DAS @ GAMC 2022 by Difficult Airway Society

@ GAMC 2022 ft. #JanuAIRWAY

GAMC 2022

Disclaimers This material is an extract from #JanuAIRWAY - the compilation - please refer to the complete document for all disclaimers and more details on further reading. Every effort has been made to ensure the content is factually correct and up to date. It is not intended to replace other existing educational materials. If you identify any errors please notify us at trainee@das.uk.com. This is intended to be a learning resource - it is not a guideline. For all DAS Guidelines please refer to the peer reviewed publications.

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GAMC 2022

#JANUAIRWAY 2022 | Helen Aoife Iliff and Tom Lawson | The #JanuAIRWAY twitter educational event concluded on 31.01.2022. It consisted of daily tweetorial threads which include a series of one-pagers on topics related to airway management – posted via the @dastrainees twitter account. There has been an overwhelmingly positive response online to the series with excellent feedback. Thank you to everyone who took the time to provide us with feedback. We are

developed with Professor Tim Cook and Barry McGuire.

delighted the series was so widely accessed,

The compilation was launched on 10th March

not just globally but also across professional

2022 and was viewed over 4000 times in more

domains, specialities and training grades.

than 80 countries across 6 continents the rst 3

The series had gained: >3 million impressions; >13.5 thousand likes and >5 thousand retweets. The DAS education team

weeks. It is freely available and fully downloadable via issuu. Please share the link with any colleagues you think may nd it useful.

are already using on the feedback received

Thank you to all of our content contributors,

to plan future content. We’ve already snuck

reviewers and to all of those who have taken

some new #OnePages into the compilation

the time to support the series. We hope you

including the one in this extract on

enjoyed it!

oesophageal intubation which was

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BASIC AIRWAY EQUIPMENT | Good workers know their tools | Good workers know their tools – knowing our equipment is essential! See the #OnePagers for the fundamentals of masks, NP/OPs, SADs, ETTs and Frova intubating introducer. Speci c airway devices such as Cook airway exchange catheters, Aintree Intubation Catheters, Staged Extubation Kits, OLV equipment, Tracheostomies, are covered later in the compilation. Here are some papers / links that you might nd interesting: a. Laurie A, Macdonand J. Equipment for airway management. Anaesthesia and Intensive Care Medicine. 2018; 19: 389-96 b. Bjurström MF, Bodelsson M, Sturesson LW. The Dif cult Airway Trolley: A Narrative Review and Practical Guide. Anesthesiology Research and Practice. 2019 c. Chishti K. Setting up a Dif cult Airway Trolley. 2015 (online) d. Gibbins M, Kelly FE, Cook TM. Airway management equipment and practice: time to optimise institutional, team, and personal preparedness. British Journal of Anaesthesia. 2020; 125: 221-4

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AIRWAY LARYNGOSCOPY | DL, VL or Combined FB:VL? | Laryngoscopy, as a prelude to tracheal intubation, is an essential skill for airway managers. There is a wide array of laryngoscope types and approaches used to achieve this view of the glottis. Broadly speaking, laryngoscopy can be direct (DL) or indirect (VL) and can involve a rigid or a exible device. All devices and approaches require speci c skills and may require additional intubation aids, such as a stylet. The term ‘videolaryngoscopy’ has now been adopted for all rigid laryngoscopes that deliver an indirect view of the glottis. Innovators will develop new techniques, such as combining videolaryngoscopy and exible bronchoscopy, to overcome dif culty. It is important to understand the Cormack and Lehane classi cation, universally adopted for grading of direct laryngoscopy view. This becomes less relevant with indirect laryngoscopy, where there is no agreed classi cation system. The Video Classi cation of Intubation (VCI) score is a potential model (*inclusion in this material does not constitute DAS endorsement).

Here are some papers / links that you might nd interesting: a. Jackson, C.

The technique of insertion of intratracheal insuf ation tubes.

