Airway Management Equipment Research Articles

Are prehospital airway management resources compatible with difficult airway algorithms? A nationwide cross-sectional study of helicopter emergency medical services in Japan.

Purpose Immediate access to the equipment required for difficult airway management (DAM) is vital. However, in Japan, data are scarce regarding the availability of DAM resources in prehospital settings. The purpose of this study was to determine whether Japanese helicopter emergency medical services (HEMS) are adequately equipped to comply with the DAM algorithms of Japanese and American professional anesthesiology societies.MethodsThis nationwide cross-sectional study was conducted in May 2015. Base hospitals of HEMS were mailed a questionnaire about their airway management equipment and back-up personnel. Outcome measures were (1) call for help, (2) supraglottic airway device (SGA) insertion, (3) verification of tube placement using capnometry, and (4) the establishment of surgical airways, all of which have been endorsed in various airway management guidelines. The criteria defining feasibility were the availability of (1) more than one physician, (2) SGA, (3) capnometry, and (4) a surgical airway device in the prehospital setting.Results Of the 45 HEMS base hospitals questioned, 42 (93.3 %) returned completed questionnaires. A surgical airway was practicable by all HEMS. However, in the prehospital setting, back-up assistance was available in 14.3 %, SGA in 16.7 %, and capnometry in 66.7 %. No HEMS was capable of all four steps.ConclusionIn Japan, compliance with standard airway management algorithms in prehospital settings remains difficult because of the limited availability of alternative ventilation equipment and back-up personnel. Prehospital health care providers need to consider the risks and benefits of performing endotracheal intubation in environments not conducive to the success of this procedure.Electronic supplementary materialThe online version of this article (doi:10.1007/s00540-015-2124-7) contains supplementary material, which is available to authorized users.

Airway management in UK ambulance services: results of the National Ambulance Service Airway Management Audit

Aim: To establish the range of airway devices provided to ambulance staff employed by the UK NHS ambulance services, which level of practitioner is allowed to use which device or intervention, and what the main factors were in the purchasing decisions taken. Methods: Medical directors from all 14 UK NHS ambulance services were invited to participate in an anonymous, web-based survey of emergency airway management equipment provided within their service and which grades of practitioner were authorised to use the equipment they provided. Additionally, they were asked for the main reasons for the purchase of the selected equipment. Results: All 14 ambulance services completed the survey questionnaire. A range of clinical grades is now employed by UK ambulance services although there is inconsistency in both title and skill set. All services provide a range of airway equipment, but there is no common inventory across UK ambulance Trusts. Nearly all staff were authorised to use some of the basic equipment, but wider variations appear with more complex or sophisticated techniques. In particular there appears to be significant gaps in advanced equipment and those authorised to use it in respect of children. Conclusions: The range of airway equipment and those authorised by ambulance services to undertake airway management interventions appears to be evolving. It is of concern that there remains an apparent lack of standardisation of the range of airway equipment provided by UK NHS ambulance services.

Paediatric procedural sedation for radiological imaging

Sedation is frequently undertaken for radiological imaging procedures in paediatric patients. Movement during procedure degrades all images of a particular sequence. A deeper level of sedation is needed. The sedation of children is different from the sedation of adult. The safe sedation of children for imaging procedure requires a systematic approach that includes the followings. Careful presedation health evaluation of the child with ASA classification. Appropriate fasting guidelines for sedation procedure. Detailed airway examination for any airway abnormalities that might increase the potential for airway obstruction. Adequate training and skills of sedating personnel in paediatric airway management. Age and size appropriate equipment for airway management and venous access. Adequate medications to combat adverse events. Monitoring of vital parameters during and after the procedure. A properly equipped and staffed recovery area. Recovery to presedation level of consciousness of patient before discharge from medical supervision and appropriate discharge instructions. The whole procedure should be well documented. Children who have contraindications to sedation should be selected for general Anaesthesia. This review article has been made to discuss the need for sedation of children during radiological imaging, currently practiced different regimens of sedation, safe guidelines for sedation and also covers the debate between need for GA versus sedation. DOI: http://dx.doi.org/10.3329/jbsa.v24i2.19805 Journal of Bangladesh Society of Anaesthesiologists 2011; 24(2): 70-76

Anesthesia in neurologic and psychiatric diseases: is there a 'best anesthesia' for certain diseases?

