#JanuAIRWAY 2022 The Compilation

Page 1

#JanuAIRWAY 2022 The 31 day Twitter educational event compilation Brought to you by @dastrainees, @Vapourologist and #DASeducation


#JanuAIRWAY

2022

Editors Helen Aoife Iliff Tom Lawson

Contributors Tom Lawson Helen Aoife Iliff Imran Ahmad Alistair Baxter Tim Cook Adam Donne Sadie Khwaja Nuala Lucas Moon-Moon Majumdar Brendan McGrath Barry McGuire Andrew McKechnie Alistair McNarry Sarah Muldoon Anil Patel Elizabeth Ross Natalie Silvey

Illustrations, Graphics and Images The large majority of graphics and illustrations are by Tom Lawson or Helen Aoife Iliff. Some have been adjusted from the original Twitter content in an effort to prevent any potential copyright infringements in this compilation. Original images sources can be found in the further reading. We thank all image contributors. Some images have been reproduced in good faith, for educational purposes only. Where possible permissions have been sought. If any copyright holders have any issues please contact us at trainee@das.uk.com and the content will be withdrawn.


#JanuAIRWAY

2022

Acknowledgements We thank and acknowledge all those who contributed to the #JanuAIRWAY 2022 content, both for the original twitter event and this compilation. We thank the Dif cult Airway Society (DAS), Society for Obesity and Bariatric Anaesthesia (SOBA) and British Association of Otorhinolaryngology (ENT-UK) for their direct or member support and engagement in this work. We thank Imran Ahmad, Alistair Baxter, Ravi Bhagrath, Abhijoy Chakladar, Tim Cook, Adam Donne, Gunjeet Dua, Kariem El-Boghdadly, Craig Johnstone, Sadie Khwaja, Nuala Lucas, Moon-Moon Majumdar, Brendan McGrath, Barry McGuire, Andrew McKechnie, Alistair McNarry, Fauzia Mir, Sarah Muldoon, Achuthan Sajayan, Ellen O’Sullivan, Anil Patel, James Peyton, Elizabeth Ross, Natalie Silvey and Sarah Tian for their review of the content. We offer particular thanks to Jeff Gadsden for the inspiration.

fi

3


#JanuAIRWAY

2022

Disclaimers This is the compilation of tweetorial content from #JanuAIRWAY. Every effort has been made to ensure the content is factually correct and up to date. It is not intended to replace other existing educational materials. If you identify any errors please notify us at trainee@das.uk.com. This is intended to be a learning resource - it is not a guideline. For all DAS Guidelines please refer to the peer reviewed publications. Inclusion of content (equipment, techniques and scoring systems etc.) in #JanuAIRWAY does not constitute DAS endorsement. Some images have been reproduced in good faith, for educational purposes only. Where possible permissions have been sought. If any copyright holders have any issues please contact us at trainee@das.uk.com and the content will be withdrawn.

DAS Education and Joining DAS The DAS Education team are passionate about delivering good quality learning resources. Our Educations Co-leads work closely with our Trainee Reps to put together material and events we hope our members will bene t from.

Details on how to become a DAS member are available here

fi

4


2022

FORWARD | on behalf of the Difficult Airway Society | DAS is mostly known for its airway management guidelines, Annual Scienti c Meetings and airway courses. However, this year we decided to try something new, something that is beyond the traditional scope of DAS. The brain child of one of our Education leads with help from the current DAS Trainees DAS took on #JanuAIRWAY - a month of daily educational tweets covering all matters airway! An immense amount of work has been involved in putting this educational material together and we feel it has been a huge success. Many congratulations to the team involved, in particular Tom Lawson and Helen Iliff, who have given a huge amount of time to the preparation and delivery of this project! The overwhelmingly positive response, excellent feedback and huge twitter engagement has encouraged us to put together this compilation. We hope you enjoy the content and will share this free and valuable educational resource. - Imran Ahmad, DAS President

All the best ideas are stolen. #Blocktober,

#JanuAIRWAY was no different.

Dr Jeff Gadsden’s

31 days of regional anaesthesia content; each day highlighting a

different block, provided the inspiration.

A programme of airway-related teaching

materials (with a suitable month pun name) was created covering a broad range of airway management topics, that could appeal to the widest audience, from the novice to the experienced. With the help of an amazing team (thanks to our contributors, but special thanks to the DAS trainee representatives; Natalie Silvey, Moon-Moon Majumdar and especially, Helen Iliff), over the last year, the project has evolved from those amateurish beginnings into something far greater than I could’ve hoped for alone. I hope that #JanuAIRWAY and this compilation will become an evolving airway training resource that is used by practitioners across the globe for many years to come. - Tom Lawson, DAS Education Co-lead & Creator of #JanuAIRWAY

Natalie, Moon-moon and I have thoroughly enjoyed working with Tom to bring you #JanuAIRWAY 2022. We hope those on twitter have enjoyed not just the content, but also engaging with DAS in a less traditional form. For those not on twitter I hope you nd the compilation an interesting read and useful educational resource - and perhaps it may convince you to join us in the twittersphere @dastrainees for #JanuAIRWAY in 2023! - Helen Aoife Iliff, Trainee Rep

If anyone has any feedback please feel free to contact us at either trainee@das.uk.com or ezine@das.uk.com

5

fi

fi

#JanuAIRWAY


#JanuAIRWAY

2022

CONTENTS Day and Theme

Day and Theme

1st

Oxygen Physiology

19th The Obstructed Airway: Nasal / Oral

2nd

Airway Assessment

20th The Obstructed Airway:

3rd

De ning the Dif cult Airway

4th

Airway Investigation, Lung Function Tests and Airway Ultrasound

5th

Airway Strategy/Planning

6th

Basic Airway Equipment

7th

Airway Laryngoscopy

8th

Capnography & Oesophageal

9th

Larynx / Laryngopharyngeal 21st The Obstructed Airway: Larynx / Extrathoracic Trachea 22nd The Obstructed Airway: Intrathoracic 23rd Malacias; Bleeding & SVC Obstruction 24th The Paediatric Airway 25th The Obstetric Airway

Intubation

26th The Traumatic Airway

High Flow Nasal Oxygen (HFNO)

27th The Neurosurgical Airway

10th Cook Airway Exchange Catheter

28th The Bariatric Airway

11th Aintree Intubation Catheter

29th Extubation & Cook Staged Extubation

12th Awake Tracheal Intubation (ATI) 13th Jet Ventilation 14th One Lung Ventilation

Set 30th Guidelines, Guidelines, Guidelines 31st Dif cult Airway Conditions

15th Tracheostomies and Laryngectomies 16th eFONA: Cannula Techniques 17th eFONA: Scalpel Techniques 18th Extra eFONA equipment

Further Reading

fi

fi

fi

6


#JanuAIRWAY

2022

“Here’s the rule: no one’s expected to have all the answers. If you are asked a question, and do not know the answer, just say, “I don’t know, but I’ll nd out.” And when you do, never fail to pass along the correct information. You can never tell who the elephant in the room may be – because elephants just don’t forget.”

- Marty Sklar, Imagineer

fi

7


#JanuAIRWAY

2022

OXYGEN PHYSIOLOGY | Always. Be. Oxygenating! | The meaningful delivery of adequate oxygen is the fundamental aim of all airway management. Think A.B.O. – Always. Be. Oxygenating. Knowledge of the three basic equations for oxygen physiology is essential: 1. Arterial Oxygen Content 2. Oxygen Delivery 3. Oxygen Consumption They can steer us towards various physiological parameters that we can manipulate to treat (failure of tissue oxygenation)/hypoxaemia (a low concentration of oxygen in arterial blood). The oxygen cascade shows levels and processes involved and differentials for hypoxaemic hypoxia: 1. Decreased inspired partial pressure of oxygen (e.g. altitude or low FiO2) 2. Alveolar gas mixture - dilution with CO2 (hypoventilation – for example excess opiate) 3. Diffusion (e.g. pulmonary brosis) 4. Shunt, V/Q mismatch (e.g. pneumonia, pulmonary oedema) 5. Increased O2 demand/use (e.g. sepsis, malignant hyperthermia) Other causes of hypoxia include anaemic hypoxia (e.g. anaemia, carbon monoxide poisoning), stagnant or ischaemic hypoxia (e.g. cardiogenic shock), and rarely – histotoxic hypoxia (e.g. cyanide toxicity). The Oxy-Hb curve shows why the focus in desaturation must be getting oxygen in. When the SpO2 starts to fall, it’s slow initially but then precipitous. The bene t is, often a little oxygen going back in, in general means a rapid rise back to safety.

fi

fi

8


#JanuAIRWAY

2022

Pre/apnoeic oxygenation are key weapons, but must be done well.

Patience, vital capacity

breaths +/- high ow nasal oxygen are key. They are of particular importance in patients with obesity, who may have a smaller functional residual capacity and be more dif cult to facemask ventilate. Here are some articles that might be of interest: a. Patel A, Nouraei SA. Transnasal Humidi ed Rapid-Insuf ation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with dif cult airways. Anaesthesia. 2015; 70: 323-9 b. McNamara MJ, Hardman JG. Hypoxaemia during open-airway apnoea: a computational modelling analysis. Anaesthesia. 2005; 60: 741-6 c. Levitan R. NO DESAT! Emergency Physicians Monthly. 2010 (online)

fi

fi

fl

fi

fl

9


#JanuAIRWAY

2022

10


#JanuAIRWAY

2022

11


#JanuAIRWAY

2022

12


#JanuAIRWAY

2022

AIRWAY ASSESSMENT | Needs to be global | NAP4 showed poor airway assessment contributes to poor outcomes. Thorough assessment is essential.

There are a number of bedside tests available to help assess for potential dif cult

airway management. Airway Assessment should be holistic & comprised of three basic parts: 1. History - including review of previous management (if possible) 2. Examination - visual examination and bedside tests 3. Investigations NAP4 gives us a structure to focus our examination on anatomical/procedural dif culty: 1. Dif cult bag mask ventilation 2. Dif cult Supraglottic Airway Device (SAD) insertion 3. Dif cult laryngoscopy 4. Dif cult tracheal intubation 5. Dif cult Front of Neck Airway (FONA) 6. Dif cult tracheal extubation The problem is that individually, none of these are perfect, with widely variable sensitivity & speci city; possibly improved when combined. But many unanticipated dif cult airways are still missed - see this 2018 Cochrane review.

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

13


#JanuAIRWAY

2022

A thought-provoking nding of Norskov et al's Danish Airway Database cohort study was that dif cult mask ventilation was unanticipated in 94% of cases (808/857). This is why airway assessment needs to be holistic. Here are some papers / links that you might nd interesting: a. Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, Riou B. Prediction of dif cult mask ventilation. Anesthesiology. 2000; 92:1229-36 b. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009; 110: 891-7 c. Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict dif culty at intubation in the emergency department? Emergency Medicine Journal. 2005; 22: 99-102 d. Detsky ME, Jivraj N, Adhikari NK, et al. Will This Patient Be Dif cult to Intubate? The Rational Clinical Examination Systematic Review. JAMA. 2019; 321: 493–503

fi

fi

fi

fi

fi

fi

14


#JanuAIRWAY

2022

15


#JanuAIRWAY

2022

16


#JanuAIRWAY

2022

DEFINING THE DIFFICULT AIRWAY | It’s complicated | The term “Dif cult Airway” has de nitions. NAP4 has a procedural framework - useful but not the whole picture. Hans Huitink and Bouwan’s introduce “complexity factors” in their 2015 editorial on “The myth of the dif cult airway:airway management revisited”. Complexity factors make easy things dif cult e.g. operator experience, location, time pressures. They have to be considered. Huitink also suggests ditching the term ‘dif cult’ in favour of ‘basic and advanced’. Our airway assessment aims to determine dif culty of management. We want to use our holistic assessment (history, examination and investigations) to answer several questions. As well as consideration of complexity factors we also need situational awareness. We like to imagine concentrating ‘thinking zones’ emanating from the patient. 1. Patient (anatomy, physiology) 2. Airway manager (experience, fatigue, stress) 3. Team (experience, number) 4. Environment (time, familiarity, safety)

fi

fi

fi

fi

fi

fi

17


#JanuAIRWAY

2022

When we want to integrate our assessment info and situational awareness, the Cyne n framework (by Dave Snowden) and the Johari window can help our mental model for decision-making in ‘dif cult airways’.

Here are some papers / links that you might nd interesting: a. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit Project: Major complications of airway management in the United Kingdom. 2011 (online) b. Grey AJG, Hoile RW, Ingram GS, Sherry KM. The Report of the National Con dential Enquiry into Perioperative Deaths 1996/1997. 1998 (online) c. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists' prediction of dif cult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015; 70: 272-81

fi

fi

fi

fi

fi

fi

18


#JanuAIRWAY

2022

19


#JanuAIRWAY

2022

20


#JanuAIRWAY

2022

AIRWAY INVESTIGATIONS, LUNG FUNCTION TESTS AND AIRWAY ULTRASOUND | Physiology and physics in action | 2 broad categories we can use to round out our airway assessment; ow/volume-based lung function tests & imaging techniques. They vary in their usage and usefulness. Spirometry (literally ‘measuring breath’) and

ow-volume loops give us information on the

mechanics of ventilation. They can be helpful in a more global assessment of respiratory function, but are less helpful in acute airway management. Diffusing Capacity / Transfer factor can augment lung function tests and give us info about alveolar diffusion and alveolar thickness. Again, helpful in global assessment, but less helpful acutely. Imaging techniques – these can be incredibly useful in peri-operative management. Two main types: radiological (CT, MRI and/or USS) and endoscopic techniques. The key information you want is: 1. Is an airway abnormality present? 2. If so what kind – usually compression / stenosis a. Lesion location and extent? b. Maximal airway diameter? c. Airway displacement? d. Other structures involved / in the way (e.g. blood vessels)?

Here are some papers / links that you might nd interesting: a. Crawley SM and Dalton AJ. Predicting the dif cult airway, British Journal of Anaesthesia Education, 2015; 15: 253–7 b. Ahmad I, Millhoff B, John M, Andi K, Oakley R. Virtual endoscopy--a new assessment tool in dif cult airway management. Journal of Clinical Anesthesia. 2015; 27: 508-13 c. Zhou Z, Zhao X, Zhang C, Yao W. Preoperative four-dimensional computed tomography imaging and simulation of a

breoptic route for awake intubation in a patient with an

epiglottic mass. British Journal of Anaesthesia. 2020;125: e290-2

fl

fl

fi

fi

fi

fi

21


#JanuAIRWAY

2022

22


#JanuAIRWAY

2022

23


#JanuAIRWAY

2022

24


#JanuAIRWAY

2022

25


#JanuAIRWAY

2022

26


#JanuAIRWAY

2022

What about Airway Ultrasound? It’s a useful, yet simple, skill to support safe airway management. Check out Michael Seltz Kristensen's work – undisputed master of airway ultrasound. Indications? Scan to locate: • Cricoid cartilage for cricoid pressure • Cricothyroid membrane if at risk of cricothyroidotomy • Tracheal rings for tracheostomy • Superior laryngeal nerve for regional anaesthesia (For point-of-care gastric USS check out this summary by El-Boghdadly, Wojcikiewicz and Perlas - here.) Here we focus on the transverse views for cricothyroidotomy. Start by getting the patient in the position, in which you would perform a tracheostomy – consider a bag of

uid

under the shoulders. Linear probe / transverse orientation. Start with the probe on the neck under the chin. Scan caudally until you see the thyroid cartilage – triangular or inverted V-appearance between strap muscles (angle of the thyroid cartilage is more acute in males).

fl

27


#JanuAIRWAY

2022

Scan caudally looking for the air-mucosa interface - a bright hyperechoic white line - represents the beginning of the tracheal lumen below the cricothyroid membrane– hence a target for cricothyroidotomy (reverberation artefact is below in tracheal lumen beneath).

You can mark the position of the cricothyroid membrane at this level with a pen on either side of the probe (left and right, top and bottom). Continuing caudally the cricoid cartilage comes into view as a hypoechoic inverted U or horseshoe shape with the Air-Mucosa Interface below.

28


#JanuAIRWAY

2022

The tracheal rings will come into view as hypoechoic ring-like shapes with air-muscosa interface below and thyroid gland above and to either side – useful to know its location and vascularity before percutaneous tracheostomy.

