The Difficult Airway in Patients with Cancer.

PURPOSE OF REVIEW: The goal of this review is to provide an overview of difficult airway management in the cancer population. RECENT FINDINGS: Difficult airways can be unanticipated; however, several anatomical and physiological features may predict difficult airway management, with several specific for the cancer patient population. New technologies and techniques for airway management, including non-invasive oxygenation, and even the utilization of ECMO, have led to better outcomes and decreased morbidity. Furthermore, the incorporation of multidisciplinary airway teams has helped reduce morbidity associated with predicted and known difficult airways. Cancer patients may exhibit or develop anatomic and physiologic features that may predispose them to difficulty with airway management. As our technologies for airway management continue to advance, as well as further commitment to more interdisciplinary collaboration, difficult airway management in the cancer population will continue to become safer.

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study.

PURPOSE: Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA). METHODS: An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements. RESULTS: The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care. CONCLUSION: Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

Methods and evaluation metrics for reducing material waste in the operating room: a scoping review.

BACKGROUND: Operating rooms contribute up to 70% of total hospital waste. Although multiple studies have demonstrated reduced waste through targeted interventions, few examine processes. This scoping review highlights methods of study design, outcome assessment, and sustainability practices of operating room waste reduction strategies employed by surgeons. METHODS: Embase, PubMed, and Web of Science were screened for operating room-specific waste-reduction interventions. Waste was defined as hazardous and non-hazardous disposable material and energy consumption. Study-specific elements were tabulated by study design, evaluation metrics, strengths, limitations, and barriers to implementation in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. RESULTS: A total of 38 articles were analyzed. Among them, 74% of studies had pre- versus postintervention designs, and 21% used quality improvement instruments. No studies used an implementation framework. The vast majority (92%) of studies measured cost as an outcome, whereas others included disposable waste by weight, hospital energy consumption, and stakeholder perspectives. The most common intervention was instrument tray optimization. Common barriers to implementation included lack of stakeholder buy-in, knowledge gaps, data capture, additional staff time, need for hospital or federal policies, and funding. Intervention sustainability was discussed in few studies (23%) and included regular waste audits, hospital policy change, and educational initiatives. Common methodologic limitations included limited outcome evaluation, narrow scope of intervention, and inability to capture indirect costs. CONCLUSION: Appraisal of quality improvement and implementation methods are critical for developing sustainable interventions for reducing operating room waste. Universal evaluation metrics and methodologies may aid in both quantifying the impact of waste reduction initiatives and understanding their implementation in clinical practice.

Pro-Con Debate: Videolaryngoscopy Should Be Standard of Care for Tracheal Intubation.

In this Pro-Con commentary article, we discuss whether videolaryngoscopy (VL) should be the standard of care for tracheal intubation. Dr Aziz makes the case that VL should be the standard of care, while Dr Berkow follows with a challenge of that assertion. In this debate, we explore not only the various benefits of VL, but also its limitations. There is compelling evidence that VL improves first-pass success rates, reduces the risk of intubation failure and esophageal intubation, and has benefits in the difficult airway patient. But VL is not without complications and does not possess a 100% success rate. In the case of failure, it is important to have back-up plans for airway management. While transition of care from direct laryngoscopy (DL) to VL may result in improved airway management outcomes, the reliance on VL may degrade other important clinical skills when they are needed most. If VL is adapted as the standard of care, airway managers may no longer practice and retain competency in other airway techniques that may be required in the event of VL failure. While cost is a barrier to broad implementation of VL, those costs are normalizing. However, it may still be challenging for institutions to secure purchase of VL for every intubating location, as well as back-up airway devices. As airway management care increasingly transitions from DL to VL, providers should be aware of the benefits and risks to this practice change.

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.

Multidisciplinary Difficult Airway Course: An Essential Educational Component of a Hospital-Wide Difficult Airway Response Program.

