Telemedicine Strategies Advancing

The world is leading toward more and more connectedness and the potential to extend the footprint of very knowledgeable people is great as tele systems gather strength. The use of commercially available I Phones and FaceTime for Medical consultation was first reported for Airway Management by Dr John Sakles and Dr Jarrod Mosier from the University of Arizona . (Telebation : Next-Generation telemedicine in remote airway management using current wireless technologies. Telemed J E health 2013,Feb 19,(2): 95-8.)

This new study from Japan extends this theme

A pilot study of tele-anaesthesia by virtual private network between an island hospital and a mainland hospital in Japan

1. Tetsuya Miyashita, Yusuke Mizuno,Yo Sugawara, Yusuka Nagamine, Yukihide Koyama
2. Tomoyuki Miyazaki, Kazuhiro Uchimoto, Yasuhiro Iketani, Kentaro Tojo, Takahisa Goto.

1. Department of Anesthesiology, Yokohama City University Hospital, Japan

1. Dr Tetsuya Miyashita, Department of Anesthesiology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama City, Kanagawa 236-0004, Japan. Email: yushukyo@gmail.com

We studied the use of tele-anaesthesia between Sado General Hospital (SGH) located on Sado Island and Yokohama City University Hospital (YCUH) located in mainland Japan. The two sites were connected via a virtual private network (VPN). We investigated the relationship between the bandwidth of the VPN and both the frame rate and the delay time of the tele-anaesthesia monitoring system. The tool used for communication between the two hospitals was free videoconferencing software (FaceTime), which can be used over Wi-Fi connections. We also investigated the accuracy of the commands given during teleanaesthesia: any commands from the anaesthetist at the YCUH that were not carried out for any reason, were recorded in the anaesthetic records at the SGH. The original frame rate and data rate at the SGH were 5 fps and approximately 18 Mbit/s, respectively. The frame rate at the transmission speeds of 1, 5 and 20 Mbit/s was 0.6, 1.6 and 5.0 fps, respectively. The corresponding delay time was 12.2, 4.9 and 0.7 s. Twenty-five adult patients were enrolled in the study and tele-anaesthesia was performed. The total duration of anaesthesia was 37 hours. All 888 anaesthetic commands were completed. There were 7 FaceTime disconnections, which lasted for 10 min altogether. Because no commands needed to be given during the FaceTime disconnection, the telephone was not used. The anaesthesia assistance system might form part of the solution to medical resource shortages.

• Accepted September 26, 2014.

GlideScope use in ICU Teaching Environment produces Superior results.

There is an interesting development in the use of video laryngoscopy in ICU settings that is associated with modern trends in training:

1. When Anesthesiologists administer care in adult ICU the incidence of difficult airways is 22% so that one could argue that intubation attempts should begin with the most effective available device which I suggest is a Video laryngoscope. Florian Heuer  2012 :40 Anesthesia Intensive Care .

2. When the ICU trainees and Fellows come from a Medical background where intubation skills are dramatically less developed than anesthesiologists , then it is not possible to obtain DL skills quickly enough to have an experience of 100 cases that could bring the rates of success to 90%. Thus the trainees would almost always be operating at an unacceptable level. It is however to have VL skills after many fewer cases , perhaps 10 , and then function better. The paper by Silverberg suggests that VL is much more effective in an ICU for obtaining higher success levels.

Comparison of Video Laryngoscopy Versus Direct Laryngoscopy During Urgent Endotracheal Intubation: A Randomized Controlled Trial.

Silverberg, Michael J. MD; Li, Nan MD; Acquah, Samuel O. MD; Kory, Pierre D. MD, MPA 

Objectives: In the critically ill undergoing urgent endotracheal intubation by direct laryngoscopy, multiple attempts are often required with a higher complication rate due to the urgency, uncontrolled setting, comorbidities, and variability in expertise of operators. We hypothesized that Glidescope video laryngoscopy would be superior to direct laryngoscopy during urgent endotracheal intubation.

Design: Single-center prospective randomized controlled trial.

Setting: Beth Israel Medical Center, an 856-bed urban teaching hospital with a 16-bed closed medical ICU.

Patients: Of 153 consecutive patients undergoing urgent endotracheal intubation by pulmonary and critical care medicine fellows, 117 met inclusion criteria.

Interventions: Patients undergoing urgent endotracheal intubation were randomized to Glidescope video laryngoscopy or direct laryngoscopy as the primary intubation device.

