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 TOOLCarin 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 Ian Latto and Michael Rosen DIFFICULT AIRWAY MANAGEMENT IS ONE OF THE MOST CHALLENGING TASKS FOR ANESTHESIOLOGISTSDoes the Airway Examination Prevent Difficult Intubation ?DMV grossly 1 :1000D- Laryngoscopy 10 : 100Difficult Intubation 1 : 100Difficult SGA management ?Difficult Surgical Airway ?“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
3 at a minimum, a preanesthesia physical examination should include (1) an airway exam [100% consultants (72), 100% ASA members (273)]…
4 The specific respiratory events are depicted here The specific respiratory events are depicted here. Difficult intubation and inadequate ventilation/oxygenation account are the most prevalent and account for almost half of the damaging events. Esophageal intubation and premature extubation were the next most common. Other respiratory events were endobronchial intubation, bronchospasm, and inadvertent extubation.Anesthesia care was judged by the reviewers to be less than appropriate in 64% of the respiratory-related damages,as compared to 28% in the CV event group. Among the respiratory events, care was most often judged to be less than appropriate in claims for esophageal intubation and premature extubation and inadequate ventilation. The aspiration group had the lowest proportion of claims where the care was judged as less than apporpriate.
5 APSF SURVEY RESULTS IDENTIFY SAFETY ISSUES PRIORITY: AIRWAY STILL #1 Difficult Airway ManagementCost-Saving: Production PressuresAnesthesia Delivery: Remote SitesAnesthesia Delivery: Office-BasedNeurologic Deficit Due to Anes TechCoronary Heart Disease (Pts)Occupational StressFatigueMedication ErrorsCost-Saving: Time for Pre-op EvalIn late 1998, the Executive committee of the Anesthesia Patient Safety Foundation conducted a survey designed to identify the most important anesthesia patient safety issues as perceived by practicing anesthesiologists. The survey was administered by mail to 1660 members of the ASA. It was also available at the APSF Booth at the 1998 ASA annual meeting. The top 10 safety issues are shown here and as you can see, DAM was the highest, being marked as high priority by 72% of the 801 respondents. NO WONDER YOU ARE SITTING IN THIS AUDIENCE!!!!Of course, if you are working in a free standing sugery centerr and concerned about production and your patient has CAD, you are really going to be stressed.In late 1998, the Executive Committee of the Anesthesia Patient Safety Foundation (APSF) conducted a survey designed to identify the most important anesthesia patient safety issues as perceived by practicing anesthesiologists. The survey was initially administered by mail to 1660 members of the ASA and it was also available for on-site completion to visitors at the APSF/ASA Patient Safety Booth at the ASA Annual Meeting in Oct, 1998.The 10 most important anesthesia patient safety issues as determined by a “High Priority” ranked by 801 anesthesiologist respondents rated Difficult Airway Management as the most important patient safety issue being ranked by 72%. NO WONDER YOU ARE ALL HERE IN THIS ROOM, HEARING THIS LECTURE.Stoelting RK: APSF Newsletter 1999; 14:6
6 WHY IS THIS STUDY IMPORTANT? Difficult airway management pertains to every anesthesiologistMay reduce stress for both the anesthesiologist and patientMay reduce morbidity and mortalityMay create a universal evaluation systemMay increase overall knowledge about airway features
7 STUDY DESIGN – GOALS 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: New preoperative form will result in greater resident recognition of patients at high risk for difficult airway as judged independently by senior anesthesiology facultyGreater number of awake intubations by residents using the new formNumber of multiple intubation attempts and invasive surgical intubation techniques may decrease with residents using the new formIdentify and characterize features of Difficult SGD and Surgical AirwayIncreased spontaneous knowledge of important airway features by 18 months for residents using the new formObservations during the study will help refine the new form
