Sep - Oct 2013 - Vol.17 Issue 3 The Official Publication of the Society for Airway Management

Inside: New SAM Members Presidents Message Editorial Expressions Preview: SAM 2014 SAM 2013 Meeting WAMM SAM Forum E-Lights Application

SAM Contacts: Telephone: 773-834-3171 Fax: 773-834-3166 Address: 5753 Tanager St. / Schereville, IN 46375 Website: http://samhq.com

Society for Airway Management 2013-2014 Officers and contact information

Board of Directors:

President Richard Cooper, MD

Richard.Cooper@uhn.ca

President-Elect Ashutosh Wali, MD awali@bcm.tmc.edu

Vice President Lorraine Foley, MD ljfoley@comcast.net

Secretary Lauren Berkow, MD lberkow1@jhmi.edu

Treasurer Arnd Timmermann, MD

atimmer@web.de

Immediate Past-President Maya Suresh, MD

msuresh@bcm.tmc.edu

Executive Director: Carin Hagberg, MD

Carin.A.Hagberg@uth.tmc.edu

Board Members at Large:

Ankie Hamaekers, MD a.hamaekers@mumc.nl

Michael Seltz Kristensen, MD Michael.seltz.kristensen@rh.hosp.dk

Richard Levitan, MD airwaycam@gmail.com

Joseph Quinlan, MD quinlanjj@anes.upmc.edu

John Sakles, MD sakles@aemrc.arizona.edu

Felipe Urdaneta, MD furdaneta1@mac.com

Airway Gazette Information

Editor-in-Chief: Katherine Gil, MD

k-gil@northwestern.edu

Associate Editors: Valerie Armstead, MD

vearmstead@gmail.com

Richard Cooper, MD Richard.Cooper@uhn.ca

Administrative Director:

Anne-Marie Prince amprince@peds.bsd.uchicago.edu

Layout Editor:

Kathryn Nicole Gil-Ludmer Issues are published four times per year in the following order: March/April, June/July, September/October, and December/January

Material published in the Airway Gazette is copyrighted through the Society for Airway Management and cannot be reproduced without its written consent.

Submissions for publication should be made according to published guidelines at least one month before the issues are finalized. Submissions must cite material obtained from other sources before publication.

Disclaimer: Published manuscripts in the Gazette are not necessarily reflective of views of the Gazette or the Society for Airway Management.

SAM Connections: The SAM Forum on the Internet Twitter: Look us up on twitter: @WEBPAGESAM Facebook: https://www.facebook.com/pages/SAM/471944679556805?ref=hl

Nick Abbott, MD (New Zealand) Sean Adams, MD (Naperville, IL) Pilar Aguirre Puig, MD (Spain) Engin Ahmed, MD (New Zealand) Kevin Arthur, MD (New Zealand) Shawn Beaman, MD (Pittsburgh, PA) Richard Beck, MD (Jacksonville, FL) Dennis Boon von Ochssee, MD (New Zealand) Jeffrey Brand, MD (Marblehead, MA) Patricia Cardoso Imperatriz, MD (Brazil) Matthew Chia (Peoria, IL) Robert Culver, MD (Ellijay, GA) John Crowe (Little Rock, AR) Dave Duncan, MD (Penryn, CA) Richard Dutton, MD (Park Ridge, IL) Rob Eastan (Brooklyn, NY) Rhashedah Ekeoduru, MD (Houston, TX) Anne Elliott, MD (New Zealand) Suzanne Escudier, MD (Lubbock, TX) Nadia Forbes, MD (New Zealand) Daniel Francis, MD (Houston, TX) Helen Frith, MD (New Zealand) John George, III, MD (Pepper Pike, OH) Yair Grinberg, MD (New Preston, CT) Zoya Haitov, MD (Israel) Deborah Harrison, MD (Stamford, CT) David Harvey, MD (New Zealand) Melanie Hollidge, MD (Canada) Lara Hopley, MD (New Zealand) Grant Lindsay Hounsell, MD (New Zealand) Daniel Howell, MD (Lubbock, TX) Gareth Jenkin, MD (New Zealand) Cynthia Jenson, MD (Waterville, ME) Usha Kolpe, MD (Oak Brook, IL) RJ LaGrone (Benton, AR) Dianne Lieberman, MD (Canada) Laura Lindsay, MD (Boise, ID) Jennifer Linzalone (Plantation, FL) Tracy Lords, MD (Belt, MT) Nathan Luibrand (Little Rock, AR) Issam Mardini, MD (Philadelphia, PA) Alonso Mesa, MD (Weston, FL) Andrew McWilliam, MD (New Zealand) Harry Miller, MD (Beverly Hills, CA) Michael Need, MD (Indianapolis, IN) Duc Nguyen, MD (Los Angeles, CA) Lale Odekon, MD (Brooklyn, NY) Joanne Paver, MD (New Zealand) Allison Pierce (Little Rock, AR) Andrew Pinto, MD (Brazil) Carol Pinto (Santa Barbara, CA) Otoniel Puerto, MD (Sommerset, KY) Devi Pujara, MD (Orwigsburg, PA) Marcelo Ramos, MD (Brazil) Keith Rees, MD (Australia) Grant Ryan, MD (New Zealand) Shilpi Seth (Chicago, IL) Richard Shockley, MD (Wellesley, MA) Stephen Smith, MD (Ballwin, MO) Lawrence Siu-Chun Law (Durham, NC) Tish Stefanutto, MD (Australia) Caroline Solly (United Kingdom) Raji Swamidurai, MD (Chino Hills, CA) Mingjuan Tan (Durham, NC) Jamie Taylor, MD (Canada) Matt Taylor, MD (New Zealand) Jose de Jesus Teran Guevava, MD (Mexico) Cuong Tran (Plantation, FL) Susan Trinh (New York, NY) Albert Varon, MD (Miami, FL) Joanne VonMach, MD (Birmingham, MI) Angela Wang, MD (Fair Oaks, CA) Yvonne Wagner, MD (New Zealand) Joanne Warren, MD (Woodstock, MD) Jonathon Webber, MD (New Zealand) Tina Whitty, MD (Canada) Andrew Wong, MD (New Zealand) Andrew Wong, MD (Philadelphia, PA) Warrick Wrightson, MD (New Zealand) Jinbin Zhang, MD (Singapore)

