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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