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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Frances R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Martín LJR, Leis CC, Ramírez SE, Orgeira JMF, Lima MJV, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Executive Summary of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2024:S2173-5735(24)00061-9. [PMID: 38797374 DOI: 10.1016/j.otoeng.2024.05.001] [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: 09/06/2023] [Accepted: 03/08/2024] [Indexed: 05/29/2024]
Abstract
The Airway section of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) present the Guidelines for the integral management of difficult airway in adult patients. This document provides recommendations based on current scientific evidence, theoretical-educational tools and implementation tools, mainly cognitive aids, applicable to the treatment of the airway in the field of anesthesiology, critical care, emergencies and prehospital medicine. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations and optimization in the progression of the application of strategies to preserve adequate alveolar oxygenation in order to improve safety and quality of care.
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Affiliation(s)
- Manuel Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, Spain.
| | - José Alfonso Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Teresa López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Rubén Casans-Frances
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - José Carlos Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Vicente Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | | | | | | | | | | | | | - Javier García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain; Presidente de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), Spain
| | | | | | | | | | | | | | - Miguel Mayo-Yáñez
- Department of Otorhinolaryngology - Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, Galicia, Spain
| | - Pablo Parente-Arias
- Department of Otorhinolaryngology - Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, Galicia, Spain; Department of Otorhinolaryngology, Universidade de Santiago de Compostela, Galicia, Spain
| | - Jon Alexander Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Spain; Presidente de la Comisión de Tumores de la OSI Donostialdea, Spain
| | - Manuel Bernal-Sprekelsen
- Department of Otorhinolaryngology, University of Barcelona, Barcelona, Spain; Department of Otorhinolaryngology, Hospital Clinic Barcelona, Spain; Presidente de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC), Spain
| | - Pedro Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:207-247. [PMID: 38340790 DOI: 10.1016/j.redare.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitary Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology. Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Emergency Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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3
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Hori K, Matsuura T, Tsujikawa S, Hino H, Kuno M, Oda Y, Nishikawa K, Mori T. Lipid emulsion facilitates reversal from volatile anesthetics in a rodent model. Clin Toxicol (Phila) 2022; 60:716-724. [PMID: 34985393 DOI: 10.1080/15563650.2021.2020280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lipid emulsion infusion is a first-line therapy against the toxicity of local anesthetics and is a potential treatment for other drug overdoses, especially for highly lipophilic drugs. Considering the lipophilic property of volatile anesthetics, we hypothesized that lipid emulsion could reverse general anesthesia. METHODS Using adult rats, we tested the effect of lipid emulsion infusion on time to emergence after discontinuation of sevoflurane and isoflurane, and further evaluated restoration of righting reflex under continuous sevoflurane anesthesia. Electroencephalogram during lipid emulsion infusion was also investigated under continuous sevoflurane inhalation. The effect of lipid emulsion on sevoflurane-induced respiratory and hemodynamic depressions was evaluated by measuring respiratory rate, PaCO2 (arterial partial pressure of CO2), blood pressure, and heart rate. The binding property of lipid emulsion on sevoflurane and isoflurane was assessed using in vitro setting with a conical flask. RESULTS Lipid emulsion infusion significantly decreased time to emergence from sevoflurane anesthesia (131 ± 53 vs. 237 ± 69 s) and restored righting reflex during continuous sevoflurane inhalation, by comparing normal saline infusion. Consistent with the behavioral findings, the electroencephalogram under continuous sevoflurane showed decreased power of the δ bands at 5 min after the initiation of lipid emulsion infusion. In addition to reversing hypnosis, lipid emulsion recovered respiratory as well as hemodynamic depressions induced by sevoflurane. Decreased time to emergence was observed also in isoflurane anesthesia (203 ± 111 vs. 314 ± 154 s). To investigate the binding mechanism of lipid emulsion infusion, in vitro experiments revealed significantly decreased anesthetic concentrations of sevoflurane and isoflurane by mixing with lipid emulsion. CONCLUSIONS Lipid emulsion facilitated reversal from volatile anesthetics, as shown by several parameters. As lipid emulsion could bind to volatile anesthetics and simply decrease their effects, our findings suggest that lipid emulsion is a potentially useful agent to reverse general anesthesia.
