Guidelines For Difficult Airway Management Research Articles

Practice Guidelines for Difficult Airway Management: Comment: Erratum.

Erratum| May 2023 Practice Guidelines for Difficult Airway Management: Comment: Erratum Anesthesiology Newly Published on May 2023. doi: https://doi.org/10.1097/ALN.0000000000004628 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn Email Cite Icon Cite Get Permissions Search Site Citation Practice Guidelines for Difficult Airway Management: Comment: Erratum. Anesthesiology Newly Published on May 31, 2023. doi: https://doi.org/10.1097/ALN.0000000000004628 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll PublicationsAnesthesiology Search Advanced Search In the author list of the correspondence beginning on page 514 in the October 2022 issue, Dr. Pete G. Kovatsis was incorrectly listed as “Peter”. The publisher regrets the error. The online version and PDF of the article have been corrected. DOI: 10.1097/ALN.0000000000004628 You do not currently have access to this content.

Recent advances in airway management.

Airway management is a core skill essential for anaesthesiologists and health care providers involved in resuscitation and acute care of patients. Advancements in airway management are continuously evolving. This narrative review highlights the recent advancements with respect to innovations, tools, techniques, guidelines, and research in both technical and non-technical aspects of airway management. These include nasal endoscopy, virtual endoscopy, airway ultrasound, video endoscopes, supraglottic airways with enhanced protection against aspiration, hybrid devices, and the use of artificial intelligence and telemedicine, the utility of which has increased in recent times, thereby improving success with airway management and enhancing patient safety. There has been an increasing emphasis on peri-intubation oxygenation strategies to reduce complications in patients with a physiologically difficult airway. Recent guidelines for difficult airway management and preventing unrecognised oesophageal intubation are available. Large multicentre airway data collection helps us examine airway incidents, aetiology, and complications to expand our knowledge and give us insights for change in practice.

AIRWAY MANAGEMENT GUIDELINES IN OBSTETRICS.

Anatomic and physiologic changes during pregnancy make it more difficult to establish a safe airway in pregnant women in case of the need for surgery under general anesthesia than in the non-obstetric population. The inability to ventilate and oxygenate is one of the most common causes of morbidity and mortality associated with general anesthesia for cesarean section. The aim of this paper is to present and analyze modern guidelines and algorithms for the management of difficult airway in obstetrics as an important segment of anesthesiology practice. Modern difficult airway management guidelines for pregnant women describe the procedure of difficult facemask ventilation, difficult airway management by using supraglottic devices, difficult endotracheal intubation, and emergency cricothyrotomy or tracheotomy in a situation where oxygenation and ventilation are impossible. Algorithms describe the procedures and equipment for each variant of difficult airway and decision-making strategies in situations when neither airway nor adequate oxygenation can be provided. Croatian anesthesiologists in most obstetric departments have appropriate equipment, as well as necessary experience in difficult airway management for pregnant women, and modern algorithms from the most developed countries can be adopted and accommodated to our daily practice, as well as incorporated into the training curricula of residents.

Difficult Airway Management in Adult Coronavirus Disease 2019 Patients: Statement by the Society of Airway Management.

