Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Airway management is a daily occurrence in the practice of critical care.
Speaker: Complications associated with airway management have a potential devastating impact on patients, causing severe morbidity and mortality.
Speaker: In today's episode of Critical Matters, we will discuss the management of the difficult airway.
Speaker: Our guest is Dr. Thomas Heidegger.
Speaker: Dr. Heidegger is an anesthesia intensive care physician.
Speaker: He holds faculty appointments as professor in the Department of Anesthesia, Spital Grabs and Grabs,
Speaker: in the Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern in Bern, both in Switzerland.
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.
Speaker: We are honored to have him as a guest.
Speaker: Thomas, welcome to the podcast.
Speaker: Sergio, thank you very much for inviting me.
Speaker: I'm really pleased to join this meeting.
Speaker: Excellent.
Speaker: Well, we have a
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 world.
Speaker: So maybe we could start, Thomas, with a definition on what is a difficult airway from your perspective.
Speaker: Yeah, that's a tough question because
Speaker: We don't agree what, we don't have a standard definition of a difficult airway at this time.
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,
Speaker: So that is a difficult airway.
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.
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?
Speaker: So a lot of people might think that the intubation itself is the difficulty, but you talked about face mask ventilation,
Speaker: disvalidization, tracheal intubation, or supraglottic management.
Speaker: So those four are very important, right?
Speaker: Absolutely, absolutely.
Speaker: And that's a problem with some of the guidelines.
Speaker: Many guidelines start with a problem with tracheal intubation, but air management starts before.
Speaker: So if your patient gets unconscious, then you have to manage this airway.
Speaker: And the first technique you normally use is mask ventilation.
Speaker: So that's critically important to talk about mask ventilation before we talk about difficult intubation.
Speaker: Absolutely.
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?
Speaker: Yeah, on face mask ventilation, there are many, many definitions.
Speaker: I think one,
Speaker: A very practical definition is from HAN.
Speaker: It's a HAN score.
Speaker: It's not perfect, but I think for daily practice, we use that in our hospital every day.
Speaker: It's four grades.
Speaker: Grade one is no problem with mask ventilation.
Speaker: Grade two is ventilation by mask is possible with an oral airway or another adjuvant.
Speaker: And grade three mask ventilation is difficult, defined as inadequate, unstable,
Speaker: or requiring two providers and grade four mask ventilation is impossible.
Speaker: Well, it's not perfect, but I think it is very useful for daily practice.
Speaker: I think ideally ventilation should be confirmed, not only by this clinical science, but also by technical science.
Speaker: So if you have a capnographic tracing, you can add this
Speaker: to define if mask ventilation works or doesn't work.
Speaker: So ideal ventilation should be confirmed by an observation of a rise in the chest.
Speaker: That's a clinical sign.
Speaker: By a capnographic tracing, that's a technical sign.
Speaker: And by, of course, at least by an increase in oxygen saturation.
Speaker: So that's a combination of a technical and clinical sign.
Speaker: Excellent.
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%.
Speaker: Absolutely.
Speaker: That grade zero is not very frequent, right?
Speaker: Yeah.
Speaker: That's the main problem and the main challenge.
Speaker: Fortunately, the real difficult airway is a rare phenomenon.
Speaker: That's
Speaker: Fortunately, it is a rare phenomenon.
Speaker: And so it is also, therefore, as a consequence, it is very difficult to predict a difficult airway in beforehand.
Speaker: Absolutely.
Speaker: Because the absolute, the event itself, the difficult airway is a rare event.
Speaker: So it's always, all those tests, a combination of tests to predict the difficult airway will finally more or less fail because
Speaker: The event itself, the difficult airway, is a rare event.
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.
Speaker: That means that you have to always be prepared, that you can always be encountered with a difficult airway, even though
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.
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.
Speaker: It's an anticipated difficult airway situation.
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.
Speaker: And we forget that any test, no matter how good performance, will be impacted by that, right?
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
Speaker: can sometimes, I mean, influence what a false positive looks like and what a false negative looks like.
Speaker: Absolutely, absolutely.
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.
Speaker: It is the understanding sensitivity and specificity with the right side of the brain.
Speaker: It's a fantastic article to explain
Speaker: terms like sensitivity, specificity, positive or negative predictive value.
