Science topic

Airway Management - Science topic

Evaluation, planning, and use of a range of procedures and airway devices for the maintenance or restoration of a patient's ventilation.
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What would be the MMP grade if uvula is not seen, but soft palate alone is visible?
Scenario : The first year resident claimed it as MMP 4, & second year resident claimed it as MMP 3. Intraoperatively, it turned out to be unanticipated difficult airway, with CL grades 3b (epiglottis tip only visible).
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Grade II- portion of uvula is seen and grade III- base of uvula is seen, IV- only hard plate
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A paramedic is an emergency medical technician(EMT) with additional advanced training to perform more difficult pre-hospital medical procedures. A paramedic functions as the most extensively trained primary care provider in the pre-hospital setting. The paramedic is responsible for all aspects of care provided to the sick and injured. They provide both basic and advanced life support, including comprehensive patient assessment, invasive airway management, cardiac monitoring and administration of medications.
Skills required to be EMTs and Paramedics
• Confidence
• Excellent Judgment
• Independent Functioning
• Physical Strength
• Problem-Solving Skills
• Speaking Skills
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Dear Juan March, thanks for your answer and proposals..
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Please share your experience.
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Semi-inflated
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The gold standard for managing this situation was inhalational induction ( to avoid Airway loss) until the patient became deep enough to tolerate endotracheal intubation. This technique has been questioned recently because it is not as smooth as expected and on many occasions the situation is even more complicated and worsens in several ways. The suggested alternative is to put the patient to sleep and to administer long-acting muscle relaxant, so as to achieve an ideal situation for intubation, however, in case of losing the airway you should be able to perform an emergency FONA ( Front of the Neck access) using a scalpal, Bougie and a small endotracheal tube,
What is your opinion about the pros and cons of both approaches, do you have other suggestions?
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In any way you will be able to use a fiberoptic laryngoscope and ready for alternative intubation such as emergency tracheastomy.
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discuss the use of Vortex approach to airway management for:
  • obese patient
  • head injury patient
  • pregnant patient
  • pediatric patient
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It is important to note that the
failure of one device increases the possibility of failure of the next one, for example, in an obese patient with
positive predictors of difficulty for intubation, has a higher incidence of difficulty for ventilation
(including ventilation through a supraglottic device); likewise, percutaneous access to VA can be
very complicated.
Fortunately, we can exchange between these
access to the VA when one of them fails, being able to be
used interchangeably as a rescue for oxygenation
of the patient.
British Journal of Anaesthesia, 117 (S1): i20–i27 (2016) doi: 10.1093/bja/aew175
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In your point of view, which are the most important points we should discuss concerning intubation / airway management in trauma patients with unstable c-spine fracture?
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Airway management in unstable cervical spine fracture patient is always challenging. The primary reason for intubation may differ in different situations.It can be both difficult as well as dangerous due to various factors and always needs to be individualised with minimised spine movements.
Patient related factors-
Urgency of intubation- can be immediate, emergent, urgent or elective- actually dictates the decision, technique of airway management as well as drug used. The patient may be hypoxic, almost in arrest to relatively stable.
Level of injury (e.g. C1-C2 or lower cervical), Degree of instability and Severity of spinal cord compression, Anterior or posterior compression (which movement can aggravate the compression and hence to avoid), Presence of Spinal shock, Immobilisation
Presence of traumatic brain injury (increased ICP) and/ or polytrauma leading to shock or crush injury (dose and response to drugs) Facial or airway trauma, Full stomach status, Anatomical factors for difficult airway.
Other factors to be considered-
Level of experience of the person performing intubation
Equipments available for intubation (special equipments- videolaryngoscopes or flexible scopes), Drugs available for intubation, Time and place of intubation (ER/ Trauma ICU/ primary care center before transfer).
Later on, presence/absence of major neurological deficit also affects technique of airway management though such assessment may not be possible in emergent unconscious patients.
Additionally, often the issue is whether to intubate (in inadequately equipped place by inexperienced person) and then transfer to higher center is safer or the other way round. Mode of transport also needs to be addressed.
