Adam gives practical pearls about managing the unexpected difficult airway. He uses a good example, emphasises the importance of effective teamwork and draws from the Vortex approach and the DAS guidelines. Watch out for more from Adam via the Safe Airway Society.
7. Case Study
• 69y/o BIBA with severe SOB
• Suspected cardiogenic
pulmonary oedema
• PHx IHD/AMI/Poor LVEF
• BMI 35
• SpO2 92% on non-rebreather
• Confused and combative,
removing mask
• Refusing NIV/CPAP/BiPAP
• Plan to intubate
8. Airway Plan
Delayed sequence induction
(ketamine) RSI with CP
• Plan A
• CMac #4 blade
• CMac D blade
• 3rd attempt only If anaesthestic
help arrives
• Plan B
• iGel
• Plan C
• FMV w OPA/NPA & two-hands
• Plan D
• CICO Rescue scalpel technique
10. Case Study
Airway Rescue
• FMV attempted but big leak due
to beard
• Unable to get iGel into mouth
• 100mg Sux given
• SpO2 76% when fasciculations end
• Grade IV larynx with standard #4
Macintosh blade laryngoscope
• Grade IV larynx with cMac #4
blade
• Grade IIIb larynx with CMac D
blade (CP removed, BURP
attempted)
• SpO2 68%
Is this CICO?
11. Case Study
Return to FMV
• FMV with OPA and two hands
produces some chest movement
• Poor capnograhy trace
• SpO2 steady at 84%
What now?
12. Case Study
Anaesthetic Registrar Arrives
• A.R. - “What have you tried?”
• FACEM – “We’ve tried
everything…can barely
ventilate with FMV and LMA
didn’t work. Couldn’t intubate
with cMac. Do you want to have
a look?”
What now?
13. Case Study
Anaesthetic Registrar
• Attempts intubation with Mac #4
blade – Grade IV view
• SpO2 70%
• cMac #4 blade – Grade IV view
• Returns to FMV – impossible
• SpO2 58%
• cMac D-blade – Grade IIIb view,
blind insertion = No ETCO2
• SpO2 unrecordable
• Returns to FMV – impossible…”I
think this is CICO”
Is it?
Who? How?
14. Case Study
CICO Rescue
• FACEM – “Do you want to do
it?”
• A.R. – “Ok. Give me a 14G
cannula”
• 2 mins - Cannula inserted
• A.R. – “Have you got a Rapid-
O2?....What about an ENK?”
• (Silence)....
• 3 mins - FACEM performs
scalpel-bougie
• 5 mins – O2 delivered, SpO2
90%
15. The Unanticipated Difficult Airway
Management Goals
• Try all three lifelines
• Optimise all three
lifelines
• Do it quickly (minimum no.
of attempts)
• Don’t repeat anything
• Recognise and exploit
opportunities of the GZ
• Know when to declare CICO
• Be ready to perform CICO
Rescue
16. • Try all three lifelines
• Optimise all three
lifelines
• Do it quickly (minimum no.
of attempts)
• Don’t repeat anything
• Recognise and exploit
opportunities of the GZ
• Know when to declare CICO
• Be ready to perform CICO
Rescue
The Unanticipated Difficult Airway
Management Goals
17. The Unanticipated Difficult Airway
Management Goals
• Try all three lifelines
• Optimise all three
lifelines
• Do it quickly (minimum no.
of attempts)
• Don’t repeat anything
• Recognise and exploit
opportunities of the GZ
• Know when to declare CICO
• Be ready to perform CICO
Rescue
The Unanticipated Difficult Airway
Management Goals
18. • Try all three lifelines
• Optimise all three
lifelines
• Do it quickly (minimum no.
of attempts)
• Don’t repeat anything
• Recognise and exploit
opportunities of the GZ
• Know when to declare CICO
• Be ready to perform CICO
Rescue
The Unanticipated Difficult Airway
Management Goals
19. • Try all three lifelines
• Optimise all three
lifelines
• Do it quickly (minimum no.
of attempts)
• Don’t repeat anything
• Recognise and exploit
opportunities of the GZ
• Know when to declare CICO
• Be ready to perform CICO
Rescue
The Unanticipated Difficult Airway
Management Goals
23. Dual-process theory
• Default to type 1 decision-making
• Biases & errors
• Compounded by distractors and
technical tasks
Fundamental airway errors – Why?
