JB Brodsky-Core Topics in Anesthesia and Perioperative care 2018 -VL

New Book : Comments about VL combined with Cricoid Pressure

Professor JB Brodsky is a Stanford based Anesthesiologist focused on advanced airway applications to Obesity Surgery and Thoracic Anesthesia with an interesting observation about use of Video laryngoscopy and Rapid Sequence intubation.

Professor Brodsky notes that the controversial item of cricoid pressure application may be a problem with video laryngoscopy application.

Highly Angled Video Laryngoscopy Blades (eg. GlideScope and Mcgrath)

• The physical lifting of the tip of the laryngoscope blade is often not appreciated by the casual user. Those familiar with classic DL blades increase lifting effort when ever they have a problem with the view. Usually backing off the tip of the blade by 1/2 -1 cm is the correct response . increased force of lifting of the tip can produce such angulation of the airway with a peak at the cricoid position that even though the view seems to be excellent there is no way to pass the ETT into the descending trachea. Brodsky points out that pressure on the cricoid actually increases this airway distortion and makes intubation even more difficult.

• Bottom line is that the skilled user must ask the question: what are my efforts doing to deform the airway?  The usual answer is that a very light lift of the tongue with minimal lift of the tip of the blade will allow you to see and easily pass the ETT into the trachea which normally lies just anterior to the esophagus and should remain there.

• The use of the directive stylet is essential to have a high degree of control of the endotracheal tube and this device should be used with a gentle touch under visual control to avoid unnecessary injury to the palate or tonsils.

Direct Viewing Video Laryngoscope Blades ( typical Storz Blade and Glidescope Direct)

• There is less problem with these blades because they do less distortion of the airway.

• The direct blade is just that and it will be unable to handle more challenging airway anatomy because it is fundamentally a direct laryngoscope albeit a more effective one.

• The direct blade is easier to use for new users of video laryngoscopy and is excellent for training and development of airway skills.

Conclusion:

Professor Brodsky's point may be a bit subtle but one must understand this to be a truly skilled video airway expert.


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It is time for "High Flow Nasal Oxygen" to be included in the Difficult Airway Strategy

ADVANCED OXYGEN DELIVERY 2018

Urgent Need to add Hi Delivery Nasal Oxygen to Algorithms

The tool kit available for airway management has evolved rapidly in the last 20 years to include the following :

1. There are algorithms such as the ASA Difficult Airway Algorithm 2013, the DAS  (UK) Algorithm and the Canadian Focus Group Recommendations. 

2. Training including Airway Fellowships have been developed.

3. Equipment has been developed and proven to be effective in situations where Practitioners have been trained to a competent level with the devices prior to emergency events.

4. The Airway Tool Kit includes:

      a. oxygen delivery by preoxygenation, nasal oxygenation, Nasal CPAP (as Per James Tse), 

          and Hi Flow oxygen  such as Thrive.

      b. Oral and nasal airways

      c.  Supraglottic Airways

      d. Tracheal Intubation- Direct Laryngoscopy

      e.  Tracheal Intubation- Video Laryngoscopy

      f.  Tracheal Intubation - Flexible Scope application

      g. Direct Surgical Airway 

      h.  ECMO

N Shallik and A Karmakar  , Doha Qatar , online June 25, 2018

DOI:https://doi.org/10.1016/j.bja.2018.05.052

The above authors have suggested that there is urgency to place the advanced methods of Oxygen Delivery such as Hi Flow Nasal O2 into the Difficult Airway algorithms forthwith.

The world moves at a different pace at this time.

The ASA Algorithm 2013 should be updated immediately to avoid a gap in application of advanced oxygenation methods known to extend the period of acceptable blood oxygen levels by minutes . These nethods include high flow  (Thrive) and also Nasal CPAP oxygen .

The risk of inclusion of these excellent methods as an urgent need is close to zero because there are few side effects and the oxygen provides an extended working and thinking time for care givers.

Glidescope versus McGrath Video Laryngoscope used by Anesthetic Residents- Thailand

Journal of the Medical Association of Thailand

 J Med Assoc Thai 2018 , 101 (6): 803

Comparison of Glidescope and McGrath Video Laryngoscope for Intubation and Adverse Events by Anesthetic Residents

Methods:

A prospective randomized trial was performed with 40 patients betweenthe ages of 18-65 who were ASA Class I-III for elective surgery. Patients were randomly allocated to : Glidescope group or the McGrath group using computer generated numbers applied to a group of first year anesthesia residents with a minimum of 3-6 months experience with Direct Laryngoscopy.

