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7/23/2019 jurnal anestesi 2
http://slidepdf.com/reader/full/jurnal-anestesi-2 1/23
PERIOPERATIVE MEDICINE
An Algorithm for Difficult Airway Management,Modified for Modern Otical De!ice" #Airtra$
%aryngo"coe& LMA CTrach'(
A 2-Year Prospective Validation in Patients for Elective
Abdominal, Gynecologic, and Thyroid Surgery
Roland Amathieu, M.D.,* Xavier Combes, M.D.,* Widad Abdi, M.D.,† Loutfi El Housseini,
M.D.,† Ahmed Reou!, M.D.,† Andrei Din"a, M.D.,† #elislav $lavov, M.D.,† $e% bastien
&lo", M.D.,† 'illes Dhonneur, M.D., (h.D.)
A)*TRACT
Background: Because algorithms for difficult airway man-
agement, including the use of new optical tracheal intubation
devices, require prospective evaluation in routine practice, we
prospectively assessed an algorithm for difficult airway
management that included two new airway devices.
Methods: After 6 months of instruction, training, and clin-ical
testing, 15 senior anesthesiologists were ased to use anestablished algorithm for difficult airway management in
anestheti!ed and paraly!ed patients. Abdominal, gyneco-logic,
and thyroid surgery patients were enrolled. "mer-gency,
obstetric, and patients considered at ris of aspiration were
e#cluded. $f tracheal intubation using a %acintosh
laryngoscope was impossible, the Airtraq laryngoscope
&'()*+, "couen, rance was recommended as a first step
and the LMA CTrach &/"BA0, antin, rance as a sec-
* Assistant Professor, † Sta Anesthesiologist, ‡Professor and Head of Department, Jean VerdierUniversity Hospital of Paris, Anaesthesia and ntensive
!are Unit Department, "ondy, #ran$e, and Paris %&University S$hool of 'edi$ine, "o(igny, #ran$e)
e$eived from the Anesthesia and ntensive !are'edi$ine De+partment, Jean Verdier University Hospitalof Paris, "ondy, #ran$e) S(mitted for p(li$ation April-, ./%/) A$$epted for p(li$ation Septem(er %0, ./%/)Spport 1as provided solely from instittional and2ordepartment sor$es) 3illes Dhonner is a $onsltantand mem(er of the 4aryngeal 'as5 !ompany 4imited
Advisory "oard 6Jersey, !hannel slands7)
Address $orresponden$e to Dr) Dhonner8 Anesthesiaand n+tensive !are 'edi$ine Department, Jean VerdierUniversity Hospital of Paris, "ondy, #ran$e)gilles)dhonner9:vr)aphp)fr) nformation on pr$hasingreprints may (e fond at 111)anesthesiology)org or on
the masthead page at the (eginning of this isse) A ;<S=H<S>4>3? @S arti$les are made freely a$$essi(le toall readers, for personal se only, 0 months from the$over date of the isse)
Copyright © 2010, the American Society of Anesthesiologists,
Inc. Lippincott Williams &
Wilkins. Anesthesiology./%% %%B8 .C&&
+hat +e Already nowa-out Thi" Toic
1• niforma++li"ation of a diffi"ultaira- al!orithm mi!htde"rease the in"iden"eof h-+o/i" braindama!e durin! anesthesia indu"tion
+hat thi" Article Tell"." that i" New
1• 0n a lar!e+ros+e"tive stud-,a++li"ation of a sim+leaira- al!orithm,in"ludin! use of nevisual intubationdevi"es, a"hieved hi!hadheren"e rate andsu""essful tra"healintubation in all +atientsith diffi"ult aira-s
ond. A gum elastic bougie
was advocated to facilitate
tracheal access with the
%acintosh and Airtraq
laryngoscopes. $f ven-tilation
with a facemas was
impossible, the LMA
CTrach was to be used,
followed, if necessary, by
transtracheal o#y-genation.
atient characteristics,
adherence to the algorithm,
efficacy, and early
complications were recorded.
Results: *verall, 12,225
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patients were included during 2 yr. $ntubation was achieved
using the %acintosh laryngoscope in 34 cases. $n the
remainder of the cases &26, a gum elastic bougie was used
with the %acintosh laryngoscope in 278 &49. :he Airtraq
laryngoscope success rate was 38 &28 of 24. :he LMA
CTrach allowed rescue ventilation &n 2 and visually
directed tracheal intubation &n . $n one patient, ventilation
by facemas was impossible, and the LMA CTrach was
used successfully.
1his arti"le is a""om+anied b- to Editorial #ies. (lease
see2 $"hmidt , Ei3ermann M2 4r!aniational as+e"ts of dif
fi"ult aira- mana!ement2 1hin3 !loball-, a"t lo"all-. A5E$1HE
$04L4'6 7899: 99;2<= >: 0sono $, 0shi3aa 12 4/-!enation,
not intubation, does matter. A5E$1HE$04L4'6 7899: 99;2?=@.
