jurnal anestesi 2

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PERIOPERATIVE MEDICINE

An Algorithm for Difficult Airway Management,Modified for Modern Otical De!ice" #Airtra$

%aryngo"coe& LMA CTrach'(

A 2-Year Prospective Validation in Patients for Elective

Abdominal, Gynecologic, and Thyroid Surgery

Roland Amathieu, M.D.,* Xavier Combes, M.D.,* Widad Abdi, M.D.,† Loutfi El Housseini,

M.D.,† Ahmed Reou!, M.D.,† Andrei Din"a, M.D.,† #elislav $lavov, M.D.,† $e% bastien

&lo", M.D.,† 'illes Dhonneur, M.D., (h.D.)

A)*TRACT

Background: Because algorithms for difficult airway man-

agement, including the use of new optical tracheal intubation

devices, require prospective evaluation in routine practice, we

prospectively assessed an algorithm for difficult airway

management that included two new airway devices.

Methods: After 6 months of instruction, training, and clin-ical

testing, 15 senior anesthesiologists were ased to use anestablished algorithm for difficult airway management in

anestheti!ed and paraly!ed patients. Abdominal, gyneco-logic,

and thyroid surgery patients were enrolled. "mer-gency,

obstetric, and patients considered at ris of aspiration were

e#cluded. $f tracheal intubation using a %acintosh

laryngoscope was impossible, the Airtraq laryngoscope

&'()*+, "couen, rance was recommended as a first step

and the LMA CTrach &/"BA0, antin, rance as a sec-

* Assistant Professor, † Sta Anesthesiologist, ‡Professor and Head of Department, Jean VerdierUniversity Hospital of Paris, Anaesthesia and ntensive

!are Unit Department, "ondy, #ran$e, and Paris %&University S$hool of 'edi$ine, "o(igny, #ran$e)

e$eived from the Anesthesia and ntensive !are'edi$ine De+partment, Jean Verdier University Hospitalof Paris, "ondy, #ran$e) S(mitted for p(li$ation April-, ./%/) A$$epted for p(li$ation Septem(er %0, ./%/)Spport 1as provided solely from instittional and2ordepartment sor$es) 3illes Dhonner is a $onsltantand mem(er of the 4aryngeal 'as5 !ompany 4imited

Advisory "oard 6Jersey, !hannel slands7)

Address $orresponden$e to Dr) Dhonner8 Anesthesiaand n+tensive !are 'edi$ine Department, Jean VerdierUniversity Hospital of Paris, "ondy, #ran$e)gilles)dhonner9:vr)aphp)fr) nformation on pr$hasingreprints may (e fond at 111)anesthesiology)org or on

the masthead page at the (eginning of this isse) A ;<S=H<S>4>3? @S arti$les are made freely a$$essi(le toall readers, for personal se only, 0 months from the$over date of the isse)

Copyright © 2010, the American Society of Anesthesiologists,

Inc. Lippincott Williams &

Wilkins. Anesthesiology./%% %%B8 .C&&

+hat +e Already nowa-out Thi" Toic

1• niforma++li"ation of a diffi"ultaira- al!orithm mi!htde"rease the in"iden"eof h-+o/i" braindama!e durin! anesthesia indu"tion

+hat thi" Article Tell"." that i" New

1• 0n a lar!e+ros+e"tive stud-,a++li"ation of a sim+leaira- al!orithm,in"ludin! use of nevisual intubationdevi"es, a"hieved hi!hadheren"e rate andsu""essful tra"healintubation in all +atientsith diffi"ult aira-s

ond. A gum elastic bougie

was advocated to facilitate

tracheal access with the

%acintosh and Airtraq

laryngoscopes. $f ven-tilation

with a facemas was

impossible, the LMA

CTrach was to be used,

followed, if necessary, by

transtracheal o#y-genation.

atient characteristics,

adherence to the algorithm,

efficacy, and early

complications were recorded.

Results: *verall, 12,225



patients were included during 2 yr. $ntubation was achieved

using the %acintosh laryngoscope in 34 cases. $n the

remainder of the cases &26, a gum elastic bougie was used

with the %acintosh laryngoscope in 278 &49. :he Airtraq

laryngoscope success rate was 38 &28 of 24. :he LMA

CTrach allowed rescue ventilation &n 2 and visually

directed tracheal intubation &n . $n one patient, ventilation

by facemas was impossible, and the LMA CTrach was

used successfully.

1his arti"le is a""om+anied b- to Editorial #ies. (lease

see2 $"hmidt , Ei3ermann M2 4r!aniational as+e"ts of dif

fi"ult aira- mana!ement2 1hin3 !loball-, a"t lo"all-. A5E$1HE

$04L4'6 7899: 99;2<= >: 0sono $, 0shi3aa 12 4/-!enation,

not intubation, does matter. A5E$1HE$04L4'6 7899: 99;2?=@.



Anesthesiology, V %%B E ;o %

.C Janary ./%%



Algorithm for Dii$lt Air1ay'anagement

Conclusi

ons:

:racheal

intubatio

n can be

achievedsuccess-

fully in a

large

cohort of

patients

with a

new

managem

ent

algorithm

incorpora

ting theuse of

gum

elastic

bougie,

Air-traq,

and LMA

CTrach

devices.

S:;$0:

adherenceto defined

strategies

and

algorithms

can resolve

most

problems

in airway

manageme

nt.1,2

:he

rench

+ational

/ociety of

Anesthesio

logy

recently

pro-posed

strategies

for

managing

<cannot

intubate,

cannot

ven-tilate=

events

based on

American/ociety of

Anesthesio

logy

guidelines,

e#pert

opinion,

consensus

conferences,

and pro-

spectively

validated

algorithms.,9

:hese

strategies

allow suc-

cessful

intubation of

most patients

with difficult

airways. :he

endotracheal

tube is

introduced

without

requiring

direct vision,

using either gum elastic

bougie &)"B

or intubating

laryngeal

mas airway.