Longitudinal/parasagittal views along trachea, air-mucosa interface = long white line, cartilages appear as hypoechoic ovals – sometimes called a ‘string of pearls’ – they look a bit like coffee beans! You can use any needle or cannula in a transverse orientation to identify the level.

Here are some papers/links that you might nd interesting: a. Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identi cation of the cricothyroid membrane: best evidence, techniques, and clinical impact. British Journal of Anaesthesia. 2016; 117: i39-i48 b. Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark identi cation for cannula cricothyroidotomy. Anaesthesia. 2010; 65: 889-94 c. Dinsmore J, Heard AM, Green RJ. The use of ultrasound to guide time-critical cannula tracheotomy when anterior neck airway anatomy is unidenti able. European Journal of Anaesthesiology. 2011; 28: 506-10 d. El-Boghdadly K, Wojcikiewicz T, Perlas A. Perioperative point-of-care gastric ultrasound. British Journal of Anaesthesia Education. 2019; 19: 219-26 e. Identi cation of the cricothyroid membrane with ultrasonography Longitudinal "string of pearls" approach - video (online)

fi

fi

fi

fi

fi

29


#JanuAIRWAY

2022

AIRWAY PLANNING | Strategies are essential (NOT just plans) | Decision making, an important non-technical skill, is a key aspect of safeairway management, and something that is often not well in training curricula. NAP4 showed that poor judgement was implicated in many airway complications. This is an issue because we encounter dif cult airways relatively infrequently, and complications are rarer still. higher anxiety.

We know that low exposure leads to

Add in multiple options Huitink & Bouwman suggest more than 1,000,000

combinations of options to oxygenate and things can get complicated. More options can mean more anxiety; in an emergency, more options are not always useful.

Cognitive load can lead to decision fatigue & increasing bias & poorer decisions. Chew et al came up with the TWED checklist which can help: T

Threat – de ne problem

W

Wrong? What if I’m wrong? What else could it be?

E

Evidence to con rm / exclude

D

Dispositional factors – environment, hunger, fatigue

The Elaine Bromiley & Gordon Ewing cases are essential reading for people that manage airways. Both highlight competing problems with task xation and failure to accept safe (but not necessarily desirably situations).

Here are the key issues & a decision cycle as a way of

combating both.

fi

fi

fi

fi

30


#JanuAIRWAY

2022

Situational awareness is key. Notices whats going on around you, take time to Understand it, Think Ahead (NUTA). @Vapourologist (Tom Lawson) uses this four step approach (below left) with ADEPT mnemonic.

You’re not alone in having airway skills – remember our surgical colleagues. Involve them early. BUT remember not all surgeons are equal (same as anaesthetists!) – we all have subspecialty interests – a rhinologist might not be comfortable performing an eFONA either!

Putting it all together – consider an airway strategy sheet to de ne problems / limits up front, involve ENT early, de ne plans A, B, C & D – consider all options, but decide on a few.

Here are some papers / links that you might nd interesting: a. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit Project: Major complications of airway management in the United Kingdom. 2011 (online) b. Chrimes N, Fritz P. The Vortex Approach to airway management (online)

fi

fi

fi

fi

31


#JanuAIRWAY

2022

32


#JanuAIRWAY

2022

33


#JanuAIRWAY

2022

Knowledge of what drugs we can use and how we use them in airway management is indispensable – especially where planning is concerned. Drugs affect the airway in one of three ways: a. Direct action e.g. local anaesthetics or bronchodilators b. Indirect action e.g. volatile anaesthetics or respiratory stimulants c. Adverse reaction e.g. as a result of anaphylaxis The three main effects drugs have on the airway are be changing: a. Airway patency – usually by reducing muscle tone b. Airway reactivity – airways can be irritated either by central or local effects c. Aspiration protection – may be reduced (e.g. drugs that reduce conscious level) or improved (e.g. PPI) Drug controversies in dif cult airways: •

To paralyse or not

Spontaneous Ventilation or IPPV during induction of anaesthesia

Key points: -

Paralysis can be reversible – have a plan

-

Maintaining spontaneous ventilation can be inconsistent

2 simple rules for drugs: 1. Use drugs that are easily titratable & reversible 2. Plan for failure Some people use a ‘wake up tray’ with NRDS drugs drawn up and ready to go N – Naloxone R – Reversal (Glyc/Neostig) D – Doxapram S – Sugammadex (if applicable) 2 main drugs: 1. Sedatives 2. Local anaesthetics

fi

34


#JanuAIRWAY

2022

https://www.youtube.com/watch?v=epGFFQcwjBA

Key is that local anaesthetic needs to be in the right place. If it is you don’t need much. This is @vapourologist after gargling 10ml instilagel with 10ml water for 2 mins. Here are some papers / links that you might nd interesting: a. Consilvio C, Kuschner WG, Lighthall GK. The pharmacology of airway management in critical care. Journal of Intensive Care Medicine. 2012; 27: 298-305 b. Royal Free Anaesthesia. How to topicalise the airway for awake beroptic intubation (AFOI) - video (online) c. Johnston KD, Rai MR. Conscious sedation for awake breoptic intubation: a review of the literature. Canadian Journal of Anaesthesia. 2013; 60: 584-99

fi

fi

fi

35


#JanuAIRWAY

2022

36


#JanuAIRWAY

2022

37


#JanuAIRWAY

2022

BASIC AIRWAY EQUIPMENT | Good workers know their tools | Good workers know their tools – knowing our equipment is essential! See the #OnePagers for the fundamentals of masks, NP/OPs, SADs, ETTs and Frova intubating introducer. Speci c airway devices such as Cook airway exchange catheters, Aintree Intubation Catheters, Staged Extubation Kits, OLV equipment, Tracheostomies, are covered later in the compilation. Here are some papers / links that you might nd interesting: a. Laurie A, Macdonand J. Equipment for airway management. Anaesthesia and Intensive Care Medicine. 2018; 19: 389-96 b. Bjurström MF, Bodelsson M, Sturesson LW. The Dif cult Airway Trolley: A Narrative Review and Practical Guide. Anesthesiology Research and Practice. 2019 c. Chishti K. Setting up a Dif cult Airway Trolley. 2015 (online) d. Gibbins M, Kelly FE, Cook TM. Airway management equipment and practice: time to optimise institutional, team, and personal preparedness. British Journal of Anaesthesia. 2020; 125: 221-4

fi

fi

fi

fi

38


#JanuAIRWAY

2022

39


#JanuAIRWAY

2022

40


#JanuAIRWAY

2022

41


#JanuAIRWAY

2022

42


#JanuAIRWAY

2022

43


#JanuAIRWAY

2022

44


2022

AIRWAY LARYNGOSCOPY | DL, VL or Combined FB:VL? | Laryngoscopy, as a prelude to tracheal intubation, is an essential skill for airway managers. There is a wide array of laryngoscope types and approaches used to achieve this view of the glottis. Broadly speaking, laryngoscopy can be direct (DL) or indirect (VL) and can involve a rigid or a exible device. All devices and approaches require speci c skills and may require additional intubation aids, such as a stylet. The term ‘videolaryngoscopy’ has now been adopted for all rigid laryngoscopes that deliver an indirect view of the glottis. Innovators will develop new techniques, such as combining videolaryngoscopy and exible bronchoscopy, to overcome dif culty. It is important to understand the Cormack and Lehane classi cation, universally adopted for grading of direct laryngoscopy view. This becomes less relevant with indirect laryngoscopy, where there is no agreed classi cation system. The Video Classi cation of Intubation (VCI) score is a potential model (*inclusion in this material does not constitute DAS endorsement).

Here are some papers / links that you might nd interesting: a. Jackson, C.

The technique of insertion of intratracheal insuf ation tubes.

Surgery,

Gynecology and Obstetrics. 1913; 17: 507-9 b. Knill RL. Dif cult laryngoscopy made easy with a "BURP". Canadian Journal of Anaesthesia. 1993; 40: 279-82 c. Chaggar RS, Shah SN, Berry M, Saini R, Soni S, Vaughan D. The Video Classi cation of Intubation (VCI) score: a new description tool for tracheal intubation using videolaryngoscopy: A pilot study. European Journal of Anaesthesiology. 2021; 38: 324-6 d. Lewis SR, Butler AR, Parker J, Cook TM, Scho eld-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. British Journal of Anaesthesia. 2017; 119: 369-83

fi

fi

fl

fi

fi

fl

fi

fi

fi

fi

45

fi

fl

#JanuAIRWAY


#JanuAIRWAY

2022

46


#JanuAIRWAY

2022

47


#JanuAIRWAY

2022

48


#JanuAIRWAY

2022

49


#JanuAIRWAY

2022

50


#JanuAIRWAY

2022

51


#JanuAIRWAY

2022

52


#JanuAIRWAY

2022

53


#JanuAIRWAY

2022

54


#JanuAIRWAY

2022

CAPNOGRAPHY & OESOPHAGEAL INTUBATION | with thanks to Tim Cook and Barry McGuire for their expert contributions | This is one of the most essential pieces of monitoring equipment needed during airway management.

But its presence isn’t enough, correct interpretation is vital. Capnography is

primarily an AIRWAY monitor. Oesophageal intubation still occurs & EtCO2 is a key tool to help prevent avoidable deaths such as Glenda Logsdail’s. Key message is that at or no trace indicates oesophageal intubation until proven otherwise. This thread by Professor Tim Cook is fantastic and we recommend everyone read it! He also has an article in FICM’s Critical Eye. The Royal College of Anaesthetists and DAS video “Capnography: No Trace = Wrong Place” is essential viewing for all airway managers.

https://www.youtube.com/watch?v=t97G65bignQ&t=8s

The RCoA have a number of other videos available on their website on a page dedicated to the prevention of future deaths. We also recommend all airway managers read this DAS ezine article by Barry McGuire Imran Ahmad, Alistair McNarry, Abhijoy Chakladar and Lewys Richmond.

fl

55


#JanuAIRWAY

2022

https://vimeo.com/662046937/ad4217b155

Another reported case in Australia has further emphasised this is not just a UK problem, it is a global issue. But as Professors Ellen O’Sullivan and Tim Cook have pointed out there is an almost 100% “Capnography Gap” in LIC (audits completed in Malawi & Uganda) which must be addressed See this recent series from Anaesthesia Journal on unrecognised oesophageal intubation • Editorial • Broadcast • Podcast

Here are some other papers / links that you might nd interesting: a. Cook, T.M., Kelly, F.E. and Goswami, A. ‘Hats and caps’ capnography training on intensive care. Anaesthesia, 2013; 68: 421 b. Joy P, Kelly FE. Unrecognised Oesophageal Intubation. Anaesthesia News. 2022 (online) c. Cook TM, Harrop-Grif ths W. Capnography prevents avoidable deaths. British Medical Journal. 2019; 364: l439 d. CORONERS COURT OF NEW SOUTH WALES Inquest into the death of Emiliana Obusan. 2021 (online) e. MILTON KEYNES CORONER’S COURT Inquest into the death of Glenda May Logsdail REGULATION 28: REPORT TO PREVENT FUTURE DEATHS f. Foy KE, Mew E, Cook TM, Bower J, Knight P, Dean S, Herneman K, Marden B, Kelly FE. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia. 2018; 73:1337-44 g. Collins J, Ní Eochagáin A, O'Sullivan EP. A recurring case of 'no trace, right place' during emergency tracheal intubations in the critical care setting. Anaesthesia. 2021; 76 :1671

fi

fi

56


#JanuAIRWAY

2022

57


#JanuAIRWAY

2022

58


#JanuAIRWAY

2022

HIGH FLOW NASAL OXYGEN | with thanks to Anil Patel for his expert contributions | This has been a game-changer in recent years. Thank you Professor Anil Patel and S Nouraei for your amazing landmark paper on THRIVEl!

Oxygen consumption continues during apnoea, gradual loss of alveolar volume/reduction in pressure. If upper airway remains patent, gas can be drawn into lower airways and oxygenation can continue and delay desaturation.

HFNO / THRIVE works by a combination of the delivery of humidi ed and warmed high ow air / oxygen, generation of positive airway pressure, improved respiratory mechanics, pharyngeal deadspace washout, apnoea oxygenation and ventilation.

fl

fi

59


#JanuAIRWAY

2022

Limitations: 1. Airway must be patent but can be signi cantly reduced 2. Secretions can accumulate 3. Morbid Obesity – shorter duration of apnoea before desaturation, more rapid desaturation 4. CO2 accumulation – without hypoxia / raised ICP 5. Epistaxis and skull fractures with the potential risk of airway soiling and pneumocephalus

Here are some papers / links that you might nd interesting: a. Patel A, Nouraei SA. Transnasal Humidi ed Rapid-Insuf ation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with dif cult airways. Anaesthesia. 2015; 70: 323-9 b. Hermez LA, Spence CJ, Payton MJ, Nouraei SAR, Patel A, Barnes TH. A physiological study to determine the mechanism of carbon dioxide clearance during apnoea when using transnasal humidi ed rapid insuf ation ventilatory exchange (THRIVE). Anaesthesia. 2019; 74: 441–9 c. Mir F, Patel A, Iqbal R, Cecconi M, Nouraei SAR. A randomised controlled trial comparing transnasal humidi ed rapid insuf ation ventilatory exchange (THRIVE) pre-oxygenation with facemask pre-oxygenation in patients undergoing rapid sequence induction of anaesthesia. Anaesthesia. 2017; 72: 439–43 d. Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal humidi ed rapid-insuf ation ventilatory exchange (THRIVE) in children: a randomized controlled trial. British Journal of Anaesthesia. 2017; 118: 232–8 e. Lodenius å., Piehl J, Östlund A, Ullman J, Jonsson Fagerlund M. Transnasal humidi ed rapid-insuf ation ventilatory exchange (THRIVE) vs. facemask breathing pre-oxygenation for rapid sequence induction in adults: a prospective randomised non-blinded clinical trial. Anaesthesia. 2018; 73: 564–71 f. Patel A, El‐Boghdadly K. Apnoeic oxygenation and ventilation: go with the ow. Anaesthesia. 2020; 75: 1002–5 g. Sud A, Patel A. THRIVE: ve years on and into the COVID-19 era. British Journal of Anaesthesia. 2021;126: 768-73 h. Patel A, El-Boghdadly K. Facemask or high- ow nasal oxygenation: time to switch? Anaesthesia. 2022; 77: 7-11 i. Rummens N, Ball DR. Failure to THRIVE. Anaesthesia. 2015. (epub) j. Levitan R. NO DESAT! Emergency Physicians Monthly. 2010 (online)

fi

fi

fl

fl

fi

fl

fi

fi

fl

fl

fi

fl

fi

fi

fl

fi

60


#JanuAIRWAY

2022

61


#JanuAIRWAY

2022

COOK AIRWAY EXCHANGE CATHETER | Useful but use with caution - know its limitations and dangers! | A useful piece of equipment, but one not everyone will be familiar with. Main function is as a stopgap to maintain tracheal access & facilitate ETT exchange. They are long, hollow, radiopaque, soft-tipped tubes – types for use with single / double lumen tubes. There are different sizes for different functions (see chart). All users MUST be trained & knowledgeable of how to use such devices together with their limitations and dangers. The Gordon Ewing case makes for tragic reading – but highlights this point. Essential reading for airway practitioners. NEVER insert beyond 26cm and NEVER insuf ate with an oxygen ow >2L/min. (or just NEVER insuf ate with oxygen) Here are some papers / links that you might nd interesting: a. Sheriffdom of Glasgow and Strathkelvin. Determination of Sheriff Linda Margaret Ruxton in Fatal Accident Inquiry in the Death of Gordon Ewing. 2010 FAI 15 (online) b. Benumof JL. Airway exchange catheters: simple concept, potentially great danger. Anesthesiology. 1999; 91: 342-4 c. Moyers G, McDougle L. Use of the Cook airway exchange catheter in "bridging" the potentially dif cult extubation: a case report. AANA Journal. 2002; 70: 275-8 d. A dangerous tracheal tube exchange from AOD. 2016 - video (online) e. Change of Endotracheal tube over tube exchanger. 2019 - video (online)

fl

fl

fi

fi

fl

62


#JanuAIRWAY

2022

63


2022

COOK AINTREE INTUBATION CATHETER | So useful, but know its limitations! | An amazingly useful piece of equipment – every airway practitioner should be familiar with. Main function of the Aintree Intubation Catheter is to facilitate intubation through a supraglotttic airway device because it is designed to t over a 4mm exible bronchoscope. It is a long, 56cm, hollow, semi-rigid, powder blue, polyurethane catheters which accommodates an ETT 7mm or larger. NEVER insert beyond 26cm and NEVER insuf ate with an oxygen ow >2l/min (..or just NEVER insuf ate) Here are some papers / links that you might nd interesting: a. Padmanabhan R, McGuire B, Morris A. Fibreoptic guided tracheal intubation through supraglottic airway device (SAD) using aintree intubation catheter. 2011 (online) b. Gruenbaum SE, Gruenbaum BF, Tsaregorodtsev S, Dubilet M, Melamed I, Zlotnik A. Novel use of an exchange catheter to facilitate intubation with an Aintree catheter in a tall patient with a predicted dif cult airway: a case report. Journal of Medical Case Reports. 2012; 13:108 c. Phipps S, Malpas G, Hung O. A technique for securing the Aintree Intubation Catheter™ to a exible bronchoscope. Canadian Journal of Anaesthesia. 2018; 65: 329-30 d. Cook Medical. Aintree Intubation Catheter (online) e. Gloucestershire Hospitals NHS Foundation Trust. Fibreoptic Guided Intubation through SGA using Aintree Intubation Catheter - video (online)

fl

fl

fl

fi

fi

fi

64

fl

fl

#JanuAIRWAY


#JanuAIRWAY

2022

65


#JanuAIRWAY

2022

AWAKE TRACHEAL INTUBATION (ATI) | with thanks to Imran Ahmad for his expert contributions | Awake Techniques – there are key skill for an airway manager. Topicalization is key (if right, may not need sedation). Top tips: • Know nerve supply – CN V, IX & X. • Block Ant.ethmoidal AND Sphenopalatine ganglion supply nasal septum • Often you don’t need high dose LA if in right spot – this video is Tom Lawson after only gargling instilagel.

https://www.youtube.com/watch?v=Pzo_1TJZSEY

66


#JanuAIRWAY

2022

Fibreoptic scopes have advanced in recent years.

