Summary
Across multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These ...events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co‐ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. The detection of ‘sustained exhaled carbon dioxide’ using waveform capnography is the mainstay for excluding oesophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected. If default tube removal is considered dangerous, urgent exclusion of oesophageal intubation using valid alternative techniques is indicated, in parallel with evaluation of other causes of inability to detect carbon dioxide. The tube should be removed if timely restoration of sustained exhaled carbon dioxide cannot be achieved. In addition to technical interventions, strategies are required to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.
Summary
Multiple professional groups and societies worldwide have produced airway management guidelines. These are typically targeted at the process of tracheal intubation by a particular provider ...group in a restricted category of patients and reflect practice preferences in a particular geographical region. The existence of multiple distinct guidelines for some (but not other) closely related circumstances, increases complexity and may obscure the underlying principles that are common to all of them. This has the potential to increase cognitive load; promote the grouping of ideas in silos; impair teamwork; and ultimately compromise patient care. Development of a single set of airway management guidelines that can be applied across and beyond these domains may improve implementation; promote standardisation; and facilitate collaboration between airway practitioners from diverse backgrounds. A global multidisciplinary group of both airway operators and assistants was assembled. Over a 3‐year period, a review of the existing airway guidelines and multiple reviews of the primary literature were combined with a structured process for determining expert consensus. Any discrepancies between these were analysed and reconciled. Where evidence in the literature was lacking, recommendations were made by expert consensus. Using the above process, a set of evidence‐based airway management guidelines was developed in consultation with airway practitioners from a broad spectrum of disciplines and geographical locations. While consistent with the recommendations of the existing English language guidelines, these universal guidelines also incorporate the most recent concepts in airway management as well as statements on areas not widely addressed by the existing guidelines. The recommendations will be published in four parts that respectively address: airway evaluation; airway strategy; airway rescue and communication of airway outcomes. Together, these universal guidelines will provide a single, comprehensive approach to airway management that can be consistently applied by airway practitioners globally, independent of their clinical background or the circumstances in which airway management occurs.
Out-of-hospital airway management is a critical skill, demanding expert knowledge and experience. The intubating laryngeal mask airway (ILMA) is a ventilatory and intubating device which may be of ...value in this arena. We evaluated the ILMA for out-of-hospital management of the difficult airway.
Twenty-one anaesthesia-trained emergency physicians (EPs) completed a training programme and used the ILMA in patients with difficult-to-manage airways. Indications for use of the ILMA included patients with difficult laryngoscopy, multiple intubation attempts, limited access to the patient’s head, presence of pharyngo-laryngeal trauma, and gastric fluids or bleeding obscuring the view of the vocal cords.
During the study period, 146 of 2513 patients underwent tracheal intubation or alternate rescue airway insertion. In 135 patients, laryngoscopy was performed and Cormack–Lehane view was recorded as grade I in 72 (53.3%), II in 45 (33.3%), III in 10 (7.4%), and IV in 8 (5.9%). EPs encountered 11 patients (7.5%) with difficult-to-manage airways. ILMA insertion and ventilation was possible in 10 patients in the first and one patient in the second attempt. ILMA-guided tracheal intubation was successful in all patients, in 10 after the first and in 1 after two attempts.
In this study, ventilation and intubation with ILMA was successful in all patients with difficult-to-manage airways. Our data support the use of the ILMA as rescue device for out-of-hospital airway management by staff who have appropriate airway skills and have received appropriate training.
We report six patients with unexpected difficult airways who underwent tracheal intubation using the Laryngeal Mask Airway CTrach. All these patients had failed orotracheal intubation using direct ...laryngoscopy and gum elastic bougie placement. Fibreoptic bronchoscopy failed in two of these patients due to blood and secretions in the airway. This report describes the successful use of this new intubating laryngeal mask in these cases, all of whom were intubated on the first attempt with this new device.
Despite the availability of several techniques and devices for the management of the difficult airway, little information has been published regarding the prevalence of their use by anesthesiologists ...in the United States. To determine current practice patterns, we surveyed clinicians using a questionnaire consisting of 14 difficult airway scenarios. Anesthesiologists were requested to indicate their likely approach to anesthetic induction (e.g., awake but sedated, general anesthesia with spontaneous ventilation, general anesthesia with apnea after assuring a patent airway, or general anesthesia with apnea) and the primary device they would use to intubate (e.g., direct laryngoscopy DL, flexible fiberoptic bronchoscope FOB, rigid fiberoptic device, surgical airway, retrograde intubation kit, laryngeal mask airway, gum elastic bougie, or Combitube). The availability of these devices was also determined (in room at all times, available "stat," available if arranged preoperatively, or not available). The survey was mailed to 1000 randomly chosen active members of the American Society of Anesthesiologists. Second and third surveys were mailed to non responders. Four hundred seventy-two completed surveys were returned. Responses by demographic groups were compared by using chi 2 analysis. DL and FOB-aided tracheal intubation techniques were chosen for most cases by most anesthesiologists (P < 0.05). Anesthesiologists with > 10 yr of clinical experience and those older than 55 yr of age preferred DL with apneic conditions (P < 0.05). Anesthesiologists who had attended workshops within the last 5 yr had greater availability of retrograde guidewire equipment and FOBs (P < 0.05). There was little use of newer alternative airway devices.
