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 from Foundation of Anesthesia Education and Research (FAER)

2. Ian Latto and Michael Rosen
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)]…

4. The specific respiratory events are depicted here
The specific respiratory events are depicted here. Difficult intubation and inadequate ventilation/oxygenation account are the most prevalent and account for almost half of the damaging events. Esophageal intubation and premature extubation were the next most common. Other respiratory events were endobronchial intubation, bronchospasm, and inadvertent extubation.
Anesthesia care was judged by the reviewers to be less than appropriate in 64% of the respiratory-related damages,as compared to 28% in the CV event group. Among the respiratory events, care was most often judged to be less than appropriate in claims for esophageal intubation and premature extubation and inadequate ventilation. The aspiration group had the lowest proportion of claims where the care was judged as less than apporpriate.

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
In late 1998, the Executive committee of the Anesthesia Patient Safety Foundation conducted a survey designed to identify the most important anesthesia patient safety issues as perceived by practicing anesthesiologists. The survey was administered by mail to 1660 members of the ASA. It was also available at the APSF Booth at the 1998 ASA annual meeting. The top 10 safety issues are shown here and as you can see, DAM was the highest, being marked as high priority by 72% of the 801 respondents. NO WONDER YOU ARE SITTING IN THIS AUDIENCE!!!!Of course, if you are working in a free standing sugery centerr and concerned about production and your patient has CAD, you are really going to be stressed.
In late 1998, the Executive Committee of the Anesthesia Patient Safety Foundation (APSF) conducted a survey designed to identify the most important anesthesia patient safety issues as perceived by practicing anesthesiologists. The survey was initially administered by mail to 1660 members of the ASA and it was also available for on-site completion to visitors at the APSF/ASA Patient Safety Booth at the ASA Annual Meeting in Oct, 1998.
The 10 most important anesthesia patient safety issues as determined by a “High Priority” ranked by 801 anesthesiologist respondents rated Difficult Airway Management as the most important patient safety issue being ranked by 72%. NO WONDER YOU ARE ALL HERE IN THIS ROOM, HEARING THIS LECTURE.
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 June 2010
Locations:
MHH
LBJ
2 groups
Group A
Current preoperative assessment
Postoperative evaluation
Group B
New preoperative airway assessment
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. DIFFICULT MASK VENTILATION PREOPERATIVE RISK FACTORS
Condition in which the anesthesiologist cannot provide adequate mask ventilation due to inadequate seal, excessive leak, or resistance to gas flow
Mask seal (M)
BMI > 26 kg/m2 (O)
Age > 55 yrs (A)
Lack of teeth (N)
History of snoring (S)
MOANS
Mask seal (beard/moustache) Can use lube or request the patient to shave. Nothing against men with beard or moustache’s, as my husband has them, but sometimes facial hair can hide anatomical abnormalities and you might uncover a DA. Rather than simply remove dentures in the DSU, you could have the patient’s leave them in until you have finished MV, yet remove them prior to intubation. Can’t do much about a patient’s age and weight or whether they wake their spouse up with snoring, but you can get an adequate preop assessment of whether or not they have OSA and what special precautions you need to perform.
Langeron O et al: Prediction of Difficult Mask Ventilation. ANESTHESIOLOGY 2000; 92:

15. DIFFICULT SUPRAGLOTTIC AIRWAY
Result of poor device placement or inability 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)
"RODS"

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

17. DIFFICULT LARYNGOSCOPY - LEMON
Look Externally (L)
Evaluate (E)
Mallampati class (M)
Obstruction (O)
Neck mobility (N)
"LEMON"
3. Mouth opening
2. Mental to hyoid
3. Hyoid to thyroid

18. Patients’ preexisting conditions:
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
Difficult laryngoscopy Requires multiple attempts
AlternativeTechniques
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
SHORT
Surgery/disrupted airway (S)
Hematoma/infection (H)
Obese/access problems (O)
Radiation/excessive bleeding (R)
Tumors (T)
Mask seal (beard/moustache) Can use lube or request the patient to shave. Nothing against men with beard or moustache’s, as my husband has them, but sometimes facial hair can hide anatomical abnormalities and you might uncover a DA. Rather than simply remove dentures in the DSU, you could have the patient’s leave them in until you have finished MV, yet remove them prior to intubation. Can’t do much about a patient’s age and weight or whether they wake their spouse up with snoring, but you can get an adequate preop assessment of whether or not they have OSA and what special precautions you need to perform.
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 May 1688 – 30 May 1744] english poet
Errare humanum est perseverare diabolicum
Seneca the Younger or Lucius Anneus Seneca (c. 4 BC – AD 65)