Airway Session | Michael Selz and friends at TBS23

1. The BIG SICK 2023 ADVANCED AIRWAY WORKSHOP airwaymanagement.dk Michael Seltz Kristensen Michael Friis Tvede Pims de Ruijter John Diaper Tatjana Dill Anne Cath- rine Haug Heleen Biersteker Søren Rudolph Richard Levitan Sandra Ellefsen James ”Jim” Ducanto Anne-Sophie Lynnerup Joerg Helge Junge Kristian B. Krogh

2. Rigshospitalet Copenhagen

3. airwaymanagement.dk

4. Ross Fisher

6. Danes and ski…………….

20. Knud, Ussaqaq og Christian

24. The BIG SICK 2023 ADVANCED AIRWAY WORKSHOP airwaymanagement.dk Michael Seltz Kristensen Michael Friis Tvede Pims de Ruijter John Diaper Tatjana Dill Anne Cath- rine Haug Heleen Biersteker Søren Rudolph Richard Levitan Sandra Larssen Clifford James ”Jim” Ducanto Anne-Sophie Lynnerup Joerg Helge Junge Kristian B. Krogh

25. What we already know: www.airwaymanagement.dk Disposition: Save the saviour Airway management what is it? – and why should that be important? Plan, prediction, preparation, combinations and special cicumstances Breaking news The Future! > Hands on !! Airwaymanagement.dk The BIG SICK 2023 ADVANCED AIRWAY WORKSHOP

33. Airway management, What is it?

34. Airway management, What is it? and Why should it be important?

37. ECMO/ Exceptions: - and it is our responsability!

38. msk@rh.dk www.rcoa.ac.uk/ nap4 Cook TM, Woodall N et al. BJA 2011

39. • Death • Brain damage • Emergency surgical airway • ICU admission resulting from an airway management complication Cook TM, Woodall N et al. BJA 2011

40. • One year data collection • 133 related to general anaesthesia • 19 deaths/brain damage • 36 in ICU • 22 deaths/brain damage • Poor care in three-quarters of cases • ICU and emergency care HIGHLY over-represented! • Only tip of the iceberg! • = often PREVENTABLE !!! Cook TM, Woodall N et al. BJA 2011

43. • One year data collection • 133 related to general anaesthesia • 19 deaths/brain damage • 36 in ICU • 22 deaths/brain damage • Poor care in three-quarters of cases • ICU and emergency care HIGHLY over-represented! • Only tip of the iceberg! Cook TM, Woodall N et al. BJA 2011

44. • One year data collection • 133 related to general anaesthesia • 19 deaths/brain damage • 36 in ICU • 22 deaths/brain damage • Poor care in three-quarters of cases • ICU and emergency care HIGHLY over-represented! • Only tip of the iceberg! • Most often PREVENTABLE !!! Cook TM, Woodall N et al. BJA 2011

45. • What happened: • Failure to plan • ..and if planning: Failure to follow the plan Cook TM, Woodall N et al. BJA 2011

48. The 7 routes for oxygenation and CO2 removal in our patient

49. The 7 routes for oxygenation and CO2 removal in our patient

50. The 7 routes for oxygenation and CO2 removal in our patient Awake / Anaesthetised breathing spontaneously / Anaesthetised apneic

51. We must have a plan……

53. US Canada

54. Can J Anaesth. 2021 Sep;68(9):1373-1404 Can J Anaesth. 2021 Sep;68(9):1405-1436

55. Part 2 ..predicted difficulty Findings and key recommendations: ”Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation….”

56. Part 2 ..predicted difficulty Findings and key recommendations: ”Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation….”

