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Anaesthetics Session: Mastering Airway Management | Ricardo Zanlorenzi

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Summary

This on-demand teaching session is for medical professionals interested in mastering airway management taught by Brazilian anesthesiologist, Riccardo Zanlorenzi. He discusses his experiences with airway management, and presents different strategies that can be employed to ensure patient safety. Mr. Zanlorenzi also presents case studies, like the Ellen Bromley case that illustrates the importance of correct airway management. In this case, a lack of airing management led to significant damage and death. The session also includes a discussion on the nature of 'Difficult Airway' and different concepts relating to it. Further reading and resources will be shared throughout the session using QR codes for easy accessibility. Attendees will also receive a certificate upon completion. Join this session to improve your skills in airway management and increase patient safety in your practice.

Description

Airway management is a critical skill in emergency and critical care settings, essential for ensuring patient safety and effective ventilation.

Joining us today is Ricardo Zanlorenzi, Consultant, Anaesthetics and intensive care medicine, Brazil

None of the planners for this educational activity have relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Dr. Zanlorenzi, faculty for this educational event, has no relevant financial relationship(s) with ineligible companies to disclose.

Learning objectives

  1. Understand and apply the American Society of Anesthesiologist guidelines for difficult airway management to improve patient safety and quality of care.
  2. Gain confidence in performing awake tracheal intubation by understanding its necessary applications and mastering its execution.
  3. Explore the concept of situational difficult airway management and how to adjust approaches according to patient conditions and available resources.
  4. Integrate human factor considerations into airway management protocols to prevent critical errors.
  5. Apply knowledge of various airway management tools and devices and learn to effectively incorporate them into practice.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Welcome everyone. Uh It's lovely to have you back to mental education today. We're gonna hear from Riccardo. He's actually joining us from Brazil. Um And he's gonna be chatting about mastering airway management. As always, we want loads of questions in that chat box, loads and loads and loads. We've got a few Psy as well. So make sure you to them, they'll be helpful. And at the end of the event, we're gonna have feedback forms into your inbox. So in an hour's time, there'll be a feedback form in your inbox. Once you've completed it, your uh attendance certificate will be on your medal account. All right. That's all I'm gonna say. I'm gonna pass it straight over to Ricardo. All right. Thank you. Thank you. Thank you. Thank you, Sue. So, hello everybody. It's really a pleasure to be here. Uh I really would like to thank me for this uh this invite and this is the subject that I love to speak about. So I'm really comfortable in speaking about this. Uh I would like just firstly apologize, maybe my pronunciation and my English sometimes would be uh a little bit different because I'm more used to giving lectures in Portuguese or sometimes, maybe uh Spanish than uh English. I'm more used to uh read and listen to English, but I'll try to do my best here. Uh So, you know, so I have no uh disclosures here. Sorry about this uh this configuration here. Uh Who am I? First of all? Like who is this guy from Brazil that is talking about the management? So I am Ricardo Zenz. I live in Brazil in Joinville. It's a city in the south of Brazil. I'm anesthesiologist here in Joinville. I'm part of a group. This one, this is anesthesiology group here. Uh Let me get a pen here. This is an anesthesiology group. We are 80 anesthesiologist that work together in the cities like an 800,000 people city in the south of Brazil. OK. The State of Santa Catarina, I am now the president of the State of Santa Catarina. This society that it's a regional society from, from our mother society that it's the Brazilian Society of Anesthesiology and White Airway, right? I love airway management since I was in the residency. And then I came here, I'm one of the coordinators of the residency in here. We have now 42 residents here in Brazil. We have three years uh program of residency after medical education, medi med school and we have 14 residents per year. Uh So, uh at the moment, we have some ones that gave up and we are with 42 residents. So it's, it's the biggest one in the south of Brazil. So it's a lot of responsibility and it's really nice to be up to date. But I love airway management and I found that this uh this name in, in Portuguese, it's, it's called a, the translation to English. It's airway school. So with this uh company, I do some lectures and trainings for people and to students regarding management. Uh a member of these three societies and I encourage you to search for them and be in touch because they have a lot of resources and uh they suggest publications to read related to R MA management. They promote a lot of uh events. There are usually free to get updated about uh ra management papers and subjects. OK. So I'm gonna begin, some of you might have already listened or heard about this case. The Ellen Ellen Bromley case for a rapid, a fast introduction here for those who haven't uh have heard about her. Uh Ellen Bromley in 2005 was the uh wife of Martin Bromley. That is this guy here. He's an airplane pilot. Uh She was scheduled for um sinus surgery and turbinectomy. She had no prior history of surgery or intubation or any events in anesthesia. She only had uh two fused uh spine here, cervical spines, uh C one and C two fused, but her neck movements, hers uh neck extension was normal. So uh the history is that she underwent to general anesthesia and they weren't able to uh get uh to ventilate her. And then they tried to ma mag mask, ventilate, they tried to uh insert a laryngeal mask airway two sizes. They weren't able to insert it. Then they tried to intubate her. Uh she was uh Karma a grade four view. And then a lot of people try to, there, there's a video in youtube if you search a case there simulation, it's really interesting to see. I II didn't put it here because it would be too low. And it's really interesting that they tried uh the same strategy and different strategies without oxygenating her. So she was like with the boo oximeter, the, the, the oxygen saturation around 40 for 2025 minutes and then she got uh permanent brain damage and she died in the IU like uh 7 to 10 days later. So Martin Bromley, he could have like prosecuted