>owever,

new devices

that provide a

viewing

system, such

as the Airtraq

laryngoscope

&A?-@

'()*+,"couen,

rance and

the LMA

CTrach

&@%A-0:

/"BA0,

antin,

rance, have

recently been

developed

and validated

for difficult

tracheal

intubation.58

:he current

algorithms for

difficult

airway

management

do not

incorpo-rate

these new

devices or

consider their

appropriate

role. Because

these devices

often can

allow tracheal

intubation

under direct

vision when

conventional

airway

management

fails, we

included these

new devices

in an updated

difficult

airwaymanagementalgorithm.

Ce

prospectivel

y assessed

an algorithm

for difficult

airway

managemen

t that

included

videoassistance

using these

two new

airway

devices. Ce

intended

that the tra-

chea of all

patients

with

difficult

airways

would be

intu-bated

using visual

guidance.

Material"andMethod"

StudyDesign

:his

prospective

validation

study was

conducted at

the Dean

'erdier

Eniversity

>ospital of

aris

&Bondy,

rance

from

Danuary2774 to

Fecember

2773. :he



hospital

"thics

0om-

mittee

waived

the need

for

informed

consent

because

ran-

domi!atio

n was not

used and

the

algorithm

was part

of rou-

tine

practice.

AnesthesiaSettingsandParticipants

Dean

'erdier

>ospital is

a tertiary,

57-bed

surgical

teaching

hospitalthat

includes a

central

surgical

unit made

of five

operating

rooms

&*;s

encircling

a 17-bed

postanesthesia care

unit and

two

e#ternali!e

d *;s

dedicated

to

emergent

and

obstetric

cases.

ifteensenior

anesthesiol

ogists with

more than 5

yr of clinical

e#perience

covering the

central

surgical unit

&gynecology,

visceral,

bariatric, and

endocrinesurgery

departments

participated

in the study.

*n a daily

basis, three

anesthesiolog

ists managed

patients in the

central

surgery unit.

An

anesthesiolog

ist supervised

one of the

*;s and the

postanesthesi

a care unit.

:he two

remaining

anes-

thesiologists

managed two

*;s each. A

speciali!ed

anesthe-

tist nurse

cared for the

patients in

each *;.

our-hands

induction of

anesthesia

wassystematical

ly

performed.

:he

anesthetic

nurse

usually

initiated

standard

airway

manage-

ment. $n

case of

failure of the

first tracheal

intubation

at-tempt

with the

%acintosh

laryngoscop

e

&%acintosh-

@ as-sisted

with )"B,

theanesthesiolo

gist was

requested to

manage the

airway.

*ver a 6-

month

period, all

participants

were

instructed in

the use of theA?-@ and

@%A-0:

devices and

then given

practical

training

using a

standard

intubation

mannequin

and a

difficultairway

management

simulator.



After

training,

the

physicians

had a

period of

clinical

e#perienc

e where

thedevices

&A?-@

and @%A-

0: were

used as

primary

airway

devices in

morbidly

obese

patients

admitted

for

elective

bari-atric

surgery.

Ce

considere

d that

clinical

proficienc

y was

acquired

after each

airway

device,

and the

video-

viewing

sys-tem

had been

used

successful

ly 17

times.

After

training,the study

period

started.

Patients

All

patients

admitted

for elective

surgery

given

general

anes-thesia

requiring

tracheal

intubation

were enrolled

in the study.

Ce included

patients

receiving

therapy for

gastric re-flu#

or patients

who werenown to

have a hiatus

hernia but

were

currently

asymptomatic

. regnant

women,

emergency

cases, and

patients at

ris for aspiration

were

e#cluded.

Preoperati ve Work- up

Anesthesia

care,

including

monitoring,

complied with

rench

/ociety of

Anesthesiolog

y and

$ntensive

0are

%edicine

clinical

practice

guidelines.

/pecial

attention was

given to preoperative

airway

assessment.

:he

participating

anesthesiologi

sts routinely

assessed the

patients

before

anesthesia

using definedmeasures of

airway

difficulty

&table 1.4 11

atients in

whom airway

man-agement

was e#pected

to be difficult

were

systematically

identi-fied

and listed ona Fifficult

Airway Board

set up in the

anes-thesia

department

and discussed

at a weely

meeting. or

patients with

three or more

features of a

difficult

airway, the

anesthesiologi

st decided

before

anesthesia

started

whether to

use

succinylcholi

ne to aid

intubation,

and how to

proceed withsubsequent

intubation.

PatientExclusions

atients

with a

mouth

opening &or

interincisor

distance of less than 25

mm, with

severe fi#ed

fle#ion

deformity of

the cervical

spine, or a

history of

previous

impossible

tracheal

intubation,

wereintubated

while awae

by use of



fiberscop

e-guided

nasotrach

eal

intubation

. All other

patients

under-

went

tracheal

intubation

given

general

anesthesia

with mus-cle

rela#ant.

AirayManage!ent

A standard

method for preo#ygenati

on was used,

aiming to

achieve an

end-tidal

o#ygen

concentration

more than

37. atient

position was

adGusted

according to body mass

inde#

Anesthesiology./%%%%B8.

C&&

.0 Amathieet al.