The operator measured and recorded the intubation time , number of attempts, complications and vital signs.

Results:

Intubation time was significantly shorter for the Glidescope when compared to the McGrath laryngoscope ( 26.8 sec. vs 55.1 sec.

  The number of intubation attempts as well as the complications were not significantly different between the 2 groups.

Conclusion:

Intubation time was significantly less with the Glidescope group of patients than the McGrath group.

Comment:

As I am the Glidescope inventor my comments will reflect my greater knowledge of the Glidescope which preceded the other device. The differences between the various video laryngoscopes is ofter minimized but there are marked differences in behavior of the highly angled (60 degree) laryngoscopes and the lesser angled devices and the intelligent user will know these differences and will apply the knowledge when choosing the tool best suited to the anatomy of the patient.

The Glidescope and McGrath devices both belong to the highly angled laryngoscope group and therefore may behave similarly. What accounts for the finding of difference in intubation time in this study?

The Glidescope ergonomics may account for the superior performance seen in this study. The great attention to detail in design may even result in more confidence especially in this group of first time users. There is great science in other fields that develops superior user interface features. Medical devices may not have such attention to detail when engineering is being implemented. The superb ergonomics of the Glidescope is well known.

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The Age of Automated Secretion Clearing

Automated Secretion Clearing

Normal is a Wonderful Thing.

    When we do our learning and get it all right such that we can chant to Next Gen. Medical staff the teachings from the mountain and have them all copy the notes to perfection. Now assign the required degree.......its a comfortable world that allows us to apply the "Normative" solutions until we are jarred into reality by the new teachings that make us change.

    Time has increasingly taught us to expect changes and disrupt our comfortable conventions.

Airway Conventions.

   Intubation and ventilation for those who are not able to sustain life giving O2 CO2 exchange we know is at this time essential lifesaving treatment. The human airway produces 200-500 cc of fluid and protein exudates or transudates every 24 hours and we accept that we must suction these fluids from their position trapped below our endotracheal cuff. We also accept that regular airway suctioning is required when we  sense that this fluid is beginning to block airway.  There is a potential for contamination of the airway with each passage of the suction so we enclose the suction in a sheath to prevent contamination. All of this is laudable but can we do better?

• What if ?  we were able to ventilate efficiently and prevent the Endotracheal tube cuff from trapping all secretions close to the lungs.
• What if ?  every stroke of the ventilator acted like a bilge pump that extracted secretions with the CO2 and Nitrogen.
• What if? The oxygen tension in the trachea was always higher than with standard tubes.
• What if ? The dead space was dramatically reduced and air trapping was unlikely.

The Pacey Secretion Clearing Endotracheal tube.

Please stand by because all of this is and more possible with the new technology Secretion Clearing Endotracheal tube. More detail is inevitable.

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Near Perfection in Airway Management is now Possible #6

Airway Management Academy Founded 2013 - Netherlands

     I speak often about the UK Concept of " designating an Airway Lead" for your hospital. The individual seeking that role must have the drive to go out and get the skills and then bring these back to the institution and convince fellow Doctors that he or she is the person to lead the charge in developing local airway leadership.

    The restless ambition and enthusiasm for teaching Airway Management Excellence is nowhere more clearly exhibited that in the case of Dr. Hans Huitink from the Mobile Anesthesiology Service Holland Foundation . Hans and his co-workers are passionate super stars who have dedicated themselves to excellence in airway management and their association has created a non-profit teaching organization  Airway Management Academy with teaching locations in Amsterdam, the Netherlands, Bern Switzerland , and Doha Qatar. Courses are offered in English, Dutch, and German languages. Experts from many countries contribute to the programs and the offsite courses.

    This is but 1 example of many high level learning opportunities that may form the core learning platform for those aspiring to be " UK style Hospital Airway Leads".  This type of learning assures that one will be mixing and meeting with the best minds available.

    Hans has developed a very dynamic team and has created a CE approved  Airway Triage Ap available for Apple devices via the I store for 3.49 Euros . This Ap provides practitioners with a valuable tool that will keep patients safe in a systematic way that can fit well with a teaching program for your "Airway Leads" to , in one step,  bring airway decision support where it is needed  at the bedside.  The development of electronic medical decision support is now in its infancy but will sweep into clinical care like a tidal wave very soon. 

      No more mindless decisions to cause one to wade in where angels fear to tread. The Ap will not escape the attention of shrewd Legal experts who can and will use it for a devastating law suit results.