Speaker: So it's a fantastic paper.
Speaker: I can really recommend to read that.
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.
Speaker: However, if you're not prepared, you didn't anticipate a difficult airway and you get in that situation, it can have devastating
Speaker: consequences for the patient.
Speaker: Absolutely.
Speaker: I think that's the key point.
Speaker: You have always to be prepared to face with, we say, unexpected, difficult airway.
Speaker: That's really the key message.
Speaker: That's a key message.
Speaker: Beyond that, of course, you need the skills to do that.
Speaker: That's another problem.
Speaker: But being prepared
Speaker: to manage an unexpected difficult airway is essential.
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.
Speaker: I do have a couple more questions on incidents before we move a little bit forward.
Speaker: What's the role of video laryngoscopy?
Speaker: That is something that obviously when I trained we didn't have it available.
Speaker: Now I have it available for every airway I do in the ICU.
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.
Speaker: Data are still conflicting.
Speaker: That's the reason why I referenced some of these papers.
Speaker: And you see this is there is no consensus.
Speaker: We have some papers who really prefer vitolaryngoscopy.
Speaker: It is much better than conventional laryngoscopy.
Speaker: Other papers just say the different, just say the opposite.
Speaker: And the Cochrane review doesn't confirm that vitolaryngoscopy is really
Speaker: It shows us that the number of intubation attempts maybe can be lowered.
Speaker: That's another topic because you shouldn't do that four or five or six times.
Speaker: I think what with your laryngoscopy is really superior to conventional laryngoscopy is in two things.
Speaker: It is first of all,
Speaker: you can watch what the other colleague or your nurse is doing.
Speaker: And on the other side, if you are teaching in a teaching hospital, others can watch what you are doing as an expert.
Speaker: So in teaching and helping juniors, it is absolutely fantastic.
Speaker: In management of the unexpected difficulty, in many cases, you have a better view than
Speaker: than with conventional laryngoscopy.
Speaker: I think that's a matter of fact.
Speaker: In very, very rare cases, it is better looking at the conventional side than on the video laryngoscopy.
Speaker: This was a result of, I think, the first large multicenter study from Europe and the United States.
Speaker: Marshall Kaplan, I think was the first author published in an American journal.
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.
Speaker: But normally, it is just the opposite.
Speaker: You see it much better on the screen than conventionally in a difficult situation.
Speaker: But what we also have learned is that laryngoscopy is not the same as in tubal patients.
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.
Speaker: And even though some colleagues don't like to hear that, but it is not a panacea for everything, for every airway situation.
Speaker: Because if you have a patient with a limited mouth opening, you can't use a video laryngoscope.
Speaker: And if you have a patient with a limited neck mobility, it doesn't help you really very much.
Speaker: So there are situations where you need a different technique to manage this airway.
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.
Speaker: And I think that that's an important point, right?
Speaker: I mean, it's a step forward.
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.
Speaker: Absolutely and please let me add something more Sergio.
Speaker: There's a special situation with the hyper-angulated with the laryngoscope.
Speaker: I mean you get a fantastic view with those devices but the
Speaker: The problem you have, you must be very skilled with this technique that you can manage the airway.
Speaker: So the problem you see that you fail is something we can really recognize quite often.
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.
Speaker: I agree.
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.
Speaker: One is patient population and specifically in females OB versus non-OB.
Speaker: And the other one is location OR versus emergency department versus ICU.
Speaker: Okay.
Speaker: Let me start with the second one, the NAP4.
Speaker: clearly showed that the problem with airway management in the ICU and in the emergency department happens more often than in the OR.
Speaker: So that's a matter of fact.
Speaker: Difficult airway management is absolutely present in the ICU and emergency department.
Speaker: It happens more often than in the OR.
Speaker: So that's a matter of fact.
Speaker: All those studies confirmed and the largest one is, of course, is NAP4.
Speaker: And the second one, your first question is obese versus non-obese.
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.
Speaker: And if you have a patient with a morbid obesity, so it's a BMI of 40 or more,
Speaker: difficult airway situations arises four times more than in the non-obese.
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.
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
Speaker: in emergency situations, either in the emergency department or in the ICU as compared to the OR.