and like got revolted. But he's a really uh elevated guy. He's uh a guy that's really smart, I think. And uh a person that should be uh really respected. He created a Clinical Human Factors Foundation uh to make that this kind of thing shouldn't happen anymore because he is an airplane pilot. And in an interview he said, well, when something goes wrong, I know exactly what I should do during my uh during my flight. So why didn't the anesthesiologist in that case, knew it. Right. So that, that's something that he questioned. And then he s, he saw that in that hospital, they had all the structure necessary. They had fiber optics. They had their intubating original mass they had at the time. They didn't, it, it wasn't available to the, the video laryngoscope, but they had all the, the blades available. They had different sizes. They have, uh, of laryngo mass airway, they had the cry pit and no one thought of awakening her. It was an elective sinus surgery they could have awaken her. And this is a human factor thing. No one took the decision nor to do the cric the cricothyrotomy, neither to awake her, right? So this is, I think the case we ii it's the base for us for reflecting about how complex is airway management. This as was an unpredicted, difficult airway, right? And for unpredicted, difficult uh airways, we have our algorithms, right? So I ask you what is a difficult airway we're going to to to pass through some concepts here that I think are essential for anyone, even the the the the the doctors or the students that are advanced and the ones who are on basics regarding airway management. This is the American Society of Anesthesiologist, uh guideline for difficult airway management, right? Uh This is for planning, right? This is before this is something you should uh evaluate your per your patient before managing the airway. So see here, if you have any of these situations, you are allowed to uh undergo to an awake airway management because we are focusing here and making the safest procedure for the patient. Ok. This is, this is always the objective, safety, safety and quality. You, you don't need to be fast. You don't need to be any, anything you need to focus on, on safety, right? No one wants to i if you ask any patient or any family, they just uh uh that go inside the hospital, they just want their care to be safe. So see you, you don't have just predictor for difficult mask ventilation, B MA or difficult laryngoscopy. You have some other factors here, significantly increased risk of aspiration, increased risk for HED rapid desaturation. These are uh conditions that if you have only one of these like a huge obese, severe obese patient, you are allowed to undergo an awake airway management and see this is not awake track you intubation. This is a way airway management. We are going to go through this if you decide to undergo through an induction. OK. You gotta have all the strategy plan. ABC, all the devices available. You have to know how to use all the devices and your, your team should know uh what are the steps you're going to follow. OK. These are all recommendations regarding airway management. So we're going to start the first all here. I would like you to answer this for me to know uh how are you regarding this situation here? So, OK, let's wait. We got some responses. Some people are not safe yet regarding uh awake tracheal intubation. All right. So, uh this is uh we have here, uh I write this to another, another suggester for a topic of a lecture, right? Because this is another lecture. I'm not going to teach you here exactly how to do an await intubation that I'd love to do. But uh this is the uh the, the, from this point, we got to reflect about how we're going to manage. You know, if you are not confident about uh performing an awake tracheal intubation, see you have a neck um II, it doesn't matter if you have all these difficulties, you're going to induce your patient and you're going to deal with all these difficulties. And if maybe your patient is, you're not able to access the, the, the, the, the last resource of your area management. That is the surgical area. Maybe the patient uh has some, I don't know uh stenosis, racial stenosis. That is a contraindication, a relative contraindication for ectomy or maybe he has prior radiation in the neck and you cannot palpate anything here. So how are you go, how, how are you going to perform and p in this patient? So this is the kind of patient you cannot put to sleep. So I can see mo the great part mo most part of you are not um comfortable in performing an awake cu intubation. This is not do, don't feel bad about it. Ok. This is most part of the doctors that, that, that perform management are not comfortable. We already done this, this kind of uh research here in Brazil, like locally in our state, in the south of Brazil and the sta the the stati statistics here are worse. No, no, like 5% of people feel comfortable, right? I really like this paper you're going to see all during all my presentation, these QR codes, all the articles that the papers are going to put here that have these QR codes are open access. So uh uh uh and, and they worth the the for you downloading them. OK. So this is uh this is an article an editorial wrote by Doctor Hans. He's from Netherlands. Uh If you have Twitter, follow him. His, his Twitter is Airway mx Academy. He discussed a lot of airway, a lot of airway resources and like I never met him personally, but it's some good things of uh internet, right? I talk a lot of him and this is a concept that he brought to us, like he's against the concept that are fixed uh difficult airway concept. So what he brings to us, uh this is the guy, he, he's really nice person, he really sympathetic. Um difficult airway does not exist. It's a situational interplay of patient. Yeah. Thank you. Thank you. Sue. Perfect. He, he, she, she put in the, in the, the chat. Uh, it's an interplay of patient practitioner, equipment, expertise and circumstances. So, uh, if you have a person that does not open his mouth or has something anatomically difficult, this in the hands of an experienced, uh, uh, doctor with and video Lagos Cope, uh, might be an easy airway but this same person in a rural hospital, uh, far from everything with uh just uh with, with uh a resident that just has graduated from his residency. This and he has no videolaryngoscope. He has no optical died. He has just a a Macintosh blade. This might become a difficult airway. So uh the airway, it might become difficult because of the physiology of the patient because of the situation you are because of the devices you have available. So this is something that for me makes sense. Uh mainly because uh in Brazil, we have so many different settings, right? You have Sao Paulo that it's uh a place that you have a quality of care that you compare to any place in USA. And you