Anatomy of an Airway Disaster: Lessons from the School of Hard Knocks Why Things Go Wrong

Anatomy of an Airway Disaster: Lessons from the School of Hard Knocks Why things go wrong

D. John Doyle MD PhD Professor of Anesthesiology Cleveland Clinic Objectives

Understand the special problems that may occur in some “difficult airway” patients. Objectives

Understand how the ASA difficult airway algorithm may help deal with “difficult airway” patients. Objectives

Understand the special issues in the “difficult extubation” patient. Airway Horror Stories

Jaws wired shut after maxillofacial surgery (and then patient has an epileptic seizure and vomits). Airway Horror Stories

ETT cuff won’t deflate (pilot line sealed shut as patient bites on it). Airway Horror Stories

ETT sutured into place by oral surgeon.

(PACU story) Airway Horror Stories

Fetal distress in a parturient with a known difficult airway. Airway Horror Stories

Epiglottitis in a child with an parent known to have malignant hyperthermia. Airway Horror Stories

Severe epistaxis following extubation after maxillofacial surgery (jaw wired shut). Airway Horror Stories

Ankylosing spondylitis so severe that the patient’s nose is in contact with her chest. Case of Dr. A. Ovassapian http://www.burnsurgery.org/Modules/initial/images/page_19b.jpg Laryngeal Edema

Laryngeal edema. Courtesy of L. Baijens.

Wittekamp et al. Critical Care 2009 13:233 doi:10.1186/cc8 142 WHY AIRWAY DISASTERS OCCUR

1. Incomplete assessment 2. No plan 3. No preparation 4. No trained assistance 5. Overconfidence/Ego 6. Fear of calling for help 7. Getting the wrong help (story) 8. No experience with LMA or Combitube 9. Fear of trying a surgical airway The Morbidly Obese Man Scheduled for Gastroplasty

Anesthetic #1 – Pentothal / Succinylcholine – Couldn’t intubate – Couldn’t ventilate well – Succinylcholine wore off – Patient woke up Anesthetic #2

– Pancuronium used for “improved relaxation” – Couldn’t intubate – Couldn't ventilate – Bradycardia – Cardiac arrest – Coroner’s inquest THE MORBIDLY OBESE WOMAN for post-gastroplasty repair

– Fentanyl / thiopental / succinylcholine induction – Couldn’t incubate; couldn’t ventilate – Experienced head and neck surgeon in the room – Decision to have surgeon do surgical airway – Surgeon decided to attempt a formal tracheostomy – Difficulty finding trachea in layer after layer of fat – Patient died (eventually) More Airway Disasters

• Facial trauma

• Aspiration

• Unrecognized esophageal intubation

• Too many attempts at laryngoscopy/intubation (too much help) http://www.onlinejets.org/articles/2009/2/1/images/JEm • Failed TTJV ergTraumaShock_2009_2_1_51_44685_u1.jpg ASA Recommendations for Known or Suspected Difficult Airway 1. Inform the patient about the special risks

2. Make sure another individual is available to assist

3. Give supplemental oxygen while managing the airway (e.g. nasal prongs during fiberoptic intubation) Three Basic Management Choices...to be made for each airway situation 1. Nonsurgical vs surgical airway for the initial approach to intubation

2. Maintenance of spontaneous breathing vs breathing for the patient

3. Awake intubation vs intubation after induction of general anesthesia Three Basic Situations You Must Always Have a Plan for

1. Awake intubation

2. The patient who is difficult to intubate but easy to ventilate

3. The patient who cannot be intubated or ventilated

THE SITUATION...

–Can’t intubate

–Can’t ventilate well

–Want to “bail out” THE OPTIONS... – Reposition head – Airway adjuncts oral airway nasopharyngeal airway – Laryngeal mask airway – 2 man - 2 hand technique person 1: 2- handed jaw thrust person 2: ventilates – Surgical airway TTJV cricothyroidotomy How Many Attempts at Elective Intubation?

