CEDIVA Dénia, Training Center in Difficult Airway Management

Anesthesia and ICU DepartmentHospital de Dénia

Francisca Llobell, Daniel Paz,Inés Carpi, Remedios Pérez, Isabel Estruch,Maria Serna, Jose Luis Dieguez, Juan Cardona.

Annual Meeting14th Annual Society for Airway Management Scientific Meeting

Prospectively evaluate the effectiveness of a simple manikin practice in teaching the technique flexible fiberscope to anesthesia trainees during anesthesia residency .

OBJETIVE

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In the workshop Cediva have a training program fibreoptic intubation during anesthesia residency that includes a number of methods of initiation into the use of the device on mannequins before fibreoptic oro/nasotracheal intubations in the operating room. The first method must practice the trainee is PRACTICE CLOCK (SEE FIG 1).

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Address to the central point . Try vertical movement following the numerical sequences. Repeat every one 10 times.(figure 2)

* 12 * 6

* 6 * 12

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Vertical movement of the tip of the fiberscope following the numerical sequence (fig 3)Repeat this sequence four times.

* 12 * 12 * 12 * 12 *

* 6

* 12 * 6 * 12 * 6 *

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Horizontal motion of the tip of the fiberscope following the numerical sequence (Fig. 4) Repeat this sequence four times.

* 9

* 3

* 9 * 3 * 9 * 3 *

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* 12 9 6 9 12 *

* 12 3 6 3 12 *

Rotational movement of the tip of the fiberscope in the sequence number (fig 5) Repeat the sequence four times.

Combined drawing a Z Movement; further sequence of letters ABCDmaneuver repeated four times.(Figure 6)

* A B C D C B A *

* B A D C D A B *

Figure 6

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With this method, assisted, the resident acquires the ability to direct manual fiberscope tip oriented in three dimensions and must be the practice of initiation in the advanced management of difficult airway requires the use of flexible fiberoptic device that demonstrated that solves 100% of cases of patients with difficult airway.

CLOCK PRACTICE

CEDIVA DENIA | Training Center in Difficult AirwayAnesthesia and ICU Department. Dénia Hospital 2010

Annual events and References

CEDIVA DENIA | Training Center in Difficult Airway Management

Annual Meetings in Dénia Hospital

CEDIVA DENIA | Training Center in Difficult Airway Management.

American Society of Anesthesiologist (ASA)

Annual Meeting

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CEDIVA DENIA | Training Center of Dificult Airway Management

Llobell F,Madrid V et al.

The Difficult Airway Extubation Table: A buffet of Airway Devices and Management Strategies. ASA 2006; A17:pp437.

American Society of Anesthesiologist. Annual Meeting , Chicago-Illinois 2006

CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA

CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREAASA 2007

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Extubating the difficult airway: A protocol for timing and not burning bridgesFrancisca Llobell, M.D.1, Patricia Marzal, M.D.1, Luis Gonzalez, M.D.1, Lauren K. Hoke, B.S.2, Yvon F. Bryan, M.D.2

1. Hospital G. U. Marina Alta, Denia (Alicante), Spain 2. Wake Forest University Baptist Medical Center, Winston-Salem, NC

Introduction Results

Abstract

Discussion

Title: Extubating the difficult airway: A protocol for timing and not burning bridges

Francisca Llobell, M.D., Patricia Marzal, M.D., Luis Gonzalez, M.D., Lauren K Hoke, B.S. and Yvon F Bryan, M.D.. Department of Anesthesiology, Hospital G.U. Marina Alta, Denia, Alicante, Spain.

Introduction

Different airway devices may be used to facilitate extubating patients with difficult airways (1, 2). The timing and devices needed to bridge the extubation, however, depend on the patients condition and risk. The possibility of aspiration, experiencing potential difficulty with oxygenation and ventilation and the need for re-intubation are problems frequently encountered. A protocol for extubation must take into account these problems and combine them with the timing of extubation and the availability of the necessary airway devices needed to bridge. We present our experience using a protocol for extubating patients with difficult airways.

Methods

The protocol for extubating patients with difficult airways combined the timing (immediate versus delayed) of extubation with the availability of the necessary airway devices required for bridging (see Figure 1). A table of airway devices set up according to their function was used for the patients (3).

Results

No complications occurred in any patients in which the protocol was used (see Table 1).

Discussion

The extubation protocol provided a strategy for timing the extubation with the necessary airway devices needed to bridge the extubation. The protocol was designed to take into account the risks associated with the patients underlying condition and/or surgical intervention with the airway device best suited for the patient. By allowing for versatility, the protocol facilitated reassessing the patients need to remain intubated, to bridge or to delay the extubation. Further studies are needed in the management of patients with difficult airways during extubation.

