Review of the New ASA Guidelines

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JOSEPH C. GABEL PROFESSOR & CHAIR ∣ DEPT. OF ANESTHESIOLOGY THE UNIVERSITY OF TEXAS MEDICAL SCHOOL AT HOUSTON

MEDICAL DIRECTOR ∣ PERIOPERATIVE SERVICES MEMORIAL HERMANN HOSPITAL, HOUSTON, TX

CARIN A. HAGBERG, MD

Review of the New ASA Guidelines Management of the Difficult Airway

RESEARCH GRANTS Karl Storz Endoscopy King Systems Ambu

UNPAID CONSULTANT Ambu

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“Sentinel Events” Associated w/ Anesthesia

J. Metzner et al; Best Practice & Research Clinical Anesthesiology; 25(2011) 263-76.

No. of Claims

Permanent Brain Damage 867

Airway Injury 581

Difficult Intubation 466

Spinal Cord Injury 417

Medication Errors 283

Aspiration 213

Central Venous Catheter Injury 183

ASA Closed Claims N=8954; 1970-2007

Closed Claims’ Analysis Best Practice & Research Clinical Anaesthesiology

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‣ Esophageal intubation has nearly dissapeared.

‣ Inadequate oxygenation or ventilation has declined in OR setting, not OOR.

‣ Difficult intubation remains a concern - 27% of adverse respiratory events.

‣ Pulmonary aspiration - 3rd most common respiratory event.

Julia Metzner MD, et al

J. Metzner et al; Best Practice & Research Clinical Anesthesiology; 25(2011) 263-76.

Practice Guidelines Management of the Difficult Airway

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‣ Systematically developed recommendations that assist the practitioner in making decisions

‣ Purpose to facilitate management of the DA & reduce the likelihood of adverse outcomes

‣ Not intended as standards of care or absolute requirements

‣ Revised & updated the 1993 and 2003 publication of ASA’s guidelines for management of the DA

An Updated Report by the ASA Task Force

Anesthesiology 2013 118:251-70

Canada (Canadian Society of Anesthesiologists)

Italy (SIARRTI)

Germany (German Society of Anesthesiologists)

Hungary (Hungarian Society of Anesthesiologists)

UK (Difficult Airway Society)

International Airway Algorithms

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Neck Circumference

Brodsky JB et al; Morbid Obesity & Tracheal Intubation. Anesth Analg 2002; 94:732-6

Aim to identify factors that complicate DL & intubation

Intubation Difficulties

Neither absolute obesity nor BMI

Large neck circumference & high Mallampati scores

100 Patients - BMI >40 kg/m2 - Elective surgery

PreOperative Measurements - TMD, SMD - Height, Weight - Neck circumference - Mouth opening

Airway history should be conducted on all patients, if

feasible.

Intent is to detect medical, surgical, & anesthetic factors

that may indicate DA.

Examine previous medical record, if available, in a timely

manner.

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Patient History


ESSENTIAL ROUTINE PREOPERATIVE AIRWAY EVALUATION

• Length of upper incisors

• Involuntary: maxillary teeth anterior to mandibular teeth

• Voluntary: protrusion of mandibular teeth anterior to maxillary teeth - lip bite test

• Interincisor distance <4 cm

• Oropharyngeal class ( 3 or 4)

• Narrowness of palate

• Mandibular space compliance

!Anesthesiology 2013; 118:251-70

ESSENTIAL ROUTINE PREOPERATIVE AIRWAY EVALUATION

• Mandibular space length • Length of neck • Head/Neck ROM • Thickness of neck

TMD <6 cm

SMD <12 cm

? >40 cm


Approach to the Difficult AirwayDifficult Laryngoscopy & Intubation: LEMON LAW

Look externally

Evaluate 3-3-2

Mallampati

Obstruction

Neck mobility

Hung, Orlando, Murphy, Michael; Management of the Difficult and Failed Airway, 2011

Pediatric Airway Assessment

Mask fit - craniofacial abnormalities

Obstruction - extrathoracic airway

Wheezing - obstructive lung dz

Spine - stiff/immobilized

Brent R. King MD, FACEP, FAAEM, FAAP Professor of Emergency Medicine and Pediatrics

Chair, Department of Emergency Medicine

Difficult Pediatric Airway: MOWS

Identify patients w/ individual predictors

Determine any combinations of predictors that may lead to difficulty

Perform additional testing & obtain preop consultation

Review w/ expert(s) to formulate plan for airway management

Ability to better accurately predict should reduce number of adverse outcomes & improve safety of airway management

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Does the airway exam predict difficult intubation?

