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Wiles MD, Iliff HA, Brooks K, Da Silva EJ, Donnellon M, Gardner A, Harris M, Leech C, Mathieu S, Moor P, Prisco L, Rivett K, Tait F, El-Boghdadly K. Airway management in patients with suspected or confirmed cervical spine injury: Guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists (AoA), British Society of Orthopaedic Anaesthetists (BSOA), Intensive Care Society (ICS), Neuro Anaesthesia and Critical Care Society (NACCS), Faculty of Prehospital Care and Royal College of Emergency Medicine (RCEM). Anaesthesia 2024; 79:856-868. [PMID: 38699880 DOI: 10.1111/anae.16290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND There are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence-based guidelines for practicing clinicians to support safe and effective airway management in this setting. METHODS An expert multidisciplinary, multi-society working party conducted a systematic review of contemporary literature (January 2012-June 2022), followed by a three-round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury. RESULTS We included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre-oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front-of-neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre-hospital care, military settings and principles in human factors. CONCLUSIONS It is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury.
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Affiliation(s)
- Matthew D Wiles
- Department of Anaesthesia and Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Centre for Applied Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | | | | | - Egidio J Da Silva
- Department of Anaesthesia, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Mike Donnellon
- Education and Standards Committee, College of Operating Department Practitioners, London, UK
| | - Adrian Gardner
- Department of Spine Surgery, The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
- Aston University, Birmingham, UK
| | - Matthew Harris
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Caroline Leech
- Department of Emergency Medicine, Institute for Applied and Translational Technologies in Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
- Prehospital Emergency Medicine, Air Ambulance Service, Rugby, UK
| | - Steve Mathieu
- Department of Critical Care, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Paul Moor
- Army Health Branch, Army HQ, Marlborough Lines, Andover, Hants, UK
- Department of Anaesthesia, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Lara Prisco
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
- Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Kate Rivett
- Patient Representative, Difficult Airway Society, London, UK
| | - Frances Tait
- Critical Care Department, Northampton General Hospital, Northampton, UK
| | - Kariem El-Boghdadly
- Department of Anaesthesia and Perioperative Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
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Nedunchezhian V, Nedunchezhian I, Van Zundert A. Clinically Preferred Videolaryngoscopes in Airway Management: An Updated Systematic Review. Healthcare (Basel) 2023; 11:2383. [PMID: 37685417 PMCID: PMC10487223 DOI: 10.3390/healthcare11172383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/11/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Videolaryngoscopes (VLs) have emerged as a safety net offering several advantages over direct laryngoscopy (DL). The aim of this study is to expand on our previous study conducted in 2016, to deduce which VL is most preferred by clinicians and to highlight any changes that may have occurred over the past 7 years. An extensive systematic literature review was performed on Medline, Embase, Web of Science, and Cochrane Central Database of Controlled Studies for articles published between September 2016 and January 2023. This review highlighted similar results to our study in 2016, with the CMAC being the most preferred for non-channelled laryngoscopes, closely followed by the GlideScope. For channelled videolaryngoscopes, the Pentax AWS was the most clinically preferred. This review also highlighted that there are minimal studies that compare the most-used VLs, and thus we suggest that future studies directly compare the most-used and -preferred VLs as well as the specific nature of blades to attain more useful results.
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Affiliation(s)
- Vikram Nedunchezhian
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, The University of Queensland, Brisbane, QLD 4029, Australia;
| | - Ishvar Nedunchezhian
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD 4215, Australia;
| | - André Van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women’s Hospital, The University of Queensland, Brisbane, QLD 4029, Australia;
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Wiles MD. Airway management in patients with suspected or confirmed traumatic spinal cord injury: a narrative review of current evidence. Anaesthesia 2022; 77:1120-1128. [PMID: 36089854 PMCID: PMC9546380 DOI: 10.1111/anae.15807] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 12/01/2022]
Abstract
Around 1 million people sustain a spinal cord injury each year, which can have significant psychosocial, physical and socio‐economic consequences for patients, their families and society. The aim of this review is to provide clinicians with a summary of recent studies of direct relevance to the airway management of patients with confirmed or suspected traumatic spinal cord injury to promote best clinical practice. All airway interventions are associated with some degree of movement of the cervical spine; in general, these are very small and whether these are clinically significant in terms of impingement of the spinal cord is unclear. Manual in‐line stabilisation does not effectively immobilise the cervical spine and increases the likelihood of difficult and failed tracheal intubation. There is no clear evidence of benefit of awake tracheal intubation techniques in terms of prevention of secondary spinal cord injury. Videolaryngoscopy appears to cause a similar degree of cervical spine displacement as flexible bronchoscope‐guided tracheal intubation and is an appropriate alternative approach. Direct laryngoscopy does cause a slightly greater degree of cervical spinal movement during tracheal intubation than videolaryngoscopy, but this does not appear to increase the risk of spinal cord compression. The risk of spinal cord injury during tracheal intubation appears to be minimal even in the presence of gross cervical spine instability. Depending on the clinical situation, practitioners should choose the tracheal intubation technique with which they are most proficient and that is most likely to minimise cervical spine movement.
