@noolslucas

@noolslucas

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 26 – The Traumatic Airway. Particularly stressful airways to manage = one part of a wider critically ill patient. Let’s kick off with a #OnePager
#FOAMed #JanuAIRWAY 1/5

The principles of Rx are:
-Beware the isolated environment
-Plan for uncooperative patient
-Prevent aspiration
-Protect C-spine
-Plan for difficult airway
#FOAMed #JanuAIRWAY 2/5

Define type of trauma early – blunt vs penetrating (neck divided into 3 zones), and assess for:
-Distorted anatomy
-Bleeding
-Subcut. Emphysema – injury to gas containing structure
-Other traumatic injury – e.g. head, thorax, abdomen, etc
#FOAMed #JanuAIRWAY 3/5

Read 6 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 25 – Obstetric Airways (thanks to @noolslucas for her expert contribution to todays content!). Let’s dive in…Here's a #OnePager and decision tools from a great review article
🔗doi.org/10.1111/anae.1…
#JanuAIRWAY 1/5

@dasairway

Failed intubation requires a different approach in Obs. The 2015 @dasairway /@OAAinfo guidelines are really helpful for this! Covering safe Obs GA, failed intubation and GA.
#JanuAIRWAY 2/5

The DAS/OAA guidelines also cover decision making – when to bail out / when to proceed and aftercare – which mustn’t be overlooked!
#JanuAIRWAY 3/5

Read 5 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

@ENT_UK

#JanuAIRWAY Day 24 -Paediatric Airways. (ft. expert contributions from Alistair Baxter and @ENT_UK’s Adam Donne). Let’s dive in … Here's some #OnePagers covering anatomy, induction, airway manoeuvres and basic airway equipment.
#JanuAIRWAY 1/10

Top tip from Alistair Baxter: Remember that a Macintosh blade is a hyperangulated blade in an infant and requires an intubation stylet shaped to match the curve of the blade
#JanuAIRWAY 2/10

The difficult paediatric airway = #SCARY. Upper airway obstruction in children – broad range of presentations, three important diagnoses; Croup, Epiglottitis and Inhaled Foreign Body. Here’s some #OnePagers.
#JanuAIRWAY 3/10

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Difficult Airway Society (DAS) Trainees

@dastrainees

@ENT_UK

#JanuAIRWAY Day 22. Airway Obstruction – Infraglottic (intrathoracic). Again, presents its own set of challenges. Let’s dive in … Here's a #OnePager (Ft. expert contribution Sadie Khwaja @ENT_UK )
#JanuAIRWAY 1/7

Issues:
- Upper/Mid lesions usually low risk – ETT may pass beyond
- Low tracheal/Bronchial lesions = high risk, best managed in specialist centres
- CT scan = essential
- Sudden obstruction can occur at ANY time
- Potential compression of heart/vessels
#JanuAIRWAY 2/7

Severe Obstruction:
- Check position patient breaths best in
- Spont vent may help, IPPV may cause airway collapse
- Opinion re: IV vs inhalational = mixed
- Ketamine ?preserves chest wall tone
- Need back up plan
- Consider Heliox/bypass/ECMO before starting
#JanuAIRWAY 3/7

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Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 21. Airway Obstruction – Infraglottic (extrathoracic). Presents a unique set of challenges. Let’s dive in … Here's a #OnePager
#JanuAIRWAY 1/6

Physiology
- Theory=fixed lesion unaffected by respiratory cycle / anaesthesia induction (most have dynamic element)
- Extrathoracic lesions usually better in expiration +ve pressure splints airway open
- Lets’ revisit flow-volume loops as they can be helpful
#JanuAIRWAY 2/6

Issues:
- Laryngoscopy likely to be uneffected. However, major concern = inability to pass ETT atraumatically beyond the level of obstruction
- Nasendoscopy can be useful to view lesion
- AFOI/FOI may cause ‘cork in bottle’ effect depending on lesion size/location
#JanuAIRWAY 3/6

Read 6 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 20. Airway Obstruction – Periglottic. Often the most challenging for the general anaesthetist. Let’s dive in … Here's a #OnePager
#JanuAIRWAY 1/6

