Editorial article
Guidelines, algorithms, and recommendations during the management of the difficult airways in the thoracic surgical patient: Are they supported by evidence based?
Guías, algoritmos y recomendaciones durante el manejo de la vía aérea difícil en el paciente de cirugía torácica: ¿están respaldados por la evidencia contrastada?
J.H. Campos
Director of Cardiothoracic Anesthesia, Executive Medical Director Perioperative Services, Department of Anesthesia, University of Iowa Health Care, Iowa City, IA, United States
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"apellidos" => "Martínez-Pallí" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935617301147" "doi" => "10.1016/j.redar.2017.04.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935617301147?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192917301750?idApp=UINPBA00004N" "url" => "/23411929/0000006500000001/v1_201802080003/S2341192917301750/v1_201802080003/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "Guidelines, algorithms, and recommendations during the management of the difficult airways in the thoracic surgical patient: Are they supported by evidence based?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "1" "paginaFinal" => "4" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "J.H. Campos" "autores" => array:1 [ 0 => array:3 [ "nombre" => "J.H." "apellidos" => "Campos" "email" => array:1 [ 0 => "javier-campos@uiowa.edu" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Director of Cardiothoracic Anesthesia, Executive Medical Director Perioperative Services, Department of Anesthesia, University of Iowa Health Care, Iowa City, IA, United States" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guías, algoritmos y recomendaciones durante el manejo de la vía aérea difícil en el paciente de cirugía torácica: ¿están respaldados por la evidencia contrastada?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients who present with a difficult airway and require thoracic surgery under one-lung ventilation (OLV) represent a challenge for the anesthesiologist. The reason being includes: to secure the airway and provide the proper lung isolation device to facilitate OLV.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Both predicted and unanticipated difficult airways may pose a challenge to tracheal intubation via direct laryngoscopy or flexible fiberoptic bronchoscopy. Failed tracheal intubation may result in increased morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> The concern for patient safety in the operating room has led to the development of new technology (video-laryngoscopes, illuminated fiberoptic stylets, etc.), also training in simulation environment, evidence based algorithm and preoperative check list. A closed claims analysis conducted under the support of the American Society of Anesthesiology (ASA) concluded that a leading cause of anesthesia related injury was the inability to intubate the trachea and secure the airway.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Dr. Granell and co-authors<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> have done an extensive review based upon more than 800 peer review reports with important information related to the use of supraglottic devices, intubating laryngeal mask airways, use of video-laryngoscopes, elastic bougies, fiberoptic stylets, the use of an airway catheter exchangers and the role of flexible fiberoptic bronchoscopy in order to secure the airway during difficult airways and lung isolation techniques and made some recommendations that are useful in the practice of thoracic surgery/anesthesia. As new technology evolves it is important to provide an update and develop algorithms that can help to manage patients with difficult airways during OLV. These types of guidelines/recommendations are on the rise.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although this review article and recommendations are useful in the practice of thoracic anesthesia, one of the limitations to support these recommendations is the lack of prospective, randomized studies in patients with difficult airways and lung isolation techniques. Currently there are very few prospective, randomized studies to support the evidence. For instance the morbidly obese patient requiring OLV can be potentially difficult to intubate. Obese patients are known to be at risk of complications during airway management due to altered airway anatomy, including a shortened neck, limited neck extension and accumulation of fat deposition in the pharyngeal wall. Many obese patients also have an obstructive/sleep apnea. Evidence based studies involving morbidly obese patients comparing the attempts of successful intubation with a left-sided DLT or a single-lumen endotracheal tubes and the placement of an independent bronchial blocker (Arndt<span class="elsevierStyleSup">®</span> blocker)<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> have shown that there was no advantage on successful tube placement on the first attempt at laryngoscopy, intubation technique or effectiveness of lung collapse with the devices studied (DLT or bronchial blocker) once in place, lung isolation, surgical exposure and intraoperative oxygenation were similar and there were no specific advantages of one device versus the other. This study clearly supports evidence based. In Dr. Granell et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> report, the vast majority of their recommendations are based upon case series reports, or limited evidence based, such as the use of video-laryngoscopes and DLT's. Ideal in their report is to have a consensus agreement and expert opinion based upon personal experience of the co-authors, particularly in the algorithm table displayed in their manuscript to make their recommendations robust.