1. First attempt 2. Second attempt – reposition head – external laryngeal manipulation – use stylet / airway introducer 3. Third attempt

If no success after 3 attempts, wake up the patient and try awake intubation or alternate plan (?insert LMA ?regional anesthesia, etc.) Techniques for Difficult Intubation • Alternative laryngoscope blades • GlideScope • Awake intubation • Blind intubation (oral, digital, nasal) • Fiberoptic intubation (awake, asleep) • Intubating stylet / tube changer • Light wand • Retrograde intubation • Surgical airway (Modified from ASA Guidelines for Management of the Difficult Airway) Difficult Airway Box

1. Extra nasopharyngeal and oropharyngeal airways 2. Selection of supraglottic airways (e.g., LMA. i-Gel) 3. ETTs of assorted sizes, including narrow diameter tubes 4. Video laryngoscope (e.g., GlideScope) 5. Equipment for awake intubation (drugs, sprayers, airways) 6. Equipment for fiberoptic intubation 7. Equipment for cricothyrotomy 8. Exhaled CO2 detector 9. Airway introducer (“gum elastic bougie”)

(Modified from ASA Airway Management Guidelines) Difficult Mask Ventilation Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, Riou B: Prediction of difficult mask ventilation. Anesthesiology 2000; 92:1229–36 Techniques for Difficult Ventilation

• Esophageal-tracheal Combitube • Intratracheal jet stylet • Laryngeal mask airway • Nasopharyngeal airway • Oropharyngeal airway • Rigid ventilating bronchoscope • Surgical airway • Transtracheal jet ventilation • Two-person mask ventilation (Modified from ASA Guideline for Management of the Difficult Airway) ASA DAA

Safe Tracheal Extubation Definition

Extubation

Extubation is the process of removing an endotracheal tube (ETT) from the patient's trachea. This should ordinarily only be done with the patient awake and obeying verbal commands. Even so, catastrophes following extubation can occur, such as total collapse of the airway in a patient with tracheomalacia. Sometimes it is wise to extubate over an ETT exchange catheter, such as in any patient who would be very difficult to reintubate. Such a device can be left in place and later used to facilitate reintubation should a trial of extubation end in failure. If reintubation becomes necessary the exchange catheter can then be used as a guide to direct the new ETT through the cords. Some exchange catheters can also be used to administer low flow oxygen deep into the lungs (eg. 2 liters/min flow rate) as well as for capnography or even emergency jet ventilation in a manner similar to transtracheal jet ventilation (TTJV) [1‐3].

References

[1] Cooper RM. The use of an endotracheal ventilation catheter in the management of difficult extubations. Can J Anaesth 1996; 43:90‐3.

[2] Cooper RM. Extubation of the difficult airway. Anesthesiology 1997;87:460.

[3] Benumof JL. Airway exchange catheters for safe extubation: the clinical and scientific details that make the concept work. Chest 1997;111:1483‐6. LMA as a “bridge to full extubation” GENERAL IDEA • Extubate ETT and replace with LMA or ILMA • Remove LMA some time later • Can reintubate via LMA if needed Tube Exchange Catheters Airway Exchange Catheters

These can be left in place and later used to facilitate reintubation should a trial of extubation end in failure. If reintubation becomes necessary the exchange catheter can then be used as a guide to direct the new ETT through the cords. Some exchange catheters can also be used to administer low flow oxygen deep into the lungs (eg. 2 liters/min flow rate) as well as for capnography or even emergency jet ventilation in a manner similar to transtracheal jet ventilation (TTJV) [1‐3].

References

[1] Cooper RM. The use of an endotracheal ventilation catheter in the management of difficult extubations. Can J Anaesth 1996; 43:90‐3.

[2] Cooper RM. Extubation of the difficult airway. Anesthesiology 1997;87:460.

[3] Benumof JL. Airway exchange catheters for safe extubation: the clinical and scientific details that make the concept work. Chest 1997;111:1483‐6. Extubation of the Difficult Airway: An Algorithm

1. Ensure leak around ETT cuff exists 2. Place tube changer (TE). 3. Ensure oxygenation and ventilation are adequate and that patient is fully awake and reversed. Then pull ETT. 4. Employ “rescue strategy” if airway unstable or lost after pulling the ETT One of Several Tube Exchange Catheter Extubation Algorithms

http://crashingpatient.com/wp-content/images/part3/extubation.jpg Cook Tube Exchange Catheter

Post-Extubation Airway Obstruction

• Often due to apposition of tongue and soft palate against posterior pharyngeal wall (oral airway often helpful)

