AANA journal course: update for nurse anesthetists--beyond the laryngoscope: advanced techniques for difficult airway management.

Airway catastrophes have been identified as the leading cause of injury and death during anesthesia. Proper management of a patient with a technically difficult airway commences with problem recognition. Physical limitations to mask ventilation and endotracheal intubation may be accurately identified by thorough observation. All patients should be examined for oral structure visibility, size of mandibular space, and ability to assume "sniffing" position. Patients with compromised airways should have patency secured while remaining awake by direct laryngoscopy, nasotracheal intubation, fiberoptic endoscopy, retrograde intubation, or possibly tracheostomy. Partial or complete airway obstruction requires immediate recognition and intervention. Repeated, unsuccessful attempts at endotracheal intubation should be avoided, as these may lead to laryngeal edema or hemorrhage which may critically compromise airway maintenance. Prudent options may include awakening the patient, proceeding with mask ventilation, or performing semi-elective tracheostomy. Emergency airway access may be achieved with a tracheoesophageal airway, esophageal tracheal combitube, laryngeal mask airway, digital intubation, or obtained surgically by transtracheal jet ventilation or tracheostomy. Reduction of airway-related morbidity and mortality is best achieved with an understanding of airway anatomy, common causes and prompt recognition of compromise, and alternative techniques of establishing patency and ventilation.

Emergency oxygen administration and airway management [continuing education credit].

Airway-directed vigilance is a priority for all critical care providers. Methodical respiratory assessment, proficient skill in basic airway support, and thorough preparation for advanced airway control modalities, uniquely enable the nurse to initiate timely airway intervention. Ultimately, this can contribute significantly to reduction and prevention of patient morbidity and mortality.

Historical perspectives on the development and use of mechanical ventilation.

Contemporary advancements in cardiothoracic and abdominal surgical procedures have been historically dependent on the development and adoption of controlled airway management, specifically endotracheal intubation, controlled positive-pressure ventilation, and the use of automatic positive-pressure mechanical ventilators. More than 400 years elapsed before the 16th Century theories of Paracelsus and the demonstrations of Vesalius were routinely adopted to solve the "pneumothorax problem" that prevented complicated or prolonged surgical procedures within the pleural cavity. Acceptance and implementation of controlled positive-pressure ventilation was impeded for decades by the inability to maintain and protect the airway. Consequently, emphasis on the development of mechanical ventilation was directed toward machinery that provided safer negative-pressure respiratory support. The introduction of curare into European anesthesia practice and the adoption of protective airway practices during the poliomyelitis epidemics led to routine use of controlled positive-pressure ventilation and construction of dependable machinery. Laboratory investigations, exploring complications from cardiothoracic surgery, brought about American acceptance and established controlled positive-pressure mechanical ventilation as an indispensable part of conventional intraoperative management.

Historical perspectives on anesthetic-related cardiac arrest and resuscitation.

Contemporary interest in resuscitation was historically related to anesthetic death. Primitive techniques of anesthetic administration, loss of airway control, and psychologically influenced sudden death contributed to unanticipated respiratory and cardiac arrest. Airway obstruction has remained the principal factor in asphyxial death, necessitating crucial preservation of respiratory function during induction of anesthesia. Early, disorganized overdose and arrest interventions included: application of cold water, manual artificial respiration, heat, friction and galvanic battery application. Cardiopulmonary resuscitation, after years of research and experimentation became an integrated plan of attack: mouth-to-mouth ventilation and maneuvers eliminating pharyngeal obstruction were proven effective; internal and external cardiac massage was incorporated and definitive drug therapy began with epinephrine, strychnine, caffeine, carbon dioxide, amyl nitrate, coramine, metrazol and procaine. Defibrillation proved electricity converted ventricular fibrillation to normal sinus rhythm. Significant lethality still occurs from anesthetic-induced cardiac arrest, despite technological advances. Causes of operating room cardiac arrests are numerous and include sudden death syndrome. Constant vigilance distinguishes variable patient response. Immediate recognition and coordinated intervention assures success.