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.

Acute Pancreatitis with Intra Abdominal Hypertension- An Airway Issue.

Acute Pancreatitis with acute intra abdominal pressure buildup is an important ICU Airway management issue from time to time. The report below brings this to our attention and while this is primarily a combined Medical / Surgical issue there are many reasons to  rethink the problem.
The recent update of general guidelines are found in the report of the working group IAP/APA Acute Pancreatitis Guidelines.

NB: These Guidelines have been reviewed in 2015

Jiten et.al. reviewed literature and have called for an update of approaches to the problem.

Complications known to occur have been listed and of course include Acute  Respiratory Failure which is approached as indicated with support by ventilation.

The issue of surgical intervention is controversial but the surgery , if done, probably should be carried out when organ failure is beginning to emerge and perhaps less than 6 hours into failure of medical therapeutic options. 

The surgery may be best carried out via a midline incision using mesh and also , importantly , the negative pressure drainage techniques now common. (1.)  This can reduce intra abdominal pressures below the 20 mm Hg level and will permit reduced compliance ventilation. This then will reduce fluid infusions necessary to maintain cardiovascular and renal support.

Conclusion:

In short the Alert from Jiten Jaipura and his team is timely and serves to refocus our attention on the criteria of the Working Group.

1. Plaudis H. et. al. Abdominal Negative Pressure Therapy: a New Method In Countering Abdominal Compartment And Peritonitis- A Prospective Study and Critical Review Of  Literature. Ann. Intensive Care2 Suppl 1 S23, 2012 PMID 23281649

Anesthesia Change Management- Nasal Tse Pap -an example of change resistance psychology

Nasal Tse PAP- The most flexible and effective Nasal Route?

The Airway management world and anesthesia in particular now recognizes the advantages of nasal routes to oxygenation in management of challenging airway management. Change is now happening in spite of the culture of resistance. 

        There are now several strategies and techniques available including:

1. The time honored "NASAL CANNULA" strategy which has been ubiquitous but not used often historically during challenging airway encounters.-this is now being changed as the simplicity and effective use as an adjunct to pre oxygenation becomes recognized.

2. Naso Pharyngeal Cannulae have been recognized as useful to enrich oxygen distal to the nose in the pharynx. The work of Richard Levitan and Scott Weinberg repeatedly pressed the advantages of this strategy.

3. The successful development and commercialization of the " THRIVE " device has added a new strategy that is being shown to be effective by creation of "high flow nasal oxygen" induced CPAP with flow rates up to 70 L/min in adults.

4.  The conception and development of NASAL TSE PAP is , I believe , an example of systematic failure to seriously study and adopt a demonstrated and recognized optimal technology. Dr. James Tse , professor of Rutgers University department of Anesthesiology , has been demonstrating the effectiveness of nasal CPAP ( I call this NASAL TSE PAP in his honour) for perhaps 10 years. Recognition of the pivotal change possible with this teaching has been best recognized by an award from the Anesthesia Patient Safety Foundation a few years ago and by repeated awards at the PGA and ASA.

     The unique value of NASAL TSE PAP is that it is far more effective that ORO-NASAL mask in many situations because of the unique splinting of the airway during ventilation. Also the transition to positive pressure ventilation is at a Medical Student Level of difficulty. The reasons for neglecting this great contribution, that works seamlessly with Video Laryngoscopy in synchronous application, is based I believe on lack of scientific discipline.

    Change management in Anesthesiology is like a popularity contest which reminds me of the adoption of the Hula Hoop in popular culture.

Anesthesia Culture and the Future of Anesthesiology 1 Definition of "Culture" and "Human Factors"

Overview

     The technological changes that have occurred in the last 25 years in delivery of Anesthetics have been paralleled by vast improvements in Education and Culture. The Society for Airway Management , created by Andranik Ovassapian and his friends, is a manifestation of these changes. This Society and all of the other changes have joined to create many improvements in patient safety. The safety of practice improvements have been reflected in some countries , like Canada, by stabilization of growth of Medical Malpractice insurance rates and claims. 

Technological change has been unrelenting and has provided challenges for those learning and teaching management of these changes.

     With these changes we have seen the evolution of a class of caregivers CRNAs who have energetically learned to work in the space , for the most part as  trusted partners of the anesthesiologist. The new technology has increased the ease and safety of using the new class of providers in an Anesthesiology Environment. These new providers are now part of an evolving  new culture. The culture of change developing  is the subject of this series of posts.

Culture Definition:  Merriam Webster Dictionary

• The integrated pattern of human knowledge , belief, and behavior that depends upon the capacity for learning and transmitting knowledge to succeeding generations.
• The customary beliefs , social forms, and material traits of a racial, religious, or social group.
• The set of shared attitudes, values, goals, and practices that characterizes an institution or organization.
•  The set of Values , conventions, or social practices associated with a particular field, activity, or social characteristic.

Human Factors Engineering Definition:  Britannica

• Human factors Engineering, also called Ergonomics, or Human Engineering Science is application of information on physical and psychological characteristics  to the design of devices and systems for human use. Think aviation culture.
• As a body of knowledge human factors is a collection of data and principles about human characteristics , capabilities, and limitations in relation to machines , jobs, and environments.
• As a profession , human factors engineering includes a range of scientists and engineers from several disciplines that are concerned with individuals and small groups at work.

