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Management Of The Difficult Airway
13 Plays4 years ago
In this episode of Critical Matters, we will discuss the management of the difficult airway.
Our guest is Dr. Thomas Heidegger. Dr. Heidegger practices anesthesia and intensive care medicine. He is a Professor in the Department of Anesthesia, Spital Grabs, in Grabs and the Department of Anesthesiology, and Pain Medicine, Bern University Hospital, University of Bern, in Bern – both in Switzerland.
Additional Resources:
Management of the Difficult Airway: https://bit.ly/2T0mXsj
Major Complications of Airway Management - Fourth National Audit Project (NAP4): https://bit.ly/2UwJZHT
Understanding Sensitivity and Specificity with the Right Side of the Brain: https://bit.ly/3gOqF1h
Canadian Airway Focus Group Updates Consensus-Based Recommendations for Management of Difficult Airways: https://bit.ly/3h0tkUt
Video - Face Mask Ventilation - Two-Handed Technique: https://bit.ly/3w0RNPj
Video - Emergent Surgical Airway (Cricothyrotomy): https://bit.ly/3zPsAKx
Books Mentioned in this Episode:
West Pulmonary Physiology: The Essentials: by John B. West and Andrew M. Luks; https://amzn.to/3gOdfm8
Thinking Fast and Slow by Daniel Kahneman: https://amzn.to/3d4bnTN
Noise: A Flaw in Human Judgment by Daniel Kahneman: https://amzn.to/35KpdXJ
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now your host, Dr. Sergio Zanotti.
Airway Management in Critical Care
00:00:33
Speaker
Airway management is a daily occurrence in the practice of critical care.
00:00:37
Speaker
Complications associated with airway management have a potential devastating impact on patients, causing severe morbidity and mortality.
00:00:44
Speaker
In today's episode of Critical Matters, we will discuss the management of the difficult airway.
Guest Expert: Dr. Thomas Heidegger
00:00:50
Speaker
Our guest is Dr. Thomas Heidegger.
00:00:52
Speaker
Dr. Heidegger is an anesthesia intensive care physician.
00:00:55
Speaker
He holds faculty appointments as professor in the Department of Anesthesia, Spital Grabs and Grabs,
00:01:00
Speaker
in the Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern in Bern, both in Switzerland.
00:01:07
Speaker
Professor Heidegger is a renowned expert in airway management and is the author of an excellent review on the topic recently published in the New England Journal of Medicine.
00:01:16
Speaker
We are honored to have him as a guest.
00:01:18
Speaker
Thomas, welcome to the podcast.
00:01:21
Speaker
Sergio, thank you very much for inviting me.
00:01:24
Speaker
I'm really pleased to join this meeting.
00:01:27
Speaker
Excellent.
00:01:28
Speaker
Well, we have a
00:01:29
Speaker
a very difficult topic, like we were mentioning, I mean, the challenges you had in putting this into a review article for the New England Journal of Medicine, but a topic that obviously is very dear to our anesthesia, our emergency medicine, and our critical care colleagues all over the
Defining Difficult Airways
00:01:45
Speaker
world.
00:01:45
Speaker
So maybe we could start, Thomas, with a definition on what is a difficult airway from your perspective.
00:01:54
Speaker
Yeah, that's a tough question because
00:01:58
Speaker
We don't agree what, we don't have a standard definition of a difficult airway at this time.
00:02:06
Speaker
So, recent guidelines about difficult airway management say that if an experienced practitioner anticipates or encounters difficulty with face mask ventilation, tracheal intubation or supraglottic airway use or recognizes the need for an emergency surgical airway,
00:02:26
Speaker
So that is a difficult airway.
00:02:29
Speaker
It doesn't help us really much, but we don't, at the moment, don't have a better definition of a difficult airway.
00:02:36
Speaker
An important aspect though of that definition that, as you said, although imperfect, still is a good framework to start is that you really talked about different stages in airway management, right?
00:02:47
Speaker
So a lot of people might think that the intubation itself is the difficulty, but you talked about face mask ventilation,
00:02:55
Speaker
disvalidization, tracheal intubation, or supraglottic management.
00:02:58
Speaker
So those four are very important, right?
00:03:02
Speaker
Absolutely, absolutely.
00:03:03
Speaker
And that's a problem with some of the guidelines.
00:03:07
Speaker
Many guidelines start with a problem with tracheal intubation, but air management starts before.
00:03:14
Speaker
So if your patient gets unconscious, then you have to manage this airway.
00:03:19
Speaker
And the first technique you normally use is mask ventilation.
Prevalence and Signs of Difficult Airways
00:03:25
Speaker
So that's critically important to talk about mask ventilation before we talk about difficult intubation.
00:03:33
Speaker
Absolutely.
00:03:34
Speaker
And in terms of incidents of difficult airways, recognizing that we have an imperfect definition, could you just make some comments on what we understand based on the literature, Thomas?
00:03:48
Speaker
Yeah, on face mask ventilation, there are many, many definitions.
00:03:52
Speaker
I think one,
00:03:54
Speaker
A very practical definition is from HAN.
00:03:56
Speaker
It's a HAN score.
00:03:57
Speaker
It's not perfect, but I think for daily practice, we use that in our hospital every day.
00:04:05
Speaker
It's four grades.
00:04:07
Speaker
Grade one is no problem with mask ventilation.
00:04:10
Speaker
Grade two is ventilation by mask is possible with an oral airway or another adjuvant.
00:04:16
Speaker
And grade three mask ventilation is difficult, defined as inadequate, unstable,
00:04:21
Speaker
or requiring two providers and grade four mask ventilation is impossible.
00:04:26
Speaker
Well, it's not perfect, but I think it is very useful for daily practice.
00:04:33
Speaker
I think ideally ventilation should be confirmed, not only by this clinical science, but also by technical science.
00:04:43
Speaker
So if you have a capnographic tracing, you can add this
00:04:49
Speaker
to define if mask ventilation works or doesn't work.
00:04:52
Speaker
So ideal ventilation should be confirmed by an observation of a rise in the chest.
00:04:57
Speaker
That's a clinical sign.
00:04:59
Speaker
By a capnographic tracing, that's a technical sign.
00:05:04
Speaker
And by, of course, at least by an increase in oxygen saturation.
00:05:10
Speaker
So that's a combination of a technical and clinical sign.
00:05:15
Speaker
Excellent.
00:05:16
Speaker
And in terms of the frequency, I know that in your review, you had cited that difficult phase mass ventilation, which I presume would be on those grades you described, anything between one and three occurs maybe 1.5 to 5%.
