ANTICIPATION OF THE DIFFICULT AIRWAY: THE PREOPERATIVE AIRWAY ASSESSMENT FORM AS AN EDUCATIONAL AND QUALITY IMPROVEMENT

1. ANTICIPATION OF THE DIFFICULT AIRWAY: THE PREOPERATIVE AIRWAY ASSESSMENT FORM AS AN EDUCATIONAL AND QUALITY IMPROVEMENT TOOL Carin Hagberg, M.D. Davide Cattano, M.D., Ph.D. Jon Tyson, M.D. Funding supplied by Research in Education Grant fromFoundation of Anesthesia Education and Research (FAER)

2. DIFFICULT AIRWAY MANAGEMENT IS ONE OF THE MOST CHALLENGING TASKS FOR ANESTHESIOLOGISTS Does the Airway Examination Prevent Difficult Intubation ? • DMV grossly 1 :1000 • D- Laryngoscopy 10 : 100 • Difficult Intubation 1 : 100 • Difficult SGA management ? • Difficult Surgical Airway ? “There is one skill above all else that an anaesthetist is expected to exhibit and that is to maintain the airway impeccably” Ian Latto and Michael Rosen

3. at a minimum, a preanesthesia physical examination should include (1) an airway exam [100% consultants (72), 100% ASA members (273)]…

5. APSF SURVEY RESULTS IDENTIFY SAFETY ISSUES PRIORITY: AIRWAY STILL #1 Difficult Airway Management Cost-Saving: Production Pressures Anesthesia Delivery: Remote Sites Anesthesia Delivery: Office-Based Neurologic Deficit Due to Anes Tech Coronary Heart Disease (Pts) Occupational Stress Fatigue Medication Errors Cost-Saving: Time for Pre-op Eval Stoelting RK: APSF Newsletter 1999; 14:6

6. WHY IS THIS STUDY IMPORTANT? Difficult airway management pertains to every anesthesiologist May reduce stress for both the anesthesiologist and patient May reduce morbidity and mortality May create a universal evaluation system May increase overall knowledge about airway features

7. STUDY DESIGN – GOALS • Primary Hypothesis • Use of a specially designed preoperative airway assessment form by anesthesiology residents will result in more complete documentation of important airway features (as designated by the American Society of Anesthesiologists) compared to use of the current forms

8. STUDY DESIGN – GOALS • Secondary Hypotheses: • New preoperative form will result in greater resident recognition of patients at high risk for difficult airway as judged independently by senior anesthesiology faculty • Greater number of awake intubations by residents using the new form • Number of multiple intubation attempts and invasive surgical intubation techniques may decrease with residents using the new form • Identify and characterize features of Difficult SGD and Surgical Airway • Increased spontaneous knowledge of important airway features by 18 months for residents using the new form • Observations during the study will help refine the new form

9. STUDY DESIGN – PARTICIPANTS • All anesthesiology residents between July 2008- June 2010 • Locations: • MHH • LBJ • 2 groups • Group A • Current preoperative assessment • Postoperative evaluation • Group B • Current preoperative assessment • New preoperative airway assessment • Postoperative evaluation • Study faculty will perform independent preoperative airway assessments • Dr. Davide Cattano • Dr. Carin Hagberg • Dr. Sara Guzman

10. STUDY DESIGN – LOGISTICS • Preoperative assessments: • Specialized attending and resident will be blind to each other’s assessment • Resident should review assessment with their assigned attending • Specialized attending will page attending assigned to case when a difficult airway is anticipated • Forms must be returned to billing • Completeness/accuracy of charting will be assessed

11. CURRENT PRE-OP ASSESSMENT FORMS

12. NEW PREOP AIRWAY ASSESSMENT FORM

13. 5 AREAS OF DIFFICULT AIRWAY MANAGEMENT Difficult mask ventilation Difficult supraglottic airway Difficult laryngoscopy Difficult intubation Difficult surgical airway

14. Mask seal (M) BMI > 26 kg/m2 (O) Age > 55 yrs (A) Lack of teeth (N) History of snoring (S) DIFFICULT MASK VENTILATIONPREOPERATIVE RISK FACTORS Condition in which the anesthesiologist cannot provide adequate mask ventilation due to inadequate seal, excessive leak, or resistance to gas flow MOANS Langeron O et al: Prediction of Difficult Mask Ventilation. ANESTHESIOLOGY 2000; 92:1229-36

15. DIFFICULT SUPRAGLOTTIC AIRWAY "RODS" Result of poor device placementorinability to adequately ventilate with device successfully placed Restricted mouth opening (R) Obstruction of upper airway (O) Distortion/disruption of airway (D) Stiff lungs (reduced compliance or increased resistance) (S)

16. DIFFICULT LARYNGOSCOPY Grade 1 Grade 2a Grade 2b Grade 3 Grade 4 Yentis & Lee Modification of Cormack & Lehane Classification Inability to visualize any portion of the vocal cords after multiple attempts at conventional laryngoscopy

17. DIFFICULT LARYNGOSCOPY - LEMON Look Externally (L) Evaluate 3-3-2 (E) Mallampati class (M) Obstruction (O) Neck mobility (N) "LEMON"

18. Difficult Intubation A Difficult Laryngoscopy does not automatically predict a Difficult Intubation Easy Laryngoscopy but conditions altering the anatomy of the larynx or the trachea AlternativeTechniques Difficult laryngoscopy Requires multiple attempts Difficult Intubations Can Be Skill Related Examples of alternative techniques: 1.FOB- fogging, bleeding 2. I-LMA- mouth opening, tonsils, alignment of axis 3. Glidescope- mouth opening, cannot pass and align the ETT • Patients’ preexisting conditions: • Severe tracheal deviation • Bleeding disorders • Neck abscess • Laryngeal and subglottic tumor • Etc.

19. DIFFICULT SURGICAL AIRWAY • Surgery/disrupted airway (S) • Hematoma/infection(H) • Obese/access problems (O) • Radiation/excessive bleeding (R) • Tumors (T) SHORT Walls R, Murphy M; National Airway Course, USA

20. PLAN DESCRIPTION • Note how you will proceed on the form • What type of anesthesia will you administer? • Local or general?

21. POSTOPERATIVE EVALUATION

22. MASK VENTILATION Evaluation of mask ventilation

23. SGA DEVICE Evaluation of supraglottic airway device (if used)

24. C-L AND INTUBATION Evaluation of Cormack and Lehane grade on DL Evaluation of Intubation (if performed)

25. SURGICAL EVALUATION Evaluation of surgical airway (if applicable)

26. EXTUBATION Evaluate extubation Register difficult airway (if applicable)

27. TO ERR IS HUMAN, TO FORGIVE IS DIVINE Alexander Pope [21 May1688 – 30 May1744] english poet Errare humanum est perseverare diabolicum Seneca the Younger or Lucius Anneus Seneca (c. 4 BC – AD 65)