Surgery,

Gynecology and Obstetrics. 1913; 17: 507-9 b. Knill RL. Dif cult laryngoscopy made easy with a "BURP". Canadian Journal of Anaesthesia. 1993; 40: 279-82 c. Chaggar RS, Shah SN, Berry M, Saini R, Soni S, Vaughan D. The Video Classi cation of Intubation (VCI) score: a new description tool for tracheal intubation using videolaryngoscopy: A pilot study. European Journal of Anaesthesiology. 2021; 38: 324-6 d. Lewis SR, Butler AR, Parker J, Cook TM, Scho eld-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. British Journal of Anaesthesia. 2017; 119: 369-83

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CAPNOGRAPHY & OESOPHAGEAL INTUBATION | with thanks to Tim Cook and Barry McGuire for their expert contributions | This is one of the most essential pieces of monitoring equipment needed during airway management.

But its presence isn’t enough, correct interpretation is vital. Capnography is

primarily an AIRWAY monitor. Oesophageal intubation still occurs & EtCO2 is a key tool to help prevent avoidable deaths such as Glenda Logsdail’s. Key message is that at or no trace indicates oesophageal intubation until proven otherwise. This thread by Professor Tim Cook is fantastic and we recommend everyone read it! He also has an article in FICM’s Critical Eye. The Royal College of Anaesthetists and DAS video “Capnography: No Trace = Wrong Place” is essential viewing for all airway managers.

https://www.youtube.com/watch?v=t97G65bignQ&t=8s

The RCoA have a number of other videos available on their website on a page dedicated to the prevention of future deaths. We also recommend all airway managers read this DAS ezine article by Barry McGuire Imran Ahmad, Alistair McNarry, Abhijoy Chakladar and Lewys Richmond.

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https://vimeo.com/662046937/ad4217b155

Another reported case in Australia has further emphasised this is not just a UK problem, it is a global issue. But as Professors Ellen O’Sullivan and Tim Cook have pointed out there is an almost 100% “Capnography Gap” in LIC (audits completed in Malawi & Uganda) which must be addressed See this recent series from Anaesthesia Journal on unrecognised oesophageal intubation • Editorial • Broadcast • Podcast

Here are some other papers / links that you might nd interesting: a. Cook, T.M., Kelly, F.E. and Goswami, A. ‘Hats and caps’ capnography training on intensive care. Anaesthesia, 2013; 68: 421 b. Joy P, Kelly FE. Unrecognised Oesophageal Intubation. Anaesthesia News. 2022 (online) c. Cook TM, Harrop-Grif ths W. Capnography prevents avoidable deaths. British Medical Journal. 2019; 364: l439 d. CORONERS COURT OF NEW SOUTH WALES Inquest into the death of Emiliana Obusan. 2021 (online) e. MILTON KEYNES CORONER’S COURT Inquest into the death of Glenda May Logsdail REGULATION 28: REPORT TO PREVENT FUTURE DEATHS f. Foy KE, Mew E, Cook TM, Bower J, Knight P, Dean S, Herneman K, Marden B, Kelly FE. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia. 2018; 73:1337-44 g. Collins J, Ní Eochagáin A, O'Sullivan EP. A recurring case of 'no trace, right place' during emergency tracheal intubations in the critical care setting. Anaesthesia. 2021; 76 :1671

Dif cult Airway Society E-Zine

January 2022

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COOK AIRWAY EXCHANGE CATHETER | Useful but use with caution - know its limitations and dangers! | A useful piece of equipment, but one not everyone will be familiar with. Main function is as a stopgap to maintain tracheal access & facilitate ETT exchange. They are long, hollow, radiopaque, soft-tipped tubes – types for use with single / double lumen tubes. There are different sizes for different functions (see chart). All users MUST be trained & knowledgeable of how to use such devices together with their limitations and dangers. The Gordon Ewing case makes for tragic reading – but highlights this point. Essential reading for airway practitioners. NEVER insert beyond 26cm and NEVER insuf ate with an oxygen ow >2L/min. (or just NEVER insuf ate with oxygen) Here are some papers / links that you might nd interesting: a. Sheriffdom of Glasgow and Strathkelvin. Determination of Sheriff Linda Margaret Ruxton in Fatal Accident Inquiry in the Death of Gordon Ewing. 2010 FAI 15 (online) b. Benumof JL. Airway exchange catheters: simple concept, potentially great danger. Anesthesiology. 1999; 91: 342-4 c. Moyers G, McDougle L. Use of the Cook airway exchange catheter in "bridging" the potentially dif cult extubation: a case report. AANA Journal. 2002; 70: 275-8 d. A dangerous tracheal tube exchange from AOD. 2016 - video (online) e. Change of Endotracheal tube over tube exchanger. 2019 - video (online)