00:05:31
Speaker
Absolutely.
00:05:31
Speaker
That grade zero is not very frequent, right?
00:05:35
Speaker
Yeah.
00:05:36
Speaker
That's the main problem and the main challenge.
00:05:39
Speaker
Fortunately, the real difficult airway is a rare phenomenon.
00:05:43
Speaker
That's
00:05:45
Speaker
Fortunately, it is a rare phenomenon.
00:05:47
Speaker
And so it is also, therefore, as a consequence, it is very difficult to predict a difficult airway in beforehand.
00:05:57
Speaker
Absolutely.
00:05:57
Speaker
Because the absolute, the event itself, the difficult airway is a rare event.
00:06:04
Speaker
So it's always, all those tests, a combination of tests to predict the difficult airway will finally more or less fail because
00:06:15
Speaker
The event itself, the difficult airway, is a rare event.
00:06:19
Speaker
So the prevalence in all those tests, the prevalence is the most important thing to say if a test, a single test, or a combination of tests can predict a real difficult airway.
00:06:35
Speaker
That means that you have to always be prepared, that you can always be encountered with a difficult airway, even though
00:06:44
Speaker
You don't expect it or your tests say this is not a difficult airway, but in fact, it can be a difficult one.
00:06:54
Speaker
You don't know it beforehand, except you have, of course, you have a patient with a limited mouth opening, a patient with absolutely morbid obesity and so on.
00:07:07
Speaker
It's an anticipated difficult airway situation.
00:07:11
Speaker
I think that's a very important point that not only applies to difficult airways, but I believe it applies to how we assess all sorts of tests in clinical practice, which is we don't usually account for the real prevalence of what we're looking for.
00:07:24
Speaker
And we forget that any test, no matter how good performance, will be impacted by that, right?
00:07:29
Speaker
So you had commented in your paper the importance of this in difficult airway prediction in terms of positive predictive value and negative predictive value and how that
00:07:40
Speaker
can sometimes, I mean, influence what a false positive looks like and what a false negative looks like.
00:07:46
Speaker
Absolutely, absolutely.
00:07:48
Speaker
So there's a wonderful publication, I referenced this in my journal, it's from Lung, or Lung, I don't know how to pronounce it correctly.
00:07:58
Speaker
It is the understanding sensitivity and specificity with the right side of the brain.
00:08:03
Speaker
It's a fantastic article to explain
00:08:07
Speaker
terms like sensitivity, specificity, positive or negative predictive value.
00:08:12
Speaker
So it's a fantastic paper.
00:08:13
Speaker
I can really recommend to read
Preparation for Unexpected Difficult Airways
00:08:15
Speaker
that.
00:08:16
Speaker
And from a clinical perspective, ultimately with difficult airway, Thomas, if you anticipate a difficult airway and you're prepared and you don't find one, there's no problems and that usually is great.
00:08:28
Speaker
However, if you're not prepared, you didn't anticipate a difficult airway and you get in that situation, it can have devastating
00:08:36
Speaker
consequences for the patient.
00:08:38
Speaker
Absolutely.
00:08:39
Speaker
I think that's the key point.
00:08:41
Speaker
You have always to be prepared to face with, we say, unexpected, difficult airway.
00:08:51
Speaker
That's really the key message.
00:08:53
Speaker
That's a key message.
00:08:55
Speaker
Beyond that, of course, you need the skills to do that.
00:08:59
Speaker
That's another problem.
00:09:00
Speaker
But being prepared
00:09:03
Speaker
to manage an unexpected difficult airway is essential.
00:09:07
Speaker
So we talked about a little bit about the incidents and like you said impossible ventilation or failed trigger intubation really occur at a very very low percent way below one percent of all airways.
00:09:22
Speaker
I do have a couple more questions on incidents before we move a little bit forward.
00:09:27
Speaker
What's the role of video laryngoscopy?
00:09:29
Speaker
That is something that obviously when I trained we didn't have it available.
00:09:34
Speaker
Now I have it available for every airway I do in the ICU.
Video Laryngoscopy vs. Conventional Methods
00:09:38
Speaker
And I just wanted to get a feel of what the literature really tells us or doesn't tell us yet about the use of video laryngoscopy, especially in the ICU.
00:09:50
Speaker
Data are still conflicting.
00:09:54
Speaker
That's the reason why I referenced some of these papers.
00:10:00
Speaker
And you see this is there is no consensus.
00:10:03
Speaker
We have some papers who really prefer vitolaryngoscopy.
00:10:08
Speaker
It is much better than conventional laryngoscopy.
00:10:11
Speaker
Other papers just say the different, just say the opposite.
00:10:16
Speaker
And the Cochrane review doesn't confirm that vitolaryngoscopy is really
00:10:24
Speaker
It shows us that the number of intubation attempts maybe can be lowered.
00:10:32
Speaker
That's another topic because you shouldn't do that four or five or six times.
00:10:38
Speaker
I think what with your laryngoscopy is really superior to conventional laryngoscopy is in two things.
00:10:45
Speaker
It is first of all,
00:10:48
Speaker
you can watch what the other colleague or your nurse is doing.
00:10:54
Speaker
And on the other side, if you are teaching in a teaching hospital, others can watch what you are doing as an expert.
00:11:02
Speaker
So in teaching and helping juniors, it is absolutely fantastic.
00:11:09
Speaker
In management of the unexpected difficulty, in many cases, you have a better view than
00:11:15
Speaker
than with conventional laryngoscopy.
00:11:17
Speaker
I think that's a matter of fact.
00:11:19
Speaker
In very, very rare cases, it is better looking at the conventional side than on the video laryngoscopy.
00:11:26
Speaker
This was a result of, I think, the first large multicenter study from Europe and the United States.
00:11:34
Speaker
Marshall Kaplan, I think was the first author published in an American journal.
00:11:40
Speaker
And we participated in this study at my former hospital, and we had some cases where we did see the glottic conventionally, but we didn't see anything on the screen.
00:11:53
Speaker
But normally, it is just the opposite.
00:11:56
Speaker
You see it much better on the screen than conventionally in a difficult situation.
00:12:01
Speaker
But what we also have learned is that laryngoscopy is not the same as in tubal patients.
00:12:08
Speaker
And that's, I think that's an important thing, an important step in our mind by using video laryngoscopy instead of conventional laryngoscopy.
00:12:19
Speaker
And even though some colleagues don't like to hear that, but it is not a panacea for everything, for every airway situation.