Patients with diseases affecting the central nervous system present a wide range of clinical manifestations increasing the perioperative risk. The following review focused on recommendations for anaesthesiological management in patients with both neurologic and psychiatric diseases. The heterogeneity of disorders affecting the central nervous system and the variability of comorbidities make definition of standards for anaesthesiological management difficult. Anatomical malpositions, pulmonary and cardiac co-morbidities determine the perioperative risk. Patients require a careful preoperative assessment, including interdisciplinary communication between neurologists, psychiatrists or paediatric physicians. Adequate devices and equipment for airway management should be available before induction of general anesthesia. For premedication in patients with limited respiratory function, clonidine, given orally, is a good alternative. The use of short-acting hypnotic and analgesic drugs (e.g. propofol/remifentanil) can be safely administered for induction and maintenance of anesthesia. The use of volatile agents and succinylcholine is strictly avoided in patients with muscular dystrophy and myopathies. Peripheral and neuroaxial regional anesthesia is not contraindicated in patients with neuromuscular diseases unless there is a rapid deterioration of the neurological status. The 'best' anesthesia includes adequate preoperative evaluation of the individual risk, optimization of comorbidities before elective surgery, the use of short-acting anesthetic agents for induction and maintenance of general anesthesia, avoidance of volatile agents and succinylcholine in muscular dystrophy and myopathies.

Essentials of airway management, oxygenation, and ventilation: part 1: basic equipment and devices.

Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Optimizing patient safety using crisis resource management (CRM) involves the entire dental office team being familiar with airway rescue equipment. Basic equipment for oxygenation, ventilation, and airway management is mandated in the majority of US dental offices per state regulations. The immediate availability of this equipment is especially important during the administration of sedation and anesthesia as well as the treatment of medical urgencies/emergencies. This article reviews basic equipment and devices essential in any dental practice whether providing local anesthesia alone or in combination with procedural sedation. Part 2 of this series will address advanced airway devices, including supraglottic airways and armamentarium for tracheal intubation and invasive airway procedures.

Adult Airway Evaluation in Oral Surgery

Patients with a history of difficult intubation or with conditions associated with difficult airway should be approached with organized primary and secondary plans for airway management. When these potential problems are detected, patient safety may be improved with use of advanced airway management techniques and equipment. Additionally, patient referral for consultation and/or management at facilities where advanced airway management practitioners and equipment are available may be beneficial in some cases.

Conscious Sedation and Anesthesia in the Cardiac Electrophysiology Laboratory

Adequate anesthesia is important for performing EP procedures such as catheter ablation and implantation of cardiac devices. A wide range of anesthesia options are available, and all can be safely administered in EP laboratory with proper monitoring, drug selection, airway management equipment, and trained personnel. In addition to knowing the patient's clinical status, a thorough understanding of the clinical pharmacology of each anesthetic agent is essential in order to select appropriate drug among a variety of available anesthetics, to monitor for adverse effects, and to ensure adequate sedation and anesthesia for a comfortable, safe, and successful procedure. After a general strategy of anesthesia is planned, an individual anesthetic agent or combination of agents can be selected based on their pharmacological properties while keeping in mind the desired sedation/anesthesia requirements. Since anesthetics are often used in combination, the synergistic interaction of several anesthetic agents (infiltrative, parenteral, and/or inhaled) needs to be considered. Further attention also needs to be paid to the interaction between anesthetics and other existing medications. Finally, all care providers should work collaboratively and communicate frequently to provide a safe and effective anesthesia.