Measurements and Main Results: The primary outcome measure was the rate of first-attempt success. Acute Physiology and Chronic Health Evaluation II scores were similar between groups (20.9 +/- 8.2 vs 19.9 +/- 7.9). First-attempt success was achieved in 74% of the Glidescope video laryngoscopy group compared with 40% in the direct laryngoscopy group (p < 0.001). All unsuccessful direct laryngoscopy patients were successfully intubated with Glidescope video laryngoscopy, 82% on the first attempt. There was no significant difference in rates of complications between direct laryngoscopy and Glidescope video laryngoscopy: esophageal intubations (7% vs 0%; p = 0.05), aspiration events (7% vs 9%; p = 0.69), desaturation (8% vs 4%; p = 0.27), and hypotension (13% vs 11%; p = 0.64).

Conclusions: Glidescope video laryngoscopy improves the first-attempt success rate during urgent endotracheal intubation performed by pulmonary and critical care medicine fellows when compared with direct laryngoscopy. 

The Airway Algorithm Game

                                      Entering the Airway Vortex
   The SAM 2014 Meeting produced a variety of timely advances in Airway thinking and procedures.
The interesting debate and Competition centering around the ASA  algorithm , the Canadian Airway study group algorithm and the Australian Vortex algorithm was resolved by audience vote in favor of the Vortex.

  The 2013 ASA algorithm notably spelled out a prominent role for video laryngoscopy which reflects common practice trends and thinking in the USA.

  The Canadian study group focussed on defining the differences between the parturient and the standard difficult airway and simplified the thought processes getting one to the surgical options.

  The Vortex concept was appreciated because it gives one a powerful graphic concept of being in a whirlpool with 3 modes to try 1. Bag Valve Mask 2. Laryngeal intubation by the best means available  3. Supraglottic airway rescue...... and should all of these be quickly applied and fail then the surgical option is required.

   The proliferation of airway algorithms seems to suggest that each region has a completely unique body of challenges related to the airway. The customization of airway thought I suppose means that each hospital region has different knowledge base, different equipment, and a non homogeneous group of providers. Standardization is needed now to focus this field, to reduce confusion and increase communication, but there are no forces available to make this happen so we will just put up with the current state of affairs.

  The Vortex appeal is the graphic nature of the presentation and one could argue that in crisis mode the simplest notions are more likely to be remembered and acted upon. The popularity of this new offering may be a sign of consensus developing.

Dissecting the ASA Difficult Airway Algorithm Part 2

This reference examines in detail , the options available for patient oxygenation , and deserves evaluation by airway students.

Dissecting the ASA Difficult Airway Algorithm -Part 2

     The Algorithm contemplates that the Questions in section 1 will have been addressed in such a way that the knowledge of the physiology , anatomy, and other conditions for executing the mission of "gaining control of the airway" will be supplemented as required to prepare for the crucial decisions of the 3rd step of decision.

     While the team prepares the patient , personnel  and equipment  section 2 prompts for oxygen delivery.
NB : The importance and potential of this step is often under appreciated , particularly now , when advanced airway devices like GlideScope make it much more likely that airway control will be expeditious.

ASA Algorithm second section:

2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management. 

     This oxygenation step provides the team with a most interesting and complex array of choices for the provision of "Pre-oxygenation". Great creativity can be used at this juncture to provide an "Oxygen soak" for the patient that adds oxygen to the tissues and fluids of the body that will extend the time available for challenging airway management should problems develop. There now exists a vast array of permutations and combinations of equipment and strategies to choose from . The possible approaches :  ( in all cases time is essential to provide the tissue soak)

• A Standard 4 minutes of face mask oxygen administration prior to intubation has been studied by Mort in critically ill patients and produced modest improvement. 1
• Apneic oxygenation via Nasal cannula  or nasal tube oxygenation can be useful and can be administered at moderate flow rates. The nasal cannula deep in the pharynx can prolong the effects of enhanced oxygen while the manipulations of tubes and SGAs are carried out. This is not without risk as the development of surgical emphysema can occur when mucosal injury is present and then , rarely , when mucosal injury cannot be found.
• CPAP or BIPAP may provide added pressure to improve the alveolar recruitment and add continuous pressure as well. 
• Rebreathing hoods combined with oxygen delivery to create a very high para oral/ para nasal oxygen concentration.
• Sedation and local anesthesia can allow SGAs such as the I-gel to be placed as an early oxygenation step and thus provide added safety while anesthesia is deepened. The SGA is an excellent bridge to intubation and can allow an FOB , GlideScope or optical stylet to visualize the anterior aspect of the lower pharynx ....  and while this is known and practiced there is considerable finesse required to get the local anesthesia of the Upper airway and the very light sedation optimized. SGA use with the awake patient would be considered to be a highly skilled manoeuvre at this time .    
• oxygen delivery via the airway exchange catheter  may provide an opportunity in certain situations .         
• The proliferation of airway tools makes possible many combined strategies which require full and complete specific equipment training to allow expert performance . Supplemental and apneic oxygenation can reach the level of a " high art"  with such skill.                                                                                                                                                                   1   
  Crit Care Med. 2005 Nov;33(11):2672-5.                                                                                                                                    
                                                                             

Dissecting The ASA Difficult Airway Algorithm-Part 1

     The 2013 version of the ASA Difficult Airway Algorithm was the second major upgrade that was carried out to recognize changes in accepted practice and available technology.

