Shared Airway During Dental Procedures

Shared Airway During Dental Procedures Practice Considerations

As an increasing number of patients of all ages and complexities seek sedation and anesthesia for dental procedures in office-based settings, it is important to keep patient safety central to the delivery of these services. While office-based dental sedation and anesthesia present several challenges, one important challenge is the shared, unsecured airway. This document describes unique practice considerations related to the shared airway for office-based dental sedation and anesthesia.

Communication Effective communication between the dentist, Certified Registered Nurse Anesthetist (CRNA, and dental assistant* is essential to maintaining a safe airway and adequate surgical access in a dental office.1-4 The dentist focuses on the procedure and therefore, relies on the CRNA to serve as the airway, anesthesia and patient safety expert throughout the dental procedure.

Prior to the procedure, the patient dental care team should develop an emergency airway management plan, including alternatives in cases of difficulty or failure of the initial plan.5-8

Patient Education Prior to the procedure, the CRNA should provide patient instructions (e.g., fasting9 and education about the anesthetic options, process for intravenous (IV moderate sedation, the differences between moderate sedation, deep sedation, and general anesthesia, and anesthesia care plan. Expectations for recovery, discharge, post-procedure pain management, and potential over-the-counter pain relievers are also discussed. For pediatric patients, discuss the procedure and anesthesia management with the parent or caregiver, answer questions, and help alleviate stress and concern.10

Patient Assessment and Evaluation Preparation is critical to the delivery of office-based sedation and anesthesia.11 The CRNA conducts a patient anesthesia assessment and evaluation and establishes a patient-specific anesthetic care plan.2,5,10,12 The evaluation should include difficult airway assessment, Mallampati classification, body mass index (BMI, history of snoring or obstructive sleep apnea (OSA, thyromental and sternomental distance, mouth opening, receding mandibular profile, prominence of upper teeth, adequacy of the oral pharynx, range of motion of the head and neck, and neck circumference.2,5,13,14 Patients with signs of significant airway obstruction (e.g., respiratory distress, stridor, an inability to lie flat, and increased oxygen requirement should be assumed to have a narrowed or anatomically abnormal airway and to be a potentially challenging intubation.14 For open airway cases, it is especially important to assess the difficulty of mask ventilation, as this is one of the first interventions in the event of airway loss.2,5

Informed Consent Informed consent for anesthesia care is obtained from the patient or patient’s legal representative, or, for a pediatric patient, legal guardian.12,13,15,16

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Anesthetic Considerations During the Procedure Since dental procedures are primarily performed in an office-based setting, the anesthetic technique should be designed with patient safety, rapid recovery, and discharge as the main objectives.2 The procedural space should allow for the CRNA to have full access to the patient, equipment, supplies, and monitors.10 The majority of office-based dental procedures or surgeries that utilize anesthesia services do not require placement of an endotracheal or nasotracheal breathing tube. However, because sedation exists along a continuum which may lead to general anesthesia or situations where the patient cannot maintain their own airway, the CRNA must be prepared to manage both the unsecured and secured airway.2 The method of ventilation depends on the type of procedure or surgery and the access required by the dentist.4,6 State dental board requirements for dentists to hold sedation permits may limit the type of anesthesia and drugs that may be administered by a CRNA.17 State dental board requirements may restrict certain sedation drugs (e.g., propofol) to general anesthesia permit holders. For most dental procedures, using IV sedation will provide the desired level of anesthesia, allowing the patient to ventilate without obstruction and maintain their protective airway reflexes.

Effective sedation is generally achieved with varied combinations of propofol, midazolam, fentanyl, ketamine and dexmedetomidine (Precedex).

