Difficult Airway Society guidelines for the management of tracheal extubation
TL;DR: The Difficult Airway Society has developed guidelines for the safe management of tracheal extubation in adult peri-operative practice, and they emphasise the importance of planning and preparation, and include practical techniques for use in clinical practice and recommendations for post-extubation care.
Abstract: Tracheal extubation is a high-risk phase of anaesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death. The need for a strategy incorporating extubation is mentioned in several international airway management guidelines, but the subject is not discussed in detail, and the emphasis has been on extubation of the patient with a difficult airway. The Difficult Airway Society has developed guidelines for the safe management of tracheal extubation in adult peri-operative practice. The guidelines discuss the problems arising during extubation and recovery and promote a strategic, stepwise approach to extubation. They emphasise the importance of planning and preparation, and include practical techniques for use in clinical practice and recommendations for post-extubation care.
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TL;DR: The Difficult Airway Management Guidelines as discussed by the authors provide a strategy to manage unanticipated difficulty with tracheal intubation and rapid sequence induction, which emphasizes assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions.
Abstract: Theseguidelines provide a strategy to manageunanticipated difficulty with tracheal intubation. Theyare foundedon published evidence. Where evidence is lacking, they have been directed by feedback from members of the Difficult Airway Society and based on expert opinion. These guidelines have been informed by advances in the understanding of crisis management; they emphasize the recognition and declaration of difficulty during airway management. A simplified, single algorithm now covers unanticipated difficulties in both routine intubation and rapid sequence induction. Planning for failed intubation should form part of the pre-induction briefing, particularly for urgent surgery. Emphasis is placed on assessment, preparation, positioning, preoxygenation, maintenance of oxygenation, and minimizing trauma from airway interventions. It is recommended that the number of airway interventions are limited, and blind techniques using a bougie or through supraglottic airway devices have been superseded by video- or fibre-optically guided intubation. If tracheal intubation fails, supraglottic airway devices are recommended to provide a route for oxygenation while reviewing how to proceed. Second-generation devices have advantages and are recommended. When both tracheal intubation and supraglottic airway device insertion have failed, waking the patient is the default option. If at this stage, face-mask oxygenation is impossible in the presence of muscle relaxation, cricothyroidotomy should follow immediately. Scalpel cricothyroidotomy is recommended as the preferred rescue technique and should be practised by all anaesthetists. The plans outlined are designed to be simple and easy to follow. They should be regularly rehearsed and made familiar to the whole theatre team.
1,232 citations
TL;DR: These guidelines describe a comprehensive strategy to optimize oxygenation,Airway management, and tracheal intubation in critically ill patients, in all hospital locations, and stress the role of the airway team, a shared mental model, planning, and communication throughout airway management.
Abstract: These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel–bougie–tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
522 citations
University of Oxford1, University of Plymouth2, Nottingham University Hospitals NHS Trust3, Royal College of Anaesthetists4, Northwick Park Hospital5, Papworth Hospital6, University of Salford7, Imperial College London8, Great Ormond Street Hospital9, Blackpool Victoria Hospital10, University of Leicester11, Royal United Hospital12
TL;DR: It is recommended that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness.
Abstract: We present the main findings of the 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia (AAGA). Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ∼1:19 600 anaesthetics (95% confidence interval 1:16 700–23 450). However, there was considerable variation across subtypes of techniques or subspecialities. The incidence with neuromuscular block (NMB) was ∼1:8200 (1:7030–9700), and without, it was ∼1:135 900 (1:78 600–299 000). The cases of AAGA reported to NAP5 were overwhelmingly cases of unintended awareness during NMB. The incidence of accidental awareness during Caesarean section was ∼1:670 (1:380–1300). Two-thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental, rapid sequence induction, obesity, difficult airway management, NMB, and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One-third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, mostly due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex, age (younger adults, but not children), obesity, anaesthetist seniority (junior trainees), previous awareness, out-of-hours operating, emergencies, type of surgery (obstetric, cardiac, thoracic), and use of NMB. The following factors were not risk factors for accidental awareness: ASA physical status, race, and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from NAP5—the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home.
404 citations
TL;DR: The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia, which comprise four algorithms and two tables.
Abstract: The Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably second-generation) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training.
396 citations
Cites background from "Difficult Airway Society guidelines..."
...Transfer to the intensive care unit for controlled ventilation and delayed extubation may be appropriate [20, 158, 160, 161]....
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...should be considered, including the immediate availability of appropriate staff, equipment and drugs [158]....
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TL;DR: This statement was planned on 11 March 2020 to provide clinical guidance and aid staff preparation for the coronavirus disease 2019 (COVID‐19) pandemic in Australia and New Zealand.