Limitations of Video Laryngoscopy
00:12:30
Speaker
Because if you have a patient with a limited mouth opening, you can't use a video laryngoscope.
00:12:37
Speaker
And if you have a patient with a limited neck mobility, it doesn't help you really very much.
00:12:43
Speaker
So there are situations where you need a different technique to manage this airway.
00:12:49
Speaker
So it is, of course, something which supports us and it is a milestone in the development of air management, but it's not a panacea for all difficult air management situations.
00:13:02
Speaker
And I think that that's an important point, right?
00:13:04
Speaker
I mean, it's a step forward.
00:13:05
Speaker
it's a great tool to have in our tool belt but like you said in there will be situations where you will need to recur to other tools and we'll talk about some of those further down in our conversation.
00:13:17
Speaker
Absolutely and please let me add something more Sergio.
00:13:22
Speaker
There's a special situation with the hyper-angulated with the laryngoscope.
00:13:27
Speaker
I mean you get a fantastic view with those devices but the
00:13:32
Speaker
The problem you have, you must be very skilled with this technique that you can manage the airway.
00:13:37
Speaker
So the problem you see that you fail is something we can really recognize quite often.
00:13:44
Speaker
So if you're really an expert, it will, it does work of course, but if you don't know those tips and tricks with using a hyper-angulated vialaryngoscope, it is really difficult to get the airway managed.
00:13:59
Speaker
I agree.
00:14:00
Speaker
The other question I had in terms of the instance of difficult airways is if you could comment on two factors and how they relate to incidents.
Impact of Patient Population on Airway Incidents
00:14:11
Speaker
One is patient population and specifically in females OB versus non-OB.
00:14:17
Speaker
And the other one is location OR versus emergency department versus ICU.
00:14:23
Speaker
Okay.
00:14:24
Speaker
Let me start with the second one, the NAP4.
00:14:30
Speaker
clearly showed that the problem with airway management in the ICU and in the emergency department happens more often than in the OR.
00:14:40
Speaker
So that's a matter of fact.
00:14:42
Speaker
Difficult airway management is absolutely present in the ICU and emergency department.
00:14:49
Speaker
It happens more often than in the OR.
00:14:53
Speaker
So that's a matter of fact.
00:14:55
Speaker
All those studies confirmed and the largest one is, of course, is NAP4.
00:15:01
Speaker
And the second one, your first question is obese versus non-obese.
00:15:07
Speaker
And all those studies confirm, it's not only NAP4, it's only the close claims analysis, that obese patients are more frequent to have a difficult airway.
00:15:22
Speaker
And if you have a patient with a morbid obesity, so it's a BMI of 40 or more,
00:15:28
Speaker
difficult airway situations arises four times more than in the non-obese.
00:15:33
Speaker
So obese and especially morbid obese patients are a population we are faced with difficult situations quite more often than in the normal population.
00:15:48
Speaker
So I think it's important to note for our listeners, especially since most of our audience, I presume, practices intensive care unit is that the frequency of these difficult airways is significantly higher
00:15:58
Speaker
in emergency situations, either in the emergency department or in the ICU as compared to the OR.
00:16:05
Speaker
I would like to move forward and talk a little bit about prediction of a difficult airway.
00:16:09
Speaker
We did talk about the false positives, false negatives and those consequences and we already established why that's so important.
00:16:14
Speaker
But if you could maybe give us a little bit of your take on how to best evaluate the airway, and that might be very different depending on the time you have in an elective case versus obviously an emergency.
00:16:25
Speaker
But also, I know that you talk about predictors of difficulty, Thomas, in terms of anatomical, physiological and contextual.
00:16:32
Speaker
If you can just expand a little bit on this area.
00:16:36
Speaker
Yeah.
00:16:37
Speaker
Well, even though we can't really predict a difficulty, we should do that because otherwise you don't forget the simple things, asking your patient to open his mouth or to move his mic forward and backward.
00:16:50
Speaker
So you should do that.
00:16:52
Speaker
And we personally do,
00:16:55
Speaker
a phyramental distance and upper lip bite test.
00:16:59
Speaker
So all those things, we do that.
00:17:02
Speaker
And we also measure the BMI.
00:17:06
Speaker
And so we don't do things you can't read in this paper.
00:17:11
Speaker
So we do all those things, but we don't do every special test.
00:17:21
Speaker
So this,
00:17:23
Speaker
You can't do that in every day's practice.
00:17:25
Speaker
So we do that.
00:17:26
Speaker
And I think really important is also the history.
00:17:30
Speaker
So does this patient has already an intubation a couple of years ago?
00:17:35
Speaker
Were there any problems?
00:17:36
Speaker
We now have electronic protocols so we can go back to the past looking whether any technical problems with intubation and so on.
00:17:49
Speaker
You have to be alert to do that.
00:17:51
Speaker
Even though you know it's not perfect, you shouldn't forget to do that because it is a memnotechnic thing that you ask the patient to open his mouth, to pull out his tongue and so on.
00:18:04
Speaker
So it's a very practical answer, not very scientifically based because all those tests do have a low positive predictive value.
00:18:17
Speaker
Absolutely.
00:18:18
Speaker
Nevertheless, do that.
00:18:19
Speaker
That's an excellent paper.
00:18:21
Speaker
Is such a test worthwhile issue or not from Steve Yantes, who was a former editor-in-chief from Anesthesia from UK.
00:18:30
Speaker
That's a fantastic paper.
00:18:31
Speaker
I can really recommend that.
00:18:32
Speaker
Okay.
00:18:33
Speaker
We'll put that on the show links.
00:18:35
Speaker
In terms of other predictors of difficulty from an anatomical, physiological, and contextual standpoint, could you just comment on some that you think are most important?
00:18:47
Speaker
Yeah.
00:18:48
Speaker
I just mentioned, I think there was the anatomical predictors, limited mouth openings, having a beard or not.
00:18:58
Speaker
Obesity, of course, are the anatomical predictors.
00:19:02
Speaker
The physiological predictors are beside, for example, a full stomach is something with your oxygen saturation rapidly decreases.
00:19:14
Speaker
and your onset of apnea starts very, very, very fast because of reduced functional residual capacity.
00:19:23
Speaker
It's a pregnant patient or a patient with a full stomach and so on, or a patient is a sepsis if the oxygen consumption is much higher than in the normal patients.
00:19:35
Speaker
So I think that's the most important physiological parameters.
00:19:40
Speaker
And also important are the contextual parameters.
00:19:43
Speaker
Because if you are inexperienced in a technique or inexperienced in an unexperienced area, you don't have enough personnel to support you in this special situation.