SAM Presidents Message I am honored to have the opportunity to serve the Society for a second term. I hope that this is a vote of confidence and not a remedial assignment. I was very pleased to see many of you at our Annual Scientific Meeting and Workshop in Philadelphia. Our thanks to the entire Program Committee and especially Chair and co-chair, Drs. Irene Osborn and Valerie Armstead, for organizing an outstanding event. Thanks also to Lynn Hancock and Denise Leary of UMass Medical School Office of Continuing Medical Education and our Executive Assistant Anne-Marie Prince, without whom we would have been lost. For many of us, this meeting is the most valuable academic event of the year. It is a chance to hear and share new ideas in a collegial, almost intimate atmosphere. Although our membership continues to grow, the meetings are still a size that allows a free and productive exchange of ideas. Next year our annual meeting will take place in Seattle, WA, September 19-21. Drs. Valerie Armstead and Felipe Urdaneta are the program co-chairs and they are excited about the arrangements that are beginning to emerge. Plan to come early. We hope to have special pre-course satellite offerings. Plan to stay late. Seattle is an exciting place. This year for the first time, in cooperation with Cooper Medical School at Rowan University, we offered a MOCA course on clinical simulation. Amanda Burden reported that this was very successful and rewarding for the participants. Plans are underway for the World Airway Management Meeting in Dublin, Nov 12-14, 2015. Past-Presidents Elizabeth Behringer (SAM) and Ellen OSullivan (DAS) are the Planning Committee co-chairs. This is the most ambitious international airway meeting ever undertaken and it promises to be an exceptional event. In addition to the principal co-sponsors, SAM and DAS, other national societies will participate. Dr. Behringer will provide us with an update as the scientific program and social activities are more fully developed. Mark your calendars. This meeting is in lieu of the 2015 annual meetings of our respective societies. We are pursuing our discussions with the Anesthesia Quality Institute concerning the objective of a nationwide collection of data to improve patient safety, and will keep you informed as things progress. Dr. Hagberg and I met with Dr. Richard Duggan, AQI Executive Director, and were very encouraged regarding this collaboration. The ASA has agreed to establish a prestige lectureshipThe Ovassapian Lecturethat will take place in alternating years during the ASA Annual Meeting. I am pleased to announce that Past-President Dr. William Rosenblatt has accepted our invitation to be the inaugural speaker in 2014. Our Society continues to grow. We have new SAM Chapters in China, Saudi Arabia, Brazil, and New Zealand. We enlisted many new members during the ASA Annual Meeting, including several medical students. Such early enthusiasm heralds an exciting future for airway management and likely reflects an encounter with a dynamic mentorquite possibly someone reading this message. Thank you. Quality teaching encourages research; both will advance patient safety. Finally, I want to draw your attention to the monumental efforts of Dr. Felipe Urdaneta in creating a new SAM website and leading us into exploring social media as a professional society. I invite you to check out 4.

our website (www.samhq.com), our Facebook page, and twitter feed. Youll find links to these pages on the upper right hand corner of the home page. Youll also see our world-wide impact on the membership map, photos of meetings, selected videos from our annual meeting, archived copies of the Gazette, committee reports, minutes of meetings, and much more. A great place to while away the hours. Want to become more involved? Get in touch. Richard Cooper, MD, President, Society for Airway Management

Dear colleagues My deepest appreciation goes to the phenomenal work done by Dr. Irene Osborn and Dr. Valerie Armstead and all the members who made the Society for Airway Managements Annual Meeting so superb! Also, I have a great appreciation of the participants for their enthusiasm and desire to help improve patient care. And particularly, I wish to send heartfelt thanks to those members that accepted and completed the task of writing some synopses for the Airway Gazette to benefit fellow members, who were unable to attend the meeting.

Luckily for everyone, I am going to have very few remarks in this editorial. In fact, with the kind permission of Dr. Daniel Perin, who you may recall, formed a SAM Chapter in Brazil, I am going to quote his words here now. These were originally included in his synopses and I thought they reflected the feelings I have heard expressed many times from SAM Meeting participants: Once again I need to say that the SAM meeting was amazing. Great lectures, awesome workshops, and what I think are the most important things, the kindness and attention of all the experts while interacting with the audience.

Last but not the least, I want to thank Dr. Irene Osborn and Dr. Valerie Armstead for the great meeting and extraordinary dinner event and all the Staff who turned SAM into the top-of-the-list meeting, that makes me travel every year since 2008 in Boston, to meet wonderful people and discuss everything about Airway Management." Daniel Perin, M.D.

Congratulations to Dr. Elizabeth Cordes Behringer! And, an even bigger congratulation to the Society for Airway Management, which was fortunate to have benefitted from all of her leadership, devotion, and energies for so many years, and rightly presented Dr. Behringer with the 2013 SAM Distinguished Service Award. Look for the next issue of the Airway Gazette for a description of how valuable she has been. Also, that issue will have the 2013 meetings award-winning presentations, a historical vignette, meeting pictures, and more. Please send messages to the Forum and especially, send in something for the Airway Gazette! With the idea of making the Airway Gazette more linked to the SAM website and so forth, I have changed its appearance it is evolving and I hope no shoes will be thrown at me write a Letter to the Editor, instead. Best regards, Katherine S.L. Gil, M.D., Editor-in- Chief

Editorial Expressions

SAMS Official Journal:

The

Journal of Clinical

Anesthesia

Q U O T E

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Preview: Society for Airway Management Annual Meeting 2014 The organizing Committee in charge of our next Society for Airway Management Annual Meeting, headed by Dr. Valerie Armstead and Dr. Felipe Urdaneta, has been working hard to bring SAM 2014 meeting attendees an exciting and novel program with workshops and activities that will provide long-lasting, pleasant memories. This meeting will take place in the awesome city of Seattle, Washington, on September 19-21, 2014. Changes and advances in the field of airway management, in terms of education, simulation, and research have been impressive and we are planning a program to reflect the latest improvements in core topics of airway management. This years motto is Back to the Future. The program, speakers, and workshops are being assembled to reflect progress and advances in topics first discussed decades ago, but still more relevant than ever. We have listened to what SAM members have requested, not just with regard to selection of speakers and topics, but also regarding small group sessions, audience response sessions, and workshop formats. We plan to announce the final program in the near future. Fig 1. Nice airway The 3-year old format, used in Scottsdale, Toronto, and Philadelphia for the workshops, will continue. They will be organized by Drs. Lauren Berkow and Ashu Wali. Participants can pre-register for a limited number of stations, which will allow for a more structured and organized experience. Drs. Ankie Hamaekers and David Wong will organize the abstract selection process, abstract sessions, and poster presentations. For the first time we will use a web-based submission process via our SAM web page. We are looking forward to again having the tremendous success reflected by participation from people all over the world. The awesome city for the meeting: Seattle was named after the native-American chief, Siahl, and nicknamed the Emerald City because of the abundance of green forest. Its climate in September usually ranges from

50F at night to mid 70F in the day. It is one of the fastest growing cities in the United States. Seattle is located in the Pacific Northwest, 113 miles (182 km) south of the U.S. Canada border. The city is known for a number of famous residents (Paul Allen, Bill Gates, Apolo Ohno, Margaret Murie, Nate Robinson, Ron Santo, Quincy Jones), many television series (Frasier, Greys Anatomy), and movies (Sleepless in Seattle, An Officer and a Gentleman). One of its best landmarks is the famous Space Needle, which was built in 1962. There are other important attractions such

Fig 2. Mt. Rainier as the Seattle Art Museum, Woodland zoo, the oldest farmers' market in the United States (Pike Place Market), and the first Starbucks coffee shop, still in its original 1971 location. But, without question, the most spell-binding site near Seattle, is the ever-present Mt. Rainier.

We look forward to seeing everyone there. Please watch for updates: homepage, Facebook, and Twitter. 6.

Dr. Carin Hagberg presented: The ASA Difficult Airway Guidelines: Whats New? She noted that management of the difficult airway (DA) remains a challenge and the incidence of an unanticipated DA is 1-3%. Although inadequate oxygenation and/or ventilation in operating rooms (OR) have become less common, these problems plus difficult intubation or aspiration numbers are rising in non-OR locations, due to over-sedation and lack of end-tidal capnography and pulse oximetry.

