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The Changing Scope of Airway Management Warren S. Sandberg, M.D., Ph.D. Professor & Chair, Anesthesiology
Vanderbilt University School of Medicine
2015 Winter Anesthesia Conference
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• None
Disclosures
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At the conclusion of the activity participants should be able to: 1. Review airway management related morbidity and
mortality over time and relate this to changes in airway management technology and cognitive tools
2. Review controversies in airway management approaches
3. Inventory currently available and emerging cognitive aids related to difficult airway assessment and management
Learning Objectives
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The Changing Scope of Airway Management
Warren S Sandberg, M.D. Ph.D. Chair, Department of Anesthesiology
Vanderbilt University School of Medicine
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Airway Management Related M & M; Relation to Techniques, Technology
and Training
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Good News: We’re Getting Better
• Death, Brain Damage and Nerve injury diminishing over time
Cheney, Anesthesiology 91: 552-6, (1999)
ASA Closed Claims Database
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Airway Events Declining
• Airway events down from 50% to ~1/3 between 1980s to 1990s
Cheney, ASA Newsletter 66(6): 6-8, (2002)
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Profile of Respiratory Events Changing
• Proportion of an absolute reduction is changing
Bailie, ASA Newsletter 75(2): 28-9, (2011)
ASA Closed Claims Database
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Aspiration is… just like we thought
• People throw up at the beginning, off site.
Bailie, ASA Newsletter 75(2): 28-9, (2011)
ASA Closed Claims Database
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• <1975: TTJV described • 1981: LMA developed • 1987: Combitube introduced • 1991: ASA Difficult Airway Algorithm first
described. • 1993: ASA Difficult Airway Algorithm
formally adopted / PUBLISHED • 1996: Inclusion of LMA proposed • 2003: 2nd Iteration of Difficult Airway
Algorithm Claims related to adverse airway events (death, brain
damage) plummet during ‘90s
History of Difficult Airway Management
Anesthesiology 103: 33-9, (2005)
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Changing Practice
• 12 years of data • Changing intubation
strategies • Reduction in fraction
judged ‘difficult’ • Tending towards LMA • Pocket-portable video is
reality
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If it’s easy with video + bougie, what do you record?
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Controversies in Airway Management and Approaches
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• Difficult Airway: • Conventionally trained anesthesiologist
• Difficulty with FM ventilation of upper airway
• Difficulty with tracheal intubation
• Difficulty with both
Definitions
Anesthesiology 98: 1269-77, (2003)
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• Difficult Mask Ventilation: • Not possible to give FM ventilation due to:
• Inadequate seal •Excessive resistance to gas flow
• Signs of inadequate ventilation: •Chest movement absent / inadequate •Breath sounds absent / inadequate / severe
obstruction •Cyanosis •Hypoxia (low / falling SpO2) •Exhaled CO2 absent / inadequate •Spirometric gas flow absent / inadequate
Definitions
Anesthesiology 98: 1269-77, (2003)
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• Difficult laryngoscopy: • Not possible to see vocal cords
• After multiple attempts
• Difficult tracheal intubation: • Requires multiple attempts
• +/- Tracheal pathology
• Failed intubation:
Definitions
Anesthesiology 98: 1269-77, (2003)
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Definition of Degrees of Difficulty
Anesthesiology 75: 1087, (1991)
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• Practice Guidelines: • Systematically developed recommendations
• Assist, not constrain decisions •Reject, modify, adopt according to clinical situation
• Not standards or requirements
• Use does not guarantee outcomes
• Not exhaustive
Definitions
Anesthesiology 98: 1269-77, (2003)
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• 30” Airway exam • Requires
preoxygenation! • LMA as 1st
emergency rescue option
• Confirm intubation (capnography, EDD)
Most Recent:
Anesthesiology 98: 1269-77, (2003)
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Vanderbilt Anesthesiology © Warren Sandberg
Difficult Airway Algorithm:
Assess the likelihood and clinical impact of basic management problems: Difficult Intubation Difficult Ventilation Difficulty with Patient Cooperation or Consent Difficult Tracheostomy
ASA Task Force on Guidelines for Difficult Airway Management, Anesthesiology, 98 , 1269-77, 2003
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Vanderbilt Anesthesiology © Warren Sandberg
VS.