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Affiliation(s)
- Kotaro Hori
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tadashi Matsuura
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shogo Tsujikawa
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hideki Hino
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Miyuki Kuno
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yutaka Oda
- Department of Anesthesiology, Osaka City Juso Hospital, Osaka, Japan
| | - Kiyonobu Nishikawa
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Anesthesiology, Shiraniwa Hospital, Nara, Japan
| | - Takashi Mori
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Davidson A, Beddoes P, Patel J, Hunningher A. Rapid upper airway obstruction after arteriovenous malformation rupture in a patient with neurofibromatosis. Anaesth Rep 2021; 9:e12132. [PMID: 34651129 DOI: 10.1002/anr3.12132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 12/19/2022] Open
Abstract
Neurofibromatosis type 1 is rarely associated with arteriovenous malformation rupture. We present a case of a rapidly compromised upper airway due to extrinsic compression as a consequence of the rupture of an arteriovenous malformation fed by the inferior thyroid artery which required emergency cricothyroidotomy following failed attempts at orotracheal intubation. While the patient had a good overall outcome, our reflection on the management of this case highlights several important learning points. These include the importance of clear communication between different medical specialties to promote shared situation awareness, the importance of training anaesthetists in the limitations of standard difficult airway management algorithms, and the implications of the skillset mix of doctors responding to airway emergencies in district general hospitals.
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Affiliation(s)
- A Davidson
- Departments of Intensive Care Medicine and Anaesthesia Homerton University Hospital London UK
| | - P Beddoes
- Department of Anaesthesia Leeds General Infirmary Leeds UK
| | - J Patel
- Department of Anaesthesia Royal London Hospital London UK
| | - A Hunningher
- Department of Anaesthesia Royal London Hospital London UK
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Barnes RK, Au J. Transtracheal jet ventilation in a general tertiary hospital: A 7-year audit. Anaesth Intensive Care 2021; 49:316-321. [PMID: 34348483 DOI: 10.1177/0310057x211002525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Airway management in patients presenting with severe airway obstruction can present a challenge to the anaesthetist, as conventional difficult airway pathways are often inappropriate. The use of a transtracheal jet cannula is an alternative means of airway securement, but lack of familiarity has limited its use in general tertiary hospitals. We report a retrospective audit of the use of transtracheal jet ventilation in a general tertiary healthcare centre over the past seven years, with a total of 50 patients with severe airway compromise undergoing pharyngolaryngeal surgery. Transtracheal jet ventilation was successful in 98% of patients, and was the definitive means of airway management in 43 cases. In six cases, the technique was a useful temporising measure while the airway was secured by other means. Minor complications occurred in 12% of patients. No major morbidities or mortalities were recorded. We conclude that transtracheal jet ventilation for high-risk pharyngolaryngeal surgery can be performed using a high frequency jet ventilator, with a high rate of success and only minor complications. Cannulation of the trachea below the cricothyroid membrane is feasible but more challenging. Low-flow apnoeic oxygenation through the transtracheal jet ventilation cannula maintains oxygenation during initial surgical airway manipulation.
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Affiliation(s)
- Richard K Barnes
- Department of Anaesthesia and Perioperative Medicine, Monash Health, Clayton, Australia
| | - Jonathan Au
- Department of Anaesthesia and Perioperative Medicine, Monash Health, Clayton, Australia
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Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth 2021; 68:1405-1436. [PMID: 34105065 PMCID: PMC8186352 DOI: 10.1007/s12630-021-02008-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient's tolerance for withdrawal of airway support and whether re-intubation might be difficult.
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BORAN ÖF, ARSLAN M, URFALIOĞLU A, ÖKSÜZ G, BİLAL B, SARICA S, ÇALIŞIR F. DEV VOKAL PROÇES GRANÜLOMU OLAN HASTANIN ANESTEZİK YÖNETİMİ. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2020. [DOI: 10.17517/ksutfd.679114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Louis M, Graham J, Spanger M, Ho A, Lee DK, Barnett S, Weinberg L. Life-Threatening Laryngeal Emphysema After Video-Assisted Thoracoscopic Surgery. J Cardiothorac Vasc Anesth 2020; 34:2460-2464. [PMID: 32144069 DOI: 10.1053/j.jvca.2020.01.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Maleck Louis
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Jonathan Graham
- Department of Anesthesia, Austin Health, Heidelberg, Australia
| | - Manfred Spanger
- Department of Radiology, Box Hill Hospital, Box Hill, Australia
| | - Alexander Ho
- Department of Anesthesia, Austin Health, Heidelberg, Australia; Department of Thoracic Surgery, Austin Health, Heidelberg, Australia
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Stephen Barnett
- Department of Thoracic Surgery, Austin Health, Heidelberg, Australia
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9
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Constable N, Thomas C, Jones M, Walters M. Acute presentation of a partially obstructing laryngeal tumour: adjuvant agents to gaseous induction of anaesthesia. BMJ Case Rep 2018; 2018:bcr-2018-224700. [PMID: 30002153 DOI: 10.1136/bcr-2018-224700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present the case of a 53-year-old man who attended our emergency department with stridor. He had recently undergone investigation for possible glottic cancer. We discuss the airway management of such a case. We believe this to be the first description of propofol target controlled infusion and clonidine to supplement a sevoflurane gas induction, in order to obtund response to intubation while maintaining spontaneous ventilation. We also consider how airway interventions may impact prognosis and need to be considered.