The coronavirus disease 2019 (COVID-19) disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), often results in severe hypoxemia requiring airway management. Because SARS-CoV-2 virus is spread via respiratory droplets, bag-mask ventilation, intubation, and extubation may place health care workers (HCW) at risk. While existing recommendations address airway management in patients with COVID-19, no guidance exists specifically for difficult airway management. Some strategies normally recommended for difficult airway management may not be ideal in the setting of COVID-19 infection. To address this issue, the Society for Airway Management (SAM) created a task force to review existing literature and current practice guidelines for difficult airway management by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. The SAM task force created recommendations for the management of known or suspected difficult airway in the setting of known or suspected COVID-19 infection. The goal of the task force was to optimize successful airway management while minimizing exposure risk. Each member conducted a literature review on specific clinical practice section utilizing standard search engines (PubMed, Ovid, Google Scholar). Existing recommendations and evidence for difficult airway management in the COVID-19 context were developed. Each specific recommendation was discussed among task force members and modified until unanimously approved by all task force members. Elements of Appraisal of Guidelines Research and Evaluation (AGREE) Reporting Checklist for dissemination of clinical practice guidelines were utilized to develop this statement. Airway management in the COVID-19 patient increases HCW exposure risk. Difficult airway management often takes longer and may involve multiple procedures with aerosolization potential, and strict adherence to personal protective equipment (PPE) protocols is mandatory to reduce risk to providers. When a patient's airway risk assessment suggests that awake tracheal intubation is an appropriate choice of technique, and procedures that may cause increased aerosolization of secretions should be avoided. Optimal preoxygenation before induction with a tight seal facemask may be performed to reduce the risk of hypoxemia. Unless the patient is experiencing oxygen desaturation, positive pressure bag-mask ventilation after induction may be avoided to reduce aerosolization. For optimal intubating conditions, patients should be anesthetized with full muscle relaxation. Videolaryngoscopy is recommended as a first-line strategy for airway management. If emergent invasive airway access is indicated, then we recommend a surgical technique such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. This statement represents recommendations by the SAM task force for the difficult airway management of adults with COVID-19 with the goal to optimize successful airway management while minimizing the risk of clinician exposure.

Methodological quality and transparency of clinical practice guidelines for difficult airway management using the appraisal of guidelines research & evaluation II instrument: A systematic review.

Complications arising from airway management represent an important cause of morbidity and mortality. Clinical practice guidelines (CPGs) are systematically created documents that summarise knowledge and assist the delivery of high-quality medical care by identifying evidence that supports best clinical care. Using the Appraisal of Guidelines for Research & Evaluation II instrument, we aimed to evaluate the methodological rigour and transparency of unanticipated difficult airway management CPGs in adults. Using PUBMED without language restrictions, we identified eligible CPGs between 1 January 1996 and 30 June 2019. All versions of a CPG were included as independent guidelines to assess improvements over time or the methodological limitations of each version. CPGs-related obstetrics or paediatrics or the management extubation in cases of difficult airway were excluded. Fourteen CPGs were included. Of the six domains suggested by the Appraisal of Guidelines for Research & Evaluation II instrument, 'applicability' had the lowest score (23%) and 'scope and objectives' had the highest score (88%). The remaining domains (stakeholder involvement, editorial independence, rigour of development and clarity of presentation) had scores ranging between 56 and 81%. Overall, the highest scored CPG was the Difficult Airway Society 2015. Future updates of CPGs for difficult airway management in adults and severely ill patients should consider more emphasis on the applicability of their recommendations to real clinical practice.

Management of Difficult Tracheal Intubation: A Closed Claims Analysis.

Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database. Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management. Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A "can't intubate, can't oxygenate" emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80). Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.

Locating the cricothyroid membrane in males: Influence of the morphological characteristics of the neck

Abstract Introduction Cricothyrotomy is a recommended technique to restore oxygenation in most of guidelines for difficult airway management. A correct location of the cricothyroid membrane (CTM) is fundamental for a proper performance of the technique. Several studies have shown poor accuracy with the identification the CTM by palpation, resulting in a high failure rate of the technique. Objective The aim of this study was to determine the impact of the patient's neck morphology on the accurate location of the CTM and on the time employed. Materials and method Observational study in which anaesthesiologists and intensivists voluntarily participated in a simulation that consisted of a “cannot intubate, cannot oxygenate” scenario, where they had to locate the CTM, as soon as possible, in 2 selected male patients with different morphological characteristics of the neck. The time was measured from the beginning of CTM palpation to locating it with a marker. Results and conclusions A higher body mass index and a higher neck circumference correlated with a 70% location failure rate and with a longer time as compared with a standard model.

Supraglottic airway devices in difficult airway management: a retrospective cohort study of 658,104 general anaesthetics registered in the Danish Anaesthesia Database.

