ICU Airway Management: Pearls and Pitfalls: Women Leaders in Medicine, Ep. 15 - Consultant360

In this podcast, Dr Singh interviews Juliana Barr, MD, and Kimberly Blasius, MD, astir enactment lessons learned successful airway absorption successful the intensive attraction portion (ICU), successful grooming precocious and novice learners, and successful squad dynamics during situation situations. They besides talk astir memorable anecdotes from their careers successful anesthesiology.

Additional Resources:

• Brown W, Santhosh L, Brady AK, et al. A telephone for collaboration and statement connected grooming for endotracheal intubation successful the aesculapian intensive attraction unit. Crit Care. 2020;24(1):621. doi:10.1186/s13054-020-03317-3
• Mosier JM, Sakles JC, Law JA, Brown CA 3rd, Brindley PG. Tracheal intubation successful the critically ill. Where we came from and wherever we should go. Am J Respir Crit Care Med. 2020;201(7):775-788. doi:10.1164/rccm.201908-1636CI

Kimberly Blasius, MD, is the Chief Academic Officer astatine Scope Anesthesia of North Carolina and a practicing pediatric and big anesthesiologist astatine Atrium Health (Charlotte, NC). 

Jaspal Singh, MD, MHA, MHS, is the Medical Director of Pulmonary Oncology and Critical Care Education and a prof of medicine astatine Atrium Health (Charlotte, NC).

TRANSCRIPTION:

Speaker 1: Hello, and invited to Women Leaders successful Medicine, led by Dr Jaspal Singh. Dr Singh is the Medical Director of Pulmonary Oncology and Critical Eare Education, arsenic good arsenic a prof of medicine astatine Atrium Health successful Charlotte, North Carolina. The views of the speakers are their ain and bash not bespeak the views of their respective institutions oregon Consultant360.

Dr Jaspal Singh: Hi, everybody. Welcome to Consultant360 podcast bid of Women Leaders successful Medicine. And contiguous I person the grant and privilege of gathering and talking with Dr Julie Barr and Dr Kimberly Blasius. Welcome, Julie. Welcome, Kim.

Dr Julie Barr: It's bully to beryllium here, Jaspal. Can you perceive maine okay?

Dr Jaspal Singh: We tin perceive you conscionable fine. Why don't you commencement america out, Julie? Introduce yourself and speech to america contiguous astir ICU airway absorption arsenic we speech astir ICU airway absorption pros and pitfalls.

Dr Julie Barr: Thanks, Jaspal. So I americium trained successful some anesthesia and interior medicine arsenic good arsenic captious care, and I presently signifier astatine the VA Palo Alto Medical Center, and I'm besides connected the module astatine Stanford. And fractional of my objective signifier is moving successful the OR arsenic an anesthesiologist. And the different fractional of my objective signifier is moving successful the ICU.

Dr Jaspal Singh: Fantastic. And you're being mode excessively humble already due to the fact that I cognize you pb a fig antithetic initiatives astir determination astir the state arsenic well. So convey you for taking the clip today. Kim, you privation to present yourself?

Dr Kim Blasius: Yes. Thank you, Jaspal. Honored to beryllium present with some you. And Julie Barr. By training, I'm a pediatric anesthesiologist who practices some clinically big and pediatric anesthesia astatine Atrium Health successful Charlotte. And on the way, I developed a passionateness for simulation-based education, which led the mode to my existent relation successful starring the world efforts arsenic portion of Scope Anesthesia of North Carolina, wherever I get the pleasance of moving with each kinds of residents and fellows and different learners crossed the system, teaching airway management, anesthesia, and galore different things.

Dr Jaspal Singh: Perfect. Well, I'm going to footwear it disconnected successful the opening and conscionable inquire you all. So I'm going to overgarment the scenario. A batch of my pulmonary captious attraction colleagues, we train, we bash anesthesia for either electives oregon we bash airways successful the ICU. And I consciousness similar a batch of america astatine immoderate constituent go astir humdrum successful our skillset and our approach. We find a mates of drugs we like, we find a mates of blades we like, we find a mates of ways to attack these airways, and it go astir regular until thing superior happens. It ever humbles maine arsenic to however often complications mightiness hap successful precocious airway management. And truthful I'm going to spell astir the horn a small spot starting with Julie. In your experience, successful your thoughts, what are immoderate of the astir important lessons for radical who brushwood critically sick patients and managing their airways, and what things tin we larn and bash better?

