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Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
Presentatie Esa Milaan 2009
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Presentatie Esa Milaan 2009

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  • When emergency intubation was first introduced in the 1880s by Jopseph O’Dwyer it was performed blindly using the fingers to palpate the larynx and direct the Endotracheal tube into the airway. Diphtheria an acute bacterial infection spread by personal contact, was the most feared of all childhood diseases. One child out of every ten that became infected died from this disease. Symptoms ranged from a severe sore throat to suffocation by the formation of a 'false membrane' over the larynx. Between 1880 and 1887, Joseph O'Dwyer devised a series of tubes to be inserted into the larnyx and thus maintain air supply until the crisis period of the illness passed. O'Dwyer's intubation tubes were not foolproof, nor simple to use, but desperate doctors and parents grasped this innovation as a precious last resort. The American medical community hailed O'Dwyer as the medical savior of thousands of children in the United States. In 1913 Henry Janeway developed a laryngoscope designed for the sole purpose of allowing the anesthesiologist to place an intratracheal conduit with consistent success to help alleviate these concerns. The speculum Janeway designed incorporated a distal light source with battery power within the laryngoscope handle itself. This handle-inclusive battery power was the first of its type. Additional features included a shortened distal end of the speculum that eliminated the need for a telescope to adequately view the larynx, a central notch for maintaining the catheter in the midline during placement, and a curve to the distal end of the blade to help direct the catheter through the vocal cords. Guedel, on the other hand, used a folding laryngoscope blade and light source for ease in transport from one anesthetizing location to another because a rigid laryngoscope was less well-suited for transport from one hospital to another. Today, most intubations worldwide are performed using technology that was developed over almost 70 years ago. Unfortunately, there are patients who cannot be intubated with a co n ventional laryngoscope because a direct line of sight cannot be achieved from the physician’s eyes to the larynx. In recent years, severall investigators have developed novel devices that incorporate video and optical technology to augment the function of the laryngoscope.
  • Group of anesthesiologists from the University of Geneva, Switserland 60 anesthesia providers (staff anaesthesists, residents and nurses); experience: ≥50 direct laryngoscopies. Scenario 1: Pharyngeal obstruction Scenario 2: Pharyngeal obstruction and cervical spine rigidity Scenario 3: Tongue oedema
  • Transcript