References

1) Anesth Analg 2007; 105:1357-1362.

2) Anesth. Analg. 2007; 105: 11821185.

3) Llobell F, et al. Euroanaesthesia 2008 Annual Meeting.

Methods

•Timing extubation in patients with difficult airways (DA’s) is critical

•Device choice for delaying or bridging extubation depends on urgency and potential problems encountered after extubation

•We present our initial experience with a protocol used for extubating patients with DA’s

•Protocol combines timing of extubation with availability of necessary devices

•Protocol provided strategy for timing extubation with the availability of devices needed to bridge

•Protocol allowed for versatility in managing various patient conditions

•Further research required in establishing extubation protocols for DA’s

ASA 2008

CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREAASA 2008

Managing the difficult airway at extubation: Vices or devicesFrancisca Llobell, M.D.1, Patricia Marzal, M.D.1, Maria Serna, M.D.1, Lauren K. Hoke, B.S.2, Yvon F. Bryan, M.D.2

1.Hospital G. U. Marina Alta, Denia (Alicante), Spain 2. Wake Forest University Baptist Medical Center, Winston-Salem, NC

Introduction

Results

Abstract

Discussion

Title: Managing the difficult airway at extubation: Vices or devices

Francisca Llobell, M.D., Patricia Marzal, M.D., Maria Serna, M.D., Lauren K Hoke, B.S. and Yvon F Bryan, M.D.. Department of Anesthesiology, Hospital G.U. Marina Alta, Denia, Alicante, Spain.

Introduction

Problems encountered during extubation of patients with difficult airways are prevalent though formal guidelines seem to be lacking (1). This dichotomy of problems occurring at extubation and a lack of specific strategies may be due to anesthesiologist experience and/or training with specialized airway devices required during the management of the difficult airway (2). Certain airway devices may be best suited for rescue (oxygenation and ventilation) while others are better used to bridge (reintubation) and to delay the extubation. We surveyed Spanish anesthesiologists about their clinical practice management for the extubation of patients with difficult airways.

Methods

A survey was sent to the anesthesiology departments of 38 hospitals in the provinces of the Comunidad Valenciana (Castellon, Valencia, Alicante) and cities in the Comunidad Murciana (Murcia, Orihuela) of Spain. The survey consisted of 10 questions pertaining to the clinical management at extubation of patients with difficult airways (see Table 1). The surveys were completed anonymously and returned via self-return envelope to Hospital G.U. Marina Alta in Denia (Alicante), Spain.

Results

A total of 10 out of 38 anesthesiology departments completed and returned the survey (as of March 1, 2008) totaling 120 anesthesiologists. Problems at extubation were reported by 95% of respondents with only 12% having a formal extubation protocol. 34% reported experiencing difficulty with reintubation and 23% reported patients requiring surgical access for airway support. 7% reported a patient death or a severe brain injury as a consequence of problems occurring at extubation. Of the airway devices used to rescue, 76% were supralaryngeal devices (LMA, ILMA, Proseal LMA). To bridge the extubation, supralaryngeal devices and airway exchange catheters were used 53% and 16% of the time, respectively. See Table 2.

Discussion

Our survey found a very high incidence of problems occurring at extubation in patients with difficult airways. A lack of established extubation protocols and training with specialized airway devices may be the reason for the problems. The devices used to rescue and bridge the extubation by the majority of respondents were supralaryngeal in nature. This may have reflected the individuals training with these devices, the unavailability of certain devices or not being familiar with other types of devices (ie, airway exchange catheters). Further research is required in the management of the difficult airway to discern which devices are best suited for rescuing and/or bridging during extubation.

References

1) Anesthesiology 2005:103(1);33-9.

2) Anesthesiology 2007:100;A934

Methods

Table 1: Extubation survey questions•Devices used during intubation may not be successful during extubation and/ or re-intubation

•Timing of extubation depends on patient condition and practioner experience

•We present the experience of anesthesiologists during extubation of patients with DA’s in a region of Spain

•Survey consisted of 10 questions regarding management of DA during extubation

•Surveyed 38 anesthesiology departments in the regions of Valenciana and Murciana in Spain

Methods

•Our survey found a high incidence of problems occuring at extubation

•Anesthesiologist experience and familiarity with different airway devices may have influenced choice of device

•Further research is required in developing protocols for use during extubation in patients with DA’s

IARS - International Anesthesia Research

SocietyIARS Annual Meeting

USA

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IARS 2007, San Francisco USA

The new VAMA® intubating airway: a unique design for fiberoptic intubation

Patricia Marzal, M.D.1, , Juan Cardona, M.D.1, Andres Madrid1, Valentin Madrid, M.D.1, Yvon F. Bryan, M.D.2*