have like some miles from there up city that you have a quality and uh of care and devices that you might find in the the worst uh uh resources uh places that we have in the world. So we have, we have a different picture and, and, and we have to, to try to teach everybody uh considering every of these situations. So this is an app that this guy has, uh, Doctor Hams has created. It isn't a paid app. But if you get to him, uh on Twitter as I did, he will give you a discount code. Uh And you put that in your uh plays store or app store and you get it for free. It has all languages. Uh It has even Portuguese and I think it must have uh uh probably you're going to use it on English, but it has a lot of resources for you to study clinical cases to record your hour cases. So I usually recommend this because it's really useful to uh study and it's something that it's really easy in the palm of your hand. OK. So something he created with other colleagues in Netherlands was these two questionnaires. I can say that you can evaluate the patient, his history, his airway here. You see that anatomy is just only a part of every uh evaluation, the surgical uh in the case of an anesthesia, he is going to be uh submitted and the vital signs here is the kind of the physiology of the thing. And we got something really uh important. So here we got the face and here we got the helt it's just to, to make it easy to record language barrier, fatigue stress. Some of us like are 24 hours on shifts like of skills regarding some kind of strategy that you might have to consider remote hospital uh patient factors. Again, here, technical problems like the the availability of devices and the time pressure that can be related to the physiology of the patient. So uh what we're going to do here, we're going to divide the airway, not in a difficult or an easy, we're going to divide the airway in a basic airway or an advanced airway. And based on this, you're going to call help. You're going to prepare, you're going to uh ask for another device or, or you're going to uh take this patient to a higher level uh hospital for a better care. So that that's something that uh for me makes sense. It's easier for you to have this, this visual thing of no, this is a basic airway. I have most of the the the people or the the doctors that uh study airway management, they can't deal with it. This is an advanced airway. So I will need help anyone uh who is going to manage this airway won't need help and needs to have a special structure for having. So all of it, it's focus focusing in the safety of the patient. So we have the basic airway and you have the advanced airway and the main aspects that we're going to consider in this thing is the uh advanced or or difficult anatomic airway, the situational difficult airway, right? Or advanced airway that it can become dependent on the place you are depending in the situation, we are depending the skills you have and the physiologic difficult or advanced airway. So airway is something that is not static, right? Uh It's something that is dynamic. So an array it can become difficult, right? So the patient, the the the that concept that we had of this patient has had a prior history, a difficult array. OK? Uh He has a prior history. OK? But maybe um im maybe myself or my, my wife, we are the moment we are healthy. Maybe if, if we got septic and we go to the hospital depending on the context, we might get difficult airway because we might get even with positive pressure, oxygen, we might be saturating like 80%. So this is going to be a physiological difficult area. We're going to have a rapid saturation. This is something we have to consider. OK. This is first part of the class that I really need you to have this concept, right? You need to evaluate every airway, you need to have this difference between basic advanced airway and not have the focus, only anatomic airway, the situation, the physiology and the anatomy can influence. Ok. The other part that I'm going to focus here is that everybody, especially anesthesiologists like me, we like to like solve most of the problem intubating like we we intubate uh every day, II work every day. Yeah. Uh schedule here that is ha have a lot of, of hours per week and I love it. But uh sometimes we have to focus not only in the track or two but in a, this is an emergency that I have the opportunity of doing uh an, an cadaver curse in Maryland in Baltimore in USA when I was uh just finished my residence and he states that no one dies from acute plastic deficiency in, people die from hypoxia. OK. So I'd like to ask you the second poll here about ethnic oxygenation. You've never heard about it. You uh use it just uh on some difficult cases that you think the physiology uh is uh you need a safe uh uh uh uh uh uh more time of safe apnea or you routinely use it. So some of you never heard about it. That makes me happy that I'm bringing something new to you. Ok? Mm but no one routinely use it. So there you, you can say answering this. Ok. So what is aake oxygenation? I'm going to bring you the concept of of oxygenation and you are never going to be the same. I'm sure about it. This is an um open access article that I really recommend you to read. Ok, please get it in the QR code here. Uh It's about Preoxygenation Act. Make oxygenation and preoxygenation are different things. OK? Preoxygenation uh is you before the patient's sleeping? Ok? You put the mask, the facial mask sealed with 100% oxygen with a gas flow, oxygen flow higher than his uh tidal volume. And you, if you have a gas analyzer that I don't have widely here, but I have in some hospital you should uh have at at least 88 to 9% of an tidal O2 and tidal O2. So the expired fraction right should be 88 to 9% as it's difficult to have it. Uh I if you seal the mask and you see the capnography curve, um if you leave it for 3 to 5 minutes, you are going to have this value in no uh critically, critically ill patients. So I recommend and not only it's not me recommending it safer to if you can prey every, each and every one of your patients. Because what's our objective here, safe apnea time? We have, we, we wanna have the patient with the a high uh high O2 saturation per saturation of oxygen uh during our hour management, right? And then we can think better. We can uh get do uh get through our plan and our strategies without stress. This, I think this graphic is one of the most used graphics here uh in, in the I in anesthesiology. I think this is we have the O2 arterial saturation and time here these patients were oxygenated. This f big A here is the alveolar fraction of O2. So they have inside their alveoli, 80% of oxygen. So it's full of oxygen. They are really highly preoxygenated, right. It takes around 10 minutes for a 7 kg at all to go to. Oh, here we have uh 100%. So for us to get to a saturation of 80% it goes like almost