Awake intubation creates feelings of being in a vulnerable situation but cared for in safe hands: a qualitative study

Knudsen, Kati; Nilsson, Ulrica; Högman, Marieann; Pöder, Ulrika

doi:10.1186/s12871-016-0240-z

Cited by 15 publications

(10 citation statements)

References 18 publications

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“…Any discomfort with ATI is typically brief and patients are usually accepting of an airway manager’s recommendation for airway management, especially when its safety aspects are discussed. 62 …”

Section: Implementation Of the Planned Strategy When Difficult Tracheal Intubation Is Predictedmentioning

confidence: 99%

“…Any discomfort with ATI is typically brief and patients are usually accepting of an airway manager's recommendation for airway management, especially when its safety aspects are discussed. 62 The Difficult Airway Society in the UK has recently published comprehensive guidelines on ATI. 63…”

Section: Awake Tracheal Intubation In the Patient With Anticipated Difficult Tracheal Intubationmentioning

confidence: 99%

See 1 more Smart Citation

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

101

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Purpose Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. Source Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. Findings and key recommendations Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient’s tolerance for withdrawal of airway support and whether re-intubation might be difficult.

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Section: Implementation Of the Planned Strategy When Difficult Tracheal Intubation Is Predictedmentioning

confidence: 99%

Section: Awake Tracheal Intubation In the Patient With Anticipated Difficult Tracheal Intubationmentioning

confidence: 99%

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Law

Duggan

Asselin

et al. 2021

Can J Anesth/J Can Anesth

101

View full text Add to dashboard Cite

show abstract

“…Both pain and distress are unpleasant, noxious experiences. Painful and distressing stimuli are known to have a negative effect on the developing nervous system [23, 24]. For a neonate, the sensation of either pain or non-painful distress can lead to increased cortisol, tachycardia, desaturation, and potentially significant deterioration.…”

Section: Weighing the Potential Harmsmentioning

confidence: 99%

To Sedate or Not to Sedate for Less Invasive Surfactant Administration: An Ethical Approach

Peterson¹,

Boer

Roehr

2021

Neonatology

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Less invasive surfactant administration (LISA) is an effective, minimally invasive technique of administering surfactant to infants with respiratory distress syndrome. While termed less invasive, LISA still requires airway instrumentation with direct laryngoscopy, thus may be considered painful. However, the issue of whether or not to routinely sedate infants for LISA remains contentious, with significant variation in practice between centres. Proponents for giving pharmacological analgesia and/or sedation predominantly focus on patient comfort during the procedure. However, those who favour non-pharmacological measures of pain management focus on the potential for procedural success without the risk of adverse events, such as respiratory depression and potentially the need for escalation to intubation, which may occur with pharmacological agents. The neonatal population who may benefit from LISA is varied. Due to this variety in presentation type, gestational age, and unit experience, there is a need to provide an individualized, tailored approach to sedation and analgesia for these infants. Using a blanket approach to sedation will lead to infants being exposed to sedative medications on the assumption of potential distress, rather than in response to signs of actual distress. This places the infant at risk of the adverse reactions, potentially without them ever having needed the beneficial effect of the medications. This seems an unnecessary risk. This article explores the ethical arguments pertaining to analgesia and sedation during the LISA technique, concluding that a standardized approach to the usage of pharmacological sedation is undesirable. Moreover, we maintain that procedural analgesia and sedation should be based on individualized, infant-centred assessment, rather than on a rigid, standardized approach.

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“…However, there are reports of necessary “awake” intubations in adults. Such a report describes the patient's experience of the procedure: “It felt like I could not swallow, like I would suffocate on the fluid, like as I cough and throw up at the same time and then it burns” 6 . This graphic description leaves the reader in no doubt that the procedure can be unpleasant.…”

Section: Introductionmentioning

confidence: 99%

New techniques, new challenges—The dilemma of pain management for less invasive surfactant administration?

Balakrishnan

Sanghera

Boyle

2020

Paediatric and Neonatal Pain

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Recent years have seen the increasing use of noninvasive respiratory support in preterm infants with the aim of minimizing the risk of mechanical ventilation and subsequent bronchopulmonary dysplasia. Respiratory distress syndrome is the most common respiratory diagnosis in preterm infants, and is best treated by administration of surfactant. Until recently, this has been performed via an endotracheal tube using premedication, which has often included opiate analgesia; subsequently, the infant has been ventilated. Avoidance of mechanical ventilation, however, does not negate the need for surfactant therapy. Less invasive surfactant administration (LISA) in spontaneously breathing infants is increasing in popularity, and appears to have beneficial effects. However, laryngoscopy is necessary, which carries adverse effects and is painful for the infant. Conventional methods of premedication for intubation tend to reduce respiratory drive, which increases the likelihood of ventilation being required. This has led to intense debate about the best strategy for providing appropriate treatment, taking into account both the respiratory needs of the infant and the need to alleviate procedural pain. Currently, clinical practice varies considerably and there is no consensus with respect to optimal management. This review seeks to summarize the benefits, risks, and challenges associated with this new approach.

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Awake intubation creates feelings of being in a vulnerable situation but cared for in safe hands: a qualitative study

Cited by 15 publications

References 18 publications

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

To Sedate or Not to Sedate for Less Invasive Surfactant Administration: An Ethical Approach

New techniques, new challenges—The dilemma of pain management for less invasive surfactant administration?

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