Dr. Hagberg reviewed the 2013 updates to the 20-year-old Difficult Airway Algorithm (DAA). They include a definition of difficult supraglottic airway (SGA) placement or ventilation. Difficult SGA placement indicates multiple attempts due to lack of seal or excessive resistance to movement of gas. Causes include RODS: R - Restricted mouth opening, O - Obstruction (upper airway), D - Distortion or Disruption (upper airway), or S - Stiff lungs. Any RODS history should be noted prior to airway management. Factors associated with difficult laryngoscopy must be identified prior to management. A mnemonic for patients at risk for difficult surgical airway is SHORT: S - Surgery or disrupted airway, H - Hematoma or infection, O - Obesity (of neck), R - Radiation (of neck), T - Tumor. Difficulty identifying the patients cricothyroid space should prompt consideration for deciding upon an awake intubation. Video-laryngoscopes (VL) in the 2013 DAA can be used as an initial device for asleep or awake intubations or after traditional-blade failed intubation. It is one of the biggest changes and is listed as a suggested device in portable DA carts. The name, Laryngeal Mask Airway (LMA) has been replaced in the DAA by supraglottic airway (SGA). Included in this category are the LMA, Fastrach, iGel, Air-Q, Laryngeal Tube, and so forth. The Combitube and rigid bronchoscope are no longer specifically mentioned, although it is possible to use devices not mentioned. Retrograde intubation and jet ventilation are listed with surgical or percutaneous cricothyrotomy as invasive techniques but retrograde intubation has been removed from a list of suggested devices in a DA cart because of excessive time needed. A plan for extubation of DA patients must also be made preemptively. TAKE HOME MESSAGE: A through airway history and examination is critical. Know the 2013 DAA. Remember SHORT and RODS.

SAM 2013 ANNUAL MEETING SYNOPSES

Moderator: Richard Aghababian, M.D.

The ASA Difficult Airway Guidelines: Whats New? Carin Hagberg, M.D.

synopses authored by Beth Ann Traylor, M.D.,

Indianapolis

Session I Airway Collaboration I

7.

The Difficult Airway Response Team - Ongoing Results/Challenges discussion was

undertaken by Dr. Lauren Berkow and Dr. Lynette Mark. The DART program, at Johns Hopkins is a multidisciplinary team of anesthesiology, otolaryngology, surgery, and emergency medicine attendings and residents, begun in 2008. It serves to provide safe intervention for airway emergencies, dissemination of information to other health providers, and education, including all-day simulation courses four times a year. High-risk patients are identified with DA bracelets and DA letters. Relevant information is communicated during handoffs and documented in medical records. Uniform DART carts are present in multiple locations. Since the inception of DART, the program has responded to 7-10% of code calls, had over 150 residents complete the airway course, noted a significant decrease in airway-related non-OR events, and observed improved resources inside the OR for unanticipated difficult intubations. Standardization and a team approach have impacted outcomes. Change takes time and money. The OR still plays an important role in completion of non-OR airway management, including less frequent, but more complex pediatric DA management. TAKE HOME MESSAGE: A multi-disciplinary team aimed at patients with complex airway issues, has proven successful to reduce the incidence of sentinel airway-related events at Johns Hopkins. They suggest that everyone consider organizing a similar team at other institutions. Dr. Scott Weingart introduced the concept of being a resuscitationist during his presentation of Airway Management in the Emergency Department - Whose Turf is it? In the emergency department (ED), 1/25 patients requiring emergency intubation are likely to have cardiac arrest. Regardless of specialty, the resuscitationist must consider the patients pathophysiology; have a plan for airway management, a reviewed checklist, and a plan (if required) for a surgical airway. To avoid arrest, the resuscitationist must work to optimize conditions prior to intubation and remember HOP: H - Hemodynamics (optimize them), O- Oxygenation (maximize it), P ph (reduce acidosis). If intubation is indicated, there must be adequate patient preparation and proper equipment, including DA adjuncts. If a surgical airway is required, decision-making to do so is the hardest part. This concept was reiterated several times at this meeting. A quick and easy way to do a surgical airway is the bougie-aided cricothyrotomy requiring a scalpel, finger, and bougie. TAKE HOME MESSAGE: The ED is often different from the operating room, requiring hemodynamic resuscitation of patients as the initial maneuver and then airway management. Decisions for surgical airway should be made early, before it is too late.

Difficult Airway Response Team Ongoing Results/Challenges

Lauren Berkow, M.D., Lynette Mark, M.D.

Airway Management in the Emergency Department - Whose Turf is it? Scott Weingart, M.D.

8.

During the lecture titled: Collaboration with ENT: What can we learn, what can we teach? Dr. David Healy emphasized this sentence: Standardize what you can and communicate what you cant. Talking improves patient care. It is clear that communication with each team member involved with the case (anesthesia, staff, surgeon) is fundamental for patient safety. He also commented about Lean Project. Lean is a management system designed to enhance productivity by eliminating causes of time wastage, resources, and ineffective activity. The application of this technique to a single operating room and surgical service improves efficiency and morale, sustains resident education, and can provide considerable financial gains. Identification of MUDA (major areas of waste) and thinking about solutions will help everyone to improve quality and security. Dr. Healy also stressed that it is important to reach a consensus where you can: preoperative, intraoperative or postoperative. Keyword: COMMUNICATION. Dr. Keith Haller, during the lecture Evolution of new pediatric airway techniques and algorithms, reported on the largest case series (350), using video-laryngoscopy in pediatric patients with airway anomalies. Infants, children and young adults with congenital vascular and lymphatic malformations of the head and neck present a unique set of challenges to the anesthesiologist. Methodology included inhalational induction of general anesthesia, maintaining spontaneous respiration, obtaining intravenous access, and administering appropriate doses of Fentanyl and Propofol before instrumentation of the airway. Then, laryngoscopy was performed with an age-appropriate size of GlideScope video-laryngoscope (Verathon, Inc.). Patients who could not be intubated with this technique were submitted to another technique including combined GlideScope VL / fiberoptic bronchoscope (FB), FB alone, or a Lindholm bivalve laryngoscope with zero degree rigid scope.

Moderator: Valerie Armstead, M.D.

Collaboration with ENT: What can we learn, what can we teach David Healy, M.D.

synopses authored by Daniel Perin, M.D.,

Brazil

Session II Airway Collaboration II

Evolution of new pediatric airway techniques and algorithms Keith Haller, M.D.

9.

