Updating our approach to the difficult and failed airway: time to “stop and think”

Brindley, Peter G.; Beed, Martin; Duggan, Laura V.; Hung, Orlando; Murphy, Michael

doi:10.1007/s12630-016-0594-1

Cited by 17 publications

(17 citation statements)

References 18 publications

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“…[11][12][13][14] Specifically, the 2015 Difficult Airway Society Guidelines highlighted the need to ''stop and think''. In other words, comprehensive airway management includes not only procedural interventions but also cerebral aspects and verbal interactions.…”

Section: Achieving Better Airway Teamwork Outside the Operating Roommentioning

confidence: 99%

Airway management outside the operating room: how to better prepare

Brindley

Beed

Law

et al. 2017

Can J Anesth/J Can Anesth

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Airway management outside the operating room is associated with increased risks compared with airway management inside the operating room. Moreover, airway management-whether in the intensive care unit, emergency department, interventional radiology suite, or general wards-often requires mastery of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. The 2015 Difficult Airway Society Guidelines encourage the airway team to ''stop and think''. This article provides a practical review of how that evidence applies during emergency airway management outside of the operating room. To counter the challenges of airway management outside the operating room, we offer a mnemonic that combines both technical and non-technical insights summarized using the seven letters of the word PREPARE (P: pre-oxygenate/position; R: reset/resist; E: examine/explicit; P: plan A/B; A: adjust/ attention; R: remain/review; E: exit/explore). We hope it can unite potentially disparate personnel with a structure that allows them to make acute decisions, coordinate action, and communicate unequivocally. This multidisciplinary publication also hopes to encourage common understanding and language between anesthesiologists and non-anesthesiologists about the perils of airway management outside the operating room and the importance of airway teamwork.Résumé La gestion des voies aériennes en dehors de la salle d'opération est associée à une augmentation des risques, comparativement à leur gestion à l'intérieur de la salle d'opération. De plus, la gestion des voies aériennes -que ce soit en unité de soins intensifs, aux urgences, dans une unité de radiologie interventionnelle ou dans un service général -nécessite souvent une maîtrise face, tout d'abord, aux voies aériennes compliquées sur le plan anatomique, mais aussi face aux voies aériennes difficiles à gérer sur le plan physiologique et en situation. Les lignes directrices 2015 de la DAS (Difficult Airway Society) encouragent l'équipe de prise en charge des voies aériennes à « faire une pause et réfléchir ». Cet article fournit une synthèse pratique de l'application des données probantes au cours de la gestion des voies aériennes en urgence, en dehors de la salle d'opération. Pour faire face aux défis de la gestion des voies aériennes en dehors de la salle d'opération, nous proposons un moyen mnémotechnique qui combine des points techniques et non techniques, résumés dans les sept lettres du mot PRÉ PARE (P : préoxygéner/position; R : reprendre/ résister; E : examiner/expliquer; P : plan A/plan B; A : adapter/attention; R : rester/revoir; E : explorer/quitter). Nous espérons que cela peut rassembler des personnels potentiellement disparates dans une structure qui leur permette de prendre des décisions, coordonner leurs

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Section: Achieving Better Airway Teamwork Outside the Operating Roommentioning

confidence: 99%

Airway management outside the operating room: how to better prepare

Brindley

Beed

Law

et al. 2017

Can J Anesth/J Can Anesth

Self Cite

View full text Add to dashboard Cite

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“…Considerations should also relate to accurate pre-device testing, the design of teaching/tutorial methods especially for medical students, the design of the teaching space for procedural training, and the interaction behaviours within this space. [7][8] Improving existing equipment presents an opportunity to increase the safety and efficiency of procedures within anaesthesia, especially when using a bougie. Common problems with the bougie relate to shape retention, tip pressure forces and steer-ability, amongst others.…”

Section: Introductionmentioning

confidence: 99%

Tracheal intubation: Improving first pass success with smart material solutions

Breedon¹,

Siena²,

Armstrong³

2017

JHD

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SUMMARYAirway management and intubation procedures continue to challenge anaesthetists. With current equipment not always providing an optimum solution, this can lead to potential serious complications if an airway is not secured quickly. Improvements in airway devices need to be discussed, designed, tested, and implemented. The implementation of the appropriate smart technologies and materials present an opportunity to resolve key issues with bougie-guided intubation. It is suggested that the development of a novel steerable Bougie could improve current tracheal intubation practice. This proposition is grounded on using the appropriate research and design development strategies combined with a structured methodological approach.

