Do you use difficult airways algorithms and guidelines in your daily practice or do you have your own strategy? Which algorithm have you found preferable? Do you think current guidelines are simple and easy? Any recent updates?
I normally use the algorithm of the guidelines recommended by our Italian Society of Anesthesia, and i believe that a useful algorithm.
ASA published only recently their updated airway algorithm (Anesthesiology 2013; 118:251-70). Current algorithms (ASA, DAS) are very useful, but we found some of them difficult to follow in critical airway situations. We developed our own algorithm which starts with mask ventilation - the first measure the anesthesiologist will try if any problem occurs. We also included all the tools that are available at our institution. I attached a translated version of the algorithm. Any critics? Suggestions?
Giovanni Consani
Would you upload an English version of your guideline?
Ruediger Noppens
Interesting. At a glance less complex than ASA/ DAS guidelines.
Dear Ruediger
I had a look at your algorithm and have one or two comments. Firstly, congratulation on concentrating attention on successful mask ventilation rather than intubation and on introducing videolaryngoscopes into the algorithm.
However, I think that the right hand side of the algorithm (emergency airway) allows for too many manouvers before the stage of surgical airway is reached. If there is no success with mask ventilation and videlaryngoscope (VL) guided intubattion then trying any 'alternative technique' is waste of valuable time in a patient who you have failed to oxygenate. DAS UK guidelines have this right in my opinion. DAS guidelines allow for one insertion of the supraglottic airway before doing surgical airway in a situation of 'can't intubate, can't ventilate'. Use of any other device (VL is there twice - if it has failed once why try it again?) such as Bonfils or FOS requires time that a patient that has not been oxygenated for few minutes does not have.
I would also like to add that when using supraglottic device before surgical airway, it seems to make sense to give a muscle relaxant if not already given as this may increase your chances in oxygenating with suppraglottic airway device (recommended by NAP4). By doing this you loose nothing and may avoid having to do surgical airway.
A link comparing some known algorithms of difficult airway. I found the text and its references helpful. There are still debates on the issue. Has the last update of ASA (Anesthesiology 2013; 118:251-70) added to our current knowledge about the management of difficult airway?
http://lifeinthefastlane.com/education/ccc/difficult-airway-algorithms/
Dear Ruediger Noppens,
By reviewing your algorithm, I think your attempt to put an emphasis on the importance of mask ventilation as the first step is logical. Besides, you've tried to include all available devices at your hospitals in your algorithm. So, I think by means you may not forget to use a helpful device in an emergency situation.
However, my main question is "why you did not find supraglottic devices superior to Bonfils and Videolaryngoscopy? We know devices such as LMA probably are helpful in difficult ventilation and our main goal is ventilating not intubating the patient. Nonetheless, in left arm of the algorithm, how much is the possibility of successful mask ventilation when suppragottic ventilation fails. Is it necessary to try for this step when we are behind the time in non-ventilate patient?
There are some minor comments too. In my opinion, we are better to have everything in one arm algorithm (rather than two or more arms) for simplicity as it is in DAS algorithm. Moreover, the next step is justified when the previous step fails. So, the user does not lose anything without answering "successful?" with yes or no in any step.
Thank you very much for sharing your algorithm.
Note my recent E-letter about "ASA difficult airway algorithm 2013" in BJA.
http://bja.oxfordjournals.org/forum/topic/brjana_el%3b9922
Share your comments.
Dear Dr. Najafi, congratulations on your correspondence published in BJA. I skimmed over the publication and it was comprehensive and said it all.
Certainly, current algorithms (especially ASA 2013) are complex and difficult to follow in emergency situations. The idea of having a simpler approach is great and cardiopulmonary resuscitation (CPR) guidelines is a good template. However, we consider CPR guidelines as algorithms, isn't it?
Management of difficult airway is really difficult! Although Vortex approach is simple, there are many questions about this approach. How they use indirect laryngoscopy, how they save the time in non intubate non ventilate patients, ...? We are probably better to wait and see how this novel idea works in daily practice.
Thanks to all for your thoughts. My reading would be that there is lots of opinion, quite a lot of thought, but (so far) little evidence of efficacy or what they should look like. Doesn't mean that opinions are wrong of course.
DAS guidelines 2015 planned to be released in November. See main proposed changes here: http://www.das.uk.com/files/DAS_intubation_guidelines_2015_update1.pdf
What do you think about new changes?
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