The benefits to anesthesiologists were: a database for visual airway history and physical inspection. Twelve teaching modules in a 2-DVD set were divided into three categories: 1) teaching for successful laryngoscopy, 2) adapting to various anatomical challenges, and 3) diagnostic use of video-laryngoscopy. The benefits to surgeons were acquiring therapeutic strategy-planning and decision-making capabilities. Finally, the benefits to patients were visual tools for teaching parents and patients, and the development of the Airway Passport. This Passport concept was very interesting. A DVD/USB copy of the laryngoscopy can be given to the patient in a manner similar to medical alert bracelets and in case of an emergency surgery in which anesthesia is required. An anesthesiologist unfamiliar with the patient can view the videos and know what to expect on intubation. Keyword: AIRWAY PASSPORT. Dr. Katherine Gil talked brilliantly about Medical missions Who should go? What should they bring? It was a great lecture and also an excellent guide to everyone who wants to go to a mission abroad. You need to think about what equipment you will have to carry and how to adapt this equipment and any existing equipment according to the reality of the mission site. Decide what kind of mission you are more inclined to (routine or disasters) and try to figure out what are the mission supports because they can be very variable. Anticipate medical mission effects and assess mission fitness. Participating in a mission means that you will need to have good qualifications, good professional skills, and great adaptive skills including language skills. You will need to ask some questions: What is missing? Do we have professional resources? Look for free medical supplies for physicians on various Internet sites, try to use your networking, and consider enlisting a biomedical engineer and/or an anesthesiology technician. Whatever missions you decide to go on, check it out for safety/efficacy and try to resolve problems in a smart way. Dont forget about possible negative mission effects like multiple vaccinations, anti-malarial drugs, health risks, loss of vacation time, debriefings, media interviews, and be prepared for some missions where people will die! Be sure that you will benefit from the positive mission effects: privilege of assisting patients, learning what floor nurses do, working with caring people, incredible memories, and finally many wonderful people. Keyword: PREPARE YOURSELF.

Find all the information you need on the SAM website at http://www.samhq.com

Airway Gazette publishing guidelines are also on the website

Medical missions Who should go? What should they bring? Katherine Gil, M.D.

During his lecture entitled, Research in Airway Devices: What Questions Should We Be Asking? Dr. Michael Aziz explained different study designs (cohort, observational, randomized controlled trials, and systematic reviews). He emphasized the FINER criteria: 1) Feasible: ask yourself a question and fine tune a hypothesis, conduct a power analysis, and use collaboration with others such as statisticians, epidemiologists, and experts 2) Interesting: you must be interested and the reader must be, too; ask your colleagues to give their opinions 3) Novel: try approaches that havent been studied 4) Ethical: use the local research integrity offices 5) Relevant: ask yourself if the subject will change your practice, if it will definitely answer the question, or will it guide future research In conclusion, research ideas should be first exposed to the FINER criteria and ensure that the study is feasible and relevant. Also, the effect size and the sample size estimates are critical. And, if possible, it is always good to try something new.

Simulation Research: Are Trainees the New Guinea Pigs? was presented by Dr. Meltem Yilmaz and Dr. Ljuba Stojiljkovic who stated that the technical skill learning curve in airway management consists of three phases: cognitive, integrative, and automatic. The cognitive phase consists of observing a procedure and trying to replicate observations. During training, this phase is prone to cognitive errors. It was affirmed that we have two types of thinking: System 1: Intuitive and System 2: Rational. System 1 is automatic, neglects ambiguity, and suppresses doubt. It executes skilled responses and generates skilled intuitions after adequate training but is prone to bias because it relies on the most readily available answers and

Moderator: Arnd Timmermann, M.D.

Research in Airway Devices: What Questions Should We Be Asking?

Michael Aziz, M.D.

synopses authored by Mauricio Amaral, M.D.,

Brazil

Session III Collaboration in Research

Simulation Research: Are Trainees the New Guinea Pigs? Meltem Yilmaz, M.D., Ljuba Stojiljkovic, M.D.

11.

is not capable of statistical thinking. System 2 is slow and easily distracted or overwhelmed. It is responsible for editing, questioning, and correcting. It is directly impacted by time pressure and can easily defer to system 1s conclusions. It requires continuous exertion: vigilance. Its clinical effect on trainees, include dilated pupils and increased heart rate. The imbalance between these two systems leads to judgment errors and bias. The concept of cognitive ease is what makes one susceptible to illusions, while cognitive strain shifts one from intuitive to analytic thinking. Unless System 2 is activated, judgment and decisions will be shaped almost exclusively by bias and illusion/intuition. It was concluded that in the case of emergency airway training, selection and order of presentation of examples and stimuli affected decision-making and vulnerability to cognitive bias and the curricular design should consider potential effects of cognitive bias and errors. Dr. Yandong Jiang discussed Ventilation via the Nasal Route: Implications for Resuscitation. He showed that in 2010, the American Heart Association guideline for cardiopulmonary resuscitation stated that for most adults with out-of-hospital cardiac arrest, bystander CPR with chest-compression-only resuscitation appeared to achieve outcomes similar to those of conventional CPR. However, for children, conventional CPR was superior. He explained that one recent finding published in 2011 in the BMJ stated that conventional CPR was associated with better outcomes than chest compression-only CPR for one-month survival and neurologically favorable one-month survival. Dr. Jiang also showed studies indicating that the nasal route is better than the oral route for ventilation in three scenarios: under general anesthesia, during sleep, and during pediatric CPR. He compared nasal-mask ventilation versus face-mask ventilation, and mouth-to-mouth breathing with the head in neutral or extended positions versus mouth-to-nasal breathing with the head in neutral or extended positions. The study concluded that nasal-mask ventilation produced more effective ventilation than that by face-mask. Also, mouth-to-nose breathing was more effective than mouth-to-mouth breathing with the head in a neutral position. Finally, he concluded his lecture by saying that the nasal route ventilation is more effective than oral route in emergency situations but the efficiency and effect on outcome of the victim requiring CPR remains to be established. We need more research to decide if ventilation should be abandoned during field CPR.

For All SAM MEMBERS

We all appreciate getting tips on airway management Please help your colleagues: Send in your TIPS and TRICKS, case reports,

ideas for topic reviews, work projects, and/or research. E-mail k-gil@northwestern.edu

Ventilation via the Nasal Route: Implications for Resuscitation Yandong Jiang, M.D.

synopses authored by Katherine Gil, M.D.,

Chicago

The DAS Speaker, Dr. Peter Groom, began his explanation of Management of the Anticipated Difficult Airway with a description of the fascial deep neck spaces. Their importance is due to intercommunication where cases of infection can spread extensively, leading to upper airway obstruction with high mortality rates (mediastinitis 40-50%, carotid artery rupture 20-40%, Lemierres syndrome 60%) and possible osteomyelitis causing spinal cord injury. The five deep spaces are shown in figure 1. Infections can spread wickedly fast in diabetics or immunosuppressed patients and usually are due to odontogenic causes in adults or tonsillitis in children.

To complete a thorough preoperative assessment, he emphasized analyzing answers to six questions: Fig. 1 Middle: five spaces 1) How much time is there? Nonerequires immediate action Some timeactions may improve or worsen the time frame Enough timethese latter two can be differentiated by symptomatology (degree of sepsis, trismus, temporomandibular joint involved, stridor, dysphagia, drooling, and/or immobile tongue). Nasal endoscopy and radiologic studies may help. 2) Which spaces are affected? Floor of the mouth is most worrisome for airway compromise Submasseteric is a lesser concern Ludwigs angina is associated with very rapid infectious spread 3) How compromised is the airway? Any of the symptomatology mentioned may reflect compromise. Plus, how septic the patient appears, whether there is rigidity of the mouth floor, mediastinitis, extensiveness of cellulitis, and the likelihood of performing a successful tracheostomy are factors for consideration. 4) What airway access is feasible? nose, mouth, neck 5) Which airway management plan is best? 6) What could make the situation worse? such as Direct laryngoscopy (DL): rupturing an abscess, airway soiling, failed intubation, trauma, edema Awake nasal intubation: Similar to DL, plus excess sedation, epistaxis Awake tracheostomy: trachea not found, airway loss, bleeding, and infection

He advised that a clear understanding of the situation, equipment preparedness, and colleague consultation might be of prime importance.