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Another area that deserves attention is the limited information related to the preoperative evaluation of the patient with potential difficult airway. The authors briefly described the challenges on intubation in the upper or lower airway, specific information will be helpful to identify these patients and select the best option to manage the difficult airway.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients with a large mediastinal mass involving the left hemithorax can potentially distort the tracheobronchial anatomy. Displacing the trachea toward the right and compression of the entrance of the left main bronchus in a patient that otherwise presents normal airway for intubation. A review of radiological studies must be performed in every patient requiring OLV. In addition a review of the multidetector computed tomography scan allow to determine the precise size and location of the compression in the lower airway (distal third of the trachea or entrance of the left main bronchus) and select the best option to manage OLV. Also, the use a right-sided DLT can be an option in cases where the left sided bronchus presents with a lower airway abnormalities particularly where there is a contradiction to use a left-sided DLT.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Cases where the difficult airway during OLV is a dilemma, the primary objective is to secure the airway first and then select as a secondary end point the lung isolation device based upon the distorted tracheobronchial anatomy and expertise of the anesthesiologist in placing a DLT or a single-lumen endotracheal tube with a bronchial blocker (which can be an Arndt<span class="elsevierStyleSup">®</span>, Cohen<span class="elsevierStyleSup">®</span>, Fuji Uniblocker<span class="elsevierStyleSup">®</span> or the EZ-blocker<span class="elsevierStyleSup">®</span>).<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Recognition of normal and abnormal tracheobronchial anatomy with a flexible fiberoptic bronchoscopy and skills with lung isolation techniques will determine the success of lung separation and outcome on the thoracic surgical patient. Previous studies<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> have shown that anesthesiologists with limited thoracic experience have a high incidence of malpositions and frequently fail to successfully place lung isolation devices in patients with normal airway anatomy. The potential explanation to the high incidence of malposition is due to lack of recognition of tracheobronchial anatomy with flexible fiberoptic bronchoscopy.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The recommendations by Dr. Granell et al. discussing the latest technology with the use of video-laryngoscopes,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a> airway catheter exchangers or use of independent bronchial blockers in patients with difficult airways are good, assuming that the anesthesiologists are familiar with lung isolation devices and ancillary equipment to manage the difficult airway. In reality many anesthesiologists are lacking skills with the use of fiberoptic bronchoscopy and recognition of tracheobronchial anatomy. We should be cautious to follow strict recommendations even an awake flexible fiberoptic bronchoscopy, considered as the gold standard technique, in the case of anticipated difficult airways has recently been challenged by the use of video-laryngoscopy.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> In this study the authors compared the use of flexible fiberoptic intubation with the use of the McGrath video-laryngoscope for oral tracheal intubation in the awake adult patients with an anticipated difficult intubation. The authors reported no difference between the two techniques regarding time to intubation or success rate. This data suggests that video-laryngoscopy should improve patient safety by allowing a higher success rate in airway management. Dr. Granell et al. have done an extensive review on the use of video-laryngoscopes with the use of DLT's in difficult airways and their limitations while in use. It is important to use all devices in patients with normal airway anatomy, so when the situation arises (difficult airway and OLV) the anesthesiologist is prepared to provide the best care for the patient.</p><p id="par0050" class="elsevierStylePara elsevierViewall">It is my personal opinion based upon experience in thoracic anesthesia and upon evidence based that every patient that presents with a difficult airway and is intubated successfully (awake with fiberoptic bronchoscopy or with the use of video-laryngoscopes or with the use of airway catheter exchangers) a complete fiberoptic bronchoscopy exam must be consider in order to inspect the airway to ensure that there is no damage due to multiple attempts to establish an airway. There are multiple case reports of patients undergoing OLV with difficult airway involving airway catheter exchangers where the membranous portion of the trachea was lacerated or ruptured with the use of lung isolation devices.