   The following Major organizations are now available to build community for the Local Hospital Airway Lead:

• The Society For Airway Management SAM
• The UK Difficult Airway Society DAS
• The European Difficult Airway Society
• The Chinese Difficult Airway Society
• The World Airway Management Meeting WAMM (Amsterdam 2019)

   The new tools and the new training opportunities allow excellence to be learned and taught worldwide. I attended the initial meeting of the Chinese Difficult Airway Society  2010 with , I was told starting Membership of 500.  Very keen and impressive key Chinese Anesthesiologists were eagerly preparing to learn and add to the worlds collective airway expertise. 


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Secretion Clearing During prolonged Ventilation- The next Big Thing!

Overview of Secretion Clearing Strategy

       The accepted method of clearing secretions in ICU or the OR would be for the MD or RN to regularly examine the airway and its output to be alert for opportunities to suction the ETT or airway. This is particularly important when secretions become more prolific in volume or more tenacious in quality such as cases of pulmonary failure associated with pneumonia or CHF.   While this activity is indispensible it is expensive and highly variable because the activity is dependent on staffing levels, lunch breaks, nursing skill and other factors. Variability is the enemy of quality because on any spectrum there is a range of excellent to inferior quality. 

      Therefore to have a system that is designed to remove secretions on a regular basis whenever they become apparent is likely to keep the systems cleaner and promote more rapid return to normal. The following patent provides for such a cleaning process to be installed into an ETT or LMA type of conduit and allow for irrigation of the airway to hasten mobilization of secretions. There is also less dead space in the system which aids ventilation.

Hopefully this Secretion clearing technology will be world changing.

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Near Perfection in Airway Management is now Possible #5

Fullfillment of the Andy Ovassapian Dream

The Society For Airway Management in 1995 was perhaps the crowning achievement of Andy Ovassapian in his quest for excellence in teaching and practise of Airway Management. 

Quote, Wood Library-Museum of Anesthesiology.

"In the 1970s, Dr. Ovassapian began using an endoscope to insert endotracheal tubes in patients where conventional techniques were difficult. By the early 1980s, he and his colleagues had established the first formal fiberoptic airway management teaching program for residents. In 1984, they also developed a workshop for practicing anesthesiologists. Dr. Ovassapian filed to patent the design for his intubating airway in 1988. In 1995, he founded the Society for Airway Management. Airway management refers to a broad number of techniques aimed at keeping an open pathway for air to move in and out of a patient's lungs."       .

Flexible Airway Endoscopy

      Andy was a rising force when the first flexible endoscopes were introduced to the medical world in the 1980s. He focussed early on this new equipment and continued teaching Flexible technique throughout his medical career. There was no doubt that Andy was the "Go to person" for evil airways . He applied the flexible scope technology in many original ways. When I first went to Chicago in 2002 to attend the Chicago Airway course ,Andy dropped by the Glidescope table and offered some fatherly advice to the upstart video laryngoscopy team from Saturn Biomedical. "Teach, teach , teach is the only way you are going to sell anything really new. Follow the example of Cook and LMA in the workshop world." 

       

     Teaching of the FOB and FOL were always a mystery to me, a Vascular and General Surgeon GI Endoscopist, who was often self taught as an endoscopist. The Anesthesia and ICU physicians appeared to stand back often when flexible endoscopy was required. The teaching 

studies demonstrated that while skills could be taught and retained by some the rate of loss of skills was very high as a rule. I thought at the time that this must have been a lifelong frustration for Andy who was a Wizard with the FOB and FOL. I then asked myself why so few practitioners were true experts in flexible endoscope use.  I concluded that opportunities for use were not great so students would need to exploit opportunities on a regular basis to build the skill and judgement so that it would be present when it was needed. Good equipment is required but it is expensive and takes a special dedication to overcome budget resistance. The equipment is not robust and many costly breakages occur. This all conspires against the general need for skill development.

Industry has played a great role in alleviating this problem by providing equipment for workshops for ED, Thoracic Anesthesia, and Flexible endoscopy workshops. The problem of flexible endoscopic skill development remains an unsolved one.

The establishment of an "Airway Lead" and an "Airway Rotation"are measures currently recommended as first steps.

Near Perfection in Airway Management is now Possible #4

Nasal Oxygen Delivery- Profound Discovery.

