Surgeons Guide to Airway Management Dr. John Allen Pacey MD , FRCS(c) No.3

If The Tools Exist , How Do We Then Achieve Excellence?

If the tools are now available for Airway Management Excellence then why do we struggle and how should we proceed in a way that will  provide high quality care that is reproducible and measurable .  The goal of this work is to provide a guide for system change and method of measuring the performance of the new process.

The science of change management must be brought to bear on this. Medical change process started perhaps with Fredrick Winslow Taylor who introduced the concept that waste and inefficiency was caused by haphazard unscientific management.  The book 1911 book “The Principles of Scientific Management” was a first attempt to define a science for change. This proved to be an authoritarian approach suited to a society where workers had fewer means of education. Later, Peter Drucker in a prodigious effort well summarized in   2008  , “ The Essential Drucker The Best Of Sixty Years of Peter Drucker’s Essential Writings on Management ” introduced the notion of management of “Knowledge Workers” who have substantial core information that will inform change toward more highly functioning organizations. The notion that organizations trend toward chaos is perhaps pessimistic but is widely believed today.

Modern leaders set a frame work of goals and base rules which allow for distributed leadership of ways and means to get to change on a local basis. This is demonstrated with the new organization of the US Army where the strategy and clear objectives are defined at the center , the Pentagon,  and the assignment of an Expeditionary commander begins a process where the elements required for success (such as IT Support, Transport, Air ) are defined and assigned by the unit who is responsible for execution. This devolution of decision making to those who are answerable for the outcome thus  places the HQ in the position of being the responsible observer monitoring  progress .

The focus for us professionals should be on the individual unit or work space like the OR, ICU or ED and begin to seek ways of achieving perfection that is built on the skills and initiative of the local professionals but is wedded to the IT and management framework and goals for the organization overall. This local initiative produces high energy activity that entrains all of the brilliance available. The trick then for the local change agents must be to have appropriate goals so that the change does not collapse into petty politics and divisions. The energy of a fully engaged community with measurements for results is thus converted into forward action.

The process becomes a big part of the reason for a great or less than great outcome. As stated previously there are many capabilities needed for any professional team so the learning must go on in many directions at the same time. The development of British style “team leads” can be a useful way to start the process .

Professionals in the organization must be taught to become agents for change rather than curmudgeons or foot draggers. The new Systems for quality demand a new set of attitudes geared to embrace real change.

Surgeons Guide to Airway Management Dr John Allen Pacey MD , FRCSc No.2

The Tools For Excellence In Airway Management Are Now Available.

         The last 20 years have provided many new tools for airway management with the result that there are many options now available for management of most anatomical and physiological states. This is not meant to be any kind of complete history of development of useful devices and will not consider, for example, the “Iron Lung” developed for the polio era or many other useful devices.

         The “Big Seven” Airway Tool Strategies include :

1. Direct surgical access. 

2. Facial Masks – Standard Face Mask and Nasal Mask.

3. DL-Direct Laryngoscopy.

4. FOL-Fiberoptic Laryngoscopy.

5. VL-Video Laryngoscopy.

6. Supra-Glottic Airways –LMA , I-GEL , King LT etc.

7. HFN- Hign Flow Nasal (THRIVE) or High Pressure Nasal (NASAL _TSE PAP)

·      The ancient tracheotomy and surgical approach to the airway goes back to Egyptian Medicine circa 3600 BC where tablets have been found with images of tracheal access surgery. The relief of airway obstruction in ancient times was not documented in a way that would allow determination of how many thousand years BC this practice was invented.

·      The cuffed endotracheal tube was invented by Trendelenburg  in approximately 1895 and popularized the development of endotracheal anesthesia that replaced the Ether drop and Chloroform muzzle of earlier days.

·      The vintage 30 degree angulated Direct view Macintosh laryngoscope  1943  with its partner the Direct view Miller Laryngoscope have been the mainstay resources throughout the development of Intubation strategies for Anesthesiology and Emergency Medicine. While these devices were not the first Direct viewing devices they were substantial leaps forward with implementation of a reliable light carried onboard.

·      The development of a fiberoptic endoscope in 1957 with light bundle fiber clusters to carry light to the body interior and then carry an image back to the Medical observer. This led to the first indirect viewing class of endoscopes that proved to be a great advance in capability. These devices were popularized by Andranic Ovassapian who later with friends in the airway community innovated the “Society for Airway Management” designed to develop and foster a culture aimed at solving the difficult airway conundrum.

·      The flexible light fibers and small DC bulbs also permitted development of lighted flexible stylet products , some with viewing capability like the Shikani laryngoscope and others without viewing such as  the Trachlight class of lighted stylets.

