Search

Tracheal extubation is a high-risk intervention that should be managed strategically by anesthesia providers. The outcomes of a difficult airway extubation can be catastrophic, ranging from significant morbidity to mortality. The purpose of this project was to increase the awareness of anesthesia providers managing difficult airway extubation and assess the willingness to utilize the difficult airway extubation guidelines to guide care. The Difficult Airway Society and the American Society of Anesthesiologists have developed extubation guidelines to mitigate peri-operative complications that can arise during tracheal extubation. These guidelines have been developed as a resource for tracheal extubation and emergence. For this project, an educational presentation was used to increase provider awareness and utilization of difficult airways. Additionally, a cognitive aid of the difficult airway extubation guidelines was developed as a resource for anesthesia providers. A quantitative pre- and post-intervention design was used to evaluate this quality improvement project. When evaluating this quality improvement (QI) project, the data showed a statistical significance for an increase in awareness of risk factors that impact difficult airway management following the educational presentation. Data also supported increasing provider willingness to utilize the difficult airway extubation guidelines when comparing the pre- and post-survey assessment. This QI project was effective in increasing provider awareness and willingness to utilize the difficult airway extubation guidelines. This project created value by increasing awareness and willingness to utilize the difficult airway extubation guidelines thereby prioritizing the highest standard of care for airway extubation management.

BackgroundDifficult facemask ventilation is perilous in children whose tracheas are difficult to intubate. We hypothesised that certain physical characteristics and anaesthetic factors are associated with difficult mask ventilation in paediatric patients who also had difficult tracheal intubation.MethodsWe queried a multicentre registry for children who experienced "difficult" or "impossible" facemask ventilation. Patient and case factors known before mask ventilation attempt were included for consideration in this regularised multivariable regression analysis. Incidence of complications, and frequency and efficacy of rescue placement of a supraglottic airway device were also tabulated. Changes in quality of mask ventilation after injection of a neuromuscular blocking agent were assessed.ResultsThe incidence of difficult mask ventilation was 9% (483 of 5453 patients). Infants and patients having increased weight, being less than 5th percentile in weight for age, or having Treacher-Collins syndrome, glossoptosis, or limited mouth opening were more likely to have difficult mask ventilation. Anaesthetic induction using facemask and opioids was associated with decreased risk of difficult mask ventilation. The incidence of complications was significantly higher in patients with "difficult" mask ventilation than in patients without. Rescue placement of a supraglottic airway improved ventilation in 71% (96 of 135) of cases. Administration of neuromuscular blocking agents was more frequently associated with improvement or no change in quality of ventilation than with worsening.ConclusionsCertain abnormalities on physical examination should increase suspicion of possible difficult facemask ventilation. Rescue use of a supraglottic airway device in children with difficult or impossible mask ventilation should be strongly considered.

BackgroundFailed management of unanticipated difficult airway situations contributes to significant anesthesia-related morbidity and mortality. Optimization of design and layout of difficult airway trolleys (DATs) may influence outcomes during airway emergencies. The main objective of the current study was to evaluate whether a difficult airway algorithm-based DAT with integrated cognitive aids improves efficiency and team performance in difficult airway scenarios.MethodsIn a crossover design, 16 teams (anesthetist, nurse anesthetist, assistant nurse) completed two high-fidelity simulated unanticipated difficult airway scenarios. Teams used both an algorithm-based DAT and a comparison, standard DAT, in the scenarios and were randomized to order of trolley type. Outcome measures included objective efficiency parameters, team performance assessment and subjective user-ratings. Linear mixed models ANOVA, including DAT type and order of condition as main factors, was utilized for the primary analyses of the team results.ResultsUsage of the algorithm-based DAT was associated with fewer departures from the difficult airway algorithm (p = .010), and reduced number of unnecessary drawer openings (p = .002), but no significant differences in time to retrieval of airway devices or time to first effective ventilation, compared to the standard DAT. There were no significant differences in team performance, although participants expressed strong preference for the algorithm-based DAT (all user-rated measures p < .0001). Higher percentage of female members of the team improved adherence to the difficult airway algorithm (p = .043).ConclusionsAlgorithm-based DATs with integrated cognitive aids may improve efficiency in difficult airway situations, compared to traditional DATs. These findings have implications for improvement of anesthetic practice.

Purpose: This quality improvement (QI) project aims to present emerging changes to the American Society of Anesthesiologists (ASA) 2022 Difficult Airway Algorithm. The intervention is provider education. This project will encompass multiple factors of airway management, including airway assessment tools, difficult airway algorithms, high flow nasal oxygenation, awake intubation, ultrasound for emergency airway management, human factors in difficult airway management, and closed claims analysis. A pre-education and post-education evaluation tool will be used to determine teaching effectiveness. Background: The ASA Difficult Airway Algorithm is updated every ten years to provide the best evidence-based practice guidelines in airway management. Nearly half of the airway claims involving patient death or brain damage are due to airway issues. Airway algorithms assist anesthesia providers during airway challenges and reduce patient complications. Method: Education provided via an online Panopto recording to anesthesia providers within the Arizona Anesthesia Solutions (AzAS) group. A 10-minute virtual educational presentation was emailed to approximately 100 anesthesia providers by the Regional Director. A pre- and post-intervention survey via Qualtrics was included to evaluate provider knowledge and confidence in the new practice guidelines. Results: 28 anesthesia providers completed the demographic questionnaire, 16 completed the pre-education survey, and 15 completed the post-survey. Improvement in the knowledge and confidence scores is seen in the results. Open-ended questions are used to determine airway challenges and determine improvement in clinical practice.

Introduction: Previous studies suggest improved intubation success using video laryngoscopy (VL) vs direct laryngoscopy (DL), yet recent randomized trials have not shown clear benefit of one method over the other. These studies, however, have generally excluded difficult airways and rapid sequence intubation. In this study we looked to compare first-pass success (FPS) rates between VL and DL in adult emergency department (ED) patients with difficult airways.  Methods: We conducted a secondary analysis of prospectively collected observational data in the National Emergency Airway Registry (NEAR) (January 2016–December 2018). Variables included demographics, indications, methods, medications, devices, difficult airway characteristics, success, and adverse events. We included adult ED patients intubated with VL or DL who had difficult airways identified by gestalt or anatomic predictors. We stratified VL by hyperangulated (HAVL) vs standard geometry VL (SGVL). The primary outcome was FPS, and the secondary outcome was comparison of adverse event rates between groups. Data analyses included descriptive statistics with cluster-adjusted 95% confidence intervals (CI). Results: Of 18,123 total intubations, 12,853 had a predicted or identified anatomically difficult airway. The FPS for difficult airways was 89.1% (95% CI 85.9-92.3) with VL and 77.7% (95% CI 75.7-79.7) with DL (P <0.00001). The FPS rates were similar between VL subtypes for all difficult airway characteristics except airways with blood or vomit, where SGVL FPS (87.3%; 95% CI 85.8-88.8) was slightly better than HAVL FPS (82.4%; 95% CI, 80.3-84.4). Adverse event rates were similar except for esophageal intubations and vomiting, which were both less common in VL than DL. Esophageal intubations occurred in 0.4% (95% CI 0.1-0.7) of VL attempts and 1.5% (95% CI 1.1-1.9) of DL attempts. Vomiting occurred in 0.6% (95% CI 0.5-0.7) of VL attempts and 1.4% (95% CI 0.9-1.9) of DL attempts. Conclusion: Analysis of