Abstract: Introduction This statement was planned on 11 March 2020 to provide clinical guidance and aid staff preparation for the coronavirus disease 2019 (COVID-19) pandemic in Australia and New Zealand. It has been widely endorsed by relevant specialty colleges and societies. Main recommendations Generic guidelines exist for the intubation of different patient groups, as do resources to facilitate airway rescue and transition to the "can't intubate, can't oxygenate" scenario. They should be followed where they do not contradict our specific recommendations for the COVID-19 patient group. Consideration should be given to using a checklist that has been specifically modified for the COVID-19 patient group. Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non-invasive ventilation. Significant institutional preparation is required to optimise staff and patient safety in preparing for the airway management of the COVID-19 patient group. The principles for airway management should be the same for all patients with COVID-19 (asymptomatic, mild or critically unwell). Safe, simple, familiar, reliable and robust practices should be adopted for all episodes of airway management for patients with COVID-19. Changes in management as a result of this statement Airway clinicians in Australia and New Zealand should now already be involved in regular intensive training for the airway management of the COVID-19 patient group. This training should focus on the principles of early intervention, meticulous planning, vigilant infection control, efficient processes, clear communication and standardised practice.
364 citations
Cites background from "Difficult Airway Society guidelines..."
...Extubation practices Generic guidelines exist for extubation.(21) These should be followed where they don’t conflict with the special considerations for extubation of the COVID-19 patient group outlined below....
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References
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01 Jun 2007
TL;DR: In this paper, the authors examined the development of moral development from the perspective of major theoretical approaches, emphasizing cultural differences in individualism and collectivism, which result in the acquisition of moralities based on the centrality of individuals and rights or the group and duties.
Abstract: Moral development is examined from the perspective of the major theoretical approaches. The chapter begins with discussion of historical roots of the psychology of morality. The issues accorded greatest emphasis in each approach organize the remainder of the chapter. The first section reviews conceptions of morality based on the idea that character traits constitute morality. The next section deals with approaches emphasizing emotions and processes of internalization of morality. Then comes a discussion of theories proposing that there are substantive differences between females and males in moral orientations. Next attention is given to approaches emphasizing cultural differences in individualism and collectivism, which result in the acquisition of moralities based on the centrality of individuals and rights or the group and duties. Much of the rest of the chapter focuses on approaches that emphasize the role of judgments in the development of morality defined in terms of welfare, justice, and rights. This work has examined how children's multifaceted experiences result in the development of distinct domains of judgment, including the moral, social conventional, and personal domains. The implications of the development of different domains of reasoning for contextual variations and heterogeneity within cultures are considered.
Keywords:
collectivism;
constructivism;
contexts;
domains;
individualism;
internalization;
justice;
morality of care;
reciprocal interactions;
rights;
welfare
2,320 citations
TL;DR: The potential benefits, limitations, and harms of clinical guidelines are examined, a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports.
Abstract: This is the first in a series of four articles on issues in the development and use of clinical guidelines
Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. Every day, clinical decisions at the bedside, rules of operation at hospitals and clinics, and health spending by governments and insurers are being influenced by guidelines. As defined by the Institute of Medicine, clinical guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”1 They may offer concise instructions on which diagnostic or screening tests to order, how to provide medical or surgical services, how long patients should stay in hospital, or other details of clinical practice
The broad interest in clinical guidelines that is stretching across Europe, North America, Australia, New Zealand, and Africa (box) has its origin in issues that most healthcare systems face: rising healthcare costs, fueled by increased demand for care, more expensive technologies, and an ageing population; variations in service delivery among providers, hospitals, and geographical regions and the presumption that at least some of this variation stems from inappropriate care, either overuse or underuse of services; and the intrinsic desire of healthcare professionals to offer, and of patients to receive, the best care possible. Clinicians, policy makers, and payers see guidelines as a tool for making care more consistent and efficient and for closing the gap between what clinicians do and what scientific evidence supports.
As guidelines diffuse into medicine, there are important lessons to learn from the firsthand experience of those who develop, evaluate, and use them.3 This article, the first of a four part series to reflect on these lessons, examines the potential benefits, limitations, and harms of clinical guidelines. Future articles will review lessons learned …
2,316 citations
"Difficult Airway Society guidelines..." refers background in this paper
...situations, and have been shown to improve outcomes [16, 163–170]....
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TL;DR: For the first time there has been a reduction in the inequalities gap, with a significant decrease in maternal mortality rates among those living in the most deprived areas and those in the lowest socio-economic group.
2,288 citations
TL;DR: This document updates the “Practice Guidelines for Management of the Difficult Airway: An Updated Report by”, which provides basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open-forum commentary, and clinical feasibility data.
Abstract: RACTICE Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open-forum commentary, and clinical feasibility data. This document updates the “Practice Guidelines for Management of the Difficult Airway: An Updated Report by
2,284 citations
TL;DR: The incidence of death and brain damage from airway management during general anaesthesia is low, and statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported, providing an indication of the lower limit for incidence of such complications.
Abstract: Results. Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics [95% confidence interval (CI) 38 ‐54] or one per 22 000 (95% CI 1 per 26‐ 18 000). Anaesthesia events led to 16 deaths and three episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8‐ 8.3): one per 180 000 (95% CI 1 per 352‐120 000). These estimates assume that all such cases were captured. Rates of death and brain damage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management was considered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only three deaths was airway management considered exclusively good. Conclusions. Although these data suggest the incidence of death and brain damage from airway management during general anaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airway management indicates that in a majority of cases, there is ‘room for improvement’.
1,610 citations