Airway

Intubation in OR vs ICU

A Spanish study compares OR vs ICU intubation by direct laryngoscopy. Everything was somewhat worse in  the ICU: worse view, lower first attempt success, higher rate of difficult intubation and use of airway adjuncts,  and higher complication rate. They suggest that patient and environmental factors may be of more importance than the operator (even previously known easy intubations were more difficult in ICU). Despite all that, their success rate was better than other studies, which they attribute to high use of neuromuscular blocking agents, an increasingly recommended practice. Videolaryngoscopy has met with better success in many but not all studies.

At the least, greater preparation, optimized positioning and airway equipment,  and trained assistance should be available for non-OR intubation

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Sedation and Pediatric NPO in ER

“In this study, there was no association between fasting duration and any type of adverse event. These findings do not support delaying sedation to meet established fasting guidelines”.

An observational study sparse on details on what sedation was used, depth of sedation and the procedures in ER. And the rate of vomiting was 5% but they evidently mostly got away with it. A study unlikely to convince anesthesiologists to abandon ASA and other fasting guidelines in this Pediatric population (or adults).

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Cook Staged Extubation

Many successful difficult airway cases become undone at extubation, where disasters and deaths have occurred. Even seemingly routine ICU extubations may go awry. Moderate success was reported with the Cook Airway Exchange Catheter but the next generation device is the Cook Staged Extubation Set, a device with wire and bougie – link to Cook

This small study is encouraging in its use and tolerability up to 4 hours with no major adverse effects and further studies should occur  link

 

Difficult Airway from Obstruction

A resent article on management of a difficult obstructed airway. Airway assessment and preparation are key, including preparing for cricothyrotomy. Perennial themes are awake vs. asleep and IV vs. inhalational.

Newer themes include the use of high flow nasal oxygen (Optifow or even just nasal cannula cranked up to max) and the use of videolaryngoscopy for awake intubation, or its combination with fibre optic intubation.

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Airway Changes in Labor and Delivery

Mallampati scores increase during pregnancy. Pregnancy is associated with lower oncotic pressures and increase in edema and weight;  bearing down, oxytocin and fluids in labor and delivery lead to further worsening of the score. The study below shows this to be common to both pre-eclamptic and normotensive women, but the pre-eclamptic group had greater increase in soft tissue at the hyoid level, using ultrasound.

The effects lasted up to 48 hours post partum. Whether the hyoid tissue was correlated with more difficult laryngoscopy is difficult to ascertain due to neuraxial anesthesia being mostly the first choice. And we know Mallampati scores’ sensitivity is not high. Ultrasonography for airway assessment is becoming a tool, one that does not necessarily correlate with Mallampati scoring.

It is clearly important to assess the airway comprehensively and immediately before anesthesia, all the more so in longer labors and to remain on alert for 2 days post partum in all obstetric patients    link

 

Airway App and Front of Neck Airway

Emergency Front of Neck Airway (FONA) data was collected from a smartphone app. 82% were performed by non-surgeons (Anesthesia, ER, paramedics, intensivists) and 64% were ‘cannot intubate, cannot oxygenate’ emergencies.

First attempt at FONA was successful in 72%. The most successful technique was the scalpel-bougie technique ( blog link ). Absolute numbers were low in other techniques like open/cannula/wire-guided/per cutaneous/open tracheotomy, along with varying supraglottic airway rescue and second attempts.

Delay in proceeding to FONA, fixation on multiple tracheal intubation attempts and/or the failure to plan for failure were the three most common negative factors, while positive factors were good communication, teamwork and skilled personnel.

Anaesthesia retweets “The successful management of ‘cannot intubate, cannot oxygenate’ will be determined more by the psychological aspects of making an appropriate clinically contextual response and familiarity with technique than what method is chosen.”    Anaesthesia article