> For the complete documentation index, see [llms.txt](https://bens-disorganisation.gitbook.io/anzca-rga-notes/llms.txt). Markdown versions of documentation pages are available by appending `.md` to page URLs; this page is available as [Markdown](https://bens-disorganisation.gitbook.io/anzca-rga-notes/curriculum/2.-rga-clinical-fundamentals/2.1-airway-management.md).

# 2.1 Airway Management

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<summary>AM 1.6 Discuss the clinical features, possible causes and management of perioperative airway obstruction</summary>

#### Clinical Features

1. Signs of Obstruction:
   * Stridor, wheezing, or gurgling.
   * Paradoxical chest and abdominal movement (increased effort without airflow).
   * Reduced or absent breath sounds on auscultation.
   * Cyanosis or hypoxemia (SpO₂ drop).
   * Hypercapnia (increased EtCO₂) or loss of capnographic waveform.
2. Hemodynamic Changes:
   * Tachycardia or bradycardia.
   * Hypotension in severe cases due to hypoxemia.
3. Visualization:
   * Visible swelling, hematoma, or foreign body in the oropharynx.
   * Airway collapse or obstruction on bronchoscopy or laryngoscopy.

***

#### Possible Causes

1. Anatomical Obstruction:
   * Tongue or soft tissue obstruction (e.g., in sedated patients).
   * Laryngospasm.
   * Foreign body or secretions (e.g., blood, vomit, mucus).
2. Pathological:
   * Airway swelling (e.g., anaphylaxis, angioedema).
   * Trauma or hematoma (e.g., post-intubation injury).
   * Airway masses (e.g., tumors, goiter, epiglottitis).&#x20;
3. Mechanical Issues:
   * Endotracheal tube (ETT) kinking, dislodgement, or blockage.
   * Equipment malfunction (e.g., valve failure in ventilators).
4. Neuromuscular Issues:
   * Incomplete reversal of neuromuscular blockade.
   * Vocal cord paralysis or dysfunction.

***

#### Management

1. Immediate Action:
   * Call for Help: Engage experienced colleagues and prepare for advanced airway intervention.
   * Oxygenation: Administer 100% oxygen via facemask, bag-valve mask, or supraglottic airway device.
   * Clear Obstruction:
     * Suction secretions or remove foreign bodies.
     * Reposition the head (e.g., chin lift, jaw thrust).
2. Specific Interventions:
   1. Laryngospasm:
      * Apply continuous positive airway pressure (CPAP) with 100% oxygen.
      * Administer small doses of IV muscle relaxants (e.g., succinylcholine).
   2. Swelling/Anaphylaxis:
      * Administer adrenaline, corticosteroids, and antihistamines.
      * Prepare for surgical airway if swelling progresses.
   3. ETT Issues:
      * Check for kinks or obstruction; replace tube if necessary.
3. Advanced Airway Management:
   * Perform laryngoscopy, fiberoptic intubation, or cricothyroidotomy in extreme cases.
4. Post-Event Care:
   * Monitor closely for recurrence or complications.
   * Investigate underlying causes (e.g., imaging, allergy testing).
   * Document and debrief with the team.

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<summary>AM 1.7 Outline an appropriate ventilation strategy, including different modes of ventilation, suitable for elective and emergency patients</summary>

#### **Principles of Ventilation:**

* Goals: Ensure adequate oxygenation and ventilation while minimizing lung injury.
* Assess patient-specific factors: age, comorbidities, surgical procedure, and urgency of intervention.
* Use protective ventilation strategies: low tidal volumes (4-8 mL/kg predicted body weight) and appropriate PEEP levels.

**Modes of Ventilation:**

* **Volume-Controlled Ventilation (VCV):**
  * Delivers a preset tidal volume.
  * Suitable for controlled environments like elective surgery.
  * Risks: potential barotrauma in patients with poor compliance.
* **Pressure-Controlled Ventilation (PCV):**
  * Delivers a preset pressure; tidal volume varies.
  * Useful for patients with variable lung compliance (e.g., obesity, ARDS).
* **Pressure-Support Ventilation (PSV):**
  * Patient-triggered; supports spontaneous breaths.
  * Ideal for awake or recovering patients and during emergence.
* **SIMV (Synchronized Intermittent Mandatory Ventilation):**
  * Combines mandatory breaths with patient-initiated breaths.
  * Useful in transitioning between controlled and spontaneous ventilation.

#### **Ventilation in Elective Patients:**

* Preoperative considerations: optimise pulmonary function, especially in patients with respiratory comorbidities.
* Tailor ventilation to surgical needs (e.g., laparoscopic surgeries may require higher PEEP to counteract pneumoperitoneum effects).
* Use neuromuscular blockade to ensure synchrony in controlled modes if necessary.