It is important for airway managers to be

familiar with and have knowledge of the ergonomics and the basics of the exible bronchoscope. • Know your equipment – set-up, usage and limitations • Two positions for scope handling – Bazooka (facing patient) or Statue of Liberty (standing at head end)

Ancillary equipment can make or break an awake intubation. These can be broken down into 3 main types: • Those which aid oxygen delivery • Those which aid drug delivery • Those which aid scope delivery (oral airways) There are many different recipes for ATI. It is worth being familiar with the different drugs that can be used and recommend using the DAS approach to ATI. There are a lot of potential problems that can be encountered during ATI – these need to be planned for. Be familiar with the basics of troubleshooting, complications and how to manage unsuccessful ATI. Remember HFNO can help and a good knowledge of airway pharmacology is essential for awake techniques. Here are some papers / links that you might nd interesting: a. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020; 75: 509-28 b. Royal Free Anaesthesia. How to topicalise the airway for awake beroptic intubation (AFOI) - video (online) c. Bailin S. Awake Tracheal Intubation - video (online) d. Awake Airway Management. Videolaryngoscopic awake tracheal intubation, no sedation video (online)

fl

fi

fi

fi

67


#JanuAIRWAY

2022

68


#JanuAIRWAY

2022

69


#JanuAIRWAY

2022

70


#JanuAIRWAY

2022

71


#JanuAIRWAY

2022

72


#JanuAIRWAY

2022

73


#JanuAIRWAY

2022

74


#JanuAIRWAY

2022

75


#JanuAIRWAY

2022

76


#JanuAIRWAY

2022

77


#JanuAIRWAY

2022

JET VENTILATION | niche anaesthesia, but fascinating | This is a bit more niche in anaesthesia / airway management, but fascinating. There are 2 modes of jet ventilation: • Low Frequency (<60 jets/min) & • High Frequency (>60). Frequency determines device. 2 commonly used devices are the Manujet (modi ed hand operated Sanders injector) or Monsoon (specialised jet ventilator). There are several different potential mechanisms to apnoic oxygenation during High Frequency Jet Ventilation, including: • Bulk ow • Laminar ow • Taylor dispersion • Pendelluft • Molecular diffusion • Cardiogenic mixing

fi

fl

fl

78


#JanuAIRWAY

2022

Key clinical pearl is the critical airway diameter for exhalation. Dworkin et al showed that jetting across a glottis <4.0 - 4.5mm in diameter leads to gas trapping, independent of jet ventilator settings. There MUST be a path for exhalation.

3 route for jet ventilation: • Supraglottic – attached to a surgical laryngoscope • Subglottic – using a specialised jet ventilation catheter • Transtracheal – using a cannula via the cricothyroid membrane

79


#JanuAIRWAY

2022

Increasingly jet ventilation is being used outside of ENT, in interventional radiology and cardiac catheter labs to improve image quality. Here are some papers / links that you might nd interesting: a. Pearson KL, McGuire BE. Anaesthesia for laryngo-tracheal surgery, including tubeless eld techniques. British Journal of Anaesthesia Education. 2017; 17: 242-8 b. Patel C. Chet Patel describes the anaesthetic technique of jet ventilation - video (online) c. Anaesthesia Galway. Manujet Ventilator - video (online) d. Sivasambu B, et al. Initiation of a High-Frequency Jet Ventilation Strategy for Catheter Ablation for Atrial Fibrillation: Safety and Outcomes Data. JACC Clinical Electrophysiology. 2018; 4: 1519-25

fi

fi

80


#JanuAIRWAY

2022

81


#JanuAIRWAY

2022

82


#JanuAIRWAY

2022

83


#JanuAIRWAY

2022

84


#JanuAIRWAY

2022

85


#JanuAIRWAY

2022

86


#JanuAIRWAY

2022

ONE LUNG VENTILATION | Physiology in action | There are several indications for One Lung Ventilation (OLV). The commonest are thoracic surgery & some oesophagectomies. There are essentially three ways to achieve OLV: • Use of a double lumen tube • Use of a bronchial blocker • Elective endobronchial intubation

The key physiological change is the creation of a large shunt – deoxygenated blood (which would normally be oxygenated), returns to the left heart resulting in hypoxaemia.

87


#JanuAIRWAY

2022

Often OLV is done in the lateral decubitus position. This has several effects on V/Q relations. As we can see in this diagram.

Evolution is amazing, because we have a friend to help us deal with shunt – hypoxic pulmonary vasoconstriction.

The bottom line is the mechanism is complicated - it’s biphasic, aims to

decrease shunt to non-ventilated lung and can be in uenced by several factors. Tips for One Lung Ventilation: • Choose your airway wisely – get it right rst time – use a beroptic scope • If using bronchial blocker – consider going outside ETT. • Be aware of physiological interplay • Plan to deal with hypoxaemia A knowledge of bronchoscopic anatomy is incredibly useful in anaesthesia / critical care – especially when performing OLV. Here are some papers / links that you might nd interesting: a. Ashok V, Francis J. A practical approach to adult one-lung ventilation. British Journal of Anaesthesia Education. 2018; 18: 69-74 b. Bronchoscopy Simulator (online) c. Gloucestershire Hospitals NHS Foundation Trust. Double Lumen Tube Training video. 2020 - video (online) d. Bronchial Blocker Insertion. 2012 - video (online) e. Bronchial Blockers: EZ-Blocker. 2016 - video (online)

fi

fl

fi

fi

88


#JanuAIRWAY

2022

89


#JanuAIRWAY

2022

90


#JanuAIRWAY

2022

91


#JanuAIRWAY

2022

92


#JanuAIRWAY

2022

93


#JanuAIRWAY

2022

94


#JanuAIRWAY

2022

TRACHEOSTOMIES (AND LARYNGECTOMIES) | with thanks to Brendan McGrath for his expert contributions | More than just an ETT through the neck. Tracheostomies have potentially been performed since ancient Egypt. The

rst non-

emergency tracheostomy was thought to be performed by Asclepiades. He was also a proponent of music therapy – might be of interest to Veena. There are 4 basic indications for tracheostomy: 1. Facilitate prolonged (or weaning from) mechanical ventilatory support. 2. Provide a patent airway in cases of actual or threatened upper airway obstruction. 3. Provide a degree of airway protection, usually associated with central neurological or bulbar neuromuscular conditions. 4. Facilitate clearance of pulmonary secretions where coughing is inadequate. What physiological changes are associated with tracheostomies? 1. Upper airway natural humidi cation is completely or at least partially bypassed – additional humidi cation is essential 2. Reduced dead space – may help with work of breathing 3. Dif cult or impossible vocalisation without dedicated strategies 4. Impaired swallowing Tracheostomies can be performed using either a surgical or percutaneous technique. There are 3 main surgical techniques: • Surgical window • Slit type • Björk ap - There are 2 reasons to mention Björk aps really – 1 they often have a confusing anterior suture which needs to be noted on the bedhead sign; and the Swedish cardiothoracic surgeon who described them has one of the best names in medicine: Viking Björk!

fi

fl

fi

fi

fl

fi

95


#JanuAIRWAY

2022

An important difference is time for tract maturity: • Percutaneous = 7 - 10 days • Surgical = 2 - 4 days Also important in decannulation as a false tract can occur if re-inserting before tract maturity! MUST establish whether upper airway is present – i.e. tracheostomy or laryngectomy (neck-only breather). All patients with a tracheostomy or laryngectomy should have the appropriate bed head sign indicating type, size and date of insertion. NTSP have great resources available on their website to support this.

96


#JanuAIRWAY

2022

NAP4 & NCEPOD show poor outcomes still occur. NTSP has fantastic algorithms for both emergency tracheostomy and laryngectomy management. There’s a lot of important aspects to tracheostomy care – check out this amazing resource from Portsmouth Intensive Care Unit. Here are some papers / links that you might nd interesting: a. McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012; 67: 1025-41 b. National Tracheostomy Safety Project (NTSP) resources (online) c. Lewith H, Athanassoglou V. Update on management of tracheostomy. British Journal of Anaesthesia Education. 2019; 19: 370-376 d. Paulich S, Kelly FE, Cook TM. 'Neck breather' or 'neck-only breather': terminology in tracheostomy emergencies algorithms. Anaesthesia. 2019; 74: 947 e. Pracy JP, Brennan L, Cook TM, Hartle AJ, Marks RJ, McGrath BA, Narula A, Patel A. Surgical intervention during a Can't intubate Can't Oxygenate (CICO) Event: Emergency Front-of-neck Airway (FONA)? British Journal of Anaesthesia. 2016; 117: 426-8 f. El-Wajeh Y, Varley I, Raithatha A, Glossop A, Smith A, Mohammed-Ali R. Opening Pandora's box: surgical tracheostomy in mechanically ventilated COVID-19 patients. British Journal of Anaesthesia. 2020; 125: e373-5

fi

97


#JanuAIRWAY

2022

98


#JanuAIRWAY

2022

99


#JanuAIRWAY

2022

100


#JanuAIRWAY

2022

TITLE ||

101


#JanuAIRWAY

2022

PLAN D: EFONA | with thanks to Alistair McNarry for his expert contributions | Language around this scenario is continually evolving. Whether its referred to as CICO - Can’t intubate, Cant Oxygenate or CICV - Cant Intubate, Cant Ventilate; it is important to recognise this is a scenario. They all describe the scenario where all other attempts at airway management and oxygen delivery have failed. Whereas eFONA (emergency front-of-neck airway) is a procedure carried out in response to a CICO scenario. This is a rare event and raises a dichotomy. i. If when conducting an airway assessment you feel an eFONA might be required, STOP, get help and consider an airway management plan that avoids this requirement (eg an awake technique - see section on awake tracheal intubation) ii. However, if you are managing a patient’s airway and all other attempts at oxygenation have failed then you must PROCEED to eFONA without delay.

102


#JanuAIRWAY

2022

Before commencing an eFONA technique ensure that a large dose of neuromuscular blocking agent has been given (treats laryngospasm and paralyses the patient). Know your technique before you are ever required to do it, rehearse it mentally i. where would you stand ii. who would you send for equipment iii. how would you extend the neck etc In adults DAS guidelines recommend scalpel eFONA techniques ( nal common pathway of CICO), however cannula technique is advocated in children between 1 and 8 years in a Can’t Intubate Can’t Oxygenate scenario (see the DAS APA guidelines). For more on the cannula technique check out Dr Andy Heard’s work at the Perth ‘wet’ lab. There are 2 anatomical scenarios for eFONA – palpable and impalpable anatomy. DAS guidelines recommend everyone should know scalpel eFONA techniques (scalpel bougie tube (palpable anatomy), scalpel nger bougie tube (impalpable anatomy).

https://www.youtube.com/watch?v=B8I1t1HlUac

The most dif cult part of the process is making the decision to pick up the scalpel. Mental models and thinking tools like the Vortex can be useful. Check out Nicholas Chrimes & Peter Fritz's work. Remember you’re not alone in having airway skills. Remember your surgical colleagues & involve them early. But also remember not all surgeons will feel comfortable in performing an eFONA - in that it case it will have to be YOU!

fi

fi

fi

103


#JanuAIRWAY

2022

Training in eFONA is vital - not just for you. Train everyone who might be involved in an eFONA event - nursing staff, anaesthetic assistants, scrub nurses (they are always there when you are doing an operation regardless of the time of the day). Training MUST use the locally available equipment - please make sure that your plan for eFONA is deliverable where you work (and remember that can change from hospital to hospital).

Here are some papers / links that you might nd interesting: a. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall NM, Ahmad I; Dif cult Airway Society intubation guidelines working group. Dif cult Airway Society 2015 guidelines for management of unanticipated dif cult intubation in adults. British Journal of Anaesthesia. 2015; 115: 827-48 b. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018; 120: 323-52 c. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Dif cult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75: 785-99 d. Heard A, Dinsmore J, Douglas S, Lacquiere D. Plan D: cannula rst, or scalpel only? British Journal of Anaesthesia. 2016; 117: 533-5 e. Mann CM, Baker PA, Sainsbury DM, Taylor R. A comparison of cannula insuf ation device performance for emergency front of neck airway. Pediatric Anesthesia. 2021; 31: 482-90 f. Chrimes N, Fritz P. The Vortex Approach to airway management (online) g. Heard AM. DrAMBHeardAirway YouTube Channel (online)

fi

fi

fl

fi

fi

fi

fi

fi

104


#JanuAIRWAY

2022

105


#JanuAIRWAY

2022

106


#JanuAIRWAY

2022

107


#JanuAIRWAY

2022

108


#JanuAIRWAY

2022

109


#JanuAIRWAY

2022

110


#JanuAIRWAY

2022

111


#JanuAIRWAY

2022

112


#JanuAIRWAY

2022

THE OBSTRUCTED AIRWAY | with thanks to Anil Patel, Elizabeth Ross, Sadie Khwaja and Adam Donne | | for their expert contributions | The Obstructed Airway - think: NOLIMBS • Nose, Nasal Cavity and Nasopharynx • Oral Cavity and Oropharynx • Larynx, Laryngopharynx and Extra-thoracic (subglottic) Trachea • Intra-thoracic • Malacias • Bleeding • SVC Obstruction

Nasopharyngeal and Oropharyngeal Airway Obstruction Possible issues: • Risk of total obstruction with low tone • Distorted anatomy and/or trismus • Nasopharyngeal/Oropharyngeal airway too short? • Strong jaw thrust may/may not relieve obstruction • Dif cult mask ventilation and/or laryngoscopy • Repeated laryngoscopy may make a manageable airway unmanageable.

fi

113


#JanuAIRWAY

2022

Planning in airway obstruction is key. Nasendoscopy can save lives here! ASSESSMENT informs STRATEGY. Remember the decision-making process is multifactorial and it is important to maintain situational awareness.