Indications for using supraglottic airway devices have widened over time and they now hold a prominent role in guidelines for difficult airway management. We aimed to describe the use of supraglottic airway devices in difficult airway management. We included adult patients undergoing general anaesthesia registered in the Danish Anaesthesia Database from 2008 to 2012 whose airway management had been recorded as difficult, defined as: ≥3 tracheal intubation attempts; failed tracheal intubation; or difficult facemask ventilation. In the Danish Anaesthesia Database, a separate difficult airway management module requires the technique used in each successive airway management attempt to be recorded. The primary aim of the study was to describe the use of supraglottic airway devices in cases of difficult airway management. Secondary aims were to examine success rates of supraglottic airway devices in difficult airway management cases, and specifically in the cases of 'cannot intubate, cannot facemask ventilate'. Difficult airway management occurred in 4898 (0.74% (95%CI 0.72-0.76%)) of 658,104 records of general anaesthesia. Supraglottic airway devices were used or use was attempted in 607 cases of difficult airway management (12.4% (95%CI 11.5-13.3%)), and were successful in 395 (65.1% (95%CI 61.2-68.8%)) cases. In 'cannot intubate, cannot facemask ventilate' situations, supraglottic airway devices were used in 86 (18.9% (95%CI 15.6-22.8%)) of 455 records and were successful in 54 (62.8% (95%CI 52.2-72.3%)) cases. We found that supraglottic airway devices are not widely used in the management of the difficult airway despite their prominent role in difficult airway management guidelines.

Air-Q ® versus LMA Fastrach™ for fiberoptic-guided intubation: A randomized cross-over manikin trial

Abstract Introduction Airway management is still a major cause of anaesthesia-associated morbidity and mortality. Supraglottic devices are recommended in difficult airway management guidelines. The aim of this study was to compare the performance of the Air-Q® and the LMA Fastrach™ for fibreoptic guided tracheal intubation. Methods Thirty-three anaesthesia trainees participated in this randomized crossover study. Time to insert the dedicated airways (insertion of the airway into the manikin and delivery of two breaths), time to tracheal intubation (fibreoptic-guided tracheal intubation), time to remove the dedicated airway (removal of the Air-Q®/LMA Fastrach™ over the tracheal tube) and the opinion of the ease of use of the anaesthesia trainees were measured. Results There was 100% success rate for tracheal intubation with both devices on the first attempt. Time to insert the dedicated device and deliver two breaths was 10 ± 3 s for the Air-Q® and 11 ± 3 s for the LMA Fastrach™, p = 0.07. Time taken to intubate the trachea was shorter with the Air-Q®, 38 ± 15 s, than with the LMA Fastrach™, 47 ± 19 s, p = 0.017. Overall procedure time was significantly shorter with the Air-Q® as compared with the LMA Fastrach™, with a mean time of 74 ± 21 s and 87 ± 28 s respectively, p = 0.002. Air-Q® removal was considered easier than LMA Fastrach™ removal, p = 0.005. There were no tube dislodgements during the removal of the dedicated airways. Conclusions Inexperienced anaesthesia residents can perform fibreoptic-guided intubation through Air-Q® and LMA Fastrach™ in a clinically acceptable time with high success.

Estudio aleatorizado cruzado para evaluar la intubación guiada con fibrobroncoscopio a través del dispositivo Air-Q® versus la mascarilla laríngea Fastrach™ en maniquís

IntroductionAirway management is still a major cause of anesthesia-associated morbidity and mortality. Supraglottic devices are recommended in difficult airway management guidelines. The aim of this study was to compare the performance of the Air-Q® and the LMA Fastrach™ for fiberoptic guided tracheal intubation. MethodsThirty-three anesthesia trainees participated in this randomized crossover study. Time to insert the dedicated airways (insertion of the airway into the manikin and delivery of two breaths), time to tracheal intubation (fiberoptic-guided tracheal intubation), time to remove the dedicated airway (removal of the Air-Q®/LMA Fastrach™ over the tracheal tube) and the opinion of the ease of use of the anesthesia trainees were measured. ResultsThere was 100% success rate for tracheal intubation with both devices on the first attempt. Time to insert the dedicated device and deliver two breaths was 10±3s for the Air-Q® and 11±3s for the LMA Fastrach™, P=.07. Time taken to intubate the trachea was shorter with the air-Q®, 38±15 s, than with the LMA Fastrach™, 47±19s, P=.017. Overall procedure time was significantly shorter with the Air-Q® as compared with the LMA Fastrach™, with a mean time of 74±21s and 87±28s respectively, P=.002. Air-Q® removal was considered easier than LMA Fastrach™ removal, P=.005. There were no tube dislodgements during the removal of the dedicated airways. ConclusionsInexperienced anesthesia residents can perform fiberoptic-guided intubation through Air-Q® and LMA Fastrach™ in a clinically acceptable time with high success.