Dr. Groom finished the session by reminding everyone of the post-operative concerns, such as whether or not the patient needs to remain intubated. Knowledge of the possibility of worsening edema, airway monitoring,

Moderator: Richard Cooper, M.D.

DAS Speaker: Management of the Anticipated Difficult Airway

Peter Groom, M.D.

Session VI Plenary Session

DAS Representative

13.

and communication of patient problems prominently displayed, are all valid points to keep in mind. When planned difficult extubation is considered, appropriate plans and settings should be investigated. LTC Robert Mabry, MD gave an overview of Lessons from the Battlefield: Airway Casualties and Preparedness that kept hushed participants on the edges of their seats with an engrossing video of trauma occurring to an actual soldier during battle, up to the point of assistance from his companions.

Dr. Mabry emphasized the differences associated with military casualties including the fact that the battlefields are often in close proximity to hospitals. Fellow military personnel frequently manage injured patients in dark, noisy surroundings. These assistants are often comrades in peril, attempting to give medical treatment and often, what often amounts to life-saving care from only a backpack full of equipment. Casualties are more likely to be multiple and have distinct injuries.

Commonly, combat medics and corpsmen have EMT-B level training, mostly on mannequins, including SGA and surgical cricothyrotomy (CT) and often are in combat for the first time. Most medical officers are primary care specialists with training including rapid sequence induction and intubation. Often there is no oxygen, suction, or refrigeration.

Outcomes for prehospital combat patients included correctly placed endotracheal tubes in 94% of patients. In contrast, for most vertical incision CT, success was noted to be ~75%. Dr. Mabry presented an algorithm for improved CT success shown in figure 2. He described a study on cadavers comparing standard CT to a bougie style device allowing for visual and tactile confirmation of CT placement. This latter device was associated with faster CT placement and much more successful intratracheal placement.

Future problems needing resolution within the military arena included optimal traumatic brain injury management in the field, a consensus as to which is the best SGA, sedation options, technology advances such as a small end-tidal carbon dioxide monitor, and training of medical personnel.

Dr. Eric Hodgson presented a discussion of the Management of Difficult Airways with Limited Resources, starting with the three As of airway management: 1) Assessment of laryngoscopy and mask ventilation with rescue backups as either supra or infraglottic, 2) Apparatus location, and 3) Attempt at optimal laryngoscopy. Difficult laryngoscopy in turn was more likely in the presence of the four Ds: 1) Distortion of airway, 2) Dentition problems, 3) Disproportion of anatomic structures, and 4) Dysmobility of neck and so forth.

Ovassapian Lecture: Lessons from the Battlefield: Airway Casualties and Preparedness

LTC Robert Mabry, M.D. Ovassapian Memorial Lecture

International Speaker: Management of Difficult Airways with Limited Resources Eric Hodgson, M.D.

International Lecturer

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Supraglottic difficulty was anticipated with the mnemonic, RODS: Restricted mouth opening, Obstruction of upper airway, Distortion/disruption of trachea, and Stiff lungs. Infraglottic difficulty could be suspected with the mnemonic, SHORT: Surgery in the area, Hematoma or other problem causing impalpability of the CT space, Obese or impossible access, Radiation or Trauma in the neck. Dr. Hodgson remarked on how anesthesia providers had to choose equipment that everyone would come to know, do this wisely in terms of cost, and had to be resourceful when equipment was unavailable.

He described cheaper single-use fiberscopes that possibly could be re-used in limited resource situations. He showed pictures of a cut oropharyngeal airway adapted as an intubating oral airway. Retrograde intubation is a commonly used, cheaper technique for difficult intubation patients when significant desaturation is not present.

Dr. Hodgson favoured training teams in practice simulation scenarios. He advocated optimization of airway maneuvers, including experienced providers, optimal position, sufficient assistance, appropriate devices, and adjuncts.

If the ETT goes into the esophagus, he suggested keeping it there to allow removal of gastric contents and prevention of a repeat occurrence of this happening. Reverse transillumination for intubation and radiologic support are also worthwhile.

He also advocated improving the lost art of facemask ventilation skills by obligating the mask ventilation of all patients for the first 20 minutes of anesthesia (where not contraindicated). Similarly, he recommended increased use of blind nasal intubation (while utilizing cuff inflation to direct the tip anteriorly) and the use of VL. He also advised that airway management providers should try to obtain Combitube and CT experiences.

Particularly, Dr. Hodgson observed that for ecological and economical purposes, many devices considered disposable or having limited reusability, are being reused many times after appropriate cleaning (such as the 40-use LMA, which in South Africa may be used over 140 times). The lecture titled: Intubation Via a Supraglottic Device, was thoroughly detailed by Dr. David Wong. He initially discussed the 2013 ASA Difficult Airway Algorithm and paid particular attention to the steps that occurred in sequence subsequent to unsuccessful beginning attempts at intubation. The next step was an attempt at facemask ventilation. If this is proved to be unsuccessful, SGA or attempts at other methods of intubation were the succeeding steps. He compared this to the 2004 DAS Difficult Airway algorithm, which after initial intubation failure, quickly moves on to placement of ILMA or LMA devices as a plan B, followed by intubation through either device. Plan C reverts to face mask ventilation if plan B is unsuccessful for oxygenation through either of the two devices.

SAM 2013 SYNOPSES Part Deux

Moderator: Lorraine Foley, M.D.

Intubation Via a Supraglottic Device David Wong, M.D.

Session VII How I Do It Some Real World Solutions

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Dr. Wong described several SGA devices which permitted passage of a full adult-size ETT, including the ILMA (Fastrach), air-Q, and i-gel and noted that others brands were also available. In contrast, LMA variants such as Classic, Supreme, or Proseal have problems with passage of these sizes for various reasons (tube size, aperture bars, and so forth) and require insertion of some sort of introducer (such as an Aintree catheter through these SGA devices with a secondary step of railroading an ETT over the introducer catheter. He described the advantages of intubating through a SGA, including: use for unanticipated difficult intubation, patient being asleep and paralyzed, ability to use SGA devices in bloodied or collapsed airways (bloodied material within the SGA should be suctioned before passing the ETT), and ability for SGA rescue ventilation. Lastly, Dr. Wong indicated what should be done for cannot intubate, cannot ventilate situations in the following steps: 1) Remove SGA and perform FOI 2) Remove SGA, and use a GlideScope 3) Remove SGA, place an intubating SGA, and intubate through it 4) Intubate via the SGA Dr. Sonia Vaida spoke expertly on the topic of Exchanging a Combitube / Easy-tube / King LT for a Definitive Airway. She described endoluminal exchanges (Endo E) with exchange catheters (fiberoptic or blind wire-aided) and extraluminal exchange (Extra E) methods. Extra E methods may require at least partial deflation of the devices cuff (note that the King has a single inflation design for both cuffs, as opposed to the other two devices, which have separate cuff inflations. For the Extra E method, a pediatric fiberscope is passed intranasal and the pharyngeal cuff is deflated to allow passage toward the larynx. Even partial deflations of the pharyngeal cuffs however, often still allow relatively adequate seals and oxygenation/ ventilation. Increased muscle tone and spontaneous movement of the epiglottis and vocal cords during spontaneous ventilation improve identification of the epiglottis and larynx. Endo E usually take ~40% less time than Extra E which average ~110 seconds, with advantages of coursing a shorter distance and allowing continued oxygenation/ ventilation. Problems with exchanges include: 1) loss of airway, 2) the need for assistance, 3) complexity of procedure, and 4) through the King LT, cuff deflation may not allow ventilation because both cuffs deflate simultaneously.