00:20:00
Speaker
Or the patient, you can't do an awake intubation because the patient doesn't tolerate it and say nothing about that.
00:20:08
Speaker
So, yeah.
00:20:10
Speaker
if the situation doesn't allow you to do that, what you really want to do or you should do, or you're not experienced or what was a result from NEP4 regarding management of the anticipated difficult airway and fiber optic intubation.
00:20:25
Speaker
There were two things that's really worth mentioning.
00:20:29
Speaker
The first one was that some of the colleagues recognized that this situation
00:20:36
Speaker
renders a fiber optic intubation and they didn't do that because of two reasons.
00:20:40
Speaker
First, they didn't do it because they weren't available to do to manage this technique because they had no skills or they tried to do a fiber optic intubation but it failed because they had no skills.
00:21:01
Speaker
I think that's a contextual issue.
00:21:03
Speaker
You should do something.
00:21:04
Speaker
You know that you should do fiber optic innovation, but you don't do it because you are not skilled with this technique or you do it, but your skills are not enough to manage this airway.
00:21:16
Speaker
So the contextual issues are, I think, an important point in those predictors.
00:21:22
Speaker
So prediction is very, very important, even though we can't really predict a difficult airway situation.
Always Be Prepared for Difficult Airways
00:21:29
Speaker
Absolutely.
00:21:30
Speaker
I think like Neil Bors would say, right?
00:21:34
Speaker
The climate prediction of the future that's very difficult to do, right?
00:21:38
Speaker
And I think that... Absolutely.
00:21:42
Speaker
Exactly.
00:21:43
Speaker
But I think the exercise, like you mentioned, of always being ready and thinking ahead of time when we have the time and having that discipline of evaluating the airway and understanding because when you find
00:21:58
Speaker
that your assessment suggests a difficult airway, there's really no reason for you to be unprepared, right?
00:22:05
Speaker
So you should be prepared.
00:22:07
Speaker
And the problem is that you might think it's an easy airway and then get into trouble.
00:22:11
Speaker
So the bottom line is you should be prepared as well.
00:22:14
Speaker
And I think that that's really the message that we'll try to get along.
00:22:18
Speaker
So we could move on, Thomas, and talk about the management of the difficult airway.
00:22:24
Speaker
And many guidelines and your review have separated this into unanticipated difficulty versus anticipated difficulty.
00:22:33
Speaker
And that might give you different options of a different kind of roadmap to follow.
Handling Unexpected Difficult Airways
00:22:39
Speaker
Considering that the vast majority, in some studies, over 93, 94% of difficult airways are unanticipated, why don't we start with how you would manage the unanticipated difficult airway, especially in the ICU?
00:22:55
Speaker
I think it doesn't really make a large difference.
00:22:59
Speaker
If you get the patient unconscious and then you have trouble with face mask ventilation, if you do that, in ICU, maybe you do a rapid sequence induction.
00:23:15
Speaker
So we maybe could talk about that a little bit later.
00:23:19
Speaker
But if you try to ventilate this patient by face mask and you can do that,
00:23:24
Speaker
So then you have time to think about, okay, I will conventionally intubate them with the laryngoscope or a VDLaryngoscope.
00:23:33
Speaker
But if you have trouble with face mask ventilation, then you have to decide, can I oxygenate this patient?
00:23:43
Speaker
Yes or no.
00:23:45
Speaker
If no, you don't have a lot of time, especially on the ICU, because those patients
00:23:51
Speaker
have reduced, most of them have reduced functional residual capacity.
00:23:56
Speaker
Oxygen consumption is much higher than in the normal patient.
00:23:59
Speaker
So you have really very quickly an immediate emergency situation, cannot oxygenate situation.
00:24:08
Speaker
So I think you should always be prepared to perform emergency front of neck access in the ICU much quicker
00:24:20
Speaker
than in the OR.
00:24:22
Speaker
If you can oxygenate the patient, then you have some options.
00:24:27
Speaker
You can try a supraglottic airway.
00:24:29
Speaker
First of all, of course, you would try to intubate this patient, and then you can try it a second time.
00:24:35
Speaker
Then you should choose maybe the operator or the laryngoscope to with the laryngoscope or in ICU, I would recommend
00:24:48
Speaker
If you are firm with that and if you're familiar with that and if you have enough experience, the guidelines, the new guidelines from the Canadian colleagues, they recommend using video laryngoscope as the first technique.
00:25:05
Speaker
If you're experiencing that, that's important.
00:25:08
Speaker
So these are the options.
00:25:11
Speaker
The most important decision you have to make is can you oxygenate the patient?
00:25:16
Speaker
Yes or no.
00:25:19
Speaker
Yeah, and I think that you talked about two very important topics that I would like to dig in a little bit deeper, Thomas.
Timely Surgical Airway Procedures
00:25:26
Speaker
The first one is if you are in a can't ventilate, can't intubate, can't oxygenate situation in the ICU, multiple studies, especially looking at close claims and evaluating cases that went wrong, suggest that delays in doing a front-of-neck surgical airway is a big problem.
00:25:47
Speaker
Could you talk a little bit about that first?
00:25:51
Speaker
Absolutely.
00:25:52
Speaker
Absolutely.
00:25:55
Speaker
You might know the case of Elaine Bromley, for example.
00:26:02
Speaker
Her husband was this pilot and you can find it in the internet.
00:26:09
Speaker
The problem there was this was a lady with a little bit of limited movement in the neck.
00:26:17
Speaker
They couldn't manage this airway and this wife finally died.
00:26:22
Speaker
And there were two ENT surgeons and two anesthetists on the scene and they couldn't manage this airway.
00:26:32
Speaker
They were paralyzed and they did the wrong decision.
00:26:35
Speaker
They tried to do a tracheostomy instead of a cricotherotomy.
00:26:41
Speaker
So being paralyzed in such a situation
00:26:46
Speaker
is something we know that from cases which you are informed.
00:26:56
Speaker
That's one thing.
00:26:57
Speaker
And the other thing is you don't know what to do.
00:27:02
Speaker
Taking a knife or taking a needle and doing that.
00:27:08
Speaker
Not only, okay, I theoretically know what to do, but in the situation,
00:27:14
Speaker
I don't do that because I'm getting paralyzed.
00:27:18
Speaker
So I think that's, and the second one is that you don't accept that you will lose this patient if you don't make this step now.
00:27:35
Speaker
So, okay, you should communicate with the team.
00:27:40
Speaker
I can't oxygenate this patient.