Speaker: I would like to move forward and talk a little bit about prediction of a difficult airway.
Speaker: We did talk about the false positives, false negatives and those consequences and we already established why that's so important.
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.
Speaker: But also, I know that you talk about predictors of difficulty, Thomas, in terms of anatomical, physiological and contextual.
Speaker: If you can just expand a little bit on this area.
Speaker: Yeah.
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.
Speaker: So you should do that.
Speaker: And we personally do,
Speaker: a phyramental distance and upper lip bite test.
Speaker: So all those things, we do that.
Speaker: And we also measure the BMI.
Speaker: And so we don't do things you can't read in this paper.
Speaker: So we do all those things, but we don't do every special test.
Speaker: So this,
Speaker: You can't do that in every day's practice.
Speaker: So we do that.
Speaker: And I think really important is also the history.
Speaker: So does this patient has already an intubation a couple of years ago?
Speaker: Were there any problems?
Speaker: We now have electronic protocols so we can go back to the past looking whether any technical problems with intubation and so on.
Speaker: You have to be alert to do that.
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.
Speaker: So it's a very practical answer, not very scientifically based because all those tests do have a low positive predictive value.
Speaker: Absolutely.
Speaker: Nevertheless, do that.
Speaker: That's an excellent paper.
Speaker: Is such a test worthwhile issue or not from Steve Yantes, who was a former editor-in-chief from Anesthesia from UK.
Speaker: That's a fantastic paper.
Speaker: I can really recommend that.
Speaker: Okay.
Speaker: We'll put that on the show links.
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?
Speaker: Yeah.
Speaker: I just mentioned, I think there was the anatomical predictors, limited mouth openings, having a beard or not.
Speaker: Obesity, of course, are the anatomical predictors.
Speaker: The physiological predictors are beside, for example, a full stomach is something with your oxygen saturation rapidly decreases.
Speaker: and your onset of apnea starts very, very, very fast because of reduced functional residual capacity.
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.
Speaker: So I think that's the most important physiological parameters.
Speaker: And also important are the contextual parameters.
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.
Speaker: Or the patient, you can't do an awake intubation because the patient doesn't tolerate it and say nothing about that.
Speaker: So, yeah.
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.
Speaker: There were two things that's really worth mentioning.
Speaker: The first one was that some of the colleagues recognized that this situation
Speaker: renders a fiber optic intubation and they didn't do that because of two reasons.
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.
Speaker: I think that's a contextual issue.
Speaker: You should do something.
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.
Speaker: So the contextual issues are, I think, an important point in those predictors.
Speaker: So prediction is very, very important, even though we can't really predict a difficult airway situation.
Speaker: Absolutely.
Speaker: I think like Neil Bors would say, right?
Speaker: The climate prediction of the future that's very difficult to do, right?
Speaker: And I think that... Absolutely.
Speaker: Exactly.
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
Speaker: that your assessment suggests a difficult airway, there's really no reason for you to be unprepared, right?
Speaker: So you should be prepared.
Speaker: And the problem is that you might think it's an easy airway and then get into trouble.
Speaker: So the bottom line is you should be prepared as well.
Speaker: And I think that that's really the message that we'll try to get along.
Speaker: So we could move on, Thomas, and talk about the management of the difficult airway.
Speaker: And many guidelines and your review have separated this into unanticipated difficulty versus anticipated difficulty.
Speaker: And that might give you different options of a different kind of roadmap to follow.
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?
Speaker: I think it doesn't really make a large difference.
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.
Speaker: So we maybe could talk about that a little bit later.
Speaker: But if you try to ventilate this patient by face mask and you can do that,
Speaker: So then you have time to think about, okay, I will conventionally intubate them with the laryngoscope or a VDLaryngoscope.
Speaker: But if you have trouble with face mask ventilation, then you have to decide, can I oxygenate this patient?
Speaker: Yes or no.
Speaker: If no, you don't have a lot of time, especially on the ICU, because those patients
Speaker: have reduced, most of them have reduced functional residual capacity.
Speaker: Oxygen consumption is much higher than in the normal patient.
Speaker: So you have really very quickly an immediate emergency situation, cannot oxygenate situation.
Speaker: So I think you should always be prepared to perform emergency front of neck access in the ICU much quicker
Speaker: than in the OR.