The world is slowly awakening to the importance of the Nasal Ventilation and Oxygenation and its many merits. Like all great changes recognition begins and spreads from the early adopters, to the early majority and then becomes fully incorporated in Airway Culture. To the impatient observer this is painfully slow as all changes prove to be. To be featured on the ASA Algorithm , wide recognition must be achieved.  

The superiority of Nasal Route of ventilation has been recognized and promoted by basic scientists who have surely documented the advantage of positive pressure delivered via nasal route. The mechanics are such that the pressure from an oral mask which normally presses the tongue backward to occlude the pharynx becomes a force that pushes the tongue forward and greatly improves the passage way for Oxygen and air.

Flush Nasal Oxygen with Nasal Prongs

The routine use of nasal prongs in the pre-induction state is a widely appreciated method of delivering oxygen. The use of high flows , 15L/min or more, can provide some apneic ventilation at times but must be monitored for effectiveness as the results are variable without CPAP. This strategy has been promoted for an extended period by Scott Weingart and Dr. Richard Levitan and reviewed in their excellent paper.
Preoxygenation and prevention of desaturation during emergency airway management.

Ann Emerg Med. 2012 Mar;59(3):165-75.e1. doi: 10.1016/j.annemergmed.2011.10.002. Epub 2011 Nov 3.

Modified Pediatric Nasal Mask

James Tse- Legendary work demonstrating Rescue with Nasal Tse PAP (Use of a modified Pediatric facemask) allows positive pressure ventilation via nasal route, intubation with GlideScope (highly angled feature is important) , without removal of the nasal mask. Thus a high oxygen environment and flexibility is maintained while the enhanced nasal route pressure CPAP tends to keep the tongue and pharynx open. Dr. Tse has presented multiple times at ASA and SAM winning the anesthesia safety foundation award. This strategy is very economical with oxygen use.

Thrive- A Great Australian Contribution

The Thrive device is extraordinary as it is used to deliver up to 70 L of humidified oxygen flow during extended periods of apnea lasting over 30 minutes at times. This allows Dr. Patel to work for an extended time on his specialty Tracheal stenosis cases. The Thrive device uses a large amount of oxygen in use , and  therefore is not suited to austere environments. The lifesaving potential of this equipment during airway emergencies cannot be overstated. It is imperative that emergence airway managers be aware of the huge advantage of this equipment. The ED and ICU Airway Lead should make the equipment fully available for severe problems but it is not suited to routine airway management when high flow nasal prongs or Nasal CPAP could do the job much more economically.

Anaesthesia 2015, 70, 323–329 Patel and Nouraei | THRIVE oxygenation in difficult intubation.


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Near Perfection in Airway Management is now possible #3

The Age Of Simulation is Here.

The Airway Lead Concept
The UK Airway lead concept is a useful one to begin to establish an orderly development of airway capability within an institution or group of hospitals. The Airway lead will be dedicated to recommending appropriate equipment , setting up an Airway Rotation for Anesthesiologists, establishing appropriate expectations for staff and residents, and establishing a reporting system that reflects good and bad outcomes within the realm. 

The Airway Rotation

    Experience with DL, VL, FOB, SGA(at least 1 selected), Simulation plan, and decision support with ASA style Algorithm. Attachment with designated enthusiasts for airway excellence training would be appropriate. Success of the program must be measured by institutional performance measurement.  ICU and ED also must be incorporated in this effort because in these areas much valuable airway work is necessary.

High Fidelity Simulators

   Extending Airway competence training to sister departments is a duty of the Anesthesia home of airway excellence. This can be done by establishing ED and ICU members of the Airway teaching group. Funding must be part of the solution because cost effective equipment must be available for self teaching and backed up by useful online airway curriculum that could be made universally available in the Hospital group catchment area. The airway community can thus be enlarged 

Simple Manikins

        Specific Device Performance teaching

Teaching New airway managers the fundamentals of use of complex airway tools like FOB or Video Laryngoscopy is increasingly being done with simulators in a calm teaching lab. This allows the understanding of the tool and how it performs prior to the clinical phase which then integrates the tool with patient variability. The tools have their own personality and there is occasional use by those who rather rely on their own bravado and skill rather that taking the time to find instruction. The tool may then be used in an advanced DAW situation and provide suboptimal performance-the tool gets the blame.