• But often due to laryngospasm (oral airway may worsen situation) Airway Edema

• Mechanical trauma • Impeded venous drainage (eg. SVC syndrome) • Airway instrumentation • Pregnancy (esp with preeclampsia) • Head & neck injury Vocal Cord Paralysis

• Usually secondary to RLN injury, resulting in an unopposed SLN mediated cord adduction • Causes: • Thyroidectomy • IJ line placement • ETT related (ETT cuff compression of RLN against lamina of thyroid cartilage) Extubation Wisdom

• Don’t take out anything out of the patient you can’t put back in . • If in doubt, extubate wide awake. • A person who is bucking on the tube may not necessarily be safe to extubate. • You can get into trouble even when extubating the awake patient. • Always have a backup (rescue) plan More Wisdom (Warning!)

“Reintubation over a tube exchanger is not uniformly successful. Success rate can be enhanced by rotation of the ETT and simultaneous bronchoscopy...”

(Miller et al., 1995) WARNING : Use of Relaxants When Reintubating Over a Tube Exchanger

• “Although the administration of a small dose of muscle relaxant may permit reintubation over a stylette, such an intervention carries significant risk if persistent spontaneous ventilation has helped maintain... ventilation and oxygenation.” • If a failure occurs: – “... medicolegal opinions concerning the use of muscle relaxants in such a manner are not likely to be uniformly favorable.” (Miller et al., 1995) Intrapulmonary Capnography as an Aid to the Clinical Management of a Patient with Poor Respiratory Function Ryan Huffman MD, D. John Doyle MD PhD, Robert R. Lorenz, MD Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio

His room air oxygen saturation was 90%, mouth opening 2.5 cm, and no Introduction pharyngeal structures were visible on Technique Discussion Abnormal Capnograms bedside examination. His neck flexion The intratracheal tube exchanger was While extubation is uncomplicated in connected to a capnograph for most cases, the identification of The potential need for reintubation and extension were limited as a result of monitoring. It was noted that the end- patients with potential problems such Sudden loss of Sudden decrease in following postoperative extubation in a the cervical fusion procedure. It was EtCO2 to zero or tidal CO2 concentrations were in the as airway obstruction, hypoventilation, EtCO2 to low non- patient known to be difficult to intubate known that the patient was unable to be near zero zero value 70s, but it was also apparent that there hypoxemic respiratory failure, or the can pose a challenge even for intubated for a previous surgical was a substantial amount of inability to protect their airway against experienced anesthesiologists. Various procedure. intratracheal rebreathing due to the aspiration are of particular importance approaches have been advocated to Following the IV administration of capnograph tracing no longer falling to because of a greater likelihood of a Possible Causes: maximize the likelihood of a good Possible causes: Leak in the airway system midazolam and glycopyrrolate as well as zero with inspiration. Furthermore, the need for reintubation. In the case of Airway disconnection ET tube in hypopharynx outcome in this setting [1-3], while a Dislodged ET tube/esophageal Poorly fitting anesthetic mask nebulized lidocaine, further lidocaine was respiratory rate started to climb into difficult reintubation, use of a tube intubation Partial airway obstruction variety of weaning protocols have been Partial disconnect from ventilator circuit the high 30s. The patient was exchanger can be helpful. Totally obstructed/kinked ET tube advocated in the intensive care unit sprayed on the glottis under direct vision Complete ventilator malfunction using a GlideScope. A size 6 ETT was encouraged to take larger, slower Additionally, it also can be used to setting [4-5]. Biofeedback has been Sustained low EtCO2 then passed awake into the trachea on the breaths to lower his respiratory rate. monitor end-tidal CO2 [7]. Rise in described as a method of providing self- with good alveolar When the patient did this, the Baseline and control in the process of weaning from second attempt, and the patient then plateau rebreathing vanished, but the patient We have documented a case of EtCO2 long-term mechanical ventilation [6]. In given propofol to induce general would subsequently return to a rapid successful biofeedback using the this report we describe an acute clinical anesthesia. Subsequently, rocuronium was administered to facilitate the shallow breathing pattern with intratracheal capnogram tracing Possible causes: application of biofeedback as an aid to Hyperventilation procedure. rebreathing. Since the patient was still obtained through a tube exchanger to Hypothermia Possible causes: the breathing coaching of a patient with Sedation, anesthesia Defective exhalation valve awake and cooperative, he was shown teach the patient how to breath Dead space ventilation Rebreathing of previously exhaled respiratory failure. CO2 Immediately following intubation it was the capnograph tracing on the monitor effectively and eventually avoid Exhausted CO2 absorber noticed that the end-tidal CO2 ran over and taught how the desired reintubation. Sustained low EtCO2 without Case Report 60 mm Hg, but gradually declined with nonrebreathing pattern could be Exponential decrease alveolar plateau ventilation. The surgical procedure was obtained by taking larger, slower To our knowledge this combination of in EtCO2 difficult but uneventful. In view of the breaths. With this feedback, the tools including capnography via a tube patient’s breathing improved and the exchanger and breathing coaching potential for post-extubation difficulties, Possible causes: A morbidly obese 44-year-old man Incomplete exhalation tube exchanger was removed. Arterial have yet to be described as a means to Possible causes: when the patient awoke and was Partially kinked ET tube Cardiopulmonary arrest presented for direct laryngoscopy with Brochospasm blood gases were not taken. The prevent reintubation postoperatively in Pulmonary embolism breathing 100% oxygen with full reversal Mucous plugging Sudden hypotension; massive blood loss removal of a left vocal cord verrucous Poor sampling techniques of neuromuscular blockade, the patient patient was discharged home after a patients with marginal respiratory Cardiopulmonary bypass lesion. He weighed 179 kg, with a was extubated with a Cook tube stay in the post-anesthetic care unit. function. height of 182 cm (BMI = 53.7), smoked, exchanger in place. 100% oxygen was References Elevated EtCO2 Gradually increasing had untreated type II diabetes, and had with good alveolar EtCO2 then delivered via facemask. 1. Lang S, Johnson DH, Lanigan DT, Ha H. Difficult tracheal extubation. Canadian Journal of Anesthesia. 36:340-342, 1989 plateau previous surgery for obstructive sleep 2. Cooper RM. The use of an endotracheal ventilation catheter in the management of difficult extubations. Canadian Journal of Anesthesia. 1996; 43:90-3. 3. Kumar V, Lazar HL. Extubation of the patient after a difficult intubation. Annals of apnea as well as a past cervical fusion. Thoracic Surgery 1998;65:1778-1780. Possible causes: 4. MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and Hypoventilation discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the Rising body temperature/malignant American College of Critical Care Medicine. Chest. 2001;120(suppl 6):375S-395S. Possible causes: hyperthermia 5. Walsh TS, Dodds S, McArdle. Evaluation of simple criteria to predict successful Inadequate minute Increased metabolism weaning from mechanical ventilation in intensive care patients. British Journal of ventilation/hypoventilation Anesthesia. 2004; 92: 793-9 Partial airway obstruction 6. Hannich HJ, Hartmann U, Lehmann C, Grundling M, Pavlovic D, Reinhardt F. Respiratory-depressant drugs Absorption of CO2 from exogenous Biofeedback as a supportive method in weaning long-term ventilated critically-ill Hyperthermia, pain, shivering source patients. Medical Hypotheses. 2004; 63:21-5 7. Millar FA, Hutchinson GL, Glavin R. Gum elastic bougie, capnography and apnoeic oxygenation. European Journal of Anaesthesiology. 2001. 18: 51-3 From www.oridion.com Airway Exchange Catheter

Mort T.C. Continuous airway Access for the Difficult Extubation: The Efficacy of the Airway Exchange Catheter. Anesthesia and Analgesia. Vol. 105, No. 5, November 2007 1357-62

A patient who had undergone maxillofacial reconstructive surgery was extubated with the use of a pediatric airway exchange catheter (PAEC) in the intensive care unit. The PAEC was left in place for 6 hours, and the patient did not require reintubation after the PAEC had been removed. Dosemeci et al. Critical Care 2004 8:R385 A patient who underwent maxillofacial surgery due to trauma. She was extubated with the use of the pediatric airway exchange catheter (PAEC), and required reintubation after 6 hours of extubation. This was easily achieved over the PAEC without cutting the archbar. Dosemeci et al. Critical Care 2004 8:R385 Anesthesia Ideas Discussion Group

http://health.groups.yahoo.com/gr oup/Anesthideas/ Deep Extubation

Best method for deep extubation? Posted Jan 1, 2009 Hey all,

Can anyone provide a method they prefer the most for deep extubation on pts?