27. Solutions?
Safe Airway Society
• Multi/interdisciplinary
• Focus on universal
principles, not
discipline-specific
• Watch this space
28. Summary
• High rates of morbidity including avoidable
complications
• Complex patients/situations require robust
teamwork practices
• Coordination
• Shared mental models
• Rehearsal and practice
• Much still to learn in this area
I want to begin by acknowledging Nickn Chrimes and Peter Fritz who created the Vortex tool and the overall Vortex Approach concept. I want to acknowledge Nick for the broader Vortex Aproach as outlined on the website of the same name. The presentation was originally listed as beyond vortex, which implies I somehow think it is somehow time to move past the Vortex, which is not the intention of this presentation. Instead I am encouraging all practitioners involved in airway management to move beyond the vortex tool and think about how the broader Vortex Approach can enhance team performance
No conflicts of interest. My biggest disclosure is, however, given away by the letters after my name…
Yep, I am from the wrong tribe…So what is an anaesthetist doing here mansplaining your jobs to you?
I spend a fair proportion of my time in the sim lab, often teaching multidisciplinary groups. I have spent considerable time on committees looking at critical incident reports, and what I have learnt from simulation, which is backed up by studies such as the NAp4 study out of the UK and other studies, is that we make fundamental errors in judgement, descion making and communication during airway management in critically ill patients. These manifest as..
Provide the participants with any additional info they need. 18G IV in left hand. BP 98/60. PR 95 SR.
Predicted difficulty with FMV (beard).
Tricky right?
Anaesthesic help requested
The airway plan (strategy) is based on the DAS ICU approach
So how did we go? What went right? There were some good aspects. What went wrong? To really assess what went right and wriong we need to first define what theggoals of Mx are during the unanticipated difficult airway (or just difficult airway) Mx
The the goals of Mx are all contained within the vortex tool or vortex approach. Go through these
So, looking at these goals, which did we meet and which didn’t we meet?
Were all 3 tried? Yes, but..were they optimized? LMA never attempted after NMBDs given
Was anything repeated? Yes, just about everything
When the patient was ventilatable (ie in the GZ), was this opportunity declared or exploited? Not really, rather than discussing options the choice was made to let the AR have a go at intubating. The GZ provides opportunity to optimize/oxygenate, gather resources, possibly move to theatre, etc, etc
Fundamental errors – why?
To begin with, although the vortex tool appears simple, it is actually a complex tool and covers a lot of ground. Similarly, the DAS approach is not easy to draw upon under pressure
Then we have the issue of patient complexity – he was far from straight forward. The issues of flash teams – members arriving at random times, not necessarily familiar with each other, roles unclear. And finally, you have the problem of the airway management model existing largely in the mind of the operator – whether it be people using the vortex approach as a personal aide memiore or apttempting to follow the DAS algorithm – the moment this patient became apneic and strayed from the predetermined plan there was no shared mental model
To understand what contributes to or exacerbates these issues it is worth mentioning the body of work pioneered by Danial Kahneman on dual process decision making. Give summary. Explain that under time critical situations we tend to defsault to Type 1 thinking which is fast easy but very prone to biases and errors. Instead of considering the question at hand we look for shortcuts which ofeten means substitutimg easy answwrs based on experience or external cues. The substitute answers might be “the D-blade always works”, or “the anaesthetic registrars will definitey solve the problem”, or “this must be CICO” even when things ahavnet been attempted.
All of this is vastly exagereated when we try to perform any technical tasks while trying to make complex decisions
On top of all of this there is often a lack of role clarity. This is some unpublished data from our hopsital
Ok, so what are the solutions.
To begin with, regardless of what airway management tool or approach we are following, we need to take it out of the realm of personal aide memoire and make it “the” shared mental model during the entire episode
Next, in order to have, and maintain a shared mental model we need a central coordinator charged with the decision making and sharing information
It is reassuring to see increasing numbers of intubation checklists encouraging/forcing allocation of a TL for airway Mx
And finally, for any team to work together effectively using a specific protocol or model of care, we need multidisciplinary team training with a focus on human factors and non technical skills – simulation would be the logical vehicle for this
The is the perfect time to plug a new initiative. The area of non-technical skills in airway management including team dynamics in multidisciplinary situations is new territory
Go over process and what is in store