Ta-le /0 Ris3 a"tors for Aira- Mana!ement Diffi"ult- $-stemati"all- Assessed at the (reo+erative #isit

eature Details

Men B8 -r 4besit- ith &M0 <8 3!m

7

$lee+ a+nea s-ndrome Dia!nosed, treated, or hi!hl- sus+e"ted on the base of the da-time

slee+iness7< s"ale @ and a +reo+erative slee+ a+nea s"reenin!tool

7; 9B

Mallam+ati "lasses 000 and 0# (atient sittin!, head in neutral fle/ione/tension +osition, ton!ue

Mouth o+enin! or inter!in!ival distan"eout, ithout +honation

<B mm1h-roid to mentum distan"e >B mm

Loer in"isors "annot advan"e to meet u++er in"isors@,7B

$everel- limited a +rotrusion

5e"3 "ir"umferen"e2 ;8 "m in Measured at the level of the th-roid "artila!e7>

omen and ;B "m in men

&M0 bod- mass inde/.

&B%$. $f B%$ was more than 5 gHm

2

, the head and nec position was raised for preo#ygenation and tracheal intuba-

tion. $n patients with fewer than three adverse predictors, the

anesthesia provider assessed the ease of facemas ventilation

before giving muscle rela#ant &atracurium or vecuronium.

:he ease or difficulty of facemas ventilation was graded,

using a simple score, as followsI

1● )rade $I ventilation without the need for an oral

airway

2● )rade $$I ventilation requiring an oropharyngeal

airway

3● )rade $$$I difficult and variable ventilation requiring

an oral airway and two providers, or an oral airway and one

provider using pressure-controlled mechanical

ventilation requiring more than 25 cm >2* and

4● )rade $'I ventilation inadequate with no end-tidal

carbon dio#ide measurement and no perceptible chest wall

move-ment during attempts at positive pressure ventilation.

:o reduce the duration of apnea, succinylcholine &1 mgH

g was given when ventilation difficulty was graded $$$ or $'.

$n patients with grade $ and $$ facemas ventilation, intubation

was planned min after rela#ant administration.

Algorith! Description)"B and A?-@ were available in each *;. $n the central

postanesthesia care unit, 17 meters from each *;, additional

equipment was permanently available, consisting of two sets

of three @%A-0: chassis &si!esI , 9, and 5, two @%A-0:

viewers placed in their charger, and the C$$ viewer for A?-

@. Ce considered gum elastic bougie &Boussignac Bou-gie

'()*+ as an adGunct to facilitate tracheal access when

%acintosh-@ and A?-@ were used. *nce the muscle rela#ant

had been given, the anesthesia providers followed a set algo-

rithm &fig. 1.

$f tracheal intubation was not possible using a %acin-tosh-@

fitted with a si!e blade, then the A?-@ device was used,followed, if necessary, by the @%A-0: device. $mpos-sible direct

tracheal access was considered to be current if tracheal access was

not possible after two attempts, using

either %acintosh-@ or A?-@,

aided by use of the )"B and

changes in head position ande#ternal laryngeal manipula-

tion as necessary. :he A?-@

and @%A-0: devices were

used e#actly according to

the manufacturerJs

instructions and de-

partmental

recommendations. or A?-

@, video-controlled tracheal

intubation was first

attempted using the standard

technique of insertion of thedevice or the rotation

maneu-ver.4 *nce a good

view of the glottis was

obtained, the en-dotracheal

tube was passed through the

vocal cords and held in place

as the device was removed.

Ce used a si!e 5 @%A-0:

for male patients and a si!e 9

for female patients, inserted as

described.3 'entilation was

maintained during both

sealing and viewing

procedures. *nce a good view

of the glottis was obtained,

ventilation was discontinued

and a reinforced fle#ible

endotracheal tube was

inserted through the metallic

chassis of the @%A-0: and

pushed through the vocal

cords into the trachea under

visual control. acemas

ventilation was recommended

between intubation attempts,if pulsed arterial o#ygen

saturation &/p*2 decreased to

less than 37. :he



anesthesiologist could decide at any time to discontinue

intubation attempts and allow the patient to recover.

$f mas ventilation was impossible, despite changes in

head position or mas si!e, the @%A-0: device was used

immediately. $f @%A-0: ventilation failed, indicated by no

end-tidal carbon dio#ide curve and chest wall movement

within 7 s after laryngeal mas placement, percutaneous

transtracheal Get rescue o#ygenation &%anuDet 'B%, Al-leins,

rance was to be used.

A proven difficult

airway was defined as

grade $$$ and $' ventilation

difficulty or failed

conventional %acintosh-@

tra-cheal intubation despite

)"B use.

Study Data Collection

$f the first step of the difficult

airway management process

was taen, the attending

senior anesthesiologist

managed the airway, and the

anesthetic nurse collected

airway manage-ment details

and outcome variables. :he

physical character-

Anesthesiology ./%% %%B8.C&& .-

Amathie et al.




1ig0 /0 De"ision tree for mus"le rela/ant "hoi"e and aira- mana!ement. 1he diffi"ult ventilation !radin! s"ale is the folloin!2

'rade 0, ventilation ithout the need for an oral aira-: !rade 00, ventilation reuirin! an oral aira-: !rade 000, diffi"ult and

unstable ventilation reuirin! an oral aira- and to +roviders, or an oral aira- and one +rovider, usin! me"hani"al ventilation

F+ressure"ontrolled modeG: and !rade 0#, im+ossible ventilation. 'E& !um elasti" bou!ie.

istics of all patients with difficult airways were recordedfrom the anesthesia record.

"utco!e #aria$les

:he main outcome variables were the success rate for tracheal intubation using visual guidance and adherence tothe man-agement algorithm. *ther endpoints were theincidence of complications &hypo#emia, noted as the

lowest /p*2 during airway management, pulmonaryaspiration, and evidence of airway trauma.

