Workshop Manual, Second Edition, 2015 Department of Anaesthesia University of Cape Town Clinical Skills Laboratory Groote Schuur Hospital 2015 Table of Contents Title page ................................................................................................................................................. 1 Programme ............................................................................................................................................. 3 Introduction ............................................................................................................................................ 4 Contributors ............................................................................................................................................ 5 Sponsors .................................................................................................................................................. 5 Airway Anatomy and Endoscopy Tips ..................................................................................................... 6 Equipment for Endsoscopic Intubation ................................................................................................ 10 Types of airway endoscopes for intubaiton ...................................................................................... 10 Rigid intubating endoscopes ............................................................................................................. 10 Flexible endoscopes .......................................................................................................................... 11 Care and cleaning .............................................................................................................................. 11 Rescuing the Airway: Rigid Bronchoscopy ............................................................................................ 12 Videolaryngoscopy: Strategies for Mastery .......................................................................................... 14 Balancing topicalization and sedation in AFOI ...................................................................................... 17 Psychological preparation facilitates the procedure. ....................................................................... 17 Adequate topicalization of the airway .............................................................................................. 17 Sedative agents ................................................................................................................................. 18 Practical Awake Flexible/Fibreoptic Intubation .................................................................................... 19 Advantages of the awake state for flexible fibreoptic intubation .................................................... 19 Definition of a difficult airway .......................................................................................................... 19 Indications ......................................................................................................................................... 20 The difficult airway with impending airway obstruction .............................................................. 20 Patients at risk of aspiration ......................................................................................................... 20 Requirements for AFOI ..................................................................................................................... 21 The flexible bronchoscope ............................................................................................................ 21 Nasal vs oral intubation ................................................................................................................ 21 Airway Innervation ............................................................................................................................ 21 Nasal cavity ................................................................................................................................... 21 Oropharynx ................................................................................................................................... 21 Larynx ............................................................................................................................................ 22 Anaesthetising the airway ................................................................................................................ 22 Some techniques of airway anaesthesia ....................................................................................... 22 Topical anaesthesia ....................................................................................................................... 22 Airway nerve blocks ...................................................................................................................... 23 Antisialogogue .............................................................................................................................. 24 AEIOU – Airway Endoscopy for Intubation and Other Uses – Workshop Manual,2nd Ed, December 2015 2 Sedation ............................................................................................................................................ 24 Benzodiazepines ........................................................................................................................... 25 Propofol ........................................................................................................................................ 25 Opioids .......................................................................................................................................... 26 Conclusion on sedation ................................................................................................................. 27 Supplemental oxygen........................................................................................................................ 28 Complications of AFOI ....................................................................................................................... 28 Training ............................................................................................................................................. 28 A stepwise approach to training would be as follows .................................................................. 28 A needle-free technique for nasal AFOI ............................................................................................ 29 References for this section ............................................................................................................... 30 Appendix A – ASA Difficult Airway Algorithm ....................................................................................... 31 Appendix B – Precedex (Dexmedetomidine) AFOI Protocol ................................................................. 32 Appendix C – DAS FOI via SAD with Aintree Intubation Catheter ........................................................ 33 Appendix D – References ...................................................................................................................... 