OBJECTIVE: A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). DESIGN: The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scores and themes derived from qualitative assessments, and prepost course knowledge assessment MCQ scores. SETTING: Tertiary care academic hospital center PARTICIPANTS: Students, residents, fellows, and practicing physicians from the departments of Surgery, Otolaryngology Head and Neck Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine; advanced practice providers (nurse practitioners and physician assistants), nurse anesthetists, nurses, and respiratory therapists. RESULTS: Totally, 23 MDACs have been conducted, including 499 participants. Course evaluations were uniformly positive with mean score of 86.9 of 95 points. Qualitative responses suggest major value from high-fidelity simulation, the hands-on skill stations, and teamwork practice. MCQ scores demonstrated significant improvement: median (interquartile range) pre: 69% (60%-81%) vs post: 81% (72%-89%), p < 0.001. CONCLUSIONS: Implementation of a MDAC successfully disseminated principles and protocols to all airway providers. Demonstrable improvement in prepost course knowledge assessment and overwhelmingly positive course evaluations (quantitative and qualitative) suggest a critical and ongoing role for the MDAC course.

The Technology of Video Laryngoscopy.

Tracheal intubation via laryngeal exposure has evolved over the past 150 years and has greatly expanded in the last decade with the introduction and development of newer, more sophisticated optical airway devices. The introduction of indirect and video-assisted laryngoscopes has significantly impacted airway management as evidenced by the presence of these devices in the majority of published difficult airway algorithms. However, it is quite possible that many airway managers do not have a thorough comprehension of how these devices actually function, an understanding that is vital not only for their use but also for assessing the devices' limitations. This article discusses the development of video laryngoscopy, how the video laryngoscope works, and the impact of video laryngoscopy on difficult airway management.

Anesthetic management and human factors in the intraoperative MRI environment.

PURPOSE OF REVIEW: The use of intraoperative MRI technology during neurosurgery has become increasingly more common over the past several years. These surgical procedures require a specialized operating room designed to accommodate an MRI machine, as well as MRI-compatible anesthesia equipment and monitors. The MRI environment also poses unique risks and challenges to both patients and medical staff. RECENT FINDINGS: General anesthesia in the MRI operating room suite poses several challenges not routinely experienced in a conventional operating room suite, and anesthesia providers delivering care in these suites must complete specialized training and screening. The presence of a magnetic field, as well as reduced access to the patient during the MRI scan, require high levels of vigilance. SUMMARY: The use of checklists and teamwork training can maximize both patient and provider safety in the intraoperative MRI environment.

Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.

BACKGROUND: Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS: We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS: Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS: DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.

A novel role for otolaryngologists in the multidisciplinary Difficult Airway Response Team.

OBJECTIVES/HYPOTHESIS: The Difficult Airway Response Team (DART) was implemented in July 2008 to address emergent difficult airway situations. The main objective of this study was to highlight the unique role and skill set that otolaryngologists bring and their impact on patient outcomes. STUDY DESIGN: Retrospective review of prospectively collected data from the hospital's airway registry. METHODS: We collected data on demographics, airway characteristics, airway management techniques used by each specialty, and clinical outcomes (such as cricothyrotomies) for patients for whom a code was activated between July 2006 and June 2010. We compared data between pre- and post-DART cohorts and between DART and non-DART patients using a matched case-control approach. RESULTS: Of the 2,826 codes, 90 patients required DART management between July 2008 and June 2010. Body mass index, cervical spine injury/fixation, history of difficult airway, head and neck mass, and oropharyngeal and/or supraglottic angioedema were identified as significant predictors for DART activation. Forty-nine (60%) patients' airways were secured by anesthesiologists, 30 (36%) by otolaryngologists, and three (4%) by trauma surgeons. Otolaryngologists were able to use specialized techniques such as Holinger and Dedo laryngoscopes to significantly decrease the number of cricothyrotomies from seven (0.73%) pre-DART implementation to four (0.21%) post-DART implementation. CONCLUSIONS: Otolaryngologists were able to decrease the need for cricothyrotomies using specialized techniques for patients with difficult airways. Otolaryngologists bring a special skill set to the DART that is beyond the scope of anesthesiologists and trauma surgeons and that can improve patient outcomes by preventing unnecessary emergency surgical airways.

Complications of airway management.

