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ANTICIPATION OF THE DIFFICULT AIRWAY: THE PREOPERATIVE AIRWAY ASSESSMENT FORM AS AN EDUCATIONAL AND QUALITY IMPROVEMENT TOOL Carin Hagberg, M.D. Davide.

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Presentation on theme: "ANTICIPATION OF THE DIFFICULT AIRWAY: THE PREOPERATIVE AIRWAY ASSESSMENT FORM AS AN EDUCATIONAL AND QUALITY IMPROVEMENT TOOL Carin Hagberg, M.D. Davide."— Presentation transcript:

1 ANTICIPATION OF THE DIFFICULT AIRWAY: THE PREOPERATIVE AIRWAY ASSESSMENT FORM AS AN EDUCATIONAL AND QUALITY IMPROVEMENT TOOL Carin Hagberg, M.D. Davide Cattano, M.D., Ph.D. Jon Tyson, M.D. Funding supplied by Research in Education Grant from Foundation of Anesthesia Education and Research (FAER)

2 DIFFICULT AIRWAY MANAGEMENT IS ONE OF THE MOST CHALLENGING TASKS FOR ANESTHESIOLOGISTS There is one skill above all else that an anaesthetist is expected to exhibit and that is to maintain the airway impeccably Ian Latto and Michael Rosen DMV grossly 1 :1000 D- Laryngoscopy 10 : 100 Difficult Intubation 1 : 100 Difficult SGA management ? Difficult Surgical Airway ? Does the Airway Examination Prevent Difficult Intubation ?

3 at a minimum, a preanesthesia physical examination should include (1) an airway exam [100% consultants (72), 100% ASA members (273)]…

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5 APSF SURVEY RESULTS IDENTIFY SAFETY ISSUES PRIORITY: AIRWAY STILL #1 Difficult Airway Management Cost-Saving: Production Pressures Anesthesia Delivery: Remote Sites Anesthesia Delivery: Office-Based Neurologic Deficit Due to Anes Tech Coronary Heart Disease (Pts) Occupational Stress Fatigue Medication Errors Cost-Saving: Time for Pre-op Eval Stoelting RK: APSF Newsletter 1999; 14:6

6 WHY IS THIS STUDY IMPORTANT? Difficult airway management pertains to every anesthesiologist May reduce stress for both the anesthesiologist and patient May reduce stress for both the anesthesiologist and patient May reduce morbidity and mortality May reduce morbidity and mortality May create a universal evaluation system May create a universal evaluation system May increase overall knowledge about airway features May increase overall knowledge about airway features

7 STUDY DESIGN – GOALS Primary Hypothesis Primary Hypothesis Use of a specially designed preoperative airway assessment form by anesthesiology residents will result in more complete documentation of important airway features (as designated by the American Society of Anesthesiologists) compared to use of the current forms

8 STUDY DESIGN – GOALS Secondary Hypotheses : Secondary Hypotheses : New preoperative form will result in greater resident recognition of patients at high risk for difficult airway as judged independently by senior anesthesiology faculty Greater number of awake intubations by residents using the new form Number of multiple intubation attempts and invasive surgical intubation techniques may decrease with residents using the new form Identify and characterize features of Difficult SGD and Surgical Airway Increased spontaneous knowledge of important airway features by 18 months for residents using the new form Observations during the study will help refine the new form

9 STUDY DESIGN – PARTICIPANTS All anesthesiology residents between July June 2010 Locations: MHH LBJ 2 groups Group A Current preoperative assessment Postoperative evaluation Group B Current preoperative assessment New preoperative airway assessment Postoperative evaluation Study faculty will perform independent preoperative airway assessments Dr. Davide Cattano Dr. Carin Hagberg Dr. Sara Guzman

10 STUDY DESIGN – LOGISTICS Preoperative assessments: Specialized attending and resident will be blind to each others assessment Resident should review assessment with their assigned attending Specialized attending will page attending assigned to case when a difficult airway is anticipated Forms must be returned to billing Completeness/accuracy of charting will be assessed

11 CURRENT PRE-OP ASSESSMENT FORMS

12 NEW PREOP AIRWAY ASSESSMENT FORM

13 5 AREAS OF DIFFICULT AIRWAY MANAGEMENT Difficult mask ventilation Difficult supraglottic airway Difficult laryngoscopy Difficult intubation Difficult surgical airway

14 Mask seal (M) BMI > 26 kg/m 2 (O) Age > 55 yrs (A) Lack of teeth (N) History of snoring (S) DIFFICULT MASK VENTILATION PREOPERATIVE RISK FACTORS Langeron O et al: Prediction of Difficult Mask Ventilation. ANESTHESIOLOGY 2000; 92: Condition in which the anesthesiologist cannot provide adequate mask ventilation due to inadequate seal, excessive leak, or resistance to gas flow

15 DIFFICULT SUPRAGLOTTIC AIRWAY Result of poor device placement or inability to adequately ventilate with device successfully placed Restricted mouth opening (R) Obstruction of upper airway (O) Distortion/disruption of airway (D) Stiff lungs (reduced compliance or increased resistance) (S)

16 DIFFICULT LARYNGOSCOPY Inability to visualize any portion of the vocal cords after multiple attempts at conventional laryngoscopy Grade 1Grade 2a Grade 2b Grade 3Grade 4 Yentis & Lee Modification of Cormack & Lehane Classification

17 DIFFICULT LARYNGOSCOPY - LEMON Look Externally (L) Evaluate (E) Mallampati class (M) Obstruction (O) Neck mobility (N)

18 Difficult Intubation A Difficult Laryngoscopy does not automatically predict a Difficult Intubation Difficult Intubations Can Be Skill Related Examples of alternative techniques: 1.FOB- fogging, bleeding 2. I-LMA- mouth opening, tonsils, alignment of axis 3. Glidescope- mouth opening, cannot pass and align the ETT Patients preexisting conditions: Severe tracheal deviation Bleeding disorders Neck abscess Laryngeal and subglottic tumor Etc. Difficult laryngoscopy Requires multiple attempts Easy Laryngoscopy but conditions altering the anatomy of the larynx or the trachea AlternativeTechniques

19 (S) Surgery/disrupted airway (S) (H) Hematoma/infection (H) (O) Obese/access problems (O) (R) Radiation/excessive bleeding (R) (T) Tumors (T) Walls R, Murphy M; National Airway Course, USA

20 PLAN DESCRIPTION Note how you will proceed on the form What type of anesthesia will you administer? Local or general?

21 POSTOPERATIVE EVALUATION

22 MASK VENTILATION Evaluation of mask ventilation

23 SGA DEVICE Evaluation of supraglottic airway device (if used)

24 C-L AND INTUBATION Evaluation of Cormack and Lehane grade on DL Evaluation of Intubation (if performed)

25 SURGICAL EVALUATION Evaluation of surgical airway (if applicable) Evaluation of surgical airway (if applicable)

26 EXTUBATION Evaluate extubation Register difficult airway (if applicable)

27 Errare humanum est perseverare diabolicum Seneca the Younger or Lucius Anneus Seneca (c. 4 BC – AD 65)4 BCAD 65 TO ERR IS HUMAN, TO FORGIVE IS DIVINE Alexander Pope [21 May 1688 – 30 May 1744] english poet21 May May1744


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