Airway Management Anesthesia View

Andreas Grabinsky, MDAssistant Professor, Dept. of AnesthesiologyProgram Director and Section Head, Emergency & Trauma AnesthesiaHarborview Medical Center

Overview

•Airway management in the field

•Airway management in the hospital

•Indications

•Priorities

•Problems

OR Airway Management

Field Airway Management

In the OR

OR Setting

•26 Operating rooms

•> 1.000 cases per month

•13 Anesthesiology Attendings

•26 Residents / CRNA’s

•Start 07:30AM (Wednesday 08:30AM)

•26 potential airways at 07:30AM

The OR Whiteboard

What to do ?•Find the Anesthesiologist in charge

•Find the anesthesiologist (covers 2-3 rooms)

•Help out

•Hope you “get the airway”

•Stay in one of the rooms (first rotation)

•Find a “late start room” for another airway (second rotation)

Learning Goals

•Identify difficult airway

•Proficient bag/mask ventilation

•Use of alternative airway techniques

•Prepare Intubation

•Learn about RSI

•Demonstrate Laryngoscopy / Intubation

The Intubator

Airway Priorities

1. Oxygenate2. Ventilate3. Protect Airway

Airway Management•Spontaneous ventilation

•Assisted mask/bag ventilation

•Controlled mask/bag ventilation

•Intubation + controlled ventilation

•Surgical airway + controlled ventilation

Use the least aggressive means necessary for airway management

Indications for Intubation

•Insufficient Oxygenation

•Insufficient Ventilation

•Loss of airway protection

•Impending airway problems (CNS, Trauma)

Preparation

•Oxygen

•Ambu bag with mask

•Suction

•Laryngoscope (working)

•different size ETT

•Suction

•Plan B (Adjuncts)

Prevention of Failure

•Assess situation

•Decision for specific airway management

•Communicate

•Plan B

•Reassess (change plan, if needed)

Failure to intubate in the OR

•Use alternative methods

•Get help

•Wake patient up

Failure to intubate in the Field

•Use alternative methods

•Failure is not an option !

Prevention of Failure

Do not mess with a perfectly fine airway.

Publications

Airway Assessment

Difficult Airway

Harborview Specials

Indications for Intubation

•Insufficient Ventilation

•Insufficient Oxygenation

•Loss of airway protection

•Impending airway problems (CNS, Trauma)

Training

Preparation•Oxygen

•Ambu bag with mask

•Suction

•Laryngoscope (working)

•different size ETT

•Suction

•Plan B

Tools

Real Men use Miller Blades

i-gel

Res-Q-Scope

Glidescope

Glidescope

Glidescope•25 Paramedic students

•Glidescope versus Macintosh 3 blade

•100 intubations in different scenarios on manekin

•Significant better visualized glotic opening with Glidescope

•Same success rate of 76%

•Increased time to intubation with GlidscopeAziz, Michael, Dillman, Dawn, Kirsch, Jeffrey R. and Brambrink, Ansgar(2009)'Video Laryngoscopy with the Macintosh Video Laryngoscope in Simulated Prehospital Scenarios by Paramedic Students',Prehospital Emergency Care,13:2,251 — 255

Res-Q-Scope•22 US military parmedic (50 manekin and 8

human intubations)

•22 Emergency medicine residents/attending

•20 minutes instruction and 20 minutes training, 3 trials with each device

•Intubation time Res-Q-Scope 25.9 seconds

•Intubation time direct Laryngoscopy 14.6 secondsShawn M. Varney MD , Melissa Dooley MD, Vikhyat S. Bebarta MD ⁎

Faster intubation with direct laryngoscopy vs handheld videoscope in uncomplicated manikin airwaysAmerican Journal of Emergency Medicine (2009) 27, 259–261

Questions ?