Statistical Analyses

Fescriptive statistics, including frequency counts,

proportion, mean, and /F calculation, were computed

using K@/:A: 2774 &Addinsoft, aris, rance.

Re"ult"

Patients and Anesthesia

$n the 2-yr study period, 12,225 patients were admitted for

planned elective surgery given general anesthesia. :heir mean

&/F age was 51 &19 yr and gender ratio &%H was 66H99. A

difficult airway was encountered in 125 patients &1.

hysical characteristics and ris factors for airway

management of all participants &n 12,225 and details of

patients with airway management difficulties &n 125 are listedin table 2. )eneral anesthesia and paralysis were in-duced in

12,221 of these patients. :he four other patients

underwent awae

fiberscope-guided

nasotracheal intuba-tion. *f

these four patients, one had

a history of previous

difficult intubation &5 gHm

B%$, 22 mm interincisor

dis-tance, and %allampati

class $', one had a large

thyroid tumor distorting the

upper airway and severely

narrowing the trachea, and

two had a fi#ed fle#ion

deformity of the cervical

spine and a limited mouth

aperture &27 mm pre-

venting airway insertion and

manipulation.

Airay Manage!ent"utco!es

:he pattern of management of

the patients is shown in figure

2. *utcome of airway

management of all

anestheti!ed par-ticipants &n

12,221 and of patients withairway manage-ment

difficulties &n 125 are listed

in table . )rade $$$ or $'

ventilation difficulty occurred

in 179 patients &7.4. :wo

patients &7.71 could not be

ventilated by facemas &grade

$', and 172 patients &7.4

had grade $$$ ventilation

difficulty. Among these

patients, 12 received primary

succi-nylcholine because they

showed at least three

predictors of difficult airway

management and 37 received

secondary suc-cinylcholine

because of grade $$$

ventilation difficulty Gust after

induction before muscle

rela#ant inGection. Fifficult

ventilation &grade $$$ was

encountered in 68 &8 obese

patients &B%$ more than 7

gHm. 0ombined grade $$$

ventilation difficulty and

impossible %acintosh-@

intubation despite )"B use

occurred in 8 &7.75

patients. 'entilation difficulty

&grade $' was encounteredtwice in this seriesI Gust after

induction of anesthesia and

during A?-@ intubation at-



Anesthesiology ./%% %%B8.C&& .F

Amathie et al.




Ta-le 20 (h-si"al Chara"teristi"s and Ris3 a"tors for Aira- mana!ement of All (arti"i+ants Fn 97,77BG and

Details of (atients ith Aira- Mana!ement Diffi"ulties Fn 97BG

(atients, n FG

or Mean $D

All +arti"i+ants Fn 97,77BG

(lanned aa3e fibers"o+e!uided nasotra"heal intubation ; $ur!er-

Abdominal >,@>@FB?G'-ne"olo!i"al ;,?>IF<@G1h-roid ;IIF;G

4bese +atients ith &M0 <8 3!m Fn ?I@G Abdominal sur!er- B?@F?;G'-ne"olo!i"al sur!er- 9B9F9@G1h-roid sur!er- B@F?G

Morbidl- obese +atients ith &M0 B8 3!m Fn 98;G Abdominal sur!er- IIFIBG'-ne"olo!i"al sur!er- 9BF9;G1h-roid sur!er- 9F9G

(atients shoin! < diffi"ult aira- mana!ement fa"tors at the +reo+erative

anesthesia visit Fn 9IIG Abdominal sur!er- 9;?F?IG'-ne"olo!i" sur!er- <BF9IG1h-roid sur!er- >F;G

(atients ith aira- mana!ement diffi"ulties* Fn 97BG'ender FMG ratio >><;Mean a!e, -r B8 9<Mean bod- mass inde/, 3!m ;< 9;Mean interin"isor distan"e, mm << ;Mean th-romental distan"e, mm >; BRetro!nathia 9>F9<G$everel- limited a +rotrusion 98FIG4bstru"tive slee+ a+nea I7F>>GMallam+ati "lass Fn +er "lassG 0B 00<7 000?B 0#97Mean "ervi"al ne"3 "ir"umferen"e, "m ;; B

Cri"oth-roid membrane a""ess diffi"ult- s"ore† Fn +er s"oreG 8<7 9I7 798 <7

* A +atient ith aira- mana!ement diffi"ulties as arbitraril- defined as fa"emas3 ventilation diffi"ult- !rade 000=0# or failed Ma"intoshlar-n!os"o+e tra"heal intubation, des+ite !um elasti" bou!ie use. Diffi"ult ventilation !radin! s"ale2 'rade 0, ventilation ithout theneed for an oral aira-: !rade 00, ventilation reuirin! an oral aira-: !rade 000, diffi"ult and unstable ventilation reuirin! an oral aira-and to +roviders, or an oral aira- and one +rovider, usin! me"hani"al ventilation F+ressure"ontrolled modeG: and !rade 0#,im+ossible. † Diffi"ult- of "ri"oth-roid membrane a""ess as evaluated b- anterior ne"3 +al+ation usin! a ;+oint s"ore F8 eas-, 9moderatel- diffi"ult, 7 diffi"ult, < ver- diffi"ultG.

&M0 bod- mass inde/.

tempts in another patient. :hese two patients who benefited

from rescue ventilation with the @%A-0: device were intu-

bated using visual guidance through the laryngeal mas.