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COOK AINTREE INTUBATION CATHETER | So useful, but know its limitations! | An amazingly useful piece of equipment – every airway practitioner should be familiar with. Main function of the Aintree Intubation Catheter is to facilitate intubation through a supraglotttic airway device because it is designed to t over a 4mm exible bronchoscope. It is a long, 56cm, hollow, semi-rigid, powder blue, polyurethane catheters which accommodates an ETT 7mm or larger. NEVER insert beyond 26cm and NEVER insuf ate with an oxygen ow >2l/min (..or just NEVER insuf ate) Here are some papers / links that you might nd interesting: a. Padmanabhan R, McGuire B, Morris A. Fibreoptic guided tracheal intubation through supraglottic airway device (SAD) using aintree intubation catheter. 2011 (online) b. Gruenbaum SE, Gruenbaum BF, Tsaregorodtsev S, Dubilet M, Melamed I, Zlotnik A. Novel use of an exchange catheter to facilitate intubation with an Aintree catheter in a tall patient with a predicted dif cult airway: a case report. Journal of Medical Case Reports. 2012; 13:108 c. Phipps S, Malpas G, Hung O. A technique for securing the Aintree Intubation Catheter™ to a exible bronchoscope. Canadian Journal of Anaesthesia. 2018; 65: 329-30 d. Cook Medical. Aintree Intubation Catheter (online) e. Gloucestershire Hospitals NHS Foundation Trust. Fibreoptic Guided Intubation through SGA using Aintree Intubation Catheter - video (online)

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BLEEDING & AIRWAYS | with thanks to Anil Patel and Elizabeth Ross for their expert contributions|

The Obstructed Airway - think: NOLIMBS • Nose, Nasal Cavity and Nasopharynx • Oral Cavity and Oropharynx • Larynx, Laryngopharynx and Extra-thoracic (subglottic) Trachea • Intra-thoracic • Malacias • Bleeding • SVC Obstruction

Bleeding & Airways Need to consider “WHERE” the bleeding is coming from. In general there are 3 possibilities: • Above (Nasal Cavity / Nasopharynx / Oral Cavity / Oral Cavity / Laryngopharynx) • Below (Tracheal / Lung / Oesophagus / GI) • Around airway (consider full circumference of airway - any haematoma in the airway can cause localised airway oedema and/or airway compression) Airway obstruction due to neck haematoma: • Can be fatal • Is normally due to laryngeal oedema NOT tracheal compression • Need to open wound immediately and manually evacuate haematoma to relieve pressure – think SCOOP See guidelines from DAS, BAETS and ENT-UK.

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AWAKE TRACHEAL INTUBATION (ATI) | with thanks to Imran Ahmad for his expert contributions | Awake Techniques – there are key skill for an airway manager. Topicalization is key (if right, may not need sedation). Top tips: • Know nerve supply – CN V, IX & X. • Block Ant.ethmoidal AND Sphenopalatine ganglion supply nasal septum • Often you don’t need high dose LA if in right spot – this video is Tom Lawson after only gargling instilagel.

https://www.youtube.com/watch?v=Pzo_1TJZSEY

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Fibreoptic scopes have advanced in recent years.

