Joanna Blondeau, CRNA, Staff CRNA, MedStream Anesthesia, Hilton Head Island, S.C.
Most airway management for anesthesia providers and airway experts is routine, predictable, uneventful and straightforward. However, when a challenging airway occurs in a clinical situation, it can lead to adverse effects and life-threatening consequences for the patient and anxious moments for the provider. The inability to successfully open the airway to ventilate or secure an airway with intubation are among the most challenging clinical situations that anesthesia providers encounter. Opening and securing the airway in a timely fashion is key to improving outcomes. Despite some improvements in airway management,1 these difficult events still contribute to morbidity and mortality and closed legal claims in anesthesia.2-4
Advanced airway tools have improved outcomes. Video laryngoscopes, laryngeal mask airways, positive airway pressure (PAP) devices, high-flow nasal cannula (HFNC) devices and cricothyrotomy kits all offer options for managing airways to assist patient breathing. However, core airway tools—the oropharyngeal airway (OPA) and nasopharyngeal airway (NPA)—have not advanced to address current patient needs, leaving a gap in airway management.
In the United States, the average patient is taller, heavier and older than patients from previous generations.5 These older, heavier patients are often prone to obstructive sleep apnea (OSA). Current OPA designs do not reach the distal pharyngeal tissue beyond the tongue that commonly obstructs the airway.6 An NPA can stimulate epistaxis, further compromising the airway. As a result, the risk for hypoxia due to upper airway obstruction during and after anesthesia has increased as well.7,8
To address challenges from apnea, hypoventilation or soft tissue obstruction during sedation or positive pressure ventilation, some anesthesia providers have begun to use a new distal pharyngeal airway (DPA) (Figure 1). The DPA stents open distal pharyngeal tissue beyond the tongue (Figure 2). When used with a connector, the airway also can bypass difficult mask ventilation variables with patients who have a beard, are obese or have OSA (Figure 3).
Figure 1. Distal pharyngeal airway.
All images courtesy of McMurray Medical.
Figure 2. Placement of the distal pharyngeal airway device.
Figure 3. Intraoral positive pressure ventilation while manually closing the nares and mouth.
Two case studies illustrate the utility of the new DPA device in obtaining a patent airway under urgent and difficult circumstances.
Case Report 1
A 60-year-old male with a body mass index (BMI) of 30 kg/m2 was hospitalized with COVID-19. The patient was intubated and on a ventilator in the ICU for two weeks. The surgeon was to perform a tracheostomy in the OR under general anesthesia. A bronchoscope was placed in the endotracheal tube to provide visualization of the percutaneous needle and wire placement. As the anesthesia team (anesthesiologists and CRNAs) carefully retracted the bronchoscope, the ETT inadvertently became dislodged. Oxygen saturation dropped quickly to approximately 30%. Mask ventilation and reintubation attempts by two different anesthesia providers, using both direct laryngoscopy and video laryngoscopy, were unsuccessful due to laryngeal edema from prolonged intubation. As the team was preparing for an emergent tracheostomy, an anesthesia provider quickly placed a DPA and started positive pressure intraoral ventilation. Oxygen saturation returned to baseline and the trach was subsequently successfully placed in a controlled setting.
Case Report 2
A 40-year-old male with a BMI of 40 and a medical history of cervical stenosis and bilateral arm neuropathy presented for anterior cervical discectomy and fusion (ACDF) surgery. A general anesthetic was started without incident, but intubation was challenging. After the surgical procedure was successfully completed, a hard collar was placed, and the awake patient was extubated with no coughing. However, in the recovery room, upper airway obstruction developed after the patient was medicated for pain, leading to desaturation and hypoxia.
Knowing that the patient had a challenging airway with excessive neck tissue and a large head, and that the surgeon did not want the collar to be removed to prevent disruption of the cervical repair, anesthesia personnel effortlessly placed the DPA. Intraoral ventilation was initiated and oxygen saturation reached baseline. With the DPA in place, the patient was assisted with occasional intraoral bag ventilation when saturation dropped. The DPA was removed when the patient was awake enough to maintain an open airway and adequate ventilation. The DPA proved to be an effective tool to keep the patient breathing without disrupting the surgical repair.
After this event, the nurses in this recovery room routinely used the DPA as an urgent intervention while waiting for anesthesia personnel to arrive with additional assistance. Staff who have limited intubating skills can place the DPA easily, helping to manage hypoxia quickly.
Conclusion
Airway management can be challenging in some patients. Airway tools have evolved, but traditional OPAs and NPAs historically relied upon as essential airway management devices have not advanced appreciably since their creation many decades ago. Today’s patients are more susceptible to upper airway obstruction due to increased weight, age and OSA. There is now a third option available to add to the core set of airway management tools. DPAs are easy-to-use devices that quickly open the distal tissue beyond the base of the tongue, helping to provide a patent airway, ventilation and a lower risk for hypoxia.
Blondeau reported no relevant financial disclosures.
References
- Cook TM. Strategies for the prevention of airway complications – a narrative review. Anaesthesia. 2018;73(1):93-111.
- Larson SL, Matthews RW, Jordan L, et al. Improving patient outcomes through closed-claims analysis: salient characteristics and patterns associated with respiratory events. AANA J. 2018;86(3):201-208.
- Mora JC, Kaye AD, Romankowski ML, et al. Trends in anesthesia-related liability and lessons learned. Adv Anesth. 2018;36(1):231-249.
- Cook TM, Scott S, Mihai R. Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995-2007. Anaesthesia. 2010;65(6):556-563.
- NCD Risk Factor Collaboration (NCD-RisC). A century of trends in adult human height. ELife. 2016;5:13410.
- Garvey J, Pengo M, Drakatos P, et al. Epidemiological aspects of obstructive sleep apnea. J Thorac Dis. 2015;7(5):920-929.
- Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 2014;311(8):806-814.
- Krogh M. Obesity and anesthesia practice. In: Nagelhout J, Elisha S, Plaus K, eds. Nurse Anesthesia. 6th ed. Elsevier Saunders; 2018:998-1014.
Used with permission from Anesthesiology News 3/2022