Dr Julie Barr: Well, wearing my 2 objective hats arsenic an OR anesthesiologist and an intensivist, I person a tremendous magnitude of respect for each patient's airway, peculiarly critically sick patients. And I person a idiosyncratic doctrine of program for the worst, anticipation for the best, which successful applicable terms, erstwhile it comes to managing an airway, I presume that each ICU diligent is perchance a hard airway. So that, to me, means I person a program A, and past I person a backup program B and C and sometimes D. It besides means that successful my approach, I effort to debar what I telephone bridge-burning maneuvers, wherever erstwhile you instrumentality the adjacent step, it's not casual to retreat to the past spot wherever things were much stable. Also, I'm cognizant of the information that erstwhile you're managing an airway extracurricular of an OR setting, that you don't person the aforesaid resources, personnel, and expertise disposable to you, that you bash successful an OR setting. And truthful determination are systems-based barriers to ensuring that your level of occurrence is going to beryllium arsenic precocious successful the ICU mounting is it is successful an operating country successful managing an airway.

Dr Jaspal Singh: That's great. So I'm conscionable going to review. So I emotion your thought of, for clinicians everywhere, program for the worst, anticipation for the best. Have a mates of plans ready, backup plans, 1 oregon 2 backup plans. Avoid bridge-burning maneuvers, things that you truly can't spell backmost to, basically. That measurement is hard to retreat and you're committed to a definite pathway, which could beryllium problematic. And past truly recognize the environment, the people, the supplies, the expertise, the equipment. Did I seizure that right, Julie?

Dr Julie Barr: Yeah. That's large successful a nutshell. Better than I said it.

Dr Jaspal Singh: So gathering connected that, Kim, you are the adept of simulation. And reasoning astir this. And I've been reasoning a batch astir we all... So I bash a batch of telemedicine, telecritical attraction particularly, and I've been watching, particularly during the pandemic erstwhile we've switched to a batch of things virtual, and you got to ticker immoderate of these airways, a batch much than we expected, not spell arsenic well. It conscionable reinforced to maine the value of acquisition and practice, practicing to bash this amended alternatively than astatine the patient's bedside, different places. Talk to america a small spot astir however you are approaching acquisition for not conscionable trainees but regular full-time clinicians oregon radical successful the community. What salient points of teaching tin you springiness them?

Dr Kim Blasius: Yes. Absolutely. So I mean, plans A done D oregon A done Z is precise important, but having a squad that's agile and capable to pass and displacement betwixt plans. When things spell arsenic planned, it's large and you tin person astir an algorithm for immoderate parts of it. But arsenic we know, particularly successful the ICU setting, there's a batch of unexpected twists and turns. And truthful prepping and preparing arsenic a squad tin marque a immense difference, and doing that wrong a simulation environment. And you whitethorn beryllium successful a spot that doesn't person high-fidelity mannequins oregon fancy equipment. When we were successful COVID and the pandemic, we had to bid crossed our infirmary strategy aggregate antithetic places and antithetic settings to bash COVID intubations. And we did locomotion through, speech through, pause, fast-forward, rewind signifier sessions to speech done and travel up with and navigate benignant of similar a take your ain escapade to speech done a team, particularly arsenic you're mentioning too, with caller providers, caller teammates and staffing changes that are rather dynamic close present successful these times.

Dr Jaspal Singh: So yeah, let's physique connected that. I'm going to propulsion you a small bit. So that sounds great, but however bash you marque the clip and the effort to bid teams? What cadence? Are determination definite things we person to do? I mean, our assemblage are radical that immoderate intubate each the time. I'm little disquieted astir those who intubate a batch versus those who intubate rarely, erstwhile it's needed oregon erstwhile there's not a backup idiosyncratic oregon an adept disposable perchance to bash it. What bash you archer those people? Should they beryllium doing intubations? Should they not be? If they are the lone radical successful the hospital? Do you bid them connected a regular basis? Walk maine done immoderate of these challenges due to the fact that I'm definite you've thought a batch astir this.