In severe Nasal/Oral and Naso-Oro-Pharyngeal obstruction an awake technique may be advantageous. Options may include: • HFNO as a helpful stop-gap measure • Standard Intubation • ATI/AFOI • Awake/asleep FOI +/- transtracheal catheter • Awake/asleep tracheostomy

114


#JanuAIRWAY

2022

115


#JanuAIRWAY

2022

116


#JanuAIRWAY

2022

117


#JanuAIRWAY

2022

118


#JanuAIRWAY

2022

119


#JanuAIRWAY

2022

Laryngeal / Laryngopharyngeal Airway Obstruction (Periglottic) Often the most challenging for the general anaesthetist. Issues: • Must discuss with ENT colleagues • Preoperative nasendoscopy by experienced nasendoscopist is very helpful • AFOI may worsen obstruction – cork in bottle • Inhalational induction will be dif cult Key Q's • Is the obstruction static or dynamic? • Can an ETT be passed through the airway? Options: • May be able to pass ETT depending on narrowing - consider using a micro laryngeal tube or jet ventilation catheter. • Apnoeic (HFNO) or intermittent oxygenation/intubation technique – depending on type of surgery (elective/emergent) • Awake Tracheal Intubation • Transtracheal catheter (+/- subsequent jet ventilation) • Awake tracheostomy

Here are some papers / links that you might nd interesting: a. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020; 75: 509-28 b. Lynch J. Crawley SM. Management of airway obstruction. British Journal of Anaesthesia Education. 2017; 18: 46-51 c. Bryant H. Batuwitage B. Management of the Obstructed Airway. Anaesthesiology: Tutorial of the Week. 2016 (online) d. Bruce IA, Rothera MP. Upper airway obstruction in children. Pediatric Anesthesia. 2009; 19(S1): 88-99 e. McAvoy J, Ewing T, Nekhendzy V. The value of preoperative endoscopic airway examination in complex airway management of a patient with supraglottic cancer. Journal of Head & Neck Anesthesia. 2019; 3: e19

fi

fi

fi

120


#JanuAIRWAY

2022

121


#JanuAIRWAY

2022

Larynx and Extrathoracic Tracheal Airway Obstruction Presents a unique set of challenges. Physiology: • In theory a xed obstructive lesion (eg tracheal stenosis) is unaffected by the respiratory cycle or anaesthesia induction • Extrathoracic lesions tend to be better in expiration as positive pressure splints the airway open Issues: • Laryngoscopy likely to be uneventful – however the major concern is the inability to pass an ETT atraumatically beyond the level of obstruction • Nasendoscopy can be useful to view lesion • AFOI may cause ‘cork in bottle’ effect depending on lesion size and location of the obstruction or stenosis • Consider use of tubeless techniques for airway intervention where possible eg foreign body removal or tumour debulking

Here are some papers / links that you might nd interesting: a. Nouraei SAR, Girgis M, Shorthouse J, El-Boghdadly K, Ahmad I. A multidisciplinary approach for managing the infraglottic dif cult airway in the setting of the Coronavirus pandemic. Operative Techniques in Otolaryngology Head and Neck Surgery. 2020; 31: 128-37 b. Scholz A, Srinivas K, Stacey MR, Clyburn P. Subglottic stenosis in pregnancy. British Journal of Anaesthesia. 2008; 100: 385-8 c. Ellis H, Iliff HA, Lahloub FMF, Smith DRK, Rees GJ. Unexpected dif cult tracheal intubation secondary to subglottic stenosis leading to emergency front-of-neck airway. Anaesthesia Reports. 2021; 9: 90-94 d. Phillips JJ, Sansome AJ. Acute infective airway obstruction associated with subglottic stenosis. Anaesthesia. 1990; 45: 34-5 e. Bulbulia BA, Ahmed R. Anaesthesia and subglottic airway obstruction. South African Journal of Anaesthesia and Analgesia. 2011; 17: 182-4 f. Venugopal N, Youssef M, Nortcliffe S. Airway management in a case of critical sub-glottic stenosis: The use of a preformed tracheal tube. The Internet Journal of Anesthesiology. 2007; 15:

fi

fi

fi

fi

122


#JanuAIRWAY

2022

123


#JanuAIRWAY

2022

124


#JanuAIRWAY

2022

Intrathoracic Airway Obstruction Again, presents its own set of challenges. Issues: • Upper and mid lesions are usually considered lower risk – due to potential to pass reinforced ETT beyond the level of obstruction • Lower tracheal / Bronchial lesions are high risk and best managed in specialist centres due to increased dif culty siting an endobronchial tube and rigid bronchoscope as a rescue manoeuvre beyond level of obstruction • A CT scan is mandatory (except in life-threatening scenarios) • Sudden obstruction can occur at ANY time • Remember there is potential for compression of the heart or great vessels Severe Obstruction Considerations: • Maintain the patient’s preferred position • Spontaneous ventilation may bene cial - negative intrapleural pressure helps splint airway open and IPPV may cause airway collapse • Many centres use IV induction techniques • Ketamine - preserves chest wall tone and FRC • Have a back up plan Potential rescue manoeuvres: In an emergency – consider passing an ETT tube & then placing a jet catheter (e.g. Cook or Aintree) beyond obstruction. Alternatively, most MLTs are long enough to reach the carina and should be available when managing patients with airway obstruction.

Here are some papers / links that you might nd interesting: a. Kapnadak SG, Kreit JW. Stay in the loop! Annals of the American Thoracic Society. 2013; 10: 166-71 b. Nakajima A, Saraya T, Takata S, Ishii H, Nakazato Y, Takei H, Takizawa H, Goto H. The sawtooth sign as a clinical clue for intrathoracic central airway obstruction. BMC Research Notes. 2012; 5: 388 c. Ahuja S, Cohen B, Hinkelbein J, Diemunsch P, Ruetzler K. Practical anesthetic considerations in patients undergoing tracheobronchial surgeries: a clinical review of current literature. Journal of Thoracic Disease. 2016; 8: 3431-41

fi

fi

fi

125


#JanuAIRWAY

2022

126


#JanuAIRWAY

2022

Malacias Malacias are a cause of rare dynamic airway obstruction (congenital or acquired) due to loss of support (by widening of both the cartilaginous arch and the membranous trachealis) • Decreased intratracheal pressure + increased intrathoracic pressure lead to airway compression • Severity is proportional to expiratory force • Intrathoracic and extrathoracic malacia may collapse at different points in the respiratory cycle Issues: • Obstruction can occur even in asymptomatic patients • Aim to maintain spontaneous ventilation • Emergency management = Positive pressure (to splint airways open) or bypassing obstruction • Surgery depends on the anatomical location and extent • Consider extubating deep (to avoid coughing) or directly to CPAP or HFNO

Bleeding & Airways Need to consider “WHERE” the bleeding is coming from. In general there are 3 possibilities: • Above (Nasal Cavity / Nasopharynx / Oral Cavity / Oral Cavity / Laryngopharynx) • Below (Tracheal / Lung / Oesophagus / GI) • Around airway (consider full circumference of airway - any haematoma in the airway can cause localised airway oedema and/or airway compression) Airway obstruction due to neck haematoma: • Can be fatal • Is normally due to laryngeal oedema NOT tracheal compression • Need to open wound immediately and manually evacuate haematoma to relieve pressure – think SCOOP See guidelines from DAS, BAETS and ENT-UK.

127


#JanuAIRWAY

2022

SVC Obstruction Obstruction below the thoracic inlet (cancer / vascular / infection / thrombosis). • Pemberton’s sign useful (face ushing on raising arms) • Valsalva challenge - syncope indicates a risk of complete vascular obstruction • Severe cases need treatment (intravascular stenting by interventional radiology) BEFORE general anaesthesia Airway Options • Depend on level and degree of obstruction • If the obstruction is at or above thoracic inlet standard laryngoscopy, jet ventilation or rigid bronchoscopy tend to suf ce • If the obstruction is below the thoracic inlet - awake techniques, jet ventilation or rigid bronchoscopy may be preferred. If the patient cannot be treated preoperatively • Keep the patient sat up • High ow O2 or HFNO • Vascular Access: ✦

Large bore, lower limb IV access – consider Rapid Infusion Catheter or Swann Introducer

Arterial line - consider lower limb also

• Smooth IV induction to avoid coughing (may be slow) • There is potential for cerebral oedema which may lead to slow wakening and/or recovery Here are some papers / links that you might nd interesting: 1. Austin J, Ali T. Tracheomalacia and bronchomalacia in children: pathophysiology, assessment, treatment and anaesthesia management. Pediatric Anesthesia. 2003; 13: 3-11 2. Findlay JM, Sadler GP, Bridge H, Mihai R. Post-thyroidectomy tracheomalacia: minimal risk despite signi cant tracheal compression. British Journal of Anaesthesia. 2011; 106: 903-6 3. Sajid B, Rekha K. Airway Management in Patients with Tracheal Compression Undergoing Thyroidectomy: A Retrospective Analysis. Anesthesia Essays Researches. 2017; 11: 110-6 4. Chaudhary K, Gupta A, Wadhawan S, Jain D, Bhadoria P. Anesthetic management of superior vena cava syndrome due to anterior mediastinal mass. Journal of Anaesthesiology Clinical Pharmacology. 2012; 28: 242-6 5. Kristensen MS, McGuire B. Managing and securing the bleeding upper airway: a narrative review. Canadian Journal of Anesthesia. 2020; 67: 128-140

fi

fl

fi

fi

fl

128


#JanuAIRWAY

2022

129


#JanuAIRWAY

2022

130


#JanuAIRWAY

2022

131


#JanuAIRWAY

2022

132


#JanuAIRWAY

2022

133


#JanuAIRWAY

2022

134


#JanuAIRWAY

2022

THE PAEDIATRIC AIRWAY | with thanks to Alistair Baxter and Adam Donne for their expert contributions | The dif cult paediatric airway = #SCARY but rare! Upper airway obstruction in children – broad range of presentations, three important diagnoses; Croup, Epiglottitis and Inhaled Foreign Body. Remember 2 types of airway obstruction- anatomical and physiological. Top tip from Alistair Baxter: Remember that a Macintosh blade is in effect a hyperangulated blade in an infant and requires an intubation stylet shaped to match the curve of the blade.

TIVA is ever increasing in popularity as is “O”s up the nose and HFNO which is generally well tolerated, allows a true tubeless eld, and can buy time during a dif cult intubation. Videolaryngoscopy as a rst choice is evidently a better technique in children of all ages - see PeDI registry data. Fibreoptic intubation is an advanced technique that requires attention to detail and practice to understand all the steps involved.

Intubation via a SAD is a nice technique and evidence is

increasing that it can be used in children of all ages as a second choice technique. Here are some papers / links that you might nd interesting: a. Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal humidi ed rapid-insuf ation ventilatory exchange (THRIVE) in children: a randomized controlled trial. British Journal of Anaesthesia. 2017; 118: 232-8 b. Bagshaw O, McCormack J, Brooks P, Marriott D, Baxter A. The safety pro le and effectiveness of propofol-remifentanil mixtures for total intravenous anesthesia in children. Pediatric Anesthesia. 2020; 30: 1331-9

fi

fi

fi

fi

fi

fl

fi

fi

135


#JanuAIRWAY

2022

c. The Royal Children’s Hospital Melbourne. Clinical Practice Guidelines (online) d. Von Ungern-Sternberg BS, Boda K, Chambers NA, Rebmann C, Johnson C, Sly PD, Habre W. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet. 2010; 376: 773-83 e. Dif cult Airway Society and Association of Paediatric Anaesthetists. Paediatric Dif cult Airway Guidelines (online) f. Engelhardt T, Virag K, Veyckemans F, Habre W; APRICOT Group of the European Society of Anaesthesiology Clinical Trial Network. Airway management in paediatric anaesthesia in Europe-insights from APRICOT (Anaesthesia Practice In Children Observational Trial): a prospective multicentre observational study in 261 hospitals in Europe. British Journal of Anaesthesia. 2018; 121: 66-75 g. Jagannathan N, Sohn L, Fiadjoe JE. Paediatric dif cult airway management: what every anaesthetist should know! British Journal of Anaesthesia. 2016; 117: i3-5 h. Walas W, Aleksandrowicz D, Kornacka M, Gaszyński T, Helwich E, Migdał M, Piotrowski A, Siejka G, Szczapa T, Bartkowska-Śniatkowska A, Halaba ZP. The management of unanticipated dif cult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel. Scandinavian Journal of Trauma Resuscitation and Emergency Medicine. 2019; 27: 87 i. King MR, Jagannathan N. Best practice recommendations for dif cult airway management in children-is it time for an update? British Journal of Anaesthesia. 2018; 121: 4-7 j. Sun Y, Lu Y, Huang Y, Jiang H. Pediatric video laryngoscope versus direct laryngoscope: a meta-analysis of randomized controlled trials. Pediatric Anesthesia. 2014; 24: 1056-65 k. Klabusayová E, Klučka J, Kosinová M, Ťoukálková M, Štoudek R, Kratochvíl M, Mareček L, Svoboda M, Jabandžiev P, Urík M, Štourač P. Videolaryngoscopy vs. Direct Laryngoscopy for Elective Airway Management in Paediatric Anaesthesia: A prospective randomised controlled trial. European Journal of Anaesthesiology. 2021; 38: 1187-93 l. Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX Jr, Litman RS, Kovatsis PG. Airway management complications in children with dif cult tracheal intubation from the Pediatric Dif cult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respiratory Medicine. 2016; 4: 37-48 m. Gupta A, Sharma R, Gupta N. Evolution of videolaryngoscopy in pediatric population. Journal of Anaesthesiology Clinical Pharmacology. 2021; 37: 14-27 n. Anderson BJ, Bagshaw O; Practicalities of Total Intravenous Anesthesia and Targetcontrolled Infusion in Children. Anesthesiology. 2019; 131: 164–185.

fi

fi

fi

fi

fi

fi

fi

136


#JanuAIRWAY

2022

137


#JanuAIRWAY

2022

138


#JanuAIRWAY

2022

139


#JanuAIRWAY

2022

140


#JanuAIRWAY

2022

141


#JanuAIRWAY

2022

142


#JanuAIRWAY

2022

143


#JanuAIRWAY

2022

144


#JanuAIRWAY

2022

THE OBSTETRIC AIRWAY | with thanks to Nuala Lucas for her expert contributions | Let’s start with some decision tools from a great review article.

145


#JanuAIRWAY

2022

Failed intubation requires a different approach in Obstetrics. The 2015 OAA/DAS guidelines are really helpful for this!

Covering planning to maximise safety for obstetric GA and the

management of failed intubation.

146


#JanuAIRWAY

2022

147


#JanuAIRWAY

2022

The 2015 OAA/DAS guidelines also cover decision making – when to bail out / when to proceed and aftercare – which mustn’t be overlooked!

