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Airway

Due to rapid changes in the accepted standards of practice for airway management and the proliferation in available technical equipment for managing airway problems, we feel that all residents should complete a mandatory airway rotation in their senior years (PGY3 – PGY5).  This rotation will be one month in duration and will occur at the General Campus focusing on adult patients.  The resident will continue to assume their usual night call duties.  Experience with airway equipment should ideally be obtained under the supervision of a staff anesthesiologist in patients with a normal airway evaluation, ASA class I or II, scheduled for an elective procedure in the supine position, and not requiring extensive monitoring or involving the head or neck.  Key articles will be identified for directed study during the rotation.  The anesthesia simulator or an airway mannequin will be used to practice infrequent techniques such as retrograde intubation, or insertion of a combitube. Patients identified to have an abnormal airway and requiring awake intubation will be prioritized to the airway resident when feasible.  We will try to avoid the having the resident move from room to room to gather experience, rather, the resident will be assigned to a single room to gain experience on airway techniques on two to four patients per day (40 – 50 patients per rotation).  Faculty with an interest in teaching airway management skills will be scheduled to work with the airway resident.

 

Residents are directed to review existing expert publications on the proper use of various airway devices (O. Hung, Bullard, Brain, etc), rather than struggling with unfamiliar equipment and acquiring unconventional personal techniques.  (Recommended text: JL Benumof.  Airway Management, Principles and Practice.  Mosby 1996, and Finucane B.T.  Principles of Airway Management.  Mosby 1996, both available in the anesthesia library).  When possible the departmental airway mannequin should be utilized to gain experience with unfamiliar airway equipment.

 

The suggested progression during the month airway rotation is to gain experience in:

 

1.               Inhalational induction

2.               Alternatives to bag mask ventilation with the LMA and Fastrak:

a.          Intravenous induction

b.          Inhalational induction

3.               Adjuncts to the direct laryngoscope

a.          Bougie

b.          Straight Blade

c.           McCoy Blade

4.               Alternatives to the direct laryngoscope

a.          Trachlight

b.          Bullard Laryngoscope (with and without video)

5.               Flexible fiberoptic intubation

a.          Awake

b.          Asleep

6.         Review of exposure and remedial supplemental training.

 

An afternoon session at the medical school anatomy lab to gain experience with more invasive techniques such as retrograde intubation and cricothyroidotomy can be arranged if interested.  This would also allow for dissection and anatomical study of the airway and can be arranged on an intermittent basis every 3 – 4 months with a limited number of residents who have completed or will be completing their airway rotation.


 

 

A.   Mandatory Airway Rotational Objectives:

Objective

Objective completed

1.    Perform an airway examination and identify features of a difficult airway.

 

2.    Describe techniques for airway topicalization, including acceptable doses of LA.

 

3.      Describe techniques for sedation and monitoring during airway topicalization.

 

 

To gain experience with airway equipment including:

 Equipment

Experience

Before Rotation

(Scale 0 – 5)

Experience

During rotation

(record with checkmarks)

Comments

Inhalational induction – intubation

 

 

 

Inhalational induction – LMA placement

 

 

 

Fast Trak LMA insertion

 

 

 

Gum Rubber Bougie intubation

 

 

 

Lighted stylet intubation

 

 

 

Bullard intubation (with and without Video)

 

 

 

Bullard intubation with independent stylet

 

 

 

Fiberoptic intubation awake

 

 

 

Nasal intubation

 

 

 

Nebulized LA airway topicalization

 

 

 

Superior LN blocks

 

 

 

Cricothyroid puncture and LA topicalization

 

 

 

 

Scale     (0 = No experience or exposure;  1 = understand theoretical application;  2 = used once;  3 = used clinically 2 or 3 times;  4 = used many times;   5 = Understands limitations, applications, and able to teach technique)

 

B.    Optional Airway Rotational Objectives:

Equipment

Experience before Rotation

Experience during rotation

Comments

LMA and FOB examination

 

 

 

Fast Trak LMA and intubation:

*     blindly

*     trachlight guidance/confirmation

*     with FOB guidance

 

 

 

Straight blade intubation

 

 

 

Fiberoptic intubation – asleep

 

 

 

Digital intubation (airway mannequin)

 

 

 

Retrograde intubation (airway mannequin)

 

 

 

Inhal. induction nasal intubation:

*     sevoflurane ind. with endotral ETT

*     sevoflurane ind. with trachlight assisted intubation (stylet removed).  

 

 

 

Tracheostomy under LA

 

 

 

Combitube placement (airway mannequin)

 

 

 

Dissection of Larynx (anatomy lab):

*     SNL identification

*     Retrograde intubation

*     Cricothyroidotomy / intubation

 

 

 

 

Scale     (0 = No experience or exposure;  1 = understand theoretical application;  2 = used once;  3 = used clinically 2 or 3 times; 4 = used many times;   5 = Understands limitations, applications, and able to teach technique)

 

 

Please return your completed airway rotational objectives to Lynne McHardy B309 Civic Campus Ottawa Hospital.


 

 

C.    Mandatory Reading:

 

References

Completed

1.       Finucaine BT, Santora AH.  Principles in Airway Management.  Second Edition.  Mosby 1996.  Suggested Core Reference Text.

 

2.     Crosby ET, Cooper RM, Douglas MJ, et al.  The unanticipated difficult airway with recommendations for management.  Can J anesth1998; 45: 757–76.

 

3.  Caplan RA, Benumof JL, Berry FA, et al.  Practice guidelines for management of the difficult airway.  A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.  Anesthesiology 1993; 78: 597-602.

 

4.      Crosby ET.  The difficult airway in obstetrical anesthesia. In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996: 638-661.

 

5.      Sanchez A, Trivedi NS, Morrison DE.  Preparation of the patient for awake intubation. In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996: 159-180.

 

6.      Mallampati SR.  Recognition of the difficult airway.  In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996: 126-142.

 

7.      Hung OR, Stewart RD.  Illuminating stylet (lightwand).  Chapter 18  In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996

 

8.      Girish PJ, Smith I, White PG.  Laryngeal Mask Airway.  Chapter 19  In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996

 

 

D.  Optional Reading:

 

References

Completed

1.      Benumof JL.  The ASA management of the difficult airway algorithm and explanation-analysis of the algorithm. In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996: 143-156.

 

2.      Cooper SD.  The Evolution of Upper Airway Retraction:  New and Old Laryngoscopy Blades.  Chapter 20  In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996

 

3.      Murphy MF, Hung OR.  Blind digital intubation. In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996: 277-281.

 

4.      Ovassapian A, Wheeler M.  Fiberoptic Endoscopy-Aided Techniques. Benumof JL. In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996: 282-275.

 

5.      Sanchez A, Pallares V.  Retrograde intubation technique. In: Benumof JL (Ed.).  Airway Management:  Principles and Practice.  St. Louis:  Mosby-Year Book, 1996: 320- 339.

 

 

 

Please return your completed airway rotational objectives to Lynne McHardy B309 Civic Campus Ottawa Hospital.