Although the teaching of alternative methods of securing a difficult airway has become ubiquitous, most anesthesiologists rely on direct laryngoscopy and fiberoptic-aided intubation in most clinical circumstances. Although workshops in the management of the difficult airway may have resulted in increased use of the fiberoptic bronchoscope and the availability of retrograde guidewire intubation equipment, other devices have not enjoyed such an increase.
Summary
We report two patients with difficult airways who underwent tracheal intubation using the new fibreoptic intubating Laryngeal Mask Airway CTrach™. The imaging technology of the LMA‐CTrach was ...decisive in the management of these two patients. The first patient had lingual tonsillar hyperplasia, and an omega‐shaped retroflexed epiglottis. The second patient had a C2‐occipital fusion and was completely unable to extend her head. Given the anatomical difficulties encountered, it was likely that intubation would have been difficult or impossible through the LMA‐Fastrach™. The aim of this report is to describe the successful use of this new intubating laryngeal mask airway in these two challenging patients.
The intubating laryngeal mask airway (ILM) was introduced in 1997 as a modification of the classic laryngeal mask airway. In addition to serving as an elective or emergency ventilating device, it is ...designed to allow blind intubation. We report 3 cases of airway management in the emergency department of Yale–New Haven Hospital where the ILM was used to establish ventilation and intubation in patients in whom direct laryngoscopy had failed. The 3 cases are representative of situations commonly seen in the ED: the obtunded and apneic (“crash airway”) patient, failed rapid sequence intubation, and the recognized difficult airway/awake intubation. In all 3 cases, a clear airway was established on initial placement of the ILM, and intubation was achieved on the first attempt at blind advancement of the endotracheal tube. Although the ILM may be an important addition to the armamentarium of the emergency physician, proficiency in its use requires practice under controlled conditions. We suggest that the emergency physician seek out elective practice in either a teaching workshop or hospital operating theater.
Rosenblatt WH, Murphy M: The intubating laryngeal mask: Use of a new ventilating-intubating device in the emergency department.
Ann Emerg Med February 1999;33:234-238.
Context. The closest ever fly-by of the Martian moon Phobos, performed by the European Space Agency’s Mars Express spacecraft, gives a unique opportunity to sharpen and test the Planetary Radio ...Interferometry and Doppler Experiments (PRIDE) technique in the interest of studying planet–satellite systems. Aims. The aim of this work is to demonstrate a technique of providing high precision positional and Doppler measurements of planetary spacecraft using the Mars Express spacecraft. The technique will be used in the framework of Planetary Radio Interferometry and Doppler Experiments in various planetary missions, in particular in fly-by mode. Methods. We advanced a novel approach to spacecraft data processing using the techniques of Doppler and phase-referenced very long baseline interferometry spacecraft tracking. Results. We achieved, on average, mHz precision (30 μm/s at a 10 s integration time) for radial three-way Doppler estimates and sub-nanoradian precision for lateral position measurements, which in a linear measure (at a distance of 1.4 AU) corresponds to ~50 m.
Two adult brothers, one documented to have methylmalonic acidemia with homocystinuria, or cobalamin C deficiency, after autopsy, displayed severe but divergent neurological presentations. One ...exhibited a myelopathy and the other chronic endocrine problems (Schmidt's syndrome) followed by a neuropsychiatric and dementing disorder owing to cerebral perivascular demyelination. The recognition of cobalamin C deficiency has practical implications because it is one of the few inherited diseases of central white matter that is treatable. Ann Neurol 2001;49:396–400
To define sociodemographic characteristics, medical factors, knowledge, attitudes, and health-related behaviors that distinguish women with established diabetes who seek pre-conception care from ...those who seek care only after conception. A multicenter, case-control study of women with established diabetes making their first pre-conception visit (n = 57) or first prenatal visit without having received pre-conception care (n = 97). Pre-conception subjects were significantly more likely to be married (93 vs. 51%), living with their partners (93 vs. 60%), and employed (78 vs. 41%); to have higher levels of education (73% beyond high school vs. 41%) and income (86% > $20,000 vs. 60%); and to have insulin-dependent diabetes mellitus (IDDM) (93 vs. 81%). Pre-conception subjects with IDDM were more likely to have discussed pre-conception care with their health care providers (98 vs. 51%) and to have been encouraged to get it (77 vs. 43%). In the prenatal group, only 24% of pregnancies were planned. Pre-conception patients were more knowledgeable about diabetes, perceived greater benefits of pre-conception care, and received more instrumental support. Only about one-third of women with established diabetes receive pre-conception care. Interventions must address prevention of unintended pregnancy. Providers must regard every visit with a diabetic woman as a pre-conception visit. Contraception must be explicitly discussed, and pregnancies should be planned. In counseling, the benefits of pre-conception care should be stressed and the support of families and friends should be elicited.
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