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Anesthesiology, V %%B E ;o %
.C Janary ./%%
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Algorithm for Dii$lt Air1ay'anagement
Conclusi
ons:
:racheal
intubatio
n can be
achievedsuccess-
fully in a
large
cohort of
patients
with a
new
managem
ent
algorithm
incorpora
ting theuse of
gum
elastic
bougie,
Air-traq,
and LMA
CTrach
devices.
S:;$0:
adherenceto defined
strategies
and
algorithms
can resolve
most
problems
in airway
manageme
nt.1,2
:he
rench
+ational
/ociety of
Anesthesio
logy
recently
pro-posed
strategies
for
managing
<cannot
intubate,
cannot
ven-tilate=
events
based on
American/ociety of
Anesthesio
logy
guidelines,
e#pert
opinion,
consensus
conferences,
and pro-
spectively
validated
algorithms.,9
:hese
strategies
allow suc-
cessful
intubation of
most patients
with difficult
airways. :he
endotracheal
tube is
introduced
without
requiring
direct vision,
using either gum elastic
bougie &)"B
or intubating
laryngeal
mas airway.
>owever,
new devices
that provide a
viewing
system, such
as the Airtraq
laryngoscope
&A?-@
'()*+,"couen,
rance and
the LMA
CTrach
&@%A-0:
/"BA0,
antin,
rance, have
recently been
developed
and validated
for difficult
tracheal
intubation.58
:he current
algorithms for
difficult
airway
management
do not
incorpo-rate
these new
devices or
consider their
appropriate
role. Because
these devices
often can
allow tracheal
intubation
under direct
vision when
conventional
airway
management
fails, we
included these
new devices
in an updated
difficult
airwaymanagementalgorithm.
Ce
prospectivel
y assessed
an algorithm
for difficult
airway
managemen
t that
included
videoassistance
using these
two new
airway
devices. Ce
intended
that the tra-
chea of all
patients
with
difficult
airways
would be
intu-bated
using visual
guidance.
Material"andMethod"
StudyDesign
:his
prospective
validation
study was
conducted at
the Dean
'erdier
Eniversity
>ospital of
aris
&Bondy,
rance
from
Danuary2774 to
Fecember
2773. :he
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hospital
"thics
0om-
mittee
waived
the need
for
informed
consent
because
ran-
domi!atio
n was not
used and
the
algorithm
was part
of rou-
tine
practice.
AnesthesiaSettingsandParticipants
Dean
'erdier
>ospital is
a tertiary,
57-bed
surgical
teaching
hospitalthat
includes a
central
surgical
unit made
of five
operating
rooms
&*;s
encircling
a 17-bed
postanesthesia care
unit and
two
e#ternali!e
d *;s
dedicated
to
emergent
and
obstetric
cases.
ifteensenior
anesthesiol
ogists with
more than 5
yr of clinical
e#perience
covering the
central
surgical unit
&gynecology,
visceral,
bariatric, and
endocrinesurgery
departments
participated
in the study.
*n a daily
basis, three
anesthesiolog
ists managed
patients in the
central
surgery unit.
An
anesthesiolog
ist supervised
one of the
*;s and the
postanesthesi
a care unit.
:he two
remaining
anes-
thesiologists
managed two
*;s each. A
speciali!ed
anesthe-
tist nurse
cared for the
patients in
each *;.
our-hands
induction of
anesthesia
wassystematical
ly
performed.
:he
anesthetic
nurse
usually
initiated
standard
airway
manage-
ment. $n
case of
failure of the
first tracheal
intubation
at-tempt
with the
%acintosh
laryngoscop
e
&%acintosh-
@ as-sisted
with )"B,
theanesthesiolo
gist was
requested to
manage the
airway.
*ver a 6-
month
period, all
participants
were
instructed in
the use of theA?-@ and
@%A-0:
devices and
then given
practical
training
using a
standard
intubation
mannequin
and a
difficultairway
management
simulator.
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After
training,
the
physicians
had a
period of
clinical
e#perienc
e where
thedevices
&A?-@
and @%A-
0: were
used as
primary
airway
devices in
morbidly
obese
patients
admitted
for
elective
bari-atric
surgery.
Ce
considere
d that
clinical
proficienc
y was
acquired
after each
airway
device,
and the
video-
viewing
sys-tem
had been
used
successful
ly 17
times.
After
training,the study
period
started.
Patients
All
patients
admitted
for elective
surgery
given
general
anes-thesia
requiring
tracheal
intubation
were enrolled
in the study.
Ce included
patients
receiving
therapy for
gastric re-flu#
or patients
who werenown to
have a hiatus
hernia but
were
currently
asymptomatic
. regnant
women,
emergency
cases, and
patients at
ris for aspiration
were
e#cluded.
Preoperati ve Work- up
Anesthesia
care,
including
monitoring,
complied with
rench
/ociety of
Anesthesiolog
y and
$ntensive
0are
%edicine
clinical
practice
guidelines.