like nine minutes. But you see that uh uh of a normal adult, 70 kg that is moderately ill. He is going to have half of the safe apnea time. A child we have, we know the child has uh an a higher um oxygen rate, consumption rate, higher uh oxygen consumption to consumption rate and uh a le uh uh uh uh a lower reserve uh as well as the obese. So you see the the saturation here, these patients are highly preoxygenated. So what we want to do, I used to compare, we want to fill in the tank, we will fill the tank that it is the lung with oxygen. We want to take out the nitrogen we we have in our for pure air in the atmosphere, 21% of oxygen. We want to give the 100% oxygen and we want that 100% oxygen to take place in inside the alveoli. OK. And we want all the the the highest fraction of oxygen inside the alveoli. OK. OK. What the hell is apnic oxygenation? So it's oxygenation during the ethnic phase preceding intimation in prehospital emergency party. Emerg uh intensive care or if you want to do like a procedure, uh I do a lot of anesthesia for every procedures. So the patient stay up like 10 minutes, 15 minutes only being oxygenated passively. True. Uh uh apneic oxygenation. So this is a pretty nice ii think it's the best one that you can read for, for learning about this subject uh about the mechanism. I'll try to explain here. So this is the steps right? During and if you wanna use it in an anesthesia induction, you are preoxygenated the patient and you need to preoxygenate the patient to have uh uh higher safe apnea time. Then here you have a res because for you to get the oxygen to the lower airway, you got to have the have the airway, this obstructed. This is a high uh flow nasal canal. You don't need a high flow nasal canal. I don't have it here. OK. Uh I use the conventional one, right? And this is amazing, but I don't have it here and during the laryngoscopy because during the laryngoscopy, you are uh these uh on uh taking off the, the, the, the tongue and you are distrusting the airway. So how does the AIC mechanism works? So please pay attention here. Uh Our basal metabolic rate per minute is around 250 MLS per minute of oxygen. OK. 250 mL milliliters cc of oxygen per liter, right? So, imagine the alveoli here. Ok. 250. This is an alveole. Ok. So it's going from the alveoli to the bloodstream. 250. Ok. And the CO2 goes off from the, the, the bloodstream to the alveoli to be expired around 10 to 20 mL per minute. Can you understand that you generate a negative pressure from around 232 140 mL because it's going in 250 it's going out 10 to 20 mL. So if you are putting a continuous flush of oxygen in an not obstructed airway, this O2 is going to be pulled down from the airway and that's how APN oxygenation works. OK. But why do I need to preoxygenate to have a better APN oxygenation? Because if I have most of my ability uh full of nitrogen, this nitrogen is not going to go in. So what is going to go in? It's oxygen. OK. So if it's previously full oxygen, uh the negative pressure is higher. I learned this with Doctor Richard. OK. This is emer emergencies from USA and he created this. No, this set that it's to make you right. Uh Make you remember no B set, it's nasal oxygen during efforts to secure a tube. OK. Then after this class put on Google, no B set, Richard Leviton, you're going to see some articles and blogs and you're going to, to, to go through it. There's so many pictures. So you put like 5 to 10 L per minute in a nale prone normal one, not high flow. This is another, this is from this article here. OK. This is the uh uh a draw from the article. I think it's kind of confused here, but you might understand, I think it's better. This one. OK. This is a, um, a presentation that I saw from him that he, he gave me authorization to reproduce it, right? In the same presentation he puts that I'm not like inventing the wheel, right? See this paper published it in 1959. They already done these studies. Of course, see the P CO2 here. So this is the problem. But that of course, you, when you passively oxygenate, you are not eliminating CO2. OK? This is bad for 30 45 55 minutes. But for 5 to 10 minutes, if you get 5 to 10 minutes, uh more of a max of apnea, safe apnea, time to manage your airway, maybe this is the time you need to make the airway successfully be guaranteed by and, and attractive tube by a laryngo mask airway or maybe and surgical airway that we should not do when the pa I the patient is almost arresting. We should do it before. Ok? Because remember the patient, the patients die from hypoxia, not from the deficient son. Mas car away or from attracted to, ok. Understood. If you didn't understand this, please let me know. Uh After then, uh I'll try to, to, to go back to this. OK. So we're going to go to the next pole here uh are going further here about patient positioning. I'm going to see if you position your patient. Oh No, let's see what we have here. This, this is the kind of discussion I uh I like uh I prefer set goal. I prefer no position. Well, nice. I don't like what? When everybody agrees. This is, this is not, this is not fun. Nice. Better yet. So I'll try to prove you my point here. OK. Let's go for, oh I, if you don't understand it eventually something, some word I say, please don't hesitate to, to ask on chat. OK, I'm sorry. Um This is another um slide from Doctor Richard Leviton. Uh And you see uh this is cervical radiographies. So what what I want to to show you here. It's this, this is this black region here. It's the air in the upper airway. So the larger this this area here, the higher percentage of air we have here and more open is the airway. The better is to insert a subotic airway is better to uh perform a di direct laryngoscopy is better to perform a videoscopy is better to perform a fiber optic intubation being the patient awake or the patient sleeping. So the nr one, we already knew that it wasn't like really amazing. But the the one that I like to compare the most here and gives me uh it, it's the most discussed, especially uh in the, the, the, when I, when I gave lectures and classes, people like to hyperextend. OK, I would like to ask you, look at the camera now, look to me. OK, to my face. Have you ever seen someone getting into the emergency room like this? Just with hyperextension? People don't arrive there with hyperextension with shortness of breath. People arrive like this. They are doing this sniffing position to open the airway. People do um inconscient. They, they are not conscious of what they are doing and they do this sniffing position, the head forward, position, the to sternal notch because it opens the airway. So ear to sternal notch, it's the position that opens the airway and it's the best position for managing the airway. This is the counter, this is our two theories. The, the, the the axis, the airway axis theories that I don't really like it. I