#### **Ventilation in Emergency Patients:**

* Rapid assessment of airway and respiratory function.
* Prioritise oxygenation and ventilation in critically ill patients.
* Use rapid sequence induction (RSI) for patients at risk of aspiration, with immediate initiation of controlled ventilation.
* In trauma or ARDS, consider PCV or lung-protective strategies to prevent ventilator-induced lung injury (VILI).

#### **Special Situations:**

* **ARDS:** Low tidal volumes, higher PEEP, permissive hypercapnia, and prone ventilation as appropriate.
* **Obese Patients:** PCV with higher PEEP to optimise oxygenation and prevent atelectasis.
* **Neurosurgical Patients:** Maintain normocapnia to avoid intracranial pressure fluctuations.
* **Pregnancy:** Avoid hyperventilation; maintain normal PaCO₂ to ensure uteroplacental perfusion.

#### **Monitoring and Adjustments:**

* Use capnography, pulse oximetry, and arterial blood gases to guide ventilation settings.
* Regularly reassess lung mechanics and compliance to optimise ventilatory parameters.
* Be vigilant for complications such as barotrauma, volutrauma, and atelectrauma.

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<summary>AM_1.9 Describe a ‘can’t intubate, can’t oxygenate’ drill, including equipment required to be immediately available and the technique for performing an emergency surgical airway Refer to ANZCA professional document: PG61(A) Guideline for the management of evolving airway obstruction: transition to the Can’t Intubate Can’t Oxygenate airway emergency 2017</summary>

#### Can’t Intubate, Can’t Oxygenate (CICO) Drill: ANZCA Guidelines Summary

**Overview**

The *PG61(A) Guideline for the Management of Evolving Airway Obstruction: Transition to CICO 2017* outlines the principles for managing airway emergencies when both intubation and oxygenation have failed. This involves transitioning to infraglottic rescue techniques (Front of Neck Access, FONA) and using a structured approach to mitigate risks.

***

#### **1. Key Components of a CICO Drill**

**A. Phases Leading to CICO Declaration**

1. **Supraglottic Rescue Pathways**:
   * **Bag Mask Ventilation (BMV)**: Ensure two-person technique, optimize head position, and use oro/nasopharyngeal airways.
   * **Supraglottic Airway Device (SGA)**: Attempt two devices of different types or sizes.
   * **Endotracheal Tube (ETT)**: Maximize up to three attempts using adjuncts (e.g., stylet, bougie) or alternative blades (e.g., video laryngoscope).
2. **Criteria for CICO Declaration**:
   * Failed BMV, SGA, and ETT despite optimized techniques.
   * Oxygen saturation ≤90% or imminent desaturation.
   * Waking the patient is not feasible.
3. **Team Preparation**:
   * Mobilize resources for FONA.
   * Brief team members and encourage assertive communication.

***

**B. Transition to FONA**

1. **Verbal Declaration**: Clearly state: “This is a CICO situation.”
2. **Method Selection**:
   * **Scalpel-Bougie Technique**: The primary method recommended for surgical airway access.
   * **Cannula-Based Technique**: Alternate technique if resources or expertise support it.

***

#### **2. Equipment Required**

**Immediate Availability**

1. **Airway Devices**:
   * Bag-mask ventilation equipment.
   * SGAs of various sizes and types.
   * Endotracheal tubes, stylets, and bougies.
2. **FONA Equipment**:
   * Scalpel (#10 blade).
   * Bougie (15 Fr or equivalent).
   * Endotracheal tube (size 6.0–7.0 mm).
3. **Additional Tools**:
   * Suction devices.
   * Supplemental oxygen sources.
   * Monitoring equipment (e.g., pulse oximetry).

***

#### **3. Technique for Surgical Airway (Scalpel-Bougie)**

**Steps:**

1. **Prepare the Neck**:
   * Identify cricothyroid membrane through palpation.
   * Position the neck optimally (extension).
2. **Incision**:
   * Make a horizontal incision through the skin and cricothyroid membrane.
3. **Introduce the Bougie**:
   * Insert bougie into the trachea through the incision.
4. **Secure the Airway**:
   * Pass an endotracheal tube over the bougie into the trachea.
   * Confirm placement with capnography and auscultation.

***

#### **4. Human Factors and Teamwork**

**A. Effective Communication:**

* Use cognitive aids to ensure adherence to best practices.
* Maintain clear and concise instructions, employing closed-loop communication.

**B. Team Coordination:**

* Assign roles (e.g., airway operator, assistant, oxygenation support).
* Regularly update the team on patient status.

