Thread by @OBsleepmerchant

Just off great @dasairway @OAAinfo #OBAnes airway masterclass webinar with @silv24 chairing, @ProfEllenO @noolslucas @Chakladar_A and @DesireOnwochei giving expert opinions - lots of notes taken, tweets to follow twitter.com/i/web/status/1…

Right, let’s get to it. The #OBAnes airway - shifting the paradigm; a @dasairway & @OAAinfo masterclass. Two Profs in the corner… this should be interesting. @noolslucas kicks off the webinar.

What is a difficult airway? @ASALifeline definition: a clinical situation, conventionally trained anesthesiologist, difficult face mask ventilation/ intubation/ both.

Complications - hypoxemia: @MariePierreBon2 et al @BJAJournals 2020, @DavidGray37 @rosshofmeyr and co, SAJAA… twitter.com/i/web/status/1…

Are #OBAnes patients really more difficult to intubate? Reale et al @_Anesthesiology 2022 - risk factors the same as general population. Does increase in MP grade during pregnancy explain it (Pilkington et al @BJAJournals 1995)? Likely other factors.

@noolslucas makes an… twitter.com/i/web/status/1…

Now with @DesireOnwochei playing devils advocate @Chakladar_A takes centre stage to give his opinions on converting #OBAnes airway from a threat to a challenge.

No slides, so I made notes. I take no responsibility for misquotation 😜

Anxiety & time pressure are real during a category 1 section, and it’s hard not to feel that anaesthesia is rate limiting step.

Faced with a high risk situation, with >1 patient in front of you.… twitter.com/i/web/status/1…

Pre- vs Per- vs PERIoxygenation - oxygenation is the key. Do basics right.

Remember there are several unfamiliar teams, each team have a different take on the situation, a different priority.

@Chakladar_A speaking on unfamiliarity- #OBAnes OR layout different to main OR, may… twitter.com/i/web/status/1…

@Chakladar_A expands…
#OBAnes

https://twitter.com/chakladar_a/status/1661458810706227200

@DesireOnwochei a difficult taskmaster (must have watched @gdavies). But @Chakladar_A a cool calm customer (@Airwayman1/ @Fionafionakel’s 4C’s)

Call for help early.

@DesireOnwochei sets the scene of a Cat 1 C-section: come in to OR with chaos, 3 RN, 2-3 midwife, 3 neonatal… twitter.com/i/web/status/1…

@Chakladar_A suggests talking aloud to share plan - remember you’re managing colleagues as well Important to create a culture of support.

Simplify simplify simplify!

Multidisciplinary team is important - #OBAnes is a team sport (@NoelleHealy #OAA23ASM). How manage MDT training… twitter.com/i/web/status/1…

@Chakladar_A acknowledges MDT training difficult everywhere - hard to pull from clinical work.

However, potential for MDT training in any setting. Gamify every opportunity- play “what if”. Talk to your colleagues.

Use a VL with a BIG screen,,facing the rest of the team -… twitter.com/i/web/status/1…

But before we go there: #humanfactors 101 from @Airwayman1 at #OAA3dc2022
#OBAnes

https://twitter.com/obsleepmerchant/status/1590737440398274561

And of course, #humanfactors 202, from a previous @dasairway webinar: @Fionafionakel

https://twitter.com/obsleepmerchant/status/1631426654412128264

Which brings us back to VL and Guidelines from @UniversalAirway on preventing UOI. @ProfEllenO takes us onwards to use of VL whenever feasible, in #OBAnes and indeed, #AnyAnes. Like @Chakladar_A - verbalizing/ talking aloud is key.

However, @ProfEllenO points out that VL is fallible: Glottic impersonation (George Kovacs, @drlauraduggan, Peter Brindley @CJA_Journal) more likely during emergency airway situations, secondary stress-induced aggressive laryngoscopy. #OBAnes

Avoid glottic impersonation by deliberate observation, identifying anatomical structures, performing precision intubation. #OBAnes

VL allows visual confirmation, verbalisation, with #humanfactors advantages, including optimal cricoid pressure application (or release). Definite #Humanfactors benefits for #AnyAnes & #OBAnes

What does literature say? Most recent @CochraneLibrary 2022 by @VirtueOfNothing et al (including @doctimcook) - advantages of Mac & HA blade VL. #OBAnes

@CochraneLibrary review 2022 (@VirtueOfNothing et al) supports VL in adults as more effective than DL (in experienced hands) with multiple outcome benefits. Irrespective of design, VL likely safer risk profile compared to DL. DL vs VL wrt UOI, VL less likely.