Speaker: If you can oxygenate the patient, then you have some options.
Speaker: You can try a supraglottic airway.
Speaker: First of all, of course, you would try to intubate this patient, and then you can try it a second time.
Speaker: Then you should choose maybe the operator or the laryngoscope to with the laryngoscope or in ICU, I would recommend
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.
Speaker: If you're experiencing that, that's important.
Speaker: So these are the options.
Speaker: The most important decision you have to make is can you oxygenate the patient?
Speaker: Yes or no.
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.
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.
Speaker: Could you talk a little bit about that first?
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: You might know the case of Elaine Bromley, for example.
Speaker: Her husband was this pilot and you can find it in the internet.
Speaker: The problem there was this was a lady with a little bit of limited movement in the neck.
Speaker: They couldn't manage this airway and this wife finally died.
Speaker: And there were two ENT surgeons and two anesthetists on the scene and they couldn't manage this airway.
Speaker: They were paralyzed and they did the wrong decision.
Speaker: They tried to do a tracheostomy instead of a cricotherotomy.
Speaker: So being paralyzed in such a situation
Speaker: is something we know that from cases which you are informed.
Speaker: That's one thing.
Speaker: And the other thing is you don't know what to do.
Speaker: Taking a knife or taking a needle and doing that.
Speaker: Not only, okay, I theoretically know what to do, but in the situation,
Speaker: I don't do that because I'm getting paralyzed.
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.
Speaker: So, okay, you should communicate with the team.
Speaker: I can't oxygenate this patient.
Speaker: Okay.
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.
Speaker: And if it doesn't work, we then perform a front of neck access.
Speaker: So that's the problem we know from NEP4 and from other important studies, getting paralyzed, waiting too long
Speaker: until you do this step and the patient is almost in a dying situation and you are too late.
Speaker: That's one thing.
Speaker: The other thing is the skills.
Speaker: You don't have the skills, but it is very difficult to get the skills in front of neck access.
Speaker: So you have to get that in workshops, cadaver workshops and so on.
Speaker: Yeah, but that's the only thing you can do.
Speaker: Yeah, and when you think about it from a purely
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 things that we do.
Speaker: But like you said, the difficult part is that it's something that we don't encounter in our practices with any frequency.
Speaker: And when we need to do it, we don't feel ready.
Speaker: So the only way is through simulation, either cadavers or things, but it's a skill.
Speaker: probably worth having.
Speaker: And I doubt that there's a lot of people who've done like tons of these, right?
Speaker: Just because it's not something that's very, very frequent.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: You know that the Difficult Airways Society from the UK recommends always a scalpel bougie tube technique.
Speaker: Colleagues from other countries say if you are experienced in a needle cricotherotomy, you can use this technique as well.
Speaker: I agree.
Speaker: But if you have troubles with identifying the Cricuit, I would also recommend a Scalpel Bougie tube technique.
Speaker: So you have to be familiar with this Scalpel Bougie tube technique.
Speaker: Yeah.
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
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.
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?
Speaker: Because if we just do the same thing over and over again, obviously that's not likely to lead to a different outcome.
Speaker: And the second is the avoidance, and that's something we might talk later in human factors,
Speaker: of perseveration, which is something that I've seen a lot of colleagues fall into.
Speaker: Yeah, absolutely.
Speaker: That's an important point.
Speaker: I think that's one of the most important points.
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.
Speaker: But the situation is stable.
Speaker: So then you're in a situation where you can say, okay, stop and think, what should we do next?
Speaker: But if you try them a third or a fourth or a fifth time,
Speaker: then situation is going to become worse.
Speaker: So I think more or less all guidelines recommend not more than three attempts.
Speaker: Then you should change the operator and also the technique.
Speaker: Some say after two attempts, the newest Canadian guidelines say a maximum of three attempts.
Speaker: The DAS guidelines also recommend maximum three attempts.
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.
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.
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.
Speaker: I think that's a brilliant, very easy technique.
Speaker: I think those are the two options if you have to intubate a patient.
Speaker: The other thing is, okay, do we have to intubate this patient really?
Speaker: And say, no, maybe we can go with a supraglottic airway.
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.
Speaker: That's not possible in the ICU.
