I was honoured to be invited back on the Critical Care Scenarios (@icuscenarios) podcast, to chat this time about airway management in COVID-19, but also talking about how it’s helping to focus improving our emergency airway management in general. Check it out at this link:
Some photos of the action at the Nairobi Surgical Skills Centre this week. Many thanks to the local faculty from the University of Nairobi and other institutions, the companies that supported use of the facilities and equipment, and the enthusiastic delegates!
Resources and notes from the course are available on the course page here.
Herewith a collaborative effort from the airway Twitterati to establish a list of common airway abbreviations:
- AFOI – Awake fibre-optic (or flexible optic) intubation
- ApOX – Apnoeic Oxygenation
- BB – Bronchial blocker
- BVM – Bag/Valve/Mask device (see BVMR)
- BVMR – Bag/Valve/Mask/Reservoir device (see BVM)
- CICO – Can’t intubate, can’t oxygenate (see CICV)
- CICV – Can’t intubate, can’t ventilation (CICO now in use)
- CL – Cormack-Lehane grade
- DL – Direct laryngoscopy
- DLT – Double-lumen endobronchial tube
- DSI – Delayed sequence induction
- ESA – Emegency Surgical Airway (see FONA)
- ETI – Endotracheal intubation
- ETT – Endotracheal tube
- EtCO2 – End-tital carbon dioxide
- EXIT – EX-utero Intrapartum Treatment
- FB – Foreign body
- FETO – Fetal Endoscopic Tracheal Occlusion (or Fetoscopic EndoTracheal Occlusion)
- FiO2 – Fraction of inspired oxygen
- FOI – Fibre-optic intubation
- FONA – Front-of-neck access (see ESA)
- LA – Local anaesthetic
- LMA – Laryngeal Mask Airway (trade name, see SGA etc)
- MAD – Mucosal Atomisation Device
- MP – Mallampati grade
- NPA – Nasopharyngeal airway
- NODESAT – Nasal Oxygenation During Efforts at Secuing A Tube
- OPA – Oropharyngeal airway
- PLA – Perilayngeal airway
- RSI – Rapid sequence induction
- SAD – Supraglottic airway device (see SGA, EGA, XGA)
- SGA – Supraglottic airway (see SAD, EGA, XGA)
- THRIVE – Transnasal, Humidified, Rapid-Insufflatory Ventilatory Exchange
- VL – Video layngoscopy
- XGA – Extraglottic airway (see EGA, SAD, SGA)
Contributions/comments? DM @openaiwayorg or @rosshofmeyr
Thanks to @AirwayMxAcademy for initiating the idea!
A short presentation on a selection of airway themes and some of the papers from 2016 for our FCA Part 2 candidates. Definitely not intended to be a systematic or exhaustive review! Click the image to download a PDF of the slides, or the link below for the resources.
You can watch a 9-minute video of the slides and attendant video clips below. Please note that this is not narrated.
Another quick training video, on the basic techniques of driving a flexible scope (fibreoptic or video) for intubation. This was made specifically as a primer for people in our own department taking part in a training study, but hopefully it is useful to a larger audience!
Please put your comments and (hopefully constructive) critique below. As always, you’re welcome to use with attribution!
A quick overview of the basic technique using the Fastrach ILMA.
As always, these videos are unscripted, so if you have suggestions or critique, please use the comments section!
Despite making a previous post and video to explain the way to make sure the device switches on, I regularly get told that the Pocket Monitor (PM) for our C-MAC video laryngoscope is not working/charging/switching on. This is in fact a design feature to prevent accidental activation or discharge. Watch here to find out more:
Thanks to the lovely Sam Adams for playing along…good career in acting if anaesthesia were to ever become boring!
Hot of the press – the Obstetric Anaesthetists’ Association and Difficult Airway Society have released their combined guidelines on difficult and failed intubation in obstetrics, which are freely available from Anaesthesia online.
- Click here for the online publication
- Click here to access the PDF
- Click here to read the accompanying editorial by Rucklidge and Yentis
The guidelines are presented as a ‘Master Algorithm’ and several sub-algorithms to deal with specific aspects of obstetric airway management, and a guide to making the decision to awake the patient or continue with surgical delivery after an airway event:
Some thoughts (COI – the author did provide feedback on the draft algorithms):
- Stressing good positioning for airway management is absolutely critical in this population, and especially in practice environments where patients tend to have a high BMI (a common situation in our South African setting). The guidelines include ramping and the ear-to-sternal-notch (E2SN) position.
- The inclusion of cricoid pressure will inevitably spark the usual debate, but it is this author’s contention that this is likely an appropriate use until more evidence to the contrary emerges. The guidance to consider CP reduction or release in the event of difficulty is apt.
- The inclusion of gentle face-mask assisted ventilation during RSI is a welcome inclusion. Will we see NPO2 or HFNC included in later editions as more outcomes evidence emerges?
- Advocating the use of VL in obstetrics certainly sounds like a good idea, but is not attainable for most of the developing world. This is a huge area for growth/research – the development of low-cost VL solutions.
This is a great step forward in promoting safe airway management and guiding training in a particularly dangerous corner of our practice.
For some more thoughts and images, here is a Prezi on the subject presented at the SASA Difficult Airway workshop in 2014:
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:
The authors discuss the predictors of difficult mask ventilation and report/propose another two mnemonics, to add to the existing stable (MOANS, BONES, etc):
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.
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.
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!