Inherently, dental procedures are performed in the mouth, and the shared airway poses unique challenges and considerations that require vigilance by the CRNA, dentist, and dental assistants. These considerations include: • Patient anxiety, among other factors, may increase the amount of time needed to deliver a safe anesthetic treatment.10 • Heavy bleeding could occur due to the vast blood supply to the head and neck region.10 • The airway may be soiled with blood or debris, and stimulation of trigeminal nerve increases chances of arrhythmia during the procedure or surgery.11 • The use of small instruments, dental drill bits, files, implants, and filling materials in the mouth could potentially fall into the oropharynx or be aspirated.10 • Patients may be receiving dental prosthetic devices such as crowns, bridges, or dentures, which can affect access to the airway.10 • Patients may experience pain transmitted primarily by the maxillary and mandibular divisions of the trigeminal nerve.10 • With deeper sedation or in patients with obstructive sleep apnea (OSA) or obesity, a nasopharyngeal airway may be used to keep the airway patent and allow the dentist unobstructed access to the mouth.2 The CRNA, therefore, should be familiar with management and complications of this modality.2 • It is important to maintain the throat as dry as possible during a dental procedure. o Suctioning by the dental assistant is vital to prevent fluid from going to the back of the throat. When blood or secretions go to the back of the throat, the patient requires suctioning of the oropharynx. The CRNA may need to step in and suction the oropharynx. o Antisialagogue (e.g., glycopyrrolate) may be necessary to keep the airway dry, as dental surgery can stimulate the flow of saliva, leading to coughing, choking, laryngospasm, or aspiration by the sedated patient.10 2 of 5 \ American Association of Nurse Anesthesiology | 10275 W. Higgins P Road, Suite 500 | Rosemont, IL 60018 | AANA.com Professional Practice Division l 847-655-8870 l practice@aana.com

o Throat packs may be spread across the oropharynx to absorb as much fluid as possible and serve as a barrier to prevent surgical debris from entering the airway or digestive tract.7 Throat packs must be changed before becoming saturated.7 o If blood or secretions are not monitored and controlled through suction, throat packs, if used, can move to the back of the throat and trachea potentially causing coughing, laryngospasm, or aspiration.

Monitors, Equipment, and Preparation for Emergencies The office-based dental setting should include equipment that is appropriately sized for the patient population, including, but not limited to a reliable source of oxygen, suction, bag-valve mask, sphygmomanometer appropriately sized for the patient, EKG/defibrillator, and drugs and equipment required to resuscitate the patient in case of emergency.7,11,13,18-20 State law mandates minimum levels of equipment required in office-based facilities. Any time moderate sedation or a greater depth of anesthesia is required, standard monitors include blood pressure, heart rate, pulse oximetry, electrocardiography, and end tidal CO2.2,7,12,13 In dental procedures, a precordial stethoscope may be used as an additional monitoring device.

An important factor, particularly during an emergency, is position in the dental chair, which may make it difficult to resuscitate the patient should an emergency occur.11 The CRNA should be vigilant of what is going into the mouth during the procedure. For example, a dropped instrument or miscounted throat pack can easily lead to an airway obstruction and lifethreatening emergency. In the event of an airway obstruction, it is the CRNA’s responsibility to establish a patent airway. Traditional techniques include repositioning, chin lift, or jaw thrust.

Although rare, the potential for airway fire during dental surgery exists, especially in procedures involving sedation or general anesthesia where oxygen is delivered.2,4,12,21,22 Preventive measures should be taken to minimize the risk of the components that lead to fires: a source of fuel, a source of heat sufficient to cause ignition, and the presence of oxygen (or any other oxidizer such as nitrous oxide.2,4,12,21-23 Caution should be taken with common materials such as tape, gauze packs, cotton rolls, sterile drapes and towels; equipment such as electrocautery, electrosurgery, laser units, fiber-optic light units; and supplemental oxygen.21,23 Rapid response to an airway fire is essential.23 The CRNA must discontinue all gases, remove flammable and burning materials from the airway, and pour saline into the airway.23 The CRNA should ventilate with a mask and bag until all possible sources of fire or reignition are eliminated and intubate, if necessary.23

Recovery and Discharge Rapid recovery and discharge are important in a dental office procedure.2,3 Emergence delirium can be a significant problem following office-based anesthesia that can potentially result in disruption of the office, damage to instruments and equipment, and injury to the patient or office personnel.2 Discharge criteria, policies, and protocols, including the availability of a responsible adult for safe transport, should be in place to facilitate safe patient post-procedure monitoring, assessment, and discharge.2,3,7,11,24