It is important for airway managers to be

familiar with and have knowledge of the ergonomics and the basics of the exible bronchoscope. • Know your equipment – set-up, usage and limitations • Two positions for scope handling – Bazooka (facing patient) or Statue of Liberty (standing at head end)

Ancillary equipment can make or break an awake intubation. These can be broken down into 3 main types: • Those which aid oxygen delivery • Those which aid drug delivery • Those which aid scope delivery (oral airways) There are many different recipes for ATI. It is worth being familiar with the different drugs that can be used and recommend using the DAS approach to ATI. There are a lot of potential problems that can be encountered during ATI – these need to be planned for. Be familiar with the basics of troubleshooting, complications and how to manage unsuccessful ATI. Remember HFNO can help and a good knowledge of airway pharmacology is essential for awake techniques. Here are some papers / links that you might nd interesting: a. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020; 75: 509-28 b. Royal Free Anaesthesia. How to topicalise the airway for awake beroptic intubation (AFOI) - video (online) c. Bailin S. Awake Tracheal Intubation - video (online) d. Awake Airway Management. Videolaryngoscopic awake tracheal intubation, no sedation video (online)

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DAS UNANTICIPATED DIFFICULY INTUBATION GUIDELINES | having a strategy (a series of plans) is essential |

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DAS UNANTICIPATED DIFFICULT INTUBATION GUIDELINES EXTENDED VERSION | having a strategy (a series of plans) is essential |

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PLAN D: EFONA | with thanks to Alistair McNarry for his expert contributions | Language around this scenario is continually evolving. Whether its referred to as CICO - Can’t intubate, Cant Oxygenate or CICV - Cant Intubate, Cant Ventilate; it is important to recognise this is a scenario. They all describe the scenario where all other attempts at airway management and oxygen delivery have failed. Whereas eFONA (emergency front-of-neck airway) is a procedure carried out in response to a CICO scenario. This is a rare event and raises a dichotomy. i. If when conducting an airway assessment you feel an eFONA might be required, STOP, get help and consider an airway management plan that avoids this requirement (eg an awake technique - see section on awake tracheal intubation) ii. However, if you are managing a patient’s airway and all other attempts at oxygenation have failed then you must PROCEED to eFONA without delay.

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Before commencing an eFONA technique ensure that a large dose of neuromuscular blocking agent has been given (treats laryngospasm and paralyses the patient). Know your technique before you are ever required to do it, rehearse it mentally i. where would you stand ii. who would you send for equipment iii. how would you extend the neck etc In adults DAS guidelines recommend scalpel eFONA techniques ( nal common pathway of CICO), however cannula technique is advocated in children between 1 and 8 years in a Can’t Intubate Can’t Oxygenate scenario (see the DAS APA guidelines). For more on the cannula technique check out Dr Andy Heard’s work at the Perth ‘wet’ lab. There are 2 anatomical scenarios for eFONA – palpable and impalpable anatomy. DAS guidelines recommend everyone should know scalpel eFONA techniques (scalpel bougie tube (palpable anatomy), scalpel nger bougie tube (impalpable anatomy).

https://www.youtube.com/watch?v=B8I1t1HlUac

The most dif cult part of the process is making the decision to pick up the scalpel. Mental models and thinking tools like the Vortex can be useful. Check out Nicholas Chrimes & Peter Fritz's work. Remember you’re not alone in having airway skills. Remember your surgical colleagues & involve them early. But also remember not all surgeons will feel comfortable in performing an eFONA - in that it case it will have to be YOU!

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Training in eFONA is vital - not just for you. Train everyone who might be involved in an eFONA event - nursing staff, anaesthetic assistants, scrub nurses (they are always there when you are doing an operation regardless of the time of the day). Training MUST use the locally available equipment - please make sure that your plan for eFONA is deliverable where you work (and remember that can change from hospital to hospital).

Here are some papers / links that you might nd interesting: a. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall NM, Ahmad I; Dif cult Airway Society intubation guidelines working group. Dif cult Airway Society 2015 guidelines for management of unanticipated dif cult intubation in adults. British Journal of Anaesthesia. 2015; 115: 827-48 b. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018; 120: 323-52 c. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Dif cult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75: 785-99 d. Heard A, Dinsmore J, Douglas S, Lacquiere D. Plan D: cannula rst, or scalpel only? British Journal of Anaesthesia. 2016; 117: 533-5 e. Mann CM, Baker PA, Sainsbury DM, Taylor R. A comparison of cannula insuf ation device performance for emergency front of neck airway. Pediatric Anesthesia. 2021; 31: 482-90 f. Chrimes N, Fritz P. The Vortex Approach to airway management (online) g. Heard AM. DrAMBHeardAirway YouTube Channel (online)

