Article of the Month

    

Dear colleagues and airway enthusiast 
The European Airway Management Society is introducing a new feature – Article of the Month. 
This is designed to provide an opportunity to our members to highlight and share airway related topics and to open discussion forums in order to share clinical experience for the benefit of all EAMS members. 
The Article of the Month will be made available via the EAMS website and is going to be accompanied by a short text (up to 200 words) explaining why is this article being selected. 
EAMS members with login to eamshq.net will have access to the articles as full-text PDF's.
We would like to encourage our members to propose articles of the month. The short text accompanying the article will also be made available on line with full acknowledgement of the author who proposed the article. 
The final decision to go on-line will be taken by the EAMS Board of Directors. 

Best regards 
R. Tino Greif 
President of the European Airway Management Society

    

Dear Airway Enthusiasts

This month's article is a Cohrane review and coming from the president: Prof. Greif. The unanticipated difficult airway is a potentially life-threatening event during anaesthesia or acute conditions. An unsuccessfully managed upper airway is associated with serious morbidity and mortality. Several bedside screening tests are used in clinical practice to identify those at high risk of difficult airway. Their accuracy and benefit however, remains unclear.
The objective of this review is to characterize and compare the diagnostic accuracy of the Mallampati classification and other commonly used airway examination tests for assessing the physical status of the airway in adult patients with no apparent anatomical airway abnormalities.

Have fun!

Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H.Roth D, Pace NL, Lee A, Hovhannisyan K, Warenits AM, Arrich J, Herkner H: Airway physical examination tests for detection of difficult airway management in apparently normal adult patient. Cochrane Database of Systematic Reviews 2018, Issue 5.

 

Dear EAMS Members;

This month's article was recently published by Massimiliano Sorbello et al. in European Journal of Anaesthesiology. Looks like we need to take lessons from their experience.

Dear Collogues and Airway Enthusiasts,

This month's article, chosen by Dr. Michael Seltz Kristensen, is a reminder that: if difficult/failed direct laryngoscopy is expected we must: 1) at least consider awake intubation... and 2) if we decide to induce anaesthesia we must not soleley rely on the success of an angulated videolaryngoscope, but we must have other rescue options avalable, including alternative techniques for intubation and a plan that is predicted to be successfull for ventilation/front of neck access. 

Arslan Zİ: The Channelled Airtraq® as a Rescue Device Following Failed Expected Difficult Intubation withArslan Zİ. The Channelled Airtraq® as a Rescue Device Following Failed Expected Difficult Intubation withan Angulated Video Laryngoscope. Turk J Anaesthesiol Reanim 2018; 46(5): 399-401.

Dear EAMS-Members,

Article of the Month September is recommended by Michael Seltz Kristensen from Denmark:
"This is THE SINGLE AIRWAY PAPER TO READ IF YOU ONLY WANT TO READ ONE PAPER IN ALL YOUR CAREER: The Canadian guidelines - so much covered in such a stringent manner in ONE paper!"

Dear EAMS-Members,

After a short summer holiday season, we are back with the article of month. This month’s contribution came from Prof. Arnd Timmermann. His article of the month is a German study done by the anesthesiologist and A&E physician Michael Bernhard and Coworkers from Leipzig, Germany. He took a closer look to the raising concerns around the usage of supraglottic airway devices (SAD) for out-of-hospital airway management. The dominate SAD device in Germany is the laryngeal tube (LT). The LT was critized for the unrecognized malposition’s leading in massive stomach inflation (≈10%) and severe tongue swelling (≈40%). It is unclear, if the usage of the LT and the specific malposition’s had any influence in the outcome of patients ventilated by the LT. Therefore the authors retrospectively analyzed data from the German Resuscitation Registry for a study period of 6½ years, including approximately 43.000 patients after out of-hospital cardiac arrest treated with manual chest compression and automated chest compression devices and who were ventilated by a laryngeal tube or an endotracheal tube. Nearly 27.500 patients fulfilled study criteria and were including for further analysis. This study demonstrated that patients treated with SAD only suffered from the lowest hospital admission rate with ROSC, lowest survival rate to hospital, discharge, and lowest survival rate to hospital discharge with good neurological outcome in comparison to all other airway and compression methods. The result were better if the LT was immediately was replaced with an ET by a supporting emergency physician at the out of hospital scene. The authors concluded that SAD only should be avoided or SAD should be changed into ETI, independent of whether chest compression method was used.