VS.
VS.
Difficult Airway Algorithm:
❖ Awake Intubation
❖ Non-invasive Technique for Initial Approach to Intubation
❖ Preservation of Spontaneous Ventilation
❖ Intubation Attempts After Induction of General Anesthesia
❖ Invasive Technique for Initial Approach to Intubation
❖ Ablation of Spontaneous Ventilation
Anesthesiology, 98 , 1269-77, 2003
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Vanderbilt Anesthesiology © Warren Sandberg
Difficult Airway Algorithm:
Anesthesiology, 98 , 1269-77, 2003
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Vanderbilt Anesthesiology © Warren Sandberg
Recognized
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Vanderbilt Anesthesiology © Warren Sandberg
Recognized Difficult Airway:
Anesthesiology, 98 , 1269-77, 2003
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Vanderbilt Anesthesiology © Warren Sandberg
Awake Options
Shouldn’t be a dog-show
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Vanderbilt Anesthesiology © Warren Sandberg
Recognized
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Vanderbilt Anesthesiology © Warren Sandberg
What People Actually Do
ASA: Recognized Awake Intubation Survey of active ASA members: staff & residents Survey period: Winter 1996 1000 subjects, 472 actually returned survey 14 scenarios presented; anesthesiologists chose
first, best response
Stratified by years in practice Respondents:
81% male 88% Board Certified 88% primarily adult practice
Rosenblatt, et. al. Anes Analg, 87, 153-157
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Vanderbilt Anesthesiology © Warren Sandberg
What People Actually Do Recognized Awake Intubation Choices
Anes Analg, 87, 153-157
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Vanderbilt Anesthesiology © Warren Sandberg
What People Actually Do Recognized Awake Intubation Choices
Anes Analg, 87, 153-157
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Vanderbilt Anesthesiology © Warren Sandberg
What People Actually Do Recognized Awake Intubation Choices
Anes Analg, 87, 153-157
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Vanderbilt Anesthesiology © Warren Sandberg
Refresh: 1999
Roughly 450 anesthesiologists, surveyed at ASA 1999
J. Clin. Anesth. 15, 419-423, 2003
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Vanderbilt Anesthesiology © Warren Sandberg
Unexpected Difficult Airway
1:10000 chance of walking into unexpected “Can’t Ventilate / Can’t Intubate” situation
Anesthesiology, 98 , 1269-77, 2003
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Vanderbilt Anesthesiology © Warren Sandberg
Critical Branch Point
GA test mask.
If mask inadequate EMERGENCY.
Think: GET HELP!
Attempt LMA, readying other options.
Anesthesiology, 98 , 1269-77, 2003
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Vanderbilt Anesthesiology © Warren Sandberg
LMA as Rescue Airway:
Laryngeal mask airway provides an excellent conduit to the larynx.
Reliably relieves supraglottic obstruction.
Effective in abnormal upper airway anatomy
“Works well even when used poorly”
2.6/10k incidence of aspiration (same as for GA) Anesthesiology 84, 686-699, 1996
Int Anes Clin 38 29-45, 2000
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Vanderbilt Anesthesiology © Warren Sandberg
What People Actually Do:
Single, large academic practice
Airway SWAT team LMA 1st rescue choice in
CV/CI scenario Difficult oxygenation:
SpO2<90% Rescue: SpO2>90% 25 episodes in 24k cases
over 2 years (1:1000)
Anes Analg 87 661-65, 1998
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Vanderbilt Anesthesiology © Warren Sandberg
What People Actually Do:
SWAT team called in 13/25 cases LMA succeeded in 16/17 uses; failure due to airway
thrombus after failed TTJV
LMA rescue Other rescue technique
Anes Analg 87 661-65, 1998
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Vanderbilt Anesthesiology © Warren Sandberg
What People Actually Do:
Alternate techniques not so reliably effective as initial intervention
LMA rescue Other rescue technique
Anes Analg 87 661-65, 1998
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Vanderbilt Anesthesiology © Warren Sandberg
What People Actually Do:
LMA 1st rescue choice in CV/CI scenario 17/25 instances
Difficult oxygenation: SpO2<90%
Lowest SpO2 noted before LMA placement
Many laryngoscopies prior to first rescue application of LMA
Anes Analg 87 661-65, 1998
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Anesthesiology, 110 , 891-7, 2009
What People Actually Do:
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Vanderbilt Anesthesiology © Warren Sandberg
Outcomes & Predictors:
Anesthesiology, 110 , 891-7, 2009
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Summary
• We have a useful algorithm (in revision) • Have we hit ceiling with this guideline?