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
Speaker: If you have an emergency intubation in the ICU, that's not really an option.
Speaker: I also mentioned that in the article.
Speaker: So that's not an option in the emergency situation in the ICU.
Speaker: It's an option in the OR.
Speaker: So you have to really be prepared if your first technique fails.
Speaker: And I think that it's just to review in terms of
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?
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.
Speaker: Changing, like you said, from conventional to a video,
Speaker: considering using a fiber optic, if that's what you have, are all things that would help.
Speaker: Are there any other tricks that you might suggest?
Speaker: I know some people like to use a bougie sometimes, but that's more when it could be helpful.
Speaker: Any other suggestions from your standpoint or from the guidelines, Thomas?
Speaker: Well, I would like to answer that in a more principled manner.
Speaker: So I think you should,
Speaker: in such a situation you should always use a technique or an instrument you are familiar with in daily practice.
Speaker: I would never use a new device.
Speaker: I have never used that before.
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
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
Speaker: And I think it's an important one that the best, there is no perfect tool.
Speaker: Everything has a place and a role.
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.
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.
Speaker: Absolutely.
Speaker: Now, we can talk a little bit about the anticipated difficult airway.
Speaker: And like you said, this is more of a lot of times might be in the ICU.
Speaker: If you have a very obese patient, you're anticipating you might have more support and more people ready.
Speaker: But also in the OR, I mean, you have a little bit more options.
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?
Speaker: And maybe airway management of the obese patients that we didn't cover yet?
Speaker: Yes, yes, absolutely.
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.
Speaker: I mean, this decision
Speaker: is a subjective decision and you don't know beforehand if this is the right decision.
Speaker: There are other, I think, other philosophies as well.
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.
Speaker: If you have a patient with a BMI over 35,
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.
Speaker: Then we always do the fiber optic intubation.
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.
Speaker: Most patients are sedated.
Speaker: more or less.
Speaker: Some patients are sedated.
Speaker: It's something similar, very similar to general anesthesia.
Speaker: And there are different techniques how to do this.
Speaker: I think very rarely it is really done awake.
Speaker: So this needs time and needs a lot of experience.
Speaker: And most cases are done in a conscious sedation technique.
Speaker: We, that's one technique,
Speaker: We use a two-step technique.
Speaker: We place the scope in an awake patient.
Speaker: Patient is really awake.
Speaker: We do a local anesthesia for the nose and a transcrique puncture.
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.
Speaker: So it's a two-step technique.
Speaker: patient placement of the scope in the wake patient, but advancing the tube in the anesthetized patient.
Speaker: And we performed this technique for over 30 years.
Speaker: And I have experience in thousands of patients with this technique, but it's not an awake technique.
Speaker: Yeah, that's what I can say.
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.
Speaker: Interesting.
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?
Speaker: So you might not have the luxury of time for that.
Speaker: Yeah.
Speaker: Well, we do this fiber optic intubation in the meantime very quickly.
Speaker: So we don't inform our surgeons that we do no fiber optic intubation because it is integrated in daily practice.
Speaker: So we don't need more time to do a fibroblatic intubation than a conventional one.
Speaker: Okay, excellent.
Speaker: And another topic that is very important to this whole conversation, Thomas, is extubation of a patient with a known or predicted difficult airway.
Speaker: And this is something that happens in the ICU.
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
Speaker: airway if we were to extubate the patient.
Speaker: Any suggestions on how to handle this in the ICU?
Speaker: Yes, absolutely.
Speaker: Because this topic of extubation is a little bit forgotten during airway management, but it is very important.
Speaker: Not only in the ICU, also in the OR, but I think it's more critical in the ICU.
Speaker: And indeed, I think about a third of all the cases
Speaker: happened at the end of the surgery or at extubation in the ICU.
Speaker: So it is absolutely a very important part of airway management.
Speaker: Well, the key question is very simple.
Speaker: The key question is, is it safe to remove the tube?
Speaker: So if you say yes, so patient is awake, patient can manage his airway without any
Speaker: support, then you can remove the tube.
Speaker: If you say no, you have to either postpone the extubation or you have to perform a tracheostomy.
Speaker: And this question is very important.