148


#JanuAIRWAY

2022

Here are some other papers / links that you might nd useful: a. Bonnet MP, Mercier FJ, Vicaut E, Galand A, Keita H, Baillard C; CAESAR working group. Incidence and risk factors for maternal hypoxaemia during induction of general anaesthesia for non-elective Caesarean section: a prospective multicentre study. British Journal of Anaesthesia. 2020; 125: e81-7 b. Howle R, Onwochei D, Harrison SL, Desai N. Comparison of videolaryngoscopy and direct laryngoscopy for tracheal intubation in obstetrics: a mixed-methods systematic review and meta-analysis. Canadian Journal of Anesthesia. 2021; 68: 546-65 c. Odor PM, Bampoe S, Moonesinghe SR, Andrade J, Pandit JJ, Lucas DN; Pan-London Perioperative Audit and Research Network (PLAN), for the DREAMY Investigators Group. General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multicentre observational study. Anaesthesia. 2021; 76: 460-71 d. McGuire B, Lucas DN. Planning the obstetric airway. Anaesthesia. 2020; 75: 852-5

fi

149


#JanuAIRWAY

2022

150


#JanuAIRWAY

2022

THE TRAUMATIC AIRWAY | One part of a wider critically ill patient | These can be particularly stressful airways to manage. It is important to remember they are one part of a wider critically ill patient. The principles of treatment/management are: • Beware the isolated environment • Plan for uncooperative patient • Prevent aspiration • Protect C-spine • Plan for dif cult airway De ne type of trauma early – blunt vs penetrating (neck divided into 3 zones), and assess for: • Distorted anatomy • Bleeding • Subcutaneous Emphysema – injury to gas containing structure • Other traumatic injury – e.g. head, thorax, abdomen, etc

Here are some papers / links that you might nd interesting: a. Jain U, McCunn M, Smith CE, Pittet JF. Management of the Traumatized Airway. Anesthesiology. 2016; 124: 199-206 b. Brown CVR, Inaba K, Shatz DV, Moore EE, Ciesla D, Sava JA, Alam HB, Brasel K, Vercruysse G, Sperry JL, Rizzo AG, Martin M. Western Trauma Association critical decisions in trauma: airway management in adult trauma patients. Trauma Surgery & Acute Care Open. 2020; 5: e000539 c. Mercer SJ, Jones CP, Bridge M, Clitheroe E, Morton B, Groom P. Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma. British Journal of Anaesthesia. 2016; 117: i49-59 d. National Institute of Health and Care Excellence. Quality Statement 1: Airway Management. In: Trauma Quality Standard [QS166]. 2018 (online)

fi

fi

fi

151


#JanuAIRWAY

2022

e. Crewdson K, Lockey D, Voelckel W, Temesvari P, Lossius HM; EHAC Medical Working Group. Best practice advice on pre-hospital emergency anaesthesia & advanced airway management. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2019; 27: 6 f. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018; 120: 323-52 g. Wiles MD. Manual in-line stabilisation during tracheal intubation: effective protection or harmful dogma? Anaesthesia. 2021; 76: 850-3

fi

152


#JanuAIRWAY

2022

153


#JanuAIRWAY

2022

THE NEUROSURGICAL AIRWAY | with thanks to Sarah Muldoon for her expert contributions | Head Vs Spine. Elective Vs Emergency, So many points of interest for airway managers. Key principles: • Prevent rises in ICP • Avoid hypoxia & low BP • Consider potential for c-spine injury • Be aware of positioning • Beware potential dif cult airway in neurosurgical pathology • Beware of post-op issues e.g. haematoma post-ACDF We can, in general, divide acute / emergency patients into 2 groups: 1. Cooperative – awake techniques may be the best option in anticipated dif culty 2. Uncooperative – asleep laryngoscopy or asleep FOI (consider LMA conduit) Here are some papers / links that you might nd interesting: a. Elwishi M, Dinsmore J. Monitoring the brain. British Journal of Anaesthesia Education. 2019; 19: 54-9 b. Perelló-Cerdà L, Fàbregas N, López AM, Rios J, Tercero J, Carrero E, Hurtado P, Hervías A, Gracia I, Caral L, de Riva N, Valero R. ProSeal Laryngeal Mask Airway Attenuates Systemic and Cerebral Hemodynamic Response During Awakening of Neurosurgical Patients: A Randomized Clinical Trial. Journal of Neurosurgical Anesthesiology. 2015; 27: 194-202 c. Lockey DJ, Wilson M. Early airway management of patients with severe head injury: opportunities missed? Anaesthesia. 2020; 75: 7-10 d. McCredie VA, Ferguson ND, Pinto RL, Adhikari NK, Fowler RA, Chapman MG, Burrell A, Baker AJ, Cook DJ, Meade MO, Scales DC; Canadian Critical Care Trials Group. Airway Management Strategies for Brain-injured Patients Meeting Standard Criteria to Consider Extubation. A Prospective Cohort Study. Annals of the American Thoracic Society. 2017; 14: 85-93 e. Langford RA, Leslie K. Awake

breoptic intubation in neurosurgery. Journal of Clinical

Neuroscience. 2009; 16: 366-72 f. Yi P, Li Q, Yang Z, Cao L, Hu X, Gu H. High- ow nasal cannula improves clinical ef cacy of airway management in patients undergoing awake craniotomy. BMC Anesthesiology. 2020; 20: 156

fi

fi

fi

fl

fi

fi

154


#JanuAIRWAY

2022

155


#JanuAIRWAY

2022

156


#JanuAIRWAY

2022

THE BARIATRIC AIRWAY | with thanks to Andrew McKechnie and SOBA for their expert contributions | Key principles: • Ensure good positioning & adequate logistics • Good preoxygenation with tight seal is essential • Timely ETT placement • Beware of extubation - risk of hypoxia /airway obstruction – minimise PEEP loss Patients living with obesity frequently suffer from obstructive sleep apnoea. A sound understanding of its pathophysiology, investigation, diagnosis and perioperative management is really helpful

Here are some papers / links that you might nd interesting: a. Society for Obesity and Bariatric Anaesthesia. Anaesthesia of the Obese Patient. 2020 (online) b. Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Wetterslev J. High body mass index is a weak predictor for dif cult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology. 2009; 110: 266-74 c. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009; 110: 891-7 d. Association of Anaesthetists and Society for Obesity and Bariatric Anaesthesia. Perioperative management of the obese surgical patient. 2015 (online) e. Hashim MM, Ismail MA, Esmat AM, Adeel S. Dif cult tracheal intubation in bariatric surgery patients, a myth or reality? British Journal of Anaesthesia. 2016; 116: 557-8 f. Fox WT, Harris S, Kennedy NJ. Prevalence of dif cult intubation in a bariatric population, using the beach chair position. Anaesthesia. 2008; 63: 1339-42 g. Moon TS, Fox PE, Somasundaram A, Minhajuddin A, Gonzales MX, Pak TJ, Ogunnaike B. The in uence of morbid obesity on dif cult intubation and dif cult mask ventilation. Journal of Anesthesia. 2019; 33: 96-102

SOBA-UK Website

fi

fi

fi

fi

fl

fi

fi

157


#JanuAIRWAY

2022

158


#JanuAIRWAY

2022

159


#JanuAIRWAY

2022

160


#JanuAIRWAY

2022

161


#JanuAIRWAY

2022

EXTUBATION AND THE COOK STAGED EXTUBATION SET | don’t take off if you haven’t considered how to land the plane | Needs planning, just like intubation. Key principles: • Most airway complications occur during extubation • Extubation = elective event • Get it right rst time • Consider risk factors for dif cult extubation AND dif cult re-intubation See the DAS extubation guidelines

Pre-extubation risk assessment can include: • Arterial blood gas - to assess adequacy of gas exchange, if in doubt • Direct laryngoscopy or beroptic examination of laryngopharynx +/- other structures • Leak test

fi

fi

fi

fi

162


#JanuAIRWAY

2022

163


#JanuAIRWAY

2022

Potential options for dif cult extubation: • Extubation directly onto HFNO or CPAP • Airway exchange catheter / staged extubation catheter • Switch to Supraglottic Airway Device under GA • Remifentanil technique • Prolonged intubation and sedation • Tracheostomy Looking speci cally at the Cook Staged Extubation Set: An excellent, but maybe underknown piece of equipment. Consider in patients that may have: • Inability to tolerate extubation / need for reintubation – e.g. obstruction, poor ventilation/ oxygenation, unable to protect airway • Dif culty in re-establishing airway – known dif culty with intubation, injury, emergency, etc Set consists of a wire, placed pre-extubation, & left in-situ post-extubation (usually well-tolerated) allows for rapid re-intubation via tapered catheter. Check out this video.

https://www.youtube.com/watch?v=iuICquziUM8

Here are some papers / links that you might nd interesting: a. Batuwitage B, Charters P. Postoperative management of the dif cult airway. British Journal of Anaesthesia Education. 2017; 17: 235-41 b. Parotto M, Cooper RM, Behringer EC. Extubation of the Challenging or Dif cult Airway. Curr ent Anesthesiology Reports. 2020; 10: 334-40 c. Hagberg CA, Artime CA. Extubation of the perioperative patient with a dif cult airway. Colombian Journal of Anesthesiology. 2014; 42: 295-301

fi

fi

fi

fi

fi

fi

fi

fi

164


#JanuAIRWAY

2022

d. Cavallone LF, Vannucci A. Review article: Extubation of the dif cult airway and extubation failure. Anesthesia and Analgesia. 2013; 116: 368-83 e. D'Silva DF, McCulloch TJ, Lim JS, Smith SS, Carayannis D. Extubation of patients with COVID-19. British Journal of Anaesthesia. 2020; 125: e192-5 f. Furyk C, Walsh ML, Kaliaperumal I, Bentley S, Hattingh C. Assessment of the reliability of intubation and ease of use of the Cook Staged Extubation Set-an observational study. Anaesthesia and Intensive Care. 2017; 45: 695-9 g. McManus S, Jones L, Anstey C, Senthuran S. An assessment of the tolerability of the Cook staged extubation wire in patients with known or suspected dif cult airways extubated in intensive care. Anaesthesia. 2018; 73: 587-93 h. Corso RM, Sorbello M, Mecugni D, Seligardi M, Piraccini E, Agnoletti V, Gamberini E, Maitan S, Petitti T, Cataldo R. Safety and ef cacy of Staged Extubation Set in patients with dif cult airway: a prospective multicenter study. Minerva Anestesiologica. 2020; 86: 827-34 i. Gentek Medical. Staged Extubaiton Set - video (online)

fi

fi

fi

fi

165


#JanuAIRWAY

2022

166


#JanuAIRWAY

2022

167


#JanuAIRWAY

2022

GUIDELINES, GUIDELINES, GUIDELINES | “Guidelines are like toothbrushes. They are also like floss” | | @GongGasGirl #GAMC2021 | DAS are probably best known for our guidelines. Recently, we have updated our methodology to ensure all guidelines documents are of suf cient rigour to include best evidence and the most clinically relevant recommendations. However, it is important to recognise they are just that – recommendations and guidelines. Guidelines are not intended to represent a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement. They present key principles and suggested strategies for the management of certain clinical scenarios. They are intended to guide appropriately trained healthcare professionals. We have many DAS guidelines and have contributed to many others in partnership with other organisations, here are links to some: a. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall NM, Ahmad I; Dif cult Airway Society intubation guidelines working group. Dif cult Airway Society 2015 guidelines for management of unanticipated dif cult intubation in adults. British Journal of Anaesthesia. 2015; 115: 827-48 b. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018; 120: 323-52 c. Dif cult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Dif cult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012; 67: 318-40 d. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020; 75: 509-28 e. Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, Quinn AC; Obstetric Anaesthetists' Association; Dif cult Airway Society. Obstetric Anaesthetists' Association and Dif cult Airway Society guidelines for the management of dif cult and failed tracheal intubation in obstetrics. Anaesthesia. 2015; 70: 1286-306 f. Dif cult Airway Society and Association of Paediatric Anaesthetists. Paediatric Dif cult Airway Guidelines (online)

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

168


#JanuAIRWAY

2022

g. Iliff HA, El-Boghdadly K, Ahmad I, Davis J, Harris A, Khan S, Lan-Pak-Kee V, O'Connor J, Powell L, Rees G, Tatla TS. Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Dif cult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery. Anaesthesia. 2022; 77: 82-95 h. McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012; 67: 1025-41

Our guidelines have also been adapted to guide management of patients with COVID-19: a. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Dif cult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75: 785-99

Other airway organisations also have their own guidelines. Here are just a few from America, Canada and Australia and New Zealand (there are many more). a. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Dif cult Airway. Anesthesiology. 2022; 136: 31-81 b. 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; Canadian Airway Focus Group. The dif cult airway with recommendations for management--part 1--dif cult tracheal intubation encountered in an unconscious/induced patient. Canadian Journal of Anesthesia. 2013; 60: 1089-118 c. 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; Canadian Airway Focus Group. The dif cult airway with recommendations for management--part 2--the anticipated dif cult airway. Canadian Journal of Anesthesia. 2013; 60: 1119-38 d. Australian and New Zealand College of Anaesthesia & Faculty of Pain Medicine. Guideline for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t Oxygenate airway emergency. 2017 (online) Note: we have not provided the one pagers for this tweetorial as they are all freely available from the hyperlinks previous and are best viewed with the accompanying text.

fi

fi

fi

fi

fi

fi

fi

169


#JanuAIRWAY

2022

DIFFICULT AIRWAY CONDITIONS | there are LOADS! | The following pages do not form a de nitive list.

Here are some papers / links on some lesser known eponymous syndromes that you might nd interesting: a. Crawley SM, Dalton AJ. Predicting the dif cult airway. British Journal of Anaesthesia Education. 2015; 15: 253-7 b. Phulkar P, Waghalkar P. Anaesthetic Management of a Patient with West Syndrome. Journal of Anaesthesia & Critical Care Case Reports. 2018; 4: 11-13 c. Gurumurthy T, Shailaja S, Kishan S, Stephen M. Management of an anticipated dif cult airway in Hurler's syndrome. Journal of Anaesthesiology Clinical Pharmacology. 2014; 30: 558-61 d. Park SJ, Choi EK, Park S, Bae K, Lee D. Successful dif cult airway management using GlideScope video laryngoscope in a child with Cornelia de Lange Syndrome. Yeungnam University Journal of Medicine. 2018; 35: 219-21 e. Sequera-Ramos L, Duffy KA, Fiadjoe JE, Garcia-Marcinkiewicz AG, Zhang B, Perate A, Kalish JM. The Prevalence of Dif cult Airway in Children With Beckwith-Wiedemann Syndrome: A Retrospective Cohort Study. Anesthesia and Analgesia. 2021;133: 1559-67 f. Venkat Raman V, de Beer D. Perioperative airway complications in infants and children with Crouzon and Pfeiffer syndromes: A single-center experience. Pediatric Anesthesia. 2021; 31: 1316-24 g. Oliveira CRD. Pediatric syndromes with noncraniofacial anomalies impacting the airways. Pediatric Anesthesia. 2020; 30: 304-10 h. Oe Y, Godai K, Masuda M, Kanmura Y. Dif cult airway associated with bi d glottis and coexistent subglottic stenosis in a patient with Pallister-Hall syndrome: a case report. JA Clinical Reports. 2018; 4: 20 i. Chura M, Odo N, Foley E, Bora V. Cervical Deformity and Potential Dif cult Airway Management in Klippel-Feil Syndrome. Anesthesiology. 2018; 128:1007 j. Bangera A, Shetty D. Management of a case of anticipated dif cult airway in a patient with Moebius syndrome. Indian Journal of Anaesthesia. 2020; 64: 985-6

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

170


#JanuAIRWAY

2022

171


#JanuAIRWAY

2022

172


#JanuAIRWAY

2022

173


#JanuAIRWAY

2022

174


#JanuAIRWAY

2022

175


#JanuAIRWAY

2022

176


#JanuAIRWAY

2022

177


#JanuAIRWAY

2022

178


#JanuAIRWAY

2022

179


#JanuAIRWAY

2022

FURTHER READING | note: this may not be an exhaustive list | Miscellaneous 1. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit Project: Major complications of airway management in the United Kingdom. 2011 (online) 2. Cook TM, Kristensen MS. Core Topics in Airway Management. 3rd Edition. Cambridge University Press. Cambridge, United Kingdom. 2020 3. Aston D, Rivers A and Dharmadasa A. Equipment in Anaesthesia and Critical Care. A complete guide for the FRCA. Scion Publishing Limited. United Kingdom. 2014 4. Hagberg C. Benumof and Hagberg’s Airway Management. 3rd Edition. Elsevier Inc. 2013 5. Popat M. Dif cult Airway Management. Oxford University Press. Oxford, United Kingdom. 2009 6. Levine AI, Govindaraj S, DeMaria S. Anesthesiology and Otolaryngology. Springer Science and Business Media. New York. 2013 7. Abdlmalak B, Doyle J. Anesthesia for Otolaryngologic Surgery. Cambridge University Press. Cainmbridge, United Kingdom. 2012

Oxygenation 8. Patel A, Nouraei SA. Transnasal Humidi ed Rapid-Insuf ation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with dif cult airways. Anaesthesia. 2015; 70: 323-9 9. McNamara MJ, Hardman JG. Hypoxaemia during open-airway apnoea: a computational modelling analysis. Anaesthesia. 2005; 60: 741-6 10. Levitan R. NO DESAT! Emergency Physicians Monthly. 2010 (online) 11. Teller LE, Alexander CM, Frumin MJ, Gross JB. Pharyngeal insuf ation of oxygen prevents arterial desaturation during apnea. Anesthesiology. 1988; 69: 980-2 12. Taha SK, Siddik-Sayyid SM, El-Khatib MF, Dagher CM, Hakki MA, Baraka AS. Nasopharyngeal oxygen insuf ation following pre-oxygenation using the four deep breath technique. Anaesthesia. 2006; 61: 427-30 13. Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. Journal of Clinical Anesthesia. 2010; 22:164-8

fi

fl

fl

fi

fi

fl

fi

180


#JanuAIRWAY

2022

Airway Assessment 14. Samsoon GI, Young JR.

Dif cult tracheal intubation: a retrospective study.

Anaesthesia.