**C. Training and Simulation:**

* Conduct regular CICO drills to reinforce technical skills and teamwork.

***

#### **5. Post-Event Management**

* **Documentation**: Record all interventions and outcomes.
* **Patient Notification**: Provide an airway alert letter for future anaesthetic care.
* **Debriefing**: Conduct team debrief to identify improvement opportunities.

***

#### **Conclusion**

A structured approach to managing CICO, supported by proper equipment, skilled execution of the FONA technique, and effective team communication, is critical to patient safety during airway emergencies.

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<summary>AM 1.10 Outline the important patient, staff and facility factors in determining the suitability of a patient for transfer to, and then discharge from the post anaesthesia care unit</summary>

**1. Patient Factors**

* **Airway and Breathing:**
  * Patent airway without significant obstruction or risk (e.g., no excessive secretions or swelling).
  * Stable respiratory parameters (adequate oxygen saturation, respiratory rate, and absence of apnea or stridor).
  * Ability to maintain oxygenation on room air or low supplemental oxygen.
* **Circulation:**
  * Hemodynamically stable (normal blood pressure, heart rate, and no ongoing bleeding or signs of shock).
  * Adequate perfusion (warm extremities, good capillary refill).
* **Neurological Status:**
  * Responsive to stimuli and oriented (or returning to preoperative baseline if altered consciousness is expected).
  * Adequate recovery from neuromuscular blockade (sustained head lift, handgrip strength, or negative inspiratory force test).
* **Pain and Comfort:**
  * Adequate pain control (manageable with appropriate medication).
  * No severe nausea or vomiting (or adequately managed with antiemetics).
* **Surgical Site:**
  * Stable wound with no active bleeding.
  * Drains or catheters functioning properly with acceptable output.
* **Co-morbidities:**
  * Addressed pre-existing conditions (e.g., glucose control in diabetics, stable cardiovascular disease).

**2. Staff Factors**

* **Training and Expertise:**
  * PACU staff trained in managing airway, hemodynamic instability, and postoperative complications.
  * Adequate staff-to-patient ratio for monitoring and interventions.
* **Communication and Handover:**
  * Comprehensive handover from the anaesthetist to PACU staff using structured formats (e.g., SBAR).
  * Clear documentation of medications administered, surgical events, and anticipated complications.
* **Decision-Making Authority:**
  * Presence of senior clinicians to make transfer and discharge decisions for high-risk patients.

**3. Facility Factors**

* **Equipment and Monitoring:**
  * Availability of appropriate monitoring (ECG, pulse oximetry, capnography) and emergency equipment (defibrillator, airway management tools).
  * Access to medications (analgesics, antiemetics, vasopressors).
* **Space and Resources:**
  * Adequate physical space to accommodate patient needs.
  * Resources for specific requirements (e.g., heated blankets, oxygen therapy, suction).
* **Escalation Pathways:**
  * Clear protocols for managing emergencies (e.g., code blue, ICU transfer).
  * Ability to perform point-of-care testing (e.g., blood gases, glucose).
* **Patient Flow and Discharge Criteria:**
  * Standardized discharge criteria ensuring safety for transfer to wards or home (e.g., Aldrete score ≥ 9).
  * Availability of beds in the next stage of care (e.g., ward, ICU).

**Considerations for Discharge from PACU**

* Patient meets criteria for transfer to the next care setting.
* Staff confidence in the patient’s stability and clear post-PACU care instructions.
* Ward readiness to accept the patient, with appropriate follow-up monitoring and interventions in place.

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<summary>AM 1.11 Discuss nasal intubation indications and contraindications</summary>

* **Surgical Access:**
  * Oral and maxillofacial surgeries (e.g., mandibular or maxillary fractures).
  * Dental procedures requiring a clear oral cavity.
  * ENT surgeries needing unimpeded oral access.
* **Oral Obstruction:**
  * Limited mouth opening (e.g., trismus from trauma, infection, or tetanus).
  * Tumors or foreign bodies obstructing the oral airway.
* **Prolonged Intubation:**
  * Prevents oral pressure sores or ulcers from prolonged use of an oral tube.
  * Allows better patient comfort for alert or semi-conscious patients.
* **Specific Situations:**
  * Patients in whom oral intubation is technically challenging (e.g., congenital anomalies, postoperative changes).
  * Situations requiring stable tube fixation (e.g., awake fibre-optic intubation).