Issues:
- Must d/w with ENT colleagues
- Preop nasendoscopy by experienced nasendoscopist = essential
- AFOI may worsen obstruction – cork in bottle
- Inhalational induction may be difficult

Key Q's
- Static or dynamic obstruction?
- Will ETT pass?
#JanuAIRWAY 2/6

Options:
- May be able to pass ETT – consider MLT or jet vent.
- Apnoeic (HFNO) or intermittent oxygenation technique depending on type of surgery (elective/emergent)
- Awake Tracheal Intubation
- Transtracheal catheter (+/- jet ventilation)
- Awake tracheostomy
#JanuAIRWAY 3/6

Read 6 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 19. The Obstructed Airway – Think SPIMS
-Supra-
-Peri-
-Infra-glottic – extra/intrathoracic
-Malacias
-SVC Obstruction
Today we’re going to focus on Supraglottic Airway Obstruction. Here's a #OnePager to get started! #FOAMed
#JanuAIRWAY1/7

Possible issues:
-Risk of total obstruction with low tone
-Distorted anatomy
-NP/OP airway too short?
-+++jaw thrust may/may not relieve obstruction
-Difficult BVM/laryngoscopy
-+++ laryngoscopy may make manageable unmanageable (e.g.bleeding)
#FOAMed
#JanuAIRWAY 2/7

Planning in airway obstruction = Key. NASENDOSCOPY can save lives here! ASSESSMENT informs STRATEGY. Let’s revisit some #OnePagers on key questions and airway planning. Remember the decision-making process is multifactorial (maintain situational awareness).
#JanuAIRWAY 3/7

Read 7 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 18. Extra CICO Equipment. At least 2 pieces of equipment deserve extra attention – Rapid-O2 & the Melker airway (key components of the cannula technique one for initial oxygenation & one for securing the airway)! Here’s a pair of #OnePagers to get started.. 1/5

A bonus #OnePager on the QuickTrach airway – used for wide bore cricothyroidotomy, it may still lurk in a few departments throughout the land! Here’s a video as well #FOAMed
#JanuAIRWAY 2/5

Double bonus #OnePager – on the Ventrain Device – a newer, but interesting, device! Can be used both electively & as part of CICO. Here’s a recent paper that highlights its potential read.qxmd.com/read/33432628/… #FOAMed
#JanuAIRWAY 3/5

Read 5 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

@dasairway

#JanuAIRWAY Day 17. CICO - Scalpel Techniques. Absolutely ESSENTIAL knowledge for anyone involved in airway management! Here’s a #OnePager with the @dasairway algorithm. Let’s dive in… #FOAMed
#JanuAIRWAY 1/6

DAS advocates scalpel-bougie-tube technique for palpable anatomy and scalpel-finger-bougie-tube technique for impalpable anatomy. Here are some #OnePagers #FOAMed
#JanuAIRWAY 2/6

@VortexApproach

Perhaps the most difficult part of the process is making the mental leap to pick up the scalpel. That's why mental models and thinking tools like the @VortexApproach are so useful. Check out @NicholasChrimes & Peter Fritz's work
🔗vortexapproach.org
#JanuAIRWAY 3/6

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Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 16 (we’re over ½ way!) Cannot Intubate Cannot Oxygenate (CICO) Scenario - Needle Techniques. Potentially controversial (DAS primarily advocates scalpel techniques), but worth knowing about - particularly for paeds! Here’s some #OnePagers to start..
#JanuAIRWAY 1/7

@dasairway

CICO Key = decide on your plan before you're in the situation. @dasairway promotes scalpel techniques (final common pathway of CICO) MUST be taught. For more on the Needle technique check of Dr Andy Heard’s work at the Perth ‘wet’ lab. 🔗bjanaesthesia.org.uk/article/S0007-…
#JanuAIRWAY 2/7

Integrating the needle technique into CICO algorithms could look something like this #OnePager. There are 2 scenarios for each technique (needle & scalpel):
-palpable and
-impalpable anatomy
another reason to decide early –> lower cognitive load. #FOAMed
#JanuAIRWAY 3/7

Read 7 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 15. Tracheostomies – more than just an ETT through the neck. Here’s a #OnePager covering some of the different tube types. Let’s dive in…
#JanuAIRWAY 1/9