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Affiliation(s)
- M D Wiles
- Department of Critical Care, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.,University of Sheffield Medical School, Sheffield, UK
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Innovative artificial lesions to mimic difficult airway pathology in cadavers, supporting airway management training. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kuo YM, Lai HY, Tan ECH, Li YS, Chiang TY, Huang SS, Huang WC, Chu YC. Cervical spine immobilization does not interfere with nasotracheal intubation performed using GlideScope videolaryngoscopy: a randomized equivalence trial. Sci Rep 2022; 12:4041. [PMID: 35260735 PMCID: PMC8904815 DOI: 10.1038/s41598-022-08035-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 03/01/2022] [Indexed: 11/09/2022] Open
Abstract
GlideScope-assisted nasotracheal intubation (NTI) has been proposed as an alternative to difficult orotracheal intubation for critical patients or those under cervical immobilization. We evaluated the difficulty of performing NTI using GlideScope under cervical orthosis. A total of 170 patients scheduled for elective cervical spinal surgery that required NTI were randomized to receive cervical immobilization using a cervical collar (collar group) or no cervical immobilization at all (control group) before anesthetic induction (group assignment at 1:1 ratio). All NTI during anesthetic induction were performed using the GlideScope. The primary outcome was time to intubation. The secondary outcomes were ease of intubation, including the necessity of auxiliary manipulations to assist intubation, and the nasotracheal intubation difficulty scale (nasoIDS). An exploratory analysis identified morphometric parameters as predictors of time to intubation, the necessity of auxiliary manipulations, and a nasoIDS score ≥ 4. For time to intubation, the mean difference (collar group-control) was - 4.19 s, with a 95% confidence interval (CI) of - 13.9 to 5.52 that lay within our defined equivalence margin of 16 s. Multivariate regressions precluded the association of cervical immobilization with a necessity for auxiliary manipulations (adjusted odds ratio [aOR] 0.53, 95% CI [0.26-1.09], P = 0.083) and a nasoIDS ≥ 4 (aOR 0.94 [0.84-1.05], P = 0.280). Among all morphometric parameters, the upper lip bite test class was predictive of a longer time to intubation (all analyses relative to class 1, 14 s longer for class 2, P = 0.032; 24 s longer for class 3, P = 0.070), increased necessity for auxiliary manipulation (aOR 2.29 [1.06-4.94], P = 0.036 for class 2; aOR 6.12 [1.04-39.94], P = 0.045 for class 3), and nasoIDS ≥ 4 (aOR 1.46 [1.14-1.89], P = 0.003 for class 3).The present study demonstrated that GlideScope achieved NTI in patients with or without cervical immobilization equivalently with respect to intubation time and ease.
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Affiliation(s)
- Yi-Min Kuo
- Department of Anesthesiology, Taipei Veterans General Hospital, Beitou Dist., Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, 30010, Taiwan
| | - Hsien-Yung Lai
- Department of Anesthesiology, Mennonite Christian Hospital, Hualien, 970, Taiwan
| | - Elise Chia-Hui Tan
- National Research Institute of Chinese Medicine, Ministry of Health and Welfare, Taipei, 11217, Taiwan.,Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Hsinchu, 30010, Taiwan
| | - Yi-Shiuan Li
- Department of Anesthesiology, Taipei Veterans General Hospital, Beitou Dist., Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, 30010, Taiwan
| | - Ting-Yun Chiang
- Department of Anesthesiology, Taipei Veterans General Hospital, Beitou Dist., Taipei, 11217, Taiwan.,School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, 30010, Taiwan
| | - Shiang-Suo Huang
- Department of Pharmacology, Institute of Medicine, Chung Shan Medical University, Taichung, 40201, Taiwan.,Department of Pharmacy, Chung Shan Medical University Hospital, Taichung, 40201, Taiwan
| | - Wen-Cheng Huang
- School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, 30010, Taiwan.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, 11217, Taiwan
| | - Ya-Chun Chu
- Department of Anesthesiology, Taipei Veterans General Hospital, Beitou Dist., Taipei, 11217, Taiwan. .,School of Medicine, National Yang Ming Chiao Tung University, Hsinchu, 30010, Taiwan.
