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Inside:

New SAM Members

Presidents Message

Editorial Expressions

Preview: SAM 2014

SAM 2013 Meeting

WAMM

SAM Forum E-Lights

Application
























































SAM Contacts:
Telephone: 773-834-3171
Fax: 773-834-3166
Address: 5753 Tanager St. / Schereville, IN 46375 Website:
http://samhq.com




Society for Airway Management 2013-2014
Officers and contact information

Board of Directors:

President
Richard Cooper, MD
Richard.Cooper@uhn.ca
President-Elect
Ashutosh Wali, MD
awali@bcm.tmc.edu
Vice President
Lorraine Foley, MD
ljfoley@comcast.net
Secretary
Lauren Berkow, MD
lberkow1@jhmi.edu
Treasurer
Arnd Timmermann, MD
atimmer@web.de



Immediate Past-President
Maya Suresh, MD
msuresh@bcm.tmc.edu



Executive Director:
Carin Hagberg, MD
Carin.A.Hagberg@uth.tmc.edu


Board Members at Large:

Ankie Hamaekers, MD
a.hamaekers@mumc.nl
Michael Seltz Kristensen, MD
Michael.seltz.kristensen@rh.hosp.dk
Richard Levitan, MD
airwaycam@gmail.com
Joseph Quinlan, MD
quinlanjj@anes.upmc.edu
John Sakles, MD
sakles@aemrc.arizona.edu
Felipe Urdaneta, MD
furdaneta1@mac.com





Airway Gazette Information
Editor-in-Chief:
Katherine Gil, MD
k-gil@northwestern.edu

Associate Editors:
Valerie Armstead, MD
vearmstead@gmail.com

Richard Cooper, MD
Richard.Cooper@uhn.ca


Administrative Director:
Anne-Marie Prince
amprince@peds.bsd.uchicago.edu

Layout Editor:
Kathryn Nicole Gil-Ludmer

Issues are published four times per year in
the following order: March/April, June/July,
September/October, and December/January

Material published in the Airway Gazette is
copyrighted through the Society for Airway
Management and cannot be reproduced
without its written consent.

Submissions for publication should be made
according to published guidelines at least
one month before the issues are finalized.
Submissions must cite material obtained
from other sources before publication.

Disclaimer:
Published manuscripts in the Gazette are not
necessarily reflective of views of the Gazette
or the Society for Airway Management.






























































SAM Connections:
The SAM Forum on the Internet
Twitter: Look us up on twitter: @WEBPAGESAM
Facebook: https://www.facebook.com/pages/SAM/471944679556805?ref=hl


