACKGROUND

Full-scale simulators have been developed in anaesthesia. We aimed at assessing Danish anaesthesia residents' knowledge and management of a standardized difficult airway situation in an advanced airway simulator. The reliability of the assessment was also determined.

METHODS

Thirty-six residents answered a questionnaire testing their knowledge on difficult airway management and practice patterns. Secondly, all residents attempted management of a standardized 'cannot ventilate, cannot intubate' airway scenario. Three observers independently assessed a video recording of the performance.

RESULTS

Only 17% of the residents passed the written test. Ninety-seven per cent stated that they had difficulties recalling the American Society of Anesthesiologists'(ASA) difficult airway algorithm and 53% did not know how to oxygenate through the cricothyroid membrane. Seventeen per cent had previously been involved in emergency situations with severe complications due to insufficient airway management. In the scenario 75% of the residents established ventilation using a laryngeal mask airway. After establishing ventilation, 26% would continue with surgery without a definitive airway, despite the risk of aspiration. Analysis of the interobserver agreement showed good (Kappa = 0.63) to excellent (Kappa = 0.78) consistency for objective parameters in the scoring scheme. Inter-observer reliability was satisfactory (R = 0.43) for trained Crisis Resource Management evaluators.

CONCLUSIONS

Theoretical and practical education in difficult airway management needs to be improved among Danish anaesthesia residents. Simulator assessment should only be performed using well-defined objective parameters and trained assessors.

The airway approach algorithm: a decision tree for organizing preoperative airway information

Anticipatory decision-making in airway management requires the integration of both history and physical examination findings. Though all airways can be managed along some branch of the American Society of Anesthesiologists' (ASA) Difficult Airway Algorithm, by predicting specific difficulties and integrating this information into an airway approach strategy, emergency branches of the ASA algorithm may be avoided. The Airway Approach Algorithm (AAA) consists of five clinical questions, with "yes" or "no" answers, to be addressed prior to the management of the airway. A positive answer to any question leads the clinician to the next, whereas a negative answer directs the operator to a root point of the ASA algorithm. The AAA is introduced with the anticipation that trainees in Anesthesiology, as well as others, will find it helpful in organizing preoperative information concerning the airway.

Preoperative planning of airway management in critical care patients

OBJECTIVE

The aim of this article is to review aspects of airway evaluation that may affect the care of the critical care patient whose airway is to be managed. This information must then be incorporated into the decision-making process of the "airway manager."

DESIGN

Literature review.

RESULTS

Historically used indexes of airway evaluation suffer from low sensitivity and only modest specificity in identifying the difficult-to-intubate patient. Using each index in isolation of others contributes to their poor predictive power. An understanding of anatomical relationships that these indexes measure should help the clinician in evaluating the airway. The clinician's impression of the airway, as well as the likelihood of trouble with supraglottic ventilation, the patient's inability to take food orally, and the patient's general condition can be used to formulate a management plan. This plan should be consistent with the American Society of Anesthesiologist's difficult airway algorithm.

CONCLUSIONS

Rote decision making on airway management, based on commonly used indexes, is not adequate. The vital role of airway in anesthetic management of the critical care patient demands thoughtful consideration. Patient conditions including the need for airway control, the likelihood of difficult laryngoscopy or supraglottic ventilation, the patient's inability to take food orally, and the medical state of the patient must be incorporated.

Anaesthesiological airway management in Denmark: assessment, equipment and documentation

BACKGROUND

Failed intubation remains one cause of anaesthesia-related morbidity and mortality. In a recent survey in Denmark, 20% of respondents reported preventable mishaps in airway management.

METHODS

Assessment of the airway, and its documentation, as well as the availability of various equipment to manage a difficult airway, and the existence of a failed intubation plan were surveyed by mailing a questionnaire to the clinical directors of all 69 anaesthesia departments in Denmark.

RESULTS

Fifty-six departments (81%) returned the questionnaire. Pre-operative airway evaluation is performed in 90% of the departments. The tests included the mouth-opening test (77%), Mallampati score (48%), lower jaw protrusion (34%), neck mobility (63%), the measurement of the thyromental (11%) and sternomental distance (4%). The result of the tests are documented by 38% of the departments in the anaesthetic chart (96%), in the record (54%), on a card given to the patient (23%), in a letter sent to the patient's general practitioner (2%) or in a database (13%). The patients are personally informed in 82% of the departments. Only 54% of the departments have a failed intubation plan readily available.

CONCLUSION

The preoperative assessment of the airways and its documentation is still unsatisfactory, as is communicating with the patient after a case of a difficult/impossible intubation. The adoption of internationally recognized recommendations might improve airway management and teaching to the best standard possible in the already well-equipped Danish anaesthetic departments.

Use of the bougie in simulated difficult intubation. 1. Comparison of the single-use bougie with the fibrescope

We studied the success rates for tracheal intubation in 64 healthy patients during simulated grade III laryngoscopy after induction of anaesthesia, using either the single-use bougie or oral flexible intubating fibrescope, both in conjunction with conventional Macintosh laryngoscopy. Patients were randomly allocated to either simulated grade IIIa or grade IIIb laryngoscopy, and also to one of the two study devices. Success rates for tracheal intubation (primary outcome measure) and times taken to achieve intubation (secondary outcome measure) were recorded. For the simulated grade IIIa laryngoscopy group, the fibreoptic scope was more successful than the bougie (16/16 successful intubations vs. 8/16; p = 0.02). For the simulated grade IIIb laryngoscopy group, the fibreoptic scope was also more successful than the bougie (8/16 successful intubations vs. 1/16; p = 0.02), but clearly use of the fibreoptic scope was not as successful as it had been in simulated grade IIIa laryngoscopy (p = 0.04). With either device, median (range) total tracheal intubation times for successful attempts with either grade of laryngoscopy were less than 60 s (19-109) and there were no clinically important differences. We conclude that the fibrescope used in conjunction with Macintosh laryngoscopy is a more reliable method of tracheal intubation than the single-use bougie in both types of grade III laryngoscopy. This finding has implications for the management of patients in whom grade III laryngoscopy is encountered unexpectedly after induction of anaesthesia, and also for the management of patients previously known to have grade III view at laryngoscopy.

Advances in airway management for outpatients

PURPOSE OF REVIEW

As outpatient anaesthesia increases in volume so does research, especially in ways to reduce morbidity from relatively minor complications such as sore throat and hoarseness, as well as aiming to reduce costs and length of hospital stay. The past year has produced many studies in which newer airway devices have been compared with the laryngeal mask airway and this review evaluates them all.

RECENT FINDINGS

The relatively recent introduction of the ProSeal laryngeal mask airway shows promise when insertion of a gastric tube is preferred in patients breathing spontaneously, whilst the intubating laryngeal mask airway has demonstrated its usefulness in those situations where the patient prefers to be anaesthetized but intubation may be difficult following classic laryngoscopy. The cuffed oropharyngeal airway and combitube probably only have a place in emergency airway management rather than elective anaesthesia.

SUMMARY

Despite the introduction of new airway devices, some of which have specific indications for use, the classic laryngeal mask airway remains the 'gold standard' with which newer devices are compared. Whilst some of these new devices show promise in the outpatient setting, further research is required before their universal acceptance.