Bakgrund: Specialistsjuksköterskor ska kunna identifiera och hantera ofri luftväg utifrån kunskap och fastställda riktlinjer inom den prehospitala vården. Att kunna identifiera svårigheter kan vara livräddande för en kritiskt sjuk eller skadad patient. Sverige är en av få länder i världen som bemannar ambulansen med minst en sjuksköterska, och som därtill utbildar sjuksköterskor till specialister. Specialistsjuksköterskor som jobbar prehospitalt skiljer sig i mängd erfarenhet och kunskap om prehospital vård. Syfte: Syftet med studien var att beskriva vilka faktorer som försvårar specialistsjuksköterskors luftvägshantering prehospitalt. Metod: Kvantitativ tvärsnittsstudie med enkäter samt fritextsvar. Deltagarna var specialistsjuksköterskor (n=37) vilka hade haft svårt och/eller misslyckats skapa en fri luftväg under senaste året. Det kvantitativa resultatet analyserades med student–t test, chi-två test samt Fishers Exakta test och det kvalitativa resultatet analyserades med kvalitativ innehållsanalys. Resultat: De faktorer som identifierades var Svårigheter relaterat till hjälpmedel, Svårigheter relaterat till patient samt Utveckling och utbildning. Resultatet visade en signifikant skillnad i hur trygga specialistsjuksköterskor inom olika inriktningar upplever sig vara vid hanteringen av de olika hjälpmedlen och en signifikant variation mellan antal yrkesverksamma år. Anestesisjuksköterskorna skattade sig högst och hade längst erfarenhet. Ambulanssjuksköterskorna och anestesisjuksköterskorna upplevde att deras utbildning hade hjälpt dem i deras hantering av svår luftväg, men ansåg ändå att mer utbildning och årlig repetition rörande luftvägshanteringen är nödvändig. Slutsats: Studiens resultat tyder på att teoretisk kunskap tillsammans med reell kompetens har betydelse för adekvat vård vid luftvägshantering och därmed kan öka patientsäkerheten. Vidare att specialistsjuksköterskorna önskar återkommande repetitionsutbildning i luftvägshantering via arbetsgivaren. Slut

Introduction: Previous studies suggest improved intubation success using video laryngoscopy (VL) vs direct laryngoscopy (DL), yet recent randomized trials have not shown clear benefit of one method over the other. These studies, however, have generally excluded difficult airways and rapid sequence intubation. In this study we looked to compare first-pass success (FPS) rates between VL and DL in adult emergency department (ED) patients with difficult airways.  Methods: We conducted a secondary analysis of prospectively collected observational data in the National Emergency Airway Registry (NEAR) (January 2016–December 2018). Variables included demographics, indications, methods, medications, devices, difficult airway characteristics, success, and adverse events. We included adult ED patients intubated with VL or DL who had difficult airways identified by gestalt or anatomic predictors. We stratified VL by hyperangulated (HAVL) vs standard geometry VL (SGVL). The primary outcome was FPS, and the secondary outcome was comparison of adverse event rates between groups. Data analyses included descriptive statistics with cluster-adjusted 95% confidence intervals (CI). Results: Of 18,123 total intubations, 12,853 had a predicted or identified anatomically difficult airway. The FPS for difficult airways was 89.1% (95% CI 85.9-92.3) with VL and 77.7% (95% CI 75.7-79.7) with DL (P <0.00001). The FPS rates were similar between VL subtypes for all difficult airway characteristics except airways with blood or vomit, where SGVL FPS (87.3%; 95% CI 85.8-88.8) was slightly better than HAVL FPS (82.4%; 95% CI, 80.3-84.4). Adverse event rates were similar except for esophageal intubations and vomiting, which were both less common in VL than DL. Esophageal intubations occurred in 0.4% (95% CI 0.1-0.7) of VL attempts and 1.5% (95% CI 1.1-1.9) of DL attempts. Vomiting occurred in 0.6% (95% CI 0.5-0.7) of VL attempts and 1.4% (95% CI 0.9-1.9) of DL attempts. Conclusion: Analysis of

Purpose To explore Swedish registered nurse anesthetists’ (RNAs’) different ways of understanding difficult airway algorithms. Design A qualitative study design, using a phenomenographic approach, was chosen to describe variations in RNAs’ understanding of difficult airway algorithms. Methods Individual interviews were conducted with eighteen RNAs working at three hospitals in Sweden. The data were analyzed using a qualitative method.FindingsThree ways of understanding algorithms were identified: (1) Algorithms constitute a plan not communicated at the clinic; (2) Algorithms constitute a shared plan to improve teamwork; (3) Algorithms constitute a plan for how to think and work systematically. Conclusions According to the RNAs, airway management algorithms should be discussed more openly at the workplace. RNAs expressed their desire to have a shared algorithm and to use it as a tool during team simulations. Airway algorithms were seen as constituting a plan for how to think and work systematically to improve patient safety.

Purpose To explore Swedish registered nurse anesthetists’ (RNAs’) different ways of understanding difficult airway algorithms. Design A qualitative study design, using a phenomenographic approach, was chosen to describe variations in RNAs’ understanding of difficult airway algorithms. Methods Individual interviews were conducted with eighteen RNAs working at three hospitals in Sweden. The data were analyzed using a qualitative method.FindingsThree ways of understanding algorithms were identified: (1) Algorithms constitute a plan not communicated at the clinic; (2) Algorithms constitute a shared plan to improve teamwork; (3) Algorithms constitute a plan for how to think and work systematically. Conclusions According to the RNAs, airway management algorithms should be discussed more openly at the workplace. RNAs expressed their desire to have a shared algorithm and to use it as a tool during team simulations. Airway algorithms were seen as constituting a plan for how to think and work systematically to improve patient safety.