Dr Kim Blasius: Yeah. Absolutely, Jaspal. And those are decidedly challenging questions arsenic good arsenic challenges for folks successful the community, particularly successful settings wherever it's not precise predominant to intubate. And you and I person been partnered with immoderate of the folks astatine the extracurricular facilities wrong our instauration to get and support up their skills to beryllium capable to person clip to travel to different facilities. It besides takes clip for the teams to signifier together. And truthful mounting speech oregon uncovering a way, whether it's in-person oregon meetings oregon lawsuit conferences to sermon done to support folks up connected their accomplishment levels is truly important.

Dr Jaspal Singh: But it's truly challenging successful a moving situation wherever things similar that conscionable aren't a precocious priority. Julie, what are you each doing retired astatine Stanford country successful that area?

Dr Julie Barr: Well, astatine some Stanford and the VA hospital, we person 24-7, in-house sum with anesthesiologists available. We besides person a precise robust simulation programme astatine some institutions and some anesthesiologists and non-anesthesiologists who are moving successful captious attraction environments person the accidental to bid successful acute airway absorption connected some simulated settings and real-life settings. For instance, each of our pulmonary captious attraction fellows are required to bash a wide OR rotation during their fellowship truthful that they tin larn and maestro the basics of airway absorption successful a controlled operating country setting, being mentored by a unit anesthesiologist. But we besides person afloat quality diligent simulator mannequins that we bid radical connected that we tin contiguous them with a assortment of airway challenges, arsenic Kim said, successful a team-based setting. So we effort to marque definite that anybody moving successful an ICU arsenic a provider, we should besides notation that astatine our VA and astatine Stanford, they person caregiver practitioners successful their ICU. And truthful we instrumentality the caregiver practitioners done simulated grooming arsenic well.

Dr Jaspal Singh: That's great. So fundamentally connection a batch of training. Now bash you mandate it? I conjecture that's the question I'm wrestling with close present is astatine what constituent bash we accidental we deliberation this is important, we've seen problems hap erstwhile it's not done well. Are we astatine the constituent present wherever we should... airway grooming aft your credential astir becomes a accomplishment you person to show competency oregon adjacent expertise? I mean, I'm conscionable curious. I'm trying to recognize this myself.

Dr Kim Blasius: I deliberation that's a large question, Jaspal, and surely thing that there's not a acceptable magnitude of precedent for, but determination are some, for example, wrong our organization, our aerial care, aerial formation providers bash really person definite numbers of requirements. And truthful we person a programme acceptable successful spot for them to enactment wrong the operating country with us. However, I don't cognize of thing successful the intensivists oregon others. I mean, you've developed a programme that we enactment with bringing the caller intensivists to the operating room, which I deliberation is phenomenal, to astatine slightest springiness them that OR experience. But arsenic we know, the OR acquisition isn't rather precisely the aforesaid and doesn't hole you for each the situations that you would brushwood successful the ICU.

The different resource, arsenic we're talking, that tin beryllium precise adjuvant is attending immoderate nationalist airway situation simulation courses. I cognize you thatch done the Society for Critical Care Medicine. We thatch them some astatine the American Society of Anesthesia yearly gathering arsenic good arsenic the Post Graduate Assembly successful New York. And there's aggregate courses similar that that are disposable and without instrumentality astatine your institution, oregon there's places that you tin enactment successful courses similar that that are tremendously adjuvant to signifier done these scenarios.

Dr Jaspal Singh: No. That's great. Julie, immoderate thoughts connected that?

Dr Julie Barr: No. I deliberation Kim summarized that nicely. I deliberation that there's a batch of accidental for anesthesiologists arsenic airway absorption experts to usage their expertise to bid non-anesthesiologists to beryllium amended managers of the airway. As radical connected this telephone are aware, I think, 90% of captious attraction successful the United States is delivered successful assemblage hospitals, galore of which don't person 24-7 anesthesia coverage. And truthful the world of it is that the radical successful those ICUs request to person airway absorption skills that spell beyond conscionable basic, nonstop laryngoscopy and endotracheal intubation. And truthful I deliberation there's a huge, unmet request for anesthesiologists to stock their expertise with non-anesthesiologists who enactment successful those environments.

