#JanuAirway Day 2. Yesterday highlighted the need for strategy, so let’s talk Airway Planning. Decision making = the true art of airway management! NAP4 @doctimcook showed that poor judgement is implicated in many airway complications. This #OnePager covers the major themes. 1/9 #JanuAirway What's the issue? We encounter difficult airways relatively infrequently, & complications are rare. Low exposure leads to high anxiety. Add in multiple options @huitink & Bouwman suggest >1mill combinations of options to oxygenate. More options = more anxiety 2/9

Welcome to #JanuAIRWAY2024. Every weekday we'll be bringing you Airway #FOAMed. Starting off with management of transgender airway -here's a #OnePager. It's a huge topic going beyond just the airway. Thanks to Drs @LukeFlower1 @drkamillak & Alice Humphreys for all their help! 1/7 The facts are that there's a huge knowledge gap when it comes to healthcare providers and gender diverse patients. Let's start with terminology, the gender continuum and principles of gender-affirming care - here's a #OnePager covering just that! 2/7

The law and airway management, looking at what we do through a different lens now with Maryanne Balkin. The tort of negligence has 4 elements:
1. duty of care
2. breach of standard of care
3. causation
4. injury or harm

#DAS2022 Expert witnesses are paramount in establishing the standards of care in cases where there is an issue with diagnosis or treatment #DAS2022

Peri-extubation complications - where are we? @MatteoParotto #DAS2022 For every study on extubation there are almost 10 on intubation, we don't appear to pay as much attention for extubation....#DAS2022

Why do we used cuffed tracheal tubes in children? Starting the international session this afternoon, the links @dasairway has with other airway societies is wonderful The subglottic area is the narrowest part in children, the resistance whilst advancing the ETT is due to stenosis in the subglottic region #DAS2022

Preventing unrecognised oesophageal intubation from @doctimcook. The recent guideline is an absolute must read …-publications.onlinelibrary.wiley.com/doi/full/10.11… For me the saddest part of @doctimcook's anatomy of an unrecognised oesophageal intubation

"family plead for it not to happen to others"

#DAS2022

The wonderful @Fionafionakel updating on human factors guidelines that are coming from DAS soon.....#DAS2022 Human factors are not just non-technical skills, design of safe systems is the most important aspect in #DAS2022

Mass casualty events @karimbrohi - recent special issue of the @BJAJournals is a must read bjanaesthesia.org/issue/S0007-09…

Anaesthetists are right in the middle of this when they occur....has your department thought about this and what are your plans? #DAS2022 Phases of mass casualty events
Chaos - the unknown and the surge
Reception - patients arrive
Consolidation
Definitive Care
Rehabilitation - for patients, staff and the department #DAS2022

Pre-hospital urban trauma in London - Dr Claire McCahill. Majority penetrating trauma and relating to knife crime, road traffic collisions, fall from height - also trains and underground incidents #DAS2022 Safety concerns with knife crime - wearing a stab vest to intubate sounds awful #DAS2022

Being stuck in a trauma situation is bad - increase in mortality when longer pre-hospital time to in-hospital trauma care. What analgesia you use to facilitate movement and transfer is vital #DAS2022 Pre-hospital blood transfusion, the evidence is still out on this. Can be used as a temporary measure but obviously can't carry enough for a massive haemorrhage scenario #DAS2022

Specific airway concerns - facial swelling from proning, very PEEP dependant and body habitus concerns - making transfers of COVID-19 patients more challenging #DAS2022 Airway triage crucial for deciding which patients to transfer - ruled out difficult intubations, maintaining patient safety, sedating and paralysing patients for the transfer and ensuring the tube was well secured #DAS2022

#JanuAIRWAY Day 31 (the last day!) – Difficult Airway Conditions. There are loads – what follows isn’t a definitive list – but it’s pretty long all the same! Let’s dive in…
#DifficultAirway #FOAMed
#JanuAIRWAY 1/7 They keep coming! #JanuAIRWAY #FOAMed #DifficultAirways #Eponyms #Anaesthesia #Syndromes
#JanuAIRWAY 2/7

#JanuAIRWAY Day 27 – The Neurosurgical Airway (thanks to @gasgal13 for her expert contribution to today’s content!). Head Vs Spine. Elective Vs Emergency. So many points of interest for airway managers. Here's a pair of #OnePagers to kick off!
#JanuAIRWAY 1/5 Key principles:
- Prevent rises in ICP
- Avoid hypoxia & low BP
- Minimise C-spine movement where indicated
- Be aware of positioning
- Beware of potential difficult airway in neurosurgical pathology
- Beware of post-op issues e.g. haematoma post-ACDF
#JanuAIRWAY 2/5

#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

#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 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

#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

#JanuAIRWAY Day 23 (the final stretch!). Malacias and SVC Obstruction. Here's a pair of #OnePagers to get started..
#JanuAIRWAY 1/10 What are malacias? = rare dynamic airway obstruction - (congenital / acquired) due to loss of cartilaginous support
Decreased intratracheal pressure + increased intrathoracic pressure lead to airway compression
Severity is proportional to expiratory force
#JanuAIRWAY 2/10

#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

And just like that we’re 3 weeks into #JanuAIRWAY. Here’s your week 3 round up!

Day 15 – Tracheostomies

https://twitter.com/dastrainees/status/1482241843907735552?s=20

Day 16 – CICO Needle Techniques

https://twitter.com/dastrainees/status/1482604351822733313?s=20

Day 17 – CICO Scalpel Techniques

https://twitter.com/dastrainees/status/1482963027376979968?s=20

#JanuAIRWAY 1/4 Day 18 – CICO Extra Equipment

https://twitter.com/dastrainees/status/1483324416406827009?s=20

Day 19 – The Obstructed Airway: Supraglottic

https://twitter.com/dastrainees/status/1483694368473108481?s=20

Day 20 – The Obstructed Airway: Periglottic

https://twitter.com/dastrainees/status/1484051776902942726?s=20

#JanuAIRWAY 2/4

#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

#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