/pecial
attention was
given to preoperative
airway
assessment.
:he
participating
anesthesiologi
sts routinely
assessed the
patients
before
anesthesia
using definedmeasures of
airway
difficulty
&table 1.4 11
atients in
whom airway
man-agement
was e#pected
to be difficult
were
systematically
identi-fied
and listed ona Fifficult
Airway Board
set up in the
anes-thesia
department
and discussed
at a weely
meeting. or
patients with
three or more
features of a
difficult
airway, the
anesthesiologi
st decided
before
anesthesia
started
whether to
use
succinylcholi
ne to aid
intubation,
and how to
proceed withsubsequent
intubation.
PatientExclusions
atients
with a
mouth
opening &or
interincisor
distance of less than 25
mm, with
severe fi#ed
fle#ion
deformity of
the cervical
spine, or a
history of
previous
impossible
tracheal
intubation,
wereintubated
while awae
by use of
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fiberscop
e-guided
nasotrach
eal
intubation
. All other
patients
under-
went
tracheal
intubation
given
general
anesthesia
with mus-cle
rela#ant.
AirayManage!ent
A standard
method for preo#ygenati
on was used,
aiming to
achieve an
end-tidal
o#ygen
concentration
more than
37. atient
position was
adGusted
according to body mass
inde#
Anesthesiology./%%%%B8.
C&&
.0 Amathieet al.
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PERIOPERATIVE MEDICINE
Ta-le /0 Ris3 a"tors for Aira- Mana!ement Diffi"ult- $-stemati"all- Assessed at the (reo+erative #isit
eature Details
Men B8 -r 4besit- ith &M0 <8 3!m
7
$lee+ a+nea s-ndrome Dia!nosed, treated, or hi!hl- sus+e"ted on the base of the da-time
slee+iness7< s"ale @ and a +reo+erative slee+ a+nea s"reenin!tool
7; 9B
Mallam+ati "lasses 000 and 0# (atient sittin!, head in neutral fle/ione/tension +osition, ton!ue
Mouth o+enin! or inter!in!ival distan"eout, ithout +honation
<B mm1h-roid to mentum distan"e >B mm
Loer in"isors "annot advan"e to meet u++er in"isors@,7B
$everel- limited a +rotrusion
5e"3 "ir"umferen"e2 ;8 "m in Measured at the level of the th-roid "artila!e7>
omen and ;B "m in men
&M0 bod- mass inde/.
&B%$. $f B%$ was more than 5 gHm
2
, the head and nec position was raised for preo#ygenation and tracheal intuba-
tion. $n patients with fewer than three adverse predictors, the
anesthesia provider assessed the ease of facemas ventilation
before giving muscle rela#ant &atracurium or vecuronium.
:he ease or difficulty of facemas ventilation was graded,
using a simple score, as followsI
1● )rade $I ventilation without the need for an oral
airway
2● )rade $$I ventilation requiring an oropharyngeal
airway
3● )rade $$$I difficult and variable ventilation requiring
an oral airway and two providers, or an oral airway and one
provider using pressure-controlled mechanical
ventilation requiring more than 25 cm >2* and
4● )rade $'I ventilation inadequate with no end-tidal
carbon dio#ide measurement and no perceptible chest wall
move-ment during attempts at positive pressure ventilation.
:o reduce the duration of apnea, succinylcholine &1 mgH
g was given when ventilation difficulty was graded $$$ or $'.
$n patients with grade $ and $$ facemas ventilation, intubation
was planned min after rela#ant administration.
Algorith! Description)"B and A?-@ were available in each *;. $n the central
postanesthesia care unit, 17 meters from each *;, additional
equipment was permanently available, consisting of two sets
of three @%A-0: chassis &si!esI , 9, and 5, two @%A-0:
viewers placed in their charger, and the C$$ viewer for A?-
@. Ce considered gum elastic bougie &Boussignac Bou-gie
'()*+ as an adGunct to facilitate tracheal access when
%acintosh-@ and A?-@ were used. *nce the muscle rela#ant
had been given, the anesthesia providers followed a set algo-
rithm &fig. 1.
$f tracheal intubation was not possible using a %acin-tosh-@
fitted with a si!e blade, then the A?-@ device was used,followed, if necessary, by the @%A-0: device. $mpos-sible direct
tracheal access was considered to be current if tracheal access was
not possible after two attempts, using
either %acintosh-@ or A?-@,
aided by use of the )"B and
changes in head position ande#ternal laryngeal manipula-
tion as necessary. :he A?-@
and @%A-0: devices were
used e#actly according to
the manufacturerJs
instructions and de-
partmental
recommendations. or A?-
@, video-controlled tracheal
intubation was first
attempted using the standard
technique of insertion of thedevice or the rotation
maneu-ver.4 *nce a good
view of the glottis was
obtained, the en-dotracheal
tube was passed through the
vocal cords and held in place
as the device was removed.