Nick Abbott, MD (New Zealand) Sean Adams, MD (Naperville, IL)
Pilar Aguirre Puig, MD (Spain) Engin Ahmed, MD (New Zealand)
Kevin Arthur, MD (New Zealand) Shawn Beaman, MD (Pittsburgh, PA)
Richard Beck, MD (Jacksonville, FL) Dennis Boon von Ochssee, MD (New Zealand)
Jeffrey Brand, MD (Marblehead, MA) Patricia Cardoso Imperatriz, MD (Brazil)
Matthew Chia (Peoria, IL) Robert Culver, MD (Ellijay, GA)
John Crowe (Little Rock, AR) Dave Duncan, MD (Penryn, CA)
Richard Dutton, MD (Park Ridge, IL) Rob Eastan (Brooklyn, NY)
Rhashedah Ekeoduru, MD (Houston, TX) Anne Elliott, MD (New Zealand)
Suzanne Escudier, MD (Lubbock, TX) Nadia Forbes, MD (New Zealand)
Daniel Francis, MD (Houston, TX) Helen Frith, MD (New Zealand)
John George, III, MD (Pepper Pike, OH) Yair Grinberg, MD (New Preston, CT)
Zoya Haitov, MD (Israel) Deborah Harrison, MD (Stamford, CT)
David Harvey, MD (New Zealand) Melanie Hollidge, MD (Canada)
Lara Hopley, MD (New Zealand) Grant Lindsay Hounsell, MD (New Zealand)
Daniel Howell, MD (Lubbock, TX) Gareth Jenkin, MD (New Zealand)
Cynthia Jenson, MD (Waterville, ME) Usha Kolpe, MD (Oak Brook, IL)
RJ LaGrone (Benton, AR) Dianne Lieberman, MD (Canada)
Laura Lindsay, MD (Boise, ID) Jennifer Linzalone (Plantation, FL)
Tracy Lords, MD (Belt, MT) Nathan Luibrand (Little Rock, AR)
Issam Mardini, MD (Philadelphia, PA) Alonso Mesa, MD (Weston, FL)
Andrew McWilliam, MD (New Zealand) Harry Miller, MD (Beverly Hills, CA)
Michael Need, MD (Indianapolis, IN) Duc Nguyen, MD (Los Angeles, CA)
Lale Odekon, MD (Brooklyn, NY) Joanne Paver, MD (New Zealand)
Allison Pierce (Little Rock, AR) Andrew Pinto, MD (Brazil)
Carol Pinto (Santa Barbara, CA) Otoniel Puerto, MD (Sommerset, KY)
Devi Pujara, MD (Orwigsburg, PA) Marcelo Ramos, MD (Brazil)
Keith Rees, MD (Australia) Grant Ryan, MD (New Zealand)
Shilpi Seth (Chicago, IL) Richard Shockley, MD (Wellesley, MA)
Stephen Smith, MD (Ballwin, MO) Lawrence Siu-Chun Law (Durham, NC)
Tish Stefanutto, MD (Australia) Caroline Solly (United Kingdom)
Raji Swamidurai, MD (Chino Hills, CA) Mingjuan Tan (Durham, NC)
Jamie Taylor, MD (Canada) Matt Taylor, MD (New Zealand)
Jose de Jesus Teran Guevava, MD (Mexico) Cuong Tran (Plantation, FL)
Susan Trinh (New York, NY) Albert Varon, MD (Miami, FL)
Joanne VonMach, MD (Birmingham, MI) Angela Wang, MD (Fair Oaks, CA)
Yvonne Wagner, MD (New Zealand) Joanne Warren, MD (Woodstock, MD)
Jonathon Webber, MD (New Zealand) Tina Whitty, MD (Canada)
Andrew Wong, MD (New Zealand) Andrew Wong, MD (Philadelphia, PA)
Warrick Wrightson, MD (New Zealand) Jinbin Zhang, MD (Singapore)

SAM resldenL's Message

l am honored Lo have Lhe opporLunlLy Lo serve Lhe SocleLy for a second Lerm. l hope LhaL
Lhls ls a voLe of confldence and noL a remedlal asslgnmenL.

l was very pleased Lo see many of you aL our Annual SclenLlflc MeeLlng and Workshop ln hlladelphla.
Cur Lhanks Lo Lhe enLlre rogram CommlLLee and especlally Chalr and co-chalr, urs. lrene Csborn and
valerle ArmsLead, for organlzlng an ouLsLandlng evenL. 1hanks also Lo Lynn Pancock and uenlse Leary of
uMass Medlcal School Cfflce of ConLlnulng Medlcal LducaLlon and our LxecuLlve AsslsLanL Anne-Marle
rlnce, wlLhouL whom we would have been losL. lor many of us, Lhls meeLlng ls Lhe mosL valuable
academlc evenL of Lhe year. lL ls a chance Lo hear and share new ldeas ln a colleglal, almosL lnLlmaLe
aLmosphere. AlLhough our membershlp conLlnues Lo grow, Lhe meeLlngs are sLlll a slze LhaL allows a free
and producLlve exchange of ldeas.

nexL year our annual meeLlng wlll Lake place ln SeaLLle, WA, SepLember 19-21. urs. valerle ArmsLead and
lellpe urdaneLa are Lhe program co-chalrs and Lhey are exclLed abouL Lhe arrangemenLs LhaL are
beglnnlng Lo emerge. lan Lo come early. We hope Lo have speclal pre-course saLelllLe offerlngs. lan Lo
sLay laLe. SeaLLle ls an exclLlng place.