     The culture we now have in Anesthesiology is amazing in its power and reflects the enormous  output of the University systems and Industry output.  There is a complex intertwining of private medicine with new Government Care funding and all of this has a large bureaucracy attached.

What would be the feature set of a new culture  created to provide a path to the future:

• The new culture must have a strong central theme benefiting from "Enlightened Management ".
• The new culture must not be centrally micromanaged but must allow "islands of change that are locally inspired and controlled". Think of the hospital group , ICU level or the stand alone OR as examples of scale of the agents of change.
• The culture of change should weld into its DNA the benefits of Telemedicine that enables shared Electronic Medical Record , practice guidelines, inter hospital and inter service coordination while remaining decentralized in many ways.
• The culture of change should be viewed as a continuous process that engages all players.
• The culture of change should embrace the science of change management and the disciplines of Human Factors Engineering.

The Medical Professional of the future should be educated and enabled to be able to lead in local change initiatives in a role change that exploits the intellect and history of our profession.

To do this refocussing the training and preparation for change must be embraced and incorporated in Medical Training as a sub specialty. Medical schools should spend valuable teaching time serving this need.

Anesthesiologists can become the visionaries and agents of change in developing this new culture by reinventing them selves and learning to create " a new Personal Brand " as a change agent. 

The great technical development we have experienced now makes us the weak link in the " quality of care" equation. The way we behave leaves great opportunity for us to measure and improve our contributions to the great " Hippocratic Tradition".

Post Operative Continuous Positive Airway Pressure : ( New Book Reference)

The critical Postoperative period is different for those with risk of hypoventilation , subsequent respiratory failure, atelectasis, pneumonia, acute illness factors, and exacerbation of underlying lung disease or OSA than for those with short surgery with no risk factors.
         As an aside that corresponds with my intense interest in Nasal Tse Pap:
The provision of CPAP (preferably from the nasal route a la Rutgers Professor Dr. James Tse "Nasal Tse Pap" ) is a superior way of managing those at risk. The benefits , arguably ,  should be provided more liberally as opposed to the current practice where use is indicated " as required for problem solving".  This is an evolving topic which parallels a similar discussion around the 2013 ASA minimal requirement for "pre oxygenation" during intubation .  Nasal CPAP can provide extra preop benefits (next post). Dr Tse has received numerous awards from ASA Patient safety poster competitions for creative demonstrations of Nasal CPAP applications at Rutger's University Medical School.

Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care

Springer
Editor  : Antonio M. Esquinas
ISBN  978-3-319-04258-9 Print
           978-3-319-04259-6 Online

The Physiologically Difficult Airway

Jarrod M. Mosier, MD , Raj Joshi, MD , Cameron Hypes, MD, Garrett Pacheco MD, Terrence Valenzuela, MD, John Sakles MD.
                                      University of Arizona ICU and ED Departments.
                                   Published, Western Journal of Emergency Medicine 2015

Full text available via open access http: escholarship.org/uc/uciem_westjem 

DOI 10.5811/westjem/ 2015

With recognition that many tools ( DL, VL, FOB, Surgical neck access),  are now available for the placement of endotracheal tubes and that CPAP , BIPAP also make a powerful contribution to oxygenation and ventilation ,  there remains another dimension of the airway management problem that needs to be addressed. 

Physiological Factors:

This important contribution to the teaching of Airway strategy underlines the four physiological states that add a complexity and risk to the Difficult Airway patient management. The special problems in the ICU and the ED are often coloured by the complex physiology of people who are suffering from profound general disorders. It is therefore fitting that this new look at the difficult Airway should come from Mosier (ICU) and Sakles (ED). Separation of these factors for special education and acute care consideration will surely make care safer in critical care areas.

1. Hypoxemia - with a patient at an unfavourable point on the oxygen dissociation curve leaving reduced margin for rapid deterioration. The pre oxygenation process becomes important prior to attempts at intubation. The use of Nasal approaches to provision of procedural oxygen are currently attracting more attention and study. These include the Thrive Hi Flo Nasal oxygen strategy, the simple use of nasal prongs (less effective but still added value) and nasal TSE PAP which uses the nose as a conduit for CPAP with a modified #2 Childrens mask.

    2. Hypotension- addressed  with standard volume optimization support  and pressor use as indicated. 

    3. Severe Metabolic acidosis - treated with disease specific therapy (i.e. Diabetic Keto-acidosis) and or other cause specific therapy such as septic state therapy.

    4. Right Ventricular failure - firstly awareness of the diagnosis is key followed by excellent strategies defined by truly expert care. The following are considered to be of value by Mosier and his team 1. Available bedside cardiac echo to assess right heart reserve allowing fluid use, 2. pre oxygenation (see above) 3. consider etomidate induction, 4. consider Norepinephrine to increase systemic pressure, and low mean airway pressure ventilation. To obtain a discussion of these outline points consult the original detail embodied in the paper itself.

Abstract