Esophageal oncologic surgery seems to be a true challenge for anesthesiologists due to aggressive surgery techniques requested considering where the tomour is located as well as the experience of the surgical staff. Transthoracic approaching or Ivor-Lewis technique is a two ways surgery: laparotomy for gastroplasty and one-lung ventilation right thoracotomy for dissection, tumor resection and anastomosis. The patient had airway distortion due to previous oropharyngeal surgery and radiation therapy, as well as neoadjuvance for the esophageal tumor. Thus, awake tracheal intubation is considered, using a fiberbronchoscopy and a standard endotracheal tube. Throught it an independent bronchial screen to his right lung bronchus. We choose not to use the double-lumen tube due to its high complexity in a DA scenario and also because of tracheal injury risk. Surgery was developed with no problem at all and pulmonary exemption was properly reached., La cirugía oncológica esofágica es siempre un reto para el anestesiólogo debido a la agresividad de las técnicas quirúrgicas empleadas según la localización del tumor y la experiencia del equipo quirúrgico. El abordaje transtorácico o técnica de Ivor-Lewis es una cirugía en dos campos: laparotomía para la gastroplastia y toracotomía derecha con ventilación unipulmonar (VUP) para la disección, resección tumoral y anastomosis. El paciente presentaba distorsión de la vía aérea debido a cirugía orofaríngea y radioterapia (RT) previas, además de neoadyuvancia para el tumor esofágico. Por ello se decidió una intubación orotraqueal despierto, con fibrobroncoscopio (FOB), utilizando un tubo endotraqueal estándar (TET). A través de él, se introdujo un bloqueador bronquial independiente (BB) hacia el bronquio pulmonar derecho. La intervención se realizó sin incidencias y se logró la exclusión pulmonar adecuadamente.

A 70-year-old man with prostate neoplasia. Finding in the extension study of a lung mass compatible with lung neoplasia. He was referred to the pulmonology service for study. Appointment for diagnostic fiberoptic bronchoscopy. Obese patient with difficult airway predictors: short neck, III / IV mesh, thyromental distance <6cm. Fiberoptic bronchoscopy is performed under deep sedation. When introducing the fiberoptic bronchoscope, anatomical variation with significant glottic destructuring, poor differentiation of the epiglottis, arytenoids, and adjacent structures was visualized. The entrance to the trachea is intuited by the appearance of a small opening hole with the inspiration of the patient. This image shows that the difficulty for intubation not only corresponds to poor visualization of the airway due to difficulty in direct or indirect laryngoscopy maneuvers, but also due to the existence of non-pathological anatomical variants that represent a challenge even in experienced hands., Varón de 70 años con neoplasia de próstata. Hallazgo en el estudio de extensión de una masa pulmonar compatible con neoplasia pulmonar. Se remite al servicio de neumología para estudio. Se cita para fibrobroncoscopia diagnóstica. Paciente obeso con predictores de vía aérea difícil: Cuello corto, mallampati III/IV, distancia tiromentoniana < 6cm. Se realiza fibrobroncoscopia bajo sedación profunda. Al introducir el fibrobroncoscopio se visualiza variación anatómica con importante desestructuración glótica, escasa diferenciación de la epiglotis, aritenoides y estructuras adyacentes. Se intuye la entrada a tráquea por la aparición de un pequeño orificio de apertura con la inspiración del paciente. Esta imagen demuestra que la dificultad para la intubación no sólo se corresponde con una mala visualización de la vía aérea por dificultad en las maniobras de laringoscopia directa o indirecta, sino también por la existencia de variantes anatómicas no patológicas que representan un reto incluso en manos experimentadas.

Noonan syndrome (SN) is a monogenic disease with an autosomal dominant inheritance pattern with an incidence of 1: 1500-2500. This syndrome is of particular interest to the anesthesiologist because it is considered a probable difficult airway, presenting short stature, facial dysmorphia, haemostasis, musculoskeletal and cardiological alterations, among others, whose evolution determines life expectancy reaching more advanced ages at present thanks to the control of them. Consequently, they require interventions in adulthood where there are not as many cases as in childhood. We report a case of a 53-year-old patient with NS scheduled for cervical neuroma resection with increased bleeding during surgery. Our goal is to establish a specific anesthetic plan after exposing the characteristics of the disease to minimize perioperative complications., El síndrome de Noonan (SN) es una enfermedad monogénica con patrón de herencia autosómico dominante con una incidencia de uno de 1:1500-2500. Este síndrome es de particular interés para el anestesiólogo por ser considerado probable vía aérea difícil, presentar talla baja, dismorfia facial, alteraciones en la hemostasia, musculoesqueléticas y cardiológicas, entre otras, cuya evolución condicionan la esperanza de vida alcanzando edades más avanzadas en la actualidad gracias al control de las mismas . Por consiguiente requieren intervenciones en la edad adulta donde no hay tantos casos reportados como en la infancia . Presentamos un caso de un paciente de 53 años con SN programado para resección de neurinoma cervical durante el cual destacó un sangrado aumentado durante la cirugía no esperado. Nuestro objetivo es establecer un plan anestésico específico tras exponer las características de la enfermedad para minimizar las complicaciones perioperatorias.

Bakgrund: Specialistsjuksköterskor ska kunna identifiera och hantera ofri luftväg utifrån kunskap och fastställda riktlinjer inom den prehospitala vården. Att kunna identifiera svårigheter kan vara livräddande för en kritiskt sjuk eller skadad patient. Sverige är en av få länder i världen som bemannar ambulansen med minst en sjuksköterska, och som därtill utbildar sjuksköterskor till specialister. Specialistsjuksköterskor som jobbar prehospitalt skiljer sig i mängd erfarenhet och kunskap om prehospital vård. Syfte: Syftet med studien var att beskriva vilka faktorer som försvårar specialistsjuksköterskors luftvägshantering prehospitalt. Metod: Kvantitativ tvärsnittsstudie med enkäter samt fritextsvar. Deltagarna var specialistsjuksköterskor (n=37) vilka hade haft svårt och/eller misslyckats skapa en fri luftväg under senaste året. Det kvantitativa resultatet analyserades med student–t test, chi-två test samt Fishers Exakta test och det kvalitativa resultatet analyserades med kvalitativ innehållsanalys. Resultat: De faktorer som identifierades var Svårigheter relaterat till hjälpmedel, Svårigheter relaterat till patient samt Utveckling och utbildning. Resultatet visade en signifikant skillnad i hur trygga specialistsjuksköterskor inom olika inriktningar upplever sig vara vid hanteringen av de olika hjälpmedlen och en signifikant variation mellan antal yrkesverksamma år. Anestesisjuksköterskorna skattade sig högst och hade längst erfarenhet. Ambulanssjuksköterskorna och anestesisjuksköterskorna upplevde att deras utbildning hade hjälpt dem i deras hantering av svår luftväg, men ansåg ändå att mer utbildning och årlig repetition rörande luftvägshanteringen är nödvändig. Slutsats: Studiens resultat tyder på att teoretisk kunskap tillsammans med reell kompetens har betydelse för adekvat vård vid luftvägshantering och därmed kan öka patientsäkerheten. Vidare att specialistsjuksköterskorna önskar återkommande repetitionsutbildning i luftvägshantering via arbetsgivaren. Slut

Purpose To explore Swedish registered nurse anesthetists’ (RNAs’) different ways of understanding difficult airway algorithms. Design A qualitative study design, using a phenomenographic approach, was chosen to describe variations in RNAs’ understanding of difficult airway algorithms. Methods Individual interviews were conducted with eighteen RNAs working at three hospitals in Sweden. The data were analyzed using a qualitative method.FindingsThree ways of understanding algorithms were identified: (1) Algorithms constitute a plan not communicated at the clinic; (2) Algorithms constitute a shared plan to improve teamwork; (3) Algorithms constitute a plan for how to think and work systematically. Conclusions According to the RNAs, airway management algorithms should be discussed more openly at the workplace. RNAs expressed their desire to have a shared algorithm and to use it as a tool during team simulations. Airway algorithms were seen as constituting a plan for how to think and work systematically to improve patient safety.