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Comparison of video-stylet and video-laryngoscope for endotracheal intubation in adults with cervical neck immobilisation: A meta-analysis of randomised controlled trials. Anaesth Crit Care Pain Med 2021; 40:100965. [PMID: 34687924 DOI: 10.1016/j.accpm.2021.100965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/30/2021] [Accepted: 05/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The efficacy of video-stylet versus video-laryngoscope for tracheal intubation in patients with cervical spine immobilisation, which is known to impede the intubation process, remains unclear. METHODS We searched electronic databases including EMBASE, MEDLINE, Google Scholar, and Cochrane Library for randomised controlled trials comparing video-stylets with video-laryngoscopes in human subjects with cervical spine immobilisation from inception to the 25th of January 2021. The primary outcome was the rate of successful first-attempt intubation, while secondary outcomes included overall intubation success rate, time for successful intubation, and risk of tissue damage. RESULTS Five trials (709 patients) published between 2009 and 2020 met the inclusion criteria. There were four types of video-stylets and three types of video-laryngoscopes examined. Hard cervical collar was applied in four studies, while manual inline stabilisation was used in one study for cervical immobilisation. There was no difference in successful first-attempt intubation rate between the video-stylet and the video-laryngoscope groups [risk ratio (RR) = 0.96, 95% CI: 0.90-1.03, p = 0.3; I2 = 47%] (5 trials, 709 patients). The overall success rate (RR = 0.98, 95% CI: 0.96-1.0, p = 0.05; I2 = 0%), intubation time [mean difference (MD) = 5.24, 95% CI: -8.95 to 19.43, p = 0.47; I2 = 92%], and risk of tissue damage (RR = 0.87, 95% CI: 0.26-2.85, p = 0.81; I2 = 39%) were also comparable between the two groups. CONCLUSIONS This study validates the efficacy of both video-stylets and video-laryngoscopes for tracheal intubation in the situation of cervical spine immobilisation. Further large-scale trials are warranted to support our findings in this clinical setting.
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d'Arville A, Walker M, Lacey J, Lancman B, Hendel S. Airway management in the adult patient with an unstable cervical spine. Curr Opin Anaesthesiol 2021; 34:597-602. [PMID: 34325462 DOI: 10.1097/aco.0000000000001040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The ideal airway management of patients with unstable spinal injury presents a perennial challenge for anaesthesiologists. With competing interests, potentially catastrophic complications, and a scarcity of evidence to support common practices, it is an area rich with dogma and devoid of data. This review seeks to highlight recent evidence that improves our assurance that what we do to manage the airway in the unstable cervical spine is supported by data. RECENT FINDINGS The increasing range of available technology for intubation provides important opportunities to investigate the superiority (or otherwise) of various techniques - and a chance to challenge accepted practice. Long-held assumptions regarding spinal immobilisation in the context of airway management may require refinement as a true base of evidence develops. SUMMARY Video laryngoscopy may replace direct laryngoscopy as the default technique for endotracheal intubation in patients with suspected or confirmed spinal instability. Immobilisation of the unstable cervical spine, manually or with rigid cervical collars, is increasingly controversial. It may be that hard collars are used in specific circumstances, rather than as universal precaution in the future.There are no recent data of significantly high quality to warrant wholesale changes to recommended airway management practice and in the absence of new information, limiting movement (in the suspected or confirmed unstable cervical spine) remains the mainstay of clinical practice advice.
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Affiliation(s)
- Asha d'Arville
- Department of Anaesthesiology and Perioperative Medicine, Alfred Health, Melbourne, Australia
| | - Matthew Walker
- Department of Anaesthesiology and Perioperative Medicine, Alfred Health, Melbourne, Australia
- The Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, Canada
| | - Jonathan Lacey
- Department of Anaesthesiology and Perioperative Medicine, Alfred Health, Melbourne, Australia
| | - Benn Lancman
- Department of Anaesthesiology and Perioperative Medicine, Alfred Health, Melbourne, Australia
| | - Simon Hendel
- Department of Anaesthesiology and Perioperative Medicine, Alfred Health, Melbourne, Australia
- The Central Clinical School, Monash University
- The National Trauma Research Institute, Melbourne, Australia
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Neuroanesthesiology Update. J Neurosurg Anesthesiol 2021; 33:107-136. [PMID: 33480638 DOI: 10.1097/ana.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.
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