1987; 42: 487-90 15. Bellhouse CP, Dore C. Criteria for estimating likelihood of dif culty of endotracheal intubation with the Macintosh laryngoscope. Anaesthesia and Intensive Care Medicine. 1988; 16: 329-37 16. Takenaka I, Aoyama K and Kadoya T. Mandibular Protrusion Test for Prediction of Dif cult Mask Ventilation. Anesthesiology. 2001; 94: 935 17. Frerk C. Predicting dif cult intubation. Anaesthesia. 1991; 46: 1005-8 18. Murphy MF, Wall RM. The dif cult and failed airway. In: Manual of Emergency Airway Management. Chicago, IL. Lippincott Williams and Wilkins; 2000: 31-39 19. Dif cult Airway Management in the Pregnant Patient. Anaesthesia Key. 2016 (online) 20. Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H. Airway physical examination tests for detection of dif cult airway management in apparently normal adult patients. Cochrane Database of Systematic Reviews. 2018 (online) 21. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists' prediction of dif cult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015; 70: 272-81 22. Dif cult Airway Society. How to perform a nasendoscopy - video by DAS members. (online)

fi

fi

fi

fi

fi

fi

fi

fi

fi

181


#JanuAIRWAY

2022

23. Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, Riou B. Prediction of dif cult mask ventilation. Anesthesiology. 2000; 92:1229-36 24. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009; 110: 891-7 25. Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict dif culty at intubation in the emergency department? Emergency Medicine Journal. 2005; 22: 99-102 26. Detsky ME, Jivraj N, Adhikari NK, et al. Will This Patient Be Dif cult to Intubate? The Rational Clinical Examination Systematic Review. JAMA. 2019; 321: 493–503

De ning the Dif cult Airway 27. Huitink JM, Bouwman RA. The myth of the dif cult airway: airway management revisited. Anaesthesia. 2015; 70: 244-9 28. Snowdon DJ and Boone, ME. A Leader’s Framework for Decision Making. Harvard Business Review. 2007 (online) 29. Luft J and Ingram H. The Johari window, a graphic model of interpersonal awareness. 1982 (online) 30. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit Project: Major complications of airway management in the United Kingdom. 2011 (online) 31. Grey AJG, Hoile RW, Ingram GS, Sherry KM. The Report of the National Con dential Enquiry into Perioperative Deaths 1996/1997. 1998 (online) 32. Nørskov AK, Rosenstock CV, Wetterslev J, Astrup G, Afshari A, Lundstrøm LH. Diagnostic accuracy of anaesthesiologists' prediction of dif cult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database. Anaesthesia. 2015; 70: 272-81

Airway Investigations, Lung Function Tests and Airway Ultrasound 33. Crawley SM and Dalton AJ. Predicting the dif cult airway, British Journal of Anaesthesia Education, 2015; 15: 253–7 34. Ahmad I, Millhoff B, John M, Andi K, Oakley R. Virtual endoscopy--a new assessment tool in dif cult airway management. Journal of Clinical Anesthesia. 2015; 27: 508-13 35. Zhou Z, Zhao X, Zhang C, Yao W. Preoperative four-dimensional computed tomography imaging and simulation of a breoptic route for awake intubation in a patient with an epiglottic mass. British Journal of Anaesthesia. 2020;125: e290-2 36. Chambers D, Huang C, Matthews G. Spirometry. In: Basic Physiology for Anaesthetists. Cambridge, UK. Cambridge University Press, 2018: 56-63

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

182


#JanuAIRWAY

2022

37. Chambers D, Huang C, Matthews G. Alveolar Diffusion. In: Basic Physiology for Anaesthetists. Cambridge, UK. Cambridge University Press, 2018: 40-44 38. Modi P, Cascella M. Diffusing Capacity Of The Lungs For Carbon Monoxide. In: StatPearls 2022 (online) 39. Cotes JE, Chinn DJ, Quanjer PhH, Roca J, Yernault JC. Standardization of the measurement of transfer factor (diffusing capacity). European Respiratory Journal 1993 6: 41-52 40. Zhao Y, Hernandez AM, Boone JM, Molloi S. Quanti cation of airway dimensions using a high-resolution CT scanner: A phantom study. Medical Physics. 2021; 48: 5874-83 41. Grenier PA, Beigelman-Aubry C, Fétita C, Prêteux F, Brauner MW, Lenoir S. New frontiers in CT imaging of airway disease. European Radiology. 2002; 12: 1022-44 42. Radiopaedia (online) 43. Kristensen MS. Ultrasound for safe airway management (online) 44. Kristensen MS, Teoh WH, Graumann O, Laursen CB. Ultrasonography for clinical decisionmaking and intervention in airway management: from the mouth to the lungs and pleurae. Insights Imaging. 2014; 5: 253-79 45. Kristensen MS. Ultrasonography in the management of the airway. Acta Anaesthesiologica Scandinaviaica. 2011; 55: 1155-73 46. Kristensen MS, Teoh WH. Ultrasound identi cation of the cricothyroid membrane: the new standard in preparing for front-of-neck airway access. British Journal of Anaesthesia. 2021; 126: 22-27 47. Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identi cation of the cricothyroid membrane: best evidence, techniques, and clinical impact. British Journal of Anaesthesia. 2016; 117: i39-i48 48. Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark identi cation for cannula cricothyroidotomy. Anaesthesia. 2010; 65: 889-94 49. Dinsmore J, Heard AM, Green RJ. The use of ultrasound to guide time-critical cannula tracheotomy when anterior neck airway anatomy is unidenti able. European Journal of Anaesthesiology. 2011; 28: 506-10 50. El-Boghdadly K, Wojcikiewicz T, Perlas A. Perioperative point-of-care gastric ultrasound. British Journal of Anaesthesia Education. 2019; 19: 219-26 51. Identi cation of the cricothyroid membrane with ultrasonography Longitudinal "string of pearls" approach - video (online)

fi

fi

fi

fi

fi

fi

183


#JanuAIRWAY

2022

Airway Planning 52. The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit Project: Major complications of airway management in the United Kingdom. 2011 (online) 53. Huitink JM, Bouwman RA. The myth of the dif cult airway: airway management revisited. Anaesthesia. 2015; 70: 244-9 54. Chew KS, Durning SJ, van Merriënboer JJ. Teaching metacognition in clinical decisionmaking using a novel mnemonic checklist: an exploratory study. Singapore Medical Journal. 2016; 57: 694-700 55. Bromiley M. The Case of Elaine Bromiley (online) 56. Sheriffdom of Glasgow and Strathkelvin. Determination of Sheriff Linda Margaret Ruxton in Fatal Accident Inquiry in the Death of Gordon Ewing. 2010 FAI 15 (online). 57. Chrimes N, Fritz P. The Vortex Approach to airway management (online) 58. Warters RD, Szabo TA, Spinale FG, DeSantis SM, Reves JG. The effect of neuromuscular blockade on mask ventilation. Anaesthesia. 2011; 66:163-7 59. Nouraei SA, Giussani DA, Howard DJ, Sandhu GS, Ferguson C, Patel A. Physiological comparison of spontaneous and positive-pressure ventilation in laryngotracheal stenosis. British Journal of Anaesthesia. 2008; 101: 419-23 60. Bennett JA, Abrams JT, Van Riper DF, Horrow JC. Dif cult or impossible ventilation after sufentanil-induced anesthesia is caused primarily by vocal cord closure. Anesthesiology. 1997; 87: 1070-4 61. Patel A. Approaches to Anaesthetic Management of the Shared Airway. 2019 (online)

fi

fi

fi

184


#JanuAIRWAY

2022

62. Dif cult Airway Society. How to perform a nasendoscopy - video by DAS members. (Online) 63. Consilvio C, Kuschner WG, Lighthall GK. The pharmacology of airway management in critical care. Journal of Intensive Care Medicine. 2012; 27: 298-305 64. Royal Free Anaesthesia. How to topicalise the airway for awake beroptic intubation (AFOI) video (online) 65. Johnston KD, Rai MR. Conscious sedation for awake breoptic intubation: a review of the literature. Canadian Journal of Anesthesia. 2013; 60: 584-99 66. Scarth E, Smith S. Drugs in Anaesthesia and Intensive Care. Fifth Edition. Oxford, UK. Oxford University Press. 2016

Basic Airway Equipment 67. Laurie A, Macdonand J. Equipment for airway management. Anaesthesia and Intensive Care Medicine. 2018; 19: 389-96 68. Bjurström MF, Bodelsson M, Sturesson LW. The Dif cult Airway Trolley: A Narrative Review and Practical Guide. Anesthesiology Research and Practice. 2019 69. Chishti K. Setting up a Dif cult Airway Trolley. 2015 (online) 70. Gibbins M, Kelly FE, Cook TM. Airway management equipment and practice: time to optimise institutional, team, and personal preparedness. British Journal of Anaesthesia. 2020; 125: 221-4 71. Sheriffdom of Glasgow and Strathkelvin. Determination of Sheriff Linda Margaret Ruxton in Fatal Accident Inquiry in the Death of Gordon Ewing. 2010 FAI 15 (online) 72. Physics and modelling of the Airway. 2015 (online) 73. Cook Medical. Frova Intubating Introducer (online)

Airway Laryngoscopy 74. Jackson, C.

The technique of insertion of intratracheal insuf ation tubes.

Surgery,

Gynecology and Obstetrics. 1913; 17: 507-9 75. Magill IW. Endotracheal anesthesia. American Journal of Surgery. 1936; 34: 450-455 76. Bannister F, Macbeth R. Direct laryngoscopy and tracheal intubation. Lancet. 1944; 244: 651-654 77. Chrimes N. Flextension. 2020 (online) 78. Cook TM. Bath Technique. 2021 (online)

fl

fi

fi

fi

fi

fi

185


#JanuAIRWAY

2022

79. Biro, P; Spahn, D R. The dif cult intubation drill at the University Hospital Zürich. Jurnalul Român de Anestezie Terapie Intensivã. 2009 16:147-153. 80. Cook TM. A new practical classi cation of laryngeal view. Anaesthesia. 2000; 55: 274-9 81. Chaggar RS, Shah SN, Berry M, Saini R, Soni S, Vaughan D. The Video Classi cation of Intubation (VCI) score: a new description tool for tracheal intubation using videolaryngoscopy: A pilot study. European Journal of Anaesthesiology. 2021; 38: 324-6 82. Knill RL. Dif cult laryngoscopy made easy with a "BURP". Canadian Journal of Anesthesia. 1993; 40: 279-82 83. Lewis SR, Butler AR, Parker J, Cook TM, Scho eld-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. British Journal of Anaesthesia. 2017; 119: 369-83

Capnography and Oesophageal Intubation 84. Joy P, Kelly FE. Unrecognised Oesophageal Intubation. Anaesthesia News. 2022 (online) 85. Judiciary.UK. In the Milton Keynes Coroner’s Court. Inquest into the death of Glenda May Logsdail, Regulation 28: report to prevent future deaths. 2021. (online) 86. CORONERS COURT OF NEW SOUTH WALES Inquest into the death of Emiliana Obusan. 2021 (online) 87. Cook TM, Harrop-Grif ths W. Capnography prevents avoidable deaths. British Medical Journal. 2019; 364: l439 88. Cook TM. Preventing Undetected Oesophageal Intubation - a twitter thread. 2021 (online) 89. Royal College of Anaesthetists. Prevention of future deaths 2021 (online) 90. Ahmad I, McGuire B, McNarry A, Chakladar A, Richmond L. Unexpected Oesophageal Intubation. DAS Members EZINE. 2022 (online) 91. Jooste R, Roberts F, Mndolo S, Mabedi D, Chikumbanje S, Whitaker DK, O'Sullivan EP. Global Capnography Project (GCAP): implementation of capnography in Malawi - an international anaesthesia quality improvement project. Anaesthesia. 2019; 74: 158-166 92. Pandit JJ, Young P, Davies M. Why does oesophageal intubation still go unrecognised? Lessons for prevention from the coroner's court. Anaesthesia. 2022 Feb; 77: 123-128 93. Twitter Broadcast: Why does oesophageal intubation still go unrecognised? - Anaesthesia (online) 94. Podcast: Why does oesophageal intubation still go unrecognised? - Anaesthesia (online) 95. Collins J, Ní Eochagáin A, O'Sullivan EP. A recurring case of 'no trace, right place' during emergency tracheal intubations in the critical care setting. Anaesthesia. 2021; 76 :1671

fi

fi

fi

fi

fi

fi

186


#JanuAIRWAY

2022

96. Cook, T.M., Kelly, F.E. and Goswami, A. ‘Hats and caps’ capnography training on intensive care. Anaesthesia, 2013; 68: 421 97. Royal College of Anaesthetists. Capnography: No Trace = Wrong Place - video (online) 98. Foy KE, Mew E, Cook TM, Bower J, Knight P, Dean S, Herneman K, Marden B, Kelly FE. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia. 2018; 73:1337-44 99. Kodali BS. Capnography. 12th Edition. 2022 (online) 100.Eipe N, Doherty DR. A review of pediatric capnography. Journal of Clinical Monitoring and Computing. 2010; 24: 261-8

High Flow Nasal Oxygen 101.Patel A, Nouraei SA. Transnasal Humidi ed Rapid-Insuf ation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with dif cult airways. Anaesthesia. 2015; 70: 323-9 102.Hermez LA, Spence CJ, Payton MJ, Nouraei SAR, Patel A, Barnes TH. A physiological study to determine the mechanism of carbon dioxide clearance during apnoea when using transnasal humidi ed rapid insuf ation ventilatory exchange (THRIVE). Anaesthesia. 2019; 74: 441–9 103.Mir F, Patel A, Iqbal R, Cecconi M, Nouraei SAR. A randomised controlled trial comparing transnasal humidi ed rapid insuf ation ventilatory exchange (THRIVE) pre-oxygenation with facemask pre-oxygenation in patients undergoing rapid sequence induction of anaesthesia. Anaesthesia. 2017; 72: 439–43 104.Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal humidi ed rapid-insuf ation ventilatory exchange (THRIVE) in children: a randomized controlled trial. British Journal of Anaesthesia. 2017; 118: 232–8 105.Lodenius å., Piehl J, Östlund A, Ullman J, Jonsson Fagerlund M. Transnasal humidi ed rapid-insuf ation ventilatory exchange (THRIVE) vs. facemask breathing pre-oxygenation for rapid sequence induction in adults: a prospective randomised non-blinded clinical trial. Anaesthesia. 2018; 73: 564–71 106.Patel A, El‐Boghdadly K. Apnoeic oxygenation and ventilation: go with the ow. Anaesthesia. 2020; 75: 1002–5 107.Sud A, Patel A. THRIVE:

ve years on and into the COVID-19 era. British Journal of

Anaesthesia. 2021;126: 768-73 108.Patel A, El-Boghdadly K. Facemask or high- ow nasal oxygenation: time to switch? Anaesthesia. 2022; 77: 7-11 109.Rummens N, Ball DR. Failure to THRIVE. Anaesthesia. 2015. (epub)

fi

fi

fi

fl

fl

fl

fi

fl

fl

fi

fi

fi

fl

fl

187


#JanuAIRWAY

2022

110.Levitan R. NO DESAT! Emergency Physicians Monthly. 2010 (online) 111.Papazian L, Corley A, Hess D, Fraser JF, Frat JP, Guitton C, Jaber S, Maggiore SM, Nava S, Rello J, Ricard JD, Stephan F, Trisolini R, Azoulay E. Use of high- ow nasal cannula oxygenation in ICU adults: a narrative review. Intensive Care Med. 2016; 42:1336-49

Cook Airway Exchange Catheter 112.Sheriffdom of Glasgow and Strathkelvin. Determination of Sheriff Linda Margaret Ruxton in Fatal Accident Inquiry in the Death of Gordon Ewing. 2010 FAI 15 (online) 113.Benumof JL. Airway exchange catheters: simple concept, potentially great danger. Anesthesiology. 1999; 91: 342-4 114.Moyers G, McDougle L. Use of the Cook airway exchange catheter in "bridging" the potentially dif cult extubation: a case report. AANA Journal. 2002; 70: 275-8 115.A dangerous tracheal tube exchange from AOD. 2016 - video (online) 116.Change of Endotracheal tube over tube exchanger. 2019 - video (online) 117.Cook Medical. Cook® Airway Exchange Catheter (online)

Cook Aintree Intubation Catheter 118.Padmanabhan R, McGuire B, Morris A. Fibreoptic guided tracheal intubation through supraglottic airway device (SAD) using aintree intubation catheter. 2011 (online)

fl

fi

188


2022

119.Gruenbaum SE, Gruenbaum BF, Tsaregorodtsev S, Dubilet M, Melamed I, Zlotnik A. Novel use of an exchange catheter to facilitate intubation with an Aintree catheter in a tall patient with a predicted dif cult airway: a case report. Journal of Medical Case Reports. 2012; 13:108 120.Phipps S, Malpas G, Hung O. A technique for securing the Aintree Intubation Catheter™ to a exible bronchoscope. Canadian Journal of Anesthesia. 2018; 65: 329-30 121.Cook Medical. Aintree Intubation Catheter (online)