think it's too confused and the theory proposed by Doctor Greenland. OK. Doctor Greenland, it's a doctor from Australia. He uh suggested that we do two curves here. The two curve theory from Corina to the glottis and from the glottis to the incisor, upper incisors. So everything you do to flatten these curves, OK? And these uh the uh elevated face parallel, the uh sorry, I forgot the name, the head forward positioning. This makes the uh airway more open and this flattens these curves, OK. And the direct laryngoscopy is going to compress the submandibular structures and it is going to flatten more this curve making possible to intubate the patient. So if you analyze the two positioning theories validated by uh magnetic rail, we can see that the elevated face parallel to the ceiling position, right and or the ear to sternal notch and face parallel to the ceiling. It's the best position to make an airway uh managed with success. So I put some steps here that I think with air management, we got it to be a little bit methodical. OK. So positioning it's basic. OK? I see here every day in my uh anesthesia group, uh people that usually just do like the traditional cases, not uh elective surgeries and people relax, you know, I don't need to position. OK? It's OK. I can uh ii intubate every day and when you get a difficult airway, uh then it's the biggest problem. OK? Because you are not positioned and you're not maybe going to remember to position. And when you forget the basics, you cannot do the advance. So please every patient here to sternal notch. OK? I keep uh here. My, my gift didn't, didn't work here. OK? But she was taking out the, the, the, the, the pillow here and it's not to take out the pillow in this case. OK? Because she's going, she's now in a smoking position. And she's going to be in the ok, in Children as well. Ok. It's not different in the pediatric population. Ok. Here to Sternal March, please. Ok, obese. Ok. Higher bm. I, you're going to have probably, you're going to have to get a little bit more sheets here or pillows to put under the shoulder and be able to get the ear to sternal arch. Because if you get only over the occipital, uh, bone here, the pain is going to be like not face parallel to the ceiling and it might not be able to get the tr dose right to the, the e to the sternal arch. You're going to have to elevate uh the shoulder too. And he here II, put the rampant position. There's some people that uh answer that prefer the rampant position. So the recommendation here is ear to sternal notch face parallel to the ceiling and uh and the head elevated but not hyperextension. Ok. Hyperextension is worse than your sternum. M please. Ok. You should not look from back while you are doing Laos, you should look from up. Ok. I'm going to to put some, some other uh some other orientations for you there. Thi this is a situation that people usually ask me with cervical color. OK? Uh You can leave it on the ultra position or you can put a sheet, just small sheets uh under it. It's better than, than nothing. OK? It helps a, a little bit, but in these situations and II don't do prehospital uh care, but usually I uh manage the airway with aspartic or an extraglottic airway. And then when I arrive to the hospital, uh with cervical collar, I prefer to uh perform a video endoscopy with hyper regulated plates. Ok. Uh but you can say, ok, Ricardo, I don't have uh videoscopy. So then you, you have to, to, to, to be uh really aware of all your steps that you're going to have because uh making performing a direct laryngoscopy in trauma patient with cervical color, it's really, it's really something that people underestimate in my opinion. OK. So they said you are going to lecture about airway management and you told us about something that it's called epic oxygenation. And now positioning. Where the hell is the Air Man Management here? I consider this to be airway management. OK. So this is, this is part of Airway management planning, is Airway management up oxygenation and preoxygenation is Airway management. Positioning is part of airway management. If you forget these basics, probably if you perform the best laryngoscopy, if you have the best video laryngoscope or fiber bronchoscope, maybe you are not able to perform it uh in a uh in, in a way that's going to be successful because you forgot the basics, right? This is something that I always say to my residents and to everyone. In course, your first attempt to intubate be must be the best. Why do you think in many papers they, if they usually the outcomes I II is their first best su success. What is the, the, the the rate of first, best success? Because if you don't have since in the first pass, you have a lot that come from this, from this situation. OK. So uh you decide to induce your patients. OK? You have everything prepared here, right? You're positioning your patient, you uh uh preoxygenated. You did the uh are doing the, you, you are doing the APN oxygenation and you see this disease and uh American Society of Neology recommendation here. OK? You have continuous liver oxygen here. OK. Then you have uh the emergency pathway that it's an emergency situation that when you do not ventilate and you do not uh or do not oxygenate or do not uh ventilate and do not intubate. And remember people don't die from plastic deficiency, they die from hypoxia. Don't forget to. So you have treatment on every strategy here. This is something I would like to reinforce for you follow, use these cognitive uh aids here. OK? Don't forget it, right? Uh I'm going to pass a little bit fast uh through the f the the main strategies for every management with some uh suggestions that I learned through uh these many courses and some practices that I had. Laryngoscopy. OK, video or direct laryngoscopy, issued, use uh rigid stylet uh or abu uh uh track tube introducer. Right? I really like these rigid stylets here and it, it's important to you to know that uh, this straight curve here. Ok. It's the best way and not curved in this, this way here because this way you're, you're not be able to be, make it go, uh, through the trachea. It's going to be hitting in the, in the rings, ok? In the trachea rings. So it should be straight to occur to not uh make any, uh, injuries in the trachea. Ok. And if you use a bougie, sometimes you have to cure the bing. Ok. Uh, and sometimes, uh, you need, uh, to make, uh, a slightly uh angle to prove, especially with hyper angulated uranoscopus. But I prefer the, uh, the, the rigid ST anyway, every intubation should be, we should use a ST. Ok. And I would like to know about you. Do you use routinely STT ok. A BOJ or any tracker introducer during your intubation? Ok. It depends on the case but it's not uh, routine use. Uh, ok. Maybe you don't have it available. I usually try without any, try to introduce it all. Nice. I was usually at that time. So