Tracheostomies have potentially been performed since ancient Egypt. The first non-emergency trache was thought to be performed by Asclepiades. He was also a proponent of music therapy (might be of interest to Veena).
#JanuAIRWAY 2/9

There are 4 basic indications for tracheostomy:
1. Provide patent airway
2. Protect the airway
3. Clear secretions
4. Aid weaning from ventilator – the timing of which was investigated in the Tracman study in 2013 (jama.jamanetwork.com/article.aspx?a…)
#JanuAIRWAY 3/9

Read 9 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

@vapourologist

#JanuAIRWAY Day 14. One Lung Ventilation – one of @vapourologist’s favourite procedures in anaesthesia – physiology in action! Here’s a #OnePager. Let’s dive in…
#JanuAIRWAY 1/9

Several indications for OLV, commonest are thoracic surgery & some oesophagectomies. Essentially three ways to achieve OLV - use of:
- Double lumen tube
- Bronchial Blocker
- Elective endobronchial intubation
Here are some #OnePagers covering the basics
#JanuAIRWAY 2/9

The key physiological change is the creation of a large shunt – deoxygenated blood (which would normally be oxygenated), returns to the left heart resulting in hypoxaemia.
#JanuAIRWAY 3/9

Read 9 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 13. Jet Ventilation – this is a bit more niche in anaesthesia / airway management, but fascinating. Here’s a #OnePager covering the basics. Let’s dive in…
#JanuAIRWAY 1/8

2 modes of jet ventilation – low frequency (<60 jets/min) & high frequency (>60). Frequency determines device. 2 commonly used devices – Manujet (modified hand operated Sanders injector) or Monsoon (specialised jet ventilator). Here’s a some #OnePagers
#JanuAIRWAY 2/8

Several different potential mechanisms to apnoic oxygenation during HFJV, including:
-Bulk flow
-Laminar flow
-Taylor dispersion
-Pendelluft
-Molecular diffusion
-Cardiogenic mixing
derangedphysiology.com has a great article & this diagram #FOAMed
#JanuAIRWAY 3/8

Read 8 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

@dr_imranahmad

#JanuAIRWAY Day 12. Awake Techniques (ft. expert contributions from @dr_imranahmad). This is a key skill for an airway manager. Here’s a #OnePager covering the basics of Awake Tracheal Intubation (ATI) and nasendoscopy. Let’s dive in…
#JanuAIRWAY 1/11

Key = topicalization (if right, may not need sedation). Top tips:
- Know nerve supply CN V, IX & X.
- Block Ant.ethmoidal AND Sphenopalatine ganglion supply to the nasal septum
#JanuAIRWAY 2/11

@Vapourologist

Often you don’t need high dose LA if in right spot – this video is @Vapourologist after only gargling instilagel.
#JanuAIRWAY 3/11

Read 11 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 11. The Aintree Intubation Catheter – an amazingly useful piece of equipment – every airway practitioner should be familiar with. Here’s a #OnePager. Let’s dive in…
#JanuAIRWAY 1/5

Main function is as a stop-gap to maintain tracheal access & facilitate tracheal intubation through a supraglottic airway device (SAD) using a fibreoptic scope. They are Long, hollow, semi-rigid, powder blue, polyurethane catheters
#JanuAIRWAY 2/5

To highlight: NEVER insert beyond 26cm. NEVER insufflate with an oxygen flow >2l/min … or just NEVER use for insufflation!
#JanuAIRWAY 3/5

Read 5 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 10. The Cook Airway Exchange Catheter – it’s a useful piece of equipment, but one not everyone will be familiar with. Here’s a #OnePager. Let’s dive in…
#JanuAIRWAY 1/6

Main function is as a stop-gap to maintain tracheal access & facilitate ETT exchange. They are long, hollow, radiopaque, soft-tipped tubes – types for use with single / double lumen tubes.
#JanuAIRWAY 2/6

All users MUST be trained & knowledgeable of how to use such devices together with their limitations and dangers. The Gordon Ewing case makes for tragic reading – but highlights this point. Essential reading for airway practitioners.
🔗scotcourts.gov.uk/search-judgmen…
#JanuAIRWAY 3/6