·      The development of the Laryngeal Mask Airway concept was innovated by Archie Brain to move the mask seal component from the face where seals could be problematic to the area immediately behind the glottic complex. This strategy was effective and provided a “Plan B “ backup for the cannot intubate cannot ventilate ( CICV) situation that was causing a continuous string of failed airways resulting in patient death and cerebral cell death. Then a prolific period of innovation provided a plethora of SGA (Supra Glottic Airways) that followed the original designs.

·      The invention of the GlideScope Highly Angled CMOS Video Laryngoscope (60 Degree)by Pacey in 2000 provided a new asset for airway managers and proved to be a useful new portable device for hospital and out of hospital use. Storz developed their fiberoptic rigid laryngoscope direct view device by adding a video camera in the handle. Later a variety of 60-90 degree rigid video laryngoscopes were introduced by Pentax, McGrath and others.  Some carried display screens on the handle while Saturn introduced the rugged compact 1.5 lb. water proof  USAF inspired Ranger for Military and Civil EMS application. Verathon subsequently has developed and marketed in excess of 30 variants of the original GlideScope. The video laryngoscope has subsequently earned a place in the DAS 2015 and ASA 2013 difficult airway guidelines where its use may be implemented as a first attempt device or at many stages in the decision making tree.

·       Surgical kits designed to gain access to the trachea used the Seldinger strategy with guide wires and even ultrasound guidance to aid the user. A series of dilating devices like the “ Blue Rhino” became common for ICU tracheostomy to elegantly wean ventilated patients.

The field use of these surgical kits proved to be less satisfactory because usually the application of these kits was carried out too late at a time when the patient was in an extreme pre- arrest state. The US Army had a disappointing legacy with these devices because of the training gap that exists for a device or system that requires a significant judgement level for optimal application.

·       Nasal strategies are now the most quickly developing  approaches to attack the problem of inadequate ventilation prior to intubation. The initial work was done using normal flow nasal prongs to augment the standard 4 minute BVM preoxygenation . Then higher flows were used to provide a flush during intubation and mixed results were obtained but these efforts were encouraging in some patients. The goal is to increase the period of sustained oxygenation and slow the deterioration on the classic curve of Benumof which shows the minutes to desaturation for Obese, Normal 10 Kg. Child , Moderately ill Adult, Normal 70 Kg. Adult .

The evolution in Nasal Oxygen delivery has progressed to the delivery of up to 70 L/min. of HFNO (High Flow Nasal Oxygen) via the proprietary  THRIVE device from Australia which can deliver humidified high flow Nasal O2 and result in a defacto Nasal CPAP where the flow is so high that continuous positive pressure exists. This high flow is in effect providing CPAP and apneic oxygenation with the attendant expenditure of copious amounts of oxygen. ( 40-70L/min.) This use of oxygen could be a problem for prehospital transfer or forward military sites  where  oxygen supplies are less plentiful.

Dr James Tse has taken another tack with nasal TSE PAP which involves using a Pediatric size 2 oro-nasal mask  which is applied to the nose of an adult and used to create Nasal CPAP which acts by opening the Nares, Displacing the soft palate forward against the tongue, avoidance of posterior displacement of the Jaw and tongue, and finally administration of a positive pressure throughout the respiratory cycle. This has been shown to be superior to the classic  Facial mask which applies pressure to the jaw and mouth area forcing the jaw back and the posterior aspect of the tongue against the posterior wall of the pharynx.

         The mask can be in position throughout the intubation process as well with the effect that the only time that TsePAP is not providing positive pressure is during actual laryngoscopic opening of the oropharynx. During this reduction in pressure the nasal oxygen continues to flow providing an oxygen rich environment down to the Glottis and to alveoli that have just recently been opened by the TsePAP effect. The net result is that it is uncommon to have oxygen saturation below 100 % even when various manouvers have been executed.  The consumption of oxygen with TsePAP is more in the range of 5-10 L/min.

Figure. 1 Time in minutes to precipitous desaturation of oxygen in the blood for (Left to Right) obesity , 10 Kg. Child , & 70 Kg. moderately ill Adult, and Normal Adult  .

Surgeons Guide to Airway Management Dr John Allen Pacey MD , FRCSc

Introduction

         This work is to be approached from the point of view of  students , who we all are, wishing  to develop a functional point of view from an analytic perspective. The current assets promoting the spread of knowledge provide such a diverse number of points of view that an analytic approach is always the right approach to the written word. We are working from from a knowledge perspective that is incomplete and evolving.

         Q. How does one write usefully in any field that is continuously evolving and has a steady stream on new information , people , and devices or tools that continuously change the equation?

 This is important to conceptualize because our world is filled with new methods of capturing and displaying information with the result that virtually every morning there are nuance changes to the state of the art.

A.   Focus on the missions that you will choose to be involved in executing to first understand the problems and then the actions necessary to solve them. The personalized approach then will continuously morph as your personal “capability equation “ changes.