Purpose To explore Swedish registered nurse anesthetists’ (RNAs’) different ways of understanding difficult airway algorithms. Design A qualitative study design, using a phenomenographic approach, was chosen to describe variations in RNAs’ understanding of difficult airway algorithms. Methods Individual interviews were conducted with eighteen RNAs working at three hospitals in Sweden. The data were analyzed using a qualitative method.FindingsThree ways of understanding algorithms were identified: (1) Algorithms constitute a plan not communicated at the clinic; (2) Algorithms constitute a shared plan to improve teamwork; (3) Algorithms constitute a plan for how to think and work systematically. Conclusions According to the RNAs, airway management algorithms should be discussed more openly at the workplace. RNAs expressed their desire to have a shared algorithm and to use it as a tool during team simulations. Airway algorithms were seen as constituting a plan for how to think and work systematically to improve patient safety.

Purpose To explore Swedish registered nurse anesthetists’ (RNAs’) different ways of understanding difficult airway algorithms. Design A qualitative study design, using a phenomenographic approach, was chosen to describe variations in RNAs’ understanding of difficult airway algorithms. Methods Individual interviews were conducted with eighteen RNAs working at three hospitals in Sweden. The data were analyzed using a qualitative method.FindingsThree ways of understanding algorithms were identified: (1) Algorithms constitute a plan not communicated at the clinic; (2) Algorithms constitute a shared plan to improve teamwork; (3) Algorithms constitute a plan for how to think and work systematically. Conclusions According to the RNAs, airway management algorithms should be discussed more openly at the workplace. RNAs expressed their desire to have a shared algorithm and to use it as a tool during team simulations. Airway algorithms were seen as constituting a plan for how to think and work systematically to improve patient safety.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Bakgrund: Specialistsjuksköterskan i en prehospital miljö ställs inför utmaningar när en svår luftväg inte längre kan hanteras genom basal luftvägshantering. Denna situation kräver spetskompetens inom avancerad luftvägshantering och anestesi, samt särskilda hjälpmedel. Inom vissa regioner finns en prehospital förstärkningsenhet som har som uppgift att komplettera ordinarie verksamhet med spetskompetens när det finns behov av avancerad luftvägshantering. Syfte: Syftet med studien var att studera anestesisjuksköterskors strategier vid hantering av svår luftväg i en prehospital förstärkningsenhet. Metod: En kvalitativ studie med datainsamling via enkät tillämpades och analyserades med kritisk incident teknik (CIT). Sexton anestesisjuksköterskor i en prehospital förstärkningsenhet i Sverige besvarade enkäten. Resultat: Analysen ledde fram till fyra betydelsefulla strategier för att hantera en svår luftvägprehospitalt. Förberedelse i att ställas inför en svår luftväg, mental förberedelse på väg ut på larm, möjligheten att lägga upp en primär samt en sekundär plan tillsammans med kollegan och att våga agera direkt var strategier som identifierades för att hantera en svår luftvägprehospitalt. Detsamma gällde att ta beslut i tid, att flytta patienten så att omhändertagandet inte behövde anpassas i onödan av omständigheter som kanske gick att undvika, att skapa åtkomst och insyn till patientens luftväg och ha närhet till egen utrustning vid hantering av en svår luftväg. Kollegan, teamkänsla, kommunikation, igenkännande, förståelse för varandras uppdrag och kännedom om varandras arbetssätt och utrustning var framgångsfaktorer för att få ett bra och effektivt teamarbete runt den svårt sjuka patienten. Utrustning som normalt inte fanns i en akutambulans som videolaryngoskop, endotrakealtub förberedd med ledare, kapnograf och en bra sug var framgångsfaktorer för att hantera en svår luftväg prehospitalt. Slutsats: Resultatet kan komplettera specialistutbildningar och introduktion

Bakgrund: Specialistsjuksköterskan i en prehospital miljö ställs inför utmaningar när en svår luftväg inte längre kan hanteras genom basal luftvägshantering. Denna situation kräver spetskompetens inom avancerad luftvägshantering och anestesi, samt särskilda hjälpmedel. Inom vissa regioner finns en prehospital förstärkningsenhet som har som uppgift att komplettera ordinarie verksamhet med spetskompetens när det finns behov av avancerad luftvägshantering. Syfte: Syftet med studien var att studera anestesisjuksköterskors strategier vid hantering av svår luftväg i en prehospital förstärkningsenhet. Metod: En kvalitativ studie med datainsamling via enkät tillämpades och analyserades med kritisk incident teknik (CIT). Sexton anestesisjuksköterskor i en prehospital förstärkningsenhet i Sverige besvarade enkäten. Resultat: Analysen ledde fram till fyra betydelsefulla strategier för att hantera en svår luftvägprehospitalt. Förberedelse i att ställas inför en svår luftväg, mental förberedelse på väg ut på larm, möjligheten att lägga upp en primär samt en sekundär plan tillsammans med kollegan och att våga agera direkt var strategier som identifierades för att hantera en svår luftvägprehospitalt. Detsamma gällde att ta beslut i tid, att flytta patienten så att omhändertagandet inte behövde anpassas i onödan av omständigheter som kanske gick att undvika, att skapa åtkomst och insyn till patientens luftväg och ha närhet till egen utrustning vid hantering av en svår luftväg. Kollegan, teamkänsla, kommunikation, igenkännande, förståelse för varandras uppdrag och kännedom om varandras arbetssätt och utrustning var framgångsfaktorer för att få ett bra och effektivt teamarbete runt den svårt sjuka patienten. Utrustning som normalt inte fanns i en akutambulans som videolaryngoskop, endotrakealtub förberedd med ledare, kapnograf och en bra sug var framgångsfaktorer för att hantera en svår luftväg prehospitalt. Slutsats: Resultatet kan komplettera specialistutbildningar och introduktion