1hls year for Lhe flrsL Llme, ln cooperaLlon wlLh Cooper Medlcal School aL 8owan unlverslLy, we offered a
MCCA course on cllnlcal slmulaLlon. Amanda 8urden reporLed LhaL Lhls was very successful and rewardlng
for Lhe parLlclpanLs.

lans are underway for Lhe World Alrway ManagemenL MeeLlng ln uublln, nov 12-14, 2013. asL-
resldenLs LllzabeLh 8ehrlnger (SAM) and Lllen C'Sulllvan (uAS) are Lhe lannlng CommlLLee co-chalrs.
1hls ls Lhe mosL amblLlous lnLernaLlonal alrway meeLlng ever underLaken and lL promlses Lo be an
excepLlonal evenL. ln addlLlon Lo Lhe prlnclpal co-sponsors, SAM and uAS, oLher naLlonal socleLles wlll
parLlclpaLe. ur. 8ehrlnger wlll provlde us wlLh an updaLe as Lhe sclenLlflc program and soclal acLlvlLles are
more fully developed. Mark your calendars. 1hls meeLlng ls ln lleu of Lhe 2013 annual meeLlngs of our
respecLlve socleLles.

We are pursulng our dlscusslons wlLh Lhe AnesLhesla CuallLy lnsLlLuLe concernlng Lhe ob[ecLlve of a
naLlonwlde collecLlon of daLa Lo lmprove paLlenL safeLy, and wlll keep you lnformed as Lhlngs progress.
ur. Pagberg and l meL wlLh ur. 8lchard uuggan, ACl LxecuLlve ulrecLor, and were very encouraged
regardlng Lhls collaboraLlon.

1he ASA has agreed Lo esLabllsh a presLlge lecLureshlp-1he Cvassaplan LecLure-LhaL wlll Lake place ln
alLernaLlng years durlng Lhe ASA Annual MeeLlng. l am pleased Lo announce LhaL asL-resldenL ur.
Wllllam 8osenblaLL has accepLed our lnvlLaLlon Lo be Lhe lnaugural speaker ln 2014.

Cur SocleLy conLlnues Lo grow. We have new SAM ChapLers ln Chlna, Saudl Arabla, 8razll, and new
Zealand. We enllsLed many new members durlng Lhe ASA Annual MeeLlng, lncludlng several medlcal
sLudenLs. Such early enLhuslasm heralds an exclLlng fuLure for alrway managemenL and llkely reflecLs an
encounLer wlLh a dynamlc menLor-qulLe posslbly someone readlng Lhls message. 1hank you. CuallLy
Leachlng encourages research, boLh wlll advance paLlenL safeLy.
llnally, l wanL Lo draw your aLLenLlon Lo Lhe monumenLal efforLs of ur. lellpe urdaneLa ln creaLlng a new
SAM webslLe and leadlng us lnLo explorlng soclal medla as a professlonal socleLy. l lnvlLe you Lo check ouL
4.
our webslLe (www.samhq.com), our lacebook page, and LwlLLer feed. ?ou'll flnd llnks Lo Lhese pages on
Lhe upper rlghL hand corner of Lhe home page. ?ou'll also see our world-wlde lmpacL on Lhe membershlp
map, phoLos of meeLlngs, selecLed vldeos from our annual meeLlng, archlved coples of Lhe CazeLLe,
commlLLee reporLs, mlnuLes of meeLlngs, and much more. A greaL place Lo whlle away Lhe hours.

WanL Lo become more lnvolved? CeL ln Louch.

8lchard Cooper, Mu, resldenL, SocleLy for Alrway ManagemenL










uear colleagues. My deepesL appreclaLlon goes Lo Lhe phenomenal work done
by ur. lrene Csborn and ur. valerle ArmsLead and all Lhe members who made
Lhe SocleLy for Alrway ManagemenL's Annual MeeLlng so superb! Also, l have a
greaL appreclaLlon of Lhe parLlclpanLs for Lhelr enLhuslasm and deslre Lo help
lmprove paLlenL care. And parLlcularly, l wlsh Lo send hearLfelL Lhanks Lo Lhose
members LhaL accepLed and compleLed Lhe Lask of wrlLlng some synopses for
Lhe Alrway CazeLLe Lo beneflL fellow members, who were unable Lo aLLend Lhe
meeLlng.

Lucklly for everyone, l am golng Lo have very few remarks ln Lhls edlLorlal. ln facL, wlLh Lhe
klnd permlsslon of ur. uanlel erln, who you may recall, formed a SAM ChapLer ln 8razll, l am
golng Lo quoLe hls words here now. 1hese were orlglnally lncluded ln hls synopses and l
LhoughL Lhey reflecLed Lhe feellngs l have heard expressed many Llmes from SAM MeeLlng
parLlclpanLs:
Cnce agaln l need Lo say LhaL Lhe SAM meeLlng was amazlng. CreaL lecLures, awesome
workshops, and whaL l Lhlnk are Lhe mosL lmporLanL Lhlngs, Lhe klndness and aLLenLlon
of all Lhe experLs whlle lnLeracLlng wlLh Lhe audlence.

