Nasal Tse PAP -the next big thing in Anesthesiology

The Emergence of Nasal Tse-PAP 

     The tools available for the practice of Anesthesiology have been growing in number recently and it is now clear that the pace has been too fast for the Medical Profession to step up and adopt them. Such is the case with Nasal CPAP which I have renamed for Branding purposes as Nasal Tse-PAP in honour of Dr James Tse , who has been striving to teach the profession the great benefits of this technology. James has won important prizes and has greatly expanded the clinical experience with this technology.

     The contribution possible from nasal routes is being recognized by leaders in airway management thinking and might be summarized as falling into 4 general Groups in ascending order of effectiveness:

  1. Nasal Airway- alternate method of dealing with transient upper airway obstruction.

  2. Nasal Prongs- low flow transition for supplementary oxygen.

  3. HFNO - High Flow Nasal Oxygen -typified by the Vapotherm (R) which delivers 40 L/min or Optiflow(R) 1. which can deliver up to 70 L humidified oxygenated air to the pharynx via a nasal apparatus. This extremely effective strategy will save many lives by at once causing great turbulence , high oxygen availability for apnoeic Oxygenation, and a degree of CPAP.

4. Nasal TsePAP - this strategy promoted for many years by Dr James Tse from Rutger's University  has demonstrated the elegant and highly effective use of a Prediatric facemask , slightly modified , to generate nasal pressure as an induction strategy or as a rescue method. The ease of ventilation of a large range of patients (Obesity, Pediatric, Procedural MRI CT, and importantly as a transition to Intubation using a highly angled Video Laryngoscope like the GlideScope.

The advantages of this method include the use in bearded patients and use in patients having failed facemark ventilation. The nasal Tse PAP method pressurizes the nasal channels and tends to push the soft palate , tongue forward while delivering positive pressure and peep effects. This great work has been presented  at ASA, SAM, PGA, and internationally for many years. Patient safety Prize  has been awarded to Dr Tse for his work.

                CT Nasal Tse PAP in use - positive pressure can be added any time that the clinical situation requires it. The comfort of the apparatus is suited to long term application.

Dr Tse demonstrating the transition from Nasal Tse PAP to GlideScope intubation with out removal of the Nasal Tse PAP mask. The oxygenation continues at all stages of the procedure.

Nasal Tse Pap paediatric size 2 mask in place during care for a bearded patient cared for by Dr Tse at Robert Wood Johnson University Hospital. The ability to easily ventilate many patients with difficult face mask ventilation using a Nasal mask is important. The ability to deliver positive pressure easily ,as required , during procedures like MRI is also a good contribution to patient safety.

Nasal Tse PAP Apparatus - Dr James Tse - including attached oral CO2 monitor channel. Transition to positive pressure ventilation is done without changing the equipment and by preventing oral leakage of gas. 

Summary:
Nasal Strategies for ventilation are proven to add to patient safety and this has been recognized widely . Adoption has lagged and it is time that the Anesthesiology world quickly moved to catch up to the technical advances developed by Dr Tse and others.
Key Nasal rescue strategies are possible and are gaining recognition.


COI.
   I , as Glidescope Inventor and Consultant to Rutgers University must disclose a conflict of interest on this topic, having a minor interest in Nasal Tse PAP success.

1. Patel Anaesthesia 2015, 70, 323–329

The Emergence of the vomiting Manikin - SALAD - Suction Assisted Laryngoscopic Airway Decontamination.

                                                     SALAD TRAINING

 The development of simulation centres has improved the level of teaching available in Surgery and also Anesthesia. There are 2 steps involved in this innovation: First to expose students of all experience levels to consistent training scenarios. then Secondly to begin testing retention of material known to be necessary for competent application.

      Specific problems are identified such as difficult airway , airway fires, equipment malfunction and  other "imagined difficulties" and then a teaching approach is constructed to teach management.  The development of vomiting during attempts to intubate is one of the most challenging events one can encounter. The vomiting manikin  recently popularized by great airway innovator from Milwaukee Dr Jim Ducanto  and by Dr Yen Chow of Thunder Bay EMS service is a remarkable addition to simulation centre teaching capability.

     Using these manikins  is surprisingly instructive because one can learn to aggressively attack the appearance of vomitus and control the situation quickly  to avert disaster. The first realization is that quick action is effective, the rapid suctioning followed by placing the suction on the left side of the laryngoscope can permit one to focus on getting the view and then placing an endotracheal tube. The Video Laryngoscope is effective in these situations because the elevation of the tongue allows fluids to collect in the back of the pharynx whereas the direct laryngoscope creates a channel that narrows as it gets closer to the larynx with the result that fluids collect at the critical spot essential for visualization. Many opinions will emerge on this point but I am confident that Video will prevail. This is apparent with the vomikin manikins.