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> By performing a systematic exam with flexible fiberoptic bronchoscopy the anesthesiologist and surgeon should be able to recognize the problem and treat the complication based upon their findings. In the review article will be beneficial to add information regarding the importance of the use of flexible fiberoptic bronchoscopy at the end of the operation particularly in cases involving airway catheter exchangers.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We should consider adding within their recommendations, that anesthesiologists must have available an emergency airway cart that includes all ancillary equipment needed particularly for the unexpected difficult airway. In our department of anesthesia through the operating rooms, there are multiple emergency airway carts available and ready to be used (airways pediatric and adult carts) if the situation arises so there is no delay to manage the difficult airway in these cases. In addition, every anesthesia machine should have available: laryngeal mask airways, bougies, airway catheter exchangers, cricothyrotomy kits and ancillary equipment needed to manage a difficult airway.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Another area of interest related to the management of the difficult airway and OLV, is the role of simulation involving trainees and anesthesiologist with limited thoracic experience to practice and learn how to be prepared for these challenging cases.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> To date, there is no clinical trial that defines the experience necessary for proficiency in lung isolation techniques. It is important during the residency that every trainee becomes knowledgeable not only about the devices themselves, but about fiberoptic bronchoscopy techniques and recognition of tracheobronchial anatomy with the fiberscope. Anesthesiologists with limited thoracic experience in OLV devices should have more exposure to these types of devices. Anesthesia simulators have been used to enhance learning and to improve performance usually under the personal direction of an experienced clinician. Perhaps a different teaching method, such as an anatomical simulator that combines with the use of devices for management of the difficult airway in lung isolation would help the anesthesiologist with limited experience to gain more experience particularly in challenging airway cases.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Studies involving high-fidelity simulation of lung isolation techniques with DLT's and bronchial blockers in anesthesiology residents showed that their performance to place lung isolation devices was very successful.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">14,15</span></a> Developing clinical scenarios of management the difficult airway during OLV should be considered in every anesthesia department or society of anesthesiology.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In patients who require OLV and present with difficult airways, a key element during the preoperative assessment is recognition and identification of the potentially difficult airway. Then the safest way to establish an airway is by securing the airway with a single-lumen endotracheal tube place orally or nasotracheally with the aid of flexible fiberoptic bronchoscopy. Lung isolation in these patients is achieved best with the use of an independent bronchial blocker as recommended by Dr. Granell et al. An alternative can be the use of a DLT with an airway catheter exchange technique. For the patient who has a tracheostomy in place, the use of an independent bronchial blocker through a single-lumen endotracheal tube or through a tracheostomy cannula in place is recommended.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The review by Dr. Granell et al. brings an update related to managing the difficult airway in thoracic surgery. I will complement to their review that for all devices used during the management of the difficult airway, a flexible fiberoptic bronchoscopy examination should be considered prior, during placement and at the conclusion of the use of lung isolation devices, to confirm that the airway remains intact or to diagnose potential complications. Developing of additional management strategies for difficult airways during OLV encountered during emergence or recovery from anesthesia might improve patient safety. Also, I recommend that they should advocate the training in simulation in difficult airway considering the experience of the group of thoracic anesthesiologists that contributed to these guidelines.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Campos JH. Guías, algoritmos y recomendaciones durante el manejo de la vía aérea difícil en el paciente de cirugía torácica: ¿están respaldados por la evidencia contrastada? Rev Esp Anestesiol Reanim. 2018;65:1–4.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lung isolation techniques for patients with difficult airway" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.H. 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