he, he was something really typical that, uh, the intensive care doctors and emergency doctors, they usually use bougie and, or, or uh, uh rigid toilet because their, their patients are really, uh, critically ill and anesthesiologist because, uh, we intubate a lot of, uh, patient elective surgery patients. Uh We don't use like I don't include myself because I use on all my patients, but my colleagues do not use. Uh but I think we should use because uh that statement that we should make the best, the best laryngoscopy, our first uh attempt. So this includes using uh uh try to introduce her. You don't know you, we don't, we, we cannot predict difficult areas. We are really bad at predicting difficult areas. Uh There, there's a lot of literature on this, there's another class uh because there are a lot of literature on it, but we are really bad at predicting difficult areas. OK? But together with the track or introducer, uh I would like to suggest you that not only making the position here to sternal launch, I would like to suggest you to make an additional head elevation. OK. So usually uh the face is parallel to the ceiling, the patient with trying uh sternal notch. And if you're having some difficulties, you've got like maybe a grade three A or three B. If you get the, the, the, the, the, the head of the patient higher and you ask for your assistant to hold it and you do an external laryngeal maneuver, not necessarily burp, but you do an external laryngeal maneuver. Uh and you get, and you have an introducer, you can get most of the airway with direct laryngoscopy. I am a fan and a defense of video laryngoscopy universally use but I know how my country works. I know how the world works and this is probably will never be a reality and we should be, we you should be able to take the, the uh the best of ee each and every uh device. OK. So the manual laryngoscopy associated. So you just turn arch preoxygenation up, make oxygen head, elevated laryngoscopy and external laryngeal maneuver. All of these associated you have higher chances of achieving a success in your intubation and having a safer apnea time for your patient. OK. So what is more important? This is, this is really AAA um uh uh something that I discussed with residents, everybody wants to intubate but no, no one wants to learn how to ventilate. And this is something that Doctor Bradley is, is from Australia too. And he published in bridge Journal of education. This, this uh a paper that is not uh free online that why I didn't put the, the cure code here. But I put AAA picture here. That is pretty uh I think it's pretty di didactic. OK. So this is the groups we can have to help us to have achieved successful uh back max. So this is the traditional c this is two handed c but the one that I learned in this uh one that I had forgot or maybe I've never seen it before. It's this two hand group. Of course, the patient is induced here. OK? He's induced if he's not awake, OK. And you do a jaws and you press firmly here with this uh part, alter, part of your hand here. Obviously, if you are in this situation, probably the patient is with an oral airway or a nasopharyngeal airway. OK. Uh So in uh in this way, uh it's really difficult for us to have a patient that has an impossible ventilation. Ok. We have to have all the strategy to be able to not only to intubate but to ventilate this patient too. This is an authorized image of a patient that I uh was scheduled for endoscopy uh last week. And I asked permission for taking a picture for him that I said I was going to to lecture to an international delegates and he said, no, you can put my image there is sleeping. I used to put an image that was not mine. This one is mine now. So imagine that I have this was under just a endoscopy with sedation with propofol. But imagine if I had to back mass ventilate this patient. OK. If for some reason, he would desaturate and he desaturate a little bit because he has obstructive sleep apnea, which is some of the difficult uh causes of difficult to face mask ventilation. So all of these we should take care like or elder elderly patients that have uh that don't have any teeth in the mouth. So this is something that makes pretty easy because the structure of the mouth loses you can, you don't have anything to get here to make that, that, that strategies of ventilation. OK. Of course, laryngo spots, ok. Some deformity of chest wall uh and see here in experienced or unskilled operator, we have to train face mask ventilation, we cannot train only intubation, right? And this is the monitor that I most love capnography. Well, this is the highest five the the the the most accurate way of uh evaluating your back mass ventilation is with capnography proof. OK. So we have other classification that's looking chess writing. And this one is more objective. And you say Ricardo, I don't have CN so maybe you already know this initiative. But I used to uh go together with these guys here and they publish it all in editorial in the, in the Anesthesiology magazine uh in December about this project together with my train and this lightbox that they provide a lot of devices monitor. They already had an initiative for providing pulse oximeters for low resource countries, low income countries. So if you need, maybe if you need and you don't have access, maybe um one way is to get in touch with these guys. Uh I've got in touch to, to try to, to, to make uh some uh marketing for them uh in ways in, in places here that uh they don't have access to capnography here in Brazil. By law. Every operating room has to have um capnography. Uh So this is uh something good but in emergency rooms and intensive care, we don't have, I work it in the pandemic COVID-19 pandemic in ICU. And I wasn't used anymore to intubate patients without capnography. And these were critically ill patients. Maybe some of you know, that, that uh critically ill COVID patients, you intubate them and their oxygen saturation goes to 4050 in 30 seconds and they don't go up. So if the patient is fat and you are not even, you're not able to see their chest rising, uh you get like uh and uh yy, you have real uh a lot of doubt if you put the, the tube in the right place. OK. So capnography is something essential. OK? Uh Maybe this ii never lived in this era without laryngo mask airway. OK. So I can't imagine how it's to be to have three options, face mask ventilation, tral tube, and surgical airway. Like I love super Lactic airway. OK? And I think I, I'm, I'm sure that people uh underuse them because they don't know how to use them. Well, OK. Let me see if I can put the video here. So this is the first video I have a channel on profile on Instagram that I put these videos. Let me take out just a sound here and this is a cadaver. OK? This is a cadaver here and you see the, let me put the pointer here and you can see the hep glottis here