        Preconceived strategies

Teaching pre-conceived clinical drills can add quickly to airway skill.

       a. Tomahawk Procedure

The intubation of patients in a sitting position facing the intubator is an advanced skill that may be useful in ICU , ED, or EMS. This skill relies on inversion of the screen to get left and right corrected so that the procedure can be carried out easily.

        b.Endotracheal Tube exchanges
This is a common procedure carried out in ICU to replace a double lumen tube or adjust the ETT size. Training makes the task much safer using a tube exchange catheter and a video Laryngoscope to guide the procedure and avoid tube advancement problems.

This common act using an endotracheal tube exchanger is usually done in high risk ICU patients. The skills are specific and include getting assistance prior to the event. Planning extubation is closely related in risk and uses similar skills.

        c. Intubation during simulated ongoing CPR.
This skill greatly enhances airway management during external compression. It is possible to train intubators to do Video Glidescope intubation without stopping CPR. It is proven that stopping CPR is undesireable.

Salad Simulators

 The SALAD -Suction Assisted Laryngoscopic (video) Airway Decontamination - simulator is experiencing increasing popularity as a training aid to teach caregivers to handle massive airway contamination. This picture shows a trainee handling a massive airway contamination event . There are some interesting strategies emerging such as placement of the continuous suction device to the left side of the pharynx during attempts at intubation to suction out the cavity.

High Fidelity Full body Computerized Manikins

These highly computerized devices are used in larger fixed asset simulation ORs where team resource management is taught to train crisis organization for ED and ICU teams . This kind of training has been perfected in the aviation industry where cockpit resource management refines team performance.

Near Perfection in Airway Management is now possible #2

Steps Required to Soar with Eagles

• The Important decision to strive for excellence.

No great achievement is ever accomplished by accident. One must consciously decide to strive for excellence and greatness. When you make public your institutional goal to be among the best it is necessary to make a plan and begin to act on it. Get the data on your current state and find a way to measure accurately where you are. Do you talk about your nasty little secrets? - do you encourage the nursing and Airway specialists in your ERs and ICUs to report suboptimal results for the greater good?

• The Airway Lead concept.

UK leads the way in invoking a structure that encourages performance. Volunteer or work to appoint an Airway lead in your institution.

1.     Every Unit and Hospital has individuals who have developed extra skill and understanding about Airway Management. Celebrate these local resources and encourage them to teach and form the team needed for excellence. "The Lone Ranger" is a great person but this person may not be there when you want / need him or her.
2.     UK has a "National Airway Lead" to assist making this a reality for your institution or unit. The celebrated NAP4 ( 4th National Audit Project) had as a key recommendation that a local hospital "Airway Lead" should coordinate training and equipment to support the Airway managers team so that :

         Simulation equipment is readily available and training is carried out.

         Tools needed for modern airway management are ready for use , conveniently stored and charged . This would include Flexible scopes, video laryngoscopes like the Glidescope , SGAs, Bougies, Nasal Ventilation Masks, as well as traditional gear. An airway resource cart .

         Data is collected on disasters and highly skilled work as well.

• The Airway Toolkit
• "You know that you are excellent when you measure it."

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Near Perfection in Airway Management is now possible #1

This series of posts is directed at proving the notion that Perfection in Airway Management is now possible and that achievement of this goal is now dependent on achieving a "Cultural Shift" that has at times been called " Team resource management" ,

The Question for all is how do we teach providers to have skill and decision making knowledge with the wonderful tools now available.

1. Definitions:   Skill:  the ability to use a given device so that 75% of its full value can be applied to the appropriate patient.
                          Tool: a proven device of accepted value.
                          Decision : The possession of sufficient knowledge of the tool Kit to apply the most                                    appropriate tool from those available.
                                Bringing in team members as required before the "crisis"
                                Bringing in the equipment so that it is available for teaching and application- its                                   necessary to buy the fire truck before the fire and have it on the spot.
                                Having a teaching learning culture for the team.

2. The Tool Box:  This will change but these are all available and should be part of the skillset.
                          1. Airways and Oxygen
                          2. The Direct Laryngoscope
                          3. The Supraglottic airway - Get good with 1 good SGA
                          4. The Video Laryngoscope- Get good with 1 great video Laryngoscope like the                                                Glidescope.
                          5.  The Flexible Laryngoscope/bronchoscope- an essential tool and skill that needs                                             regular  practice.                                       
                          6. Surgical Airway skill- usually life saving airway is only 6mm away from the skin.
                          7. Know where the nearest ECMO provider can be found.

3. The Airway Culture Team Manager
      Who will establish and be responsible for the development of "excellence in culture".

           The British Airway Lead Concept must be adopted as the finest idea, in my view.