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Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 8. Capnography. This is one of essential pieces of monitoring equipment needed during airway management. But its presence isn’t enough, correct interpretation is vital. Let’s start with a #OnePager looking at the different waveforms.
#JanuAIRWAY 1/10

Oesophageal intubation still occurs & EtCO2 = key tool to help prevent avoidable deaths such as Glenda Logsdail’s. Key message = flat or no trace indicates oesophageal intubation until proven otherwise #NoTraceWrongPlace
#JanuAIRWAY 2/10

@doctimcook

This thread by @doctimcook is fantastic and we recommend everyone read it! #NoTraceWrongPlace
🔗

https://twitter.com/doctimcook/status/1455871411730452483?s=20

#JanuAIRWAY 3/10

Read 10 tweets

Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 7. Equipment. Laryngoscopy is an essential skill for airway managers. Let’s start with #OnePagers looking at a classification of the different types of laryngoscopes
1/6

A fundamental understanding of ‘position’ theory can help e.g. the two-curve theory for videolaryngoscopy. Primary Curve either needs to be flattened or ‘looked around’. Here’s some #OnePagers
#JanuAIRWAY 2/6

2 basic techniques direct (DL) & video (VL), but different scopes require specific techniques. We may even combine multiple scopes (there’s no universally agreed term for this, here we’ve called it Flexi-Assisted Laryngoscopy (FL) Here’s some #OnePagers
#JanuAIRWAY 3/6

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Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 6. Equipment. Good workers know their tools – knowing our equipment is essential! Here’s some #OnePagers - the fundamentals of masks, NP/OPs, SADs, and ETTs.

#JanuAIRWAY 1/4

We’ll cover specific airway devices such as Cook airway exchange catheters, Aintree Intubation Catheters, Staged Extubation Kits, OLV equipment, Tracheostomies, etc later in the month. But in the meantime here's a #OnePager on Frova intubating introducers

#JanuAIRWAY 2/4

Here are some papers / links that you might find interesting:
a.anaesthesiajournal.co.uk/article/S1472-…
b.ncbi.nlm.nih.gov/pmc/articles/P…
c.das.uk.com/content/diffic…
d.ncbi.nlm.nih.gov/pmc/articles/P…
If you have any others of interest, tweet them to us for inclusion next time!

#JanuAIRWAY 3/4

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Difficult Airway Society (DAS) Trainees

@dastrainees

@doctortimcook

#JanuAirway Day 5. Airway Planning. Decision making is the true art of airway management, and something that we don’t really get taught! NAP4 @doctortimcook showed that poor judgement was implicated in many airway complications. Here’s a #OnePager covering the major themes. 1/16

@AirwayMxAcademy

#JanuAirway Why is this an issue? Difficult airways = relatively rare & complications = rarer still. Low exposure --> high anxiety. Add in multiple options @AirwayMxAcademy & Bouwman suggest >1,000,000 combinations of options to oxygenate. More options = more anxiety 2/16

#JanuAirway
Cognitive load can lead to decision fatigue/increased bias/poor choices. Chew et al’s ncbi.nlm.nih.gov/pmc/articles/P… TWED metacognition checklist may help: -
Threat– define problem
Wrong- What if I’m wrong?
Evidence
Dispositional factors – environment/hunger/fatigue 3/16

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Difficult Airway Society (DAS) Trainees

@dastrainees

#JanuAIRWAY Day 4. Airway Investigations. 2 broad categories we can use to round out our airway assessment; flow/volume-based lung function tests & imaging techniques. They vary in their usage and usefulness. Here's some #OnePagers #FOAMed on Spirometry and Flow-volume loops 1/17

Spirometry (literally ‘measuring breath’) and flow-volume loops give us information on the mechanics of ventilation. They can be helpful in a more global assessment of respiratory function, but are less helpful in acute airway management.

#JanuAIRWAY #FOAMed 2/17

Diffusing Capacity / Transfer factor can augment lung function tests and give us info about alveolar diffusion and alveolar thickness. Again, helpful in global assessment, but less helpful acutely. Here’s another #OnePager covering the theory and the practice

#JanuAIRWAY 3/17

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