57. Is evaluation and prediction useful? 1) Nørskov A et al. Unanticipated difficult tracheal intubation…..., BJA, 2016 , 2) Teoh WH, Kristensen MS. Prediction in Airway management…… BJA, 2016

59. That took 15 sec

60. Is evaluation and prediction useful? 1) Nørskov A et al. Unanticipated difficult tracheal intubation…..., BJA, 2016 , 2) Teoh WH, Kristensen MS. Prediction in Airway management…… BJA, 2016 With this or even less prediction effort: >50% of difficult intubations predicted

61. Is evaluation and prediction useful? 1) Nørskov A et al. Unanticipated difficult tracheal intubation…..., BJA, 2016 , 2) Teoh WH, Kristensen MS. Prediction in Airway management…… BJA, 2016 With this or even less prediction effort: >50% of difficult intubations predicted …and they are likely to be the most obvious and the most difficult patients that are identified

62. Caldiroli, Minerva Anesthesiol 2011 SARI/EGRI > 6 Chose awake intubation with flexible optical scope 2011

63. Is evaluation and prediction useful? 1) Nørskov A et al. Unanticipated difficult tracheal intubation…..., BJA, 2016 , 2) Teoh WH, Kristensen MS. Prediction in Airway management…… BJA, 2016 With this or even less prediction effort: >50% of difficult intubations predicted …and they are likely to be the most obvious and the most difficult patients that are identified Yes !!

76. What makes “awake” such a good approach? www.airwaymanagement.dk Aziz M, Kristensen MS, Anaesthesia 2020:

77. awake anaesthetised & Paralyzed Advantages Open airway preserved Y n Spontaneous breathing preserved Y n Easier to localise glottic opening (air bubbles) Y n Easier to intubate (oropharyngeal axis) Y n The patient can help Y n The patient can be sitting Y n Some protection against aspiration Y n Observing patients neurological status Y n Allows decision making (intubate or not?) DURING the endoscopy y n Avoid cardiovascular depression Y n Dis-advantages Airway narrowing due to local anaesthetics Y n Cardiovascular stimulation Y n Patient dis-comfort? ? n More time consuming? ? n Aziz M, Kristensen MS, Anaesthesia 2020:

95. Can J Anaesth. 2021 Sep;68(9):1373-1404 Can J Anaesth. 2021 Sep;68(9):1405-1436

96. Part 1

97. Part 1

98. Part 1

99. Part 1

102. LMA C-trach

103. How can we further improve success ?

104. How can we further improve success ? Combination techniques!

105. LMA C-trach

106. LMA C-trach

107. LMA C-trach

108. Sandra here…

109. Tube Tip In Pharynx (TTIP) ventilation A simple life-saving technique for emergency airway management Sandra Ellefsen Anesthesiology resident, Department of Anesthesia, Stavanger University Hospital Assistant Professor, Faculty of Health Sciences, University of Stavanger airwaymanagement.dk

110. Collaboration partners Michael Seltz Kristensen Department of Anaesthesia and Operating Theatre Services, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark Anja Stubager Nurse Anesthetist Department of Anaesthesia and Operating Theatre Services, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark Tube Tip In Pharynx (TTIP) ventilation – a case presentation airwaymanagement.dk

111. Collaboration partners Michael Seltz Kristensen Department of Anaesthesia and Operating Theatre Services, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark Anja Stubager Nurse Anesthetist Department of Anaesthesia and Operating Theatre Services, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark No conflicts of interest Tube Tip In Pharynx (TTIP) ventilation – a case presentation airwaymanagement.dk

112. • Airway management and establishing airway patency: the cornerstone of anesthetic practice • We’ve had considerable advances and innovation in airway management equipment in the past decades →Nevertheless, these are not always at one’s disposal, particularly not in austere and low-resource settings Tube Tip In Pharynx (TTIP) ventilation – a case presentation Background – Case Presentation – The TTIP technique - Discussion

113. Aim of this presentation: Highlight the Tube Tip in Pharynx (TTIP) technique - a simple way of solving a potentially life-threatening situation in a matter of seconds → Simple, singled-handed technique → Requires minimal and readily available equipment Tube Tip In Pharynx (TTIP) ventilation – a case presentation Background – Case Presentation – The TTIP technique - Discussion airwaymanagement.dk

114. Background – Case Presentation – The TTIP technique - Discussion Port Harcourt, Nigeria, Africa airwaymanagement.dk Tube Tip In Pharynx (TTIP) ventilation – a case presentation

115. Tube Tip In Pharynx (TTIP) ventilation – a case presentation Background – Case Presentation – The TTIP technique - Discussion airwaymanagement.dk