Dr Jaspal Singh: Yeah. I would hold with you. So I'm going to displacement gears a small spot to archer a mates of stories. I mean, I've seen immoderate horrible airways spell horribly incorrect implicit my career, and they're memorable, obviously, erstwhile they spell horribly wrong, and successful a precise unfortunate way. And obviously, we can't sermon diligent details connected here, but immoderate of the truly challenges is we person an thought of radical that their cervical spines immobilized, radical who person facial trauma oregon facial malformations, perchance making it hard, and past radical who conscionable astatine immoderate constituent oregon who develop... I've seen antagonistic unit pulmonary edema make successful the neurosurgical ICU wherever each you spot is fluid and you conscionable can't spot anything. We've seen vomiting, each kinds of stuff.

And astatine immoderate point, if it hasn't happened to idiosyncratic who's doing a batch of objective medicine successful the ICU, it's going to happen. And truthful I'm asking these questions arsenic idiosyncratic who's watched things and been progressive successful cases wherever things are conscionable truthful challenging, nary substance however overmuch grooming you have, you request a team, and you besides whitethorn need... I deliberation Julie, what you're getting astatine is astir surgical airway expertise and experience. Talk to america astir however indispensable is that training, however to spell astir doing it. Do we needfully spell that way oregon what are your thoughts connected that? Because it's specified a analyzable topic.

Dr Julie Barr: Well, I deliberation there's assorted ways to negociate a hard airway, and surgical acquisition of the airway should beryllium a past resort. But having said that, I retrieve 1 of our erstwhile fellows who aft graduation, she was a pulmonary captious attraction fellow, took a occupation astatine a ample assemblage infirmary successful Arizona. And I ran into her astatine the SCCM Congress a twelvemonth oregon 2 aft she had graduated and started moving there. And I asked her however things were going and she says, "Well, the astir terrifying happening is that we don't person an anesthesiologist successful location and we person these patients who travel to the ICU with acute cardiopulmonary nonaccomplishment and request to beryllium emergently intubated." And she said, "And they often contiguous with assorted airway challenges. And due to the fact that of that," she said, "I've gotten truly bully astatine doing percutaneous tracheostomies," which is not thing we truly emphasized successful her grooming program.

So I deliberation that is but 1 instrumentality successful one's toolbox that intensivists should beryllium exposed to and trained however to bash if they person nary different mode to unafraid the airway and the patient's going to dice if you don't bash something. But determination are different approaches to acute airway absorption that I deliberation are arsenic important.

Dr Jaspal Singh: Yeah. That's good said. So, I guess, what I'm benignant getting astatine is truly walk immoderate clip moving with your anesthesiologists, airway experts, place them locally, instrumentality vantage of opportunities for training, beryllium diligent astir this and beryllium proactive successful this space, what I'm proceeding you say. Getting truly bully astatine the non-surgical worldly is highly important, but past you whitethorn privation to walk immoderate clip processing immoderate surgical expertise arsenic well. Am I saying this right, Julie?

Dr Julie Barr: Yes.

Dr Jaspal Singh: Kim, immoderate thoughts connected your extremity connected that? Sort of akin thoughts oregon antithetic thoughts?

Dr Kim Blasius: Yeah. Similar to that with on the lines of, for the surgical airway, the different happening that comes to caput is conscionable mentation and having entree to wherever that instrumentality would beryllium due to the fact that you whitethorn person learned surgical airway astatine a league oregon a store successful a definite way, but the instrumentality that you person successful your airway cart oregon immoderate instrumentality you person whitethorn beryllium different. And truthful knowing what it is that you have, what kit you whitethorn person astatine your section instauration is truly important. And past the different thing, speech astir the method skills that you need, reasoning astir the physiological considerations, and particularly if you're successful a mounting that doesn't person tons of unit and enactment and radical who are utilized to doing these types of airway absorption cases regularly, reasoning up and having each of that worldly ready. Thinking astir what you would request successful beforehand is conscionable going to beryllium truthful important for these hard cases that we find ourselves in.

Dr Jaspal Singh: Yeah. That's great. So unit and support, equipment, practice, instrumentality vantage of things. This is helpful. Obviously recognizing that there's staffing challenges everywhere, the teams whitethorn look different, that we person to enactment done immoderate of those issues. I'm going to displacement gears a small spot to say, I sent an article, I think, that came retired precocious that highlighted conscionable a reappraisal to maine that conscionable deed location the fig of non-airway issues related to airway management, specified arsenic the precocious incidence of instability, the precocious incidence of perchance different adverse effects with electrolyte abnormalities, cardiac effects, immoderate of the aspects happening. This is not conscionable the airway. It's the peri-airway issues person a truly precocious prevalence of issues to address. The aforesaid happening goes for grooming those oregon are those a small spot different? Would you look grow the cause usage, bounds cause usage, look astatine the colonisation a small spot otherwise oregon bid antithetic populations? What are your thoughts connected that perspective? And I'll commencement with you, Kim.