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Affiliation(s)
- Natalie Constable
- Anaesthetics, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Carolyn Thomas
- Anaesthetics, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, UK
| | - Martyn Jones
- Anaesthetics, Nottingham University Hospitals NHS Trust, Nottingham, UK
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10
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Cheng LTW, Sim TB, Kuan WS. Noninvasive Ventilation as a Temporizing Measure in Critical Fixed Central Airway Obstruction: A Case Report. J Emerg Med 2018; 54:615-618. [PMID: 29482923 DOI: 10.1016/j.jemermed.2017.12.059] [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] [Received: 07/07/2017] [Revised: 10/30/2017] [Accepted: 12/30/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critical central airway obstruction (CAO) requires emergent airway intervention, but current guidelines lack specific recommendations for airway management in the emergency department (ED) while awaiting rigid bronchoscopy. There are few reports of the use of noninvasive ventilation (NIV) in tracheomalacia, but its use as a temporizing treatment option in fixed, malignant CAO has not, to the best of our knowledge, been reported. CASE REPORT An 84-year-old woman presented to the ED in respiratory distress, too breathless to speak and using her accessory muscles of respiration, with bilateral rhonchi throughout the lung fields. Point-of-care arterial blood gas revealed severe hypercapnia, and NIV was initiated to treat a presumed bronchitis with hypercapnic respiratory failure. Chest radiography revealed a paratracheal mass with tracheal deviation and compression. A diagnosis of critical CAO was made. While arranging for rigid bronchoscopic stenting, the patient was kept on NIV to good effect. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Recommendations for emergent treatment of life-threatening, critical CAO before bronchoscopic intervention are not well established. Furthermore, reports of NIV use in CAO are rare. We suggest that emergency physicians consider NIV as a temporizing measure for critical CAO while awaiting availability of bronchoscopy.
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Affiliation(s)
- Lenard Tai Win Cheng
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore
| | - Tiong Beng Sim
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore; Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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11
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Lee PKG, Booth AWG, Vidhani K. Spontaneous Respiration Using Intravenous Anesthesia and High-Flow Nasal Oxygen (STRIVE Hi) Management of Acute Adult Epiglottitis: A Case Report. A A Pract 2018; 10:73-75. [PMID: 28953487 PMCID: PMC5802268 DOI: 10.1213/xaa.0000000000000635] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2017] [Indexed: 01/03/2023]
Abstract
High-flow nasal oxygen (HFNO) is a potentially life-saving adjunct in the emergency management of the obstructed airway. HFNO has multiple beneficial applications in critical care and respiratory support, but its use in emergency-obstructed airway management has not been defined. This case report describes spontaneous respiration using intravenous anesthesia and high-flow nasal oxygen to successfully manage acute adult epiglottitis with rapidly progressing airway obstruction. Oxygenation, carbon dioxide levels, and airway patency were maintained, which facilitated endotracheal intubation while the patient was spontaneously breathing during general anesthesia. The application of HFNO can be extended to emergency airway obstruction.
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Affiliation(s)
- Phillip Kwan-Giet Lee
- From the University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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12
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Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2017; 120:323-352. [PMID: 29406182 DOI: 10.1016/j.bja.2017.10.021] [Citation(s) in RCA: 447] [Impact Index Per Article: 63.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
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Affiliation(s)
- A Higgs
- Anaesthesia and Intensive Care Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK(8).