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Introduction: The evaluation and prediction of a difficult airway in the pediatric patient is of great importance for its correct management, application of algorithms and reduction of complications. This study is aimed at identifying risk factors through the application of the COPUR scale as a fundamental tool to identify the incidence and problems in the pediatric airway. Objectives: To determine the incidence of difficult airway and identify risk factors in pediatric patients with heart disease from 1 day to 10 years old, who underwent surgery under general anesthesia through the COPUR scale. Methodology: This is a cross-sectional analytical study conducted in 235 children with congenital heart disease in a Pediatric Hospital in Quito-Ecuador undergoing elective surgery under general anesthesia in the period between June 2015 and December 2016. Results: Normal and easy intubation was found in 73.19%, more difficult intubation and necessary laryngeal pressure maneuver in 24.26% and difficult intubation with requirement of devices (fiberscope or video laryngoscopy) was 2.25%. Conclusion: The incidence of difficult airway was 2.25% and risk factors such as mandibular hypoplasia, a mouth opening smaller than 20 mm, previous difficult intubation, a partially visible uvula, and a range of motion less than 30 degrees together allow an adequate prediction of a difficult airway, its anticipation allows adequate training, disciplined compliance with the algorithm and a better approach for an immediate solution., Introducción: La evaluación y predicción de una vía aérea difícil en el paciente pediátrico es de gran importancia para su correcto manejo, aplicación de algoritmos y disminución de complicaciones. Este estudio va dirigido a identificar los condicionantes de riesgo a través de la aplicación de la escala COPUR como herramienta fundamental para identificar la incidencia y problemas en la vía aérea pediátrica. Objetivos: Determinar la incidencia de vía aérea difícil e identificar los factores de riesgo en los pacientes pediátricos con cardiopatía de 1 día hasta 10 años, sometidos a cirugía bajo anestesia general a través de escala de COPUR. Metodología: Es un estudio analítico transversal realizado en 235 niños con cardiopatías congénitas de un Hospital Pediátrico en Quito- Ecuador sometidos a intervenciones quirúrgicas electivas bajo anestesia general en el período entre junio de 2015 y diciembre del 2016. Resultados: Se encontró una intubación normal y fácil en un 73.19%, una mayor dificultad en la intubación y una necesaria maniobra de presión laríngea en el 24.26% y una difícil intubación con requerimiento de dispositivos (fibroscopio o video laringoscopia) fue 2,25%. Conclusión: La incidencia de vía aérea difícil fue del 2,25% y los factores de riesgo como una hipoplasia mandibular, una apertura bucal menor 20 mm, previa intubación difícil, una úvula parcialmente visible, y un rango de movimiento menor a 30 grados en conjunto nos permite una adecuada predicción de una vía aérea difícil, su anticipación permite el entrenamiento adecuado, el cumplimiento disciplinario del algoritmo y un mejor abordaje para una solución inmediata.

Four basic types of visual aids are used for teaching airway management and decision-making in simulated as well as in real clinical situations: universal algorithms, sets of limited algorithms, concept-based cognitive aids, and checklists. The first three may represent an evolution in the understanding of the role of human error in both successful and failed airway management. Complex visual aids such as the American Society of Anesthesiology difficult airway algorithm may be more useful for teaching, while graphic cognitive aids like the Vortex may be more helpful for decision-making under stress. Not surprisingly, there is a lack of outcome studies, although some cognitive aids have been evaluated in simulation settings.

Introduction: in assessing the difficulty of performing conventional laryngoscopy, the necessary integration of essential clinical aspects related to respiratory control is not enhanced.Objective: to validate a prediction model of an anatomically difficult laryngoscopy in the patient that requires orotracheal intubation.Method: An analytical study was carried out in a population of 17,966 patients in need of direct laryngoscopy for an orotracheal intubation for surgical purposes at the General Teaching Hospital "Dr. Agostinho Neto” from Guantanamo between 2015 and 2018. A sample of 17,068 patients was determined by randomized sampling. The following variables were studied: peripheral stigma for difficult laryngoscopy, difficult laryngoscopy after anesthetic induction, laryngoscopic evaluation according to Cormack-Lehane, diagnostic value of the predictive evaluation model for laryngoscopy.Results: the high degrees in the classification of predictive clinical aspects and the coexistence with the morphological alteration of the epiglottis were the markers most associated with the probability of anatomically difficult laryngoscopy. With the integration of four essential clinical aspects, the degree of probable difficulty in visualizing the vocal cords was identified.Conclusions: a model was designed that allowed the prediction of an anatomically difficult laryngoscopy, whose validation certified its feasibility to apply it in medical practice., Introdução: na avaliação da dificuldade na realização da laringoscopia convencional, a integração necessária dos aspectos clínicos essenciais relacionados ao controle respiratório não é aprimorada.Objetivo: validar um modelo de previsão de uma laringoscopia anatomicamente difícil no paciente que necessita de intubação orotraqueal.Método: foi realizado um estudo analítico em uma população de 17.966 pacientes com necessidade de laringoscopia direta para intubação orotraqueal para fins cirúrgicos no Hospital Geral de Ensino "Dr. Agostinho Neto” de Guantánamo entre 2015 e 2018. Uma amostra de 17.068 pacientes foi determinada por amostragem aleatória. Foram estudadas as seguintes variáveis: estigma periférico para laringoscopia difícil, laringoscopia difícil após indução anestésica, avaliação laringoscópica segundo Cormack-Lehane, valor diagnóstico do modelo de avaliação preditiva para laringoscopia.Resultados: os altos graus na classificação dos aspectos clínicos preditivos e a coexistência com a alteração morfológica da epiglote foram os marcadores mais associados à probabilidade de laringoscopia anatomicamente difícil. Com a integração de quatro aspectos clínicos essenciais, foi identificado o grau de provável dificuldade na visualização das cordas vocais.Conclusões: foi elaborado um modelo que permitia prever uma laringoscopia anatomicamente difícil, cuja validação atestava sua viabilidade de aplicá-la na prática médica., Introducción: en la valoración de dificultad para realizar la laringoscopia convencional no se realza la integración necesaria de aspectos clínicos esenciales relacionados con el control respiratorio.Objetivo: validar un modelo de predicción de una laringoscopia anatómicamente difícil en el paciente que requiere de intubación orotraqueal.Método: se realizó un estudio analítico en una población de 17 966 pacientes con necesidad de laringoscopia directa para una intubación orotraqueal con fines quirúrgicos en el Hospital General Docente “Dr. Agostinho Neto” de Guantánamo entre el 2015 y el 2018. Se determinó por muestreo aleatorizado una muestra de 17 068 pacientes. Se estudiaron las siguientes variables: estigma periférico para laringoscopia difícil, laringoscopia difícil pos-inducción anestésico, evaluación laringoscópica según Cormack-Lehane, valor diagnóstico del modelo de evaluación predictiva para laringoscopia.Resultados: los altos grados en la clasificación de aspectos clínicos predictivos y la coexistencia con la alteración morfológica de la epiglotis fueron los marcadores más asociados con la probabilidad de laringoscopia anatómicamente difícil. Con la integración de cuatros aspectos clínicos esenciales se identificó el grado de dificultad probable para visualizar las cuerdas vocales.Conclusiones: se diseñó un modelo que posibilitó la predicción de una laringoscopia anatómicamente difícil, cuya validación certificó su viabilidad para aplicarlo en la práctica médica.