LasL buL noL Lhe leasL, l wanL Lo Lhank ur. lrene Csborn and ur. valerle ArmsLead for Lhe greaL meeLlng
and exLraordlnary dlnner evenL and all Lhe SLaff who Lurned SAM lnLo Lhe Lop-of-Lhe-llsL meeLlng, LhaL
makes me Lravel every year slnce 2008 ln 8osLon, Lo meeL wonderful people and dlscuss
everyLhlng abouL Alrway ManagemenL." .uanlel erln, M.u.

CongraLulaLlons Lo ur. LllzabeLh Cordes 8ehrlnger! And, an even blgger congraLulaLlon Lo Lhe SocleLy for
Alrway ManagemenL, whlch was forLunaLe Lo have beneflLLed from all of her leadershlp, devoLlon, and
energles for so many years, and rlghLly presenLed ur. 8ehrlnger wlLh Lhe 2013 SAM ulsLlngulshed Servlce
Award. Look for Lhe nexL lssue of Lhe Alrway CazeLLe for a descrlpLlon of how valuable she has been. Also,
LhaL lssue wlll have Lhe 2013 meeLlng's award-wlnnlng presenLaLlons, a hlsLorlcal vlgneLLe, meeLlng plcLures,
and more. lease send messages Lo Lhe lorum and especlally, send ln someLhlng for Lhe Alrway CazeLLe!

WlLh Lhe ldea of maklng Lhe Alrway CazeLLe more llnked Lo Lhe SAM webslLe and so forLh, l have changed lLs
appearance. lL ls evolvlng. and l hope no shoes wlll be Lhrown aL me. wrlLe a LeLLer Lo Lhe LdlLor," lnsLead.
Best regards, Katherine S.L. Gil, M.D., Editor-in- Chief

Editorial Expressions



SAMS
Official
Journal:

The
Journal of
Clinical
Anesthesia





Q
U
O
T
E
5.
"#$%&$'( )*+&$,- .*# /&#'0- 10203$4$2, /22506 1$$,&23 789:

1he organlzlng CommlLLee ln charge of our nexL SocleLy for Alrway ManagemenL Annual MeeLlng, headed by
ur. valerle ArmsLead and ur. lellpe urdaneLa, has been worklng hard Lo brlng SAM 2014 meeLlng aLLendees
an exclLlng and novel program wlLh workshops and acLlvlLles LhaL wlll provlde long-lasLlng, pleasanL memorles.
1hls meeLlng wlll Lake place ln Lhe awesome clLy of SeaLLle, WashlngLon, on SepLember 19-21, 2014. Changes
and advances ln Lhe fleld of alrway managemenL, ln Lerms of educaLlon, slmulaLlon, and research have been
lmpresslve and we are plannlng a program Lo reflecL Lhe laLesL
lmprovemenLs ln core Loplcs of alrway managemenL.

1hls year's moLLo ls 8ack Lo Lhe luLure." 1he program, speakers, and
workshops are belng assembled Lo reflecL progress and advances ln
Loplcs flrsL dlscussed decades ago, buL sLlll more relevanL Lhan ever.
We have llsLened Lo whaL SAM members have requesLed, noL [usL
wlLh regard Lo selecLlon of speakers and Loplcs, buL also regardlng
small group sesslons, audlence response sesslons, and workshop
formaLs. We plan Lo announce Lhe flnal program ln Lhe near fuLure. Fig 1. Nice airway

1he 3-year old formaL, used ln ScoLLsdale, 1oronLo, and hlladelphla for Lhe workshops, wlll conLlnue. 1hey
wlll be organlzed by urs. Lauren 8erkow and Ashu Wall. arLlclpanLs can pre-reglsLer for a llmlLed number of
sLaLlons, whlch wlll allow for a more sLrucLured and organlzed experlence. urs. Ankle Pamaekers and uavld
Wong wlll organlze Lhe absLracL selecLlon process, absLracL sesslons, and posLer presenLaLlons. lor Lhe flrsL
Llme we wlll use a web-based submlsslon process vla our SAM web page. We are looklng forward Lo agaln
havlng Lhe Lremendous success reflecLed by parLlclpaLlon from people all over Lhe world.