and this is the tip of laryngo mask airway. I wanna prove you that the, the best way that you can achieve more successfully, the, the, the uh a better seal with uh a laryngo mask airway. It's inserting, it's these inflated. OK. So you see one that is passing this insufflated, that perfectly reaches the place, one that the point, the tip of it itself and it uh takes the, the hypoglottis and the one that is partially, partially insufflated. So this is to prove that we need to, this seems to play to have higher success. And we have all the technique for inserting. This is a video, this is something Portuguese rolled out up there. OK? So this is a, an active patient. I don't remember what he was scheduled for. This is a land I may pursue. So you see that I can do kind of a jaw truist. I put my finger there to make the tip go down. Then I do like a jaw thrust, putting the mandible up and then I insert it pretty easily. I just insert the cuff, get the perometer to see the, the cuff fracture and just uh go through the procedure. OK. So it has a technique is, it has to be trained as well as an intubation. So this is how your la should look like before inserting it. OK? This is the classic one. This is one of my most love. I like the old ones. We are, we are having all the second generation that is the recommended but still we have most of many many first generation. OK. This video, please don't get scared. This is the last strategy. OK. This is surgical airway. This is the recommended by difficult airway society and all the airway societies right now recommend the surgical airway should be the scalp bougie technique. That is the one that is being performed here. OK. This video is on youtube. This is by an emergency doctor. Uh Let me get a pointer here. OK. So this, he, he cannot palpate rightly the tricot membrane. He get the scalpel and he does a longitudinal incision. That is the recommendation for uh cricothyrotomy because now you see that he's not a surgeon, right, by the way, he get the scalpel, uh he's cutting many times to see if he gets deeper in the in the TSU. And now he's going to palpate. OK. Now I found and now he's going to make the transverse incision a little bit more. OK. Now he sure, OK. You see the patient was obstructed there. Is there passing through? He got, he is in the, in the right place. Someone's going to have the brilliant idea of giving him some gauzes right now because it's a bloody mess. OK? Now he's going to get a bougie and he's going to insert the bougie. OK? The patient is probably under Ketamine. I think he's eye open. Ok. And his, in his, in spontaneous ventilation. Mhm. He is going to pass the bougie. He feels resistance. He's probably the carina. And he, he, here in Brazil we have an archit that is cheaper. We have a 660 tube, normal one tracker tube. He's going to insert that uh tracheostomy canal that is better. Uh, it's, it's, it's more suitable but it's more expensive as well. So he's going to insert the bush is the guide for him. Ok. The moviemaker. I think it's kind of nervous with the situation. How is going to connect what ethnography? Ok. And then he's going to connect the ventilation, insufflate the cuff. Nice. This guy performed it. This guy was saved. Ok? So people, every time you're going to manage an airway, please have a plan, share your plan with your team. This way your team knows what you're going to do and they can help you to if you go uh off your plan. If you forgot your plan, if you change your plan, the, the people that are with you, your team, the the nurse are uh your colleague, anesthesiology, emergency doctor resident that is with you would say, but Ricardo, didn't you say that you're going to back mass ventilate the patient if you could not intubate? Ok. Yeah. Yeah, you're, you're right. So we have to have strategy. We have to have plan ABC and we have to have all the equipment readily available. So this is an area I'm going to manage. So I have the plan A. Ok. Back mass. I have my plan B that I'm going to insert the intubation laryngeal mask airway. And I have my plan C that is going to be the direct laryngoscopy. And I have here an oropharyngeal airway that might help my back mass ventilation. I have a partially insufflated b uh a mask that might help to seal my my ventilation there in the, in the face of the patient. Ok. Ok. So um we're going to the end of the presentation. I just would like to discuss this case. This case was brought by an emergency doctor. Ok. This emergency doctor, this is, is was on society for Airway Management forum that this is a forum that uh the doctors bring airway specialist, bring their cases and this is a pretty interested interest one that I thought uh it would be nice to share with you. So it's a 50 year, 52 year old man with a history of head and neck cancer presents to the emergency department with gross hematemesis. He had some radiation treatment in the past but was lost to follow up. He states that two hours ago he started coughing and vomiting up blood upon arrival. He has an M in his back with about 500 cc of blood on it. That's a lot. Uh BP is 8060. Heart rate is 100 40 respiratory rate is 26 and he had no fever. He was alert and extremely anxious. Of course, he's coughing blood. Uh Every assessment was difficult because he was coughing and vomiting up blood. But he had a severe TRS with mouth opening. Limited to only one finger be he was rescued bef uh with two units of blood and the BP improved to 100 and 5 to 7, but he remained extremely tard. The bleeding slowed down considerably but did not stop. We need to manage this airway because they need to solve through an endoscopy. Uh You are that is important. You are not in the uh in the operating theater, you are in a room that uh it's performed just the endoscopies. How would you approach this airway? OK. Work asleep. OK. People going to sleep. Perfect. And now another question would an elective awake, cricothyrotomy under local anesthesia be considered and as an option. So what I would like to bring with to you with this case uh even though we have some techniques like the duo salad technique that you put in uh you put some aspiration in front of the video laryngoscope when you have uh so perfect. Ah me when you have a totally bloody airway uh or a lot of secretions, it's really difficult for for us to use any optical devices, right? So here uh with the limitation of the mouth opening and this bloody airway, maybe the the the and it was done in this case, we have to think of and this, this one could be an elective tracheostomy or an elective awake cricothyrotomy under local anesthesia. Remember we have to make the option to be the safest for the patient. This must be our priority. Uh We tend to think that we should intubate. We tend to think that uh we cannot, it's our ego. You know, I have to intubate. I have to, to, to deal with this case. But sometimes