It must be appreciated that airway management is not just a technique bur a sequence of pharmacological and technical interventions right from suction and oxygenation done in least detrimental way.
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Does your hospital have an Airway Lead? Do they standardize and support your hospitals selection of airway management guidelines, airway management equipment, airway data and airway management education?
Who pays for their work? If your hospital does not have an Airway Lead what are the barriers to establishing the position?
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Thank you all for your diverse and informative answers. Dr.Paul Baker, myself and other members of the Society for Airway Management are putting together a paper on the concept of an Airway Lead. I was wondering what the level of interest would be generated by this publication. "Testing the waters" is a great service of the Research gate community. So thank you all. I have attached an Info-Graphic for our paper on Airway Lead can you let me know what you think? Clear or unclear? Too cute or the correct tone and style?
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Could someone explain the anatomical changes associated with turning a patient‘s head 22 degrees (left or right) yields unobstructed breathtaking compared to neutral (supine) positioning?
I have have noticed that when my patient obstructs during deep sedation, it may be relieved by a slight turn of the head. I have tried to conceptualize the anatomical change but am not confident that I am correct.
Interested in hearing your thoughts.
Thank you in advance.
Christopher
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Torsional retraction of the tongue and soft palate? I’m sure anaesthesiologists might also be able to help...
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What combination of quantitative and qualitative data is used by advanced practitioners to decide readiness for airway manipulation? Do you think describing this process may help trainees improve airway management skills?
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Aside from the traditional lash reflex test I will test the patient's jaw tightness before attempting an airway manipulation. Patients reach readiness for airway manipulation at different rates and with varying dosages of medications depending on, metabolic rate, cardiac function, volume status and nutritional state. So 20 seconds either way can have a big effect. If you do not have adequate hypnotic and neuromuscular junctions blockade levels at the time of airway manipulation this can cause brochospasm, laryngospasm and damage to the oropharynx.
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I am trying to write a code for Aircraft flight path optimisation in adverse weather condition.
I have a grid of 300-by-200, in which I represent two Airport locations and the normal flight path between them.
a. I want to represent adverse weather like turbulence in the flight path by polygons.
b. Now the aircraft should identify these polygons as impenetrable object and decide on an alternate path by detouring from these polygons.
How do I show or represent the polygons as an impenetrable object in Matlab? I am not getting the idea how to do this project in Matlab.
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Whereas in the ninety’s blind nasotracheal intubation (NTI) was the gold standard for medical ICU’s patients (more than 90%; Vassal et al, Intensive Care Med 1993) and the surgical ICU’s patients suspected or requiring mechanical ventilation more than 48 H (Aebert et al Intensive care Med 1988), after the implementation of rapid sequence induction (RSI), NTI’s use became confidential (less than 1% in a recent survey). Therefore, NTI is no longer taught in the ICU’s, whereas it may be necessary in some particular cases (inability to open mouth, to move the neck…) and reduces at least the risk of unplanned extubation. Moreover RSI is not so safe and easy according to the recent meta-analysis of Hubble et al (Prehosp Emerg Care 2010).
So should we save nasotracheal intubation?
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  • Its a very good question. Now a days, in today's Anaesthesiologists blind nasal intubation (BTI) is a dying art. Its a great technique in the armamentarium of anesthesiologist specially in the scinario of NIL mouth opening and there is a lack  of advanced airway gadgets ( FOB ) at your centre. In some of Asean countries, even now FOB is not available in 60-70 % teaching Hospital. In the given scinario, it becomes  a greatly useful technique.
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Emergent surgery
difficult intubation< predicted
coagulopathy
Ankylosed TMJ
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We all know there are multiple ways of securing a difficult airway. However for the scenario presented here the additional concern is a uncorrected coagulopathy. All those who might regularly do a fiberoptic nasal intubation might be well aware of the fact that despite adequate precautions and preparation railroading the ETT over successfully inserted fiberoptic bronchoscope might cause significant nasal bleed. To me its a bad choice to think of any nasal intubation tecnique in a uncorrected coagulopathy. Yes ! oral fiberoptic guided intubation does makes sense. We must perhaps choose a technique that will result in minimum chance of bleeding. To me if the anaesthesiologist is skilled and experienced in this technique he must think of Retrograde intubation using a J tipped guide wire and passing a oral fiberoptic bronchoscope followed by ETT.This should cause minimal trauma to any soft tissue.offcourse it goes without saying you need to ensure maximum patient cooperation,good topicalisation with LA and an experienced and skilled intubator.