The emergency surgical approach of the airway to a situation "can’t intubate, can’t oxygenate’ is a scenario implies an adequate training on the part of the anesthesiologist that enables a successful resolution in the shortest posible time. In view of the low frequency of this practice, many anesthesiologists choose to locate the cricothyroid membrane before performing the anesthetic induction with the head and neck in a neutral position. Considering this and that the ideal position for a cricothyroidotomy is placing the head and neck in extension, the authors of this article try to determine if there is a change in the location of the membrane with the variation of the head and neck position from neutral to extended as well as if the height of the membrane is modified. To do this, hey performed an observational study with 22 healthy volunteers to whom a radiologist with more than fifteen years of experience measures with ultrasound the distance between the upper and lower membrane edges and makes a mark at the midpoint of the same in the two positions mentioned above. The results obtained from the study lead us to an important reflection that leads us to a change in the classical paradigm of approach of the cricothyroidotomy., El abordaje quirúrgico de urgencia de la vía aérea ante una situación “no intubable – no ventilable” es un escenario que implica, por parte del anestesiólogo, un adecuado entrenamiento que posibilite una resolución exitosa en el menor tiempo posible. Dada la poca frecuencia de esta práctica, muchos anestesiólogos optan por localizar la membrana cricotiroidea antes de realizar la inducción anestésica con la cabeza y cuello en posición neutra. Ante esto, y, considerando la posición ideal para una cricotiroidotomía al paciente con la cabeza y cuello en extensión, los autores de este artículo tratan de determinar si existe realmente cambio en la localización de dicha membrana con la variación de la cabeza y cuello de posición neutra a extendida así como si se modifica la altura de la misma. Para ello, realizan un estudio observacional con 22 voluntarios sanos a los que un radiólogo, con más de quince años de experiencia, mide con ecografía la distancia entre los bordes superior e inferior de la membrana y realiza una marca en el punto medio de la misma en las dos posiciones antes citadas. Los resultados obtenidos nos llevan a una importante reflexión que nos conduce a un cambio en el paradigma clásico de abordaje de la cricotiroidotomía.

Intubation with fibrobronchoscope in the awake patient is a good option form patient with a known difficult airway who are going to undergo a scheduled surgical intervention, which allows the responsable anesthesiologist to devise a plan of action to prevent an unwanted outcome. There are many protocols that are applied for this but most of the time are due to the experience of each anesthesiologist and the results obtained with application in the usual care practice. This article is the first systematic review or randomized clinical trials focusing on this approach. Information was mainly selected from four areas of work: premedication, sedation, local anesthesia and the use of devices and auxiliary techniques to facilitate intubation in the awake patient. The authors find a great heterogeneity as far as these aspects are concerned, without any of the protocols having demonstrated superiority in safety and efficacy., La intubación con fibrobroncoscopio en el paciente despierto supone una buena opción para aquellos pacientes con vía aérea difícil conocida que se van a someter a una intervención quirúrgica programada, lo cual permite al anestesiólogo responsable idear un plan de acción para evitar un desenlace no deseado. Son muchos los protocolos que se aplican para ello, pero, la mayoría de las veces, obedecen a la experiencia de cada anestesiólogo y a los resultados obtenidos con su aplicación en la práctica asistencial habitual. Este artículo es la primera revisión sistemática de ensayos clínicos aleatorizados que se centran en este abordaje. Para ello, se seleccionó principalmente información de cuatro áreas de trabajo: premedicación, sedación, anestesia local y uso de dispositivos y técnicas auxiliares que faciliten la intubación en el paciente despierto. La conclusión final a la que llegan los autores de este artículo es la existencia de gran heterogeneidad en lo que a estos aspectos se refiere, sin que ninguno de los protocolos haya demostrado superioridad en seguridad y eficacia.

Difficult or failed extubation cases are rarely discussed in our anesthesiology community. While airway mana-gement has received considerable attention (including difficult airway), there is not enough information about cases of failed extubation. It should be remembered that unsuccessful extubation is potentially more serious threat than intubation difficulties, it is associated with greater legal responsibility. The article considers the predictors of difficult/failed extubation, solutions and prevention based on the modern studies and guidelines. It also discusses the method of staged tracheal extubation, its pros and cons, the possibility of using in modern conditions and the authors’ experience., Случаи сложной или неудачной экстубации редко обсуждаются в нашем анестезиологическом сообществе. В то время как значительное внимание уделяется налаживанию контроля над дыхательными путями (включая сложные дыхательные пути), информации о случаях неудачных экстубаций недостаточно. Нужно помнить, что неудачная экстубация является потенциально более угрожающей ситуацией, чем сложности с интубацией, и имеет серьезные последствия, включая юридическую ответственность. В статье рассмотрены предикторы сложной/неудачной экстубации и пути решения и профилактики на основании данных современных исследований и руководств. Также обсуждается методика поэтапной экстубации трахеи, особенности применения, возможность внедрения в современных условиях и опыт авторов., Випадки складної або невдалої екстубації зазвичай не обговорюються нашою анестезіологічною спільнотою. У той час, коли значна увага приділяється налагодженню контролю над дихальними шляхами (у тому числі складними дихальними шляхами), інформації про складну/невдалу екстубацію недостатньо. Треба враховувати, що невдала екстубація потенційно є більш загрозливою сітуацією, ніж складна інтубація, і тягне за собою більш суворі наслідки, у тому числі юридичні. У статті розглянуто предиктори складної/невдалої екстубації, шляхи подолання та профілактики за даними сучасних досліджень та настанов. Також обговорюється методика поетапної екстубації трахеї, її особливості, можливість застосування в сучасних умовах, досвід авторів.

A number of epidemiological and animal studies have indicated the fine balance among bone and fat metabolism as the connecting link between osteoporosis and obesity. Excess abdominal fat is associated with an abnormal lipid profile causing greater predisposition towards metabolic diseases like osteoporosis. Quantitative ultrasonometry (QUS) T-score being the surrogate marker of osteoporosis was studied in this case-control study (254 cases, 250 controls) comprising of both males and females to investigate its potential association with anthropometric predictors of adiposity and lipid parameters. According to the WHO criteria, patients with a T-score ? -1.0 SD were marked as cases and ? -1.0 SD as controls. Information on demographic and lifestyle factors, anthropometric measurements and lipid profile was recorded for all the participants. Results depicted that QUS T-score was inversely correlated with the predictors of obesity including BMI, WHtR and BAI in the pooled group, BMI, WHtR and TC in females, and directly correlated with TGL in males. After attenuating for the confounding factors, while obesity indices remained significant in pooled and females, the influence of lipid parameters among males was nullified. However, principal component analysis in all groups pointed obesity to be the major determinant, followed by lipid parameters, accounting for 90% of the variance. Additionally, calcium and fruit intake, post-menopausal and socio-economic status, and smoking had a significant role to play. To conclude, the present data indicates that individuals with greater abdominal obesity might pose a higher risk of developing bone metabolic diseases like osteopenia and osteoporosis, necessitating the need for evaluating the bone status in obese individuals, whilst, the role of lipid parameters still remains conflicting. This might open new avenues in understanding the mechanism underlying bone metabolism.