Staff Education A trained dental office staff is very important when providing office-based sedation and anesthesia.13 The CRNA should educate the dental staff on various aspects of anesthesia safety and precautions necessary during a shared airway procedure. For example, dental 3 of 5 American Association of Nurse Anesthesiology | 10275 W. Higgins Road, Suite 500 | Rosemont, IL 60018 | AANA.com Professional Practice Division l 847-655-8870 l practice@aana.com

assistants should learn how to lift the maxilla when a bite block is in place and lift the mandible to assist in preventing airway obstruction. Additionally, providing staff education is a valueadded service the CRNA can bring to the dental practice to promote vigilance of all dental team members and support patient safety.

Conclusion With effective communication and constant vigilance for monitoring the patient, the challenges of the shared airway can be managed successfully and allow for a safe, comfortable experience for the patient, dentist, CRNA, and other members of the dental team.

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Thoracic Key. https://thoracickey.com/the-shared-airway-management-of-the-patientwith-airway-pathology/. Accessed Sept 30, 2020.

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9. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126(3):376-393.

10. Sobey R, Tracy A. Nonoperating Room Anesthesia. In: Nagelhout JJ, Elisha E, eds.

Nurse Anesthesia. 6th ed. St. Louis, MO: Elsevier, Inc.; 2018:1194-1215.

11. Attri JP, Sharan R, Makkar V, Gupta KK, Khetarpal R, Kataria AP. Conscious Sedation: Emerging Trends in Pediatric Dentistry. Anesth Essays Res. 2017;11(2):277-281.

12. Standards of Nurse Anesthesia Practice. Park Ridge, IL: American Association of Nurse Anesthesiology; 2019.

13. Kapur A, Kapur V. Conscious Sedation in Dentistry. Ann Maxillofac Surg.

2018;8(2):320-323.

14. Bradley J, Lee GS, Peyton J. Anesthesia for shared airway surgery in children. Paediatr Anaesth. 2020;30(3):288-295.

15. Informed Consent for Anesthesia Care, Policy and Practice Considerations. Park Ridge, IL: American Association of Nurse Anesthesiology; 2016.

16. Documenting Anesthesia Care, Practice and Policy Considerations. Park Ridge, IL: American Association of Nurse Anesthesiology; 2016.

17. CRNAs: Providing Solutions to Dental Anesthesia Care. Park Ridge, IL: American Association of Nurse Anesthesiology; 2020.

4 of 5 American Association of Nurse Anesthesiology | 10275 W. Higgins Road, Suite 500 | Rosemont, IL 60018 | AANA.com Professional Practice Division l 847-655-8870 l practice@aana.com

18. Dym H. Preparing the dental office for medical emergencies. Dent Clin North Am. 2008;52(3):605-608, x.

19. Malignant Hyperthermia Crisis Preparedness and Treatment, Position Statement. Park Ridge, IL: American Association of Nurse Anesthesiology; 2018.

20. Airway Management: Use of Succinylcholine or Rocuronium, Practice Considerations.

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21. Weaver JM. Prevention of fire in the dental chair. Anesth Prog. 2012;59(3):105-106.

22. Guglielmi CL, Flowers J, Dagi TF, et al. Empowering providers to eliminate surgical fires.

AORN J. 2014;100(4):412-428.

23. Pollock GS. Eliminating surgical fires: a team approach. AANA J. 2004;72(4):293-298.

24. Discharge After Sedation or Anesthesia on the Day of the Procedure: Patient Transportation With or Without a Responsible Adult, Position Statement and Policy Considerations. Park Ridge, IL: American Association of Nurse Anesthesiology; 2018.

*The term “dental assistant” is used broadly to mean any auxiliary personnel authorized by state dental laws and rules, e.g., dental assistants, dental hygienists, RNs.

Adopted by AANA Board of Directors December 2020. © Copyright 2020 5 of 5 American Association of Nurse Anesthesiology | 10275 W. Higgins Road, Suite 500 | Rosemont, IL 60018 | AANA.com Professional Practice Division l 847-655-8870 l practice@aana.com