34 Programme Start Finish Topic Instructor 07h30 08h00 Registration & coffee Hofmeyr 08h00 08h10 Welcome & Housekeeping Hofmeyr 08h10 08h20 Airway anatomy and endoscopy tips Edkins 08h30 08h50 Equipment (types, function, care) Hofmeyr 08h50 09h10 Rescuing the airway with rigid bronchoscopy Edkins 09h10 09h30 Videolaryngoscopy: strategies for mastery Hofmeyr 09h30 09h45 Questions/panel discussion All 09h45 10h00 Tea 10h00 12h30 Skills Stations: Station 1: VL Masterclass Hofmeyr Station 2: BronchoBoy - anatomy and dexterity Alberts/Veronese Station 3: Dexter - anatomy and dexterity Brennan/Visser Station 4: Rigid bronch & intubating endoscopes Edkins/Prempeh Station 5: Endoscopic intubation through SGAs Duys 12h30 13h30 Lunch 13h30 13h50 Practical awake fibreoptic intubation Brennan 13h50 14h15 Balancing topicalisation and sedation Alberts Skills Stations (minimum of 5) All 14h15 16h15 Airway topicalisation & endoscopy of participants Mannequins available for extra practice/demo 16h15 16h30 Wrap-up & closure Hofmeyr AEIOU – Airway Endoscopy for Intubation and Other Uses – Workshop Manual,2nd Ed, December 2015 3 Introduction Mastery of airway assessment and management remains a key area of knowledge and core skill for anaesthetists at all levels. The specialist anaesthesiologist is expected to have a commanding grasp of the majority of airway devices and techniques, and should be intimately familiar with dealing with airway emergencies. It is essential to become adept with the use of airway rescue devices and techniques in the non-emergency situation, before such skill is required in anger. Airway equipment continues to develop along several themes, with new devices appearing with a regularity only matched by the paucity of good quality evidence about their clinical efficacy. Adequate comparative data frequently takes years to emerge. Anaesthesiologists, particularly those involved in equipment procurement, should familiarise themselves with the medical (not marketing) literature, and the suggested guidelines for device assessment.1 Algorithms for airway rescue and the management of anticipated difficulty continue to be developed and renewed. The major national and professional anaesthesia societies release updated algorithms in a roughly 5 year cycle, which are usually to be found on their respective webpages. The Difficult Airway Society (DAS)2 and Vortex3 (see below) guidelines are useful for study and reference in theatre. The 2015 DAS guideline update is anticipated in November 2015. SASA’s most recent version was published 2014 and distributed in March 2015.4 It includes lists of recommended equipment for all levels of care. Significantly trends in the various guidelines include:  Early use of video laryngoscopes where suitable skill exists  Including the use of VL as an initial plan in anticipated difficulty  Emphasis on supraglottic airways (SGAs) as rescue devices in failed intubation  SGAs for cardiac resuscitation to minimise interruptions of chest compressions  A move from referring to CICV (can’t intubate, can’t ventilate) to the more focused CICO (can’t intubate, can’t oxygenate) nomenclature  Planning of multiple strategies (Plan A, B, C etc.) before commencing airway management. An updated collection of airway algorithms from various sources (ASA, DAS, Vortex, SASA, etc.) can be found at www.openairway.org/algorithms Regardless of which algorithm is consulted, the gold standard for the management of predicted severe airway difficulty is the use of airway endoscopy to perform intubation. While video laryngoscopes continue to increase their usefulness and role, both flexible and rigid intubating endoscopes remain critical tools in the armamentarium of the airway master. The skill to operate these devices effectively, however, requires a high level of training and practice, and a fundamental understanding of the function, strengths, weaknesses and ideal applications of each type. The AEIOU workshop is designed to give both novice and experienced practitioners the opportunities to expand their hands-on skill with all forms of airway endoscopy. We aim to achieve this through brief and targeted lectures which supplement maximum skills training time on both manikins and live patient models. Your engagement and interaction during the course, and feedback upon its conclusion will assist us in improving the education we can provide in future. AEIOU – Airway Endoscopy for Intubation and Other Uses – Workshop Manual,2nd Ed, December 2015 4 Contributors To remain current and relevant, any academic document should remain away; this is certainly true of this manual. We are indebted to the faculty and instructors on the course for providing a wealth of material which contained herein. The following individuals deserve credit for the production of this foundation for the inaugural AEIOU course:  Dr Oskar Edkins, for his elucidation of airway anatomy and rigid bronchoscopy skills  Prof Andrie Alberts, for his incisive assessment of the roles of topical as a sedation  Dr Brigid Brennan, for her expansive and practical description of how to perform awake fibreoptic intubation  The entire course instructors selflessly committing the time and expertise sharing knowledge. We are exceptionally grateful to the University of Cape Town, and in particular the UCT clinical skills laboratory, for their ongoing and wholehearted support. “The only way to truly take ownership of knowledge is to freely give it away.” Dr Ross Hofmeyr August 2015 Sponsors Workshops of this calibre would not be able to be held without the strong academic backing of the Department of Anaesthesia at the University of Cape Town, and the excellent technical and financial support of the companies providing their equipment for our learning. We would like to give particular thanks to the following institutions and companies for their ongoing investment in clinical education: SSEM AEIOU – Airway Endoscopy for Intubation and Other Uses – Workshop Manual,2nd Ed, December 2015 5 Airway Anatomy and Endoscopy Tips Dr Oskar Edkins Department of Otorhinolaryngology New Somerset Hospital & UCT AEIOU – Airway Endoscopy for Intubation and Other Uses – Workshop Manual,2nd Ed, December 2015 6 AEIOU – Airway Endoscopy for Intubation and Other Uses – Workshop Manual,2nd Ed, December 2015 7 AEIOU – Airway Endoscopy for Intubation and Other Uses – Workshop Manual,2nd Ed, December 2015 8 Rigid bronchoscopes AEIOU – Airway Endoscopy for Intubation and Other Uses – Workshop Manual,2nd Ed, December 2015 9 Equipment for Endsoscopic Intubation Dr Ross Hofmeyr African Airway & Thoracic Anaesthesia Fellow University of Cape Town Types of airway endoscopes for intubation Equipment for airway endoscopy can be divided into video laryngoscopes, and endoscopes designed to be placed through an endotracheal tube. Examples of the latter class are flexible fibre-optic bronchoscopes (or flexible intubating video endoscopes) and rigid intubating endoscopes such as the Bonfils or Shikani Optical Stylet. The video laryngoscopic devices (and similar optical laryngoscopes) are described in the separate section on video laryngoscopy. There are also devices which incorporate video endoscopy into intubating laryngeal masks, such as the CTrach and the TotalTrack VLM. Endoscopic views of the airway. Left to right: video laryngoscope, rigid endoscope through supraglottic airway, flexible video endoscope. Rigid intubating endoscopes Rigid intubating endoscopes are designed to put inside an endotracheal tube, with the tip of the scope just behind the tip of the tube. This allows a view through the device during intubation. Tow techniques can be used: midline, and retromolar. For the midline technique, one hand lifts jaw, or a normal direct laryngoscope is used, which aids difficult intubation where there is limited view of the vocal cords or even epiglottis. In patients with limited mouth opening, or obstructions of the floor of the mouth (such as tumours or submandibular abscess), a retromolar technique can be employed, whereby the scope is passed posteriorly to the molars from the side of the mouth, and is brought into the midline from an oblique angle. Rigid intubating endoscopes are not designed to be passed beyond the vocal cords, but rather to obtain a view of the glottic opening and then allow the tube to be slide of into the trachea. Bonfils (left) and Clarus (right) rigid intubating endoscopes AEIOU – Airway Endoscopy for Intubation and Other Uses – Workshop Manual,2nd Ed, December 2015 10