Key @UniversalAirway guideline recommendations: routine VL, verbalise. What do society airway guidelines say? @CanadianAirway recommended VL as first choice technique.#OBAnes #AnyAnes

@dasairway 2015 recommendations - VL should be immediately available. Is that true in UK - 91% availability in OR, only 50% ITU. < 33.3 widespread use or enthusiasm. NB failed intubation is only reduced by experienced users of VL #OBAnes

Recommended reading: Patrick Ward’s letter

…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

@OAAinfo & @dasairway #OBAnes airway guidelines are currently under review.

And if you want more from @ProfEllenO on @UniversalAirway guidelines, may I recommend her excellent lecture at #OAA3dc2022 #OBAnes

https://twitter.com/obsleepmerchant/status/1589980905820409856

More of the Q&A that followed to come - stay tuned #OBAnes

@silv24 starts the discussion: time out includes what the plan is for #OBAnes airway management, however, to the rest of team(s) in the room really understand the gravity of the situation/ concerns we have?

@noolslucas says being friends saves lives - share cup of tea with your… twitter.com/i/web/status/1…

Moving on to THRIVE - should it be applied preoperatively to patients before they arrive in #OBAnes theatre? PERIoxygenation is topical.

HFNO2 no compelling evidence in favour of use for preoxygenation, however, @noolslucas suggests we should perhaps shift our focus to apnoeic… twitter.com/i/web/status/1…

@silv24 adds that at a recent PROMPT course she talked midwives through DAS decision table/ algorithm. They were shocked - engendered appreciation of potential difficulty of #OBAnes airway and anaesthesia’s role in securing it (talk to you colleagues, share fears and… twitter.com/i/web/status/1…

@ProfEllenO and panel acknowledge that VL fails (all equipment can fail) - must check before hand, have alternative plan, another VL available. Should always have another VL/ backup if that is your preferred technique (aspirational, may not be what actually exists IRL though)… twitter.com/i/web/status/1…

And yes there’s more… just lots of notes! Stay tuned #OBAnes!

Link that crashed thread.

…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

Dr Patrick Ward’s correspondence (as recommended by @ProfEllenO) in @Anaes_Journal

…-publications.onlinelibrary.wiley.com/doi/10.1111/an…

Many institutions have the distinction between Main OR vs Labour ward, neither environment nor equipment necessarily familiar. This breeds anxiety.

Junior doctors are often isolated, performing GA sections in middle of night -#OBAnes GA on one’s own at 2am with BMI > 40 is… twitter.com/i/web/status/1…

A question regarding @dasairway standing decision that “junior always wake up” failed intubation. @ProfEllenO: if life and death, SGA can proceed - depends on discussion of urgency/ emergency with the MDT.

Failed intubation in #OBAnes historically high, but likely not due to an… twitter.com/i/web/status/1…

DL skill maintenance is essential for rotating doctors, primarily because VL changes. Unfamiliarity = RISK.

@noolslucas feels #OBAnes shouldn’t lose DL until all things aligned.

@DesireOnwochei refers to @CJA_Journal 2018/19 review of #OBAnes VL’s - only 600 cases.… twitter.com/i/web/status/1…

@noolslucas: the D blade/HA is “bad”(@doctimcook rolling eyes) - very different tech, need to be used, and definitely not used for first time in anger.

@silv24 brings a question forward: Channeled vs unchannelled VL? @ProfEllenO uses channelled (AirTraq forever) - once you have… twitter.com/i/web/status/1…

Put two Prof’s in a room and there’s bound to be magic. @noolslucas and @ProfEllenO having a giggle over their stint at Hogwarts, as they individually apperate in and out of view with their atrifcial background.

@silv24 has the giggles too

And why are @noolslucas & @ProfEllenO sharing a laptop? Technology failure - as if it was ordained that they eloquently make the point that you have to have a back up because any piece of equipment, no matter how familiar it is, or expert you are, can fail. And had they not… twitter.com/i/web/status/1…

@Chakladar_A: #OBAnes need standardization to Mac 3/4 VL with HA blade for devices. Again: Don’t use unfamiliar equipment in emergency.

Use a bigger screen, so everyone can see (#OBAnes is a team sport after all)

Amazingly cricoid pressure didn’t come up on its own. It’s… twitter.com/i/web/status/1…

@ProfEllenO’s rescue trolley: Igel + 7.0 ETT + bronchoscope.

If you’ve rescued with SGA, only consider intubation once baby’s out.

Practice electively using igel/ SGA to intubate - skill acquisition requires work. AGAIN only intubate through a KNOWN SGA, don’t do two new… twitter.com/i/web/status/1…