#2 EMS Airway : GlideScope from 61% DL to 96% GVL after manikin training- Dr Rothfield

#1 EMS Airway Management- The largest opportunity to improve airway care.

Advanced airway management is necessary in prehospital trauma patients

1. D. J. Lockey1,2,*, 
2. B. Healey1, 
3. K. Crewdson1, 
4. G. Chalk1, 
5. A. E. Weaver1 and 
6. G. E. Davies1

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1. ↵*Corresponding author. E-mail: david.lockey@nbt.nhs.uk

1. ¹Institute of Pre-hospital Care, London's Air Ambulance, London E1 1BB, UK
2. ²School of Clinical Sciences, University of Bristol, Bristol BS8 1TH, UK

• Background Treatment of airway compromise in trauma patients is a priority. Basic airway management is provided by all emergency personnel, but the requirement for on-scene advanced airway management is controversial. We attempted to establish the demand for on-scene advanced airway interventions. Trauma patients managed with standard UK paramedic airway interventions were assessed to determine whether airway compromise had been effectively treated or whether more advanced airway management was required.

Methods A prospective observational study was conducted to identify trauma patients requiring prehospital advanced airway management attended by a doctor–paramedic team. The team assessed and documented airway compromise on arrival, interventions performed before and after their arrival, and their impact on airway compromise.

Results Four hundred and seventy-two patients required advanced airway intervention and received 925 airway interventions by ground-based paramedics. Two hundred and sixty-nine patients (57%) still had airway compromise on arrival of the enhanced care team; no oxygen had been administered to 52 patients (11%). There were 45 attempted intubations by ground paramedics with a 64% success rate and 11% unrecognized oesophageal intubation rate. Doctor–paramedic teams delivering prehospital anaesthesia achieved definitive airway management for all patients.

Conclusions A significant proportion of severely injured trauma patients required advanced airway interventions to effectively treat airway compromise. Standard ambulance service interventions were only effective for a proportion of patients, but might not have always been applied appropriately. Complications of advanced airway management occurred in both provider groups, but failed intubation and unrecognized oesophageal intubation were a particular problem in the paramedic intubation group.

                                   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.