Ghatge J & Hagberg C. In Fleisher L (ed). Evidence-Based Practice of Anesthesiology. Elsevier 2013 104-18

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Neck Circumference

Brodsky JB et al; Morbid Obesity & Tracheal Intubation. Anesth Analg 2002; 94:732-6

Aim to identify factors that complicate DL & intubation

Intubation Difficulties

Neither absolute obesity nor BMI

Large neck circumference & high Mallampati scores

100 Patients - BMI >40 kg/m2 - Elective surgery

PreOperative Measurements - TMD, SMD - Height, Weight - Neck circumference - Mouth opening

Shearer ES; Obesity anaesthesia; the dangers of being an apple. Br J of Anesth 2013; 110 (2):172-4

VISCERAL ADIPOSITY

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Difficult Airway Algorithm


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Basic Management Problems


Difficulty with patient cooperation or consent

Difficult mask ventilation

Difficult supraglottic airway placement

Difficult laryngoscopy

Difficult intubation

Difficult surgical airway access


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Langeron O et al; Anesthesiology 2009; 92:1229-36

Prediction of Difficult Mask Ventilation

‣ Prospective study - 1,502 pts - French university hospital

‣ DMV: inability to maintain O2 sat >92% or prevent/reverse signs of inadequate ventilation during PPMV under GA

‣ Incidence 5%

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Difficult Mask Ventilation Pre-Operative Risk Factors

M ask seal

O besity; BMI >26 kg/m2

A ge >55 yrs

N o teeth

S noring

Langeron O, et al. Anesthesiology 2000; 92:1229-36

>2 risk factors markedly increases risk

53,041 BMV attempts (2004-08) !77 Impossible BMV (0.15%) Inability to exchange air during BMV, despite multiple providers, airway adjustments, or NMB

Independent Predictors: MOANS II M ask seal O pening mouth (III or IV) A dult male N eck radiation S noring

>3 risk factors markedly increase risk for IMV

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Prediction & Outcomes: Impossible Mask Ventilation Review of 50,000 Anesthetics

Sachin K, MD, MBA et al. Anesthesiology 2009; 110

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Impossible Mask Ventilation

Difficult Intubation

4x

Sachin K, MD, MBA et al. Anesthesiology 2009; 110

2 person effort

Large oropharyngeal and/or nasopharyngeal airways

Triple Airway Maneuver - Tilt head - Advance mandible - Mouth open

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Optimal Attempt at BMV

RAMP

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Nissen IPAD

Troop Elevation Pillow

Helps maximize upper airway patency

Improves ventilation mechanics

Lengthens apneic time period to critical hypoxia in massive obesity







Difficult surgical airway access


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‣ Intratracheal jet stylet

‣ Invasive airway access

‣ SGA

‣Oral and nasopharyngeal airways

‣Rigid ventilating bronchoscope

‣Two-person mask ventilation

Techniques for Difficult Ventilation


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SGA placement requires multiple attempts, in the

presence or absense of tracheal pathology

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Incidence ?

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Difficult SGA Placement


In addition to routine airway evaluation tests, whether the LMA can be correctly placed and provide adequate ventilation should be evaluated before inducing GA

• Angle between the oral and pharyngeal axes <90°

• Severely limited mouth opening

• Oropharyngeal pathology

!

!

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Takenaka I et al. Is awake intubation necessary when the LMA is feasible? Anesth & Analg 2000; 91:246-7

Restricted mouth opening

Obstruction of upper airway (at or below larynx)

Distortion/Disruption

Stiff lungs/Spine


Difficult SGA placement: RODS








Difficult surgical airway accessAnesthesiology 2013 118:251-70

It is not possible to visualize any portion

of the VC after multiple attempts

at conventional laryngoscopy

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Incidence 1.5-3%

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Difficult Laryngoscopy


Predicts easy intubation in 95% of cases

!

!

!