:here were two deviations from the algorithm after failed

%acintosh-@ intubation. $n a case of %acintosh-@ failure, the

%c)rath &/"BA0 was used successfully instead of the A?-@

device. $n a patient in whom there was a grade $$$ view of the

laryn# &0ormac and @ehane, the A?-@ device was used after

%acintosh-@ direct laryngoscopy without at-tempting )"B

assistance. or all other patients, )"B was used to assist

%acintosh laryngoscopy in 26 patients &1.3, and of these

patients, successful tracheal access was achieved in 278 &49.

)"B-assisted %acintosh-@ :racheal intubation was not possible

in 23 patients &7.72. $n these patients, A?-@ intubation was

then attempted. :he A?-@ device allowed successful tracheal

intubation under visual guidance in 28 of the 23 remaining

patients, with the )"B

used as an adGunct to the

A?-@ device in of these

28 cases. $n one of these

patients, ventilation could

not be achieved after the

first A?-@ intubationattempt, and rescue @%A-

0: o#ygenation was

required followed by

tracheal intubation under

visual control through the

laryngeal mas. :he trachea

of the patient with A?-@

failure, despite )"B

assistance, was intubated

under visual control using

@%A-0:. >e was a tall &1.3

m morbidly obese man &97gHm B%$. /tandard

insertion and manipulation

of A?-@ gave a poor, distant

view of laryngeal structures

that included a long, floppy

epiglottis that could not be

lifted."pisodes of hypo#emia

&/p*2 37 occurred in 48 pa-

tients &7.8 in 18 patients

&7.1, /p*2 became less than

47. :he features of these 18

patients are presented in table 9.

:he lowest /p*2 was 64 and

occurred in the patient in whom

primary facemas ventilation

was not possible. :his patient

had a bushy beard and had five

predictive features of a difficult

airway.

Anesthesiology./%% %%B8.C&&

.G Amathie et al.




1ig0 20 4ut"ome of the mana!ement of +atients, usin! the ne al!orithm. 'E& !um elasti" bou!ie: 410 orotra"heal intubation.

+o patient suffered aspiration of gastric contents. :rauma to

the teeth by the %acintosh-@ occurred in two patients.

Di"cu""ion

$n this prospective study of 12,221 patients given general

anesthesia for elective surgery, we have shown that an

algo-rithm incorporating the )"B and two visual systems

for tracheal intubation &A?-@ and @%A-0: allowed

tracheal intubation under visual guidance in all patients in

whom airway management was difficult.

Li!itations o% the Study

*ur study has three limitations. :he first is that the patient

population is limited to abdominal, gynecologic, and thyroid

surgery. Although many of the patients were morbidly obese, we

did not include other patients with potential problems, such as

patients with tumors in the upper airway, patients with cervical

trauma and immobili!ation, or obstetric pa-tients. Application of

our algorithm to such patients may not be Gustifiable. >owever,

physicians in our obstetrics unit have also received instruction in

the use of new optical airway devices, and we now incorporate

use of A?-@ as the second step after failed %acintosh-@ tracheal

intubation in our algo-rithm for difficult tracheal intubation

during anesthesia for emergency cesarean section.12

:he second

limitation is that successful use of the algorithm was based on

thorough train-ing and practical e#perience with these new

devices. :he physicians involved in this study completed training

with

A?-@ and @%A-0: and

were accustomed to using

the de-vices clinically.Because a short time is

needed to acquire

proficiency with A?-@1

and

all participants were already

familiar with the intubating

laryngeal mas airway, we

esti-mated that proficiency

was acquired after 17

successful uses of both

devices. *n the basis of our

study, we cannot recom-

mend the current algorithmfor anesthesia providers who

are not e#perienced with

both new airway devices.

:he third weaness is the

si!e of our institutionI an

environment lim-ited to five

operating rooms and a staff

of 15 anesthesiolo-gists. $n a

larger hospital, provision of

these airway manage-ment

devices at all anestheti!ing

locations and training a

larger staff of physicians

could be a significant

financial and organi!ational

tas.

Co

nce

ptio

n o%

the

Di%%

icul

t

Air

a

y

Ma

nag

e!

ent Alg

orit

h!

Ce included A?-@ and @%A-

0: devices in a previous al-

gorithm for managing

unanticipated difficult

airways, in the operating

room1 or the prehospital

setting,19

because of their

proven efficacy, especially in

patients with ris factors.15

Ce did not consider )"B as

an airway, but rather as a tool

to promote or facilitate



tracheal access in case of 0ormac and @ehane $$$ and $' and

when the arytenoids were visible with laryngoscopes &direct or

indirect, respectively. Adherence to the algorithm was very good

&there were only two devia-tions, no doubt because of its

simplicity, device efficacy,

appropriate staff training, and

the fact that most participants

already had taen part in

validation studies on A?-@

and

Anesthesiology ./%% %%B8.C&& &/

Amathie et al.




Ta-le 30 4ut"ome of Aira- Mana!ement of All Anesthetied (arti"i+ants Fn 97,779G and of (atients ith Aira-

Mana!ement Diffi"ulties Fn 97BG

(atients, n FG

or Mean $D

Anesthetied +atients Fn 97,779G

(rimar- indi"ation for su""in-l"holine F < ris3 fa"torsG 9IIF9.BGDiffi"ult ventilation, !rade 0#* 7 Diffi"ult ventilation, !rade 000* 987F8.IG$e"ondar- indi"ation for su""in-l"holine Fdiffi"ult ventilation, !rade 000* before @8 F8.?G

mus"le rela/ant administrationG5onde+olariin! neuromus"ular blo"3ade F?7 atra"urium: 7I ve"uroniumG 99,IB7F@?GCorma"3 and Lehane !rade 000 9>?F9.<GCorma"3 and Lehane !rade 0# <F8.87BGailure usin! Ma"intosh lar-n!os"o+e 7<>F7.8Gailure usin! Ma"intosh lar-n!os"o+e 'E& [email protected]+o/emia e+isodes, $+47 @8 I?F8.?GH-+o/emia e+isodes, $+47 I8 9?F8.9G