Principles of Airway Management, 4th Edition

The fourth edition of Principles of Airway Management is a comprehensive work covering virtually all aspects of the adult and pediatric airway that any professional can hope to learn from a textbook. Indeed, its 15 chapters encompass the following topics: anatomy of the airway, evaluation of the airway, basic emergency airway management and cardiopulmonary resuscitation, basic equipment for airway management, the LMA and other supraglottic devices, advanced airway devices (including fibreoptic laryngoscopes, videolaryngoscopes, stylets, and light wands), indications and preparation of the patient for tracheal intubation, techniques of intubation, the difficult airway, pediatric airway management, fibreoptically guided airway management techniques, surgical options in airway management, mechanical ventilation and respiratory care, extubation strategies, and, finally, complications of airway management. This book is well written throughout, and the comprehensive table of contents and index enable the reader to easily find information in this lengthy textbook. The tables and figures have been improved in this edition and most are of good quality. The references are up-to-date. While the preponderance of expertise in airway management can be acquired only through experience, both novices and experts alike will gain insight into airway management by consulting this book. It provides the basic information useful to the beginner and the more advanced content useful to the expert. The book strikes the right balance between theoretical and technical information, which is another important quality. The authors offer the greatest extent of practical ‘‘how to’’ information in a textbook, notably because of the numerous figures. Although this 742-page textbook is indeed quite complete, some advanced techniques, e.g., rigid bronchoscopy, jet ventilation, and lung isolation, are covered hastily and without much technical detail. This is unfortunate since an expert might consult this textbook specifically for information regarding these perhaps less commonly used techniques. In contrast, some topics, e.g., cardiopulmonary resuscitation, are reviewed in surprising detail for a textbook dealing with airway management. Overall, this fourth edition of Principles of Airway Management constitutes a very good reference for any individual or organization interested in airway management. The depth of information goes well beyond that available in more ‘‘general’’ anesthesia textbooks, such as Miller’s Anesthesia, Seventh Edition by Ronald D. Miller and Clinical Anesthesia, Sixth Edition by Paul Barash.

Airway management practices in adult intensive care units in Israel: a national survey

Timely and adequate management of normal and compromised airway is a crucial task facing medical teams taking care of patients in intensive care units. We investigated the airway management practices in the Israeli intensive care units (ICUs). A postal survey was sent to the 20 main ICUs in Israel. We investigated which medical specialty (ICU, anesthesiology or ENT) is involved with airway management in the ICUs and summarized the availability of airway equipment and medication necessary for endotracheal intubation, the use of dedicated airway management algorithms, the approaches to specific airway scenarios and education in airway management. The response rate was 70 % (14 out of the 20 units). Intubation with normal airway is performed mainly by ICU doctors (86 %). A difficult airway is most frequently cared for by anesthesiologists (79 %), while impossible intubation/mask ventilation is mainly managed by anesthesiologists and ENT surgeons (50-79 %). Airways in C-spine injury are mainly managed by anesthesiologists (70 %). Surgical airway is mainly performed by ENT surgeons (79 %). The ASA difficult airway algorithm is used in 71 % of the units. Fiberoptic intubation is used significantly more often than other methods in two scenarios: 78 % of the difficult airways and 64 % of the C-spine injuries (p < 0.0001). Only 43 % of the units reported holding quality assurance meetings. 69 % of the units' heads are satisfied with their airway management policies. Equipment and medications necessary for airway management are available in most of the units. Difficult airways in ICUs are mainly managed by anesthesiologists and ENT surgeons. Few ICUs have quality assurance meetings.

