Article of the Month
Dear colleagues and airway enthusiast
The most stressful situation for an anaesthesiologist may be a No intubate/No oxigenate (NINO) patient. A recent study (NAP 4) says that in spite of the fact that all algorithms have a strategy for this situation- in all of them cricotirotomy is the final solution-, the resolution is not good in most of them. Why is this? How could we correct the mistakes that arise?. Simulation has proven to be an effective tool to improve how crisis resources are managed, such as NINO patient and CPR. It allows mistakes to be analyzed and solutions found, thus improving our performance. But, what if we have a NINO patient on whom we are performing cardiopulmonary resuscitation? This study by Ott et al (BMJ 2019) tries to address this question by establishing a possible airway management situation that, however infrequent, must not be forgotten. We hope you enjoy reading it.
Ott T, Stracke J, Sellin S, et al. Impact of cardiopulmonary resuscitation on a cannot intubate, cannot oxygenate condition: a randomised crossover simulation research study of the interaction between two algorithms. BMJ Open 2019;9:e030430. doi:10.1136/bmjopen-2019-030430
Open acces link (january 23th, 2020): https://bmjopen.bmj.com/content/9/11/e030430.info
March moth’s articles comes as a pair: Two 2020-papers (epub ahead of print 2019) that have to be read in conjunction: Ahmad and co-workers review on multiple aspects and practical guidance for AWAKE INTUBATION – The cornerstone technique in managing the predicted difficult airway, plus our accompanying editorial that reminds us that if an awake intubation is indicated then we shouldn’t abandon it easily – but remember that a spontaneous-ventilating intubation may be a close second best.
Ahmad I, El-Boghdadly K, Bhagrath R, et al. Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults [published online ahead of print, 2019.
Aziz MF, Kristensen MS. From variance to guidance for awake tracheal intubation [published online ahead of print, 2019.
Dear airway enthusiasts,
This month’s article is a from Fiadjoe et al. about pediatric normal and difficult airway management. If you are curious about the following questions you have to read the full text:
- • What are cognitive biases observed in pediatric difficult airway management?
- • What are the strengths and weaknesses of videolaryngoscopes and flexible bronchoscopes for tracheal intubation?
- • What is the current evidence for spontaneous versus controlled ventilation techniques when managing the anticipated difficult airway?
- • What is the role of passive oxygenation in difficult airway management in the OR and pediatric ICU?
- • What is the current evidence regarding the use of neuromuscular blockade in neonatal tracheal intubation and difficult airway in children?
Have fun at http://eamshq.net
Kemal Tolga Saracoglu
The “Article of the Month” from November and December covers the history of airway management. In a nice article series consisting of 4 individual publications in Anesthesiology, Dr Matioc has provided an excellent overview of what happened since the 1700s. Enjoy!
Dear EAMS community,
For a decade a manuscript looking at the impact of using a parachute for jumping out of a plane has been used to show the limitations of evidence-based medicine (Smith, G, Pell, J (2003) BMJ 327, 7429). Recently, a group of researches took this topic to the next level and performed a randomized, controlled trial to examine the impact of using a parachute vs. a backpack when jumping from aircraft. What has this to do with airway management? Please read this manuscript carefully! It draws some critical conclusions on how randomized trials need to be performed in order to address the clinical question or problem that counts. After reading this manuscript, you will never be reading an airway related article in the same way.
Enjoy this month's manuscript.
Robert W Yeh, Linda R Valsdottir, Michael W Yeh, Changyu Shen, Daniel B Kramer, Jordan B Strom, Eric A Secemsky, Joanne L Healy, Robert M Domeier, Dhruv S Kazi, Brahmajee K Nallamothu4 On behalf of the PARACHUTE Investigators: Parachute use to prevent death and major trauma when jumping from aircraft: randomized controlled trial, BMJ 2018;363:k5094
Emergency front-of-neck access (eFONA) is one of the most feared clinical interventions any of us is likely to face. Unfortunately, current evidence does not seem to provide enough guidance as to what is the most effective way of dealing with the dreaded can’t intubate can’t oxygenate scenario.
In this study, Rees et al have compared cannula and scalpel-bougie eFONA techniques using time to oxygen delivery as their primary outcome. The value of this study is, perhaps, not as much in the main findings as it is in the analysis of failures and repeated attempts. Rees et al. found that the participants had lower odds of failure using cannula (one failure) than using scalpel – bougie technique (15 failures).
Knowing how and why failures happen can be invaluable and is likely to help individual anaesthetist make a more informed decision about what eFONA technique is likely to suit better their clinical environment and skill mix. Well worth reading.
Rees KA, O’Halloran LJ, Wawryk JB, Gotmaker R, Cameron EK, Woonton HDJ: Time to oxygenate for cannula- and scalpel-based techniques for emergency front-of-neck access: a wet lab simulation using an ovine model. Anaesthesia 2019; Early View.
As the summer is underway, we may find time to contemplate and reflect on the issues related to anaesthesia and airway management.
To illustrate the unexpected nature of difficult airways, Pandit and Heidegger (Anaesthesia 2017; 72: 283-95) paraphrased the opening line of Tolstoy’s Ana Karenina stating that ‘all easy airways are alike, each difficult airway is difficult in its own way’.
That unexpected nature of the airway management difficulty is perhaps a good reason to read this month’s article of the month while sitting in your garden on a lazy Sunday afternoon with a glass of your favourite refreshment.