<3% need any intubation adjuncts

Likely to require gum

elastic bougie, but no other

adjuncts

easy

COOK MODIFICATION CORMACK-LEHANE CLASSIFICATION

Cook TM; Anesthesia 2000; 55:274-9

grade 1

grade 2a

Associated w/ difficult intubation in 75% of

cases !

Specialist intubation techniques are likely required

restricted difficult

grade 2b

grade 3a

grade 3b

grade 4

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Difficult Tracheal Intubation

Tracheal intubation requires multiple attempts, in the

presence or absence of tracheal pathology

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Incidence 1.2-3.8%


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‣ Awake intubation

‣ Blind intubation (oral/nasal)

‣ Fiberoptic intubation

‣ Intubating stylet-tube changer

‣ SGA as an intubation conduit

‣ Laryngoscope blades of vaying design and shape

‣ Light wand

‣ Videolaryngoscope

Techniques for Difficult Intubation








Difficult surgical airway accessAnesthesiology 2013 118:251-70

S urgery/disrupted airway

H ematoma or infection

O bese/access problem

R adiation

T umor

Difficult Cricothyrotomy: SHORT

Difficult Surgical Airway


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Difficult Surgical Airway

x

Actively pursue opportunites to deliver supplemental oxygen

throughout the process of difficult airway management.

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Anesthesiology 2003; 98:1269-77

Alveolar Oxygen Delivery

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Basic Management Choices


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vsAwake Intubation

Non-Invasive Technique!Initial Intubation Approach

Spontaneous Ventilation!Preservation

Intubation Attempts After!GA Induction

Spontaneous Ventilation!Ablation

Invasive Technique!Initial Intubation Approachvs

vs

Video-Assisted Laryngoscopy!Initial Intubation Approach


Basic Management Choices

Awake Intubation

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Awake Intubation

Invasive Airway Access(b)

SUCCEED

!Non-Invasive Intubation

FAIL

Cancel Case Consider feasibility of Other Options

(a)

Invasive Airway Access(b)


Awake Intubation

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All will work as ventilatory mechanisms

All can be inserted blindly

Few complications w/their use

LMA → SGA Anesthesia (LMA, ILMA, LT)

Awake Intubation: Revisions

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Surgical or percutaneous airway

Jet ventilation, retrograde intubation added

Awake Intubation: Revisions


  Techniques include classic, silk, guide wire (≥ 70 cm), and FOB

  Safe, effective and fast when technique is familiar

  Useful whenever anatomic limitations obscure glottic opening (pathology, CSI, upper airway trauma)

  CAN VENTILATE situations

  May be performed via a catheter (cric or AEC) or via a bronchoscope (rigid or flexible)

  Technique varies with type

of procedure   Vigilance is of the essence   Enk oxygen flow modulator

  OPEN THE AIRWAY !!!!

Invasive Airway Access

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Benumof & Hagberg’s Airway Management, 3rd Edition; 2012.

Indications for Awake Intubation

‣ Previous DI ‣Anticipated DA𝘈

Prominent protruding teeth Small mouth opening Narrow mandible Micrognathia Macroglossia Short muscular neck Very long neck Limited neck ROM Congenital airway anomalies Obesity Pathology involving airway Malignancy involving airway Upper airway obstruction

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‣ Trauma: - Face - Upper airway - Cervical spine

‣ Anticipated difficult BMV

‣ Severe risk of aspiration

‣ Respiratory failure

‣ Severe hemodynamic instability

Indications for Awake Intubation

Artime CA, Sanchez A. Preparation of the patient for awake intubation. In: CA Hagberg (ed) Benumof and Hagberg’s Airway Management 3rd ediiton. Elsevier, St. Louis, pp. 244, 2012

Intubation after Induction of GA

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Intubation Attempts After GA Initial Intubation Attempts

SUCCEED FAIL

Intubation after Induction of GA

From this point onwards consider:

1. Calling for help

2. Returning to spontaneous ventilation

3. Awakening the patient


Face Mask Ventilation - Adequate

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Alternative DI approaches include (not limited to): video-assisted laryngoscopy, alternative laryngoscope blades, SGA (LMA, ILMA) as an intubation conduit (w/ or w/out fiberoptic guidance), fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation.