'E& use ith Ma"intosh lar-n!os"o+e Fn 7<>G'E& su""ess 78?FI;G

Airtra lar-n!os"o+e use Fn 7@G$u""essful Airtra lar-n!os"o+e +lus 'E& for vieed tra"heal intubation 7?F@?GLMA CTrachJ su""ess for ventilation 7F988GLMA CTrachJ su""ess for tra"heal intubation under visual "ontrol <F988G(atients ith aira- mana!ement diffi"ulties† Fn 97BG

Corma"3 and Lehane !rade for dire"t lar-n!os"o+- Fn +er !radeG 0B 007? 000@9 0#7a"emas3 ventilation diffi"ult- Fn +er !radeG 079 00<? 000>; 0#7Combined 'rade 000 ventilation diffi"ult- and im+ossible Ma"intosh ?FBG

lar-n!os"o+e 'E&assisted tra"heal intubation

Minimum $+47 durin! aira- mana!ement, @9 ?

* Diffi"ult ventilation !radin! s"ale2 'rade 0, ventilation ithout the need for an oral aira-: !rade 00, ventilation reuirin! an oral aira-:!rade 000, diffi"ult and unstable ventilation reuirin! an oral aira- and to +roviders, or an oral aira- and one +rovider, usin!me"hani"al ventilation F+ressure"ontrolled modeG: and !rade 0#,im+ossible ventilation. † A +atient ith aira- mana!ement diffi"ultiesas arbitraril- defined as fa"emas3 ventilation diffi"ult- 'rade 000=0# or failed Ma"intoshlar-n!os"o+e tra"hKal intubation des+ite !um

elasti" bou!ie F'E&G use.&M0 bod- mass inde/: $+47 +ulse o/-!en saturation.

@%A-0: devices.1527

Ce could have chosen another video

laryngoscope, such as the )lide/cope or the %c)rath, to replace

A?-@ in the algorithm, and the wide use of these devices is

undisputable. >owever, these devices provide a very different

mechanical approach to the laryn#, and we cannot predict that the

results of the current study would be the same if we had chosen to

use them in our algorithm. %oreover, during difficult airway

management, the superi-ority of A?-@ tracheal intubation

efficiency in other optical devices and video laryngoscopes has

been systematically demonstrated. Ce confirmed the efficacy of

the A?-@ device after %acintosh-@ failure for tracheal intubation.

>owever, we encountered one case of A?-@ device failure in a

tall morbidly obese patient. Although A?-@ device failure has

already been reported,5 we could not determine the e#act reason

for failure to intubate on this occasion, despite )"B assistance.

:he clinician managing the patient considered it possible that the

standard si!e A?-@ blade was too short in this large patient.

:he use of a muscle rela#ant in the current trial is argu-able.

Ce have decided to use succinylcholine in patients with

anticipated difficult airway management and patients with grade

$$$ and $' difficult mas ventilation before inGection of

muscle rela#ants because this

strategy was currently applied

during our daily clinical

practice. *f interest, this short

du-ration depolari!ing muscle

rela#ant never worsened

facemas ventilation quality,

but rather improved it in most

cases. $ndeed, of the 37

patients that received

secondary succinyl-choline

inGection, 56 improved by one

grade their ventilation quality.

%oreover, none of the 11,39

grade $ and $$ difficult mas

ventilation patients who were

inGected with nondepo-

lari!ing muscle rela#ant

altered ventilation quality.

"utco!es o% the Airay Manage!ent

Cith the current algorithm,

we have successfully

managed the airway of many

obese patients who could have

had diffi-cult intubation or

ventilation. $nterestingly, only

a few of them &2 16 of 843

e#perienced transient /p*2

episodes less than 47. :hese

encouraging safety data may

result from both the rench

/ociety of Anesthesia 0linical

ractice )uidelines that

advise a 37 end-tidal

o#ygen concentration before

induction of anesthesia,

particularly if ris factors for

a difficult airway are present,

and also from the efficacy of

the devices used in the

algorithm. 0ompared with the

previous algorithm, which we

validated for the management

of unan-ticipated difficult

airway,1 our current trial

included many

Anesthesiology ./%% %%B8.C&& &% Amathie et al.




Ta-le 40eatures of the9?(atientsthat

E/+erien"ed

$+o7 lessthanI8durin! Aira-Mana!ement

'ender FMG ratioMean a!e, -r Mean bod- mass inde/, 3!mMallam+ati "lass Fn +er "lassG

(atients ith < +redi"tors of diffi"ultaira- mana!ement

Corma"3 and Lehane !rade for dire"tlar-n!os"o+- Fn +er !radeG

a"emas3 ventilation diffi"ult- Fn +er !radeG†

Moment of o""urren"e of $+Durin! fa"emas3 ventilation attem+tsDurin! failed Ma"intosh

lar-n!os"o+e 'E&intubation attem+ts

Durin! failed Airtra

lar-n!os"o+e 'E&

intubation attem+ts

* 1he

Corma"3

and Lehane

!rade as

not

evaluated in

one +atient

ho as

!iven LMA

CTrach

F$E&AC,

(antin,ran"eG for

res"ue

ventilation.

† Diffi"ult

ventilation

!radin!

s"ale2

'rade 0,

ventilation

ithout the

need for an

oral aira-:

!rade 00,

ventilation

reuirin! an

oral aira-:!rade 000,

diffi"ult and

unstable

ventilation

reuirin! an

oral aira- and

to +roviders,

or an oral

aira- and one

+rovider, usin!

me"hani"al

ventilation

F+ressure"on

trolled modeG:

and !rade 0#,im+ossible

ventilation.