1.Hospital G. U. Marina Alta, Denia (Alicante), Spain 2. Cincinnati Children’s Hospital Medical Center, Cincinnati,OH

Introduction Methods

Abstract

Discussion

Results

Title: The new VAMA® intubating airway: a unique design for fiberoptic intubation

Authors: Marzal Patricia, Llobell Francisca, Cardona Juan, Madrid Andres, Madrid Valentin, Bryan Yvon

IntroductionSeveral available intubating airways facilitate performing fiberoptic intubation and placing an endotracheal tube (1,2). The new VAMA intubating airway incorporates design features which address common problems encountered during fiberoptic intubation. A line with an arrow (lasermark) embedded on the distal part of the ventral surface of the posterior portion of the airway facilitates orientation (see Figure 1). A detachable piece on the proximal portion of the airway facilitates removing the VAMA airway while the endotracheal tube (ETT) remains connected to the circuit; thus avoiding interruption in ventilation and inadvertent extubation. We describe our experience with the VAMA® intubating airway for fiberoptic intubation.

MethodsAfter obtaining verbal consent, 19 patients undergoing surgery and requiring endotracheal (ETT) intubation were recruited. After general anesthesia or sedation and topical anesthesia, a 5.5 mm flexible fiberscope was loaded with an ETT and placed orally via the VAMA® airway. Using lasermark on the VAMA® for guidance, the FFB was inserted until the glottic opening was visible. After advancing the FFB through the vocal chords, the ETT was railroaded into the trachea and the position was confirmed. The detachable piece of the VAMA® was first removed and while holding the ETT, the remaining part of the VAMA® airway was removed without disconnecting the ETT from circuit.

Results

The mean and range of age and time to intubation were 57.5 years (31-86) and 42 seconds (25-70). In 13 patients, the glottic opening was visualized on first pass of the FFB placed in the VAMA® airway. In 6 patients, a chin lift exposed the glottic opening. All intubations occurred on first attempt, except one which required three attempts. Five patients had known difficult airways (DA), 7 intubations were awake and in 7 patients, paralytic agents were used. DiscussionThe lasermark of the VAMA® airway helps identify the anatomical landmarks necessary for fiberoptic intubation. Disconnecting the removable piece facilitates complete removal of the VAMA® airway. Further research is required comparing to other intubating airways in patients with known DA’s who are both awake and anesthetized.

References1) J Clin Anesth 2004 16:66-73.2) Anaesth 2004 59: 173–176.3) VAMA Canula Package Insert www.ajlsa.com

Methods

•Valentin Andres Madrid Airway (VAMA) is a new intubating airway

•New design features of VAMA facilitate FFB intubation

•We present our initial experience using VAMA airway

*Wake Forest University Baptist Medical Center

•19 patients underwent FFB using VAMA

•Awake/sedation with topical anesthesia or general anesthesia

•Lasermark of VAMA facilitates orientation

•Detachable piece facilitates removal of VAMA airway while ETT remains connected

•Removal of VAMA does not interrupt ventilation or risk inadvertent extubation

•Age (mean and range) = 57.5 years (31-86) •Time to intubation (mean,range) = 42 seconds (25-70) •Visualization of glottic opening on initial FFB introduction = 13/19 (68%) patients•Chin lift required for exposure of glottic opening = 6/19 (32%) patients•Intubations on first attempt (one patient required 3 attempts) = 18/19 (95%) patients•5 patients with known difficult airways•7 intubations performed awake/sedation, 7 intubations using paralytics

•Lasermark on VAMA allowed clinician to orient FFB

•Detachable piece of airway facilitated removal of VAMA without accidental ETT removal

•Further research required using VAMA in patients with difficult airways

A. B.

C. D.

European Society of Anesthesia

Euroanesthesia

Aquí se escribe el texto

F.Llobell, P.Marzal; M.Echeverri, L.Hoke, Y.Bryan . Strategy for extubation of the difficult airway: A protocol and table of airway devices. Eur J Anaesthesiol 2008; 25 (Suppl 44): 19AP6-8.

SEDAR Sociedad Española de Anestesia y Reanimación

Annual Meeting 2009

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M. B. Serna; F. Tarín; R. Pérez; F. Llobell. Hospital de Denia

El manejo de la vía aérea difícil conocida exige elaborar un plan para minimizar el riesgo de hipoxia aguda ante una demora en la intubación siguiendo la estrategia establecida según los algoritmos de referencia (Anesthesiology 2003).

CASO CLÍNICO• Mujer, 43 años.• Obesidad, DMNID. Varios episodios de crisis tónico-clónicas por Encefalitis de

Hashimoto.• Nuevo episodio refractario a tratamiento médico (Fenitoína y Diazepam i.v.).

