In 2011 I received an unrestricted lecture honorarium from Ambu I have been loaned equipment by Intavent Direct (Teleflex) and Aircraft Medical As an
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1 Alistair McNarry
2 In 2011 I received an unrestricted lecture honorarium from Ambu I have been loaned equipment by Intavent Direct (Teleflex) and Aircraft Medical As an organiser of airway workshops I have procured equipment for teaching purposes from a wide variety of companies Between 2010 and 2013 I sat on the DAS Committee I am now involved in the organisation of the Airway Leads Project
3 I am a head an neck anaesthetist I try and avoid Labour Ward
4 I am a head an neck anaesthetist I try and avoid Labour Ward Until 3 weeks ago We are interrupting your list to do a Caesarean Section
5 Spinal CSE Diamorphine Phenylephrine Epidural Consent NAP3 Missing segments
6
7 In 20 minutes I cannot Discuss the sugammadex question Discuss the physiology of the airway in pregnancy Discuss all of the excellent papers on the management of the airway Mention the HELP pillow, front of neck access or even afoi But the coffee break is next
8 Incidence of failed tracheal intubation 1:224 6:57 (10.5%) rescued by a 2 nd Generation SAD Overall 1:25,000 deliveries
9 The older (OR 1.07) The heavier (OR 1.06) M&P recorded and >1 (OR 3.06)
10 The older (OR 1.07) The heavier (OR 1.06) M&P recorded and >1 (OR 3.06)
11 The older (OR 1.07) The heavier (OR 1.06) M&P recorded and >1 (OR 3.06) *Age Sex *BMI *M&P MO TMD Macroglossia Receding mandible Snoring
12 Anaesthesia pages 11-18, 10 NOV 2011 DOI: /j x
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14 Obese more likely to need an LSCS (50% v 32%) GA in the morbidly obese 3% (down from 24%, 20 years earlier) 1 episode of difficulty rescued by the Glidescope
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17 January 2011 Equipment to manage a difficult airway during anaesthesia
18 26 different devices, <1minute each!!
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22 Anaesthesiologists like VLs because they make their life somewhat more serene
23 Anaesthesiologists like VLs because they make their life somewhat more serene
24 the purpose of a VL is to facilitate tracheal intubation? AMcN Anaesthesiologists like VLs because they make their life somewhat more serene
25
26 Does one laryngoscope with 2 different sorts of blade count as 2 different laryngoscopes?
27 Most tracheal intubations were rated as easy. For those that were not, the main problems consisted of awkwardness inserting the tracheal tube into the larynx, and difficulty advancing the tube into the trachea once the tip had passed between the vocal cords, despite good laryngeal views. These problems have also been reported with other videolaryngoscopes. 1,2,10,12,13,32
28 Does one laryngoscope with 2 different sorts of blade count as 2 different laryngoscopes?
29 Pblade 2.5 cm Airtraq 16-18mm (Thong & Lim see later) SAD- sagittal distance 15-18mm (Wild and Woodall)
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34 Healy et al. BMC Anesthesiology :32 doi: /
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36 3 year retrospective study 18/ 18 successful glidescope intubations For the first 21 months the VL was SIX FLOORS AWAY Conventional laryngoscopy success 157/163
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39 Looked at 40 patients in each group Difficult people were excluded McGrath was slower But apparently better (even tho the 2 grade 3 views were with the McGrath
40 1801 Patients Better glottic view (Grade I) No difference in rate of intubation
41 119 respondents by May Airtraq and Glidescope most commonly available Polio blade on the wane