1. The vomiting Manikin pump and reservoir in place prior to teaching.

2. The Clinical setup with the emergence of Pseudo Vomit.

3. The fluid challenge is seen with a suction in place on the left side of the mouth while the VL and tube are utilized. The continuous suction maintains a dry field.

Measurement of the 60 degree angle of the Glidescope Blade.

                                                   GlideScope Blade Angle
The measurement of the blade angle that is the key to success of the GlideScope Blade in management of Difficult Airway patients is carried out by comparison of what one sees when looking directly into the mouth when the GlideScope is inserted. Early experimentation clearly demonstrated that to get the 99.9% working view of the airway ( GSCL Grade 1 or 2 View ) it was necessary  to have a 60 degree angle . Lesser angles were shown clinically to be unable to get a working view in a few % of patients. The mission of the inventor was to provide a GSCL view that would permit intubation in 99.9 % of patients with the theory that if you could see it you could place the tube successfully.

Experience has shown that those users who used the GlideScope regularly could virtually always deliver the tube (especially with the highly controllable Verathon (Pacey) rigid steel stylet. Those who did not practice with the device sometimes failed to advance the ETT and blamed the tool for their performance. Because we have a large number of users who can always advance the tube when they get a good view we believe the tool is not the problem.

                                                    GSCL      Grades 1-4
Notes with respect to the Cormack - Lehane views are not relevant to video laryngoscopy and therefore I use the GSCL scale which is simply the GlideScope Cormack Lehane view scale. Because each device has its own performance characteristics this becomes relevant when transmitting patient information to future caregivers.

                                       Calculation of the 60 degree angle:
The black arrow is the line of sight when the GlideScope is inserted into the mouth.
The 60 Degree angle is thus measured.

Telemedicine -Assisted Intubation In Rural Emergency Departments: A National Emergency Airway Registry Study

Comment: This Database Study is very important as a harbinger of the future that we are about to see . The tools for excellence in airway management are now available and the future depends on the development of an airway culture that elevates the professions use of these tools. 

 Telemedicine -Assisted Intubation In Rural Emergency Departments: A National Emergency Airway Registry Study

Lucas Van Oeveren, MD,1,2  Julie Donner, MS,2

 Andrea Fantegrossi, MPH,3  Nicholas M. Mohr, MD, MS,4,5

 and Calvin A. Brown III, MD3,6

1 Section of Emergency Medicine, Avera McKennan Hospital,

Sioux Falls, South Dakota.

2 Avera eCARE, Avera Health System, Sioux Falls, South Dakota.

3 Department of Emergency Medicine, Brigham and Women’s

Hospital, Boston, Massachusetts.

4 Department of Emergency Medicine, Division of Critical Care,

and 5 Department of Anesthesia, University of Iowa Carver

College of Medicine, Iowa City, Iowa.

6 Harvard Medical School, Boston, Massachusetts.

Abstract
Background: Intubation in rural emergency departments (EDs)
is a high-risk procedure, often with little or no specialty support.
Rural EDs are utilizing real-time telemedicine links,
connecting providers to an ED physician who may provide
clinical guidance. Introduction: We endeavored to describe
telemedicine-assisted intubation in rural EDs that are served by
an ED telemedicine network. 

Materials and Methods: 

Prospective data were collected on all patients who had an intubation attempt while on the video telemedicine link from May
1, 2014 to April 30, 2015. We report demographic information,
indication, methods, number of attempts, operator characteristics,
telemedicine involvement/intervention, adverse
events, and clinical outcome by using descriptive statistics.
Results: Included were 206 intubations. The most common
indication for intubation was respiratory failure. First-pass
success rate (postactivation) was 71%, and 96% were eventually
intubated. Most attempts (66%) used rapid-sequence
intubation. Fifty-four percent of first attempts used video laryngoscopy
(VL). Telemedicine providers intervened in 24%,
43%, and 55% of first–third attempts, respectively. First-pass
success with VL and direct laryngoscopy was equivalent (70%
vs. 71%, p = 0.802). Adverse events were reported in 49 cases
(24%), which were most frequently hypoxemia. 

Discussion:

The impact of telemedicine during emergency intubation is not
defined. We showed a 71% first-pass rate post-telemedicine
linkage (70% of cases had a previous attempt). Our ultimate
success rate was 96%, similar to that in large-center studies.
Telemedicine support may contribute to success.

Conclusions:

Telemedicine-supported endotracheal intubation performed in
rural hospitals is feasible, with good success rates. Future research
is required to better define the impact of telemedicine
providers on emergency airway management.
Keywords: telemedicine, emergency medicine, teletrauma,
telehealth, e-health
Introduction