Although endotracheal intubation is commonly performed in the hospital setting, it is not without risk. In this article, we review the impact of endotracheal intubation on airway injury by describing the acute and long-term sequelae of each of the most commonly injured anatomic sites along the respiratory tract, including the nasal cavity, oral cavity, oropharynx, larynx, and trachea. Injuries covered include nasoseptal injury, tongue injury, dental injury, mucosal lacerations, vocal cord immobility, and laryngotracheal stenosis, as well as tracheomalacia, tracheoinnominate, and tracheoesophageal fistulas. We discuss the proposed mechanisms of tissue damage that relate to each and present their most common clinical manifestations, along with their respective diagnostic and management options. This article also includes a review of complications of airway management pertaining to video laryngoscopy and supraglottic airway devices. Finally, potential strategies to prevent intubation-associated injuries are outlined.

Factors affecting hemoglobin measurement.

A review of the literature shows that current "standard" laboratory measurements for hemoglobin are subject to numerous factors that affect both accuracy and reliability. In addition, total hemoglobin concentration measurements are subject to numerous factors that affect the "true" hemoglobin value. This article discusses both the physiologic factors that influence hemoglobin levels and the technical aspects and variability among the different measurement methodologies currently available.

Mechanical airway obstruction due to dislodged spinal hardware.

A difficult airway caused by mechanical obstruction from dislodged spinal hardware in a patient undergoing revision surgery for a cervical chordoma is presented. Due to the logical, sequential multidisciplinary airway and patient management by the anesthesiology, neurosurgery, and otolaryngology teams working together in an environment of clear communication, a potential life-threatening crisis was averted with successful outcome for the patient.

A novel approach to implementation of quality and safety programmes in anaesthesiology.

Far too many patients suffer preventable harm from medical errors that add to needless suffering and cost of care. Underdeveloped residency training programmes in patient safety are a major contributor to preventable harm. Consequently, the Institute of Medicine has called for health professionals to reform their educational programmes to advance health-care safety and quality. Additionally, the Accreditation Council for Graduate Medical Education (ACGME) now requires education in 'systems-based practice' and 'practice-based learning and improvement' as core competencies of residency training programmes. The specific aim of this article is to describe the implementation of a novel programme designed to enhance residency education, meet ACGME core competencies and improve quality and safety education in one residency programme at an academic medical institution.

Continuous noninvasive hemoglobin monitoring during complex spine surgery.

BACKGROUND: Monitoring hemoglobin levels in the operating room currently requires repeated blood draws, several steps, and a variable time delay to receive results. Consequently, blood transfusion management decisions may be delayed or made before hemoglobin results become available. The ability to measure hemoglobin continuously and noninvasively may enable a more rapid assessment of a patient's condition and more appropriate blood management. A new technology, Pulse CO-Oximetry, provides a continuous, noninvasive estimate of hemoglobin concentration (SpHb) from a sensor placed on the finger. We evaluated the accuracy of SpHb compared with laboratory CO-Oximetry measurements of total hemoglobin (tHb) during complex spine procedures in patients at high risk for blood loss. METHODS: Patients eligible for the study were undergoing complex spine surgery with planned invasive arterial or central venous monitoring and hourly blood draws for hemoglobin measurement. During each surgery, blood samples were obtained hourly (or more often if clinically indicated) and analyzed by the central laboratory with CO-Oximetry, a standard method of hemoglobin measurement in many hospitals. The tHb measurements were compared with SpHb obtained at the time of the blood draw. RESULTS: Twenty-nine patients were included in the study. The tHb values ranged from 6.9 to 13.9 g/dL, and the SpHb values ranged from 6.9 to 13.4 g/dL. A total of 186 data pairs (tHb/SpHb) were analyzed; after removal of SpHb readings with low signal quality, the bias (defined as the difference between SpHb and tHb) and precision (defined as 1 SD of the bias) were -0.1 g/dL ± 1.0 g/dL for the remaining 130 data pairs. Bland-Altman analysis showed good agreement of SpHb to tHb values over the range of values; limits of agreement were -2.0 to 1.8 g/dL. The absolute bias and precision were 0.8 ± 0.6 g/dL. CONCLUSIONS: Continuous, noninvasive hemoglobin measurement via Pulse CO-Oximetry demonstrated clinically acceptable accuracy of hemoglobin measurement within 1.5 g/dL compared with a standard laboratory reference device when used during complex spine surgery. This technology may provide more timely information on hemoglobin status than intermittent blood sample analysis and thus has the potential to improve blood management during surgery.