    • 1. Edward J. Pasman, Anesthesiologist Academic Medical Center (AMC) Amsterdam Royal Dutch Army Medical Core Evolving in Trauma Care Airway Management
    • 2. 452 studies (1950-2006)
      • objectives:
      • … . real or anticipated problems in maintaining an adequate airway wheter
      • emergency endotracheal intubation as opposed to other airway management techniques
      • improves the outcome in terms of survival, degree of disability at discharge or lenght of stay and complications occuring in hospital
      Emergency intubation for acutely ill and injured patients The Cochrane Library 2009, issue 2, Lecky, Bryden, Tong, Moulton
    • 3. Authors conclusions:
      • The efficacy of emergency intubation as curently practised has not been rigorously studied.
      • In trauma and paediatric patients, the current evidence base provides no imparative to extend the practice of prehospital intubation in urban systems
      • The skill level of the operator may be key
      • in detemining efficacy.
      Emergency intubation for acutely ill and injured patients The Cochrane Library 2009, issue 2, Lecky, Bryden, Tong, Moulton
    • 4. Safety Culture
      • A collection of characteristics and attitudes in an organization, promoted by its leaders and internalized by its members, that makes safety an overriding priority. (the NASA)
      • Several high-risk but high-reliability domains:
      • commercial aviation
      • the nuclear power industry
      • military aircraft carriers
      • Airway Management is therefore
      • a typical highrisk high-reliability procedure in medicine
      • up to 70% of errors in patient care are due to ‘human factors ’ including systems safety and safety culture; until now almost no research on safety questions has been done in the critical field of Airway Management.
      Best Practice & Research Clinical Anaesthesiology Vol. 19, No. 4, pp. 539–557, 2005
    • 5. Difficult Airway Definition
      • a view of the larynx corresponding to grade 3 or 4 in the classification of difficult intubation by Cormack and Lehane
      • The A.S.A defines difficult tracheal intubation as:
      • when “proper insertion of the endotracheal tube with
      • conventional laryngoscopy
      • requires more than 3 attempts, or more than 10 min”
      • “ A.S.A. & D.A.S. : Unanticipated difficult airway algorithm is based on
      • expert or concensus opinion, anecdote and literature review”
      • ( Anesthesia, 2009 , 64: 601-608)
    • 6. Airway Evaluations
      • Three criteria were found independent for difficult laryngoscopy :
      • Neck movement ≤ 80 degrees OR= 2.73 (1.14–6.51)
      • Mallampati Class 3 or 4 OR= 2.96 (1.63–5.35)
      • Ratio of Height to Thyromental Distance OR= 6.72 (3.29 –13.72)
      Anesth Analg 2005 ;101:1542–5
    • 7. Airway Evaluations 34,513 patients
      • Used alone, the Mallampati tests have limited accuracy for predicting the difficult airway and thus are not useful screening tests.
      • It has been demonstrated more recently that mouth opening is also dependent on cervical spine positioning : to achieve maximal interdental distance, the craniocervical junction must be extended
      • Craniocervical extension improves the specificity and positive predictive value of the Modified Mallampatie airway evaluation while retaining sensitivity of the traditional MMP examination.
      Anesth Analg 2006 ; 102:1867–78 & 103:1256 –9
    • 8. Predicted difficult Laryngoscopies
      • While a number of clinical tests are available to identify patients at risk for airway related difficulties, the reliability of these tests remains limited .
      • ( Best Practice & Research Clinical Anesthesiology Vol. 19, No. 4, pp. vii–ix, 2005 )
      • Out-of-hospital tracheal intubation can be challenging.
      • The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate .
      • ( Anesth Analg 2007 ;104:619 –623)
    • 9. Prehospital intubation of TBI patients
      • ATLS doctrine:
      • GCS ≤ 8 ………… Intub8
      • Recent clinical data:
      • association between early intubation and mortality
      • Subgroup analysis from the San Diego Paramedic Rapid Sequence Intubation Trial and outcome data following air medical intubation suggest that:
      • Suboptimal performance of intubation and subsequent ventilation
      • may play an important role in determining the procedure’s potential benefit or harm
      Prehospital intubation of brain-injured patients Current Opinion in Critical Care 2008 , 14: 142 - 148
    • 10. Cervical spine pathology & C-spine motion
      • 20-30% of the Poly-trauma patients
      • All types of devices and manoeuvres associated with airway management are showing some degree of Cervical Spine motion
      • It is the practitioner rather than the device that performes the intubation and perhaps the ‘best device’ is the one most familiair to the care provider
      • (Cervical spine motion during flexible bronchoscopy compared with the Lo-Pro Glidescope; BJA 2009 102(3): 424 – 430)
      • Indirect laryngoscopy does not significantly decrease movement of the nonpathologic C-spine when compared with Direct laryngoscopy.
      • It does produce a better glottic visualization
      • ( Cervical spine motion during tracheal intubation with manual in-line stabilisation: direct laryngoscopy versus glidescope videolaryngoscopy, Anesth Analg 2008 ; 106: 935-941)
    • 11. Statement:
      • The recent development of
      • video and optical laryngoscopy
      • could be the most important change
      • in the airway management paradigm
    • 12. Time line: Laryngoscopy assited intubation 1880 1913 2001 Future 129 yrs 99 yrs 8 yrs 1940 NOW 69 yrs 2009
    • 13. Need for improvement
      • A device that provides a straightforward way of dealing with difficult laryngoscopies could help prevent the serious sequelae of a failed intubation
      • The Answer:
      • Glidescope
    • 14. Videolaryngoscopy an answer to difficult laryngoscopy?
      • The mean improvement in Cormack Lehane view:
    • 15. Simulated Difficult Airways
      • In comparison with the traditional Macintosh blade,
      • Indirect laryngoscopy provides:
      • Superior intubating conditions
      • Less dental trauma
      • Easier to use even by experienced traditional intubators
      • These advantages increased with with
      • the level of difficult intubation scenario’s
      Comparison of the Glidescope, the McGrawth, the Airtraq and the Macintosh laryngoscopes in simulated difficult airways Anesthesia, 2008 ; 63: 1358-1364 J. Ass. Of Anaesthesists of great Britain and Ireland
    • 16. Real “difficult airways” in Amsterdam
      • Displacement double-lumen tube
    • 17. Real “difficult airways” in Amsterdam
      • Displacement double-lumen tube
      • Mandibula fractures
    • 18. Real “difficult airways” in Amsterdam
      • Displacement double-lumen tube
      • Mandibula fractures
      • Morbide Obesitas and a car incident (HET)
      • T-1 Victims from the Turkish Airline Crash at Schiphol airport
    • 19. Real “difficult airways” in Amsterdam
      • Displacement double-lumen tube
      • Mandibula fractures
      • Morbide Obesitas and a car incident (HET)
      • T-1 Victims from the Turkish Airline Crash at Schiphol airport
      • Swollen tongue due to Ace Inhibitor
    • 20. Real “difficult airways” in Amsterdam
      • Displacement double-lumen tube
      • Mandibula fractures
      • Morbide Obesitas and a car incident (HET)
      • T-1 Victims from the Turkish Airline Crash at Schiphol airport
      • Swollen tongue due to Ace Inhibitor
      • Delinquent jumps of balkony (6th floor)
    • 21. Real “difficult airways” in Amsterdam
      • Displacement double-lumen tube
      • Mandibula fractures
      • Morbide Obesitas and a car incident (HET)
      • T-1 Victims from the Turkish Airline Crash at Schiphol airport
      • Swollen tongue due to Ace Inhibitor
      • Delinquent jumps of balkony (6th floor)
      • Gang shooting
    • 22. Pre-Conclusions
      • Efficacy of emergency intubation is not regorously studied
      • The skill level of the operator may be key in detemining efficacy
      • Up to 70% of errors in patient care are due to ‘ human factors ’
      • Unanticipated difficult airway algorithm is based on expert or concensus opinion, anecdote and literature review
      • While a number of clinical tests are available to identify patients at risk for airway related difficulties, the reliability of these tests remains limited
      • TBI & C-spine injuries: It is the practitioner rather than the device that performes the intubation and perhaps the ‘best device’ is the one most familiair to the care provider
    • 23. Final Conclusion:
      • THE ANSWER:
      • The Glidescope
      • Superior intubating conditions
      • Less dental trauma
      • Easier to use even by experienced traditional intubators
      • advantages increase with with the level of difficult intubation scenario’s
    • 24. Questions Thank you for your attention ?

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