Airway Management Protocol Research Articles

Integrating the Airway Lead structure into a large healthcare system to appraise the landscape of airway management resources

Airway Leads are clinicians who guide safe airway management institutionally and act as liaisons between the evolving airway management landscape and bedside clinicians. Internationally, resources produced by Airway Leads Networks aid clinicians in establishing emergency airway management protocols and making difficult airway equipment decisions. The creation of an Airway Leads Network within the United States' multi-payer healthcare system is ongoing, spearheaded nationally by groups such as the Society for Airway Management. We aimed to build a committee of airway leaders across the Yale New Haven Health system and to leverage this committee to appraise the airway equipment and personnel resources throughout the system. We identified key stakeholders in airway management across the healthcare system and administered a quality improvement survey to members of the assembled committee querying their knowledge of the availability of airway management devices. The dataset was gathered from 14 airway management leaders identified across 4 surgical facilities, 6 emergency departments and 5 medical intensive care units at 8 hospitals and hospital campuses within the Yale New Haven Health system. Equipment available in greater than 75 % of locations included hyperangulated and standard geometry videolaryngoscopes, rigid tracheal tube stylets, tracheal tube introducers, flexible intubation scopes, scalpels and waveform capnography. Equipment available in 25 % to <75 % of locations included emergency invasive airway kits, wheeled airway towers or airway boxes, intubating oral airways, airway exchange and Aintree catheters, intubation-capable supraglottic airways, and awake intubation supplies. Glidescope (Verathon) was the most common videolaryngoscope and flexible intubation scope, and Aura (Teleflex) was the most common intubation-capable supraglottic airway available. The initiative illustrated the feasibility and utility of developing a committee of airway leaders in a large health system. While all locations had access to a requisite array of airway management devices, there was variation in the availability and brand of individual airway equipment.

Predictive factors for respiratory complications in pediatric anesthesia

We conducted a prospective observational, descriptive, and analytical study covering all patients under 16 years of age who were admitted to the operating room for scheduled or urgent surgery between July and August 2022. The purpose of this study was to identify the epidemiological characteristics of our population, describe the means of upper airway management in our practice, and analyze postoperative respiratory complications in pediatric anesthesia and their predictive factors. A total of 200 children were included in this study, with an average age of six years and an average weight of 21 kg. Of these, 53 (26.5%) underwent sedation with propofol 3 mg/kg and ketamine 1 mg/kg or a combination of a hypnotic (propofol or ketamine) and fentanyl at the dose of 2 gamma/kg. General anesthesia was used for 93 (46.5%) patients, while the remaining 54 (27%) were operated on under locoregional anesthesia associated with sedation. Depending on the type of surgery and anesthesia, the upper airway management protocol was chosen: 85 (42.5%) patients were operated on under an oxygen mask, 12 (6%) under a face mask, 10 (5%) under a laryngeal mask and 93 (46.5%) were intubated. Postoperative respiratory complications occurred in 28 patients (14%), with desaturation being the most common complication (10.5%). In multivariate statistical analysis, the factors found to be associated with the occurrence of postoperative respiratory complications were: weight less than 10 kg (p = 0.006, OR = 4.16 [1.54-11.22]) and unipulmonary ventilation (p = 0.008, OR = 14.77 [2.09-104.02]).

Percutaneous tracheostomy in head and neck oncology surgery: How Covid-19 changed our practice

Enhanced experience in performing percutaneous tracheostomies during the COVID-19 pandemic resulted in changes to airway management protocol for patients undergoing major head and neck reconstructive surgery within our department. Most patients now receive a percutaneous tracheostomy over the previously favoured surgical tracheostomy. The aim of this study was to review our experience in performing percutaneous tracheostomies, whilst comparing complication rates with surgical tracheostomies performed in similar settings. All consecutive patients undergoing free flap reconstructive surgery for head and neck cancer between June 2020 and November 2021 were included, with 56 patients receiving a percutaneous tracheostomy. Data across a range of variables including age, BMI, comorbidities and complications was compared with 56 surgical tracheostomies performed for the same group of patients before the COVID-19 pandemic and resultant protocol changes. In the percutaneous group, a marginally lower complication rate was observed over the surgical tracheostomy group; 28.57% and 30.35% respectively. Analysis of the 16 patients who experienced complications in the percutaneous group led to development of selection criteria to identify appropriate patients to receive a percutaneous tracheostomy in future, based on factors such as BMI, bleeding risk and positioning deformities. The COVID-19 pandemic has offered a multitude of learning experiences for healthcare professionals to change our practice. In our unit, this has involved modifying the routine tracheostomy procedure used for airway management intra- and post-operatively in major head and neck reconstruction surgery.