| | - B A McGrath
- Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Manchester, UK(9)
| | - C Goddard
- Anaesthesia & Intensive Care Medicine, Southport and Ormskirk Hospitals NHS Trust, Southport, UK(8)
| | - J Rangasami
- Anaesthesia & Intensive Care Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK(8)
| | - G Suntharalingam
- Intensive Care Medicine and Anaesthesia, London North West Healthcare NHS Trust, London, UK(10)
| | - R Gale
- Anaesthesia & Intensive Care Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK(11)
| | - T M Cook
- Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK(12)
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13
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Markova L, Stopar-Pintaric T, Luzar T, Benedik J, Hodzovic I. A feasibility study of awake videolaryngoscope-assisted intubation in patients with periglottic tumour using the channelled King Vision®videolaryngoscope. Anaesthesia 2016; 72:512-518. [DOI: 10.1111/anae.13734] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2016] [Indexed: 11/27/2022]
Affiliation(s)
- L. Markova
- Clinical Department of Anaesthesiology and Intensive Therapy; University Medical Centre Ljubljana; Ljubljana Slovenia
| | - T. Stopar-Pintaric
- Clinical Department of Anaesthesiology and Intensive Therapy; University Medical Centre Ljubljana; Ljubljana Slovenia
- Institute of Anatomy; Faculty of Medicine; University of Ljubljana; Ljubljana Slovenia
| | - T. Luzar
- Clinical Department of Anaesthesiology and Intensive Therapy; University Medical Centre Ljubljana; Ljubljana Slovenia
| | - J. Benedik
- Clinical Department of Anaesthesiology and Intensive Therapy; University Medical Centre Ljubljana; Ljubljana Slovenia
| | - I. Hodzovic
- Department of Anaesthesia, Intensive Care and Pain Medicine; School of Medicine; Cardiff University; Cardiff UK
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Daubeny T, Turner M. Reply to "Stridor in adult patients presenting from the community: An alarming clinical sign" ( Journal of the Intensive Care Society 2015, Vol. 16(3) 272-273). J Intensive Care Soc 2016; 17:267. [PMID: 28979503 PMCID: PMC5606510 DOI: 10.1177/1751143715618974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Affiliation(s)
- Thomas Daubeny
- Department of Anaesthesia, Queen Alexandra Hospital, Portsmouth, UK
| | - Matthew Turner
- Department of Anaesthesia, Queen Alexandra Hospital, Portsmouth, UK
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Kuo AS, Vijjeswarapu MA, Philip JH. Incomplete Spontaneous Recovery from Airway Obstruction During Inhaled Anesthesia Induction: A Computational Simulation. Anesth Analg 2016; 122:698-705. [PMID: 26745755 DOI: 10.1213/ane.0000000000001101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Inhaled induction with spontaneous respiration is a technique used for difficult airways. One of the proposed advantages is if airway patency is lost, the anesthetic agent will spontaneously redistribute until anesthetic depth is reduced and airway patency can be recovered. There are little and conflicting clinical or experimental data regarding the kinetics of this anesthetic technique. We used computer simulation to investigate this situation. METHODS We used GasMan, a computer simulation of inhaled anesthetic kinetics. For each simulation, alveolar ventilation was initiated with a set anesthetic induction concentration. When the vessel-rich group level reached the simulation specified airway obstruction threshold, alveolar ventilation was set at 0 to simulate complete airway obstruction. The time until the vessel-rich group anesthetic level decreased below the airway obstruction threshold was designated time to spontaneous recovery. We varied the parameters for each simulation, exploring the use of sevoflurane and halothane, airway obstruction threshold from 0.5 to 2 minimum alveolar concentration (MAC), anesthetic induction concentration 2 to 4 MAC sevoflurane and 4 to 6 MAC halothane, cardiac output 2.5 to 10 L/min, functional residual capacity 1.5 to 3.5 L, and relative vessel-rich group perfusion 67% to 85%. RESULTS In each simulation, there were 3 general phases: anesthetic wash-in, obstruction and overshoot, and then slow redistribution. During the first 2 phases, there was a large gradient between the alveolar and vessel-rich group. Alveolar do not reflect vessel-rich group anesthetic levels until the late third phase. Time to spontaneous recovery varied between 35 and 749 seconds for sevoflurane and 13 and 222 seconds for halothane depending on the simulation parameters. Halothane had a faster time to spontaneous recovery because of the lower alveolar gradient and less overshoot of the vessel-rich group, not faster redistribution. Higher airway obstruction thresholds, decreased anesthetic induction, and higher cardiac output reduced time to spontaneous recovery. To a lesser effect, decreased functional residual capacity and the decreased relative vessel-rich groups' perfusion also reduced the time to spontaneous recovery. CONCLUSIONS Spontaneous recovery after complete airway obstruction during inhaled induction is plausible, but the recovery time is highly variable and depends on the clinical and physiologic situation. These results emphasize that induction is a non-steady-state situation, thus effect-site anesthetic levels should be modeled in future research, not alveolar concentration. Finally, this study provides an example of using computer simulation to explore situations that are difficult to investigate clinically.