00:27:41
Speaker
Okay.
00:27:44
Speaker
the fauna material and we make a final step, final additional attempt in intubation or in face mask ventilation or in placement of a supraglottic airway.
00:27:58
Speaker
And if it doesn't work, we then perform a front of neck access.
00:28:03
Speaker
So that's the problem we know from NEP4 and from other important studies, getting paralyzed, waiting too long
00:28:14
Speaker
until you do this step and the patient is almost in a dying situation and you are too late.
00:28:23
Speaker
That's one thing.
00:28:24
Speaker
The other thing is the skills.
00:28:26
Speaker
You don't have the skills, but it is very difficult to get the skills in front of neck access.
00:28:31
Speaker
So you have to get that in workshops, cadaver workshops and so on.
00:28:38
Speaker
Yeah, but that's the only thing you can do.
00:28:40
Speaker
Yeah, and when you think about it from a purely
00:28:44
Speaker
a motor cognitive or motor skill, it probably is an easier technique to do a crike via a scapel thumb buji tube, right, than it is to do a lot of the other
Practicing Emergency Airway Skills
00:29:00
Speaker
things that we do.
00:29:00
Speaker
But like you said, the difficult part is that it's something that we don't encounter in our practices with any frequency.
00:29:07
Speaker
And when we need to do it, we don't feel ready.
00:29:09
Speaker
So the only way is through simulation, either cadavers or things, but it's a skill.
00:29:13
Speaker
probably worth having.
00:29:16
Speaker
And I doubt that there's a lot of people who've done like tons of these, right?
00:29:19
Speaker
Just because it's not something that's very, very frequent.
00:29:24
Speaker
Absolutely.
00:29:24
Speaker
Absolutely.
00:29:25
Speaker
You know that the Difficult Airways Society from the UK recommends always a scalpel bougie tube technique.
00:29:34
Speaker
Colleagues from other countries say if you are experienced in a needle cricotherotomy, you can use this technique as well.
00:29:44
Speaker
I agree.
00:29:47
Speaker
But if you have troubles with identifying the Cricuit, I would also recommend a Scalpel Bougie tube technique.
00:29:56
Speaker
So you have to be familiar with this Scalpel Bougie tube technique.
00:30:02
Speaker
Yeah.
00:30:04
Speaker
And the second question I wanted to ask about when we're talking about management, before we dive into some more details, was you did talk about
00:30:14
Speaker
There is a right number of attempts that we should try, but there's two things I want you to talk a little bit more about, Thomas.
00:30:24
Speaker
One is what's the right number of attempts of endotracheal intubation and what are things that we should try to do to make them a little bit different?
00:30:32
Speaker
Because if we just do the same thing over and over again, obviously that's not likely to lead to a different outcome.
00:30:38
Speaker
And the second is the avoidance, and that's something we might talk later in human factors,
00:30:43
Speaker
of perseveration, which is something that I've seen a lot of colleagues fall into.
00:30:48
Speaker
Yeah, absolutely.
00:30:49
Speaker
That's an important point.
00:30:50
Speaker
I think that's one of the most important points.
00:30:53
Speaker
If you have a situation, you can oxygenate a patient, so you can ventilate it by face mask or a superclotic airway, but you can't intubate this patient.
00:31:02
Speaker
But the situation is stable.
00:31:04
Speaker
So then you're in a situation where you can say, okay, stop and think, what should we do next?
00:31:08
Speaker
But if you try them a third or a fourth or a fifth time,
00:31:13
Speaker
then situation is going to become worse.
00:31:16
Speaker
So I think more or less all guidelines recommend not more than three attempts.
00:31:24
Speaker
Then you should change the operator and also the technique.
00:31:31
Speaker
Some say after two attempts, the newest Canadian guidelines say a maximum of three attempts.
00:31:38
Speaker
The DAS guidelines also recommend maximum three attempts.
00:31:43
Speaker
I think we can agree and say, okay, two and maximum three attempts, then you should change the operator and should change the technique.
00:31:53
Speaker
If you start with a conventional intubation technique, I think there's a really good reason to say, okay, we go for the next step with a video laryngoscope.
00:32:09
Speaker
Or what we do in our hospital, because we have a lot of experience in fiber optic intubation, we do an oral fiber optic intubation with slit or pharyngeal airway.
00:32:19
Speaker
I think that's a brilliant, very easy technique.
00:32:24
Speaker
I think those are the two options if you have to intubate a patient.
00:32:30
Speaker
The other thing is, okay, do we have to intubate this patient really?
00:32:35
Speaker
And say, no, maybe we can go with a supraglottic airway.
00:32:39
Speaker
or if the third attempt or the fourth attempt with a different operator also fails and you can still oxygenate the patient then say, okay, stop and awake the patient.
00:32:53
Speaker
That's not possible in the ICU.
00:32:54
Speaker
So I think it's much trickier to airway management done in the ICU than in the OR because the option of awake the patient
00:33:06
Speaker
If you have an emergency intubation in the ICU, that's not really an option.
00:33:11
Speaker
I also mentioned that in the article.
00:33:12
Speaker
So that's not an option in the emergency situation in the ICU.
00:33:16
Speaker
It's an option in the OR.
00:33:18
Speaker
So you have to really be prepared if your first technique fails.
00:33:25
Speaker
And I think that it's just to review in terms of
00:33:29
Speaker
If you are in the ICU, like you said, we don't usually have that luxury of not waking up the patient because usually we're in an emergency situation where we have decided that this patient needs to be intubated, right?
00:33:40
Speaker
But if you do a first attempt and you have poor visualisation, have difficulty, reposition of the neck, better sedation, neuromuscular paralysis, if you can ventilate, right, are good things to do.
00:33:54
Speaker
Changing, like you said, from conventional to a video,
00:33:58
Speaker
considering using a fiber optic, if that's what you have, are all things that would help.
00:34:05
Speaker
Are there any other tricks that you might suggest?
00:34:08
Speaker
I know some people like to use a bougie sometimes, but that's more when it could be helpful.
00:34:14
Speaker
Any other suggestions from your standpoint or from the guidelines, Thomas?
00:34:18
Speaker
Well, I would like to answer that in a more principled manner.
00:34:22
Speaker
So I think you should,
00:34:25
Speaker
in such a situation you should always use a technique or an instrument you are familiar with in daily practice.
00:34:33
Speaker
I would never use a new device.
00:34:36
Speaker
I have never used that before.