116. Tube Tip In Pharynx (TTIP) ventilation – a case presentation Background – Case Presentation – The TTIP technique - Discussion “Dear Michael, You have indirectly contributed to saving the life of one of my patients tonight – here in Africa. It is because you taught me the TTIP technique. We were in a terrible cannot intubate – cannot ventilate situation with a man who needed an urgent laparotomy. He was shot down in front of his house while his wife and children were watching. Our challenge is that we can only give 5 liters of oxygen per minute, and we have no nasal airway. This man was 100 kg (=220lbs), with a short neck and a big belly. airwaymanagement.dk

117. Tube Tip In Pharynx (TTIP) ventilation – a case presentation Background – Case Presentation – The TTIP technique - Discussion “Dear Michael, You have indirectly contributed to saving the life of one of my patients tonight – here in Africa. It is because you taught me the TTIP technique. We were in a terrible cannot intubate – cannot ventilate situation with a man who needed an urgent laparotomy. He was shot down in front of his house while his wife and children were watching. Our challenge is that we can only give 5 liters of oxygen per minute, and we have no nasal airway. This man was 100 kg (=220lbs), with a short neck and a big belly. Minutes post RSI Airway intervention Outcome 0 min. 1st intubation attempt Failed 2 min. Mask ventilation with guedel Failed 3 min. 1st TTIP - ventilation Successful 6 min. Spontanous ventilation, removal of tube Desaturation 8 min. 2nd TTIP - ventilation Successful 11 min. Tube removal, better positioning, halothane inhalation Desaturation 14 min. 3rd TTIP-ventilation Successful 18 min. 2nd Intubation attempt Failed 20 min. 3rd Intubation attempt, using a bougie Failed 22 min. 4th TTIP - ventilation Successful 26 min. Return of spontaneous ventilation while maintaining TTIP Patient awake and cooperative 35 min. Surgical airway under local anesthesia, with maintained spontaneous ventilation via the TTIP Successful airwaymanagement.dk

118. Tube Tip In Pharynx (TTIP) ventilation – a case presentation Background – Case Presentation – The TTIP technique - Discussion “Dear Michael, You have indirectly contributed to saving the life of one of my patients tonight – here in Africa. It is because you taught me the TTIP technique. We were in a terrible cannot intubate – cannot ventilate situation with a man who needed an urgent laparotomy. He was shot down in front of his house while his wife and children were watching. Our challenge is that we can only give 5 liters of oxygen per minute, and we have no nasal airway. This man was 100 kg (=220lbs), with a short neck and a big belly. Minutes post RSI Airway intervention Outcome 0 min. 1st intubation attempt Failed 2 min. Mask ventilation with guedel Failed 3 min. 1st TTIP - ventilation Successful 6 min. Spontanous ventilation, removal of tube Desaturation 8 min. 2nd TTIP - ventilation Successful 11 min. Tube removal, better positioning, halothane inhalation Desaturation 14 min. 3rd TTIP-ventilation Successful 18 min. 2nd Intubation attempt Failed 20 min. 3rd Intubation attempt, using a bougie Failed 22 min. 4th TTIP - ventilation Successful 26 min. Return of spontaneous ventilation while maintaining TTIP Patient awake and cooperative 35 min. Surgical airway under local anesthesia, with maintained spontaneous ventilation via the TTIP Successful airwaymanagement.dk

119. The TTIP technique Tube Tip In Pharynx (TTIP) ventilation – a case presentation Background – Case Presentation – The TTIP technique - Discussion Relation of the tube-tip, cuff, epiglottis and the base of the tongue in TTIP ventilation Tube Tip In Pharynx (TTIP) ventilation – a case presentation airwaymanagement.dk

120. Tube Tip In Pharynx (TTIP) ventilation – a case presentation Background – Case Presentation – The TTIP technique - Discussion airwaymanagement.dk

121. Background – Case Presentation – The TTIP technique - Discussion Classic technique: Fast technique: Kristensen MS. Tube tip in pharynx (TTIP) ventilation: simple establishment of ventilation in case of failed mask ventilation. Acta Anaesthesiol Scand 2005; 49: 252-6 Tube Tip In Pharynx (TTIP) ventilation – a case presentation airwaymanagement.dk