This months article comes from Dr. Rüdiger Noppens and focuses on a back-up strategy for potential difficult re-intubation in the ICU setting. The authors examined the impact of the guide wire of the staged extubation set on correct positioning and patient tolerance. This is one of the first manuscripts looking on the feasibility of this strategy over a prolonged time period. Have fun!

S. McManus, L. Jones, C. Anstey and S. Senthuran: An assessment of the tolerability of the Cook staged extubation wire in patients with known or suspected difficult airways extubated in intensive careAnaesthesia 2018, 73, 587–593

Dear readers of EAMS’ article of the month section. 

For this this month’s article, we present you a recent narrative review by Tim Cook, titled "Strategies for the prevention of airway complications – a narrative Review”. The article is not featuring classic research results, but you will find a nice overview of many important points that apply to airway management, up–to-date.

Enjoy!

Lorenz Theiler

T. M. Cook: Strategies for the prevention of airway complications – a narrative review. Anaesthesia 2018, 73, 93–111

Dear EAMS members,

This month’s article is from Lorenz Theiler, you will actually find 2 articles attached.

Both articles should be enlightening as they reflect this year’s European Airway Congress: From the past to the future of airway management

The first article is the classic paper by Cormack and Lehane. When you read the 1984 article carefully, you will realize that, yes, the authors do mention the four grades of the best view obtained in direct laryngoscopy. But in its core, the article is about teaching airway management. Because difficulties in airway management are rarely encountered, we have to make up for it by actively teaching it all the time. Cormack and Lehane are doing a great job in transferring this message.

The second article is another classic. Magill’s paper about airway management, dated 1930. When I read his thoughts, I was not surprised how much has changed in the last ninety years, but instead I was awed by the fact that much stayed the same. I realized many believes we have about airway management are in fact just that: believes. They come from another time, driven by circumstances very different from today. It might be worth thinking about this, and constantly keep reflecting whether our actions are still adequate. 

Enjoy!

Magill 1930 Techniques in Anaesthesia

Cormack Lehane 1984 Difficult tracheal intubation in obstetrics

Dear airway enthusiasts, This month we suggest you to read the latest guideline for the management of tracheal intubation in critically ill adults. The article is coming from Massimiliano Sorbello who is one of the Italian reviewers of this guideline with Flavia Petrini. Here you will find the tracheal intubation algorithm and the can’t intubate can’t oxygenate algorithm. Please log in and read the full text! Have fun..

A. Higgs, B. A. McGrath, C. Goddard, J. Rangasami, G. Suntharalingam R. Gale, T. M. Cook and on behalf of Difficult Airway Society, Intensive Care Society, Faculty of Intensive Care Medicine, Royal College of Anaesthetists: Guidelines for the management of tracheal intubation in critically ill adultsBritish Journal of Anaesthesia, Volume 120, Issue 2, 323 - 352

Dear airway enthusiasts;

This month’s article is about a 5-year retrospective analysis of Extraglottic airway devices. A choice from our Board member Massimiliano Sorbello. The authors point out the incidence of perioperative extraglottic airway device failure and identify modifiable factors associated with this complication that may be the target of preventative or mitigating interventions. Please login to reach the full text and enjoy the article!

For December article of the month, we have selected an article from the December issue of Anaesthesia:
 
Although this article appears to suggest what many of us think we already know, this is one of the first articles to use the power of the systematic review and meta-analysis to state that anaesthetists are better of using videolaryngoscopes when managing difficult airways. This article has confirmed that VLSs have higher success rate, shorter intubation time, are associated with fewer intubation attempts and are less likely to cause airway injury when compared to Macintosh laryngoscope. All extremely relevant factors for difficult airway management.

Please be aware that the full texts will be provided to EAMS members with login to eamshq.net.

With best wishes
Iljas Hodzovic, MD, FRCA

Dear Colleagues;

This month, the articles are related with tracheal extubation. The first paper is a guideline on ‘’Intubation and extubation of the ICU patient’’. You will find recommendations from experts of the SFAR and SRLF.