Being a resident I have had some days go much faster than others when trying different methods. Just wondering what others in the 'real world' do...

HS http://health.dir.groups.yahoo.com/group/Anesthideas/message/3080 Re: [ai] Best method for deep extubation?

Intubate through an Air-Q SGA, leave it in situ, then extubate trachea when spont vent returns at end of case and allow emergence with Air-q

James C. DuCanto, M.D. Assistant Clinical Professor Department of Anesthesiology Medical College of Wisconsin RE: [ai] Best method for deep extubation?

I keep my patients on a low dose remifentanil infusion (about 0.1 mcg/kg/min) wait for them to start breathing spontaneously, then gently extubate, they hardly ever cough and continue to breathe

Imran Ahmad Consultant Anaesthetist Guy's and St Thomas' Hospital Kempen Method for Deep Extubation Best Method for Deep Extubation?

I have been doing this for years while supervising residents and can often have the patients extubated and breathing via simple O2 masks before the bandages are complete. NO waiting means happy surgeons. NO coughing, bucking, desaturations, hemodynamic responses, etc makes for safe practice!

P Kempen, Cleveland http://health.dir.groups.yahoo.com/group/Anesthideas/message/3080 Kempen Method for Deep Extubation

Deflate ETT cuff.

Lidocaine installation into ETT

Reinflate ETT cuff.

The patient can then be emerged and extubated without knowing the ETT is in place, much like after LTA use. Allow the patient to undergo relaxant reversal and resume adequate spontaneous respiration.

Test for tracheal anesthesia by rapidly deflating and reinflating the cuff and look for any change in respiration (the ETCO2 trace can occasionally change due to breathing around the tube-but you can clinically judge for reaction, i.e. coughing or apnea). If the patient coughs upon cuff deflation testing you can repeat the dose and repeat the test as well.

If no reaction-remove the tube at 0.0 to 2 MAC. There is typically no change in respiration and you now have extubated irrespective of anesthestic depth. Kempen Method for Deep Extubation

Caveats Lidocaine allergy, aspiration risk and full stomach are the only clinical contraindications.

The less the ETT is inserted beyond the cords at intubation, the less amount of trachea needs to be topicallized, increasing success rates!

1% solutions of lidocaine are typically effective, but stronger solutions may may be needed in smokers or individuals with thick secretions. Kempen Method for Deep Extubation

Hints Be sure to inject the lidocaine down the ETT and not into the circle system during injection!

I recommend SLOW instillation of 5 cc of 1-2-4% lidocaine before relaxant reversal or lightening the anesthetic depth, if immobility is important (e.g. in headpins) [Because the instillation of lidocaine may produce airway responses.] Hints

The lidocaine only lasts around 20 to 30 minutes, so don't instill the lidocaine too early.

If extubation is performed too soon before the end of surgery you may need to provide "mask" anesthesia for some time.

Smokers may require 4% because of thick tracheal secretions and 60-120 seconds to facilitate penetration. http://health.dir.groups.yahoo.com/group/Anesthideas/message/3080 Hints Start with patients with good airways and good health until you gain confidence, or just see how it will aid or improve your "deep extubation routine". Patients will tolerate the ETT to much lighter planes of anesthesia with the lidocaine anesthesia, often opening their eyes in response to their name, will stick out the tongue on command and the tube is removed awake without coughing (emerge as after LMA!). Remember, laryngospasm is an abnormal reflex to airway stimulation in the "second stage" of light anesthesia. However If you remove the stimulus (trans-ETT LTA) you find no reflex! Re: [ai] Best method for deep extubation?

I appreciate all these hints for the "best" technique for deep extubation and may even try the lido "trickle" technique described, but I must confess that I have never been a big fan of deep extubation. Over the years I have had several partners who were fans of the technique and it always seemed that they were presenting their latest case of mysterious "laryngospasm" or airway disaster (either in the OR or PACU), even though they were well-trained and skilled practitioners. Deep extubation really should not be required to wake a patient up without an inordinate amount of coughing or "bucking" (a term I hate), and the tales of patients coughing and "bucking" bleeding to death or exploding vessels in their heads are, for the most part, the stuff of lore and bs of surgery; part of the blame anesthesia first mentality we seem to tolerate. I mean really, what is going to happen when the patient coughs in the PACU or sneezes or goes to the toilet the next day.