The introduction of Pediatric ICU Patient, Re-intubation! by Dr. Paul Baker was prefaced by statistics showing that 35% of pediatric ICU patients requiring intubation have moderate or severe tracheal injury and unplanned extubation averages 0.1 to 2.3 events per 100 intubation days. Of these, 1% suffers cardiac arrest.

Exchanging a Combitube / Easy-tube /King LT for a Definitive Airway

Sonia Vaida, M.D.

Pediatric ICU Patient, Re-intubation! Paul Baker, M.D.

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Risk factors for reintubation include prolonged mechanical ventilation, caregiver activity, sedation within two hours, copious secretions, and full ventilation at the time of the incident. The ICU setting can be problematic if information, familiarity, equipment, or assistance is missing. He recommends that the patients cardiovascular status is optimized, the patients history and physical examination (including airway) should be known, oxygenation is maximized, equipment is prepared, experts and expert assistance is available, sedation/relaxants are available, monitoring is prepared, and a thorough management plan is created. If necessary, patients should be transferred to more familiar surroundings such as the operating room for those airway providers that are more comfortable there. High flow nasal or oropharyngeal oxygen cannulae may be particularly beneficial when applied concomitantly during airway control procedures. More than 2 attempts at laryngoscopic intubation were more commonly associated with problems compared to 2 attempts in a study by Mort TC (Anesth Analg 2004). Problems in the more than 2 attempts at intubation group included seven times (7X) the occurrence rate for hypoxemia, 10X for regurgitation, 14X for aspiration, 14X for bradycardia, and 16X for cardiac arrest. Those patients also had 5X the incidence of awareness. Finally, Dr. Baker also emphasized the importance of timing and thoroughly planned management of extubation in these patients. Dr. John Sakles had the Pro side in the debate over: Video-Laryngoscopy vs. Direct Laryngoscopy in Pre-Hospital Airway Management. Aside from better teaching, there were many patient benefits that favoured VL. He noted multiple studies indicating the better views of the larynx, higher success at difficult intubation, and greater rescue of patients with VL (such as after intubation failed by direct laryngoscopy). In addition to this, the shorter learning curve made sense to use this technique in pre-hospital airway management. Dr. Richard Levitan advocated for direct laryngoscopy, emphasizing reported complaints during VL intubation attempts: the view of the larynx is wonderful, but the endotracheal tube cannot be inserted through the larynx. He also cited problems with VL such as increased time needed for intubation compared to direct laryngoscopic intubation, complications unique to VL, equipment failure, the possibility of blood or secretions obscuring the view when using VL compared to direct laryngoscopy, and costs.

Moderator: Felipe Urdaneta, M.D.

Video-Laryngoscopy vs. Direct Laryngoscopy in Pre-Hospital Airway Management

Pro: John Sakles, M.D. vs Con: Richard Levitan, M.D.

Session VIII PRO-CON Debates

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Dr. Michael Seltz-Kristensen took the Pro side in favour of taking a look at a patients airway before inducing general anesthesia, in situations where there was any doubt as to the presence of an easy airway. He cited factors such as gaining information prior to difficult airway management rather than approaching the situation blindly. He also noted Dr. William Rosenblatts study on nasal endoscopy and association with the prediction of difficult airway management. On the other side, Dr. Ralph Slepian presented arguments against the idea of: If You Can See It, Put the Patient Off to Sleep! The Awake Look. He noted no documented large prospective studies on difficult airway patients and the success of taking a look beforehand. He also cited a number of occurrences when the airway was very difficult to handle once anesthesia was induced and muscle tone was lost, even though the quick look indicated otherwise. Dr. Paul Baker was very much in favor of the Pro side of the statement: Muscle Relaxants Are Preferred for the Anticipated Difficult Airway in Pediatrics. He emphasized the fact that laryngospasm is the most common cause of respiratory factors resulting in cardiac arrest in these situations. He noted that muscle relaxants (succinylcholine) are more likely to allow mask ventilation and difficult intubation and do less disservice than the deeper anesthetic that would be otherwise required. Trauma to vocal cords and secondary respiratory consequences of difficult intubation are also less frequent with muscle relaxant. Dr. Narsimhan Jagannathan itemized problems with muscle relaxants such as the need to provide positive pressure ventilation (less hands free), the difficulty to reverse non-depolarizing muscle relaxants within a short period of time, and the possible inability to oxygenate/ ventilate if there is airway compression. He also noted that advantages of continued spontaneous ventilation, in addition to the opposite of the above situations, included a better setting for inexperienced clinicians and the possibility that some patients might have a bad reaction to muscle relaxants.

If You Can See It, Put the Patient Off to Sleep! The Awake Look Is a Valid Technique vs. Not

Pro: Michael Seltz-Kristensen, M.D. vs Con: Ralph Slepian, M.D.

Muscle Relaxants Are Preferred for the Anticipated Difficult Airway in Pediatrics vs Not

Pro: Paul Baker, M.D. vs Con: Narsimhan (Sim) Jagannathan, M.D.

The Society for Airway Management is a 501(c)(3) or not-for-profit organization

Dr. Patrick Olomu (Airway Teaching in Nigeria: Challenges and Rewards) related his experiences in Nigeria, of conducting airway training for Nigerias first organized advanced airway workshop. He met health leaders, including the Nigerian Secretary of Health and obtained firsthand knowledge on the state of anesthesia care. There is less than one anesthesia provider per 170,000 residents. One out of every 100 maternal deaths is directly related to anesthesia.

Challenges included: faculty training, transportation, funding ($25,000 in equipment and supplies were donated), personal security, and resistance by US companies to do business with Nigeria.

Goals were airway education, training of super users to oversee other learners, and networking activities for anesthesia providers and other healthcare personnel involved in airway management. The two-day curriculum included a workshop so popular that the faculty had to repeat it. One hundred and fifty eager participants received a DVD of reference materials and certificate of course completion.

Dr. Olomu presented two cases in which donated equipment and skills learned in the workshop proved to be lifesaving.

Future goals include obtaining more supplies, ongoing training sessions, establishment of an online airway forum, and support /encouragement of anesthesia resident training to grow in the anesthesia workforce.