• VENTILACIÓN DIFÍCIL - IMC 34,6 kg/m2• INTUBACIÓN DIFÍCIL – Historia de VAD anticipada, cuello corto y grueso, retracción

mandibular, macroglosia• COOPERACIÓN - NO, dada la situación clínica• TRAQUEOSTOMÍA DIFÍCIL - SI

MANEJO

* La ASA recomienda valorar:

SEDOANALGESIA CONTROL DE LA VÍA AÉREA

INTUBACIÓN ENDOTRAQUEAL

VÍA AÉREA DIFÍCILVÍA AÉREA DIFÍCIL

ESTRATEGIA* Considerar ventajas y desventajas de:

INTUBACIÓN DESPIERTO

TÉCNICA NO INVASIVA

MANTENIMIENTO DE LA VENTILACIÓN ESPONTÁNEA

INTUBACIÓN TRAS INDUCCIÓN

TÉCNICA INVASIVA

SUPRESIÓN DE LA VENTILACIÓN ESPONTÁNEA

ESTRATEGIA PRIMARIA

ESTRATEGIA SECUNDARIA

ALGORITMO 1 ASAFIBROBRONCOSCOPIO FLEXIBLE VÍA NASAL

CEDIVA DENIA |Formación Continuada en Vía AéreaServicio de Anestesiología y Cuidados Críticos del Hospital de Dénia

MASCARILLA LARÍNGEA CON CANAL DE DRENAJE GÁSTRICO:• Supreme®, Proseal®

Limitaciones en el paciente crítico vs. urgencia.

MATERIAL NECESARIO

Cánula nasal Rüsch nº26 TET reforzado nº7

Oximetazolina Spray

Lidocaína MAD Mucosal Atomization Device

MADgic Laryngo-Tracheal Mucosal Atomization Device

CONCLUSIÓN

DESCRIPCIÓN DE LA TÉCNICA

Instilación de Oximetazolina para evitar hemorragias. Atomización de Lidocaína 3% mediante MAD® de fosa nasal. Atomización de Lidocaína al 4% mediante MADgic® de cuerdas vocales.

Introducir cánula de Rusch a través del orificio nasal elegido. Introducir el TET reforzado y lubricado a través de la nariz.

Progresar a través del TET el fibrobroncoscopio hasta visualizar las cuerdas vocales. Una vez abiertas llegaremos hasta carina. Deslizar el tubo aplicando giro antihorario para facilitar su inserción.

LA TÉCNICA DE INTUBACIÓN CON FIBROSCOPIA CONSCIENTE ES APLICABLE EN SITUACIÓN DE URGENCIA SI EL ESCENARIO LO PERMITE Y EL PACIENTE LO REQUIERE.

Bibliografía:•ASA 2002 Practice Guidelines for Management of the Difficult Airway.•Engel TP, Applegate RL, Chung DM, Sanchez A. Management of the difficult airway. Gasnet, 2001.

CEDIVA DENIA | Training Center in Difficult Airway. Dénia Hospital

1. Llobell F, Madrid V, Taghon TA, Bryan Y. The Difficult Airway Extubation Table: A buffet of Airway Devices and Management Strategies. En: ASA Annual Meeting 2006; pp 437.

2. Romagosa H, Charco P, Llobell F, Madrid V, Garrido P. Prevención del edema laríngeo postextubación. Estrategias para una extubación segura. Rev Esp Anestesiol Reanim 2005; 52:202-3.

3. Llobell F, Marzal P, Bryan y, Charco P, Martinez-Pons V, Madrid V. Complicaciones tras la Extubación: Dimensionando el problema. 13 Congreso Hispano-Luso de Anestesiología. Valencia, Abril 2007.

4. Llobell F. Estrategia para el intercambio de un TET. Algoritmo de Extubación. XXVII Congreso de la SEDAR.Resúmenes de Ponencias. 2005;pp 71-3.

5. Llobell F, Madrid V, Marzal P, Hoke Lauren K, Bryan Y. Airway Management Strategies of Difficult Airways at Extubation: Despite Risk Much Left to Chance. En: ASA Annual Meeting 2007; A934.

6. F.Llobell, P.Marzal; M.Echeverri, L.Hoke, Y.Bryan . Strategy for extubation of the difficult airway: A protocol and table of airway devices. Eur J Anaesthesiol 2008; 25 (Suppl 44): 19AP6-8.

7. F.Llobell, P. Marzal, M. Serna, L. Hoke, Y Bryan. Managing the Difficult Airway at Extubation: Vices or Devices. A1725 ASA 2008.

8. F.Llobell, P. Marzal, L.Gonzalez, L. Hoke, Y Bryan. Extubating the Difficult Airway: A protocol for Timing and not Burning Bridges. A1729 ASA 2008. 

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Anesthesia and ICU DepartmentDénia Hospital

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