This month’s article of the month is a narrative review of the strategies for the prevention of airway complications. The article provides an excellent overview of the current evidence pointing towards potential surprises and how to avoid them. I am still working on making some of these strategies part of my routine when managing the airway. I am picking one strategy at a time and making it become a habit so I can implement it without actively thinking about whether or how.
This is a recent study from the Danish Anaesthesia Register and they looked at predictors for difficulties with facemask ventilation.
Interestingly if their score is between 6–10 points these patients need special attention as it could turn out difficult mask ventilation compared to those with lower score. Higher the risks are obvious. A clear cut off value was not to establish and their proposed score needs prospective validation in clinical practice. All in all a new attempt to solve a nearly impossible task - predicting what happens in the future but still a needed task - pre-anaesthesia evaluation to focus attention to possible problems of the patients, the process or the anaesthesia personnel which includes all of us.
Have fun in reading the article
Lundstrøm LH, Rosenstock CV, Wetterslev J, Nørskov AK: The DIFFMASK score for predicting difficult facemask ventilation: a cohort study of 46,804 patients, Anaesthesia. 2019 May 20. doi: 10.1111/anae.14701. [Epub ahead of print]
In patients with pathology of the neck ultrasonography is highly accurate in localizing the cricothyroid membrane and is comparable to CT-scan as the accepted standard. And in this population the cricothyroid membrane was only identified successfully in 8% of the patients whereas ultrasonography resulted in 81% success. These are the findings of our colleagues Siddiqui, You-Ten and co-workers from Toronto who authored the first of the two EAMS-articles-of-the –Month for May 2019. It thus seems beneficial to identify the cricothyroid membrane before initiating airway management in this notoriously difficult group of patients, and we should consider to use bedside-ultrasound for this purpose.
This leads to the second of the articles where we look at the useful information for managing the airway of the difficult patients that we gain from identifying both the cricothyroid membrane and other important structures of the front-of-the-neck.
Enjoy your reading!
And remember that it is possible to comment on all articles-of-the-month via our EAMS-webpage.
Best from Copenhagen!
Michael Seltz Kristensen
Siddiqui N, Yu E, Boulis S, You-Ten KE: Ultrasound Is Superior to Palpation in Identifying the Cricothyroid Membrane in Subjects with Poorly Defined Neck Landmarks: A Randomized Clinical Trial, Anesthesiology. 2018 Dec;129(6):1132-1139
Article of the Month | March 2019
Dear airway enthusiasts,
This month's article is from Arnd Timmermann. In this very large multicentre, prospective observational cohort study including almost 250000 patients from more than 200 hospitals from 28 European countries the authors could demonstrate that the use of neuromuscular blocking agents (NMBA) in general anaesthesia was associated with an increased risk of postoperative pulmonary complications. Interestingly, this was more evident in patients with ASA status I or II. Nor the use of qualitative or quantitative neuromuscular monitoring or the use of reversal agents could reduce the risk of postoperative pulmonary complications.
They concluded that Anaesthetists must balance the potential benefits of NMBA´s against the increased risk of postoperative pulmonary complications.
The reader must know that it is not clear if these increased pulmonary complication rate are due the use of NMBA´s or the use of the endotracheal tube, since the airway of the group who has received no NMBA were almost all managed by the use of supraglottic airway devices.
The article adds to the knowledge that the use of SGA in general anesthesia should be considered as the first line airway management strategy whenever feasible.
Kirmeier E, Eriksson LI, Lewald H, Jonsson Fagerlund M, Hoeft A, Hollmann M, Meistelman C, Hunter JM, Ulm K, Blobner M; POPULAR Contributors: Post-anaesthesia pulmonary complications after use of muscle relaxants (POPULAR): a multicentre, prospective observational study, Lancet Respir Med. 2019 Feb;7(2):129-140
Article of the Month | February 2019
Dear EAMS members,
The February’s Article of Month is ready for your attention on eamshq.net. A recently published review article by Ahmad I et al: Airway management research: a systematic review. The authors mention the lack of investigation for the examination of the methodology of airway research. The data they report provide a benchmark on methodology and end‐points used and demonstrate the geographical distribution of airway management research.
The authors retrieved 1505 relevant studies published between 2006 and 2017, together recruiting 359.648 subjects.A nice way to inform strategy on the future directions of airway management research. For more information we invite you to login the web page and read the full text of the article.
Article of the Month | January 2019
Article of the Month | December 2018
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.
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.
Article of the Month | November 2018
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.
Article of the Month | October 2018
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.
Article of the Month | September 2018
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!"
Article of the Month | August 2018
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.
Article of the Month | May 2018
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 care. Anaesthesia 2018, 73, 587–593
Article of the Month | April 2018
Dear readers of EAMS’ article of the month section.
Article of the Month | March 2018
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.
Magill 1930 Techniques in Anaesthesia
Cormack Lehane 1984 Difficult tracheal intubation in obstetrics
Article of the Month | February 2018
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 adults, British Journal of Anaesthesia, Volume 120, Issue 2, 323 - 352
Article of the Month | January 2018
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!
Article of the Month | December 2017
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
Article of the Month | November 2017
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.
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
Article of the Month | October 2017
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.
Have fun in reading the articles that will be provided to EAMS members with login to eamshq.net as full-text PDF's.
President of the European Airway Management Society