Dr. Elizabeth Behringers topic, Airway Equipment Guidelines: Is Recycling an Option? gave a very timely discussion of considerations in the evaluation process for choosing reusable over disposable equipment. Cost per use, environmental sustainablilty, and mandates of cleaning/processing equipment were cited as factors to determine the break-even point in the example of fiberoptic bronchoscope use. Analysis showed that fewer numbers of FOB use per month favored disposable equipment. Another analytic tool, lifecycle assessment of a device, favored reusable Laryngeal Mask Airways over disposables due to environmental impact from manufacturing and packaging polymer production. The risk of infection from equipment was highlighted by a report of five neonatal illnesses and two deaths attributed to pseudomonas from laryngoscope blades. Health Care Infection Control Practices Committee (HICPAC), JCAHO, and the CDC have since designated laryngoscope blades and handles as semi-critical

Moderator: Ashutosh Wali, M.D.

Airway Teaching in Nigeria: Challenges and Rewards Patrick Olomu, M.D.

synopses authored by Marie Young, M.D.,

Philadelphia

Session IX Current and Future Trends

Airway Equipment Guidelines: Is Recycling an Option? Elizabeth Behringer, M.D.

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devices, needing high-level disinfection and sterilized blade packaging. JCAHO has deferred to individual state mandates regarding sterilization as applied to handles. Dr. Behringer cited barriers to effective changes in behavior for personnel, including low infection risk, financial/logistical factors, and staff apathy. She concluded by reminding attendees of Dr. William Rosenblatts not-for-profit organization: Recovered Medical Equipment for the Developing World (Remedy), to send appropriate unused medical supplies to countries for global aid and encouraged SAM membership to support this effort.

The right amount of the right drug at the right time for managing the airway was the introduction to Dr. Michael Seltz-Kristensens thoughtful discourse on Drugs for Airway Management. He noted that for airway management specialists, the balance between airway protection and patency requires considerable clinical judgment and represents much of what we do. Yet, this topic is not well addressed in the many airway algorithms and guidelines. His dramatic video of induced laryngospasm reminded the audience that patient risk for laryngospasm is greatest during light anesthesia. He tackled the classic controversy over ventilate then paralyze versus paralyze then ventilate, with data illustrating that paralysis does not guarantee ability to mask ventilate, but it often improves and doesnt worsen the ability to ventilate. Since the use of short-acting neuromuscular blockade drugs (NMB) does not guarantee return of spontaneous ventilation before the onset of hypoxia, and ventilation is further suppressed by concomitant use of sedatives and opioids, he recommended choosing succinylcholine or ultra short-acting, rapid-onset NMB if administered before ventilation is attempted. Dr. Leonard Pott reported on the activities of the SAM Research Subcommittee. A blinded panel for the 2013 meeting accepted 57 abstracts. The high quality of the submissions was noted. Future meetings will require a standardized format for the presentations. Two $5000.00 research grants were awarded. Members were encouraged to apply for funding. He solicited audience feedback in determining the direction the SAM Research Subcommittee should take. Two bibliography formats were presented (posted on the SAM website). The first is more learning/education focused. The second format includes SAM member publications from the past five years, with members names highlighted. The audience was asked whether providing unique identifiers (e.g. PMID or DOI) would enhance the value of the bibliographies and a significant majority felt that this was unnecessary. Nearly 90% of the audience responded affirmatively that SAM should act as a brokering service for multicenter research.

Drugs for Airway Management Michael Seltz-Kristensen, M.D.

SAM Research Projects Leonard Pott, M.D.

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Save the Date for WAMM 2015 - the First World Airway Management Meeting!

An exciting joint venture of the Society for Airway Management (SAM) and the Difficult Airway Society (DAS) is on its way! The first World Airway Management Meeting (WAMM) will take place in Dublin, Ireland from November 12-14, 2015. This first of its kind meeting will commemorate the 20th Anniversary of each Society. The 3-day meeting will showcase a one-day airway workshop taught by international experts, plenary sessions, round table sessions, and keynote speakers.

One plenary session will be devoted to the best abstracts of the meeting. Two poster sessions will be dedicated to a variety of topics in basic and advanced airway management. The conference is dedicated to showcase the best scientific and educational information on advanced airway management while engaging a worldwide audience.

Tours of Dublin, the exciting Capital city of Ireland, will be offered. A gala evening event will be held on Friday, November 13, 2015.

Drs. Elizabeth C. Behringer (Past President of SAM) and Ellen O'Sullivan (Past President of DAS) serve of Co-Chairs of WAMM 2015. Other stellar members of the WAMM organizing committee include Drs. Carin Hagberg (SAM Executive Director), Richard Cooper (current SAM President), Anil Patel (London, UK), Michael Seltz Kristensen (Copenhagen, Denmark), Paul Baker (Auckland, NZ), J. Bernard Liban (London, UK), Ankie Hamaekers (Maastricht, Netherlands), and Arnd Timmermann (Berlin Germany). Additional information can be found at the WAMM website: www.WAMM2015.com

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SAM Forum E-Lights Felipe Urdaneta, M.D.

When discussing the usefulness and a need to revise our Difficult Airway Carts (DACs) someone brought up the point of wasted equipment. With availability of newer devices such as SGDs (or SGA), VLs, and FB, do we really need a DAC? How often have you used your DAC, and which type of equipment do you use? What about stuff that rarely gets used? Dr. Katherine Gil A) Our DAC's serve as a platform for the flexible FB's, and otherwise are tasked for holding other supplies, which are rarely needed or used. Also, the DAC hold double lumen tubes in some cases for our Thoracic cases. Having the Glidescope VL on its own rolling stand does increase its mobility. Dr. James DuCanto B) Timely discussion. I think we do need a DAC for the less commonly used items, including the bronchoscope, Intubating LMA, Airway exchange and other airway catheters, and some other specialty devices such as Jet ventilation. In our experience, as good as VLs are, they are not the solution to all problems and we need additional items to be readily available. Dr. Charles Watson Follow-up: How often do you or does anyone else ever use special airway devices such as retrograde intubation kits, combitubes, jet ventilators, etc once a month, once a year, once every ten years? For those that have large O.R.s or locations in different buildings or floors do you have DACs at each location? Dr. Katherine Gil C) We use the FOS (FB) often. Retrograde rarely now that Glidescope is here. For many, the VL has become the newest hammer and nail that is forced into every situation as DL (direct laryngoscopy) was in past. I still think we need several useful options. Dr. Charles Watson D) We have #3 DACs for the main OR (22 rooms), and #3 in the "Heart Tower". It is infrequent that anything aside from the Glidescope, or flexible bronchoscope (usually through an Air-Q) gets used nowadays. We stock the Fastrach LMA, we do not have the Combitube or Laryngeal Tubes. We keep a jet ventilator/ jet vent catheters/ Melker kit on the carts; but, they haven't been used in more than 10 years. Dr. James DuCanto E) The South African Airway Equipment guidelines make provision for two airway resources: a) An emergency airway box containing Supreme LMAs and adult and pediatric cricothyroidotomy kits. b) An airway resource cart for elective difficult airway management containing a variety of devices customized to the practice of the particular hospital. Dr. Eric Hodgson

SAM always encourages trainee participation

sending in reviews of published airway-related articles, sending in abstracts or posters for the national meeting, applying for travel awards, and becoming members!