'E& !umelasti" bou!ie:

$+47 +ulse

o/-!ensaturation.

patients with

ris factors

for a difficult

airway. %ost

of these

patients withseveral ris

factors &at

least three

would have

been

e#cluded

from our

previous

algorithm

and would

have been

managed

using afiberscope.

*nly a few

episodes of

hypo#emia

&/p*2 47

episodes

were

attributed to

diffi-culty

with

ventilation

&table 9.

%ost of

these were in

mor-bidly

obese

patients

during failed

%acintosh-@

tracheal in-

tubation

attempts, as

found in our

previous

algorithm.1

Because

most

episodes of

hypo#emia

are related to

difficult

%acintosh-@

intubation,

we believe

that previous

movement to

the secondstep of the

cannot-

intubate

branch of the

cur-rent

algorithm is

advisable.

;educing the

duration of

at-tempts

with the

%acintosh-@

could have prevented

some

episodes of

hypo#emia.

$n our

obstetric

unit, we have

now set a

time limit of

2 min for

%acintosh-@

attempts at

tracheal

intubation

before using

A?-@.

Fifficulty

with mas

ventilation

&grades $$$

and $'

&7.4 had

an incidence

similar to

that reportedin a recent

review.11

)rade $$$

difficulty in

obese

patients

occurred in

6 of

patients who

had at least

three or more

ris factors.

:his

contrasts

with a rate of



7.

grade $$$

ventilation

dif-ficulty

encounter

ed in

patients

with fewer

than three

fea-tures.

0learly,

our set of

predictors

for

difficult

airway

man-

agement

aids

detection

of patients

with

difficultairways.

/even of

our 23

)"B-

assisted

%acintosh

-@

intubation

fail-ures

had grade

$$$ mas

ventilation

difficulty,strengthen

ing

the

association

between

difficult

ventilation

and difficult

intubation.

A maGorityof our cases

with difficult

airways were

mor-bidly

obese men

more than 57

yr of age.

/leep apnea

syn-drome,

large nec,

and high

%allampatigrades $$$ and

$' were the

most frequent

features

associated

with both

difficult

ventilation

and tracheal

intubation

with the

%acintosh-@.

Ce

encountered

only one

primary

instance of

cannot-venti-

late in a 64-

yr-old

morbidly

obese patient

with many

adverse

factors and

with a bushy

beard

hampering

cricothyroid

membrane

palpation.

:his patientJs

arterial

o#ygenation

was restored

promptly with

@%A-0:.

Furing the

study period,

we used

@%A-0:

&two with si!e

9 and one

with si!e 5 in

three patients

to effectively

restore or

establish anopen airway.

:his efficacy

has already

been

recorded.21,22

$f @%A-0:

failed to

improve

o#ygenation

in this cannot-

ventilate

scenario we

encountered,

further

management

would have

been e#-

tremely

difficult

because

identification

of the trachea

surface

landmars

was

impossible. $n

this particular

case, an

attempt at

direct

laryngoscopy

could have

been

lifesaving.

Although not

recommended

by the rench

/ociety of

Anesthesia,

de-viation

from the

algorithm

might have

been

appropriate

here. After

our

e#perience

with this

patient, all



morbidly

obese

patients

with a

beard are

ased to

remove it

before

surgery.

:hose whohave three

or more

ris factors

and refuse

to shave

are

managed

with

awae

nasotrache

al

intubation.:his policy

is now

systematic

ally

applied in

case the

surgery

may

require

deep

neuromusc

ular blocade.

*ver

the 2 yr of

the study,

only four

patients

had to be

e#cluded

from this

manageme

nt

algorithm.

An

important

reason is

that head

and nec

cancer

surgery is

not

undertaen in

our hospital,

although we

did include

patients with

a history of

treated

pharyngeal or

laryngeal

tumor. :hefour

e#ceptions

had awae

fiberscope-

guided

nasotracheal

intu-bation

performed by

two

speciali!ed

senior

anesthesiolog

ists. Before

the advent of

the new

airway

devices with

a viewing

system, we

carried out 17

15

fiberscope-

guided

intubations

per year,

mostly in

super obese

patients. :his

technical ad-

vance has

clearly

changed our

practice in

airway

managementin morbidly

obese patients

and reduced

the

indications

for

fiberscope-

guided

intubation.

Conclu"ion

$n

conclusion,

we used an

algorithm for

airway

management

that

incorporates

)"B, @%A-

0:, and A?-

@ devices in

a large

cohort of

anestheti!ed,

paraly!ed

patients./uccessful

tracheal

intubation

under visual

control was

achieved in

all patients

with difficult

airways.

=he athorsa$5no1ledge 3ordon"lairDrmmond,')D), Ph)D)6Senior4e$trerfrom theDepartmentof

Anaesthesia, !riti$al!are andPain'edi$ine,oyal

nrmary,<din(rgh,S$otland7,for his veryhelpfl$ontri(tionto theeditingpro$ess of themans$ript)

Anesthesio

logy./%%%%B8.

C&&

&.

Amathie

et al.



PERIOPERATIVEMEDICINE

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1.!om(es I, 4eo ", SenP, Dmerat', 'otamed

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A ;<S=H<S>4>

3? .//B%//8%%B0 C/

2.!ros(y <=,!ooper ',Doglas 'J,Doyle DJ,Hng >,4a(re$Le P,'ir H,'rphy '#,Preston P,ose DM, oy48 =henanti$ipateddii$ltair1ay 1ithre$ommendat

ions formanagement)!an J Anesth%GGFBC8-C--0

3. Pra$ti$egidelines formanagementof the dii$ltair1ay) A report (y the

Ameri$anSo$iety of

Anesthesiologists =as5 #or$e on

'anagementof theDii$lt

Air1ay) A ;<S=H<S>4>

3? %GG&-F8CG- 0/.