Ce used a si!e 5 @%A-0:
for male patients and a si!e 9
for female patients, inserted as
described.3 'entilation was
maintained during both
sealing and viewing
procedures. *nce a good view
of the glottis was obtained,
ventilation was discontinued
and a reinforced fle#ible
endotracheal tube was
inserted through the metallic
chassis of the @%A-0: and
pushed through the vocal
cords into the trachea under
visual control. acemas
ventilation was recommended
between intubation attempts,if pulsed arterial o#ygen
saturation &/p*2 decreased to
less than 37. :he
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anesthesiologist could decide at any time to discontinue
intubation attempts and allow the patient to recover.
$f mas ventilation was impossible, despite changes in
head position or mas si!e, the @%A-0: device was used
immediately. $f @%A-0: ventilation failed, indicated by no
end-tidal carbon dio#ide curve and chest wall movement
within 7 s after laryngeal mas placement, percutaneous
transtracheal Get rescue o#ygenation &%anuDet 'B%, Al-leins,
rance was to be used.
A proven difficult
airway was defined as
grade $$$ and $' ventilation
difficulty or failed
conventional %acintosh-@
tra-cheal intubation despite
)"B use.
Study Data Collection
$f the first step of the difficult
airway management process
was taen, the attending
senior anesthesiologist
managed the airway, and the
anesthetic nurse collected
airway manage-ment details
and outcome variables. :he
physical character-
Anesthesiology ./%% %%B8.C&& .-
Amathie et al.
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Algorithm for Dii$lt Air1ay'anagement
1ig0 /0 De"ision tree for mus"le rela/ant "hoi"e and aira- mana!ement. 1he diffi"ult ventilation !radin! s"ale is the folloin!2
'rade 0, ventilation ithout the need for an oral aira-: !rade 00, ventilation reuirin! an oral aira-: !rade 000, diffi"ult and
unstable ventilation reuirin! an oral aira- and to +roviders, or an oral aira- and one +rovider, usin! me"hani"al ventilation
F+ressure"ontrolled modeG: and !rade 0#, im+ossible ventilation. 'E& !um elasti" bou!ie.
istics of all patients with difficult airways were recordedfrom the anesthesia record.
"utco!e #aria$les
:he main outcome variables were the success rate for tracheal intubation using visual guidance and adherence tothe man-agement algorithm. *ther endpoints were theincidence of complications &hypo#emia, noted as the
lowest /p*2 during airway management, pulmonaryaspiration, and evidence of airway trauma.
Statistical Analyses
Fescriptive statistics, including frequency counts,
proportion, mean, and /F calculation, were computed
using K@/:A: 2774 &Addinsoft, aris, rance.
Re"ult"
Patients and Anesthesia
$n the 2-yr study period, 12,225 patients were admitted for
planned elective surgery given general anesthesia. :heir mean
&/F age was 51 &19 yr and gender ratio &%H was 66H99. A
difficult airway was encountered in 125 patients &1.
hysical characteristics and ris factors for airway
management of all participants &n 12,225 and details of
patients with airway management difficulties &n 125 are listedin table 2. )eneral anesthesia and paralysis were in-duced in
12,221 of these patients. :he four other patients
underwent awae
fiberscope-guided
nasotracheal intuba-tion. *f
these four patients, one had
a history of previous
difficult intubation &5 gHm
B%$, 22 mm interincisor
dis-tance, and %allampati
class $', one had a large
thyroid tumor distorting the
upper airway and severely
narrowing the trachea, and
two had a fi#ed fle#ion
deformity of the cervical
spine and a limited mouth
aperture &27 mm pre-
venting airway insertion and
manipulation.