Assessment of Emergency Medical Services Personnel Compliance with Escalating Airway Algorithm Protocol.

When emergency medical services (EMS) personnel respond to emergencies, the decisions they make often can mean life or death for the patient. This is especially true in the case of advanced airway management. Protocols are set in place to ensure that the least invasive airway management techniques are used initially before more invasive techniques. The purpose of this study was to determine how often EMS personnel followed this protocol, while adequately achieving the goals of appropriate oxygenation and ventilation. This retrospective chart review was approved by the Institutional Review Board of the University of Kansas Medical Center. The authors reviewed the Wichita/Sedgewick County EMS system for cases during 2017 in which patients required airway support. We examined de-identified data to determine if invasive methods were applied in sequence. Cohen's kappa coefficient (κ) and immersion-crystallization approach were used to analyze the data. A total of 279 cases were identified in which EMS personnel used advanced airway management techniques. In 90% (n = 251) of cases, less invasive techniques were not used prior to more invasive techniques and in 80% (n = 222) of cases, the more invasive technique was used alone. A dirty airway was the most common reason for the EMS personnel's choice of using more invasive approaches in achieving the goals of appropriate oxygenation and ventilation. Our data showed that EMS personnel in Sedgwick County/Wichita, Kansas often deviated from the advanced airway management protocols when caring for patients in need of respiratory intervention. Dirty airway was the main reason for using a more invasive approach in achieving the goals of appropriate oxygenation and ventilation. It is important to understand reasons why deviations in protocol were occurring to ensure that current protocols, documentation, and training practices are effective in producing the best possible patient outcomes.

Assessment of difficult Airway management protocols used in selected Libyan hospitals and identify Major complications (Survey)

Airway management is a medical process that used to control the ventilation in clear airway problems. Most of times obstructed airway occurs due to loss of consciousness which is common in patients with serious illness or patients who require resuscitation, which may lead to cardiorespiratory arrest. In which a rapid assessment of a patient’s airway, ventilation and lung oxygenation is required to avoid hypoxia and its complications on the brain and other organs. Difficult airway management is being an alarming issue in anesthesia and in emergencies that the anesthesiologists faced with ventilation mask, tracheal incubation in some cases. The current study's goals are to evaluate and contrast the procedures and recommendations for difficult airway management that employed in selected Libyan hospitals. Using a questionnaire, the study was conducted in five hospitals in western Libya between December 2017 and June 2018. SPSS software and the F test used to analyze the collected data. The results of this study confirmed that there is no significant difference in techniques used in management patients with of difficult intubation among compared hospitals in the selected sample. To conclude, most of airway complications are unsuspected and can increase the mortality rate, particularly in the intensive care unit and emergency department, which must have well trained, prepared and educated staff in addition the most developed devices. These complications include; pulmonary aspiration, esophageal intubation, and failed airway management.

See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine.

Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees. This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods. There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p=0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1year (incidence rate ratio=0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio=0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods. The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.

Efficacy of I- gel™ for airway management of neonates with Pierre Robin sequence undergoing glossopexy: A prospective study

This paper aims to review the utility of I- gel as a successful airway management device for infants with Pierre robin sequence (PRS) undergoing glossopexy. A prospective study was conducted on PRS neonates. The algorithm followed was putting a ‘Tongue traction stitch’ followed by the following sequence – two trials with direct laryngoscope intubation, two attempts with fiberoptic endoscope intubation followed by insertion of I-gel™ to manage difficult airway during glossopexy procedure. 6 patients were intubated with direct laryngoscope, 12 patients were intubated with fibreoptic endoscope and the rest 13 patients were intubated using I-gel™. Successful management of difficult airway was achieved with this airway management protocol during glossopexy and nil postoperative complications were encountered. Within the limitations of the study it seems that, I-gel™ is a relevant alternative toprovide a reliable and secure airway access to carry out glossopexy procedure in such patients.

Medication-Facilitated Advanced Airway Management with First-Line Use of a Supraglottic Device - A One-Year Quality Assurance Review.

