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British Journal of Anaesthesia Dec 2012Airway management complications causing temporary patient harm are common, but serious injury is rare. Because most airways are easy, most complications occur in easy... (Review)
Review
Airway management complications causing temporary patient harm are common, but serious injury is rare. Because most airways are easy, most complications occur in easy airways: these complications can and do lead to harm and death. Because these events are rare, most of our learning comes from large litigation and critical incident databases that help identify patterns and areas where care can be improved: but both have limitations. The recent 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society provides important detailed information and our best estimates of the incidence of major airway complications. A significant proportion of airway complications occur in Intensive Care Units and Emergency Departments, and these more frequently cause patient harm/death and are associated with suboptimal care. Hypoxia is the commonest cause of airway-related deaths. Obesity markedly increases risk of airway complications. Pulmonary aspiration remains the leading cause of airway-related anaesthetic deaths, most cases having identifiable risk factors. Unrecognized oesophageal intubation is not of only historical interest and is entirely avoidable. All airway management techniques fail and prediction scores are rather poor, so many failures are unanticipated. Avoidance of airway complications requires institutional and individual preparedness, careful assessment, good planning and judgement, good communication and teamwork, knowledge and use of a range of techniques and devices, and a willingness to stop performing techniques when they are failing. Analysis of major airway complications identifies areas where practice is suboptimal; research to improve understanding, prevention, and management of such complications remains an anaesthetic priority.
Topics: Airway Management; Humans; Hypoxia; Intubation, Intratracheal; Laryngeal Masks; Laryngoscopy; Obesity; Treatment Failure
PubMed: 23242753
DOI: 10.1093/bja/aes393 -
Heart Failure Reviews Sep 2022Meticulous risk stratification is essential when considering intubation of a patient with decompensated pulmonary hypertension (dPH). It is paramount to understand both... (Review)
Review
Meticulous risk stratification is essential when considering intubation of a patient with decompensated pulmonary hypertension (dPH). It is paramount to understand both the pathophysiology of dPH (and associated right ventricular failure) and the complications related to a high-risk intubation before attempting the procedure. There are few recommendations in this area and the literature, guiding these recommendations, is limited to expert opinion and very few case reports/case series. This review will discuss the complex pathophysiology of dPH, the complications associated with intubation, the debates surrounding induction agents, and the available options for the intubation procedure, with specific emphasis on the emerging role for awake fiberoptic intubation. All patients should be evaluated for candidacy for veno-arterial extracorporeal membrane oxygen as a bridge to recovery, lung transplantation, or pulmonary endarterectomy prior to intubation. Only an experienced proceduralist who is both comfortable with high-risk intubations and the pathophysiology of dPH should perform these intubations.
Topics: Airway Management; Endarterectomy; Extracorporeal Membrane Oxygenation; Humans; Hypertension, Pulmonary; Intubation, Intratracheal
PubMed: 34476657
DOI: 10.1007/s10741-021-10168-9 -
Respiratory Care Jun 2014Manual ventilation is a basic skill that involves airway assessment, maneuvers to open the airway, and application of simple and complex airway support devices and... (Review)
Review
Manual ventilation is a basic skill that involves airway assessment, maneuvers to open the airway, and application of simple and complex airway support devices and effective positive-pressure ventilation using a bag and mask. An important part of manual ventilation is recognizing its success and when it is difficult or impossible and a higher level of support is necessary to sustain life. Careful airway assessment will help clinicians identify what and when the next step needs to be taken. Often simple airway maneuvers such as the head tilt/chin lift and jaw thrust can achieve a patent airway. Appropriate use of airway adjuncts can further aid the clinician in situations in which airway maneuvers may not be sufficient. Bag-mask ventilation (BMV) plays a vital role in effective manual ventilation, improving both oxygenation and ventilation as well as buying time while preparations are made for endotracheal intubation. There are, however, situations in which BMV may be difficult or impossible. Anticipation and early recognition of these situations allows clinicians to quickly make adjustments to the method of BMV or to employ a more advanced intervention to avoid delays in establishing adequate oxygenation and ventilation.
Topics: Airway Management; Humans; Immobilization; Intubation, Intratracheal; Laryngeal Masks; Life Support Care; Patient Positioning
PubMed: 24891193
DOI: 10.4187/respcare.03060 -
The Journal of Emergency Medicine Jul 2020Successful airway management is critical to the practice of emergency medicine. Emergency physicians must be ready to optimize and prepare for airway management in... (Review)
Review
BACKGROUND
Successful airway management is critical to the practice of emergency medicine. Emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this first part of a 2-part series.
OBJECTIVE
This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases that are commonly encountered in the emergency department.
DISCUSSION
Adverse events during emergent airway management are common, with postintubation cardiac arrest reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided with the proper identification and understanding of the underlying physiology, preparation, and postintubation management. Patients with high-risk features including severe metabolic acidosis; shock and hypotension; obstructive lung disease; pulmonary hypertension, right ventricle failure, and pulmonary embolism; and severe hypoxemia must be managed with airway expertise.
CONCLUSIONS
This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician.
Topics: Airway Management; Critical Illness; Emergency Service, Hospital; Humans; Hypotension; Intubation, Intratracheal
PubMed: 32563613
DOI: 10.1016/j.jemermed.2020.05.008 -
British Journal of Anaesthesia Feb 2022We outline the history, implementation and clinical impact of the formation of an Airway Lead Network. Although recommendations to improve patient safety in airway...