#### **Contraindications**

* **Absolute Contraindications:**
  * Basal skull fractures (risk of intracranial placement and cerebrospinal fluid leakage).
  * Coagulopathy or anticoagulation therapy (increased risk of epistaxis).
* **Relative Contraindications:**
  * Nasal trauma or deformities (e.g., septal deviations or fractures).
  * Nasal polyps or tumours (risk of bleeding or obstruction).
  * Recent nasal or sinus surgery (risk of disrupting healing tissue).
  * Active sinus or nasal infections (risk of spreading infection).
* **Other Considerations:**
  * Pediatric patients with small nasal passages (higher risk of trauma).
  * Pre-existing severe airway swelling or stridor (may exacerbate obstruction).

#### **Pre-procedure Preparation**

* **Nasal Assessment:**
  * Test nasal patency with airflow check or mirror fogging.
  * Visual inspection for obstructions, deformities, or infections.
* **Medication Use:**
  * Vasoconstrictors (e.g., phenylephrine or oxymetazoline) to minimize bleeding.
  * Local anaesthetics (e.g., lidocaine spray) for patient comfort.
* **Lubrication and Equipment:**
  * Use water-soluble lubricant on the tube.
  * Select an appropriately sized nasal tube (smaller than oral intubation tubes).

#### **Complications**

* **Common Risks:**
  * Epistaxis due to trauma to nasal mucosa.
  * Nasal trauma (abrasions, ulceration, or turbinate injury).
* **Rare Risks:**
  * Tube misplacement (e.g., esophageal or intracranial).
  * Sinusitis or nasal infections from prolonged intubation.
* **Mitigation:**
  * Ensure proper technique and gentle handling.
  * Use a guide (e.g., fibre-optic scope) for difficult cases.&#x20;

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<summary>A 1.12 Discuss the issues involved with a shared airway</summary>

**Shared Airway Definition**

* A shared airway occurs when both the anaesthetist and surgeon need simultaneous access to the patient’s airway, often during head, neck, or thoracic procedures.

#### **Key Issues**

**Patient Safety**

* **Airway Obstruction:**
  * Surgical instruments or retraction can compromise ventilation or intubation tube patency.
  * Risk of dislodgement of airway devices during surgical manipulation.
* **Oxygenation and Ventilation:**
  * Limited access may restrict effective mask ventilation or intubation.
  * Risk of hypoxia or hypercapnia if ventilation is compromised.

**Surgical and Anaesthetic Coordination**

* **Limited Access for Anaesthetist:**
  * Difficulty in adjusting or re-securing the airway.
  * Restricted ability to troubleshoot airway issues promptly.
* **Positioning Challenges:**
  * Patient may be in unconventional positions (e.g., prone, lateral, or head turned), complicating airway management.

**Communication**

* Clear communication is essential to balance surgical and anaesthetic needs:
  * Timing of surgical interruptions for airway interventions.
  * Surgeons notifying the anaesthetist of impending airway manipulations or risks.

**Equipment Issues**

* **Choice of Airway Device:**
  * Endotracheal tubes with reinforced or flexible designs may reduce risk of kinking or obstruction.
  * Use of specialized equipment such as a laser tube for laser surgeries or a microlaryngeal tube for laryngeal procedures.
* **Airway Securing:**
  * Ensuring secure fixation of the tube to prevent displacement during surgery.
* **Shared Use of Instruments:**
  * Fibre-optic scopes or jet ventilation equipment may be required, adding complexity.

**Surgical Considerations**

* **Operative Field Visibility:**
  * The airway device and anaesthetic circuit can obstruct the surgeon’s view.
  * Shared airway techniques like pharyngeal packing or adjusting tube positioning may be necessary.
* **Risk of Contamination or Damage:**
  * Surgical debris or fluids entering the airway.
  * Risk of thermal or mechanical damage to the tube during procedures like cautery or laser use.

**Anaesthetic Management**

* **Optimizing the Airway:**
  * Preoperative planning to select the most suitable device and technique (e.g., awake fibre-optic intubation if difficult airway is anticipated).
* **Ventilation Strategies:**
  * Apneic oxygenation, high-flow nasal oxygen, or jet ventilation may be employed during brief interruptions of ventilation.
* **Monitoring:**
  * Continuous vigilance through capnography, pulse oximetry, and careful auscultation to detect early signs of airway compromise.

**Complications**

* **Surgical Delay:**
  * Frequent anaesthetic interruptions to address airway issues can prolong the procedure.
* **Airway Compromise:**
  * Hypoxia, aspiration, or trauma from tube displacement or shared manipulation.
* **Postoperative Concerns:**
  * Edema or trauma to the airway requiring extended postoperative monitoring or interventions.

#### **Strategies for Mitigation**

* Detailed preoperative planning and multidisciplinary discussion.
* Ensuring the availability of advanced airway management equipment and expertise.
* Clear contingency plans for airway emergencies."

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