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Affiliation(s)
- Alexander S Kuo
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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George J, Kader JA, Arumugam S, Murphy A. Successful intubation of a difficult airway due to a large obstructive vocal cord polyp augmented by the delivery of a transtracheal injection of local anaesthetic. BMJ Case Rep 2015; 2015:bcr-2015-210905. [PMID: 26628451 DOI: 10.1136/bcr-2015-210905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe a case of a very difficult intubation which was safely navigated through careful planning. Our patient presented initially with increasing hoarseness and shortness of breath over a 6-month period. This was investigated and the patient was found to have a large vocal cord mass and was referred for urgent microlaryngoscopy and vocal cord polypectomy. On the day of surgery the obstruction was noted and awake fiberoptic bronchoscopy was used with a remifentanil infusion. Given the mass was large and increased in size with expiration, the time frame to pass the tube was extremely short. We delivered a transtracheal injection of local anaesthesia. This approach allowed for safe passage of the endotracheal tube. In patients such as this it may be worth considering the use of a transtracheal injection in the first instance.
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Affiliation(s)
- Jayan George
- Department of Otorhinolaryngology, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | | | | | - Anthony Murphy
- Department of Anaesthetics, Singleton Hospital, Swansea, UK
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Wong P, Iqbal R, Light KP, Williams E, Hayward J. Head and neck surgery in a tertiary centre: Predictors of difficult airway and anaesthetic management. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815615995] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: The management of head and neck surgical patients is associated with increased morbidity and mortality, and so anticipating the difficult airway is important. Methods: We undertook a prospective survey on consecutive adult patients scheduled on the elective operating lists of four head and neck consultant surgeons. Data were collected over a 36 month period. Data included: patient characteristics; routine predictors of difficulty in airway management (bedside tests of the airway, a history of previous surgery or radiotherapy and the presence of airway symptoms); laryngoscopy grade; method of anaesthesia and airway management; and any airway complications arising during induction of anaesthesia and extubation. Results: The ‘study’ group consisted of 818 patients. The ‘direct laryngoscopy’ group contained 674 patients, that is, patients who had direct laryngoscopy and could therefore be classified as easy or difficult intubation. The prevalence of difficult intubation was 12.6%. Factors or tests that were statistically significantly associated with difficult intubation were: history of difficult airway; previous head or neck radiotherapy treatment; presence of airway symptoms; presence of moderate or severe limited neck movement; and short interdental distance. The sensitivity, specificity and positive predictive values were: history of difficult airway 16.5%, 98.6% and 63.6%; previous radiotherapy 12.9%, 96.6% and 35.5%; airway symptoms 42.9%, 69.6% and 15.9%; moderate/severe neck limitation 16.7%, 97.2% and 46.7%; Mallampati score 3 or 4, 38.8%, 83.8% and 25.8%; and interdental distance 9.4%, 98.8% and 53.3%, respectively. The Bonfils intubation fibrescope was the most commonly used indirect laryngoscopy device (63.9% of all such cases). Twenty-six patients (3.2%) had complications during their initial airway management after induction of anaesthesia. There was one case of ‘cannot intubate, cannot oxygenate’, which required an emergency tracheostomy. Conclusion: The prevalence of difficult intubation in head and neck surgical patients was higher than in the general population, but predictive tests for difficult intubation have poor to moderate value. In our study, rates of difficult face mask ventilation, failed intubation and complications during induction and extubation were low. However, serious morbidity, although rare, can still be encountered. Head and neck surgical patients can be managed safely in a tertiary centre where there is appropriate surgical and anaesthetic expertise in managing difficult airways.
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Affiliation(s)
- Patrick Wong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Rehana Iqbal
- Department of Anaesthesia, St George’s Hospital, London, UK
| | | | | | - James Hayward
- Department of Anaesthesia, Worthing District General Hospital, West Sussex, UK
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Abstract
Airway management is one of the most important aspects of anesthesia care. Although the incidence of difficult intubation is low, predicting a potentially difficult airway can ensure that necessary staff and equipment are available. A preoperative airway evaluation should include a history and physical examination focusing on elements that can cause problems with intubation. When indicated, flexible fiberoptic laryngoscopy can add valuable information regarding the upper aerodigestive anatomy. Specific patient and situational factors should be considered. Alternative plans should be defined before the initiation of anesthesia. Management of a complex airway should be a coordinated effort between anesthesiologists and otolaryngologists.