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“…Nevertheless, this will always be a double-edged sword-i.e., good that we may never have to do it, but bad in that we'll never have a chance to master it through experience. This means that, both mentally 19 and in simulation sessions, we must continue to rehearse the management techniques of a CICO scenario, including optimizing face mask ventilation; placing a supraglottic device, if not already attempted; ensuring pharmacologic paralysis if there is no prospect of a timely return to spontaneous ventilation; and performing ESA without delay. 6 Furthermore, when informed by the results of continuing investigations, we must continue to adapt to emerging evidence by modifying existing guidelines and recommendations where needed.…”

mentioning

confidence: 99%

Deficiencies in locating the cricothyroid membrane by palpation: We can’t and the surgeons can’t, so what now for the emergency surgical airway?

Law

2016

Can J Anesth/J Can Anesth

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At times, it seems that we were never meant to discover the underlying mysteries of the neck's surface anatomy. The quest first began with the cricoid cartilage and although Sellick's maneuver 1 seemed an acceptable concept, it eventually proved somewhat disappointing in its application. Who knows how often this technique actually hit its target? Now, as Hiller et al. outline in this issue of the Journal, just north of the cricoid cartilage and sorely needed for expeditious emergency surgical airway (ESA), it seems that the cricothyroid membrane (CTM) is also keeping its exact location a closely guarded secret. 2The ESA is infrequently performed by the average anesthesiologist and has had its issues. Historically, in a can't intubate, can't oxygenate (CICO) emergency, practitioners been slow to initiate the procedure. Furthermore, some of the techniques used to execute the ESA have been less than effective, perhaps accounting for the generally poor success rates.3,4 Fortunately, recently published national airway guidelines address these matters with more definitive recommendations for both when and how ESA should occur.5-7 The trouble is, establishing an ESA generally begins with identifying the location of the CTM by external palpation. As it turns out, for the life of us (not to mention that of our patients), it seems that we can't reliably accomplish this task.At least six recently published studies from a variety of countries attest to this conclusion. [8][9][10][11][12][13] These studies used similar methodologies to determine how often physician assessors correctly identified the location of the CTM by external palpation. The assessors' estimations in these studies (and similarly in the present one) were compared with the actual location of the CTM as confirmed by ultrasound. In most studies, the assessor's attempt to localize the CTM was defined as a failure if the estimation was either outside the vertical confines of the CTM or [ 5 mm from the midline. The results are sobering. Correctly identifying the CTM location using external palpation is no better than a 50:50 proposition, give or take, even in nonobese subjects. Most of the studies include scatter plots of the assessors' estimates, and in some cases, localization is off by at least 3 cm above, below, or lateral to the actual CTM location. Not surprisingly, there is a trend towards worse results in females and obese subjects given their less distinct thyroid cartilage anatomy. These findings occurred in the relatively stress-free conditions of a clinical study in volunteer subjects. We can probably expect even worse results when we add the anxiety-related performance degradation in an actual CICO situation.By adding trauma surgeons to the mix, Hiller et al. add fuel to the fire with their study of the accuracy of CTM identification by external palpation in female subjects. 2Notwithstanding their greater experience in performing ESA, the surgeons failed to demonstrate a significantly better success rate at CTM identification than their anesthesia ...

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Updating our approach to the difficult and failed airway: time to “stop and think”

Cited by 17 publications

References 18 publications

Airway management outside the operating room: how to better prepare

Airway management outside the operating room: how to better prepare

Tracheal intubation: Improving first pass success with smart material solutions

Deficiencies in locating the cricothyroid membrane by palpation: We can’t and the surgeons can’t, so what now for the emergency surgical airway?

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