Awake Tracheal Intubation 122.Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020; 75: 509-28 123.Royal Free Anaesthesia. How to topicalise the airway for awake beroptic intubation (AFOI) video (online) 124.Bailin S. Awake Tracheal Intubation - video (online) 125.Awake Airway Management. Videolaryngoscopic awake tracheal intubation, no sedation video (online) 126.Coleman L, Żakowski M, Gold JA, Ramanathan S. Functional Anatomy of the Airway. Anaesthesia Key. 2017 (online) 127.Shorten GD, Opie NJ, Graziotti P, Morris I, Khangure M. Assessment of upper airway anatomy in awake, sedated and anaesthetised patients using magnetic resonance imaging. Anaesthesia and Intensive Care. 1994; 22: 165-9 128.DAS/RCoA Teaching Material for the Novice Anaesthetist. Anatomy: From Airway Matters MOOC (online) 129.Scarth E, Smith S. Drugs in Anaesthesia and Intensive Care. Fifth Edition. Oxford, UK. Oxford University Press. 2016 130.Johnston KD, Rai MR. Conscious sedation for awake breoptic intubation: a review of the literature. Canadian Journal of Anesthesia. 2013; 60: 584-99

Jet Ventilation 131.Yartsev A. Physiology of gas exchange in high oscillatory ventilation (HFOV). Deranged Physiology. 2015 (online) 132.Dworkin R, Benumof JL, Benumof R, Karagianes TG. The effective tracheal diameter that causes air trapping during jet ventilation. Journal of Cardiothoracic Anesthesia. 1990; 4: 731-6

fi

fi

fi

189

fi

fl

#JanuAIRWAY


#JanuAIRWAY

2022

133.Calder I, Pearce A. Core Topics in Airway Management. Cambridge, UK. Cambridge University Press. 2011 134.Pearson KL, McGuire BE. Anaesthesia for laryngo-tracheal surgery, including tubeless eld techniques. British Journal of Anaesthesia Education. 2017; 17: 242-8 135.Patel C. Chet Patel describes the anaesthetic technique of jet ventilation - video (online) 136.Anaesthesia Galway. Manujet Ventilator - video (online) 137.Sivasambu B, et al. Initiation of a High-Frequency Jet Ventilation Strategy for Catheter Ablation for Atrial Fibrillation: Safety and Outcomes Data. JACC Clinical Electrophysiology. 2018; 4: 1519-25

One Lung Ventilation 138.Lohser J, Ishikawa S. Physiology of the Lateral Decubitus Position, Open Chest and OneLung Ventilation. In: Principles and Practice of Anaesthesia for Thoracic Surgery. 2011 139.Longnecker DE, Brown DL, Newman MF, Zapol WM: Anaesthesiology, 2nd Edition. McGraw Hill 140.Petersson J, Glenny RW. Gas exchange and ventilation-perfusion relationships in the lung. The European Respiratory Journal. 2014; 44: 1023-41 141.Sommer N, Strielkov I, Pak O, Weissmann N. Oxygen sensing and signal transduction in hypoxic pulmonary vasoconstriction. The European Respiratory Journal. 2016; 47: 288-303 142.Sommer N, Dietrich A, Schermuly RT, Ghofrani HA, Gudermann T, Schulz R, Seeger W, Grimminger F, Weissmann N. Regulation of hypoxic pulmonary vasoconstriction: basic mechanisms. The European Respiratory Journal. 2008; 32: 1639-51 143.Ashok V, Francis J. A practical approach to adult one-lung ventilation. British Journal of Anaesthesia Education. 2018; 18: 69-74 144.Bronchoscopy Simulator (online) 145.Gloucestershire Hospitals NHS Foundation Trust. Double Lumen Tube Training video. 2020 video (online) 146.Bronchial Blocker Insertion. 2012 - video (online) 147.Bronchial Blockers: EZ-Blocker. 2016 - video (online) 148.Marasigan BL, Sheinbaum R, Hammer GB, Cohen E. Separation of the Two Lungs. Anaesthesia Key. 2017 (online) 149.Campos JH. An Update on Bronchial Blockers During Lung Separation Techniques in Adults. Anesthesia & Analgesia. 2003; 97: 1266-74

fi

190


#JanuAIRWAY

2022

150.Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care * Illustrative case 7: Assessment and management of massive haemoptysis. Thorax. 2003; 58: 814-9 151.Koppen BM & Stanton BA. Introduction to the respiratory system. In: Berne & Levy Physiology. 7th Edition. Philadelphia, PA. Elsevier. 2018. 434-5 152.Radiopaedia (online)

Tracheostomies and Laryngectomies 153.The Royal College of Anaesthetists and The Dif cult Airway Society. 4th National Audit Project: Major complications of airway management in the United Kingdom. 2011 (online) 154.Grey AJG, Hoile RW, Ingram GS, Sherry KM. The Report of the National Con dential Enquiry into Perioperative Deaths 1996/1997. 1998 (online) 155.McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012; 67: 1025-41 156.National Tracheostomy Safety Project (NTSP) resources (online) 157.Lewith H, Athanassoglou V. Update on management of tracheostomy. British Journal of Anaesthesia Education. 2019; 19: 370-376 158.Paulich S, Kelly FE, Cook TM. 'Neck breather' or 'neck-only breather': terminology in tracheostomy emergencies algorithms. Anaesthesia. 2019; 74: 947

fi

fi

191


#JanuAIRWAY

2022

159.Pracy JP, Brennan L, Cook TM, Hartle AJ, Marks RJ, McGrath BA, Narula A, Patel A. Surgical intervention during a Can't intubate Can't Oxygenate (CICO) Event: Emergency Front-of-neck Airway (FONA)? British Journal of Anaesthesia. 2016; 117: 426-8 160.El-Wajeh Y, Varley I, Raithatha A, Glossop A, Smith A, Mohammed-Ali R. Opening Pandora's box: surgical tracheostomy in mechanically ventilated COVID-19 patients. British Journal of Anaesthesia. 2020; 125: e373-5 161.Blakeley S. A guide to tracheostomies: for the Intensive Care Unit. Portsmouth Hospitals NHS Trust. 2017 (online)

Plan D: eFONA 162.Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall NM, Ahmad I; Dif cult Airway Society intubation guidelines working group. Dif cult Airway Society 2015 guidelines for management of unanticipated dif cult intubation in adults. British Journal of Anaesthesia. 2015; 115: 827-48 163.Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018; 120: 323-52 164.Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Dif cult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75: 785-99 165.Heard A, Dinsmore J, Douglas S, Lacquiere D. Plan D: cannula rst, or scalpel only? British Journal of Anaesthesia. 2016; 117: 533-5 166.Chrimes N, Fritz P. The Vortex Approach to airway management (online) 167.Mercy EMS. QuickTrach. 2014 - video (online) 168.Mann CM, Baker PA, Sainsbury DM, Taylor R. A comparison of cannula insuf ation device performance for emergency front of neck airway. Pediatric Anesthesia. 2021; 31: 482-90 169.Dif cult Airway Society. FONA training videos. 2017 - video (online) 170.ANZCA Airway Management Working Group. Transition from supraglottic to infraglottic rescue in the “can’t intubate can’t oxygenate” (CICO) scenario. Australian and New Zealand College of Anaesthetists. 2014 (online) 171.Elliott DS, Baker PA, Scott MR, Birch CW, Thompson JM. Accuracy of surface landmark identi cation for cannula cricothyroidotomy. Anaesthesia. 2010; 65: 889-94

fi

fi

fl

fi

fi

fi

fi

fi

fi

192


#JanuAIRWAY

2022

172.Dinsmore J, Heard AM, Green RJ. The use of ultrasound to guide time-critical cannula tracheotomy when anterior neck airway anatomy is unidenti able. European Journal of Anaesthesiology. 2011; 28: 506-10 173.Heard AM. DrAMBHeardAirway YouTube Channel (online) 174.Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G; Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based recommendations for management of the dif cult airway: part 1. Dif cult airway management encountered in an unconscious patient. Canadian Journal of Anesthesia. 2021; 68: 1373-404 175.Wexler S, Hall K, Chin RY, Prineas SN. Cannula cricothyroidotomy and rescue oxygenation with the Rapid-O2™ oxygen insuf ation device in the management of a can't intubate/can't oxygenate scenario. Anaesthesia and Intensive Care. 2018; 46: 97-101 176.Melker JS, Gabrielli A. Melker cricothyrotomy kit: an alternative to the surgical technique. The Annals of Otology Rhinology and Laryngology. 2005; 114: 525-8 177.Rees KA, O'Halloran LJ, Wawryk JB, Gotmaker R, Cameron EK, Woonton HDJ. Time to oxygenation for cannula- and scalpel-based techniques for emergency front-of-neck access: a wet lab simulation using an ovine model. Anaesthesia. 2019; 74: 1153-7 178.Ventinova Medical BV. Rosenblatt Ventrain® use ESA 2015. 2017 - video (online)

The Obstructed Airway 179.Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020; 75: 509-28 180.Lynch J. Crawley SM. Management of airway obstruction. British Journal of Anaesthesia Education. 2017; 18: 46-51 181.Bryant H. Batuwitage B. Management of the Obstructed Airway. Anaesthesiology: Tutorial of the Week. 2016 (online) 182.Bruce IA, Rothera MP. Upper airway obstruction in children. Pediatric Anesthesia. 2009; 19(S1): 88-99 183.McAvoy J, Ewing T, Nekhendzy V. The value of preoperative endoscopic airway examination in complex airway management of a patient with supraglottic cancer. Journal of Head & Neck Anesthesia. 2019; 3: e19 184.Nouraei SAR, Girgis M, Shorthouse J, El-Boghdadly K, Ahmad I. A multidisciplinary approach for managing the infraglottic dif cult airway in the setting of the Coronavirus pandemic. Operative Techniques in Otolaryngology Head and Neck Surgery. 2020; 31: 128-37

fi

fi

fi

fi

fl

fi

193


#JanuAIRWAY

2022

185.Scholz A, Srinivas K, Stacey MR, Clyburn P. Subglottic stenosis in pregnancy. British Journal of Anaesthesia. 2008; 100: 385-8 186.Ellis H, Iliff HA, Lahloub FMF, Smith DRK, Rees GJ. Unexpected dif cult tracheal intubation secondary to subglottic stenosis leading to emergency front-of-neck airway. Anaesthesia Reports. 2021; 9: 90-94 187.Phillips JJ, Sansome AJ. Acute infective airway obstruction associated with subglottic stenosis. Anaesthesia. 1990; 45: 34-5 188.Bulbulia BA, Ahmed R. Anaesthesia and subglottic airway obstruction. South African Journal of Anaesthesia and Analgesia. 2011; 17: 182-4 189.Venugopal N, Youssef M, Nortcliffe S. Airway management in a case of critical sub-glottic stenosis: The use of a preformed tracheal tube. The Internet Journal of Anesthesiology. 2007; 15: 190.Kapnadak SG, Kreit JW. Stay in the loop! Annals of the American Thoracic Society. 2013; 10: 166-71 191.Nakajima A, Saraya T, Takata S, Ishii H, Nakazato Y, Takei H, Takizawa H, Goto H. The sawtooth sign as a clinical clue for intrathoracic central airway obstruction. BMC Research Notes. 2012; 5: 388 192.Ahuja S, Cohen B, Hinkelbein J, Diemunsch P, Ruetzler K. Practical anesthetic considerations in patients undergoing tracheobronchial surgeries: a clinical review of current literature. Journal of Thoracic Disease. 2016; 8: 3431-41 193.Slinger P. Management of the patient with a central airway obstruction. Saudi Journal of Anaesthesia. 2011; 5: 241-3

fi

194


#JanuAIRWAY

2022

194.Isono S, Kitamura Y, Asai T, Cook TM. Case scenario: perioperative airway management of a patient with tracheal stenosis. Anesthesiology. 2010; 112: 970-8 195.Nethercott D, Strang T, Krysiak P. Airway stents: anaesthetic implications. British Journal of Anaesthesia Education. 2010; 10: 53-8 196.Iliff HA, El-Boghdadly K, Ahmad I, Davis J, Harris A, Khan S, Lan-Pak-Kee V, O'Connor J, Powell L, Rees G, Tatla TS. Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Dif cult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery. Anaesthesia. 2022; 77: 82-95 197.Austin J, Ali T. Tracheomalacia and bronchomalacia in children: pathophysiology, assessment, treatment and anaesthesia management. Pediatric Anesthesia. 2003; 13: 3-11 198.Findlay JM, Sadler GP, Bridge H, Mihai R. Post-thyroidectomy tracheomalacia: minimal risk despite signi cant tracheal compression. British Journal of Anaesthesia. 2011; 106: 903-6 199.Sajid B, Rekha K. Airway Management in Patients with Tracheal Compression Undergoing Thyroidectomy: A Retrospective Analysis. Anesthesia Essays Researches. 2017; 11: 110-6 200.Chaudhary K, Gupta A, Wadhawan S, Jain D, Bhadoria P. Anesthetic management of superior vena cava syndrome due to anterior mediastinal mass. Journal of Anaesthesiology Clinical Pharmacology. 2012; 28: 242-6 201.Chan YK, Ng KP, Chiu CL, Rajan G, Tan KC, Lim YC. Anesthetic management of a parturient with superior vena cava obstruction for cesarean section. Anesthesiology. 2001; 94: 167-9 202.Kristensen MS, McGuire B. Managing and securing the bleeding upper airway: a narrative review. Canadian Journal of Anesthesia. 2020; 67: 128-140 203.Kim KN, Lee HJ, Choi HI, Kim DW. Airway management in patient with continuous bleeding lesion of the trachea: a case report. Korean Journal of Anesthesiology. 2015; 68: 407-10

The Paediatric Airway 204.Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal humidi ed rapid-insuf ation ventilatory exchange (THRIVE) in children: a randomized controlled trial. British Journal of Anaesthesia. 2017; 118: 232-8 205.Bagshaw O, McCormack J, Brooks P, Marriott D, Baxter A. The safety pro le and effectiveness of propofol-remifentanil mixtures for total intravenous anesthesia in children. Pediatric Anesthesia. 2020; 30: 1331-9 206.The Royal Children’s Hospital Melbourne. Clinical Practice Guidelines (online) 207.Von Ungern-Sternberg BS, Boda K, Chambers NA, Rebmann C, Johnson C, Sly PD, Habre W. Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet. 2010; 376: 773-83

fi

fi

fi

fi

fl

195


#JanuAIRWAY

2022

208.Dif cult Airway Society and Association of Paediatric Anaesthetists. Paediatric Dif cult Airway Guidelines (online) 209.Engelhardt T, Virag K, Veyckemans F, Habre W; APRICOT Group of the European Society of Anaesthesiology Clinical Trial Network. Airway management in paediatric anaesthesia in Europe-insights from APRICOT (Anaesthesia Practice In Children Observational Trial): a prospective multicentre observational study in 261 hospitals in Europe. British Journal of Anaesthesia. 2018; 121: 66-75 210.Jagannathan N, Sohn L, Fiadjoe JE. Paediatric dif cult airway management: what every anaesthetist should know! British Journal of Anaesthesia. 2016; 117: i3-5 211.Walas W, Aleksandrowicz D, Kornacka M, Gaszyński T, Helwich E, Migdał M, Piotrowski A, Siejka G, Szczapa T, Bartkowska-Śniatkowska A, Halaba ZP. The management of unanticipated dif cult airways in children of all age groups in anaesthetic practice - the position paper of an expert panel. Scandinavian Journal of Trauma Resuscitation and Emergency Medicine. 2019; 27: 87 212.King MR, Jagannathan N. Best practice recommendations for dif cult airway management in children-is it time for an update? British Journal of Anaesthesia. 2018; 121: 4-7 213.Sun Y, Lu Y, Huang Y, Jiang H. Pediatric video laryngoscope versus direct laryngoscope: a meta-analysis of randomized controlled trials. Pediatric Anesthesia. 2014; 24: 1056-65 214.Klabusayová E, Klučka J, Kosinová M, Ťoukálková M, Štoudek R, Kratochvíl M, Mareček L, Svoboda M, Jabandžiev P, Urík M, Štourač P. Videolaryngoscopy vs. Direct Laryngoscopy for Elective Airway Management in Paediatric Anaesthesia: A prospective randomised controlled trial. European Journal of Anaesthesiology. 2021; 38: 1187-93

fi

fi

fi

fi

fi

196


#JanuAIRWAY

2022

215.Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX Jr, Litman RS, Kovatsis PG. Airway management complications in children with dif cult tracheal intubation from the Pediatric Dif cult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respiratory Medicine. 2016; 4: 37-48 216.Gupta A, Sharma R, Gupta N. Evolution of videolaryngoscopy in pediatric population. Journal of Anaesthesiology Clinical Pharmacology. 2021; 37: 14-27 217.Jones RM, Jones PL, Gildersleve CD, Hall JE, Harding LJ, Chawathe MS. The Cardiff paediatric laryngoscope blade: a comparison with the Miller size 1 and Macintosh size 2 laryngoscope blades. Anaesthesia. 2004; 59: 1016-9 218.Absalom A, Amutike D, Lal A, White M, Kenny GN: Accuracy of the ‘Paedfusor’ in children undergoing cardiac surgery or catheterization. British Journal of Anaesthesia. 2003; 91: 507– 13. 219.Anderson BJ, Bagshaw O; Practicalities of Total Intravenous Anesthesia and Targetcontrolled Infusion in Children. Anesthesiology. 2019; 131: 164–185. 220.Eleveld DJ, Colin P, Absalom AR, Struys MMRF. Corrigendum to "Pharmacokineticpharmacodynamic model for propofol for broad application in anaesthesia and sedation" [British Journal of Anaesthesia. 2018; 120: 942-59]. British Journal of Anaesthesia. 2018; 121: 519 221.National Institute for Health and Care Excellence. Lidocaine Hydrochloride in: British National Formulary for Children. 2022 (online)