42 Effective Isolated case (2 more in 2007) How many swallows are required to make a summer?
43 List of devices Date available to UK Number of hospitals with device available in 2010 Airtraq (19.3) A.P. Advance 2011 Bonfils* (1.4) C-MAC (2.4) Glidescope (11.6) King Vision 2011 McGrath Series (9.7) McGrath MAC 2010 Pentax AWS (7.2) 207 respondents in Was the airtraq most common on the general side because it was Best Available (relatively) Cheap Shikani (1.0) Not Specified 42 (20.3)
44 Ten final year medical students Patients expected to be easy intubations Success defined as CL 1 or 2 7/10 students had cumulative success rates of >90% after 10 intubations
45 Ten final year medical students Patients expected to be easy intubations Success defined as CL 1 or 2 7/10 students had cumulative success rates of >90% after 10 intubations (1 for Mac)
46 20 insertions in a mannequin before clinical use 98% success by the 2 nd laryngoscopy
47 Every 6 months 6-8 trainees turn up on labour ward =6 *10 * = 5,100 per year And who would teach them? (After all there are fewer obstetric GAs these days)
48 List of devices Date available Number of Respondents to UK hospitals with with device device available available for use in 2010 in 2012 Number (percentage) Airtraq (19.3) A.P. Advance 2011 Bonfils* (1.4) C-MAC (2.4) Glidescope (11.6) King Vision 2011 McGrath Series (9.7) McGrath MAC 2010 Pentax AWS (7.2) Shikani (1.0) 319 (59.6) 61 (11.4) 102 (19.1)* 110 (20.5) 176 (32.9) 4 (0.7) 67(12.5) 47 (8.8) 46 (8.3) 7 (1.3) Not Specified 42 (20.3)
49 List of devices Number of hospitals Respondents with Respondents who have Respondents who are Respondents who are with device available in device available for use used device more than happy to use the device confident to teach use 2010 in times in a potentially difficult of the device Number (percentage) airway Airtraq 40 (19.3) 319 (59.6) 147 (27.5) 191 (35.7) 188 (35.1) A.P. Advance 61 (11.4) 24 (4.5) 50 (9.3) 44 (8.2) Bonfils* 3 (1.4) 102 (19.1)* 34 (6.4) 50 (9.3) 39 (7.3) C-MAC 5 (2.4) 110 (20.5) 71 (13.3) 101 (18.9) 105 (19.6) Glidescope 24 (11.6) 176 (32.9) 143 (26.7) 156 (29.2) 146 (27.3) King Vision 4 (0.7) 5 (0.9) 4 (0.7) 6 (1.1) McGrath Series 5 20 (9.7) 67(12.5) 47 (8.8) 51 (9.5) 56 (10.5%) McGrath MAC 47 (8.8) 36 (6.7) 41 (7.7) 46 (8.6) Pentax AWS 15 (7.2) 46 (8.3) 35 (6.5) 52 (9.7) 46 (8.6) Shikani 2 (1.0) 7 (1.3) Not Specified 42 (20.3)
50 Used > 10 times Happy to teach 50 0
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57 Conventional Laryngoscopy 6% failure Videolaryngoscopy 2% failure Able to Intubate Unable to intubate
58 1 P value Chi Square
59 1 P value Chi Square 0.8 P Number in EACH Group
60 1 P value Chi Square 0.8 P Number in EACH Group
61 1 P value Chi Square 0.8 P Number in EACH Group
62 Videolaryngoscopy 3% failure Videolaryngoscopy 2% failure Able to Intubate Unable to intubate
63 1 P value Chi Square 0.8 P Number in EACH Group
64 Whether Which VL
65 Cost Effectiveness Which VL? Training and Compatibility Cleaning
66
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69 All incorporate a draintube to separate the respiratory and gastrointestinal tracts. They also create a higher oropharyngeal leak pressure compared with the first generation SADs
70 Proseal LMA Supreme LMA I-Gel Aura-gain Guardian CPV Baska Mask
71 ELECTIVE cases Halaseh technique used for insertion (inc Propofol and Rocuronium) 99.7% first time placement BMI >30 excluded One regurgitation, no OLP
72 ELECTIVE & Urgent cases Propofol and Rocuronium with manufacturer s insertion technique 98% first time placement Cricoid off after insertion BMI >35 excluded OLP always higher than Pinsp Median 12 [3-22]
73 93% 1 ST, 96% overall insertion success OLP 26 (8) No obstetrics
74 The Leak Pressures are very impressive
75 But a device has to be inserted to work
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77 The you tube video lists 6 steps for successful insertion Just like the classic Clearly what we need is a meta analysis
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81 Whether Which 2 nd Generation
82 Ease of Insertion Cleaning Issues Your 2 nd Generation Device Leak Pressure Low Skill Fibreoptic
83 Human Factors Model Human Factors Are: Anything that affects a person s performance LMQ 2002
84 Human Factors Model Human Factors Are: Anything that affects a person s performance LMQ 2002 Ease of Insertion- 3 attempts?
85 Better oxygenation Apnoeic oxygenation High flow humdified oxygen Page 85
86
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