A number of epidemiological and animal studies have indicated the fine balance among bone and fat metabolism as the connecting link between osteoporosis and obesity. Excess abdominal fat is associated with an abnormal lipid profile causing greater predisposition towards metabolic diseases like osteoporosis. Quantitative ultrasonometry (QUS) T-score being the surrogate marker of osteoporosis was studied in this case-control study (254 cases, 250 controls) comprising of both males and females to investigate its potential association with anthropometric predictors of adiposity and lipid parameters. According to the WHO criteria, patients with a T-score ? -1.0 SD were marked as cases and ? -1.0 SD as controls. Information on demographic and lifestyle factors, anthropometric measurements and lipid profile was recorded for all the participants. Results depicted that QUS T-score was inversely correlated with the predictors of obesity including BMI, WHtR and BAI in the pooled group, BMI, WHtR and TC in females, and directly correlated with TGL in males. After attenuating for the confounding factors, while obesity indices remained significant in pooled and females, the influence of lipid parameters among males was nullified. However, principal component analysis in all groups pointed obesity to be the major determinant, followed by lipid parameters, accounting for 90% of the variance. Additionally, calcium and fruit intake, post-menopausal and socio-economic status, and smoking had a significant role to play. To conclude, the present data indicates that individuals with greater abdominal obesity might pose a higher risk of developing bone metabolic diseases like osteopenia and osteoporosis, necessitating the need for evaluating the bone status in obese individuals, whilst, the role of lipid parameters still remains conflicting. This might open new avenues in understanding the mechanism underlying bone metabolism.

type:Text, PURPOSE: Immediate access to the equipment required for difficult airway management (DAM) is vital. However, in Japan, data are scarce regarding the availability of DAM resources in prehospital settings. The purpose of this study was to determine whether Japanese helicopter emergency medical services (HEMS) are adequately equipped to comply with the DAM algorithms of Japanese and American professional anesthesiology societies. METHODS: This nationwide cross-sectional study was conducted in May 2015. Base hospitals of HEMS were mailed a questionnaire about their airway management equipment and back-up personnel. Outcome measures were (1) call for help, (2) supraglottic airway device (SGA) insertion, (3) verification of tube placement using capnometry, and (4) the establishment of surgical airways, all of which have been endorsed in various airway management guidelines. The criteria defining feasibility were the availability of (1) more than one physician, (2) SGA, (3) capnometry, and (4) a surgical airway device in the prehospital setting. RESULTS: Of the 45 HEMS base hospitals questioned, 42 (93.3 %) returned completed questionnaires. A surgical airway was practicable by all HEMS. However, in the prehospital setting, back-up assistance was available in 14.3 %, SGA in 16.7 %, and capnometry in 66.7 %. No HEMS was capable of all four steps. CONCLUSION: In Japan, compliance with standard airway management algorithms in prehospital settings remains difficult because of the limited availability of alternative ventilation equipment and back-up personnel. Prehospital health care providers need to consider the risks and benefits of performing endotracheal intubation in environments not conducive to the success of this procedure.

The Anaesthetic management of patients with post burn contracture release poses many problems to anaesthesiologist. Airway management in such cases is still challenging to anaesthesiologist as the contracture and deformity due to fibrous tissue resulting in non-alignment of oral, pharyngeal and laryngeal planes, makes laryngoscopy and endotracheal intubation very difficult or impossible and this can result in many life threatening and serious complications. We report the successful airway management of a patient with restricted neck extension and fixed flexion deformity by awake nasal fibreoptic bronchoscope guided nasotracheal intubation.

Introduction Training-induced cognitive bias may affect performance. Using a simulation-based emergency airway curriculum, we tested the hypothesis that curriculum design would induce bias and affect decision making. Methods Twenty-three novice anesthesiology residents were randomized into 2 groups. The primary outcome measure was the initiation of supraglottic airway and cricothyroidotomy techniques in a simulated cannot-ventilate, cannot-intubate scenario during 3 evaluation sessions. Secondary outcomes were response times for device initiation. After a baseline evaluation and didactic lecture, residents received an initial practical training in either surgical cricothyroidotomy (CRIC group) or supraglottic airway (SGA group). After the midtest, the groups switched to receive the alternate training. Results From baseline to midtest, the SGA group increased initiation of supraglottic airway but not cricothyroidotomy. The CRIC group increased initiation of cricothyroidotomy but not supraglottic airway. After completion of training in both techniques, the SGA group increased initiation of both supraglottic airway and cricothyroidotomy. In contrast, the CRIC group increased initiation of cricothyroidotomy but failed to change practice in supraglottic airway. Final test response times showed that the CRIC group was slower to initiate supraglottic airway and faster to initiate cricothyroidotomy. Discussion Practical training in only 1 technique caused bias in both groups despite a preceding didactic lecture. The chief finding was an asymmetrical effect of training sequence even after training in both techniques. Initial training in cricothyroidotomy caused bias that did not correct despite subsequent supraglottic airway training. Educators must be alert to the risk of inducing cognitive bias when designing curricula.

Introduction: We compared the efficacy of Karl Storz CMAC TipTM with inline suction to CMAC with traditional suction device in cadaveric models simulating difficult airways, using media mimicking pulmonary edema and vomit.Methods: This was a prospective, cohort study in which we invited emergency medicine faculty and residents to participate. Each participant intubated 2 cadavers (one with simulated pulmonary edema and one with simulated vomit), using CMAC with inline suction and CMAC with traditional suction. Thirty emergency medicine providers performed 4 total intubations each in a crossover trial comparing the CMAC with inline suction and CMAC with traditional suction. Two intubations were performed with simulated vomit and two with simulated pulmonary edema. The primary outcome was time to successful intubation; and the secondary outcome was proportion of successful intubation.Results: The median time to successful intubation using the CMAC with inline suction versus traditional suction in the pulmonary edema group was 29s and 30s respectively (p=0.54). In the vomit simulation, the median time to successful intubation was 40s using the CMAC with inline suction and 41s using the CMAC with traditional suction (p=0.70). There were no significant differences in time to successful intubation between the 2 devices. Similarly, the proportions of successful intubation were also not statistically significant between the 2 devices. The proportions of successful intubations using the inline suction were 96.7% and 73.3%, for the pulmonary edema and vomit groups, respectively. Additionally using the handheld suction device, the proportions for the pulmonary edema and vomit group were 100% and 66.7%, respectively.Conclusion: CMAC with inline suction was no different than CMAC with traditional suction and was associated with no statistically significant differences in median time to intubation or proportion of successful intubations. [West J Emerg Med. 2014;15(4):548-553.]