Anaesthesia for trauma patients

Click to increase image sizeClick to decrease image sizeKeywords: anaesthesiatrauma patientschallenges

The child with facial abnormalities

The aim of this review is to outline the priorities in the anaesthetic management of the child with facial abnormalities. It presents a practical approach to this, based on the anatomical site of the deformity and degree of mouth opening. The literature reviewed primarily consists of case reports and series describing anaesthesia in children with relevant syndromes. Also scrutinized is the literature examining the role and effectiveness of recently developed airway management equipment. This is a challenging area of anaesthetic practice but the use of a structured approach, combined with supraglottic airway devices and fibre-optic and indirect laryngoscopic equipment, has allowed the safe administration of anaesthesia to almost all children with conditions resulting in facial abnormality.

Equipment for pre-hospital airway management on Helicopter Emergency Medical System helicopters in central Europe

For advanced out-of-hospital airway management, skilled personnel and adequate equipment are key prerequisites. There are little data on the current availability of airway management equipment and standards of medical staff on Helicopter Emergency Medical System (HEMS) helicopters in central Europe. An internet search identified all HEMS helicopters in Austria, Switzerland and Luxembourg. We identified 15 HEMS helicopter bases in Switzerland, 28 in Austria and three in Luxembourg. A questionnaire was sent to all bases, asking both for the details of the clinical background and experience of participating staff, and details of airway management equipment carried routinely on board. Replies were received from 14 helicopter bases in Switzerland (93%), 25 bases in Austria (89%) and all three bases in Luxembourg. Anaesthesiologists were by far the most frequent attending physicians (68-85%). All except one bases reported to have at least one alternative supraglottic airway device. All bases had capnometry and succinylcholine. All bases in the study except two in Austria had commercial pre-packed sets for a surgical airway. All helicopters were equipped with automatic ventilators, although not all were suitable for non-invasive ventilation (NIV; Switzerland: 43%, Austria: 12%, Luxembourg: 100%). Masks for NIV were rarely available in Switzerland (two bases; 14%) and in Austria (three bases; 12%), whereas all three bases in Luxembourg carried those masks. Most HEMS helicopters carry appropriate equipment to meet the demands of modern advanced airway management in the pre-hospital setting. Further work is needed to ensure that appropriate airway equipment is carried on all HEMS helicopters.

Anesthetic and airway management of a child with a large upper-lip hemangioma

An 11-month-old male child weighing 8 kg was brought to the plastic surgery out-patient department by his parents with chief complaints of sudden increase in size of a swelling over the upper lip and difficulty in feeding for the last 7 days. It was diagnosed as a case of hemangioma of the upper lip. All the routine and special investigations including coagulation profile of the child were normal. The child was planned for ablation of feeding vessels along with intralesional steroid injection. Airway management of the child posed the challenge for us as the size and site of the lesion carried the risk of difficult intubation and possible risk of extensive hemorrhage. All the requisite equipment for difficult airway management was made ready. We were able to intubate the child with miller number-2 blade from the left angle of mouth without putting much pressure on the swelling. The surgical and postoperative period was uneventful and the child was discharged the next day to be followed up after 2 weeks.

Une gestion des voies aériennes à haut risque en médecine pédiatrique préhospitalière

We report the case of high-risk airway management performed in prehospital conditions in a 3-year-old boy suffering from a severe head and maxillofacial trauma. Tracheal intubation was decided because of a comatose status associated with an acute upper airway obstruction resulting in severe hypoxaemia. One minute after a rapid sequence induction, difficult laryngoscopy was encountered. Two tracheal intubation attempts failed. During maintained laryngoscopy, a pediatric angulated Eschmann-like stylet was blindly blocked into the trachea using a rotational maneuver. A tracheal tube was railroaded over the stylet while a hypoxic bradycardia installed. The young child was tracheostomized upon arrival in the hospital, and recovered without neurological complication. In the present case, neither facemask nor laryngeal mask ventilation would have been efficient because of oral cavity jaw and sub-mental pharyngeal open wounds. Since most paediatric emergency medicine physician are not familiar with infraglottic airway techniques, our observation questions the safety of rapid sequence induction in case of severe maxillofacial trauma and reinforces the value of pediatric Eschmann-like stylet. Minimal airway tools equipment for difficult paediatric airway management is discussed.