We outline the history, implementation and clinical impact of the formation of an Airway Lead Network. Although recommendations to improve patient safety in airway management are published and revised regularly, uniform implementation of such guidelines are applied sporadically throughout the hospital and prehospital settings. The primary roles of an Airway Lead are to ensure supply, quality and storage of airway equipment, promote the use of current practice guidelines as well as the organisation of training and audits. Locally, the Airway Lead may chair a multi-disciplinary airway committee within their organisation; an Airway Lead Network enables Airway Leads to share common problems and solutions to promote optimal airway management on a national level. Support from governing bodies is an essential part of this structure.
Topics: Airway Management; Hospitals; Humans; Patient Safety; Practice Guidelines as Topic
PubMed: 34893313
DOI: 10.1016/j.bja.2021.11.013 -
Anesthesiology Mar 2018
Topics: Airway Management; Anesthesia, Local; Anesthetics; Humans; Intubation, Intratracheal; Patient Safety
PubMed: 29324483
DOI: 10.1097/ALN.0000000000002075 -
British Journal of Anaesthesia Dec 2017In the last 25 yr, there have been several advances in the safe management of the airway. Videolaryngoscopes and supraglottic airways, now in routine use by new... (Review)
Review
In the last 25 yr, there have been several advances in the safe management of the airway. Videolaryngoscopes and supraglottic airways, now in routine use by new trainees in anaesthesia, have had their genesis in the recent past. The 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society published in 2011 a seminal report that has influenced airway management worldwide . Understanding how the report's recommendations were constructed and how clinical guidelines compliment rather than contradict them is important in understanding the tenets of safe airway management. Over the last 25 yr there has been an increasing understanding of the effects of human factors in anaesthesiology: we may not perform in a predictable or optimal manner when faced with unusual and threatening challenges. The place of cricoid pressure in anaesthetic practice has also evolved. Current recommendations are that it be applied, but it should be released rapidly should airway difficulty be encountered. The need to prevent hypoxaemia by preoxygenation has long been recognized, but the role of high-flow nasal oxygen in anaesthesia is now being realized and developed. Clinicians must decide how novel therapies and long-standing practices are adapted to best meet the needs of our patients and prevent harm during airway management.
Topics: Airway Management; Humans; Intubation, Intratracheal; Practice Guidelines as Topic
PubMed: 29161401
DOI: 10.1093/bja/aex385 -
British Journal of Anaesthesia Jul 2020
Topics: Airway Management; Intubation, Intratracheal; Laryngoscopy; Space Flight; Weightlessness
PubMed: 31918846
DOI: 10.1016/j.bja.2019.12.002 -
BioMed Research International 2015Pediatric airway management is a challenge in routine anesthesia practice. Any airway-related complication due to improper procedure can have catastrophic consequences... (Review)
Review
Pediatric airway management is a challenge in routine anesthesia practice. Any airway-related complication due to improper procedure can have catastrophic consequences in pediatric patients. The authors reviewed the current relevant literature using the following data bases: Google Scholar, PubMed, Medline (OVID SP), and Dynamed, and the following keywords: Airway/s, Children, Pediatric, Difficult Airways, and Controversies. From a summary of the data, we identified several controversies: difficult airway prediction, difficult airway management, cuffed versus uncuffed endotracheal tubes for securing pediatric airways, rapid sequence induction (RSI), laryngeal mask versus endotracheal tube, and extubation timing. The data show that pediatric anesthesia practice in perioperative airway management is currently lacking the strong evidence-based medicine (EBM) data that is available for adult subpopulations. A number of procedural steps in airway management are derived only from adult populations. However, the objective is the same irrespective of patient age: proper securing of the airway and oxygenation of the patient.
Topics: Airway Management; Anesthesia, General; Child; Evidence-Based Medicine; Humans; Intubation, Intratracheal; Laryngeal Masks; Pediatrics; Perioperative Care
PubMed: 26759809
DOI: 10.1155/2015/368761 -
Anaesthesia, Critical Care & Pain... Dec 2019To provide French guidelines about "Airway management during paediatric anaesthesia".
OBJECTIVE
To provide French guidelines about "Airway management during paediatric anaesthesia".
DESIGN
A consensus committee of 17 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie-Réanimation, SFAR) and the Association of French speaking paediatric anaesthesiologists and intensivists (Association Des Anesthésistes Réanimateurs Pédiatriques d'Expression Francophone, ADARPEF) was convened. The entire process was conducted independently of any industry funding. The authors followed the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to assess the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations were not graded.
METHODS
The panel focused on 7 questions: 1) Supraglottic Airway devices 2) Cuffed endotracheal tubes 3) Videolaryngoscopes 4) Neuromuscular blocking agents 5) Rapid sequence induction 6) Airway device removal 7) Airway management in the child with recent or ongoing upper respiratory tract infection. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the redaction of the recommendations were then conducted according to the GRADE® methodology.
RESULTS
The SFAR Guideline panel provides 17 statements on "airway management during paediatric anaesthesia". After two rounds of discussion and various amendments, a strong agreement was reached for 100% of the recommendations. Of these recommendations, 6 have a high level of evidence (Grade 1 ± ), 6 have a low level of evidence (Grade 2 ± ) and 5 are experts' opinions. No recommendation could be provided for 3 questions.
CONCLUSIONS
Substantial agreement exists among experts regarding many strong recommendations for paediatric airway management.
Topics: Administration, Topical; Airway Extubation; Airway Management; Algorithms; Child; Child, Preschool; Equipment Design; France; Humans; Infant; Intubation, Intratracheal; Laryngoscopy; Lidocaine; Neuromuscular Nondepolarizing Agents; Rapid Sequence Induction and Intubation; Respiratory Tract Infections; Video Recording
PubMed: 30807876
DOI: 10.1016/j.accpm.2019.02.004