Airway management is a controversial topic in modern Emergency Medical Services (EMS) systems. Among many concerns regarding endotracheal intubation (ETI), unrecognized esophageal intubation and observations of unfavorable neurologic outcomes in some studies raise the question of whether alternative airway techniques should be first-line in EMS airway management protocols. Supraglottic airway devices (SADs) are simpler to use, provide reliable oxygenation and ventilation, and may thus be an alternative first-line airway device for paramedics. In 2019, Alachua County Fire Rescue (ACFR; Alachua, Florida USA) introduced a novel protocol for advanced airway management emphasizing first-line use of a second-generation SAD (i-gel) for patients requiring medication-facilitated airway management (referred to as "rapid sequence airway" [RSA] protocol). This was a one-year quality assurance review of care provided under the RSA protocol looking at compliance and first-pass success rate of first-line SAD use. Records were obtained from the agency's electronic medical record (EMR), searching for the use of the RSA protocol, advanced airway devices, or either ketamine or rocuronium. If available, hospital follow-up data regarding patient condition and emergency department (ED) airway exchange were obtained. During the first year, 33 advanced airway attempts were made under the protocol by 23 paramedics. Overall, compliance with the airway device sequence as specified in the protocol was 72.7%. When ETI was non-compliantly used as first-line airway device, the first-pass success rate was 44.4% compared to 87.5% with adherence to first-line SAD use. All prehospital SADs were exchanged in the ED in a delayed fashion and almost exclusively per physician preference alone. In no case was the SAD exchanged for suspected dislodgement evidenced by lack of capnography. First-line use of a SAD was associated with a high first-pass attempt success rate in a real-life cohort of prehospital advanced airway encounters. No SAD required emergent exchange upon hospital arrival.

KISS- Keep it Simple Yet Safe: A Dependable Option in Anticipated Difficult Airways

Difficult airway guidelines provide an algorithmic approach as suggested by many international societies and journals. These guidelines have always been made with an earnest conviction at securing an airway with utmost safety and they provide a framework in times of difficulty. These guidelines are likely to add complexity with technological advances and gadgets available at hand like video laryngoscopes, fibreoptic bronchoscope etc., that may confuse the anaesthesiologist and hinder the decision making process. KISS- Keep it Simple, Stupid!– A concept well known, was first used in aviation which advices the pilot to keep things simple. We applied the same principle to our airway management protocol by modifying it into ‘Keep it simple yet safe’. The current case series describes 10 subjects which seemed to have a difficult access to airway and intubation. These patients were difficult to ventilate or difficult to intubate. Cases were successfully managed by applying this KISS technique. Due care was taken to keep our difficult airway cart ready as an alternative option.

Recommendations for airway management in a suspected or confirmed case with COVID-19. A protocol of the Department of Cardiovascular Anesthesia of the National Institute of Cardiology Ignacio Chávez

The new coronavirus SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), detected in Wuhan, China, causes coronavirus disease 2019 (COVID-19), which was declared pandemic, and has caused more than 19 million confirmed cases and more than 700 thousand deaths worldwide. When our institution was converted to COVID’s hospital since early April 2020, specific care protocols were developed, with the aim of improving the quality of care and safety of patients and the staff involved in their management. Airway management represents one of the highest risks of direct contact infection with aerosol generation (orotracheal intubation, secretion aspiration, extubation, cardiopulmonary resuscitation, high flow oxygen therapy, noninvasive ventilation, and invasive ventilation). We present the current recommendations for airway management as well as a step-by-step airway management protocol to carry out a more secure procedure based on the literature reported so far.

Variations in COVID-19 airway management and preparedness among Victorian hospitals

The COVID-19 pandemic presents significant concerns surrounding the risk of transmission to health care workers involved in airway management of patients with suspected or known infection. Limited evidence has been available to guide the preparation of staff, intubation environments, team structure and personal protective equipment. Our study invited Victorian hospitals to complete a survey on their airway management practices and protocols, in order to assess the degree of variability in practice and preparedness. Twenty hospitals responded in September 2020, during Victoria’s second wave of COVID-19. Forty percent had dedicated COVID-19 intubation teams, all including consultant anaesthetists. Seventy-five percent had negatively pressured dedicated intubation rooms. All provided airborne precautions including N95 masks for airway and cardiac arrest management of suspected or confirmed COVID-19 positive patients, with 35 per sent providing N95 mask fit-testing and 15 per cent providing powered air purifying respirators or elastomeric respirators. Thirty-five percent provided airborne precautions for cardiac arrest management of patients not suspected to be COVID-19 positive. Significant inter-hospital variations were reported in airway management practices, such as pre-oxygenation, bag-mask ventilation, medications and techniques to minimise aerosolisation. Although some of this variation was likely due to individual hospital infrastructure and resource limitations, it would be ideal to achieve a more consistent, standardised approach across Victorian hospitals. This study may highlight areas for improvement for some hospitals. These areas for improvement may include consideration of the establishment of COVID-19 intubation teams in at least major metropolitan hospitals, N95 mask fit-testing, and the use of airborne precautions for cardiac arrest management during times of increased community prevalence of COVID-19.