Quintard H, l'Her E, Pottecher J, Adnet F, Constantin JM, De Jong A, Diemunsch P, Fesseau R, Freynet A, Girault C, Guitton C, Hamonic Y, Maury E, Mekontso-Dessap A, Michel F, Nolent P, Perbet S, Prat G, Roquilly A, Tazarourte K, Terzi N, Thille AW, Alves M, Gayat E, Donetti L. Intubation and extubation of the ICU patient. Anaesth Crit Care Pain Med 2017 Oct;36(5):327-341.

No abstract available

The second paper is again from France: a randomised controlled trial  which compares suction with positive pressure before extubation in adult patients.

L'Hermite J, Wira O, Castelli C, de La Coussaye JE, Ripart J, Cuvillon P. Tracheal extubation with suction vs. positive pressure during emergence from general anaesthesia in adults: A randomised controlled trial. Anaesth Crit Care Pain Med 2017 Sep 4. pii: S2352-5568(17)30001-2. doi: 10.1016/j.accpm.2017.07.005. 

Abstract:
After general anaesthesia (GA) in adults, the optimal tracheal extubation technique (positiveBackground: After general anaesthesia (GA) in adults, the optimal tracheal extubation technique (positivepressure or suctioning) remains debated. The primary endpoint of this study was to assess the effects ofthese techniques on onset time of desaturation (SpO2 < 92%).Methods: Sixty-nine patients with a body mass index < 30 scheduled for elective orthopaedic surgerywere allocated to positive pressure (PP) or suctioning (SUC) group. GA was standardised with propofoland remifentanil via target-controlled infusion. A morphine bolus of 0.15 mg/kg was administered 20–30 mins before the end of surgery. The effect of extubation technique on onset time of desaturation (T92)was assessed during the first 10 mins after extubation during the spontaneous air breathing. Secondaryendpoints included: frequency of desaturation, respiratory complications, need to use oxygen therapyand SpO2 at the end of the first hour while breathing in air (ClinicalTrials.gov identifier: NCT01323049).Results: Baseline patient characteristics and intraoperative management data for the 68 patientsincluded had no relevant clinical difference between groups. T92 (sec) after tracheal extubation was 214(168) vs. 248 (148) in the PP and SUC groups, respectively (P = 0.44). In the PP and SUC groups, 50 and43% reached a SpO2 < 92% within the first 10 mins after extubation respectively (P = 0.73). There were nostatistically significant differences between groups for any secondary endpoints.Conclusions: Positive pressure extubation as compared with suctioning extubation did not seem to delayonset time of desaturation after GA in standard weight adult patients.

Please be aware that the full texts will be provided to EAMS members with login to eamshq.net.

With best wishes
Kemal Tolga Saracoglu
Co-secretary of the European Airway Management Society

In order to start the Article of the Month process, I have selected two articles, both related to the importance of pre-oxygenation. One of the articles discusses the physiological basis, benefits and potential risks of pre-oxygenation:

Anesth Analg. 2017 Feb;124(2):507-517. doi: 10.1213/ANE.0000000000001589. Preoxygenation: Physiologic Basis, Benefits, and Potential Risks. Nimmagadda U, Salem MR, Crystal GJ.

I have also included two meta-analyses from the emergency medicine journals related to the pre-oxyganation in the emergency room. What works in the emergency room is likely to be relevant under more controlled conditions in the operating room:

Am J Emerg Med. 2017 Aug;35(8):1184-1189. doi: 10.1016/j.ajem.2017.06.029. Epub 2017 Jun 15. Apneic oxygenation reduces the incidence of hypoxemia during emergency intubation: A systematic review and meta-analysis. Pavlov I, Medrano S, Weingart S.

Am J Emerg Med. 2017 Oct;35(10):1542-1546. doi: 10.1016/j.ajem.2017.06.046. Epub 2017 Jun 24. Apneic oxygenation during intubation in the emergency department and during retrieval: A systematic review and meta-analysis. Binks MJ, Holyoak RS, Melhuish TM, Vlok R, Bond E, White LD.

With that you should have enough arguments for any discussion about this topic.

Have fun in reading the articles that will be provided to EAMS members with login to eamshq.net as full-text PDF's.

Best regards
Tino Greif
President of the European Airway Management Society

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