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 .
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
4. Develop primary and alternative strategies:
Dr Pacey's Comment
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
• 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
• 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
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.