Speaker: There are, of course, some supporting techniques to manage extubation in a patient where you're not really sure
Speaker: whether extubation, whether airway situation works after the extubation.
Speaker: And sometimes it's always a situation, okay, now we know it because it's a hindsight bias.
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
Speaker: to support the extubation.
Speaker: If you have a problem, you can re-advance the tube over this catheter.
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.
Speaker: And like you said, I mean, that first fork is, do I feel it's safe or not?
Speaker: And if it's not,
Speaker: Can I postpone it or do I need to go to a definitive or more definitive solution like a tracheostomy?
Speaker: But like you said, this is not something that we should do hastily and we are concerned or we don't know.
Speaker: Plan, have the appropriate team they're supporting doing at the right time of the day.
Speaker: A tube exchanger is a great way when there's when there's doubt.
Speaker: And these are again, it's more about planning and having that foresight of this could be a problem.
Speaker: Absolutely, Sergio, absolutely.
Speaker: Because it's always, as you already mentioned, it's always a planned procedure.
Speaker: Excellent.
Speaker: So I would like to close the topic of the airway with a little bit of discussion on human factors.
Speaker: I know that in the anesthesia world, the human factor engineers are big.
Speaker: I think that this is something that more and more we're trying to bring outside of the OR to other areas.
Speaker: but clearly there are human factors that are involved in airway management.
Speaker: And I wanted to know if you could just maybe talk a little bit about some of them.
Speaker: We did mention some of them, but we can kind of reiterate some that are important.
Speaker: Maybe start with situational awareness.
Speaker: Absolutely.
Speaker: I think we mentioned it as you already said several times.
Speaker: The situational awareness is really important.
Speaker: And that's something I think have to do with experience.
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.
Speaker: And you sometimes anticipate a problem.
Speaker: That's the one thing.
Speaker: And the other thing is situational awareness.
Speaker: Okay, now we have a problem and communicate that you have, that we have a problem.
Speaker: Prepare the next step immediately.
Speaker: So, one good friend of mine is Professor Richard Cooper from Toronto wrote an excellent article on that.
Speaker: Always plan if you
Speaker: if your plan fails, so a plan of failure of your plan.
Speaker: And if you are in such a situation, okay, realize that situation, communicate it with your team and don't get paralyzed.
Speaker: So I think that's the important things around situational awareness.
Speaker: Absolutely.
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,
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.
Speaker: But it's something that happens to all of this.
Speaker: And it's that, I think, sunken cost bias, right?
Speaker: I'm going to get it the next time.
Speaker: And you keep working on the same thing and you get into trouble.
Speaker: And then number two, delays in surgical airways.
Speaker: So I just wanted to kind of remind our audience.
Speaker: The last thing in terms of human factors, Thomas,
Speaker: our team factors and communication.
Speaker: Any words of advice there?
Speaker: Well, I just mentioned that.
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.
Speaker: Airway management is always a strategy.
Speaker: A strategy is a steps of plans.
Speaker: What are you doing?
Speaker: So as just mentioned, plan for failure of your plan and communicate that with your team.
Speaker: So I'm a great fan of having nurse anesthetists or experienced personnel in the ICU.
Speaker: What will we do if we can't manage this airway?
Speaker: And we communicated before we started.
Speaker: I mean, that's obvious, but it's obviously, it doesn't happen very frequently.
Speaker: So, yeah, I mean, it is simple if we discuss here, but obviously in daily practice, it is very often not performed, unfortunately.
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.
Speaker: Yeah, absolutely.
Speaker: And maybe add to one other point.
Speaker: So many, many years ago, there was a fantastic article in the BMJ on safety.
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.
Speaker: That's not the time to be very nice to every in the scene.
Speaker: So you need very clear decisions and say, okay, this is what we do now.
Speaker: And I am the most experienced here.
Speaker: And I say, we do this and we do the next step, we do that.
Speaker: That's, I think that's all.
Speaker: I mean, if all are nice together to each other, but nothing is done, the patient will die.
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,
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.
Speaker: So for example, if you need help from anesthesia, unless you are to say, Thomas, call anesthesia.
Speaker: If you say, can we call anesthesia?
Speaker: Everybody assumes that everybody else is going to do it.
Speaker: And a lot of times it just delays what's going on.
