Direct Laryngoscopy Should It Be Enhanced?

Transcription

1 Direct Laryngoscopy Should It Be Enhanced? NZATS Conference Dunedin NZ 2013 Tim Carroll RRT Business Development Manager Covidien

2 Disclosure

3 Disclosure

4 Full Disclosure

5 Fuller Disclosure

6 Fullest Disclosure

7 Objectives History and laryngoscopes today What problems exist Video enhancement Looking forward

8 History

9 Philipp Bozzini

10 Philipp Bozzini Only very small and unimportant parts of the body could be examined. The Vienna Faculty of Medicine

11 Manuel Garcia

12 De Jean Czesmak

13

14 Gustav Killian 1910

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16

17

18

19 Today

20 Today

21 Today

22 Today

23 Achieving the Objective

24 Achieving the Objective

25 What Are We Actually Doing? Extend neck Distract and compress the tongue Open mouth widely Elevating the mandible Insert steel between teeth Apply tension to the tonsillar pillars Apply upward force Engage vallecula or epiglottis and hoist upwards Cooper R.M. Is direct laryngoscopy obsolete? Internet Journal of Airway Management 4,

26 What Do We Actually See?

27 What Do We Actually See?

28 What Do We Actually See?

29 What Do We Actually See?

30 Some Things We Don t Want To See

31 Tradition

32 Tradition

33 Tradition - Difficult technique to learn - Not suitable for difficult airways

34 Tradition 2013

35 Perfection?

36 What s Wrong With Direct Laryngoscopy?

37 Laryngoscopy Injuries Several studies have reported soft tissue injuries during laryngoscopy and endotracheal intubation required for general anesthesia (GA). They include lip injuries, tooth damage, laceration of oral mucosa and tongue and sore throat. Ansari: Prevention of Lip injuries following Laryngoscopy and Endotracheal Intubation during General Anesthesia. The Internet Journal of Anesthesiology Volume 7 Number 2 -

38 Warner Dental Trauma 1 : 2800 Patients who have the highest risk for dental injury are those undergoing general anaesthesia with tracheal intubation who have preexisting poor dentition and characteristics (Ie.g., limited neck motion, and a history of previous difficult intubation) likely to be associated with difficult laryngoscopy and tracheal intubation. Warner ME. et al. Perianaesthetic dental injuries. Anaesthesiology 1999, 90:

39 Windsor Dental Trauma Cause Proportion of cases Enamel fracture 32.1% Loosening of the tooth 21.1% Luxation or avulsion 12.8% Crown fracture 7.7% Crown and root fracture 1.3% The highest incidence of dental trauma occurs in patients undergoing an endotracheal intubation for a general anaesthetic. Those who present with a difficult airway are approximately 20.8 times more likely to suffer dental trauma than those with a straightforward airway. Windsor J, Lockie J. Anaesthesia and dental trauma. Anesthesia and Intensive Care Medicine 12(8) August 2011,

40 Sakles Adverse Events Number of Attempts at Laryngoscopy Incidence of Adverse Events Success at initial pass 14.2% 2 Attempts at Laryngoscopy 47.2% 3 Attempts at Laryngoscopy 63.6% > 4 Attempts at Laryngoscopy 70.6% AE = hypoxemia, esophageal intubation, regurgitation, aspiration, bradycardia, arrest Sakles, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013; 20(1):71-78

41 Mort Intubation Complications 2013

42 ASA Closed Claims 266 incidents of airway injury 80% laryngeal injuries Laryngoscopy and intubation thought to be easy Domino KB, Posner KL, Caplan RA, Cheney FW. Airway injury during anesthesia: a closed claims analysis. Anesthesiology 1999; 91:

43 Unanticipated Difficult Airways There has been no decrease in the number of reports in the ASA Closed Claims Study of adverse outcomes associated with tracheal intubation. Peterson GN, et al. Management of the difficult and failed airway: a closed claims analysis. Anesthesiology 2005; 103:33-39.