Perioperative management of obstructive sleep apnea: a systematic review.

Obstructive sleep apnea (OSA) is the leading sleep disordered breathing condition, with a prevalence rate of moderate to severe OSA of approximately 10-17% in the general population. We performed an Ovid-Medline search of all articles published up to August 2016. We included all articles providing updated evidence on epidemiology, pathophysiologic mechanisms and perioperative interventions. OSA is associated with a number of comorbidities and increased perioperative risks. Although in-laboratory polysomnography represents the gold-standard for diagnosis of OSA, it is costly and time-consuming. Anesthesiologists may screen patients for OSA through one of the available questionnaires, of which the snoring, tiredness, observed apnea, high blood pressure (STOP)-Body Mass Index, age, neck circumference and gender (Bang), STOP-bang questionnaire is the most externally validated. Although its sensitivity for the identification of mild OSA patients is 83.6%, its specificity is only 56.4%. OSA patients are associated with a higher risk of both difficult ventilation and intubation. However, practice guidelines refer to available guidelines for difficult airway management. Perioperative continuous positive airway pressure use may be of benefit since it has been reported to be associated with a reduction of both respiratory and cardiovascular complications and symptom relief. When feasible, regional anesthesia techniques and a multimodal analgesia approach should be adopted to reduce intraoperative and postoperative exposure to opioids. Preoperative screening of OSA patients is of relevance given the increased perioperative morbidity of these patients. Further studies are needed to provide conclusive data on which perioperative interventions are most effective at reducing this risk.

Abstract PR539

Background & Objectives: Difficult airway management guidelines recommend a specific learning program for improvement of technical and non-technical airway skills. Live tissue training involves the use of animals to provide realistic training programs, better simulating life threatening scenarios. The aim of the prospective study was to describe the motivations for attending the airway training and the long-term consequences for the anaesthetists practices. Materials & Methods: Since 2012, a biannual airway training course has been organised in Ponderas Training Centre,Bucharest, Romania. It is a two day course accredited by the Romanian College of Physicians with10 CME points and consists of 4 hours lectures, of 4 hours training on mannequins and 8 hours training on anaesthetized pigs. A feedback form was given to all participants after each course, and in January 2016 a survey of all participants in the last 4 years was conducted. The anonymous feedback form evaluated the instructors regarding the content, the form of presentations, the value of discussions, the practical training on manniquins and on live animals. The survey sent included questions about motivations for the educational programme and the impact of the course on personal airway management developments and practice changes, as well as the implementing of their acquired knowledge and skills. Results: The airway course participants (n=151) response rate was 100% for the feedback form and 79% for the survey. The distribution of the participants was:67 consultants,62 specialists and 22 trainees in anaesthesia and intensive care with a median age of 37years. 87 participants were from Bucharest and 64 from other Romanian cities.The necessary equipment for bronchoscopy was available in 60% of the hospitals where the participants worked but they rated as insufficient their training in supraglottic devices, airway exchangers, fiberoptic intubation and surgical airway.The practical workshop on live animals was ranked with maximum score in 100 % of cases, 97 %respondents considering training on animals more reliable than on mannequins. The first 2 motivations in the survey were “to learn technical skills-especially bronchoscopy” and to “use new devices”. The survey confirmed a practice change in 91% of the respondents but only 30 %were planning on implementing the new acquired knowledge in their institutions. Finally 87 % of the respondents answered they were more confident in their airway management practice. Conclusion: Training on live animals seemed to better simulate the airway practice and expedite the acquisition of the airway skills, aknowledging an improvement in the anaesthetists airway practice. The training for invasive procedures had a special relevance where the lack of technical skills interfere with acute psychological stress. Disclosure of Interest: None declared

Guidelines help us to keep calm when facing a difficult airway.