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Affiliation(s)
- Karla O'Dell
- Department of Otolaryngology, Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street, Los Angeles, CA 90033, USA.
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20
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Patel A. Facemask ventilation before or after neuromuscular blocking drugs: where are we now? Anaesthesia 2014; 69:811-5. [DOI: 10.1111/anae.12792] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- A. Patel
- Royal National Throat Nose and Ear Hospital & University College Hospital London UK
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Mendonca C. Sugammadex to rescue a 'can't ventilate' scenario in an anticipated difficult intubation: is it the answer? Anaesthesia 2013; 68:795-9. [PMID: 24044438 DOI: 10.1111/anae.12311] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- C Mendonca
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
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22
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Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM, Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey S, Turkstra TP, Wong DT. The difficult airway with recommendations for management--part 2--the anticipated difficult airway. Can J Anaesth 2013; 60:1119-38. [PMID: 24132408 PMCID: PMC3825645 DOI: 10.1007/s12630-013-0020-x] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 08/13/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway. METHODS To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned. PRINCIPAL FINDINGS Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician's experience, must also be considered in deciding the appropriate strategy. CONCLUSIONS With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.
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Affiliation(s)
- J Adam Law
- Department of Anesthesia, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada,
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Johnston KD, Rai MR. Conscious sedation for awake fibreoptic intubation: a review of the literature. Can J Anaesth 2013; 60:584-99. [PMID: 23512191 DOI: 10.1007/s12630-013-9915-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 03/05/2013] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Awake fibreoptic intubation (AFOI) is the gold standard of management of the predicted difficult airway. Sedation is frequently used to make the process more tolerable to patients. It is not always easy to strike a balance between patient comfort and good intubating conditions on the one hand and maintaining ventilation and a patent airway on the other. In the last 30 years, many drugs and drug combinations have been described, but there is very little in the literature to help guide the practitioner to choose between them. The objective of this article is to discuss the evidence supporting the use of the agents described with regard to their efficacy, recommended doses and techniques, and limitations to their use for AFOI. SOURCE Publication databases were searched for articles published from 1996 to 2012 relating to sedation for AFOI. PRINCIPLE FINDINGS Benzodiazepines, propofol, opioids, alpha2-adrenoceptor agonists, and ketamine are the main classes of drugs that have been described to facilitate AFOI. Drugs that are most suitable have a combination of both anxiolytic and analgesic properties. The ideal choice of drug may vary depending on the patient and the indication for AFOI. CONCLUSION There is good evidence to support the use of two drugs in particular, remifentanil and dexmedetomidine. Each has certain unique characteristics that make them an attractive choice for an AFOI.
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Affiliation(s)
- Kevin D Johnston
- Department of Anesthesia, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK.
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Abstract
PURPOSE OF REVIEW Difficulties in pediatric airway management are common and continue to result in significant morbidity and mortality. This review reports on current concepts in approaching a child with a difficult airway. RECENT FINDINGS Routine airway management in healthy children with normal airways is simple in experienced hands. Mask ventilation (oxygenation) is always possible and tracheal intubation normally simple. However, transient hypoxia is common in these children usually due to unexpected anatomical and functional airway problems or failure to ventilate during rapid sequence induction. Anatomical airway problems (upper airway collapse and adenoid hypertrophy) and functional airway problems (laryngospasm, bronchospasm, insufficient depth of anesthesia and muscle rigidity, gastric hyperinflation, and alveolar collapse) require urgent recognition and treatment algorithms due to insufficient oxygen reserves. Early muscle paralysis and epinephrine administration aids resolution of these functional airway obstructions. Children with an 'impaired' normal (foreign body, allergy, and inflammation) or an expected difficult (scars, tumors, and congenital) airway require careful planning and expertise. Training in the recognition and management of these different situations as well as a suitably equipped anesthesia workstation and trained personnel are essential. SUMMARY The healthy child with an unexpected airway problem requires clear strategies. The 'impaired' normal pediatric airway may be handled by anesthetists experienced with children, whereas the expected difficult pediatric airway requires dedicated pediatric anesthesia specialist care and should only be managed in specialized centers.
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Pandit JJ, Cook TM. Guest editors’ commentary: ‘State of the art’ in airway management in 2011. Anaesthesia 2011; 66 Suppl 2:1-2. [DOI: 10.1111/j.1365-2044.2011.06927.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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