122. Patient with a Body Mass Index (BMI) of 46 Background – Case Presentation – The TTIP technique - Discussion Kristensen MS. Tube tip in pharynx (TTIP) ventilation: simple establishment of ventilation in case of failed mask ventilation. Acta Anaesthesiol Scand 2005; 49: 252-6 Tube Tip In Pharynx (TTIP) ventilation – a case presentation airwaymanagement.dk

123. Possible indications: • Difficult/impossible bag-mask ventilation • Difficult/impossible LMA placement • As a conduit for fiberoptic intubation However: • Not widely taught nor practiced • Studies should be performed to obtain precise indications and limitations Background – Case Presentation – The TTIP technique - Discussion airwaymanagement.dk Tube Tip In Pharynx (TTIP) ventilation – a case presentation

124. Take home messages • Airway management does not have to be expensive to be effective • Remember the TTIP technique (placed orally or nasally) as a potential maneuver when encountering difficult/impossible ventilation ✓Simple ✓Single-handed ✓Minimal equipment required Adventageous especially in austere and/or low-resource settings Tube Tip In Pharynx (TTIP) ventilation – a case presentation airwaymanagement.dk

125. LMA C-trach

126. LMA C-trach

127. Ref: Mørkenborg M-L, Kristensen MS. Tube Tip in Pharynx – a conduit for awake oral intubation in patients with extremely restricted mouth-opening. Can J Anaesth, accepted for publication, 2022 What if: the mouth opening is so restricted that it precludes use of an oropharyngeal airway

128. Ref: Mørkenborg M-L, Kristensen MS. Tube Tip in Pharynx – a conduit for awake oral intubation in patients with extremely restricted mouth-opening. Can J Anaesth, accepted for publication, 2022 What if: the mouth opening is so restricted that it precludes use of an oropharyngeal airway and we cannot go via the nose. ? X

129. Ref: Mørkenborg M-L, Kristensen MS. Tube Tip in Pharynx – a conduit for awake oral intubation in patients with extremely restricted mouth-opening. Can J Anaesth, accepted for publication, 2022 What if: the mouth opening is so restricted that it precludes use of an oropharyngeal airway and we cannot go via the nose. ? X

130. Ref: Mørkenborg M-L, Kristensen MS. Tube Tip in Pharynx – a conduit for awake oral intubation in patients with extremely restricted mouth-opening. Can J Anaesth accepted for publication, 2022

131. Ref: Mørkenborg M-L, Kristensen MS. Tube Tip in Pharynx – a conduit for awake oral intubation in patients with extremely restricted mouth-opening. Can J Anaesth accepted for publication, 2022

133. The bloody bleeding upper airway

134. Airwaymanagement.dk

137. Kristensen MS, McGuire B. Can J Anesth, 2020

138. Kristensen MS, McGuire B. Can J Anesth, 2020

139. LMA C-trach

140. LMA C-trach

146. Jim here…

147. Improving Emergency Airway Management with Suction Assisted Laryngoscopy Airway Decontamination Techniques James DuCanto, M.D. Staff Anesthesiologist Aurora Medical Group Milwaukee, Wisconsin, USA Twitter @jducanto Facebook SALADSimulation

148. Financial Disclosures Dr. DuCanto is the inventor of the Nasco SALAD Simulator and the SSCOR DuCanto Catheter and receives royalties on these products. sables/Accessories

149. Definition of SALAD: Suction Assisted Laryngoscopy Airway Decontamination “An incremental step-wise approach to the management of a massively contaminated airway” Resuscitation Plus (2020): 100005.

150. Pathophysiology of Airway Contamination Negates ventilation by mask or supraglottic airway Neutralizes apneic oxygenation Negates all forms of endoscopy

151. SALAD manages airway contaminants while assisting the rescuer in placing basic and advanced airways. It proactively addresses the contaminated airway while assisting insertion of airway adjuncts

153. Video Laryngoscopy Storz CMAC Ongoing CPR with Contaminated Airway

154. Video Laryngoscopy Storz CMAC Ongoing CPR with Contaminated Airway

155. Tracheal intubation during continuous chest compressions, proactive suction technique

156. Tracheal intubation during continuous chest compressions, proactive suction technique

157. 1. Opening jaw and compressing tongue into floor of mouth— while suctioning Replaces the “Scissor Technique” with a rigid tongue depressor

158. 2. Manipulation of tongue and pharyngeal tissues to maximize the view and placement of a laryngoscope

159. 3. Provides continuous decontamination of the hypopharynx during laryngoscopy SALAD Park Maneuver RSC is repositioned to the left of the laryngoscope blade, with its tip into the upper esophagus.