4.!ros A'8NUpdate onthe$onsenss$onferen$eon dii$ltair1aymanagement81hat a(otthe ftreO

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6.'ahara: !H,!ostello J#,'$Donnell

J3, Harte "H,4aey J38=he AirtraLas a res$eair1ay devi$efollo1ingfailed dire$tlaryngos$opy

8 A $aseseries)

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7. 4i <H,Qender ,3oldman AJ8=he 4'A !=ra$h inpatients 1ithdii$ltair1ays)

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3? .//G%%/8GB%&

8. 4angeron >,'asso <,Hra !,3ggiari ',"ian$hi A,!oriat P, io"8 Predi$tionof dii$ltmas5

ventilation) A ;<S=H<S>4>

3? .///G.8%..G &0

9.Mheterpal S,Han ,

=remper MM,Shan5s A,=ait A,>@eilly ',4d1ig =A8n$iden$eandpredi$tors of dii$lt andimpossi(lemas5

ventilation) A ;<S=H<S>4>

3? .//0%/C8FFCG%

10. <l+

>r(any ',Qoehl$5 HJ8Dii$ltmas5

ventilation)



Anesth Analg.//G%/G8%F-/ F/

11.Mheterpal S,'artin 4,Shan5s A',=remper MM8Predi$tionand ot$omesof impossi(lemas5

ventilation8 A revie1 of C/,///anestheti$s)

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3? .//G%%/8FG%-

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AirtraL inmor(id o(esepatientsndergoingemergen$y$esareandelivery)

A ;<S=H<S>4>

3? .//-%/080.G &/

13. 'ahara:!H, !ostello

J#, Higgins"D, Harte"H, 4aey

J38 4earningandperforman$eof tra$healint(ation (ynovi$epersonnel8 A $omparisonof the AirtraLand'a$intoshlaryn+gos$ope)

Anaesthesia.//00%80-%-

14. !om(esI, Ja(re P,

J(eili !,4ero ","ast:i+3arinS, 'ar+genet

A, Adnet #,Dhonner 38

PrehospitalstandardiKation of medi$alair1aymanagement8n$iden$e andris5 fa$tors of dii$ltair1ay) A$ad<merg 'ed.//0 %&8F.F&B

15. Dhonner 3, A(di Q,;do5o SM,

Amathie ,is5 ;, <lHosseini 4,Polliand !,!hampalt 3,!om(es I,=al 48 Video+assisteders!s$onventionaltra$healint(ation inmor(idlyo(esepatients)>(es Srg

.//G%G8%/G0 %/%

16. Dhonner 3, ;do5oSM, Amathie, Attias A,Hosseini 4<,Polliand !,=al 48 A $omparisonof t1ote$hniLesfor insertingthe AirtraLlaryngos$ope

in mor(idlyo(ese pa+tients)

Anaesthesia.//- 0.8--B-

17. Dhonner 3, ;do5oSM, ?av$hitK

A, #o$rier A,#essen+meyer!, Pollian !,!om(es I,=al 48=ra$heal

int(ation of mor(idlyo(esepatients8 4'A !=ra$h s



dire$tlaryngos+$opy) "r J

Anaesth.//0 G-8-B.C

18. ;do5oSM, Amathie, =al 4,Polliand !,Mamon Q, <lHosseini 4,!hampalt 3,Dhonner 38=ra$healint(ation of mor(idlyo(esepatients8 A randomiKedtrial$omparingperforman$eof 'a$intoshand AirtraLlaryngos$opes) "r J

Anaesth.//F%//8.0& F

19. Dhonne

r 3, ;do5oSM8 =ra$healint(ation1ith the 4'A !=ra$h ordire$tlaryngos$opy6letter7)

Anesth Analg.//-%/B8..-

20. 3oldman AJ8!omparingthe AirtraL1ith the 4'A !=ra$h)

A ;<S=H<S>4>

3? .//-%/-80-C 0

21. 4i <H,3oy Q, 4im

?, !hen #38S$$ess of tra$heal

int(ation1ithint(atinglaryngealmas5 air1ays8 A randomiKedtrial of the4'A #astra$hand 4'A !=ra$h)

A ;<S=H<S>4>

3? .//F%/F80.% 0

22. 3oldman AJ,osen(lattQH8 =he4'A !=ra$hin air1ayress$itation8Si $asereports)

Anaesthesia.//00%8G-C-

23. Johns'Q8 A ne1method formeasringdaytimesleepiness8=he <p1orthsleepinesss$ale) Sleep%GG% %B8CB/C0

24. #lemons

QQ,Qhitela1 QA,"rant ,emmers J<84i5eli+hoodratios for asleep apnea$lini$alpredi$tionrle) Am Jrespir !rit!are 'ed%GGB%C/8%.-G FC

25. !alder ,

!alder J,!ro$5ard HA8Dii$ltdire$tlaryngos$opyin patients1ith $ervi$alspine disease)

Anaesthesia%GGC C%8.FBC

26. "rods5y J", 4emmens

HJ, "ro$5+Utne J3, Vierra ',Saidman 4J8'or(ido(esity andtra$healint(ation)

Anesth Analg.//.GB8-&. 0

Anesthesiology



./%%%%B8.C

&&

&&

Amathie etal.

jurnal anestesi 2

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