Airay Manage!ent"utco!es
:he pattern of management of
the patients is shown in figure
2. *utcome of airway
management of all
anestheti!ed par-ticipants &n
12,221 and of patients withairway manage-ment
difficulties &n 125 are listed
in table . )rade $$$ or $'
ventilation difficulty occurred
in 179 patients &7.4. :wo
patients &7.71 could not be
ventilated by facemas &grade
$', and 172 patients &7.4
had grade $$$ ventilation
difficulty. Among these
patients, 12 received primary
succi-nylcholine because they
showed at least three
predictors of difficult airway
management and 37 received
secondary suc-cinylcholine
because of grade $$$
ventilation difficulty Gust after
induction before muscle
rela#ant inGection. Fifficult
ventilation &grade $$$ was
encountered in 68 &8 obese
patients &B%$ more than 7
gHm. 0ombined grade $$$
ventilation difficulty and
impossible %acintosh-@
intubation despite )"B use
occurred in 8 &7.75
patients. 'entilation difficulty
&grade $' was encounteredtwice in this seriesI Gust after
induction of anesthesia and
during A?-@ intubation at-
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Anesthesiology ./%% %%B8.C&& .F
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PERIOPERATIVE MEDICINE
Ta-le 20 (h-si"al Chara"teristi"s and Ris3 a"tors for Aira- mana!ement of All (arti"i+ants Fn 97,77BG and
Details of (atients ith Aira- Mana!ement Diffi"ulties Fn 97BG
(atients, n FG
or Mean $D
All +arti"i+ants Fn 97,77BG
(lanned aa3e fibers"o+e!uided nasotra"heal intubation ; $ur!er-
Abdominal >,@>@FB?G'-ne"olo!i"al ;,?>IF<@G1h-roid ;IIF;G
4bese +atients ith &M0 <8 3!m Fn ?I@G Abdominal sur!er- B?@F?;G'-ne"olo!i"al sur!er- 9B9F9@G1h-roid sur!er- B@F?G
Morbidl- obese +atients ith &M0 B8 3!m Fn 98;G Abdominal sur!er- IIFIBG'-ne"olo!i"al sur!er- 9BF9;G1h-roid sur!er- 9F9G
(atients shoin! < diffi"ult aira- mana!ement fa"tors at the +reo+erative
anesthesia visit Fn 9IIG Abdominal sur!er- 9;?F?IG'-ne"olo!i" sur!er- <BF9IG1h-roid sur!er- >F;G
(atients ith aira- mana!ement diffi"ulties* Fn 97BG'ender FMG ratio >><;Mean a!e, -r B8 9<Mean bod- mass inde/, 3!m ;< 9;Mean interin"isor distan"e, mm << ;Mean th-romental distan"e, mm >; BRetro!nathia 9>F9<G$everel- limited a +rotrusion 98FIG4bstru"tive slee+ a+nea I7F>>GMallam+ati "lass Fn +er "lassG 0B 00<7 000?B 0#97Mean "ervi"al ne"3 "ir"umferen"e, "m ;; B
Cri"oth-roid membrane a""ess diffi"ult- s"ore† Fn +er s"oreG 8<7 9I7 798 <7
* A +atient ith aira- mana!ement diffi"ulties as arbitraril- defined as fa"emas3 ventilation diffi"ult- !rade 000=0# or failed Ma"intoshlar-n!os"o+e tra"heal intubation, des+ite !um elasti" bou!ie use. Diffi"ult ventilation !radin! s"ale2 'rade 0, ventilation ithout theneed for an oral aira-: !rade 00, ventilation reuirin! an oral aira-: !rade 000, diffi"ult and unstable ventilation reuirin! an oral aira-and to +roviders, or an oral aira- and one +rovider, usin! me"hani"al ventilation F+ressure"ontrolled modeG: and !rade 0#,im+ossible. † Diffi"ult- of "ri"oth-roid membrane a""ess as evaluated b- anterior ne"3 +al+ation usin! a ;+oint s"ore F8 eas-, 9moderatel- diffi"ult, 7 diffi"ult, < ver- diffi"ultG.
&M0 bod- mass inde/.
tempts in another patient. :hese two patients who benefited
from rescue ventilation with the @%A-0: device were intu-
bated using visual guidance through the laryngeal mas.
:here were two deviations from the algorithm after failed
%acintosh-@ intubation. $n a case of %acintosh-@ failure, the
%c)rath &/"BA0 was used successfully instead of the A?-@
device. $n a patient in whom there was a grade $$$ view of the
laryn# &0ormac and @ehane, the A?-@ device was used after
%acintosh-@ direct laryngoscopy without at-tempting )"B
assistance. or all other patients, )"B was used to assist
%acintosh laryngoscopy in 26 patients &1.3, and of these
patients, successful tracheal access was achieved in 278 &49.
)"B-assisted %acintosh-@ :racheal intubation was not possible
in 23 patients &7.72. $n these patients, A?-@ intubation was
then attempted. :he A?-@ device allowed successful tracheal
intubation under visual guidance in 28 of the 23 remaining
patients, with the )"B
used as an adGunct to the
A?-@ device in of these
28 cases. $n one of these
patients, ventilation could
not be achieved after the
first A?-@ intubationattempt, and rescue @%A-
0: o#ygenation was
required followed by
tracheal intubation under
visual control through the
laryngeal mas. :he trachea
of the patient with A?-@
failure, despite )"B
assistance, was intubated
under visual control using
@%A-0:. >e was a tall &1.3
m morbidly obese man &97gHm B%$. /tandard
insertion and manipulation
of A?-@ gave a poor, distant
view of laryngeal structures
that included a long, floppy
epiglottis that could not be
lifted."pisodes of hypo#emia
&/p*2 37 occurred in 48 pa-
tients &7.8 in 18 patients
&7.1, /p*2 became less than
47. :he features of these 18
patients are presented in table 9.
:he lowest /p*2 was 64 and
occurred in the patient in whom
primary facemas ventilation
was not possible. :his patient
had a bushy beard and had five
predictive features of a difficult
airway.
Anesthesiology./%% %%B8.C&&
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Algorithm for Dii$lt Air1ay'anagement
1ig0 20 4ut"ome of the mana!ement of +atients, usin! the ne al!orithm. 'E& !um elasti" bou!ie: 410 orotra"heal intubation.