Conventional mechanical ventilation

The provision of mechanical ventilation for the support of infants and children with respiratory failure or insufficiency is one of the most common techniques that are performed in the Pediatric Intensive Care Unit (PICU). Despite its widespread application in the PICUs of the 21st century, before the 1930s, respiratory failure was uniformly fatal due to the lack of equipment and techniques for airway management and ventilatory support. The operating rooms of the 1950s and 1960s provided the arena for the development of the manual skills and the refinement of the equipment needed for airway management, which subsequently led to the more widespread use of endotracheal intubation thereby ushering in the era of positive pressure ventilation. Although there seems to be an ever increasing complexity in the techniques of mechanical ventilation, its successful use in the PICU should be guided by the basic principles of gas exchange and the physiology of respiratory function. With an understanding of these key concepts and the use of basic concepts of mechanical ventilation, this technique can be successfully applied in both the PICU and the operating room. This article reviews the basic physiology of gas exchange, principles of pulmonary physiology, and the concepts of mechanical ventilation to provide an overview of the knowledge required for the provision of conventional mechanical ventilation in various clinical arenas.

Practice Patterns for Predicted Difficult Airway Management and access to Airway Equipment by Anaesthetists in Queensland, Australia

A postal survey was conducted to investigate difficult airway management, training and equipment availability among Fellows of the Australian and New Zealand College of Anaesthetists in Queensland. The survey aimed to determine practise patterns for predicted difficult airways and investigate equipment availability. Participants were asked to nominate an induction method, intubation method and airway adjunct for each of the five difficult airway scenarios. The cases consisted of one elective and four emergency scenarios. Availability of difficult airway devices in their institution was also assessed, as well as demographics of practice and airway-related maintenance of professional standards participation. There were 454 surveys distributed and 250 returned (response rate 55%). Direct laryngoscopy and flexible fibreoptic intubation were the most commonly selected techniques for all five cases. Difficult intubation trolleys were available to 98% of responders. Certain types of equipment (such as fibreoptic bronchoscopes and cricothyroidotomy kits) were available less frequently in private institutions. We recommend a standardisation of difficult airway management equipment and an on-going training program to provide support for anaesthetists in all locations.

Atemwegsmanagement im deutschen Luftrettungsdienst

The equipment carried in rescue helicopters concerning airway management is not standardized in Germany. The current DIN/EN equipment regulations are not detailed for every single item resulting in differences between the various rescue bases. The aim of this survey was to show existing differences in airway management equipment. All 72 German air rescue helicopters listed in the ADAC air rescue stations atlas 2006/2007 received a questionnaire. A total of 64 bases returned the questionnaire (88.9%). The most frequent types of supraglottic airway equipment were laryngeal masks (67.2%), Combitubes (32.8%) and laryngeal tubes (29.7%). Cricothyrotomy sets were more frequent (68.8%) than tracheostomy sets (35.9%). Of the bases 18.8% had masks suitable for non-invasive ventilation (NIV). All helicopters were equipped to carry out capnometry. The rescue helicopters were found to have differences with respect to the equipment carried for airway management. Medical treatment according to current guidelines is possible on almost all bases.

Prehospital airway management on rescue helicopters in the United Kingdom

Adequate equipment is one prerequisite for advanced, out of hospital, airway management. There are no data on current availability of airway equipment on UK rescue helicopters. An internet search revealed all UK rescue helicopters, and a questionnaire was sent to the bases asking for available airway management items. We identified 27 helicopter bases and 26 (96%) sent the questionnaire back. Twenty-four bases (92%) had at least one supraglottic airway device; 16 (62%) helicopters had material for establishing a surgical airway (e.g. a cricothyroidotomy set); 88% of the helicopters had CO(2) detection; 25 (96%) helicopters carried automatic ventilators; among these, four (15%) had sophisticated ventilators and seven (27%) helicopters carried special face masks suitable for non-invasive ventilation. We found a wide variation in the advanced airway management equipment that was carried routinely on air ambulances. Current guidelines for airway management are not met by all UK air ambulances.