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Is there any risk of iatrogenic C1-C2 subluxation in case of transverse facial cleft patient intubations and operations? What if there is no vertebral anomaly visible on CT.
I would grateful if you can help me. It is very difficult to get any publication about that subject.
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Flexible Fiberoptic specially awake intubation (if applicable) is the safest.
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Feedback devices seem to improve compliance to Guidelines in CPR. Are there any outcome studies proving improved outcomes (i.e. ROSC, admission to hospital) in humans?
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Dear Paul, I Think that Answer is YES! Look This Attachment:
"Depth, Rate of Chest Compressions During CPR Impact Survival in Cardiac Arrest" -  Febbraio 6, 2015
DALLAS, Tex -- February 6, 2015 -- The depth of chest compressions and the rate at which they were applied make a significant impact on survival and recovery of patients, according to 2 studies published in Circulation and Critical Care Medicine.
Contrary to popular belief, the studies showed that cardiopulmonary resuscitation (CPR) compressions deeper than 5.5 cm resulted in decreased survival, possibly because of collateral damage to other internal organs.
Previously, investigations and guidelines indicated that deeper compressions were better. The American Heart Association's (AHA) 2010 CPR guidelines recommend compressing the chest at least 5 cm without providing any upper limit.
“Most people do not recognise that it takes quite a bit of thrust to compress the chest 2 inches,” said Ahamed Idris, MD, by UT Southwestern Medical Center, Dallas, Texas. “About 60 pounds [27 kg] of pressure are required to reach this depth, but in some cases a burly fireman or well-intended volunteer can go way past that amount, which can harm the patient.”
The researchers also found that the rate at which chest compression was applied was most important. Compression rates of 100 to 120 per minute were optimal for survival when other factors were considered.
“Survival depends on the quality of the CPR,” said Dr. Idris. “Both the depth of chest compressions and the rate at which they are applied can have important results for patients in the first moments of cardiac arrest.”
About half of responders are giving chest compressions too fast, with about a third above 120 compressions per minute, and 20% above 140 per minute, said Dr. Idris.
The researchers will continue to oversee innovative clinical trials to test the early delivery of interventions for serious trauma and cardiac arrest as part of a federally funded consortium aimed at advancing prehospital emergency care.
The Resuscitation Outcomes Consortium (ROC) has enrolled tens of thousands of patients to test prehospital interventions to improve outcomes in severely ill or injured patients before they are transported to a hospital.
SOURCE: University of Texas Southwestern Medical Center
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New extraglottic device.
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Dear Roberto, thank you for sending on my comments. I have now met the inventor who brought samples for me to use and we did use it together yesterday. A size 4 slipped in easily into a male patient and achieved a seal pressure of 34. There was slight epiglottic down folding I guess, while using this latest version. It improved when I pulled the device out partially. I will try it on my vomiting model in the next couple of weeks. It would be good to keep in touch and to do some collaborative work together. I confess that I have been slow to respond to your kind comments with many personal demands recently. My email is donald.miller@kcl.ac.uk
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I think it's not feasible, but someone else doesn't agree.
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If they need analgesia, they don't need CPR; if they need CPR, they don't need analgesia.
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In the UK, cricoid pressure (Sellick maneuver) is an almost compulsory maneuver in any rapid sequence induction (laparotomy, cesarean sections, etc). However, a recent study by Theiler et al. (Survey on controversies in airway management among anesthesiologists in the UK, Austria and Switzerland.
Theiler L, Fischer H, Voelke N, Basciani R, Hasty F, Greif R. Minerva Anestesiologica 2012) has shown that in Austria or Switzerland cricoid pressure is applied only in 30-50% of emergency cases.
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I have been doing anesthesia for 30+ years, I never believed nor practiced cricoid pressure in a single patient. I strongly support the current views that it is useless and actually might be harmful in situations like difficult intubation.