+o patient suffered aspiration of gastric contents. :rauma to
the teeth by the %acintosh-@ occurred in two patients.
Di"cu""ion
$n this prospective study of 12,221 patients given general
anesthesia for elective surgery, we have shown that an
algo-rithm incorporating the )"B and two visual systems
for tracheal intubation &A?-@ and @%A-0: allowed
tracheal intubation under visual guidance in all patients in
whom airway management was difficult.
Li!itations o% the Study
*ur study has three limitations. :he first is that the patient
population is limited to abdominal, gynecologic, and thyroid
surgery. Although many of the patients were morbidly obese, we
did not include other patients with potential problems, such as
patients with tumors in the upper airway, patients with cervical
trauma and immobili!ation, or obstetric pa-tients. Application of
our algorithm to such patients may not be Gustifiable. >owever,
physicians in our obstetrics unit have also received instruction in
the use of new optical airway devices, and we now incorporate
use of A?-@ as the second step after failed %acintosh-@ tracheal
intubation in our algo-rithm for difficult tracheal intubation
during anesthesia for emergency cesarean section.12
:he second
limitation is that successful use of the algorithm was based on
thorough train-ing and practical e#perience with these new
devices. :he physicians involved in this study completed training
with
A?-@ and @%A-0: and
were accustomed to using
the de-vices clinically.Because a short time is
needed to acquire
proficiency with A?-@1
and
all participants were already
familiar with the intubating
laryngeal mas airway, we
esti-mated that proficiency
was acquired after 17
successful uses of both
devices. *n the basis of our
study, we cannot recom-
mend the current algorithmfor anesthesia providers who
are not e#perienced with
both new airway devices.
:he third weaness is the
si!e of our institutionI an
environment lim-ited to five
operating rooms and a staff
of 15 anesthesiolo-gists. $n a
larger hospital, provision of
these airway manage-ment
devices at all anestheti!ing
locations and training a
larger staff of physicians
could be a significant
financial and organi!ational
tas.
Co
nce
ptio
n o%
the
Di%%
icul
t
Air
a
y
Ma
nag
e!
ent Alg
orit
h!
Ce included A?-@ and @%A-
0: devices in a previous al-
gorithm for managing
unanticipated difficult
airways, in the operating
room1 or the prehospital
setting,19
because of their
proven efficacy, especially in
patients with ris factors.15
Ce did not consider )"B as
an airway, but rather as a tool
to promote or facilitate
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tracheal access in case of 0ormac and @ehane $$$ and $' and
when the arytenoids were visible with laryngoscopes &direct or
indirect, respectively. Adherence to the algorithm was very good
&there were only two devia-tions, no doubt because of its
simplicity, device efficacy,
appropriate staff training, and
the fact that most participants
already had taen part in
validation studies on A?-@
and
Anesthesiology ./%% %%B8.C&& &/
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PERIOPERATIVE MEDICINE
Ta-le 30 4ut"ome of Aira- Mana!ement of All Anesthetied (arti"i+ants Fn 97,779G and of (atients ith Aira-
Mana!ement Diffi"ulties Fn 97BG
(atients, n FG
or Mean $D
Anesthetied +atients Fn 97,779G
(rimar- indi"ation for su""in-l"holine F < ris3 fa"torsG 9IIF9.BGDiffi"ult ventilation, !rade 0#* 7 Diffi"ult ventilation, !rade 000* 987F8.IG$e"ondar- indi"ation for su""in-l"holine Fdiffi"ult ventilation, !rade 000* before @8 F8.?G
mus"le rela/ant administrationG5onde+olariin! neuromus"ular blo"3ade F?7 atra"urium: 7I ve"uroniumG 99,IB7F@?GCorma"3 and Lehane !rade 000 9>?F9.<GCorma"3 and Lehane !rade 0# <F8.87BGailure usin! Ma"intosh lar-n!os"o+e 7<>F7.8Gailure usin! Ma"intosh lar-n!os"o+e 'E& [email protected]+o/emia e+isodes, $+47 @8 I?F8.?GH-+o/emia e+isodes, $+47 I8 9?F8.9G
'E& use ith Ma"intosh lar-n!os"o+e Fn 7<>G'E& su""ess 78?FI;G
Airtra lar-n!os"o+e use Fn 7@G$u""essful Airtra lar-n!os"o+e +lus 'E& for vieed tra"heal intubation 7?F@?GLMA CTrachJ su""ess for ventilation 7F988GLMA CTrachJ su""ess for tra"heal intubation under visual "ontrol <F988G(atients ith aira- mana!ement diffi"ulties† Fn 97BG
Corma"3 and Lehane !rade for dire"t lar-n!os"o+- Fn +er !radeG 0B 007? 000@9 0#7a"emas3 ventilation diffi"ult- Fn +er !radeG 079 00<? 000>; 0#7Combined 'rade 000 ventilation diffi"ult- and im+ossible Ma"intosh ?FBG
lar-n!os"o+e 'E&assisted tra"heal intubation
Minimum $+47 durin! aira- mana!ement, @9 ?
