Tag Archives: airway

Difficult Face Mask Ventilation – ATOTW 321

The newest edition of the Anaesthesia Tutorial of the Week (ATOTW #321) covers the much underestimated but critically important topic of predicting and managing difficulty in face mask ventilation.  Irish anaesthetists Jonathan Holland and Will Donaldson have created a useful resource for anyone studying or performing airway management, or refreshing for exam purposes.

ATOTW is a free resource created and hosted by the World Federation of Societies of Anaesthesiologists.  You can sign up to receive the weekly mails here, and download this edition on mask ventilation here:

ATOTW 321 – Difficult Mask Ventilation

The authors discuss the predictors of difficult mask ventilation and report/propose another two mnemonics, to add to the existing stable (MOANS, BONES, etc):

Two mnemonics for prediction of difficult face mask ventilation
Two mnemonics for prediction of difficult face mask ventilation.  Source: ATOTW 321

I’ve always used MOANS for mask factors (like I use LEMON for laryngoscopy), but all these mnemonics cover the same ground.  MOANS, for instance, stands for

  • M   Mask seal factors, like beards, NGTs, odd shaped faces
  • O   Obesity and causes of Obstruction, like tumours/angioedema
  • A   Age extremes (the elderly and very young)
  • N   No teeth (or nasty dentition)
  • S   Snoring and Stiff lungs (the latter being issues like inhalation burns and acute bronchospasm, where the higher pressures required increase the risk of gastric insufflation and Splinting of the diaphragm)

As you can see, they are all much the same, although there are a few things that are not covered by every algorithm.  The purist would point out that obesity is defined as a BMI of >30 kg/m2, not 26 as stated in the table.

Difficult_Mask_Algorithm
Hollan & Donaldson’s flowchart for management of difficult face mask ventilation. Source: ATOTW 321

The authors then present a useful flowchart for addressing unexpected difficulty, which is quite sensible.  It is much in line with the DAS guidelines and other algorithms for general airway difficulty, and useful for instruction.  Of course, in a dire emergency, using a cognitive aid such as the Vortex would be  effective.

 

7 airway questions posed to 6 airway experts

Click the image to go to the article on Anesthesiology News
Click the image to go to the article on Anesthesiology News

This month’s edition of Anesthesiology News features a worthwhile piece from Prof John Doyle, in which he poses 7 questions on the current state of airway management to 6 airway experts from around the world (Abdelmalak, Cooper, Frova, Rosenblatt, Spiegel and Doyle himself), and collates their responses into a dialogue.  Definitely worth reading to determine what some (certainly not all) of the biggest names in the world are thinking on:

  • The place for DL a decade from now
  • The (under)use of bougies
  • What airway algorithm to choose
  • Tracheostomy vs cricothyroidotomy in emergencies
  • The impact of VL on the use of flexible ‘scopes
  • Favourite SGA
  • Favourite VL

You can read the article on the Anesthesiology News site by clicking here or the image above, or download the PDF version here.

For what it is worth, here are my own answers, distilled into one-liners.  I’m very willing to enter into discussions about them!

  • Place for DL in the future: Definitely; just look at the huge needs in the Third World and then ask if (even very cheap) VLs are a priority.
  • Use of bougies: Along with good positioning and mastery of face-mask skills, I think this is one of the most neglected parts of airway training.
  • What airway algorithm: The expert can do what they wish; the trainee should learn something appropriate (like ASA or DAS); the infrequent practitioner should use the Vortex.
  • Trache vs Cric:  Cric all the way; scalpel-finger-bougie
  • Impact of VL in AFOI:  Definitely reducing the use of AFOI, but a flexible scope remains an essential tool, and every airway master should be competent in it’s use.
  • Favourite SGA:  Would love to say the 3gLM, but we need to publish the research first…
  • Favourite VL:  Hasn’t been invented yet, but watch this space.  The C-MAC with Pocket Monitor is my daily workhorse, but I have (and use) GlideScope, McGrath, AirTraq, King Vision, etc.

There are a lot of excellent (and complementary) views expressed in the article, which are worth reading.  Check it out!

FCA Part 2 Refresher Course 2015 – New Trends and Tools in Airway Rescue

Herewith the presentation that Ross cobbled together for the candidates preparing for anaesthesia finals, to give an idea of the trends and new tools in airway management at the current time.  Mostly pictures, but the lecture notes (with all the references) can be downloaded as a PDF here:

New Tools and Trends in Airway Rescue – UCTP2ARC 2015

Images are from the author, public domain, or used with attribution.

C-MAC PM not turning on?

Folks are frequently reporting that our C-MAC Pocket Monitor is not switching on when they plug it in to a blade and want to use it, without realizing that it automatically goes into a hibernation mode if left in the open position for more than 15 minutes. Check out this quick AirwayHowTo video on solving this problem:

Rigid Intubation Scopes

Rigid endoscopes are very valuable tools for intubation in certain difficult scenarios, but are not commonly used in most centres.  The techniques and learning curve differ significantly from normal direct laryngoscopy, requiring independent practice to become proficient.  Pictured here are (left to right) a rigid bronchoscope, Bonfils, Levitan and Shikani optical stylets (rigid intubating endoscopes).

(L to R) Rigid bronchoscope, Bonfils, Levitan and Shikani optical stylets.  Click to enlarge.
(L to R) Rigid bronchoscope, Bonfils, Levitan and Shikani optical stylets. Click to enlarge.

This is the set-up for basic training on an UCT Anaesthesia Airways course.  Which of these devices have you used?  Do you have tricks or comments to share?