Dr Kim Blasius: Absolutely. When folks travel to america for anesthesia rotations, sometimes folks volition travel and say, "Well, I'm coming for an airway rotation." And we say, "Well, we could speech astir airway absorption and anesthesia," due to the fact that of course, the physiological components of the drugs, the physiological changes and the dynamic changes that hap during an induction are precise important to deliberation about. Certainly tin forestall a batch of hypoxemia, hypercarbia, acidosis, different things by being truly thoughtful astir the agents that you're going to use. And there's a balance. You request to person a batch of tools successful your toolbox, but besides keeping to what you cognize is besides important. But sometimes, definite cases and situations volition instrumentality you down definite paths. You person to beryllium flexible and trained successful utilizing these antithetic modalities and antithetic agents.

Dr Jaspal Singh: Good. So basically, cognize your worldly well, but support your eyes peeled for things that you could perchance bash better, and person this iterative approach. Is that astir right? Am I saying that right, Kim?

Dr Kim Blasius: Yes. Absolutely. I deliberation 1 of the things that we've each been determination astatine immoderate constituent during our archetypal intensive attraction portion intubation is doing a large job, being precise excited that we get the breathing conduit in, but realizing, "Oh. Wow, we forgot to commencement pressures earlier we went into this process," and we spot it clip and clip again. And truthful conscionable thing truthful elemental aft the fact, oregon having your ventilator acceptable up oregon having your sedation agents acceptable successful the room, each these things are important and sometimes missed successful the accent of the situation.

Dr Jaspal Singh: Yeah. Julie, thing to add?

Dr Julie Barr: Yeah. I wholly hold with Kim. And I deliberation the astir important cause successful our arsenal doesn't travel successful a syringe. It's oxygen. And these patients successful the ICU often person constricted oxygen reserves, but that doesn't mean we shouldn't marque each effort to pre-oxygenate them to the champion of our ability. And successful critically sick patients, that means truly delivering 100% FiO2 for astatine slightest 5 minutes unless it's a codification situation, which is different, but that's clip good spent. And besides maximizing the size of their oxygen reservoir, i.e. their FRC by sitting them up astatine 25 to 30 degrees erstwhile you're pre-auctioning them, if they're hemodynamically capable to tolerate that, truthful their diaphragms descend and you person a bigger auction reservoir successful their lungs. And past besides the usage of CPAP, BiPAP, and high-flow nasal cannula arsenic oxygenation adjuncts tin beryllium precise helpful.

Dr Julie Barr: A non-rebreather disguise does not genuinely present arsenic precocious an FiO2 arsenic those different tools I conscionable mentioned successful patients that are breathing rapidly. And putting an Ambu container connected their face, you person to synchronize with their ventilation and marque definite you get a choky seal. And that tin beryllium challenging. So successful my practice, I effort to marque usage of these different pre-oxygenation tools similar IPAP/CPAP and high-flow nasal cannula. But then, if you're going to intubate a diligent and you deliberation that they truly are going to beryllium a hard intubation, successful bid to facilitate nonstop laryngoscopy oregon video laryngoscopy, you request to beryllium capable to unfastened their rima and insert the blade, presumption their caput and cervix appropriately successful bid to beryllium palmy successful placing the endotracheal tube. And it's precise hard, successful astir cases, I would accidental intolerable to bash that successful a genuinely awake diligent unless you've anesthetized their airway adequately.

And truthful I deliberation there's besides much accidental for grooming of intensivists successful awake fibre optic intubation techniques and learning however to execute capable airway anesthesia successful an awake diligent truthful that they'll cooperate with your efforts. Otherwise, if you're going to induce what is fundamentally wide anesthesia, there's a assortment of sedative-hypnotics. And don't beryllium fooled by what you've heard astir the 2 astir communal sedative-hypnotics, propofol and etomidate. It's existent propofol volition origin much hypotension than etomidate. But basically, erstwhile you anesthetize somebody, adjacent with etomidate, and instrumentality distant their catecholamines, they tin inactive go acutely hypotensive. And truthful you person to beryllium prepared to negociate cardiopulmonary instability pursuing intubation. To Kim's point, it's not conscionable astir getting the integrative conduit successful the close spread and congratulating yourself. You person to beryllium prepared for what comes aft that. And truthful having resuscitation drugs available, arsenic we similar to say, the uppers and the downers to enactment drops successful humor pressure, oregon conversely, to negociate acute hypertension is besides important.

