Advanced Airway Management Techniques - A Recent Update

Introduction:

In recent years, new techniques have emerged to assist with breathing for awake individuals and those under anesthesia. Two notable options are the Laryngeal Mask Airway (LMA) and the fiberoptic laryngoscope. The LMA is an alternative to inserting a breathing tube into the windpipe, suitable for cases requiring a gentler approach or when traditional methods are challenging. While it maintains an open airway, it does not prevent the risk of stomach contents entering the lungs. The fiberoptic laryngoscope is a significant advancement for managing difficult breathing scenarios in awake or anesthetized individuals. Additional tools like illuminated wands, specialized scopes for inserting breathing tubes, and various tests are available. Many variations of the original LMA have been developed since its inception, aiming to address its limitations or cater to specific situations.

What Are the Research Collaborations in Anesthesia Advanced Airway Management?

The Anesthesia Advanced Airway Management Research Group is involved in various research projects and partnerships related to helping people breathe better, especially in challenging situations. Here is a breakdown of what they are working on:

• Pediatric Difficult Airway (PeDI) Collaborative: This group is part of an organization that focuses on understanding and improving the breathing outcomes of children during medical procedures. They collect information from different places to find ways to enhance the care of kids who might have trouble breathing. They are also involved in creating guidelines and researching to improve things.

• American Society of Anesthesiologists (ASA) Task Force: Some research group members collaborated to create guidelines for difficult breathing situations. They also made sure to include guidelines specifically for children.

• Video Laryngoscopy in Small Infants (VISI) Trial: They did a study involving babies to compare two different ways of helping them breathe better. They published the findings in a well-known medical journal.

• Clearance Collaboration: This is a group effort to figure out the best methods for helping kids with breathing problems caused by infectious diseases. They are working with multiple organizations to find the best solutions.

• European Society of Anaesthesiology and British Journal of Anaesthesia Collaboration: The research group is part of a team working on guidelines and special articles about helping newborns and infants with breathing.

• Patient Safety Advisory Group: Some research group members are part of a team focused on ensuring that breathing procedures are as safe as possible during anesthesia.

• Development of New Equipment: They create and test new tools to help doctors manage difficult breathing situations in children. They might work on this alone or with other organizations and companies.

• Simulation Training: They are exploring ways to use training simulations to make sure doctors can successfully and safely put breathing tubes when needed.

• Collaboration with OpenAnesthesia: They are working with an online educational resource to create materials that teach people about breathing procedures and important related terms.

What Are Some Methods Used to Open up a Blocked Airway?

Clearing Blockages: If someone's upper airway is blocked, there are ways to help. Tilting the head, lifting the chin, or moving the jaw can open the airway. For babies and kids, gently suctioning the airway can remove mucus or debris. When using a suction device, it is essential to do the mouth first, then the nose, in babies.

• Oropharyngeal Airway: This device can help keep the airway open. But it is unsuitable for people with a strong gag reflex or mouth injuries.

• Nasopharyngeal Airway: Used when the gag reflex is okay, but there is a need to keep the airway open. Choosing the right size is important based on the person's height.

• Breathing Assistance with a Bag-Mask Ventilation: An essential technique to help someone breathe. It is done with a mask held over the face, and different methods can be used depending on the person's age.

• Supraglottic Devices: The laryngeal mask airway can be placed above the vocal cords to help breathing. They are simpler to use and quicker to set up, which is helpful in emergencies.

• Endotracheal Tube: A tube can be inserted into the windpipe for better airway control. This is used in more complex situations.

• Oxygen Use: Oxygen is crucial for airway management. Giving oxygen through a mask or other methods before inserting a tube can ensure enough oxygen in the body.

• Bougie: A flexible plastic tool that can guide a breathing tube into the right place.

What Are the Various Airway-Related Tasks That Can Become Difficult During Anesthesia?

A problematic airway refers to a situation during anesthesia where a doctor faces challenges or cannot perform specific airway-related tasks effectively. These tasks include using a mask to help the patient breathe, examining the vocal cords, using a special airway device, inserting a breathing tube into the trachea, removing the breathing tube, or placing a tube directly into the neck.

• Difficult Facemask Ventilation: When it is hard to provide enough air through a mask over the face due to issues like a poor seal, air leaks, or air resistance.

• Difficult Laryngoscopy: When the doctor cannot see the vocal cords even after several attempts using a laryngoscope.

• Difficult Supraglottic Airway Ventilation: When it is challenging to deliver enough air using a special airway device placed above the vocal cords due to problems like improper placement, leaks, or air resistance.

• Difficult or Failed Tracheal Intubation: Inserting a breathing tube into the windpipe requires many tries or is unsuccessful despite repeated attempts.

• Difficult or Failed Tracheal Extubation: After removing a breathing tube or special airway device, the patient's airway becomes blocked or does not allow proper breathing, especially if the patient is at risk for airway issues.

• Difficult or Failed Invasive Airway: Anatomical features or abnormalities make inserting an airway tube through the front of the neck into the windpipe hard or unlikely.

What Are the Advanced Airway Assessment Techniques?

Nasoendoscopy:

• Nasoendoscopy uses a small, flexible tube with a tiny camera to look inside the nose, throat, and voice box.

• Doctors, especially ENT specialists, use it to check for issues in the airway and throat. It helps them understand if problems are blocking breathing or causing other troubles.

• The procedure involves a trained doctor using a small camera on a flexible tube to carefully examine the nose and throat. They might use numbing medicine to make it more comfortable.

• It is used in planned situations, like before surgery and emergencies, when someone has trouble breathing.

• It gives doctors a clear view of the airway and helps them plan safe ways to manage any issues they find.

Point-of-Care Ultrasound (POCUS) for Airway Assessment:

• POCUS uses ultrasound to create images of the airway and structures of the neck. It is a non-invasive way to see inside the body.

• It helps doctors assess the airway and structures before surgery or other procedures. It can also guide decisions during emergencies.

• A doctor uses a small ultrasound device on the skin to create images. It is quick to learn and can provide valuable information about the airway.

• POCUS can help estimate the size of the trachea, locate the opening for a potential emergency breathing tube, and check for stomach contents to prevent aspiration.

• POCUS is fast, does not require radiation, and can guide essential decisions during airway management.

Virtual Endoscopy (VE):

• VE uses CT and MRI images to create a 3D airway model. It is like a virtual tour of the inside of the throat.

• It helps doctors plan how to manage difficult airways and make decisions about procedures before they happen.

• CT or MRI images create a virtual pathway through the airway. Doctors can "fly through" this pathway to see different views.

• VE provides a detailed, 3D view of the airway, which helps doctors plan safer procedures and find the best ways to manage any issues.

• VE is especially useful for patients with complex airway problems or head and neck issues. It improves the accuracy of diagnosing and planning treatment.

Conclusion:

Many severely injured trauma patients required advanced techniques to address breathing difficulties. The standard treatments ambulance crews provide are effective for some patients but are not always the most suitable choice. Both medical professionals encounter challenges when employing advanced approaches, such as inserting a tube into the throat. Errors like misplacing the tube or failing to recognize if it was in the wrong passage occurred more frequently among paramedics.