160. Immediately prior to tracheal tube delivery, the index finger of the right hand is inserted into the path of tracheal tube delivery alongside right margin of laryngoscope blade. SALAD Poke Maneuver

161. Gunshot wound to face SALAD Technique

164. www.airwaymanagement.dk

165. Emergency Anterior-Neck oxygenation by anaesthetists: Only 36% success !!

166. Emergency Anterior-Neck oxygenation by anaesthetists: Only 36% success !! Why ?

167. . Abnormal neck anatomy:

168. Dagmar Airwaymanagement.dk

176. www.AirwayManagement.dk Kristensen MS. Acta Anaesth Scand. 2011 Teoh WH, Kristensen MS. Anaesthesia 69: 649-50. 2014

177. www.AirwayManagement.dk • Thyroid cartilage • CM • Cricoid cartilage • Tracheal rings Kristensen MS. Acta Anaesth Scand. 2011 Teoh WH, Kristensen MS. Anaesthesia 69: 649-50. 2014

178. The structured stepwise “Black pearls on a white string” - approach Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011

179. Step 1 Step 1 www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011

180. Step 1 Step 1 www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011 mid-line of the trachea

181. Step 1 www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011

182. Step 2 www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011

183. Step 2 www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011 mid-line of the trachea

184. www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011

185. Step 3 www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011 ”Black pearls on a white string”

187. www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011 cricoid cartilage

189. Step 5 www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011 Thyroid cartilage

190. Step 5 www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011 Mark the longitudinal course of the airway by placing a mark at each end of transducer

191. Step 5 www.airwaymanagement.dk Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011 Shadow from the needle is between the thyroid and the cricoid cartilages

192. Step 6 Teoh WH, Kristensen MS. Anaesthesia 2014 Kristensen MS, Teoh WH. British J Anaesth. 2021 Kristensen MS. Acta Anaesthesiol Scand 2011

202. Richard here…

203. Surgical Airway

204. TTJV not Recommended in Emergency CICO Situations Transtracheal jet ventilation in the ‘can’t intubate can’t oxygenate’ emergency: a systematic review. L.V. Duggan, et al. BJA, Volume 117, Supplement 1, 2016, Pages i28-i38. Device failure in 42% of emergency CICO cases 51% rate of complications in emergency vs. 8% in elective anesthesia Barotrauma in 32% of emergency cases

205. • “Failed Airway” phrase stigmatizes procedure • The surgical airway—a small neck incision— should be viewed in larger context of patient care issues • “To save a life..sometimes you need a knife!” • Attempt to oxygenate during procedure; 100 seconds to ventilation—must begin before the patient is dead Surgical Airway ≠ “Failed Airway” Surgical Airway ≠ Rescue Airway

206. • Fluids are the enemy of everything • High-volume fluids (blood, vomitus) can prevent every means of visualization and oxygenation • High-volume fluids make every means of intubation—except cric—very challenging • Distorted midface and upper airway may preclude use of HFNC, mask, & SGA (supraglottic airway) Surgical Airway NOW! Dynamically Deteriorating with Distorted Anatomy and Fluids

207. Common Misperceptions and Errors with Surgical Cric • Lack of anatomic insight creates fear about using a scalpel—either cutting too deeply, or too far laterally • Operators are hesitant to start the procedure if they haven’t identified the cricothyroid membrane (misbelieving this is the 1st step) • Misperception of surgical skill needed to do the procedure causes delay in starting, and makes many operators “more comfortable” using a percutaneous technique

208. Operator Mindset 5 Mantras of a Surgical Cric • “To save a life, I need to use a knife” • “The laryngeal handshake will find midline” • “I will find the CTM—after—the vertical, midline skin incision” • “I am not a surgeon, but I can stabilize my hand on the patients sternum.” • “The cartilaginous cage will protect.”