This would be easy if the world delivered a fixed set

missions all packaged with appropriate labels for you to address at your leisure . The real world of course delivers problems at the most inconvenient times and with subtle variations that may or may not be obvious to the un-initiated. Thus it becomes necessary to approach any serious task from a perspective that deep knowledge will be required to allow one to cope with the many variants one will encounter.

         This work is designed to provide a series of ideas that will form a point of view designed to illustrate the problem and allow one to develop a tool kit of strategies and real tool skills that will allow one to provide a rational scaled response as problems are presented.

         The discussion in this book relates to Airway Management which has proven to be one of the most scary and humbling of Medical fields because the failure to handle oxygenation effectively in a few minutes can result in death, brain injury, and personal despair for the EMT or MD who ends up with ,for example, an endotracheal tube in the esophagus .

         Control , and the search for it, is elusive for neophytes .

One typically starts life with abundant confidence that whatever comes up will be handled by personal inventiveness and brilliance. This confidence , sadly is crushed , the first time that you have a close call or real failure. Those with luck will be rescued in time to prevent making  the patient pay too big a price for your weaknesses. Clearly realism must be combined with a careful approach to minimize risk and have options to prevent disaster.

Medical teachers and students can look at the art of training pilots as a guide to safety and emergency preparedness. As a pilot who has developed a modest skill level including Instrument flight and night operations flight it is clear to me the rather haphazard approach to skill acquisition and testing  carried out in the Medical arena needs serious work.

Q. When was the last time you were prevented from putting a patient to sleep or stepping into your ambulance because of failure to pass a multi- function scheduled skill test?

A. Never I suspect .

         The good news is that you don’t need to know everything and you don’t need to be a severe academic. You must only know a depth of knowledge that will enable you

·      to assess your own limitations,

·      know which tools are available ,

·      how well you can use them,

·      know and listen to the right people to support you own weakness,

·       be alert for ideas and people who can assist you in your lifelong quest for knowledge.

To this end you will likely need to join a “Tribe” of people interested and able to exchange knowledge . The Society for Airway Management “ or the UK DAS would be such a tribe and in addition your own hospital could have an “ Airway Competency Group” that was willing to declare standards and leadership for pursuit of excellence. Could you develop the best program in your area for this kind of learning? Unfortunately there are many areas of Medical competence to be addressed at the same time and this speaks to the need to develop declared zones of interest “ ie. Airway Leads “ for the many types of skill required for modern practice. Should you be saddled with the task of being a hospital Department Head or  EMS Medical Director then it is your duty to have all staff involved in one or the other knowledge bases so that a state of the art skill level is achieved in all areas.

         The “ Airway Lead” has several missions that are measurable by the airway management outcomes of the department

1.   Does the “Airway Lead” have state of the art knowledge ,and if not,  how is this to be developed?

2.   Does the “ Airway Lead “ have a real time knowledge of the local hospital state of practice and are the local disasters properly investigated and measured?

3.   Does the “ Airway Lead” understand the learning needs of other department members and whether they are supported for training and practice?

4.   How does the local program rank in the world of airway “Management Excellence” generally accepted measures.

5.   Does the “ Airway Lead” provide tools necessary so that staff can operate according to current norms?

The development of appropriate systems can only be done when the goals of the department are clearly vocalized and measured in such a way that sub- standard practice is not possible without bringing to bear a full disclosure. When this is done change can be continuously implemented until excellence is achieved.

Great guidelines are now available for development of policy and the ASA Algorithm rewritten in 2013 “Practice Guidelines for Management of the Difficult Airway “ and the new Guidelines 2014  written by the  UK DAS “DAS Intubation Guidelines 2015 Update” are current examples that must be studied for comprehension of the consensus knowledge available. These will be mined later in the piece for specific strategy presented.

Apnoeic Oxygenation in Patients with Intra Cranial Hemorrhage -Sakles et. al.

    The Emergency Medicine department at University of Arizona Hospital has produced yet another insight into the practice of challenging airway management. These studies are difficult to do because of the fluid nature of services that provide large amounts of daily care. 

The question posed by Sakles , Mosier and team was : What is the benefit of provision of Apnoeic Oygenation during RSI in a department where care is provided by Residents who are heavy users of Video Laryngoscopy and in patients who are proven to have Intracranial Hemorrhage . It is widely accepted now that Hypoxemia in this vulnerable group has a marked impact on survival and outcome and must be avoided at all cost.

    From a base group of 856 patients undergoing RSI 127 patients had ICH and were intubated by EM Residents of various experience and had a start saturation greater than 90% and had complete data for the period of care. 72 patients had Apneic oxygenation with a nasal cannula with flow of 15 litres or more throughout the RSI process using a non-rebreathing mask and 55 had a standard 3 minute pre oxygenation strategy with a mask.