00:34:38
Speaker
So we in our hospital and in Switzerland and Austria very rarely use a bougie for example, whereas in the UK the bougie is I think it's the best friend of the
00:34:54
Speaker
anesthetist in the uk so they of course will use a bougie so we are familiar with fiber optic intubation especially in our hospital so i would use always go for a fiber optic intubation if i can't manage this airway conventionally or with a wheeler ringoscope so be familiar with that in in the emergency situation as well and don't use a technique for the first time in that in such a situation yeah that's my key message
00:35:24
Speaker
And I think it's an important one that the best, there is no perfect tool.
00:35:29
Speaker
Everything has a place and a role.
00:35:31
Speaker
And at the end of the day, the best tools are the ones that you are more comfortable and have the greatest expertise with.
00:35:39
Speaker
So it's important to just, as a physician, to learn the tools that you have available, become proficient with them and use them in the best way in these situations.
00:35:49
Speaker
Absolutely.
00:35:52
Speaker
Now, we can talk a little bit about the anticipated difficult airway.
00:35:56
Speaker
And like you said, this is more of a lot of times might be in the ICU.
00:36:01
Speaker
If you have a very obese patient, you're anticipating you might have more support and more people ready.
00:36:07
Speaker
But also in the OR, I mean, you have a little bit more options.
00:36:11
Speaker
But are there any things that you would want to add in terms of tracheo intubation while the patient is awake when that is possible?
00:36:18
Speaker
And maybe airway management of the obese patients that we didn't cover yet?
Managing Expected Difficult Airways
00:36:24
Speaker
Yes, yes, absolutely.
00:36:27
Speaker
Management of the anticipated for their way, I think most colleagues will get the patient unconscious also in this situation if they believe they can oxygenate this patient after he is unconscious.
00:36:44
Speaker
I mean, this decision
00:36:48
Speaker
is a subjective decision and you don't know beforehand if this is the right decision.
00:36:56
Speaker
There are other, I think, other philosophies as well.
00:37:04
Speaker
So in my former hospital, we had a very strict, and I also use that in my hospital, not so strictly, but still in a very similar fashion.
00:37:13
Speaker
If you have a patient with a BMI over 35,
00:37:18
Speaker
and additional risk factors for difficult airway situation, for example, no teeth or beard or something like that, or neck to neck circumference is very large.
00:37:32
Speaker
Then we always do the fiber optic intubation.
00:37:35
Speaker
The term awake intubation, I think is a little bit of misleading term because in most cases, it's not really an awake intubation.
00:37:44
Speaker
Most patients are sedated.
00:37:48
Speaker
more or less.
00:37:49
Speaker
Some patients are sedated.
00:37:51
Speaker
It's something similar, very similar to general anesthesia.
00:37:57
Speaker
And there are different techniques how to do this.
00:38:00
Speaker
I think very rarely it is really done awake.
00:38:04
Speaker
So this needs time and needs a lot of experience.
00:38:09
Speaker
And most cases are done in a conscious sedation technique.
00:38:15
Speaker
We, that's one technique,
00:38:17
Speaker
We use a two-step technique.
00:38:20
Speaker
We place the scope in an awake patient.
00:38:25
Speaker
Patient is really awake.
00:38:26
Speaker
We do a local anesthesia for the nose and a transcrique puncture.
00:38:35
Speaker
And then we place a bronchoscope and then we start anesthesia until the patient is unconscious and then we thread the tube over the scope.
00:38:44
Speaker
So it's a two-step technique.
00:38:48
Speaker
patient placement of the scope in the wake patient, but advancing the tube in the anesthetized patient.
00:38:54
Speaker
And we performed this technique for over 30 years.
00:38:57
Speaker
And I have experience in thousands of patients with this technique, but it's not an awake technique.
00:39:05
Speaker
Yeah, that's what I can say.
00:39:06
Speaker
So I think the term awake intubation is a little bit misleading, but we don't read really a lot of that in the literature, interestingly.
00:39:18
Speaker
Interesting.
00:39:18
Speaker
Yeah, and I think that also that type of two-step technique in a situation in the ICU where you really need to intubate in an emergency might be more difficult to get ready, right?
00:39:28
Speaker
So you might not have the luxury of time for that.
00:39:32
Speaker
Yeah.
00:39:33
Speaker
Well, we do this fiber optic intubation in the meantime very quickly.
00:39:37
Speaker
So we don't inform our surgeons that we do no fiber optic intubation because it is integrated in daily practice.
00:39:45
Speaker
So we don't need more time to do a fibroblatic intubation than a conventional one.
00:39:49
Speaker
Okay, excellent.
00:39:51
Speaker
And another topic that is very important to this whole conversation, Thomas, is extubation of a patient with a known or predicted difficult
Safe Extubation Techniques
00:40:02
Speaker
airway.
00:40:02
Speaker
And this is something that happens in the ICU.
00:40:05
Speaker
We might have a patient who came to us through the OR and was a difficult intubation, or for other reasons, we anticipate a difficult
00:40:14
Speaker
airway if we were to extubate the patient.
00:40:16
Speaker
Any suggestions on how to handle this in the ICU?
00:40:20
Speaker
Yes, absolutely.
00:40:21
Speaker
Because this topic of extubation is a little bit forgotten during airway management, but it is very important.
00:40:32
Speaker
Not only in the ICU, also in the OR, but I think it's more critical in the ICU.
00:40:38
Speaker
And indeed, I think about a third of all the cases
00:40:42
Speaker
happened at the end of the surgery or at extubation in the ICU.
00:40:47
Speaker
So it is absolutely a very important part of airway management.
00:40:53
Speaker
Well, the key question is very simple.
00:40:57
Speaker
The key question is, is it safe to remove the tube?
00:41:01
Speaker
So if you say yes, so patient is awake, patient can manage his airway without any
00:41:12
Speaker
support, then you can remove the tube.
00:41:14
Speaker
If you say no, you have to either postpone the extubation or you have to perform a tracheostomy.
00:41:24
Speaker
And this question is very important.
00:41:29
Speaker
There are, of course, some supporting techniques to manage extubation in a patient where you're not really sure
00:41:39
Speaker
whether extubation, whether airway situation works after the extubation.
00:41:43
Speaker
And sometimes it's always a situation, okay, now we know it because it's a hindsight bias.
00:41:52
Speaker
So one technique which we regularly use, not only for the difficult extubation part, but also for changing a tube, for example, from nasal to oral or from oral to oral is that we use an exchange catheter
00:42:09
Speaker
to support the extubation.
00:42:12
Speaker
If you have a problem, you can re-advance the tube over this catheter.