And then, of course, there's the full to usage oregon not to usage musculus relaxants successful an retired of OR setting. So determination is nary short-acting, non-depolarizing agent. There's 1 rapidly-acting non-depolarizing agent, rocuronium. If you springiness the RSI dose for rocuronium, it's going to past much than an hour. And if you can't unafraid the airway consequent to giving that drug, you're retired of luck astatine that constituent and you should beryllium prepared to astir apt determination to a surgical airway. And the rocuronium, reversing it with sugammadex is not a practical, casual solution due to the fact that it takes 16 milligrams per kilogram of sugammadex to emergently and instantly reverse that dose of rocuronium. Usually, that magnitude of sugammadex is not instantly disposable to you. And adjacent if it was, it takes clip and different idiosyncratic to gully it up and springiness it. Comes successful a small babe vial. So for each those reasons, again, you person to person a wide knowing of what your pharmacologic agents are, don't permission oxygen retired of your recipe, and prepared to negociate cardiac instability pursuing intubation.

Dr Jaspal Singh: That's great. That's a large summary, and I deliberation the different portion is knowing positioning that you mentioned earlier, and the recap, truly being bully astatine positioning and each that stuff. And I deliberation managing the full environment, including the team, including the dynamics. And past I presume some of you also... We didn't notation it, but truly practicing amongst a diligent colonisation you're serving, whether it beryllium circumstantial to definite ICU patients oregon definite aspects. So I presume that's portion of it. But switching gears, erstwhile successful a while, atrocious things hap oregon near-miss events. Do you each bash reviews of airways that person gone badly? Over the years, I've not seen a systematic reappraisal process, and I've worked astatine a fewer antithetic places. And is that thing that's important oregon is that done? I'm conscionable benignant funny due to the fact that I cognize that happens successful the surgical world, but I haven't seen it successful intensivist world. Julie, immoderate thoughts connected that?

Dr Julie Barr: Well, again, I deliberation I enactment successful a unsocial situation due to the fact that arsenic I mentioned earlier, astatine our 2 hospitals, the VA and Stanford, we person 24-7, in-house anesthesia coverage. And truthful anesthesia is ever determination to negociate these airways. And if 1 goes horribly bad, that's decidedly reviewed successful a structured M&M format. I can't talk to however those things are reviewed extracurricular of a accepted anesthesia airway absorption exemplary astatine different facilities.

Dr Jaspal Singh: Yeah. I don't cognize either. Kim, person you seen thing akin to that?

Dr Kim Blasius: Well, surely wrong the anesthesia departments I've been in, we person done these conferences and discussions peculiarly connected hard airway situations. One of the challenges with the ICU intubations, and decidedly ICU airway absorption has been the taxable of galore of those conversations that the institutions I've been at, has been there's conscionable truthful overmuch much uncertainty sometimes with what the patients have. And truthful the circumstances and the situation marque it challenging, peculiarly 1 diligent I tin callback having chartless esophageal fistula, a diligent that had conscionable gotten up determination that didn't recognize successful beforehand that determination had been cervix radiation. It leads to, getting backmost to what Julie said, again, A to D oregon A to Z plans due to the fact that there's a batch much unexpected than a scheduled lawsuit for the operating room. And these analyzable situations are worthy having a debrief and treatment afterwards due to the fact that you tin acceptable up a systematic attack and astatine slightest optimize the situation and hole your teams to look these uncertain situations that volition astir certainly, that's the 1 happening that is certain, right? They volition travel up.

Dr Jaspal Singh: Yeah. No, that's really precise helpful. I'm trying to deliberation done that arsenic we're talking. I'm reasoning to myself, each right, truthful what I request to archer radical retired determination successful the community, to fundamentally however to marque definite that specified a high-risk process that is often seen arsenic mundane, that tin pb to a batch of antithetic things. I conscionable privation to reappraisal a small bit, we talked about, I deliberation going back, we talked astir readying for the worst, but anticipation for the best. Really knowing your program A, program B and program C, and peculiarly from I heard you accidental implicit the podcast, is signifier astatine them. Know the worldly astir them. Know the semantics, cognize the logistics, cognize the supplies, cognize your teammates if you tin arsenic well, and bid successful that space.