     Dr Archie Brain went through a series of prototypes of LMA to achieve transition of the mask from the mouth and nose area in the Pharynx close to the Laryngeal opening.
The recognition of the utility of the LMA device in rescue of patients who were either difficult laryngoscopy, difficult intubation, or cannot intubate -cannot ventilate , was an important event that allowed practitioners to transition to a totally different technique from multiple direct laryngoscopy attempts . Thus the 2003 Algorithm identified the use of the LMA at several stages including first use and rescue .

     The 2013 Algorithm changes Identified Video Laryngoscopy as a new and accepted asset in first use as well as rescue. The advent of the highly Angled 60 degree GlideScope, invented by Dr John Pacey , resulted in  widespread use of a video camera enabled laryngoscope that transferred the view point from the oral opening to a position in the pharynx looking at the larynx. The geometry of this device was uniquely effective. Now the Algorithm speaks of considering Video Laryngoscopy as a first choice , as a rescue device, and in conjunction with extubation strategies. 

            
                                                    ASA DIFFICULT AIRWAY ALGORITHM- 2013 MODIFICATION 
                                                                            Introductory Considerations

    1. Assess the likelihood and clinical impact of basic management problems: 
• Difficulty with patient cooperation or consent

• Difficult mask ventilation
• Difficult supraglottic airway placement
• Difficult laryngoscopy
• Difficult intubation
• Difficult surgical airway access

2. Actively pursue opportunities to deliver supplemental oxygen throughout the process of difficult airway management.

3. Consider the relative merits and feasibility of basic management choices:
• Awake intubation vs. intubation after induction of general anesthesia
• Non-invasive technique vs. invasive techniques for the initial approach to intubation • Video-assisted laryngoscopy as an initial approach to intubation
• Preservation vs. ablation of spontaneous ventilation 

4. Develop primary and alternative strategies:

                                                                         Dr Pacey's Comment

                                         Firstly  begin by considering the Items in Checklist 1.

• Difficulty with Patient cooperation or consent clearly complicates any evaluation , premedication, pre oxygenation, intubation (may reduce options for example for Flexible awake strategies).             Evaluate?
• Mask Ventilation difficulty is a combination of caregiver skill set , patient features like beards , facial architecture , and other equipment issues .                                                                                    Evaluate?
• This is a new concept "Difficult SGA placement" can be due to mouth size ,neck fixation, radiation , prior surgery and can result in failure to protect the airway or ventilate.                                                 Evaluate?
• Difficult Laryngoscopy with ?DL, ?VL, Radiation could for example cause this. The term is importantly separated out from difficult intubation because they are separate problems to be considered .    Evaluate?
• Difficult Intubation can occur for example with DL or VL if the operator is an infrequent or poorly trained and experienced incubator or if , for example, there is a physical mass in or around the larynx    Evaluate?
• Difficult Surgical Airway access may be caused by many factors , obesity, burns, lack of training , to mention a few . Will you want to call surgical help in advance or place a guide wire in the neck? Evaluate?

Should a checklist be printed  and used as a guide? perhaps but the main point is to separate out these issues and be sure to consider them in the plan. A written checklist may have the effect of bringing up the performance of the less experienced and in this way affecting the quality of care given.

In the next post we will work our way down the ASA Algorithm into items 2,3,4.

Ron Walls Airway World and Emergency Medicine Airway Updates

Airway Site  and Airway World
Those who are keen to follow updates in Airway Science would do well to be cognizant of the work of Harvard Professor Ron Walls , Chairman of Emergency Medicine  at Women's and Brigham Hospital , Boston. Ron is w recognized leader in the evolution of airway science and was an early and strong advocate of the benefits of the 60 degree angled GlideScope Video laryngoscope as early as 2002.
The remarkable changes seen in airway management have been taught to hundreds of Anesthesiologists, ICU , and Emergency Medicine  USA. Ron has a history of academic rigour that is applied to all of his teachings and the latest manifestation of this is the Airway World Academic teaching platform that is affiliated with the  STRATUS SIMULATION CENTER , one of the oldest and seminal teaching Simulation centres in the world.
To sample the Airway World one can log on and learn as you go. One can be assured of the quality and rigour of the Science in my experience.