Implementing healthcare professionals' training during COVID-19: a pre and post-test design for simulation training.

Coronavirus disease-19 (COVID-19) has imposed a new reality that presents several challenges for healthcare professionals. The main challenge has been the lack of proper training in relation to an unknown disease. To investigate healthcare professionals' acquisition of knowledge of a new airway management protocol for COVID-19 through their participation in simulation training. Pre and post-test study with purpose sampling, carried out in a tertiary-level hospital in the city of Campinas, state of São Paulo, Brazil. This was a cross-sectional pre and post-test intervention among healthcare professionals working in the intensive care unit and emergency department of a large hospital. The training was carried out using an in situ simulation scenario and the participants answered pre and post-tests consisting of a 20-item questionnaire about the new protocol. The paired-sample t test demonstrated that there was a significant increase in test score (t = -19.06; P < 0.001), from before the training (M = 8.62; standard deviation, SD = 3.53) to after the simulation training (M = 17.02; SD = 1.76). The simulated training had a positive impact on the healthcare professionals' acquisition of the COVID-19 protocol. We also demonstrated that in situ simulation training was an efficient tool for implementing new protocols, thus bringing benefits to healthcare systems, professionals and patients.

A National US Survey of Pediatric Emergency Department Coronavirus Pandemic Preparedness.

ObjectiveWe aim to describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a diverse set of pediatric emergency departments (PEDs) within the United States.MethodsWe conducted a prospective multicenter survey of PED medical director(s) from selected children’s hospitals recruited through a long established national research network. The questionnaire was developed by physicians with expertise in pediatric emergency medicine, disaster readiness, human factors, and survey development. Thirty-five children’s hospitals were identified for recruitment through an established national research network.ResultsWe report on survey responses from 25 (71%) of 35 PEDs, of which 64% were located within academic children's hospitals. All PEDs witnessed decreases in non–COVID-19 patients, 60% had COVID-19–dedicated units, and 32% changed their unit pediatric patient age to include adult patients. All PEDs implemented changes to their staffing model, with the most common change impacting their physician staffing (80%) and triaging model (76%). All PEDs conducted training for appropriate donning and doffing of personal protective equipment (PPE), and 62% reported shortages in PPE. The majority implemented changes in the airway management protocols (84%) and cardiac arrest management in COVID patients (76%). The most common training modalities were video/teleconference (84%) and simulation-based training (72%). The most common learning objectives were team dynamics (60%), and PPE and individual procedural skills (56%).ConclusionsThis national survey provides insight into PED preparedness efforts, training innovations, and practice changes implemented during the start of COVID-19 pandemic. Pediatric emergency departments implemented broad strategies including modifications to staffing, workflow, and clinical practice while using video/teleconference and simulation as preferred training modalities. Further research is needed to advance the level of preparedness and support deep learning about which preparedness actions were effective for future pandemics.

Retrospective Analysis of Peri-Intubation Hypoxemia During the Coronavirus Disease 2019 Epidemic Using a Protocol for Modified Airway Management.

This single-center retrospective study evaluated a protocol for the intubation of patients with confirmed or suspected coronavirus disease 2019 (COVID-19). Twenty-one patients were intubated, 9 of whom were found to have COVID-19. Adherence to the airway management protocol was high. COVID-19 patients had lower peripheral capillary oxygen saturation by pulse oximetry (Spo2) nadirs during intubation (Spo2, 73% [72%-77%] vs 89% [86%-94%], P = .024), and a greater percentage experienced severe hypoxemia defined as Spo2 ≤80% (89% vs 25%, P = .008). The incidence of severe hypoxemia in COVID-19 patients should be considered in the development of guidelines that incorporate high-flow nasal cannula and noninvasive positive pressure ventilation.