In this issue of the Korean Journal of Anesthesiology, Koh et al. [1] report that the incidence of unexpected difficult airway is 5.8% from a retrospective review of electronic medical records at a single university hospital, and that most cases were managed effectively. Among the numerous intubation difficulty scales (IDS) [2], the Cormack–Lehane grade is generally considered the most sensitive measure for predicting difficult intubation. Alternative techniques were required in 74 out of 951 cases (7.8%) to achieve intubation using the following subsidiary manipulations: the additional use of stylet only in 69 cases; use of a lightwand only in two cases; a stylet first and then a lightwand in one case; a stylet, then a lightwand, and finally fiberoptic assistance in one case; and the initial use of a stylet, subsequent use of a supraglottic airway device, and finally a surgical tracheostomy in one case. The last three cases (3/951, 0.3%), which all required two or more alternative techniques, were all difficult cases with an IDS > 5; this compares with an 8% rate of IDS > 5 reported by Adnet et al. [3]. Controlled studies of difficult airways are difficult to conduct due to the emergency nature of a difficult airway. Although there is insufficient scientific evidence to support every recommendation concerning airway management in clinical guidelines, guidance must be based on the best accessible evidence, such as expert consensus. Since the first edition of the American Society of Anesthesiologists (ASA) Difficult Airway Practice Guidelines for the management of the difficult airway was published in 1993 (updated in 2013, [4]), several national societies have proposed practice guidelines for difficult airway management, including the Difficult Airway Society (DAS) [5]. The most important development in the ASA Difficult Airway Practice Guidelines over the past two decades has been the introduction of new airway devices into clinical practice, including the laryngeal mask airway (1993–2003) and video laryngoscopy (2003–2013). Both of these have also been included in the new DAS guidelines for successful intubation in patients with a history of difficult intubation in various randomized controlled trials [6]. While the ASA guidelines focus on both the anticipated and unanticipated difficult airway, the DAS guidelines concentrate on the unanticipated difficult airway, an unpredictable problem. The new 2015 DAS guidelines differ from the original 2004 DAS guidelines in that they are more concise and pragmatic and emphasize the preparedness and accountability of the practitioner by optimizing conditions and minimizing patient morbidity in a difficult airway situation. Obtaining proper training on the use of alternative airway devices and accompanying techniques, such as emergency invasive airway access, is not only essential for physicians but is also expected. Given that repeated airway manipulation may lead to airway damage and reduce the ability to ventilate, the number of laryngoscopy attempts with any particular device should be limited. No single technique is better at securing the airway in every situation. Physicians need to be familiar with several different devices and techniques because airway devices have unique properties that may be advantageous in certain situations, yet limiting in others. Our great enterprise of difficult airway management begins with the implementation of the guidelines in the most accurate manner to manage our patients safely.

Rethinking general anesthesia for cesarean section.

In this review, we describe the current consensus surrounding general anesthetic management for cesarean section. For induction of anesthesia, rapid-sequence induction using thiopental and suxamethonium has been the recommended standard for a long time. In recent years, induction of anesthesia using propofol, rocuronium, and remifentanil have been gaining popularity. To prevent aspiration pneumonia, a prolonged preoperative fasting and an application of cricoid pressure during induction of anesthesia have been recommended, but these practices may require revision. Guidelines for difficult airway management were developed first in obstetric anesthesia, and the use of a supraglottic airway is now recognized as an effective rescue device. After the delivery of a fetus, switching from volatile anesthetics to intravenous anesthetics has been recommended to avoid uterine atony. At the same time, intraoperative awareness should be avoided. The rate of persistent wound pain is higher when only general anesthesia was used during cesarean section than with regional anesthesia, and thus it is necessary to provide a sufficient postoperative analgesia using multimodal analgesia, including intravenous patient-controlled analgesia (IV-PCA), transversus abdominis plane (TAP) block, non-steroidal inflammatory drugs, and acetaminophen.