• i.e., can it be improved? • When faced with the critical ‘Can’t mask’ scenario,
most people intubate. • Better tools make that more possible
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This is Not Always the Answer
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• Never elective; establishes emergency airway when there is a supraglottic obstruction and laryngoscopy is impossible.
• Successful in inexpert hands but many potential complications.
+ +
Needle Cricothyrotomy & Transtracheal Jet Ventilation
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• Perc Dilational Cric with a kit:
• Most people plateau at 5 attempts on a mannequin
• People under 45 are better in earlier attempts (difference gone by 4th attempt)
• Everyone can do this in <40 sec with practice.
• Take-home: PRACTICE THIS
Perc Cricothyrotomy Requires Practice
Wong et al, Anesthesiology 98: 349-53
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Airway Management Doesn’t End with Successful Intubation
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PORC - Not Bacon
• Significant residual paralysis (Post-Op Residual Curarization) defined as TOF ratio < 0.9 • TOF Ratio: (Twitch 4/ Twitch 1) • TOF Ratio <0.9 - inadequate secretion handling,
significant airway closure • Expert can’t detect TOF ratio differences once 0.7
has been achieved
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Baseline TOFR = 80
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Impacts PACU Stay
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And Worse...
• NMBA use raises risk of reintubation post-op • Monitoring does not protect • Neostigmine use makes it even worse
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Recommendations
• NMBs facilitate safe intubation • Avoid ‘convenience’ relaxation • Titrate relaxants carefully • Monitor NMB effect - and strongly consider
buying a quantitative monitoring device - with aim to limit dose
• Reverse - but recognize the consequence • Tell the PACU nurse if there is any concern of
PORC - they need this info
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Currently Available and Emerging Cognitive Aids to Improve Airway
Management
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We Don’t Do Too Well Under Pressure:
Henrichs BM. Anesth Analg 2009;108:255-626.
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Henrichs BM. Anesth Analg 2009; 108:255-626.
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Henrichs BM. Anesth Analg 2009; 108:255-626.
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“Not only are the mean scores [in the Henrichs article] ordinary, the individual scores are not bunched-up around the average, which means that some people did very poorly. No matter how artificial the tests might be, this level of mediocre performance is unacceptable for both groups of anesthesia professionals.”
McIntosh CA. Anesth Analg 2009;108:6-9.
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Even for Defibrillation…
• Coding is bad enough; waiting increases mortality
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Help In Your Hand
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Check Lists Help
• When cues are provided performance improves
• Expect more cues...
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Cognitive Aids
• Currently in fashion: Stanford edition
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Cognitive Aids
• www.vortexapproach.com • Mental construct to have in mind each time starting
a case:
Every case starts here:
Very quickly get to EMERG SURG AIRWAY
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Internally Consistent c ASA Diff AW
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Quick, Easy Stuff, Rapid Fire
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• Perc Dilational Cric with a kit:
• Most people plateau at 5 attempts on a mannequin
• People under 45 are better in earlier attempts (difference gone by 4th attempt)
• Everyone can do this in <40 sec with practice.
• Take-home: PRACTICE THIS
Perc Cric Requires Practice
Wong et al, Anesthesiology 98: 349-53
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• Difficult airways are neither as common nor as difficult as they used to be.
• Almost no scenario cannot be overcome as long as you have a plan.
• The plan must include LIMITED but fundamentally DIFFERENT approaches to allow for all possibilities.
• Trick-scopes are not the answer without expertise.
• Cognitive aids now can and should be readily available in the environment - use them
Take Home Messages