The Obstetric Airway 222.Mushambi MC, Athanassoglou V, Kinsella SM. Anticipated dif cult airway during obstetric general anaesthesia: narrative literature review and management recommendations. Anaesthesia. 2020; 75: 945-61 223.Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, Quinn AC; Obstetric Anaesthetists' Association; Dif cult Airway Society. Obstetric Anaesthetists' Association and Dif cult Airway Society guidelines for the management of dif cult and failed tracheal intubation in obstetrics. Anaesthesia. 2015; 70: 1286-306 224.Bonnet MP, Mercier FJ, Vicaut E, Galand A, Keita H, Baillard C; CAESAR working group. Incidence and risk factors for maternal hypoxaemia during induction of general anaesthesia for non-elective Caesarean section: a prospective multicentre study. British Journal of Anaesthesia. 2020; 125: e81-7 225.Howle R, Onwochei D, Harrison SL, Desai N. Comparison of videolaryngoscopy and direct laryngoscopy for tracheal intubation in obstetrics: a mixed-methods systematic review and meta-analysis. Canadian Journal of Anesthesia. 2021; 68: 546-65

fi

fi

fi

fi

fi

fi

197


#JanuAIRWAY

2022

226.Odor PM, Bampoe S, Moonesinghe SR, Andrade J, Pandit JJ, Lucas DN; Pan-London Perioperative Audit and Research Network (PLAN), for the DREAMY Investigators Group. General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multicentre observational study. Anaesthesia. 2021; 76: 460-71 227.McGuire B, Lucas DN. Planning the obstetric airway. Anaesthesia. 2020; 75: 852-5

The Traumatic Airway 228.Jain U, McCunn M, Smith CE, Pittet JF. Management of the Traumatized Airway. Anesthesiology. 2016; 124: 199-206 229.Brown CVR, Inaba K, Shatz DV, Moore EE, Ciesla D, Sava JA, Alam HB, Brasel K, Vercruysse G, Sperry JL, Rizzo AG, Martin M. Western Trauma Association critical decisions in trauma: airway management in adult trauma patients. Trauma Surgery & Acute Care Open. 2020; 5: e000539 230.Mercer SJ, Jones CP, Bridge M, Clitheroe E, Morton B, Groom P. Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma. British Journal of Anaesthesia. 2016; 117: i49-59 231.National Institute of Health and Care Excellence. Quality Statement 1: Airway Management. In: Trauma Quality Standard [QS166]. 2018 (online) 232.Crewdson K, Lockey D, Voelckel W, Temesvari P, Lossius HM; EHAC Medical Working Group. Best practice advice on pre-hospital emergency anaesthesia & advanced airway management. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2019; 27: 6

198


#JanuAIRWAY

2022

233.Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018; 120: 323-52 234.Wiles MD. Manual in-line stabilisation during tracheal intubation: effective protection or harmful dogma? Anaesthesia. 2021; 76: 850-3 235.Swaminathan A. Penetrating Neck Injuries. REBEL EM blog. 2018 (online) 236.Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ and on behalf of Kent, Surrey & Sussex Air Ambulance Trust. Critical Care. 2015; 19:134

The Neurosurgical Airway 237.Elwishi M, Dinsmore J. Monitoring the brain. British Journal of Anaesthesia Education. 2019; 19: 54-9 238.Perelló-Cerdà L, Fàbregas N, López AM, Rios J, Tercero J, Carrero E, Hurtado P, Hervías A, Gracia I, Caral L, de Riva N, Valero R. ProSeal Laryngeal Mask Airway Attenuates Systemic and Cerebral Hemodynamic Response During Awakening of Neurosurgical Patients: A Randomized Clinical Trial. Journal of Neurosurgical Anesthesiology. 2015; 27: 194-202 239.Lockey DJ, Wilson M. Early airway management of patients with severe head injury: opportunities missed? Anaesthesia. 2020; 75: 7-10 240.McCredie VA, Ferguson ND, Pinto RL, Adhikari NK, Fowler RA, Chapman MG, Burrell A, Baker AJ, Cook DJ, Meade MO, Scales DC; Canadian Critical Care Trials Group. Airway Management Strategies for Brain-injured Patients Meeting Standard Criteria to Consider Extubation. A Prospective Cohort Study. Annals of the American Thoracic Society. 2017; 14: 85-93 241.Langford RA, Leslie K. Awake

breoptic intubation in neurosurgery. Journal of Clinical

Neuroscience. 2009; 16: 366-72 242.Yi P, Li Q, Yang Z, Cao L, Hu X, Gu H. High- ow nasal cannula improves clinical ef cacy of airway management in patients undergoing awake craniotomy. BMC Anesthesiology. 2020; 20: 156

The Bariatric Airway 243.Society for Obesity and Bariatric Anaesthesia. Anaesthesia of the Obese Patient. 2020 (online) 244.Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Wetterslev J. High body mass index is a weak predictor for dif cult and failed tracheal intubation: a cohort study of 91,332

fi

fl

fi

fi

fi

199


#JanuAIRWAY

2022

consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database. Anesthesiology. 2009; 110: 266-74 245.Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation: a review of 50,000 anesthetics. Anesthesiology. 2009; 110: 891-7 246.Association of Anaesthetists and Society for Obesity and Bariatric Anaesthesia. Perioperative management of the obese surgical patient. 2015 (online) 247.Hashim MM, Ismail MA, Esmat AM, Adeel S. Dif cult tracheal intubation in bariatric surgery patients, a myth or reality? British Journal of Anaesthesia. 2016; 116: 557-8 248.Fox WT, Harris S, Kennedy NJ. Prevalence of dif cult intubation in a bariatric population, using the beach chair position. Anaesthesia. 2008; 63: 1339-42 249.Moon TS, Fox PE, Somasundaram A, Minhajuddin A, Gonzales MX, Pak TJ, Ogunnaike B. The in uence of morbid obesity on dif cult intubation and dif cult mask ventilation. Journal of Anesthesia. 2019; 33: 96-102

Extubation and the Cook Staged Extubation Set 250.Dif cult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Dif cult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012; 67: 318-40 251.Batuwitage B, Charters P. Postoperative management of the dif cult airway. British Journal of Anaesthesia Education. 2017; 17: 235-41 252.Parotto M, Cooper RM, Behringer EC. Extubation of the Challenging or Dif cult Airway. Curr ent Anesthesiology Reports. 2020; 10: 334-40 253.Hagberg CA, Artime CA. Extubation of the perioperative patient with a dif cult airway. Colombian Journal of Anesthesiology. 2014; 42: 295-301 254.Cavallone LF, Vannucci A. Review article: Extubation of the dif cult airway and extubation failure. Anesthesia and Analgesia. 2013; 116: 368-83 255.D'Silva DF, McCulloch TJ, Lim JS, Smith SS, Carayannis D. Extubation of patients with COVID-19. British Journal of Anaesthesia. 2020; 125: e192-5 256.Furyk C, Walsh ML, Kaliaperumal I, Bentley S, Hattingh C. Assessment of the reliability of intubation and ease of use of the Cook Staged Extubation Set-an observational study. Anaesthesia and Intensive Care. 2017; 45: 695-9 257.McManus S, Jones L, Anstey C, Senthuran S. An assessment of the tolerability of the Cook staged extubation wire in patients with known or suspected dif cult airways extubated in intensive care. Anaesthesia. 2018; 73: 587-93

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fl

fi

200


#JanuAIRWAY

2022

258.Corso RM, Sorbello M, Mecugni D, Seligardi M, Piraccini E, Agnoletti V, Gamberini E, Maitan S, Petitti T, Cataldo R. Safety and ef cacy of Staged Extubation Set in patients with dif cult airway: a prospective multicenter study. Minerva Anestesiologica. 2020; 86: 827-34 259.Gentek Medical. Staged Extubaiton Set - video (online) 260.Cook Medical. Staged Extubation Set. 2022 (online)

Guidelines 261.Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall NM, Ahmad I; Dif cult Airway Society intubation guidelines working group. Dif cult Airway Society 2015 guidelines for management of unanticipated dif cult intubation in adults. British Journal of Anaesthesia. 2015; 115: 827-48 262.Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018; 120: 323-52 263.Dif cult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Dif cult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012; 67: 318-40 264.Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020; 75: 509-28 265.Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, Quinn AC; Obstetric Anaesthetists' Association; Dif cult Airway Society. Obstetric Anaesthetists' Association and Dif cult Airway Society guidelines for the management of dif cult and failed tracheal intubation in obstetrics. Anaesthesia. 2015; 70: 1286-306 266.Dif cult Airway Society and Association of Paediatric Anaesthetists. Paediatric Dif cult Airway Guidelines (online) 267.Iliff HA, El-Boghdadly K, Ahmad I, Davis J, Harris A, Khan S, Lan-Pak-Kee V, O'Connor J, Powell L, Rees G, Tatla TS. Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Dif cult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery. Anaesthesia. 2022; 77: 82-95 268.McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012; 67: 1025-41

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

201


#JanuAIRWAY

2022

269.Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Dif cult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75: 785-99 270.Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Dif cult Airway. Anesthesiology. 2022; 136: 31-81 271.Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G; Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based recommendations for management of the dif cult airway: part 1. Dif cult airway management encountered in an unconscious patient. Canadian Journal of Anesthesia. 2021; 68: 1373-404 272.Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Kovacs G, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Jones PM; Canadian Airway Focus Group. Canadian Airway Focus Group updated consensus-based recommendations for management of the dif cult airway: part 2. Planning and implementing safe management of the patient with an anticipated dif cult airway. Canadian Journal of Anesthesia. 2021; 68: 1405-1436 273.Australian and New Zealand College of Anaesthesia & Faculty of Pain Medicine. Guideline for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t Oxygenate airway emergency. 2017 (online)

fi

fi

fi

fi

fi

fi

202


#JanuAIRWAY

2022

Dif cult Airway Conditions 274.Phulkar P, Waghalkar P. Anaesthetic Management of a Patient with West Syndrome. Journal of Anaesthesia & Critical Care Case Reports. 2018; 4: 11-13 275.Gurumurthy T, Shailaja S, Kishan S, Stephen M. Management of an anticipated dif cult airway in Hurler's syndrome. Journal of Anaesthesiology Clinical Pharmacology. 2014; 30: 558-61 276.Park SJ, Choi EK, Park S, Bae K, Lee D. Successful dif cult airway management using GlideScope video laryngoscope in a child with Cornelia de Lange Syndrome. Yeungnam University Journal of Medicine. 2018; 35: 219-21 277.Crawley SM, Dalton AJ. Predicting the dif cult airway. British Journal of Anaesthesia Education. 2015; 15: 253-7 278.Herd RS, Sprung J, Weingarten TN. Primary osteolysis syndromes: beware of dif cult airway. Pediatric Anesthesia. 2015; 25: 727-37 279.Sequera-Ramos L, Duffy KA, Fiadjoe JE, Garcia-Marcinkiewicz AG, Zhang B, Perate A, Kalish JM. The Prevalence of Dif cult Airway in Children With Beckwith-Wiedemann Syndrome: A Retrospective Cohort Study. Anesthesia and Analgesia. 2021;133: 1559-67 280.Venkat Raman V, de Beer D. Perioperative airway complications in infants and children with Crouzon and Pfeiffer syndromes: A single-center experience. Pediatric Anesthesia. 2021; 31: 1316-24 281.Oliveira CRD. Pediatric syndromes with noncraniofacial anomalies impacting the airways. Pediatric Anesthesia. 2020; 30: 304-10 282.Oe Y, Godai K, Masuda M, Kanmura Y. Dif cult airway associated with bi d glottis and coexistent subglottic stenosis in a patient with Pallister-Hall syndrome: a case report. JA Clinical Reports. 2018; 4: 20 283.Packiasabapathy S, Chandiran R, Batra RK, Agarwala S. Dif cult airway in Mowat-Wilson syndrome. Journal of Clinical Anesthesia. 2016; 34: 151-3 284.Chura M, Odo N, Foley E, Bora V. Cervical Deformity and Potential Dif cult Airway Management in Klippel-Feil Syndrome. Anesthesiology. 2018; 128:1007 285.Ozkan AS, Akbas S, Yalin MR, Ozdemir E, Koylu Z. Successful dif cult airway management of a child with Cof n-siris syndrome. Clinical Case Reports. 2017; 5: 1312-14 286.Bangera A, Shetty D. Management of a case of anticipated dif cult airway in a patient with Moebius syndrome. Indian Journal of Anaesthesia. 2020; 64: 985-6 287.Taharabaru S, Sato T, Nishiwaki K. Dif cult Airway Management in a Patient With NicolaidesBaraitser Syndrome Who Had a Small Jaw and Limited Mouth Opening. Anesthesia Progress. 2021; 68: 47-9

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

fi

203


#JanuAIRWAY

2022

288.Pérez Fernández-Escandón Á, Hevia Sánchez V, Llorente Pendás S, Molina Montalva F. Dif cult airway management in a patient with Treacher Collins syndrome using two-part surgery. Revista Española de Anestesiología y Reanimación (English Edition). 2019; 66: 230-4 289.Bhat R, Mane RS, Patil MC, Suresh SN. Fiberoptic intubation through laryngeal mask airway for management of dif cult airway in a child with Klippel-Feil syndrome. Saudi Journal of Anaesthesia. 2014; 8: 412-4 290.Khanna P, Ray BR, Govindrajan SR, Sinha R, Chandralekha, Talawar P. Anesthetic management of pediatric patients with Sturge-Weber syndrome: our experience and a review of the literature. Journal of Anesthesia. 2015; 29: 857-61 291.Ghaffar WB, Haq IU, Shahid A, Ismail S. Anaesthetic Challenges in a Paediatric Patient with Escobar Syndrome-Dif cult Airway and Postoperative Pneumothorax. Turkish Journal of Anaesthesiology and Reanimation. 2021; 49: 486-9 292.España Fuente L, Méndez Redondo RE, González González JL. Use of Clarus Video System® in expected dif cult airway in a patient with Rett syndrome. Revista Española de Anestesiología y Reanimación (English Edition). 2017; 64: 50-4 293.Rawat RS. Congenital syndromes affecting heart and airway alike. Annals of Cardiac Anaesthesia. 2017; 20: 393-4 294.Dwivedi D, Bhatnagar V, Tandon U, Jinjil K. Pediatric dif cult intubation in a rare genetic disorder made easy with Airtraq laryngoscope. Anesthesia, Essays and Researches. 2016; 10: 684-5 295.Oliveira CRD. Anaesthesia in patients with unusual genetic diseases. Anaesthesia, Pain & Intensive Care. 2019; 23: 5-8

fi

fi

fi

fi

fi

204


#JanuAIRWAY

2022

#JanuAIRWAY Brought to you by @dastrainees @Vapourologist and #DASeducation

205


Dif cult Airway Society Newsletter

Winter 2019

© Di cult Airway Society 2022

ffi

fi

206