DAMガイドライン─欧米におけるガイドライン─

困難気道管理ガイドラインとして，米国麻酔科学会「困難気道管理に関する診療ガイドライン」（ASA-DAA）・英国Difficult Airway Society（DAS）ガイドライン・カナダのCanadian Airway Focus Group（CAFG）の推奨を紹介した．ASA-DAAは困難気道管理における普遍的な考え方を示したものである．CAFGの推奨はASA-DAAに比べて具体的な記述が多く，アルゴリズムも単純であることから，理解しやすいアルゴリズムである．Airway Approach Algorithmは麻酔導入・気道確保をどのように行うかを判断するために非常に有用である．

Extubation of the Difficult Airway and Extubation Failure

Respiratory complications after tracheal extubation are associated with significant morbidity and mortality, suggesting that process improvements in this clinical area are needed. The decreased rate of respiratory adverse events occurring during tracheal intubation since the implementation of guidelines for difficult airway management supports the value of education and guidelines in advancing clinical practice. Accurate use of terms in defining concepts and describing distinct clinical conditions is paramount to facilitating understanding and fostering education in the treatment of tracheal extubation-related complications. As an example, understanding the distinction between extubation failure and weaning failure allows one to appreciate the need for pre-extubation tests that focus on assessing airway patency in addition to evaluating the ability to breathe spontaneously. Tracheal reintubation after planned extubation is a relatively rare event in the postoperative period of elective surgeries, with reported rates of reintubation in the operating room and postanesthesia care unit between 0.1% and 0.45%, but is a fairly common event in critically ill patients (0.4%-25%). Conditions such as obesity, obstructive sleep apnea, major head/neck and upper airway surgery, and obstetric and cervical spine procedures carry significantly increased risks of extubation failure and are frequently associated with difficult airway management. Extubation failure follows loss of upper airway patency. Edema, soft tissue collapse, and laryngospasm are among the most frequent mechanisms of upper airway obstruction. Planning for tracheal extubation is a critical component of a successful airway management strategy, particularly when dealing with situations at increased risk for extubation failure and in patients with difficult airways. Adequate planning requires identification of patients who have or may develop a difficult airway, recognition of situations at increased risk of postextubation airway compromise, and understanding the causes and underlying mechanisms of extubation failure. An effective strategy to minimize postextubation airway complications should include preemptive optimization of patients' conditions, careful timing of extubation, the presence of experienced personnel trained in advanced airway management, and the availability of the necessary equipment and appropriate postextubation monitoring.