Speaker: So I think being very deliberate and assigning tasks and next steps is also very, very critical during an emergency.
Speaker: Absolutely.
Speaker: Absolutely.
Speaker: Thomas, we'd like to close the discussion with a couple of questions that are unrelated to the clinical topic we just discussed.
Speaker: Would that be okay?
Speaker: Yes, of course.
Speaker: So the first question relates to books.
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?
Speaker: Yeah, that's an interesting question.
Speaker: I have, yes, I have two things I would like to say.
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.
Speaker: It's a fantastic book about respiratory physiology.
Speaker: for everyday practice and also for their exams.
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.
Speaker: That's a wonderful book.
Speaker: I really like that and I have read them two times.
Speaker: And I can really recommend this book to everyone.
Speaker: I think there is also a relationship to airway management.
Speaker: Things are situations where you have to react immediately.
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.
Speaker: But if you have time, stop and think.
Speaker: So that's that, I think, thinking slow and thinking
Speaker: the different options, but it's a combination of thinking fast and slow in with every advantages and disadvantages of both pathways.
Speaker: Absolutely.
Speaker: And I think that both recommendations are phenomenal.
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
Speaker: under-emphasized, right?
Speaker: So clearly understanding physiology is very important and can help us.
Speaker: And West is a great place to start.
Speaker: And hard to argue with Daniel Kahneman, obviously one of the fathers of behavioral economics and really studying judgment, right?
Speaker: And thinking fast and slow, I think is exactly what we're talking about today.
Speaker: Developing the skills so that we can do our thinking fast better
Speaker: but having the ability to recognize when the situation calls for a pause and for thinking slow, what's the next step.
Speaker: So clearly I will link both of those.
Speaker: And I'll tell you, Thomas, it's funny that you mentioned thinking fast and slow.
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.
Speaker: So I highly suggest that you pick it up.
Speaker: You will love it.
Speaker: And it's about errors in our judgment.
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.
Speaker: So I think that a great compliment to thinking fast and slow.
Speaker: That's great.
Speaker: That's great.
Speaker: I've already bought this book, Noise, but not yet read it.
Speaker: You'll enjoy it.
Speaker: I'm halfway through and I'm thoroughly enjoying it.
Speaker: Okay.
Speaker: I look forward to reading it.
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?
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.
Speaker: The first one is, I think, treat everyone as you would like to be treated yourself.
Speaker: I'm glad.
Speaker: I'm not sure, but I think it's from Confucius.
Speaker: That's quite important to say, not only for the head of the department, I think for your life as a whole.
Speaker: And the second one, as a head of a department, be available for your employees, especially in rainy days.
Speaker: That's absolutely important.
Speaker: I agree and I think that there are two things that, like you said, on a conversation like this, we all agree, right?
Speaker: But then on the day-to-day, sometimes people forget or don't act like they really believe it.
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.
Speaker: So those are very valuable.
Speaker: And the last and closing question, Thomas,
Speaker: relates to, is there anything that you would want every intensivist who's listening to us to know?
Speaker: It could be a fact, a quote, or just something related to what we discussed today.
Speaker: Okay, yes, yes.
Speaker: I think it's a summary of what I said.
Speaker: Be familiar and maintain your competence with some of those airway techniques.
Speaker: It starts with face mask ventilation, superglottic air replacement,
Speaker: tracheal intubation, I think with video laryngoscopy, you should be familiar with fiber optic intubation and with an infraglottic axis.
Speaker: That's the first one.
Speaker: The second one, have a strategy for your airway plan.
Speaker: So I would like to quote my friend Richard Cooper, always have a plan if your plan fails.
Speaker: And I think that that's a perfect place to stop, Thomas.
Speaker: It was a
Speaker: A joy to talk with you.
Speaker: Thanks for sharing your expertise.
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.
Speaker: And I look forward to having you back on the podcast to discuss this and other topics again.
Speaker: Oh, Sergio, thank you so much for inviting me.
Speaker: It was a great pleasure to talk to you.
Speaker: I hope I could get my message across.
Speaker: You know that my mother tongue is not English, it's German.
Speaker: But it was a great pleasure for me to talk to you.
Speaker: Thank you so much.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
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Speaker: Sounds transforming the way critical care is provided in hospitals across the country.
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