209. The Surgically Inevitable Airway Distorted anatomy, high volume fluids, unable to secure tracheal tube to midface BVM, SGA, HFNC cannot work

210. The Surgically Inevitable Airway GSW: Successful RSI, immediate cric plan B BVM, SGA, HFNC cannot work

211. Dynamically Deteriorating with Distorted Anatomy Lingual hematoma, secondary to stab wound. Courtesy Ed Dickinson, MD Epiglottitis as seen on suspension laryngoscopy, following emergency cric. Courtesy Mike Mallon, MD

212. inferior cornu Thyroid Cartilage is the Primary Landmark of Surgical Airway cricoid hyoid thyroid superior cornu reaches hyoid Lower thyroid overlaps cricoid

213. inferior cornu Thyroid Cartilage is the Primary Landmark of Surgical Airway Thyroid spans from hyoid to cricoid (coronal CT) cricoid hyoid thyroid superior cornu lamina notch cricoid hyoid thyroid

214. Thyroid is the Primary Landmark Cricoid Much Larger in Back cricoid hyoid thyroid spans from hyoid to cricoid trachea 30 mm posterior wall 5 mm anterior ring

215. Anterior Neck Anatomy Sternal notch Cricoid CTM Notch Thyroid

216. Mobility of Larynx: Important to Stabilize the Larynx During Cric lateral mobility vertical mobility click for video click for video

219. Localizing CTM with fingertip often fails, and delays start Fingertip palpation is a fine motor skill in setting where most operators will have elevated heart rates CTM identification is difficult through skin and adipose If operator cannot locate CTM, they are mentally defeated at outset

220. Female vs. Male Thyroid Cartilages & Implications for Finding Landmarks 120° 90° Equal prominence thyroid and cricoid lateral and frontal views Obvious thyroid prominence. Larger, longer neck. Thyroid lamina angles

221. Laryngeal Handshake Applied to Thyroid, Moves Rhomboid of Larynx 1st & 3rd digit palpates and then manipulates thyroid to identify midline Recommended in DAS Guidelines

222. Laryngeal Handshake • A Comparison of the Laryngeal Handshake Method Versus the Traditional Index Finger Palpation Method in Identifying the Cricothyroid Membrane, When Performed by Combat Medic Trainees. Moore A, et. al. J Spec Oper Med 2019;19(3):71-75. • Utility of the laryngeal handshake method for identifying the cricothyroid membrane. Oh H, et. al. Acta Anaesthesiol Scand. 2018 Oct;62(9):1223-1228. • Laryngeal handshake technique in locating the cricothyroid membrane: a non- randomised comparative study. Drew T, McCaul CL. Br J Anaesth . 2018 Nov;121(5):1173-1178.

223. Cartilaginous Cage Will Protect Anterior Lateral Posterior High back wall cricoid Small anterior ring cricoid Thyroid cricoid overlap CTM

224. Cartilaginous Cage Sagittal CT click for video

225. Cartilaginous Cage Sagittal CT click for video

226. Cartilaginous Cage Will Protect

227. • Dominant hand holds the scalpel; low grip on scalpel, like holding a pencil • Base of scalpel hand rests on patient’s sternum throughout the entire procedure—making both vertical skin and horizontal CTM incisions • Operator should be at the patient’s side, at shoulder, on the same side as operator’s dominant hand Ergnomics of Surgical Cric Cutting hand sternal stabilization Non-dominant hand laryngeal handshake from start to finish

228. • Always insert finger tip in the hole after CTM incision • Verifies entrance into airway • Verifies size of hole is adequate for tube • Some advocate bougie insertion alongside finger; It’s OK to use bougie, but never omit finger tip insertion to verify hole size • Most common mistake in open cric procedure is too small a hole, then passing a bougie or tube into subcutaneous location (same error common with chest tubes) Scalpel > Finger > Tube or Scalpel > Finger > Bougie > Tube

229. Non-Dominant Hand Position & 2nd Digit Movements Fingertip verifies CTM location after vertical skin incision 1st & 3rd digits grab thyroid Hand in same position Verifies hole size after horizontal skin incision

230. Incrementalized Surgical Cric (1) Dominant hand laryngeal handshake Non-dominant hand laryngeal handshake VERTICAL SKIN INCISION STERNAL STABILIZATION

231. Incrementalized Surgical Cric (2) Verify CTM location Stab incision pull toward R Blade flipped push L Finger in hole Tube held at proper point ~10 cm HORIZONTAL INCISION