Terry Webber Re: [ai] Best method for deep extubation?

For what it's worth I almost always extubate awake. With a decent slug of opioid on board most patients usually just open their eyes when you call their name and open their mouth when you ask. There's nothing more elegant than that.

The trick is to keep the vultures away from the patient while this process is happening. It doesn't take long.

Coughing, bucking and other unpleasantness should be a rare event, and are less of a concern than losing the airway in the PACU following a deep extubation.

Sandy Hancock Adelaide, South Australia Airway Management's Dirty Laundry – Lessons From The NAP4 Study

D. John Doyle MD PhD Cleveland Clinic 4th National Audit Project of the Royal College of Anaesthetists (NAP4)

Major complications of airway management in the UK

March 2011

http://www.rcoa.ac.uk/nap4 • A valuable educational resource, full of valuable lessons

• 24 chapters, 5 appendices

• Free download: http://www.rcoa.ac.uk/nap4 • Easy to read, engaging style

• Captured the interest of anesthesiologists around the world

• Many cautionary tales

Approximately 42% of anesthesia events reported had a primary airway event indicating intubation difficulty that was ultimately responsible for 13% of airway related mortality.

The majority of the events occurred in straightforward elective surgery in ASA I-II male patients aged <60.

A potential practice inadequacy identified was that a formal airway assessment was recorded in only 35 of 133 cases (26%).

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch Aspiration was the single most common primary cause of mortality (rather than cerebral hypoxia per se), and notably, aspiration occurred as frequently using a supraglottic airway as during the use of a tracheal tube. Aspiration accounted for 8 anesthesia deaths and two cases of brain damage. Nearly 50% of the events followed head & neck surgery.

Approximately 70% of these reports were associated with obstructive lesions within the airway & reports indicated evidence of poor anticipation and planning for management of airway instrumentation & extubation.

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch Obese patients were disproportionately represented, presenting twice as frequently in the population that suffered incidents than in the group that did not.

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch Use of a needle cricothyroidotomy as a rescue technique suffered a 65% failure rate with numerous mechanisms of failure cited including: equipment, training, insertion technique and ventilation technique.

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch An emergency surgical airway was necessary in 43% of anesthesia cases…most surgical airways were undertaken by surgeons.

One quarter of events involved emergence … usually resulting in airway obstruction from laryngospasm, biting on the airway device or airway swelling.

Reviewers found that elements of poor management were observed in the majority of cases.

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch At least 1 in 4 major airway events were from ICU or ED.

A consultant was usually present for the in-theatre events, in contrast to the ICU and ED events, where junior staff were more frequently present.

The severity of ICU and ED events was greater, with death and brain damage a more frequent outcome.

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch Displacement of tracheostomies caused 50% of ICU events.

The majority of events in ED concerned difficult or failed tracheal intubation during RSI.

In ICU/ED, capnography was often not used or was misinterpreted (especially during cardiac arrest) and was a contributory factor in 73% of deaths or neurological injury, usually due to unrecognised oesophageal intubation. http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch The executive summary suggests that when potential difficulty with airway management is identified, rather than an airway plan, a strategy is required.

An airway plan suggests a single approach to management whereas a strategy is a co-ordinated, logical sequence of plans which includes a back-up plan & rescue techniques i.e., forward planning for initial failure.

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch Of note, events were reported when supraglottic airway devices were used inappropriately, and supraglottic airways were used to avoid tracheal intubation in some patients with a recognised difficult airway without evidence of a back-up plan.

Also, the project identified numerous cases where AFOI was indicated but not used.

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch The authors suggest that choosing the safest technique for airway management may not necessarily be the anaesthetist’s most familiar and it may be necessary to seek the assistance of colleagues with specific skills.

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch The authors also suggest that obesity needs to be recognized as a risk factor for airway difficulty and strategies modified accordingly.

http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch

An Important Lesson: It is usually OK to wake up the patient and abort the anesthetic if airway problems are encountered!

Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes

SAD – supraglottic airway device Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes Some Clinical Themes

The End