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I would like to know if any of the fellow researchers face any problem in CFD analysis for human trachea; particularly because of continuity constraints ? I think that models with C0 continuity are difficult to do anlysis with. But I need to know what are the actual problems that lie.
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I could not find any comments related to problems in CFD analysis due to continuity limitations of the 3d reconstructed model. I think that models with C0 continuity are difficult to do anlysis with. But I need to know what are the actual problems that lie.
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Standard disposable tracheal tubes have a bevel facing left. This design makes the railroading of the tube over fibreoptic scope or a bougie more difficult and requires tube to be rotated 90 degrees anticlockwise (without certainty that the tip will rotate to the same degree) during railroading maneuvers in order to turn the bevel facing posteriorly. Surely, all tubes should be designed with the bevel facing posteriorly, unless I am missing something?
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The trachea curves first ventrally and then dorsally and the bevel is one of the ETT- safety design items, making sure that even when the tip of the ETT lays against he tracheal wall it is not obstructed. With the bevel ventral or dorsal (i.e. anterior or posterior) this risk of tip occlusion would be potenially threatening. The ETT design has to follow safety issues before following some special placement desires (infact, most ETT's are placed without a scope or bougie).
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There is reasonable evidence for 'normal' checklists such as WHO and SURPASS. Gawande's group have recently published simulation evidence for intra-operative crises, but airway issues were not really addressed. There are many algorithms out there, such as the UK and US difficult airway, but I am interested in the evidence, if any, for whether emergency operating procedures are effective.
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Good question; I too am only familiar with the various country / society algorithms. I've never seen evidence that specifically addresses the value of a D.A. checklist.
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Apologies, this is rather a specific question. Has anyone experienced, or heard of it occurring, cardiogenic oscillations on the end tidal CO2 waveform display, in medical helicopter transport? This was on a ZOLL CCT M, patient intubated, cuff functioning correctly. 66 Y/O Male Anterior STEMI. 150 min post onset.
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Yes, well recognised and can even trigger ASB breaths in brainstem dead patients - important in apnoea testing:
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What's your opinion about using Airtraq laryngoscope in emergency situations? Do you have Airtraq in emergency trolley in your hospital? As the first successful attempt is very important and sometimes life saving, do you use Airtraq as the first choice in cardiopulmonary resuscitations with anticipated difficult airway? What's your preference in difficult emergency cases?
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There is plenty of evidence suggesting that videolaryngoscipes are more successful at managing difficult airway (when difficulty is defined by limited view at Macintosh laryngoscopy). Choosing the videolaryngoscope that you have some experience in using in normal airways is important point mentioned previously as almost all videolaryngoscopes require some adjustment to your intubation technique.
I would disagree though with ILMA (Fastrach LMA) being selected as suitable device for use in failed intubation. This device has to be used with the guidance of fibreoptic scope if it is to be effective (UK DAS guidelines). A number of surveys in the UK pointed towards limited experience with this device. Blind intubation through the ILMA has a success rate of around 80% - not enough for a failed intubation rescue device. Fibreoptic guided intubation through ILMA has much higher success rate but requires significant amount of training before proficiency is achieved.
I would argue that learning to use a videlaryngoscope is much simpler and easier than learning to intubate through ILMA with fibreoptic guidance.
Use of Airtraq and Pentax AWS in the prehospital setting is now well researched and supports the use of these portable devices that are shock and water resistant to a reasonable degree.
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There are a wide variety of opinions with very little evidence to support certain method of airway management. Interested to find out what everyday anesthetists do in patients like this.
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Iwould like to share my experience also. Due to legal liability I think the best way is to stick with guidelines, that ASA or DAS guidelines where in predicted difficulty only awake management is proposed. I usually perform adequate local anaesthesia and then I try to perform one laryngoscopic attempt using the Airtraq laryngoscope. If there is such a narrow glottis that the tube cannot pass, I revert to surgical airway. Up to now I have not failed to manage any obstruction. I usually have the choice of fibeeoptics but from experience it is time consuming and there is a possibility of totally obstructing the already narrow glottis.