232. Incrementalized Surgical Cric (3) Tube inserted next to finger Insertion ~10 cm Held until secured

233. • Verify depth. Bifurcation of trachea is ~ 11 cm from cords—and insertion point is below the cords to start • Over-insertion causes hyper-inflation, tension physiology • Tension pneumothorax can occur from air dissecting through tissue planes • Secure tube securely Post-Surgical Cric: Depth of Tube & Pneumothorax

234. Cadaveric Lab Case Example Scalpel, Finger, Bougie Incision is widened laterally to fit finger tip Note: Better to keep finger out of hole using scalpel click for video

235. Cadaveric Lab Case Example Scalpel, Finger, Bougie Incision is widened laterally to fit finger tip Note: Better to keep finger out of hole using scalpel click for video

236. Military Training Video 1950’s Great anatomy review click for video

237. Military Training Video 1950’s Great anatomy review click for video

238. Military Training Video 1950’s click for video Demonstrations with improvised instruments

239. Military Training Video 1950’s click for video Demonstrations with improvised instruments

240. Practice Sheet Cricothyrotomy

242. “Blind” methods – not dependent on visibility in the airway – successfully used in the bleeding airway: Blind oro-digital Intubation Blind nasal Intubation Transillumination Intubation via Supraglottic Airway Device Oesophageal Combitube Ultrasound guided intubation Retrograde Intubation Cricothyroidotomy/tracheostomy Cardiac assist/bypass/ECMO + combinations Kristensen MS, McGuire B. Canadian Journal of Anesthesia, 2020

250. Søren and Michael Friis here…

251. Trauma and pre-hospital airway management What is different?

256. ARE WILL

257. Adverse location Backup Equipment Team experience Communication Need for transport

258. COMPROMISE

259. meaningful interventions

260. STOP SLOW DOWN …few patients need intubation right now

263. Prehospital Airway Management: A Systematic Review. Prehospital Emergency Care 2021

264. ” …The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion…”

265. ” …The currently available evidence does not indicate benefits of more invasive airway approaches based on survival, neurological function, ROSC, or successful airway insertion…”

266. COMPROMISE

269. ..a few THOUGHTS

271. first pass succes 92-98%

272. Intubation

273. in-hospital mortality Prehospital anaesthesia & RSI

274. AWAKE & HYPOTENSIVE OR 3.07 (1.03-9.14) P = 0.04

276. EtCO2

277. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies. Anaesthesia. 2022.

278. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies. Anaesthesia. 2022.

280. Ketamine….. … is an airway drug

281. can’t PreOX patient

282. Delayed Sequence Intubation sedative + PreOx + paralytic agent + no ventilation

283. significantly improved SpO2 prior to intubation….. Weingart SD, Wong N, Scofi J, Singh N, Rudolph SS. Ann Emerg Med. 2014

284. Incidence of hypoxaemia - absolute risk reduction 6,1%

285. …..a reasonably safe and effective approach….

286. Added benefits Positioning ”Awake” intubation Apnoic oxygenation NG tube CPAP / NIV Time Control

294. Have a structured approach for the rarely encountered situations

295. The surgically inevitable airway

296. The surgically inevitable airway

297. TECHNIQUE ?

303. Inflight intubation

310. Intubation during a medevac flight: safety and effect on total prehospital time in the helicopter emergency medical service system. Scand J Trauma Resusc Emerg Med 2020

314. www.airwaymanagement.dk Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print Infrared flashing light through the cricothyroid membrane as guidance to awake intubation with a flexible bronchoscope - A randomised cross-over study

315. What we already know: www.airwaymanagement.dk

316. The hole - may be distorted or hidden behind pathology

319. ?

320. ?