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Consider/Attempt LMA

Adequate Inadequate

EMERGENCY PATHWAYNON-EMERGENCY PATHWAY

SUCCEED FAIL

Face Mask Ventilation Adequate

Face Mask Ventilation Inadequate


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Consider/Attempt SGA

Adequate Inadequate

EMERGENCY PATHWAYNON-EMERGENCY PATHWAY

SUCCEED FAIL

Face Mask Ventilation Adequate

Face Mask Ventilation Inadequate


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Face Mask Ventilation

ADEQUATE

Patient Anesthetized Intubation Unsuccessful


Alternative Approaches to Intubation

FAIL After Multiple Attempts


Consider Feasibility of Other Options

Awaken Patient

SUCCEED

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Non-Emergency Pathway: Revisions


‣LMA → SGA Anesthesia -LMA, ILMA

‣Video-Assisted Laryngoscopy

Face Mask Ventilation - NOT Adequate

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Consider/Attempt SGA

SGA AdequateSGA NOT Adequate

Face Mask Ventilation NOT Adequate

Patient Anesthetized Intubation Unsuccessful

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Emergency Pathway Ventilation Inadequate

Intubation Unsuccessful

Emergency, Non-Invasive Airway Ventilation (e)


CALL FOR HELP

SUCCEED FAIL


(b)*

Consider Feasibility of Other Options (a)

Awaken Patient (d)

Emergency Invasive

Airway Access (b)*

Beware the inexperienced, ambitious clinician, who offers to help.

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‣ SGA - ETC not mentioned

‣Rigid Bronchoscope - Removed

‣Retrograde & Jet ventilation - Now considered “invasive”

Emergency Non-Invasive Airway Ventilation Revisions


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Airway Obstruction

NON-PATHOLOGICAL ‣ Natural Anatomy

- Tongue ‣ Supralaryngeal ventilatory mechanism

- LMA, etc - Other alternative SGA

PATHOLOGICAL ‣ Abnormal Anatomy

- Cancer - Hematoma - Abscess - Edema

‣ Subglottic ventilatory mechanism - Rigid bronch, TTJV - Surgical airway

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Surgical Technique First Choice

Laryngeal/tracheal disruption

Upper airway abscess or obstruction

Combined mandibular maxillary fractures

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‣ Contents - Alternative rigid laryngoscope

blades

-Videolaryngoscope - Tracheal tubes of various sizes

- Tracheal tube guides

- SGAs

- Flexible fiberoptic scope

- Equipment suitable for emergency invasive airway access

- An exhaled carbon dioxide detector

Suggested Contents Portable Storage Difficult Airway Management

-Retrograde intubation equipment removed !Anesthesiology 2013; 118:251-70

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‣ Devices - Conventional laryngoscope

blades

- Glidescope with stylet

- SGAs (ILMA & Disposable LMA)

- Flexible fiberoptic scope

Most Common Devices in Practice Difficult Airway Management


Extubation ASA Task Force Recommendations

‣ Consider relative merits of awake vs. deep extubation

‣ Evaluate factors that may interfere w/upper airway patency

‣ Formulate a plan for immediate reintubation if the airway becomes compromised

‣ Consider a jet stylet

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Extubation

S uction

O xygen

A irway - BMV, masks not just ETTs

P harmacology

M onitoring

E quipment

SOAP MEDifficult Extubation:

Hilary Klonin

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Lorraine Foley, MD, Tufts Medical School

Communication of the DA

Communication of the DA

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‣ Anticipate the possibility of DA management by performance of a thorough pre-op airway assessment

‣ Secure the airway awake if difficulty is suspected

‣ Have a back-up plan(s) if the initial plan to secure the airway fails

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ASA Difficult Airway Algorithm Take Home Messages

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Experience MattersGood decisions come from experience, unfortunately,

experience often comes from bad decisions.

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Summary

‣ Algorithms only serve as guidelines

‣ Become educated

‣ Equipment must be available

‣ Practice, practice, practice!!

‣ Do what works BEST for you

‣ You CAN make a difference!!

17th Annual Society Airway Management Scientific Meeting

Philadelphia PA September 20-22, 2013

Review of the New ASA Guidelines

Health & Medicine

Transcript of Review of the New ASA Guidelines