Use of personal protective equipment during infectious disease outbreak and nonoutbreak conditions: a survey of emergency medical technicians

We sought to assess the knowledge of, use of and barriers to the use of personal protective equipment for airway management among emergency medical technicians (EMTs) during and since the 2003 Canadian outbreak of Severe Acute Respiratory Syndrome (SARS). Using a cross-sectional survey, EMTs in Toronto, Ont., were surveyed 1 year after the SARS outbreak during mandatory training on the use of personal protective equipment in airway management during the outbreak and just before taking the survey. Practices that were addressed reflected government directives on the use of this equipment. Main outcome measures included the frequency of personal protective equipment use and, as applicable, why particular items were not always used. The response rate was 67.3% (n = 230). During the SARS outbreak, an N95-type particulate respirator was reported to be always used by 91.5% of respondents. Conversely, 72.9% of the respondents reported that they never used the open face hood. Equipment availability and vision impairment were often cited as impediments to personal protective equipment use. In nonoutbreak conditions, only the antimicrobial airway filter was most often reported to be always used (52.0%), while other items were used at an intermediate frequency. The most common reason for not always donning equipment was that paramedics deemed it unnecessary for the situation. Personal protective equipment is not consistently employed as per medical directives. Reasons given for nonuse included nonavailability, judgment of nonnecessity or technical difficulties. There are important public health implications of noncompliance.

Availability of difficult airway equipment to rural anaesthetists in Queensland, Australia

Since 1990 several airway devices have become available to assist in difficult intubation. Multiple surveys have assessed difficult airway equipment availability in international anaesthetic departments and emergency departments. The practice of GP anaesthetists is unique in both its multidisciplinary nature and geographical isolation. General practitioners performing general anaesthesia in rural and remote Queensland, Australia were surveyed to assess their access to difficult airway equipment and whether this was related to the remoteness of their location or attendance at continuing professional development activities. survey. proceduralists performing general anaesthesia in hospitals categorised as Rural, Remote and Metropolitan Area (RRMA) classification 4 to 7 inclusive were surveyed. data collected included demographic information, availability of airway management equipment, and attendance at continuing professional development activities. The received data was entered into a Microsoft Excel spreadsheet and analysed in Statistical Package for Social Sciences (SPSS Inc; Chicago, IL, USA) using the frequencies and crosstabs functions. The Fisher's exact test was used. A p-value of less than 0.10 was considered noteworthy and a p-value of less than 0.05 was considered to be significant. A statistical comparison was made between the known demographics of the target population and the survey responders. The known demographics were derived from the Health Workforce Queensland database and included age, gender, practice location and practitioner type. Seventy-nine surveys were distributed and 35 returned (response rate 44%). This represented 21 hospitals. There was no statistical difference between the target population and the survey responders in terms of age and gender. There was no statistical difference in terms of practice location, although the small percentage responding from RRMA 6 was notable. There was a statistically significant difference between the groups in terms of practitioner type. Hospital-based practitioners were relatively under-represented in the responder group. Eighty-two per cent of practitioners felt they had access to appropriate equipment and this was not significantly related the remoteness of their location. There was wide variation in available equipment. Simple adjuncts such as the bougie and stylet were not universally available but cricothyroidotomy sets were more common. Practitioners in the more remote locations were less likely to have attended an educational activity such as conference, workshop or skills laboratory (p=0.05). We suggest standardisation of difficult airway equipment for rural practitioners. This could be supported by increased availability of airway management workshops in remote areas. Such an intervention would be in line with other initiatives to standardise medical equipment in rural and remote Queensland hospitals. Familiarity with infrequently used equipment may assist practitioners and their locums. Standardisation of equipment and practice is a recognised method of improving patient safety.