Airway management protocol for conjoined twins delivery

ObjectiveConjoined twin deliveries require collaborative preparation by multiple specialties for successful airway management. Literature regarding neonatal airway management after conjoined twin delivery is limited to case reports. We present a case series of conjoined twins and introduce an airway management protocol for conjoined twin delivery. MethodsThe medical records of conjoined twins and their mothers at a tertiary care center were reviewed from April 2016 to December 2018. The NCBI database was queried for literature regarding preparation for neonatal airway management after conjoined twins delivery. ResultsFive sets of conjoined twins were delivered. Of 10 neonates, all required bag valve mask ventilation. Other airway interventions included continuous positive airway pressure (7), endotracheal intubation (6), and direct laryngoscopy with telescopic video evaluation (1). No patients required ex-utero intrapartum treatment or emergent tracheostomy. A protocol for airway management is described and special considerations are discussed, including anatomic variations, equipment list, operating room staffing and layout, multidisciplinary prenatal conference, and airway imaging review. ConclusionConjoined twin deliveries have significant implications for the otolaryngologist and require multidisciplinary collaboration. An airway management protocol allows for a standardized process to secure the neonatal airway and optimize patient outcomes.

Analysis and Temporal Evolution of Extubation Parameters for Patients Undergoing Single-Stage Circumferential Cervical Spine Surgery.

ObjectiveAirway obstruction after postoperative extubation is a dreaded but uncommon complication in patients undergoing circumferential cervical spine surgery (CCSS). The cuff leak test (CLT) has been utilized to assess air leak around the endotracheal tube which may reflect airway swelling. In this prospective observational study, we analyze the temporal evolution of CLT and perioperative factors that may influence it. MethodsTwenty patients undergoing single-stage CCSS were managed according to our extubation protocol. Patients were maintained intubated overnight following surgery. They were extubated if a CLT > 200 mL and both intensive care unit (ICU) and Neurosurgery teams agreed that it was safe. Patients extubated in the first postoperative day (8 of 20) comprised the early group, and the remaining patients (12 of 20) the delayed group. Patient and operative data were analyzed as a single group and comparing both groups. ResultsThe main indication for surgery was cervical deformity. Median number of levels fused was 5 anteriorly (range, 1–6) and 6 (range, 1–13) posteriorly. Patients were kept intubated for an average of 73.6 hours (range, 26–222 hours) and stayed in the ICU for 119.1 hours (range, 36–360 hours). There were 4 failed extubations and 3 patients (15%) required a tracheostomy. Patient profiles between both groups were very similar across most patient variables but differed significantly regarding infraglottic luminal area (p < 0.05). Patients with larger preoperative cuff leak values tended to have a shorter intubation period (p=0.053). ConclusionThis study objectively demonstrates the difficulties in airway management following CCSS and provides useful insight for preoperative planning and counseling. Local anatomic factors influence airway outcome more than operative factors. The study format does not allow for testing of interventions but we suggest that patients with favorable anatomy (larger infraglottic luminal area) may benefit from a less strict airway management protocol.

The complexity of respiratory disease associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection: From immunopathogenesis to respiratory therapy

SummaryCovid‐19, a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection, may present with polymorphic symptomatology and subclinical, neurological, gastrointestinal, dermatological, renal and severe acute respiratory manifestations. The diffuse alveolar damage caused by the disease presents with fibrin deposition, oedema, lymphocytic inflammatory infiltrate, destruction of epithelial cells, hyaline membrane formation and occasional angiogenesis formation of microthrombi. A common radiological finding is bilateral ground glass opacity, present even in mild cases. Severe cases occur mainly among the elderly and individuals with underlying comorbidities. Here, we provide an overview of the pathophysiology of the disease associated with SARS‐CoV‐2 infection, interaction of the virus with the immune system, and subsequent dysfunctional immune response, essential for progression of Covid‐19. We also discuss the role of the nervous system as a possible aggravating agent of the respiratory condition and propose a protocol for airway management based on the pathophysiological and immunological characteristics of the disease. Finally, we highlight the implications of such approaches for future therapeutic intervention.

Quality Improvement in a Pandemic.

Quality Improvement in a Pandemic.

Ancillary protective gears in the COVID- 19 Era.

Ancillary protective gears in the COVID- 19 Era.

Preparedness to combat COVID-19 via structured online training program regarding specific airway management: A prospective observational study.

Preparedness to combat COVID-19 via structured online training program regarding specific airway management: A prospective observational study.