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Conclusion: There are two very important questions discussed here: a) Whether we need DACs and b) If we have them, what should they include? The ASA and DAS Guidelines address this and having carts has been discussed since the first version of the ASA guidelines in 1993. Having a dedicated Cart or trolley is the best way to assure that the necessary equipment is available. Where and how many trolleys should be available is a matter for local decision and financial possibilities. The real question is about contents. This is a an interesting and provoking question that makes us look back and see the tremendous progress airway management has made over the past decade and how much might now be regarded as obsolete. One principle remains: If there is anything in the cart that people might not be familiar with periodic training should be provided. Dr. Felipe Urdaneta

Middle aged male presented for urgent surgery. The patient had multiple medical comorbidities including end-stage renal disease (ERD) on transplant list; he also had multiple indicators of difficult direct laryngoscopy: 1. Obesity/sleep apnea/fat neck, Mallampati 4, thyromental distance 6 cm, neck range of motion limited to less than 90 degrees. My Plan (A) was to pre oxygenate through BiPAP, following with DL/VL with moderate to deep sedation (no succinylcholine and non-depolarizing muscle relaxants, as mask ventilation predicted to be difficult to impossible). Plan (B) was to use an SGA based technique, based on the needs for sedation and topical local anesthetic application. This is how the plan unfolded: a. Difficult pre-oxygenation period, with light sedation (fentanyl 20 mcg, hydromorphone 0.2 mg, midazolam 1 mg) and poor mask fit with tight fitting mask straps proved to be problematic until I manually improved the mask fit and performed a light jaw thrust to allow the Oxylator to reach its pressure release setting of 20 cm H2O. b. Upon reaching the target pre oxygenation level per gas analyzer (End-tidal O2 88%), deep sedation induced with rapid injection propofol 50 mg in lidocaine 70mg. c. Direct laryngoscopy showed Cormack-Lehane grade 2A view, Video laryngoscopy grade 1 with the McGrath Mac 3. A brief pause of the tracheal tube at laryngeal opening allowed for the relaxation of vocal cords to permit tracheal tube passage off of a GlideRite stylet. Discussion: 1. BiPAP preoxygenation contributed to the safety of this procedure. Passive pre-oxygenation procedures (which are standard operating procedure in the current day and age) require substantial revision when dealing with airways in which difficulty with tracheal intubation are predicted. 2. The use of a combined DL/VL device permitted me to "grade" the DL experience for future airway needs; it also allowed me the flexibility and safety of having an advanced airway tool in the event that the intubation was not possible by DL. 3. The McGrath Mac is lightweight and allows gentle endoscopy, which permits its use during sedated laryngoscopy procedures. Follow the base of tongue with the device into the proper position before force is applied to document the DL grade, allowed the procedure under deep sedation. Dr. James DuCanto A) Thank you for sharing your always valuable insight in this challenging case! I applaud your approach: 1. Doing DL then VL, provides invaluable information in case future airway instrumentation is needed.

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2. Regarding the issue of difficulty applying BIPAP via tight face mask preintubation. I wish to share a case (http://www.springerlink.com/content/45734160p241h6h2/) we reported in a large patient with OSA and difficult bag-mask-valve (BMV)/FB on BIPAP. Whenever we removed BIPAP to topicalize for the fiberoptic intubation (FOI), he dropped saturations very quickly. We placed an Air-Q and applied BIPAP, which was well tolerated and in fact the patient was relieved. Then intubated using FB via air-Q while BIPAP was maintained. He did not drop saturations once the Air-Q was in. I believe this is a useful adjunct in difficult patients. Dr. David Wong B) I wanted to avoid the usual Monday morning quarterbacking (MMQ) because of lack of some details (e.g. no dimensions of patient and was the 90 degree ROM inclusive of flexion and extension?). Although you gave plenty of reasons why this airway would be difficult, I was wondering what your criteria were to avoid awake flexible fiber-optic intubation? Also, why hydromorphone? why not ketamine, remifentanil or dexmedetomidine? Dr. Katherine Gil C) I cannot avoid a dose of MMQ: Despite the fact that there were signs of both difficult BMV and difficult DL, the patient was sedated and put to sleep to perform both. BMV was improved by the use of BIPAP but Laryngoscopy was not optimized (no muscle relaxant was given). If there is so much concern about giving NMB agents, should the patient be put to sleep in the first place? It is hard to judge and the result was a success like many cases are, but it could have not have been. Dr. Felipe Urdaneta Follow-up: My logic doesn't move in straight lines sometimes, but to clarify, my central concern here is to minimize apnea time, and maximize ventilation. The technique worked, and everything went well, however, if it had not, I would have gone to plan B, C, or D always with the goal of maintaining ventilation. I knew this patient would present problems with DL and problems with mask ventilation. He was in renal failure, so definitely no sux. It made sense at the time to simplify his management with a method that would be fast and maximally effective, offer DL grading capability, and allow for rapid recovery from moderate to deep sedation in the event that the approach was not successful. The narcotic selection is based on my preference to combine fentanyl 100 mcg with Hydromorphone 1 mg in a 10 ml total dilution for administration during surgery. I gave 2 ml of it, i.e. 20 mcg fentanyl, .2 mg Hydromorphone. Dr. James DuCanto C) How does one apply BiPAP in the operating room using the circle system apparatus anesthesia circuit? Dr. Donald Keusch D) Jim uses the Oxylator, which is an interesting and different technology than the one used in our anesthesia machines. There are anesthesia machines that have a pressure support mode. You can achieve BiPAP with a tight fitting mask by putting the patient on pressure support and adding PEEP. Patients, particularly those on home CPAP or BiPAP for OSA, seem to tolerate it well. Dr. Richard Galgon D) In the old days we did it with an educated hand on the bag. Lately we have ventilators that mimic BiPAP with pressure support ventilation and PEEP. PS I still use my hands sometimes. Dr. C. Watson (SIC)

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SAM Membership Application, Please check appropriate category: Physician $100 CRNA/PA/AA.. $75 Resident or Fellow (must have training director letter).. $25 Paramedic/EMT/Flight Nurse/Technologist. $50 Individual Industry Representative $75 Retired Physician $75 Medical students $00 SAM discounted rate for the Journal of Clinical Anesthesia Domestic US delivery $78 International delivery.. $100 I would like to contribute to the Developing World Physician Sponsorship fund.* $_________ Total Charges: . $_________ Please Print: Last Name________________________________ Degree_________ First Name_______________________ Specialty___________________ Address____________________________________________________ City__________________________ State/Province_________________ Country_______________________________ Postal/zip code_______ Business Phone________________ Other Phone___________________ E-mail_____________________________________________________ Primary healthcare or academic affiliation________________________ I was referred to SAM by_____________________________________ Checks should be in US dollars, payable to: Society for Airway Management 5753 Tanager St. / Schereville, IN 46375 (For more information see www.samhq.com or call 773.834.3171) Credit Card Information: Visa / MasterCard Number_____________________________________ Expiration Date______________________________________________ Name on Card ______________________________________________ Cardholders Signature________________________________________ I would like my membership dues payment to recur annually.

*Yearly, the SAM International Committee will consider the sponsorship of a physician from a developing nation to attend the annual scientific meeting.