Evolving challenges and opportunities for difficult airway management guidelines

Airway management is a key competency for every anesthesiologist. In 1990, Caplan et al. reported that 34% of anesthesia-related claims were related to airway management. Since that time, several national airway management guidelines have been published with the aim to establish and promote safer airway management practice. Since the publication of those guidelines, studies have shown a decrease in anesthesia complications related to airway management. Of course, it is not possible to determine causality, and there have been other significant changes in practice over this time, e.g., supraglottic airways are now used in more than half the patients in the United Kingdom (UK). Unfortunately, despite these advances in both protocols and technology, airway complications in anesthesia still occur, and they are often associated with severe complications, i.e., brain damage or death. Herein, we consider the contents of future airway management guidelines that might create a further impact on patient safety, while bearing in mind the known problematic adherence to airway management guidelines, the role of medical education, and the rapid evolution of new airway management technology and skills. When we consider the history of major developments in airway management, we observe a recent acceleration of the development of technology and skills in this area. The Macintosh and Miller blades, designed in the 1940s when curare was introduced into anesthesia, are still in common use. Major incremental steps in airway management occurred with the development of fibreoptic intubation in the early 1970s, and again in the 1980s, with the invention of the laryngeal mask airway (LMA) and the rigid fibreoptic laryngoscopes (e.g., Bullard). Other major advances were made in the 1990s with the intubating laryngeal mask airway (ILMA), devices for transillumination (e.g., Trachlight), and videolaryngoscopy. During the last decade, anesthesiologists have used combinations of these new techniques to produce even further airway management possibilities, e.g., the combination of the LMA or the ILMA with fibreoptic bronchoscopy. The recent availability of sugammadex may change airway management practice and should be considered in new airway management guidelines. In addition to these ‘‘quantum leaps’’, there has also been a rapid increase in the number of new versions of very similar airway management devices, in part because of the ‘‘me too device’’ phenomenon. This increase in technology provides both advantages and disadvantages to anesthesiologists. Although we have more options for managing difficult intubation, it can be difficult to know the appropriate airway tool to use for a given purpose, especially considering the logistic challenges of conducting controlled trials on patients with difficult airways. A key tension for future guidelines is to reconcile the increasing number of new airway management options with Attributable to: Department of Anesthesiology, St. Michael’s Hospital, University of Toronto, 30 Bond St., Toronto, ON M5B 1W8, Canada.

Retraction Movement of the Frova Airway Intubation Introducer to Assist Nasotracheal Intubation in Patients with Limited Mouth Opening

Retraction Movement of the Frova Airway Intubation Introducer to Assist Nasotracheal Intubation in Patients with Limited Mouth Opening

Incomplete adherence to the ASA difficult airway algorithm is unchanged after a high-fidelity simulation session

Although guidelines for difficult airway management have been published, the extent to which consultant anesthesiologists follow these guidelines has not been determined. The purpose of this study is to observe how consultant anesthesiologists manage a "cannot intubate, cannot ventilate" (CICV) scenario in a high-fidelity simulator and to evaluate whether a simulation teaching session improves their adherence to the American Society of Anesthesiologists (ASA) difficult airway algorithm. With Ethics Board approval and informed consent, all staff anesthesiologists in a single tertiary care institution were invited to enrol in this study where they managed a simulated unanticipated CICV scenario in a high-fidelity simulator. The scenario involved a patient with a difficult airway whose trachea could not be intubated and where it was impossible to ventilate the patient's lungs. Airway management options, including laryngeal mask airway, a fibreoptic bronchoscope, and a Glidescope were available for use but scripted to fail. A percutaneous cricothyroidotomy was required to re-establish adequate ventilation. Following the scenario, there was a personalized one-hour video-assisted expert debriefing focusing on the ASA difficult airway guidelines and "hands-on" cricothyroidotomy teaching. The second scenario followed immediately with an identical CICV scenario. The content to either scenario was not revealed beforehand. Outcome measures included: 1) major deviations from the ASA difficult airway guidelines; 2) time to start cricothyroidotomy; and 3) time to achieve ventilation. Thirty-eight anesthesiologists agreed to participate. The number of major deviations from the ASA algorithm was similar in the first and second sessions. These deviations included: multiple laryngoscopies (0 vs 2 pre-post; P = 0.49), use of fibreoptic bronchoscope (8 vs 7 pre-post; P = 1.0), bypass of laryngeal mask airway attempt (7 vs 13 pre-post; P = 0.19), and failure to call for anesthetic help (12 vs 8 pre-post; P = 0.43). However, more participants failed to call for surgical help in the second session (7 vs 16; P = 0.04). The times to start cricothyroidotomy and the times to achieve ventilation were significantly shorter in the second session (205.5 +/- 61.3 sec vs 179.7 +/- 65.1 sec; P = 0.01 and 356.9 +/- 117.2 sec vs 269.4 +/- 77.43 sec; P = 0.0002, respectively). No substantial changes in airway management in a CICV scenario were observed after an intense one-hour personalized video-assisted airway-focused simulation debriefing session with an expert. It appears that multiple factors other than airway algorithms come into play in emergency airway decision-making processes, including one's personal clinical experience with the many available airway devices.