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GUIDELINES, GUIDELINES, GUIDELINES | “Guidelines are like toothbrushes. They are also like floss” | | @GongGasGirl #GAMC2021 | DAS are probably best known for our guidelines. Recently, we have updated our methodology to ensure all guidelines documents are of suf cient rigour to include best evidence and the most clinically relevant recommendations. However, it is important to recognise they are just that – recommendations and guidelines. Guidelines are not intended to represent a minimum standard of practice, nor are they to be regarded as a substitute for good clinical judgement. They present key principles and suggested strategies for the management of certain clinical scenarios. They are intended to guide appropriately trained healthcare professionals. We have many DAS guidelines and have contributed to many others in partnership with other organisations, here are links to some: a. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, O'Sullivan EP, Woodall NM, Ahmad I; Dif cult Airway Society intubation guidelines working group. Dif cult Airway Society 2015 guidelines for management of unanticipated dif cult intubation in adults. British Journal of Anaesthesia. 2015; 115: 827-48 b. Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM; Dif cult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. British Journal of Anaesthesia. 2018; 120: 323-52 c. Dif cult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Dif cult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012; 67: 318-40 d. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, O'Sullivan EP, Patel A, Stacey M, Vaughan D. Dif cult Airway Society guidelines for awake tracheal intubation (ATI) in adults. Anaesthesia. 2020; 75: 509-28 e. Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, Quinn AC; Obstetric Anaesthetists' Association; Dif cult Airway Society. Obstetric Anaesthetists' Association and Dif cult Airway Society guidelines for the management of dif cult and failed tracheal intubation in obstetrics. Anaesthesia. 2015; 70: 1286-306 f. Dif cult Airway Society and Association of Paediatric Anaesthetists. Paediatric Dif cult Airway Guidelines (online)

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g. Iliff HA, El-Boghdadly K, Ahmad I, Davis J, Harris A, Khan S, Lan-Pak-Kee V, O'Connor J, Powell L, Rees G, Tatla TS. Management of haematoma after thyroid surgery: systematic review and multidisciplinary consensus guidelines from the Dif cult Airway Society, the British Association of Endocrine and Thyroid Surgeons and the British Association of Otorhinolaryngology, Head and Neck Surgery. Anaesthesia. 2022; 77: 82-95 h. McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012; 67: 1025-41

Our guidelines have also been adapted to guide management of patients with COVID-19: a. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Dif cult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020; 75: 785-99

Other airway organisations also have their own guidelines. Here are just a few from America, Canada and Australia and New Zealand (there are many more). a. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, Fiadjoe JE, Greif R, Klock PA, Mercier D, Myatra SN, O'Sullivan EP, Rosenblatt WH, Sorbello M, Tung A. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Dif cult Airway. Anesthesiology. 2022; 136: 31-81 b. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM, Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey S, Turkstra TP, Wong DT; Canadian Airway Focus Group. The dif cult airway with recommendations for management--part 1--dif cult tracheal intubation encountered in an unconscious/induced patient. Canadian Journal of Anesthesia. 2013; 60: 1089-118 c. Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, Hung OR, Jones PM, Kovacs G, Massey S, Morris IR, Mullen T, Murphy MF, Preston R, Naik VN, Scott J, Stacey S, Turkstra TP, Wong DT; Canadian Airway Focus Group. The dif cult airway with recommendations for management--part 2--the anticipated dif cult airway. Canadian Journal of Anesthesia. 2013; 60: 1119-38 d. Australian and New Zealand College of Anaesthesia & Faculty of Pain Medicine. Guideline for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t Oxygenate airway emergency. 2017 (online) Note: we have not provided the one pagers for this tweetorial as they are all freely available from the hyperlinks previous and are best viewed with the accompanying text.

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Dif cult Airway Society Newsletter

Winter 2019

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