9 STUDY DESIGN – PARTICIPANTS All anesthesiology residents between July June 2010Locations:MHHLBJ2 groupsGroup ACurrent preoperative assessmentPostoperative evaluationGroup BNew preoperative airway assessmentStudy faculty will perform independent preoperative airway assessmentsDr. Davide CattanoDr. Carin HagbergDr. Sara Guzman
10 STUDY DESIGN – LOGISTICS Preoperative assessments:Specialized attending and resident will be blind to each other’s assessmentResident should review assessment with their assigned attendingSpecialized attending will page attending assigned to case when a difficult airway is anticipatedForms must be returned to billingCompleteness/accuracy of charting will be assessed
13 5 AREAS OF DIFFICULT AIRWAY MANAGEMENT Difficult mask ventilationDifficult supraglottic airwayDifficult laryngoscopyDifficult intubationDifficult surgical airway
14 DIFFICULT MASK VENTILATION PREOPERATIVE RISK FACTORS Condition in which the anesthesiologist cannot provide adequate mask ventilation due to inadequate seal, excessive leak, or resistance to gas flowMask seal (M)BMI > 26 kg/m2 (O)Age > 55 yrs (A)Lack of teeth (N)History of snoring (S)MOANSMask seal (beard/moustache) Can use lube or request the patient to shave. Nothing against men with beard or moustache’s, as my husband has them, but sometimes facial hair can hide anatomical abnormalities and you might uncover a DA. Rather than simply remove dentures in the DSU, you could have the patient’s leave them in until you have finished MV, yet remove them prior to intubation. Can’t do much about a patient’s age and weight or whether they wake their spouse up with snoring, but you can get an adequate preop assessment of whether or not they have OSA and what special precautions you need to perform.Langeron O et al: Prediction of Difficult Mask Ventilation. ANESTHESIOLOGY 2000; 92:
15 DIFFICULT SUPRAGLOTTIC AIRWAY Result of poor device placement or inability to adequately ventilate with device successfully placedRestricted mouth opening (R)Obstruction of upper airway (O)Distortion/disruption of airway (D)Stiff lungs (reduced compliance or increased resistance) (S)"RODS"
16 DIFFICULT LARYNGOSCOPY Inability to visualize any portion of the vocal cords after multiple attempts at conventional laryngoscopyGrade 1Grade 2aGrade 2bGrade 3Grade 4Yentis & Lee Modification of Cormack & Lehane Classification
17 DIFFICULT LARYNGOSCOPY - LEMON Look Externally (L)Evaluate (E)Mallampati class (M)Obstruction (O)Neck mobility (N)"LEMON"3. Mouth opening2. Mental to hyoid3. Hyoid to thyroid
18 Patients’ preexisting conditions: Difficult IntubationA Difficult Laryngoscopy does not automatically predict a Difficult IntubationEasy Laryngoscopy but conditions altering the anatomy of the larynx or the tracheaDifficult laryngoscopy Requires multiple attemptsAlternativeTechniquesDifficult Intubations Can Be Skill RelatedExamples of alternative techniques:1.FOB- fogging, bleeding2. I-LMA- mouth opening, tonsils, alignment of axis3. Glidescope- mouth opening, cannot pass and align the ETTPatients’ preexisting conditions:Severe tracheal deviationBleeding disordersNeck abscessLaryngeal and subglottic tumorEtc.
19 DIFFICULT SURGICAL AIRWAY SHORTSurgery/disrupted airway (S)Hematoma/infection (H)Obese/access problems (O)Radiation/excessive bleeding (R)Tumors (T)Mask seal (beard/moustache) Can use lube or request the patient to shave. Nothing against men with beard or moustache’s, as my husband has them, but sometimes facial hair can hide anatomical abnormalities and you might uncover a DA. Rather than simply remove dentures in the DSU, you could have the patient’s leave them in until you have finished MV, yet remove them prior to intubation. Can’t do much about a patient’s age and weight or whether they wake their spouse up with snoring, but you can get an adequate preop assessment of whether or not they have OSA and what special precautions you need to perform.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?