00:42:19
Speaker
And I think that the message really here is clear in terms of we shouldn't only be assessing for difficult airways when we're putting tubes in, but we should be thinking about this in patients when we're deciding to remove endotracheal tubes in the ICU.
00:42:34
Speaker
And like you said, I mean, that first fork is, do I feel it's safe or not?
00:42:38
Speaker
And if it's not,
00:42:39
Speaker
Can I postpone it or do I need to go to a definitive or more definitive solution like a tracheostomy?
00:42:45
Speaker
But like you said, this is not something that we should do hastily and we are concerned or we don't know.
00:42:53
Speaker
Plan, have the appropriate team they're supporting doing at the right time of the day.
00:42:56
Speaker
A tube exchanger is a great way when there's when there's doubt.
00:43:00
Speaker
And these are again, it's more about planning and having that foresight of this could be a problem.
00:43:07
Speaker
Absolutely, Sergio, absolutely.
00:43:09
Speaker
Because it's always, as you already mentioned, it's always a planned procedure.
00:43:16
Speaker
Excellent.
Importance of Communication in Airway Management
00:43:17
Speaker
So I would like to close the topic of the airway with a little bit of discussion on human factors.
00:43:24
Speaker
I know that in the anesthesia world, the human factor engineers are big.
00:43:29
Speaker
I think that this is something that more and more we're trying to bring outside of the OR to other areas.
00:43:35
Speaker
but clearly there are human factors that are involved in airway management.
00:43:40
Speaker
And I wanted to know if you could just maybe talk a little bit about some of them.
00:43:44
Speaker
We did mention some of them, but we can kind of reiterate some that are important.
00:43:49
Speaker
Maybe start with situational awareness.
00:43:53
Speaker
Absolutely.
00:43:54
Speaker
I think we mentioned it as you already said several times.
00:43:58
Speaker
The situational awareness is really important.
00:44:04
Speaker
And that's something I think have to do with experience.
00:44:09
Speaker
So I think as someone who is doing airway management should do that on a regular basis because you see those cases and you have so heavy, sometimes a smell of a difficult situation.
00:44:27
Speaker
And you sometimes anticipate a problem.
00:44:34
Speaker
That's the one thing.
00:44:35
Speaker
And the other thing is situational awareness.
00:44:38
Speaker
Okay, now we have a problem and communicate that you have, that we have a problem.
00:44:43
Speaker
Prepare the next step immediately.
00:44:49
Speaker
So, one good friend of mine is Professor Richard Cooper from Toronto wrote an excellent article on that.
00:44:59
Speaker
Always plan if you
00:45:03
Speaker
if your plan fails, so a plan of failure of your plan.
00:45:08
Speaker
And if you are in such a situation, okay, realize that situation, communicate it with your team and don't get paralyzed.
00:45:18
Speaker
So I think that's the important things around situational awareness.
00:45:24
Speaker
Absolutely.
00:45:25
Speaker
And we also talked about failure of judgment and you've discussed them, but I just want to reiterate, synthesize for our listeners that,
00:45:33
Speaker
The two things that seem to be correlated with poor outcomes and difficult airway situations are perseveration when we keep doing the same thing and do not move to the next step, which is part of the situational awareness.
00:45:45
Speaker
But it's something that happens to all of this.
00:45:47
Speaker
And it's that, I think, sunken cost bias, right?
00:45:49
Speaker
I'm going to get it the next time.
00:45:51
Speaker
And you keep working on the same thing and you get into trouble.
00:45:54
Speaker
And then number two, delays in surgical airways.
00:45:56
Speaker
So I just wanted to kind of remind our audience.
00:46:00
Speaker
The last thing in terms of human factors, Thomas,
00:46:03
Speaker
our team factors and communication.
00:46:05
Speaker
Any words of advice there?
00:46:09
Speaker
Well, I just mentioned that.
00:46:12
Speaker
I think if you anticipate a difficult situation or maybe before you start, you should think about what are you doing if your plan A, plan B, plan C fails.
00:46:29
Speaker
Airway management is always a strategy.
00:46:31
Speaker
A strategy is a steps of plans.
00:46:35
Speaker
What are you doing?
00:46:36
Speaker
So as just mentioned, plan for failure of your plan and communicate that with your team.
00:46:45
Speaker
So I'm a great fan of having nurse anesthetists or experienced personnel in the ICU.
00:46:55
Speaker
What will we do if we can't manage this airway?
00:46:59
Speaker
And we communicated before we started.
00:47:03
Speaker
I mean, that's obvious, but it's obviously, it doesn't happen very frequently.
00:47:10
Speaker
So, yeah, I mean, it is simple if we discuss here, but obviously in daily practice, it is very often not performed, unfortunately.
00:47:27
Speaker
And I think that these pre-procedure huddles where we actually talk about the plan, but also talk about, like you said, what's plan B and plan C, so everybody understands, is very important.
00:47:40
Speaker
Yeah, absolutely.
00:47:42
Speaker
And maybe add to one other point.
00:47:48
Speaker
So many, many years ago, there was a fantastic article in the BMJ on safety.
00:47:56
Speaker
And what I have learned or we should have learned from that is, so if you are in a critical situation, the most experienced person at the scene should clearly say what we should have to do.
00:48:10
Speaker
That's not the time to be very nice to every in the scene.
00:48:15
Speaker
So you need very clear decisions and say, okay, this is what we do now.
00:48:21
Speaker
And I am the most experienced here.
00:48:24
Speaker
And I say, we do this and we do the next step, we do that.
00:48:28
Speaker
That's, I think that's all.
00:48:30
Speaker
I mean, if all are nice together to each other, but nothing is done, the patient will die.
00:48:38
Speaker
And I think another important aspect of communication in an emergency that's worth commenting, Thomas, is that especially in the ICU, when things are going in the wrong direction,
00:48:51
Speaker
If you as the leader do not designate a specific person to do certain things and just say, we need to do this, nobody will do it.
00:48:59
Speaker
So for example, if you need help from anesthesia, unless you are to say, Thomas, call anesthesia.
00:49:06
Speaker
If you say, can we call anesthesia?
00:49:08
Speaker
Everybody assumes that everybody else is going to do it.
00:49:10
Speaker
And a lot of times it just delays what's going on.
00:49:12
Speaker
So I think being very deliberate and assigning tasks and next steps is also very, very critical during an emergency.
00:49:23
Speaker
Absolutely.
00:49:24
Speaker
Absolutely.
00:49:27
Speaker
Thomas, we'd like to close the discussion with a couple of questions that are unrelated to the clinical topic we just discussed.