Introduction: We compared the efficacy of Karl Storz CMAC TipTM with inline suction to CMAC with traditional suction device in cadaveric models simulating difficult airways, using media mimicking pulmonary edema and vomit.Methods: This was a prospective, cohort study in which we invited emergency medicine faculty and residents to participate. Each participant intubated 2 cadavers (one with simulated pulmonary edema and one with simulated vomit), using CMAC with inline suction and CMAC with traditional suction. Thirty emergency medicine providers performed 4 total intubations each in a crossover trial comparing the CMAC with inline suction and CMAC with traditional suction. Two intubations were performed with simulated vomit and two with simulated pulmonary edema. The primary outcome was time to successful intubation; and the secondary outcome was proportion of successful intubation.Results: The median time to successful intubation using the CMAC with inline suction versus traditional suction in the pulmonary edema group was 29s and 30s respectively (p=0.54). In the vomit simulation, the median time to successful intubation was 40s using the CMAC with inline suction and 41s using the CMAC with traditional suction (p=0.70). There were no significant differences in time to successful intubation between the 2 devices. Similarly, the proportions of successful intubation were also not statistically significant between the 2 devices. The proportions of successful intubations using the inline suction were 96.7% and 73.3%, for the pulmonary edema and vomit groups, respectively. Additionally using the handheld suction device, the proportions for the pulmonary edema and vomit group were 100% and 66.7%, respectively.Conclusion: CMAC with inline suction was no different than CMAC with traditional suction and was associated with no statistically significant differences in median time to intubation or proportion of successful intubations. [West J Emerg Med. 2014;15(4):548-553.]

Background: Complications originated in the handling of the airway represent an important cause of morbimortality associated to anesthesia. Is possible that Videolaryngoscopes make this handling easier in some specific scenarios could be better than direct laryngoscopy. The aim of this study is to present a narrative review of the different indications of use of videolaryngoscope in a variety of clinical settings. Methods: We made a nonsystematic review of literature using the Pubmed/MEDLINE database; to search studies that had as a central topic the use of videolaryngoscopes in difficult airway. Results: 21 articles were included in the final review process. Specific situations in which the videolaryngoscope becomes important were found, such as predicted difficult intubation using airway evaluation scales, patients with morbid-obesity, ICU patients, those with cervical immobilization indications and as a rescue in failed intubations using direct laryngoscopy. In addition, we found that videolaryngoscopes have a high rate of success when used by untrained and inexperienced personnel in airway handling. Conclusion: Videolaryngoscope provided greater benefits when used in specific clinical scenarios. A rigorous review is necessary to recommend the use of this new technology., Introducción: Las complicaciones que origina el manejo de la vía respiratoria representan una importante causa de morbi-mortalidad asociada a la anestesia. Los videolaringoscopios son una herramienta que parece facilitar el manejo de la vía aérea y que en condiciones específicas pueden ser más eficaces que la laringoscopia directa. El objetivo de este estudio es realizar una revisión narrativa de la literatura acerca de las indicaciones del uso del videolaringoscopio en diferentes escenarios clínicos. Metodología: Se realizó una revisión narrativa de la literatura utilizando Pubmed/MEDLINE, y se seleccionaron aquellos artículos que tuvieran como tema central el uso de los videolaringoscopios en vía aérea difícil. Resultados: Se incluyeron 22 artículos en el proceso final de revisión, encontrándose situaciones específicas en las que el videolaringoscopio cobra importancia, tales como la intubación difícil predicha mediante escalas de valoración de vía aérea, pacientes con obesidad mórbida, pacientes en UCI, aquellos con indicación de inmovilización cervical y como rescate en intubaciones fallidas con laringoscopia directa. La literatura también muestra una alta tasa de éxito cuando son utilizados por personal con poca experiencia en el manejo de la vía aérea. Conclusión: El videolaringoscopio ofrece mayores beneficios al ser usado en escenarios clínicos específicos. Se necesita una revisión más rigurosa para recomendar el uso de esta nueva tecnología.

Background: Complications originated in the handling of the airway represent an important cause of morbimortality associated to anesthesia. Is possible that Videolaryngoscopes make this handling easier in some specific scenarios could be better than direct laryngoscopy. The aim of this study is to present a narrative review of the different indications of use of videolaryngoscope in a variety of clinical settings. Methods: We made a nonsystematic review of literature using the Pubmed/MEDLINE database; to search studies that had as a central topic the use of videolaryngoscopes in difficult airway. Results: 21 articles were included in the final review process. Specific situations in which the videolaryngoscope becomes important were found, such as predicted difficult intubation using airway evaluation scales, patients with morbid-obesity, ICU patients, those with cervical immobilization indications and as a rescue in failed intubations using direct laryngoscopy. In addition, we found that videolaryngoscopes have a high rate of success when used by untrained and inexperienced personnel in airway handling. Conclusion: Videolaryngoscope provided greater benefits when used in specific clinical scenarios. A rigorous review is necessary to recommend the use of this new technology., Introducción: Las complicaciones que origina el manejo de la vía respiratoria representan una importante causa de morbi-mortalidad asociada a la anestesia. Los videolaringoscopios son una herramienta que parece facilitar el manejo de la vía aérea y que en condiciones específicas pueden ser más eficaces que la laringoscopia directa. El objetivo de este estudio es realizar una revisión narrativa de la literatura acerca de las indicaciones del uso del videolaringoscopio en diferentes escenarios clínicos. Metodología: Se realizó una revisión narrativa de la literatura utilizando Pubmed/MEDLINE, y se seleccionaron aquellos artículos que tuvieran como tema central el uso de los videolaringoscopios en vía aérea difícil. Resultados: Se incluyeron 22 artículos en el proceso final de revisión, encontrándose situaciones específicas en las que el videolaringoscopio cobra importancia, tales como la intubación difícil predicha mediante escalas de valoración de vía aérea, pacientes con obesidad mórbida, pacientes en UCI, aquellos con indicación de inmovilización cervical y como rescate en intubaciones fallidas con laringoscopia directa. La literatura también muestra una alta tasa de éxito cuando son utilizados por personal con poca experiencia en el manejo de la vía aérea. Conclusión: El videolaringoscopio ofrece mayores beneficios al ser usado en escenarios clínicos específicos. Se necesita una revisión más rigurosa para recomendar el uso de esta nueva tecnología.