* Diffi"ult ventilation !radin! s"ale2 'rade 0, ventilation ithout the need for an oral aira-: !rade 00, ventilation reuirin! an oral aira-:!rade 000, diffi"ult and unstable ventilation reuirin! an oral aira- and to +roviders, or an oral aira- and one +rovider, usin!me"hani"al ventilation F+ressure"ontrolled modeG: and !rade 0#,im+ossible ventilation. † A +atient ith aira- mana!ement diffi"ultiesas arbitraril- defined as fa"emas3 ventilation diffi"ult- 'rade 000=0# or failed Ma"intoshlar-n!os"o+e tra"hKal intubation des+ite !um
elasti" bou!ie F'E&G use.&M0 bod- mass inde/: $+47 +ulse o/-!en saturation.
@%A-0: devices.1527
Ce could have chosen another video
laryngoscope, such as the )lide/cope or the %c)rath, to replace
A?-@ in the algorithm, and the wide use of these devices is
undisputable. >owever, these devices provide a very different
mechanical approach to the laryn#, and we cannot predict that the
results of the current study would be the same if we had chosen to
use them in our algorithm. %oreover, during difficult airway
management, the superi-ority of A?-@ tracheal intubation
efficiency in other optical devices and video laryngoscopes has
been systematically demonstrated. Ce confirmed the efficacy of
the A?-@ device after %acintosh-@ failure for tracheal intubation.
>owever, we encountered one case of A?-@ device failure in a
tall morbidly obese patient. Although A?-@ device failure has
already been reported,5 we could not determine the e#act reason
for failure to intubate on this occasion, despite )"B assistance.
:he clinician managing the patient considered it possible that the
standard si!e A?-@ blade was too short in this large patient.
:he use of a muscle rela#ant in the current trial is argu-able.
Ce have decided to use succinylcholine in patients with
anticipated difficult airway management and patients with grade
$$$ and $' difficult mas ventilation before inGection of
muscle rela#ants because this
strategy was currently applied
during our daily clinical
practice. *f interest, this short
du-ration depolari!ing muscle
rela#ant never worsened
facemas ventilation quality,
but rather improved it in most
cases. $ndeed, of the 37
patients that received
secondary succinyl-choline
inGection, 56 improved by one
grade their ventilation quality.
%oreover, none of the 11,39
grade $ and $$ difficult mas
ventilation patients who were
inGected with nondepo-
lari!ing muscle rela#ant
altered ventilation quality.
"utco!es o% the Airay Manage!ent
Cith the current algorithm,
we have successfully
managed the airway of many
obese patients who could have
had diffi-cult intubation or
ventilation. $nterestingly, only
a few of them &2 16 of 843
e#perienced transient /p*2
episodes less than 47. :hese
encouraging safety data may
result from both the rench
/ociety of Anesthesia 0linical
ractice )uidelines that
advise a 37 end-tidal
o#ygen concentration before
induction of anesthesia,
particularly if ris factors for
a difficult airway are present,
and also from the efficacy of
the devices used in the
algorithm. 0ompared with the
previous algorithm, which we
validated for the management
of unan-ticipated difficult
airway,1 our current trial
included many
Anesthesiology ./%% %%B8.C&& &% Amathie et al.
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Algorithm for Dii$lt Air1ay'anagement
Ta-le 40eatures of the9?(atientsthat
E/+erien"ed
$+o7 lessthanI8durin! Aira-Mana!ement
'ender FMG ratioMean a!e, -r Mean bod- mass inde/, 3!mMallam+ati "lass Fn +er "lassG
(atients ith < +redi"tors of diffi"ultaira- mana!ement
Corma"3 and Lehane !rade for dire"tlar-n!os"o+- Fn +er !radeG
a"emas3 ventilation diffi"ult- Fn +er !radeG†
Moment of o""urren"e of $+Durin! fa"emas3 ventilation attem+tsDurin! failed Ma"intosh
lar-n!os"o+e 'E&intubation attem+ts
Durin! failed Airtra
lar-n!os"o+e 'E&
intubation attem+ts
* 1he
Corma"3
and Lehane
!rade as
not
evaluated in
one +atient
ho as
!iven LMA
CTrach
F$E&AC,
(antin,ran"eG for
res"ue
ventilation.
† Diffi"ult
ventilation
!radin!
s"ale2
'rade 0,
ventilation
ithout the
need for an
oral aira-:
!rade 00,
ventilation
reuirin! an
oral aira-:!rade 000,
diffi"ult and
unstable
ventilation
reuirin! an
oral aira- and
to +roviders,
or an oral
aira- and one
+rovider, usin!
me"hani"al
ventilation
F+ressure"on
trolled modeG:
and !rade 0#,im+ossible
ventilation.
'E& !umelasti" bou!ie:
$+47 +ulse
o/-!ensaturation.
patients with
ris factors
for a difficult
airway. %ost
of these
patients withseveral ris
factors &at
least three
would have
been
e#cluded
from our
previous
algorithm
and would
have been
managed
using afiberscope.