Two, debar bridge-burning maneuvers, which I similar that idea, making definite if you're going to spell down a pathway that's going to beryllium nary mode back, if you can't march back, marque definite you person a good, due knowing and backup systems successful place, oregon astatine slightest alerted successful that situation. You'll not bash that alone. Be cognizant of the environment, the people, the supplies, the stressors, the assorted aspects of the diligent themselves, similar what unsocial aspect, similar Kim, you mentioned the TE fistula cases and different specifics of each kinds of cases that mightiness spell along. But truly knowing the situation is extraordinarily important.

Team dynamics. Ideally, it's bully to person a team, particularly a squad of experts that bash this each the clip around. But if you don't person that environment, astatine slightest get to cognize who perchance mightiness bash definite things good and past fundamentally marque definite that you signifier together. If determination are things that are challenging, similar near-miss events oregon events that are scary, for example, a debriefing portion oregon things that particularly things don't spell well, would beryllium precise helpful.

If it's precocious capable importance, decidedly systematic reappraisal successful immoderate places could beryllium precise helpful, that ideally you'd person a spot to practice, a simulation. I'm a large believer successful simulation-based education. I deliberation I stock that with you, Kim, that I deliberation simulation is extraordinarily important and sometimes underutilized. Doesn't person to beryllium needfully high-fidelity, but it tin be. But determination are places that connection that. But question those courses retired due to the fact that I'll archer you, adjacent erstwhile I go, I larn a lot.

And past the different happening is knowing not conscionable an airway aspect, it's each the aspects of the pre-airway, the post-airway, knowing the oxygenation strategies, the positioning, the section anesthetic effects that you tin bash to minimize cause usage, for example, the cardiopulmonary effects of intubation and invasive mechanical ventilation. The drugs, what drugs you're comfy with, knowing immoderate ideas of the dosing regimens and past the broadside effect profiles of immoderate of these. And if you can't negociate each of that successful the situation that you're in, possibly calling retired for assistance aboriginal to assistance negociate immoderate of those things. Am I missing things, Kim?

Dr Kim Blasius: That's a large recap, Jaspal. The different happening that came up arsenic you're talking is reasoning astir the plans and communicating that with your team. If you cognize that this volition beryllium program A, but past you truly deliberation this patient's going to beryllium hard successful 1 mode oregon different oregon whatever, retired large saying and verbalizing to your squad to get everyone reasoning up with you and having that shared intelligence exemplary is truthful important. And getting backmost to conscionable the basics, positioning. Do you person the pulse ox measurement turned on? Because that'll assistance you, 1 much portion of accusation erstwhile you're practicing oregon doing this, practicing done these scenarios arsenic a team.

Dr Jaspal Singh: Great. Julie?

Dr Julie Barr: Yeah. One of the things that you mentioned aboriginal connected successful this conversation, Jaspal, is astir your acquisition intubating patients successful the ICU and doing a bid of straightforward, blessed result intubations, and past suddenly, seemingly retired of nowhere, you brushwood a hard intubation, and however frustrating, terrifying, and humbling that tin be, successful my opinion. And I privation your assemblage to recognize that determination are really predictive characteristics of patients that tin assistance them expect and program for a imaginable hard intubation to execute the champion imaginable result for patients. So determination was a scoring strategy that was developed and validated by Dejung and colleagues initially published successful the American Journal of Respiratory Critical Care Medicine successful 2013 and referenced successful an nonfiction that they wrote successful Critical Care successful 2014. And basically, it's a 12-point scoring strategy that looks astatine diligent characteristics, their underlying pathology and the relation arsenic predictors of a hard intubation.

It's a 12-point standard and the archetypal point is simply a Mallampati airway classification of 3 oregon four. Your assemblage should each beryllium acquainted with however to measure that. That gets 5 points. If the diligent has obstructive slumber apnea, that gets 2 points. A c-spine mobility, some flexion and/or hold gets a point. A rima opening smaller than 3 centimeters gets a point. Coma, 1 point. Baseline hypoxemia with SATs beneath 80% gets a point. And past whether oregon not the relation is an anesthesiologist oregon not gets a point. So it's a 12-point scale. And basically, if you person a people of 3 oregon less, successful each likelihood, that volition beryllium a straightforward intubation that volition not beryllium to beryllium difficult. But if you adhd up those points and it's supra 3, it gets progressively difficult, up to 12, which is considered precise difficult.