44 Unanticipated Difficult Airways It would seem that the problem lies in the significant incidence of failure to see the vocal cords with conventional laryngoscopy leading to blind techniques that produce airway trauma. Hung O., Murphy MF., Management of the difficult and failed airway. McGraw Hill Medical 2008, pg 104

45 Mallampati Predictive Value Study Patients (n) Prevalence of DAW according to reference std (%) DIFFICULT LARYNGOSCOPY 2000 Schmitt % 2001 Adnet % 2003 Ezri % 2004 Merah 80 10% DIFFICULT INTUBATION 1995 Tse % 2001 Adnet % 2004 Cattano % 2004 Mehra 80 10% Lee et al. A systematic review of the accuracy of the mallampati tests to predict the difficult airway. Anesth Anal 2006;102:

46 Unanticipated Difficult Airways Not every difficult airway can be identified ahead of time clinicians surveyed. 2-10% difficult laryngoscopies - 4% unexpected difficult laryngoscopies 840,000 unanticipated difficult laryngoscopies in U.S. each year Pennsylvania Patient Safety Authority. Management of unanticipated difficult intubation. Pa. Patient Saf. Auth. 2010;7(4): Laryngoscopy Practices, 2013 Survey Report. Covidien; 2013.

47 NAP4 Problems arose when difficult intubation was managed by multiple repeat attempts at intubation. The airway problem regularly deteriorated to a can t intubate can t ventilate situation (CICV). It is well recognised a change of approach is required rather than repeated use of a technique that has already failed. Our goal should be to reduce serious complications of airway management to zero. NAP4-4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. Major complications of airway management in the United Kingdom Report and findings March 2011

48 Enhance

49 Enhance Intensify, increase, or further improve the quality, value, or extent of. To make greater, as in value, beauty, or effectiveness; augment. To provide with improved, advanced, or sophisticated features Oxford Dictionary

50 Improve The View

51 Improve The View

52 Video in Anaesthetics Enhance

53 Video in Surgery Great views Little tissue disruption Cavity closed for procedure

54 Video Enhancement The laryngoscope of the future will provide predictable laryngeal exposure and consistently successful intubation. It will be easy to learn, quickly performed and will impose less stress upon the patient. It will be inexpensive to acquire and robust enough to withstand the hostile environment of the operating room. It will enable us to look around corners, rather than compelling us to straighten them. Cooper R.M. Laryngoscopy It s Past and Future. CAN J ANESTH 2004 / 51: 6 / pp R1 R5

55 Video Enhancement Better and consistent views Intuitive, safe and gentle Cost effective Video-laryngoscopy has the potential to become a first line option for intubation in the near future J.B. Paolini et al. Review article: Video-laryngoscopy: another tool for difficult intubation or a new paradigm in airway management? Can J Anesth/J Can Anesth (2013) 60:

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57 Difficult Airway Society Newsletter Summer 2013

58 Enhanced Most notably, the guideline recommendations included the use of video laryngoscopy for initial intubation in difficult airways as a measure to ensure a higher rate of successful intubations on the first attempt. Why not go all the way and use them in all intubations? Apfelbaum et al. Practice guidelines for management of the difficult airway, updated report by the American Society of Anesthesiologits Task Force on Management of the Difficult Airway. Anesthesiology. 2013, 118(2):

59 Enhanced We should not reserve the best methods for only our most difficult patients; they should be offered to all of our patients. This will provide our patients with the best care. Cooper R.M. Is Direct Laryngoscopy Obsolete?. Internet Journal of Airway Management, 2007

60 Conclusion Injuries and complications occur with direct laryngoscopy Multiple attempts at intubation increase risk Difficult laryngoscopies / intubations can arise unexpectedly Better laryngeal views may mitigate the risk

61 Conclusion With every intubation, you have a plan B you hope you never need a backup so that if the routine turns unexpected, you will be ready. How can you maximise first attempt success?

62 Conclusion Maybe it s time to consider a better Plan A

63 Conclusion Maybe it s time to consider enhancing the direct laryngoscope

64 What Will Become of the Direct Laryngoscope?