326. Kristensen MS and co-workers. Acta Anaesthesiol Scand 2018; 62: 19-25

329. Kristensen MS and co-workers. Acta Anaesthesiol Scand 2018; 62: 19-25 - hidden behind pathology

330. Kristensen MS and co-workers. Acta Anaesthesiol Scand 2018; 62: 19-25 - hidden behind pathology

331. Pre-anaesthetic nasendoscopy by the surgeon revealed: ”…inability to visualise the vocal cords due to a pronounced swelling”

332. www.airwaymanagement.dk Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print Infrared flashing light through the cricothyroid membrane as guidance to awake intubation with a flexible bronchoscope - A randomised cross-over study

333. Research question: www.airwaymanagement.dk Will Infrared guidance be helpful as a standard? ..in daily clinical practice? Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

334. Inclusion: Patients for oral awake intubation with a flexible optical scope Endoscopists: The doctor allocated to the operation room – both trainees and consultants www.airwaymanagement.dk Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

335. Inclusion: Patients for oral awake intubation with a flexible optical scope Endoscopists: The doctor allocated to the operation room – both trainees and consultants www.airwaymanagement.dk Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

336. Methods: Two (2) scope insertions in each patient Randomised cross-over design: Infrared first No infrared first No infrared second Infrared second Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

341. Primary endpoint: www.airwaymanagement.dk Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

342. Primary endpoint: www.airwaymanagement.dk Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

343. Results: 44 insertions of the flexible scope in 22 patients Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

344. Results: https://airwaymanagement.dk/infrared_compa rative 44 insertions of the flexible scope in 22 patients Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

345. Results:

346. Results:

347. Results:

348. Results: p = 0.005

349. Results, Secondary endpoints: The time until either the flashing light or the vocal cords was seen, was : 21 S (22) (Infrared) versus 48 S (62) (no infrared) p = 0.005 Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

350. How easy was it to perceive the entrance to the trachea ? Results, Secondary endpoints:

351. How easy was it to perceive the entrance to the trachea ? P = 0.001 Results, Secondary endpoints:

352. How easy was it to perceive the entrance to the trachea ? P = 0.001 Results, Secondary endpoints:

353. Conclusion: www.airwaymanagement.dk Addition of trans-cricothyroid infrared flashing light…..: resulted in: Unequivocal, and easier, identification of the pathway to the trachea at significantly more proximal level within the airway. …..this addition was highly beneficial for the entire airway management procedure. Kristensen MS, Hesselfeldt R, Brinkenfeldt HK…Acta Anaesthesiol Scand, January 23rd, 2023, ahead of print

355. We would like at technique that works for.. • Awake and anaesthetised/musclerelaxed patients • ..without any devices in the airway • ..with FIO2 adjustable (for laser etc..) • ..with a physiological /better hemodynamic profile • ..

357. Cuirass airwaymanagement.dk

358. Biphasic Cuirass Ventilation airwaymanagement.dk

362. airwaymanagement.dk European Journal of Cardio-thoracic Surgery Increases cardiac output

363. We would like at technique that works for.. • Awake and anaesthetised/musclerelaxed patients • ..without any devices in the airway • ..with FIO2 adjustable • ..with a physiological /better hemodynamic profile • .. airwaymanagement.dk

364. Implementing Cuirass ventilation for surgery

365. Testing on ourselves..

366. Testing on ourselves..and our residents Tidal volumes airwaymanagement.dk

369. Testing on ourselves..and our residents CO2 sampling airwaymanagement.dk

372. Implementing Cuirass ventilation for surgery airwaymanagement.dk

377. In real patients !: airwaymanagement.dk

378. Marianne airwaymanagement.dk

379. Marianne airwaymanagement.dk

380. But inside… Chondrosarcoma + multiple lesions of unknown origin... Previous: Apnea + HFNO for short diagnostc procedure Jet-ventilation resulting in difficult access Now: Need for longer acces with various devise, including ”shaver” and possibly laser airwaymanagement.dk

381. I.v. induction and maintenance Mask ventilation airwaymanagement.dk

382. Transcutaneous CO2 airwaymanagement.dk

383. Transcutaneous CO2 Arterial line airwaymanagement.dk

384. Placing the cuirass airwaymanagement.dk

385. Optimising the cuirass ventilation airwaymanagement.dk

386. Placing the surgical equipment airwaymanagement.dk

387. air/oxygen via the nose airwaymanagement.dk

388. Initiate surgery airwaymanagement.dk

397. PCO2 54 mins later: 5.7 kPa 5.5 kPa airwaymanagement.dk

399. So…good for anaesthesia .. ….what do the surgeons say? airwaymanagement.dk

Airway Session | Michael Selz and friends at TBS23

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