Quarterly Airway Management Research Update

Featuring Ron M. Walls, MD Professor & Chair, Department of Emergency Medicine Brigham & Women's Hospital, Harvard Medical School with Cheryl Lynn Horton, MD and Ali S. Raja, MD

                      GlideScope Superiority  for  patients with Neck abscesses of Dental Origin  and  reduced Mouth opening.

      The treatment of Neck infections , Epiglotitis, and Abscesses present a daunting challenge for the Anesthesiologist who must manage the toxic physiology at the same time as plan a method of Pain relief and anesthetic management. Relief of gross abcesses prior to anesthesia is always beneficial and can take the risk level down to some extent. Unfortunately drainage is usually not possible into the lumen  but can sometimes be accomplished via needle aspiration combined with imaging or external drainage. Extensive swelling and cellulitis cannot be managed this way. High doses of appropriate broad spectrum antibiotics are essential at first encounter.

     The Glidescope has been used effectively  for Epiglotittis. The risk of this entity is that pus will discharge unexpectedly or that in some other way control will be lost so management must be individualzed to control risk.

     Infections of Odontogenic origin associated with reduced mouth opening or trismus  present great risk for anesthesia and following observation that the 60 degree angle Glidescope Video laryngoscope was successful when used for failed Direct Laryngoscopy Schumann et. al. decided to test this phenomenon with a randomized study comparing patients whose care was started with DL versus those whose care was started with GlideScope 60 degree VL. 

    The results prove that in these high risk patients Glidescope intubation was clearly superior as reported here.

"Results. Intubation with the Glidescope was always successful, while conventional intubation failed in 17 out of 50 patients (P,0.0001). In all patients in whom conventional tracheal intubation failed, a subsequent attempt with the Glidescope was successful. The view at the glottis (according to Cormack and Lehane; P,0.0001), intubation duration [34 s (CI 27–41) vs 67 s (CI 52–82), mean (95% confidence interval); P1⁄40.0001], and need for supporting manoeuvres (P,0.0001) were significantly different. The inter-incisor distance improved overall with induction of anaesthesia from 2.0 cm (CI 1.8–2.2) to 2.6 cm (CI 2.3–2.9; P,0.0001) and was correlated with the duration of symptoms.

Conclusions. In patients with odentogenous abscesses, the use of a Glidescope laryngoscope was associated with significantly faster tracheal intubation, with a better view, fewer supporting manoeuvres, and a higher success rate than with a conventional laryngoscope. Improvement of the inter-incisor distance after induction of anaesthesia correlated with the duration of symptoms. "1.

Appendix:

1. Tracheal intubation in patients with odentogenous abscesses and reduced mouth opening
M. Schumann1, I. Biesler1, A. Borgers1, R. Pfortner2, C. Mohr2 and H. Groeben1*
1 Department of Anaesthesiology, Critical Care Medicine and Pain Therapy and 2 Department of Oral and Cranio-Maxillofacial Surgery, Kliniken Essen-Mitte, Henricistr. 92, Essen 45136, Germany .

British Journal of Anaesthesia 112 (2): 348–54 (2014) 

AdvanceAccesspublication26September2013 . doi:10.1093/bja/aet310 

2014 GlideScope Year " GLIDESCOPE AS A FIRST USE " CHOICE

                                                        Welcome All to 2014
                                                the year of the GLIDESCOPE.

     Let us take this opportunity to powerfully establish the use of GlideScope for all intubation related and other Airway Applications as a "FIRST USE CHOICE" for Airway.
Many leaders in Airway Management have called for and indeed used Video laryngoscopy as their first choice in airway management. The number of Emergency Departments, OR's and Clinics using GlideScope as the "first use choice" is rapidly increasing and the number of systems needed to support  this behaviour is increasing.
      Let us take this year to consolidate this trend and do a system upgrade for airway management. It is known that repeated use is the most important metric for getting over the "can see the airway but cannot introduce the Endotracheal tube".

                                                       Dr Pacey's Teaching

•     Use the 4 step approach  1. view mouth while you introduce the device slightly to left of midline  2. visualize the epiglottis then slightly lift the tip to see the airway 3. Watch the ETT pass into the mouth to avoid injury to Tonsils and Palate   4. Avoid going too deep and do a MINIMAL LIFT of the larynx while introducing the endotracheal tube by extracting the Verathon Stylet slowly.
• The Verathon Stylet is a powerful enabler for the GlideScope.
• When intubating keep the Glidescope back as far as possible to avoid excessive lifting of the Glottic Complex.

                           Stand by for exciting new improvements to the GlideScope in 2014.
                                                          Have a Great New Year!
                                                          Dr John Allen Pacey MD FRCSc
                                                          GlideScope and Aperture Inventor