the safest thing to be done is to talk with the ent or if there is no ent maybe the emergency doctor or the uh the the surgeon, the general surgeon, like could you do uh uh a tracheostomy here under local anesthesia? Explain to the patient that this is or might be the safest strategy for him. This is something that I see that people should usually don't think this is our management too. OK? And this might be the safest option to the patient. OK. So uh this is something that's meant for um taught us and I got this Churchill, this is Wisdom Churchill uh brought us N for, for the ones who don't know nap for Research National Project four. And uh you can uh uh you can read it all because it's an amazing study and you can uh you'll be there, you can download the NP seven. That is amazing. Too. Now on per peroperative cardiac arrest but failure to prepare for failure was the most. Uh the was the, the, the the cause of almost every of the complications that were studied in this audit. That was an audit airway audit in the United Kingdom. So I like this uh statement of church. If you fail to prepare, you are preparing to fail, airway management is preparing, ok. Uh It's not only intubating, it's not only introducing the, the, uh, the range mask airway. Ok. So please, uh, don't forget it and make strategies. I'm, uh, uh, I II, I'm available for any question or any doubt or any references that you might need. And II really hope to, to have contributed something in your practice. Thank you. Brilliant. Thank you very much. So, questions everyone. Do you want to put them in the chat? I'm also gonna pop this up. Very, very cheekily Cardo didn't ask me to pop this up, but here's another poll. Um, very, very cheekily, I've popped it up, please. Yeah, perfect. Yeah, please put it because II love, you know, I love to, to, to teach, to talk about this subject. And, uh, I think it's something that, uh, we need to talk more about, about, about awake intubation. Uh, people usually think because we have no videolaryngoscopy think. No, we don't need to know about this anymore. And no, we need, uh, sometimes and many times this is the safest approach to the patient, right? And we need to know uh II II used to say that every management we have to, to have it. It's, it's like uh our army. Uh the more uh like guns you have, the more the types of guns you have, the better you are prepared to face the, the dangers. Ok. So I'm after some questions though, cos I don't really have any cos I'm not medical, but I will ask one question whilst we're waiting for the others to pop up. You had three things on your intubation tray. Does that mean those things would now have to get thrown away or can they be reused or how does that work when you get stuff out to use in surgery? If it's not used? Where does it go? Is that uh ok, because yeah, thi this is, this is something we have here in Brazil and I think it, it's, it's going to finish because many of these devices that are reusable. They are not uh they are not made anymore because they are all disposable. Ok. So that is a problem, right? Because you saw that the slo airway that I opened and I did, I did it ready to use and yes, that, that I can do because I can just, just reuse it like go to the sterile package and reuse it. But if it is a disposable, no, I can't leave it open because I will open. And if I don't use. There is a giant cost, right? So that's perfect your question. This is a reality made from Brazil and not so much from developed countries. We have a lot of devices that are reusable yet because we are um uh underdeveloped countries and uh the industry they did, they take this to, to Brazil because they know Brazil doesn't buy so much disposal of things. But we have some uh accreditation in those uh accreditation companies here that they uh make it obligatory for the hospitals to have all the equipment disposable. So we have all and I think it's safer. Ok, I II think it's really, it, it's not something you can say. Oh, but what about sustainability? And I say what about safety? Uh OK, it's difficult to equilibrate. So we have to, we have to, to, to be uh uh we have to have the balance, right. Uh We can't spend so much but we have to pri prior the safety, we cannot contaminate our patient. That's why uh many of the things are now disposable because we know uh it might have some cases of cross contamination. Two brilliant. Yeah, it is just that, isn't it? There's a lot of talk about sustainability and you know, and it's just like, how do you do sustainability as well as hygiene and safety and, and you know, how does that marry together? Sorry, my cats just turned up in my office. Uh So if you can hear him. Yeah. No. Leave him there. II put my, I put my, my little one, my dog, it's out here so she might be crazy. Oh, I have two dogs behind me too. There's one just there. Exactly. Sorry. Everyone, hardly professional there. But anyway, anyone got any questions. I think everyone really appreciated. It was a big teaching session. So I think what you've taught them, they're incredibly grateful for, you can see here. Um If no one has any questions, it does also look like you might be back to do awake intubation as well. By the looks of things nobody said they already know about it. So it looks like it looks like we're getting you back again. Ricardo, if that's OK. Um Yeah. So Nicholas said uh no questions but uh especially the oh my days apneic oxygenation. Is that right? So, yeah. Yeah. Yeah, you're, well, that's perfect. Oh We have a chance of doing that one. Yeah, this is, yeah. Yeah. This is part of is like a huge learning. Thank you. You see, I'm sorry, English. We are really bad with language. I have to say we are just English is enough, right? We should learn other languages, right? But anyway, yeah. Yeah. Yeah. But, but it's good that, that, that, that now I uh I, I'm practicing more of my English so I can expand a little bit my vocabulary. Sometimes I like uh get a little bit uh uh difficult with the words. Yeah, it's fine. You, you're speaking English far better than I can speak Portuguese. Let me put it that way. So, what I'm gonna do then I think, I don't think there's any questions coming up. So everyone, your feedback form will be in your inbox, please fill it out. There's a section in there as well. Uh, most of it's about Ricardo, what you thought of is teaching, er, and that kind of thing and I'm gonna pass this all on to him if there's some teaching subjects that you want specifically within his area of expertise, pop it in there in the feedback form too and we can, I can let him know. All right. Um, we just want everyone to, to learn more and we want to be able to teach you what you want to learn, not what we think you might want to learn if that makes sense. Anyway. Take care everyone. Hopefully we'll see you on the next me, uh, education session. Ok. Take care.