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Difficult Airway Management: an Interview with Prof. Dr. med. Friedrich K. Pühringer

 Posted by Daryl AMC
 17 February 2021 09:08
 Advertorial - Anesthesiology & Emergency Medicine

Beliau lulus kedokteran umum dari Universitas Innsbruck, Austria. Beliau memegang banyak posisi akademik antara tahun 1993 dan 2000 di Innsbruck Medical School di Departemen Anaesthesiology dan Intensive Care Medicine. Pada tahun 1997 mendapatkan gelar PhD untuk Anesthesiology dan Intensive Care Medicine di Universitas Innsbruck.

Beliau juga bergelar MBA Manajemen Rumah Sakit dari School of Economics di Universitas Innsbruck. Sejak 2009 beliau menjadi Direktur Medis di Ermstalklinik di Bad Urach dan sejak 2015 menjadi Direktur Medis di Klinikum am Steinenberg di Reutlingen. Beliau sangat tertarik dengan aspek klinis keamanan pasien, juga tertarik dengan penelitian klinis efek farmakologi obat anestesi. Beliau juga meneliti berbagai peralatan yang menyangkut supraglottic airway memfokuskan penelitiannya pada difficult airway management serta strategi dalam anestesi dan perawatan intensif. Beliau author maupun co-author, lebih dari 90 makalah asli dan beberapa editorial dan beberapa bab dalam berbagai buku. Beliau telah memberikan lebih dari 500 kuliah di konferensi nasional dan internasional, juga merupakan reviewer pada berbagai jurnal ilmiah internasional anestesi.


Why is difficult airway management so important?

Difficult airway management is the core issue in anesthesiology and intensive care medicine, since lack of oxygen causes massive damage in our patients within a few minutes only. Therefore, we have to develop emergency strategies in advance and to train these algorithms continuously in non-emergency situations. To develop, to define and to implement a difficult airway algorithm is the initial important first step, this has to be done in accordance to available tools and ongoing training of the whole team, including doctors and nursing stuff. Everyone has to know, what to do and what are the next steps, if plan A and even Plan B and C fails.


How do you manage difficult airways in your center?

In general, we have to distinguish between expected difficult airways and unexpected difficult airways. Expected difficult airways, like big tumor masses in the oropharynx or in the neck, with limited mouth opening, who are detected pre-anesthesia usually require an awake fiber-optic intubation or an awake tracheostomy. These procedures can be carefully planned and performed. Nevertheless, the skills have to be trained and implemented through routine practice or on mannequins. On the other hand, unexpected difficult airways occur totally unexpected in normal and unsuspected patients. Since desaturation may happen pretty fast, we need to a clear strategy who to solve the problem, if conventional mask ventilation and/or laryngoscopy fails. From my point of view, a lot of national algorithms, as published by various national anesthesia societies around the world, are not precise enough to give a good and stringent guidance in this kind of emergency scenario. Therefore, we defined and implemented in my department our local “Reutlingen Airway Algorithm”, which had been implemented already 10 years ago. Everyone, nurses and doctors are educated and trained on it, everyone has to follow the steps, and all selected and implemented equipment is used and trained continuously in daily clinical practice.


How about normal case intubation?

Already in 2011, we implemented video laryngoscopy as our standard intubation tool in our department. When using conventional laryngoscopy, the visualization angle is only 10-12°, but increases to 80° when using video laryngoscopy. Various studies over the last years clearly showed evidence, that the incidences of successful 1st attempt intubations are around 98 % when using video laryngoscopy. In our institution the success rate in currently already above 99%. Secondly, beside the efficacy of video laryngoscopy, the C-MAC system is a perfect teaching and training tool. Every novice can be excellently guided and covered when performing an intubation.


Please share your opinion what are the ideal criterions for intubation devices?

Video devices are definitely the future in airway management. Actually, they are already the tool of choice today. Just like laparoscopic operations in surgery. No one is performing electively open cholecystectomy any more. We do know about better success rates of video laryngoscopy as mentioned already previously. In addition, the increased quality of teaching and of visualization of the procedure and structures during intubation or of a problematic situation for all stuff around is an extreme valuable effect. If a nurse can see the effect of her manipulation from outside on the screen, her support will be more effective and beneficial for the outcome. Therefore, I am very fond and absolutely convinced, that a C-Mac Monitor is fixed on the wall of every induction area in my hospital. In my hospital, there is no conventional intubation performed any more, since 2011. In addition, the modular system of the C-Mac family is another tremendous advantage. If plan A (video laryngoscopy) fails, no one has to run away to get another device, because on our C-Mac trolly Plan b is already present, the rigid fiberscope (Bonfils or C-Mac VS). Both rigid scopes are easy to teach, to learn and both devices have a steep learning curve. It is important to mention, these rigid devices can be used and trained continuously in daily clinical practice in non-emergency patients. In my department these devices are used in our neurosurgical operation room continuously.


Please share about your training center?

As already mentioned previously we are focusing to use devices and techniques in emergency situations, which can be trained and learned easily in daily clinical practice in non-emergency patients. Therefore, we developed the Reutlingen airway algorithm as followed:

Basics: No induction of anesthesia prior to proper preoxygenation (et02 > 80%)

Plan A: Video laryngoscopy (only 2 attempts including change of blades / eg. D-Blade)

Plan B: Rigid Fiberscope (Bonfils or C-Mac VS)

Plan C: Laryngeal mask (ProSeal – which is our standard in our department)

a) In ventilation is possible, consider if the operation can be performed under LMA, if yes – continue without changing the airway, if no

b) Perform an exchange maneuver using a 4.0 mm flexible Scope

(Storz) and an exchange catheter (Cook). Position the exchange catheter over the flexible scope and deliver it under sight through the LMA into the trachea. Leave the exchange catheter there, remove the flexible scope and railroad the tube over the exchange catheter into the patient. Even this maneuver can be trained easily in non-emergency patients in daily clinical practice.

Plan D: Cricothyroidotomy (Scalpel Bougie Technique), We perform teaching and training twice a year on animal (pork or sheep) larynges.

In conclusion it is of tremendous importance, that you have to set up a clear plan about the various steps in an emergency situation. In my opinion it is vital, that only things are used in a critical situation, which you are familiar with. This is the reason why we train all the devices, which are planned for rescue situations, on a daily base. Secondly, I need all hands on the patient in a critical situation, therefore I do appreciate the modular C-MAC system of Storz so much. All devices are connectable to one screen, and all devices are on the same trolly. No one needs to run away to get things. This makes also sense from the economical point of view, because you are able to buy new devices step by step and they all fit to the same monitor.

Successful airway management is a team approach, reliable on valuable tools, continuous training of doctors and nurses and clear communication of this philosophy, so every follows due to fact of being convinced rather than being forced to. (Okti)