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1. Successfully Anticipated Difficult Airway Management of a 'Can Ventilate, but Cannot Intubate' Situation for Urgent Laparoscopic Appendectomy in a Patient with Duchenne Muscular Dystrophy

Author

Fabian P. Brunner, Philippe Neth, and Alexander Kaserer

Subjects
difficult airway, Duchenne, difficult intubation, reversal of anesthesia, advanced airway management, wake-up, Medicine (General), R5-920, Medical physics. Medical radiology. Nuclear medicine, R895-920
Abstract

Background: Airway management in Duchenne patients can be challenging. We present a case of an anticipated difficult airway in a 24-year-old Duchenne patient that was managed by planning different suitable strategies based on the unanticipated difficult airway algorithm of the Difficult Airway Society (DAS). Case presentation: The patient initially presented with appendicitis, requiring a laparoscopic appendectomy within 6 h. Due to the underlying condition and a known difficult airway, we anticipated potential airway problems and successfully managed the “can ventilate but cannot intubate” situation using the algorithm. The difficult airway was attributed to reduced mandibular mobility, limited inclination or reclination, a large tongue, prominent incisors, and a posteriorly positioned epiglottis. Despite thorough preparation and team briefing, we experienced three failed intubation attempts. Considering limited nighttime resources, the urgency of the surgery, the need for a tube for laparoscopy, and the risk of exacerbating airway issues, we made the decision to awaken the patient and wait for a second attempt after the epiglottis swelling had subsided. We used reversible, short-acting agents for induction, enabling us to continue with the algorithm within the allotted timeframe. In a second stage, we successfully performed fiberoptic-guided intubation via a supraglottic airway device using the Aintree intubation catheter, utilizing more favorable resources. Conclusions: For a patient with Duchenne muscular dystrophy and a difficult airway, advanced expertise is critical. Detailed anesthesia planning, clear team communication, and the use of reversible, short-acting agents are crucial. Adherence to the Difficult Airway Society guidelines is essential for safe airway management.

Published
2024
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2. Advanced airway management in an anaesthesiologist-staffed Helicopter Emergency Medical Service (HEMS): A retrospective analysis of 1047 out-of-hospital intubations

Author

Martin Schlaepfer, Burkhardt Seifert, Philippe Neth, Simon Sulser, Kurt Ruetzler, Donat R. Spahn, Tobias Piegeler, and Roland Albrecht

Subjects
Adult, Male, medicine.medical_specialty, medicine.medical_treatment, Laryngoscopy, 030204 cardiovascular system & hematology, Emergency Nursing, Statistics, Nonparametric, 03 medical and health sciences, 0302 clinical medicine, medicine, Emergency medical services, Intubation, Intratracheal, Intubation, Humans, Intensive care medicine, Aged, Anesthetics, Retrospective Studies, medicine.diagnostic_test, business.industry, Tracheal intubation, 030208 emergency & critical care medicine, Retrospective cohort study, Air Ambulances, respiratory system, Middle Aged, Anesthesiologists, Emergency Medicine, Workforce, Airway management, Female, Clinical Competence, Cardiology and Cardiovascular Medicine, Airway, business, Advanced airway management
Abstract

Introduction Airway management in the out-of-hospital emergency setting is challenging. Failed and even prolonged airway management is associated with serious clinical consequences, such as desaturation, bradycardia, airway injuries, or aspiration. The overall success rate of tracheal intubation ranges between 77% and 99%, depending on the level of experience of the provider. Therefore, advanced airway management should only be performed by highly-skilled and experienced providers. Methods 9765 patients were treated in the out-of-hospital emergency setting by the anaesthesiologist-staffed Helicopter Emergency Medical Services (HEMS) between 2002 and 2014. Patients successfully intubated upon the first attempt were compared to patients who required more than one intubation attempts regarding several potential confounding factors such as age, gender, on-going CPR, NACA Score, initial GCS, prior administration of anaesthetic drugs, neuromuscular blocking agents, and vasopressors. Results 1573 out of 9765 patients (16.1%) required advanced airway management. 459 patients had already been intubated upon arrival of the HEMS, whereas 1114 patients (11.4%) underwent advanced airway management by the HEMS physician. 67 patients had to be excluded. Data for the remaining 1047 patients (790 males and 257 females) were analyzed further. Primary use of an alternative airway device was reported in 59 patients (5.6%), whereas 988 patients (94.4%) underwent laryngoscopy-guided tracheal intubation. 952 patients (96.4%) could be intubated upon the first attempt and overall intubation success was 99.5% (983 out of 988). Conclusion Our study demonstrates that HEMS physicians performed airway management frequently and that both the first attempt as well as the overall success rate of tracheal intubation was high. Together with the fact that all failed and difficult intubations were successfully recognized and handled and that no surgical airway had to be established, the current study once more underlines the importance of proper training of HEMS care providers regarding airway management.

Published
2016

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