*nly a few
episodes of
hypo#emia
&/p*2 47
episodes
were
attributed to
diffi-culty
with
ventilation
&table 9.
%ost of
these were in
mor-bidly
obese
patients
during failed
%acintosh-@
tracheal in-
tubation
attempts, as
found in our
previous
algorithm.1
Because
most
episodes of
hypo#emia
are related to
difficult
%acintosh-@
intubation,
we believe
that previous
movement to
the secondstep of the
cannot-
intubate
branch of the
cur-rent
algorithm is
advisable.
;educing the
duration of
at-tempts
with the
%acintosh-@
could have prevented
some
episodes of
hypo#emia.
$n our
obstetric
unit, we have
now set a
time limit of
2 min for
%acintosh-@
attempts at
tracheal
intubation
before using
A?-@.
Fifficulty
with mas
ventilation
&grades $$$
and $'
&7.4 had
an incidence
similar to
that reportedin a recent
review.11
)rade $$$
difficulty in
obese
patients
occurred in
6 of
patients who
had at least
three or more
ris factors.
:his
contrasts
with a rate of
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7.
grade $$$
ventilation
dif-ficulty
encounter
ed in
patients
with fewer
than three
fea-tures.
0learly,
our set of
predictors
for
difficult
airway
man-
agement
aids
detection
of patients
with
difficultairways.
/even of
our 23
)"B-
assisted
%acintosh
-@
intubation
fail-ures
had grade
$$$ mas
ventilation
difficulty,strengthen
ing
the
association
between
difficult
ventilation
and difficult
intubation.
A maGorityof our cases
with difficult
airways were
mor-bidly
obese men
more than 57
yr of age.
/leep apnea
syn-drome,
large nec,
and high
%allampatigrades $$$ and
$' were the
most frequent
features
associated
with both
difficult
ventilation
and tracheal
intubation
with the
%acintosh-@.
Ce
encountered
only one
primary
instance of
cannot-venti-
late in a 64-
yr-old
morbidly
obese patient
with many
adverse
factors and
with a bushy
beard
hampering
cricothyroid
membrane
palpation.
:his patientJs
arterial
o#ygenation
was restored
promptly with
@%A-0:.
Furing the
study period,
we used
@%A-0:
&two with si!e
9 and one
with si!e 5 in
three patients
to effectively
restore or
establish anopen airway.
:his efficacy
has already
been
recorded.21,22
$f @%A-0:
failed to
improve
o#ygenation
in this cannot-
ventilate
scenario we
encountered,
further
management
would have
been e#-
tremely
difficult
because
identification
of the trachea
surface
landmars
was
impossible. $n
this particular
case, an
attempt at
direct
laryngoscopy
could have
been
lifesaving.
Although not
recommended
by the rench
/ociety of
Anesthesia,
de-viation
from the
algorithm
might have
been
appropriate
here. After
our
e#perience
with this
patient, all
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morbidly
obese
patients
with a
beard are
ased to
remove it
before
surgery.
:hose whohave three
or more
ris factors
and refuse
to shave
are
managed
with
awae
nasotrache
al
intubation.:his policy
is now
systematic
ally
applied in
case the
surgery
may
require
deep
neuromusc
ular blocade.
*ver
the 2 yr of
the study,
only four
patients
had to be
e#cluded
from this
manageme
nt
algorithm.
An
important
reason is
that head
and nec
cancer
surgery is
not
undertaen in
our hospital,
although we
did include
patients with
a history of
treated
pharyngeal or
laryngeal
tumor. :hefour
e#ceptions
had awae
fiberscope-
guided
nasotracheal
intu-bation
performed by
two
speciali!ed
senior
anesthesiolog
ists. Before
the advent of
the new
airway
devices with
a viewing
system, we
carried out 17
15
fiberscope-
guided
intubations
per year,
mostly in
super obese
patients. :his
technical ad-
vance has
clearly
changed our
practice in
airway
managementin morbidly
obese patients
and reduced
the
indications
for
fiberscope-
guided
intubation.
Conclu"ion
$n
conclusion,
we used an
algorithm for
airway
management
that
incorporates
)"B, @%A-
0:, and A?-
@ devices in
a large
cohort of
anestheti!ed,
paraly!ed
patients./uccessful
tracheal
intubation
under visual
control was
achieved in
all patients
with difficult
airways.
=he athorsa$5no1ledge 3ordon"lairDrmmond,')D), Ph)D)6Senior4e$trerfrom theDepartmentof
Anaesthesia, !riti$al!are andPain'edi$ine,oyal
nrmary,<din(rgh,S$otland7,for his veryhelpfl$ontri(tionto theeditingpro$ess of themans$ript)
Anesthesio
logy./%%%%B8.
C&&
&.
Amathie
et al.
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PERIOPERATIVEMEDICINE
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./%%%%B8.C
&&
&&
Amathie etal.