00:49:36
Speaker
Would that be okay?
00:49:37
Speaker
Yes, of course.
Recommendations for ICU Practitioners
00:49:39
Speaker
So the first question relates to books.
00:49:42
Speaker
And I was wondering, are there any books or particular books that have influenced you the most or that you have gifted most often to others?
00:49:51
Speaker
Yeah, that's an interesting question.
00:49:53
Speaker
I have, yes, I have two things I would like to say.
00:49:59
Speaker
The first is, to my junior doctors, when they come in my department, I give them a present, and that's West's Respiratory Physiology, The Essentials.
00:50:14
Speaker
It's a fantastic book about respiratory physiology.
00:50:18
Speaker
for everyday practice and also for their exams.
00:50:23
Speaker
And from my personal view, my favorite book from the last years, besides some crimes, is, and I'm sure you know that, it's from Daniel Kahneman, Thinking Fast and Slow.
00:50:37
Speaker
That's a wonderful book.
00:50:40
Speaker
I really like that and I have read them two times.
00:50:44
Speaker
And I can really recommend this book to everyone.
00:50:49
Speaker
I think there is also a relationship to airway management.
00:50:52
Speaker
Things are situations where you have to react immediately.
00:50:57
Speaker
Then you don't have enough time to think, okay, the next step we are doing on the next day, so we have to do it very quickly.
00:51:08
Speaker
But if you have time, stop and think.
00:51:12
Speaker
So that's that, I think, thinking slow and thinking
00:51:18
Speaker
the different options, but it's a combination of thinking fast and slow in with every advantages and disadvantages of both pathways.
00:51:30
Speaker
Absolutely.
00:51:30
Speaker
And I think that both recommendations are phenomenal.
00:51:34
Speaker
I do believe especially true for all of us, but also in particular, I think some of our younger colleagues, the value of understanding physiology, I think is sometimes
00:51:46
Speaker
under-emphasized, right?
00:51:47
Speaker
So clearly understanding physiology is very important and can help us.
00:51:52
Speaker
And West is a great place to start.
00:51:54
Speaker
And hard to argue with Daniel Kahneman, obviously one of the fathers of behavioral economics and really studying judgment, right?
00:52:05
Speaker
And thinking fast and slow, I think is exactly what we're talking about today.
00:52:10
Speaker
Developing the skills so that we can do our thinking fast better
00:52:14
Speaker
but having the ability to recognize when the situation calls for a pause and for thinking slow, what's the next step.
00:52:21
Speaker
So clearly I will link both of those.
00:52:24
Speaker
And I'll tell you, Thomas, it's funny that you mentioned thinking fast and slow.
00:52:28
Speaker
Obviously a book that I enjoyed thoroughly, but I'm currently reading a book called Noise, which is Daniel Kahneman's last book that just came out.
00:52:38
Speaker
So I highly suggest that you pick it up.
00:52:41
Speaker
You will love it.
00:52:42
Speaker
And it's about errors in our judgment.
00:52:44
Speaker
So it goes beyond just talking about cognitive biases and talks about the concept of noise and how to reduce noise in our judgment.
00:52:52
Speaker
So I think that a great compliment to thinking fast and slow.
00:52:58
Speaker
That's great.
00:52:58
Speaker
That's great.
00:52:59
Speaker
I've already bought this book, Noise, but not yet read it.
00:53:04
Speaker
You'll enjoy it.
00:53:05
Speaker
I'm halfway through and I'm thoroughly enjoying it.
00:53:07
Speaker
Okay.
00:53:08
Speaker
I look forward to reading it.
00:53:11
Speaker
The second question is, what do you believe to be true in medicine or in life that most other people don't believe or don't act like they believe?
00:53:20
Speaker
Well, I'm not sure whether most other people don't believe this, but in my life as a head of a department, there are at least, I think, two things that are worth mentioning.
00:53:32
Speaker
The first one is, I think, treat everyone as you would like to be treated yourself.
00:53:40
Speaker
I'm glad.
00:53:41
Speaker
I'm not sure, but I think it's from Confucius.
00:53:46
Speaker
That's quite important to say, not only for the head of the department, I think for your life as a whole.
00:53:53
Speaker
And the second one, as a head of a department, be available for your employees, especially in rainy days.
00:54:04
Speaker
That's absolutely important.
00:54:09
Speaker
I agree and I think that there are two things that, like you said, on a conversation like this, we all agree, right?
00:54:17
Speaker
But then on the day-to-day, sometimes people forget or don't act like they really believe it.
00:54:23
Speaker
So I think there are two very important tidbits for all our ICU clinicians who are one way or the other leading a team at that time.
00:54:32
Speaker
So those are very valuable.
00:54:34
Speaker
And the last and closing question, Thomas,
00:54:37
Speaker
relates to, is there anything that you would want every intensivist who's listening to us to know?
00:54:42
Speaker
It could be a fact, a quote, or just something related to what we discussed today.
00:54:47
Speaker
Okay, yes, yes.
00:54:50
Speaker
I think it's a summary of what I said.
00:54:55
Speaker
Be familiar and maintain your competence with some of those airway techniques.
00:55:03
Speaker
It starts with face mask ventilation, superglottic air replacement,
00:55:07
Speaker
tracheal intubation, I think with video laryngoscopy, you should be familiar with fiber optic intubation and with an infraglottic axis.
00:55:17
Speaker
That's the first one.
00:55:18
Speaker
The second one, have a strategy for your airway plan.
00:55:24
Speaker
So I would like to quote my friend Richard Cooper, always have a plan if your plan fails.
00:55:33
Speaker
And I think that that's a perfect place to stop, Thomas.
00:55:36
Speaker
It was a
00:55:37
Speaker
A joy to talk with you.
00:55:38
Speaker
Thanks for sharing your expertise.
00:55:40
Speaker
We will link a lot of the articles that we reference and definitely your review article to the show notes so people can find them.
00:55:48
Speaker
And I look forward to having you back on the podcast to discuss this and other topics again.
00:55:54
Speaker
Oh, Sergio, thank you so much for inviting me.
00:55:56
Speaker
It was a great pleasure to talk to you.
00:55:59
Speaker
I hope I could get my message across.
00:56:03
Speaker
You know that my mother tongue is not English, it's German.
00:56:07
Speaker
But it was a great pleasure for me to talk to you.
00:56:10
Speaker
Thank you so much.
00:56:13
Speaker
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00:56:17
Speaker
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00:56:23
Speaker
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00:56:27
Speaker
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