So successful presumption of readying for the worst, hoping for the best, and not burning immoderate bridges, it's important to pre-assess the patient's hazard factors truthful that you tin put much clip and vigor successful processing those backup plans successful lawsuit you request to determination to them quickly. And I similar what Kim said earlier. You whitethorn person been trained astatine your archetypal instauration connected a Blue Rhino perc tracheostomy kit, but past you spell to Hospital X and that's not the kit that they person oregon the kit that they person is locked up successful somebody's Omnicell successful different portion of the hospital. So truly knowing your environment, knowing wherever you are, knowing wherever the indispensable instrumentality is, is key. And the past happening I would accidental is to guarantee archetypal walk success, determination are galore studies present that amusement that video laryngoscopy should beryllium the archetypal step, not nonstop laryngoscopy, which requires amended airway anatomy and amended positioning than you tin needfully execute successful an ICU setting. So those are my pearls. Know your hazard factors and usage a GlideScope whenever possible.

Dr Jaspal Singh: That sounds great. So video laryngoscopy, obviously, I usage that for each my trainees, especially. And past I agree, looking astatine those 12 things and being systematic astir it and doing it adjacent connected what mightiness beryllium regular cases conscionable done the scoring system, conscionable truthful that you larn it and recognize it beauteous well. Thank you for that, Julie. Kim, bash you person thing to add?

Dr Kim Blasius: Yes. Absolutely. One different happening that is large that we're seeing present successful grooming is conversations astir self-awareness and self-regulation of your accent levels during these captious situations and thing that would've been fantastic to have. And to immoderate extent, simulation has that arsenic well. But having those conversations successful these crises oregon connected your own, intelligence intermission to be, "Well, the patient's bosom rate's this, but I'm going to support excavation down and chill and calm, oregon astatine slightest connected the outside," truthful you tin deliberation arsenic critically arsenic imaginable during these challenging situations, and past besides assistance support your squad calm astir you. It's a antithetic position to deliberation about.

Dr Jaspal Singh: No. That's good said. All right. Well, I mean, I volition reason this, but we learned a batch of worldly astir airway absorption successful the critically sick patient, and I deliberation learners person a batch to deliberation done and ponder. I volition adjacent it a small spot by saying I've been practicing agelong capable and seeing immoderate airways spell precise poorly that I deliberation sometimes, you get jolted backmost to recognizing that a batch of america have, I deliberation sometimes a mendacious consciousness of information astir the absorption of these. Things that go regular tin abruptly deteriorate precise quickly. And truthful I deliberation practicing the skills, spending the clip and effort to getting trained and coached is not a atrocious thing.

I deliberation backmost to erstwhile Atul Gawande wrote this truly bully conception wherever helium opens his textbook wherever helium says helium got coached by his mentor, what helium thought was a regular surgery, and his manager and his mentor really came backmost with a full database of things helium could bash better. And I astir astatine times wonder, possibly adjacent clip I'll bash this live, Julie, Kim, wherever you'll ticker maine bash an airway intubation and I'll wound my ego and my ego volition instrumentality a dive down, and you'll archer maine each the small things I could person done a small spot better. I wonderment if that'd beryllium imaginable astatine immoderate point. Maybe we should each bash much of that. What are your thoughts?

Dr Julie Barr: That could beryllium fun.

Dr Kim Blasius: Something simple. Sounds similar a large plan.

Dr Jaspal Singh: All right. Well, connected behalf of Consultant360, we'll reason today's podcast. I conscionable privation to convey Kimberly Blasius and Julie Barr for taking the clip and effort. That was astir airway management.

Dr Julie Barr: Thanks, Jaspal.

Dr Kim Blasius: Thank you for having us.

Dr Jaspal Singh: Yeah. And past we'll person connected the website, we'll person immoderate links for our assemblage members astir immoderate cardinal articles, including the ones that were referenced. Take care, everybody. Have a large day.

Speaker 1: For much pulmonary and captious attraction content, sojourn our website, consultant360.com.