1he awesome clLy for Lhe meeLlng: SeaLLle was named afLer Lhe naLlve-Amerlcan chlef, Sl'ahl, and nlcknamed
Lhe Lmerald ClLy" because of Lhe abundance of green foresL. lLs cllmaLe ln SepLember usually ranges from
30l aL nlghL Lo mld 70l ln Lhe day. lL ls
one of Lhe fasLesL growlng clLles ln Lhe
unlLed SLaLes. SeaLLle ls locaLed ln Lhe
aclflc norLhwesL, 113 mlles (182 km)
souLh of Lhe u.S.- Canada border. 1he clLy
ls known for a number of famous resldenLs
(aul Allen, 8lll CaLes, Apolo Chno,
MargareL Murle, naLe 8oblnson, 8on
SanLo, Culncy !ones), many Lelevlslon
serles (lrasler, Crey's AnaLomy), and
movles (Sleepless ln SeaLLle, An Cfflcer
and a CenLleman).

Cne of lLs besL landmarks ls Lhe famous
Space needle, whlch was bullL ln 1962.
1here are oLher lmporLanL aLLracLlons such
Fig 2. Mt. Rainier as Lhe SeaLLle ArL Museum, Woodland zoo,
Lhe oldesL farmers' markeL ln Lhe unlLed SLaLes (lke lace MarkeL), and Lhe flrsL SLarbucks coffee shop, sLlll ln
lLs orlglnal 1971 locaLlon. 8uL, wlLhouL quesLlon, Lhe mosL spell-blndlng slLe near SeaLLle, ls Lhe ever-presenL
ML. 8alnler.

We look forward Lo seelng everyone Lhere. lease waLch for updaLes: homepage, lacebook, and 1wlLLer.
6.




















Dr. Carin Hagberg presented: The ASA Difficult Airway Guidelines: Whats New? She noted that
management of the difficult airway (DA) remains a challenge and the incidence of an unanticipated DA is 1-
3%. Although inadequate oxygenation and/or ventilation in operating rooms (OR) have become less common,
these problems plus difficult intubation or aspiration numbers are rising in non-OR locations, due to over-
sedation and lack of end-tidal capnography and pulse oximetry.

Dr. Hagberg reviewed the 2013 updates to the 20-year-old Difficult Airway Algorithm (DAA). They include a
definition of difficult supraglottic airway (SGA) placement or ventilation. Difficult SGA placement indicates
multiple attempts due to lack of seal or excessive resistance to movement of gas. Causes include RODS: R -
Restricted mouth opening, O - Obstruction (upper airway), D - Distortion or Disruption (upper airway), or S -
Stiff lungs. Any RODS history should be noted prior to airway management.

Factors associated with difficult laryngoscopy must be identified prior to management.

A mnemonic for patients at risk for difficult surgical airway is SHORT: S - Surgery or disrupted airway, H -
Hematoma or infection, O - Obesity (of neck), R - Radiation (of neck), T - Tumor. Difficulty identifying the
patients cricothyroid space should prompt consideration for deciding upon an awake intubation.

Video-laryngoscopes (VL) in the 2013 DAA can be used as an initial device for asleep or awake intubations or
after traditional-blade failed intubation. It is one of the biggest changes and is listed as a suggested device in
portable DA carts.

The name, Laryngeal Mask Airway (LMA) has been replaced in the DAA by supraglottic airway (SGA).
Included in this category are the LMA, Fastrach, iGel, Air-Q, Laryngeal Tube, and so forth. The Combitube and
rigid bronchoscope are no longer specifically mentioned, although it is possible to use devices not mentioned.

Retrograde intubation and jet ventilation are listed with surgical or percutaneous cricothyrotomy as invasive
techniques but retrograde intubation has been removed from a list of suggested devices in a DA cart because of
excessive time needed.

A plan for extubation of DA patients must also be made preemptively.
TAKE HOME MESSAGE: A through airway history and examination is critical. Know the 2013 DAA.
Remember SHORT and RODS.
SAM 2013 ANNUAL MLL1ING SNCSLS
Moderator:
Richard Aghababian, M.D.





The ASA Difficult Airway Guidelines: Whats New?
Carin Hagberg, M.D.

synopses authored by
Beth Ann Traylor, M.D.,
Indianapolis



Session I Airway Collaboration I




7.




The Difficult Airway Response Team - Ongoing Results/Challenges discussion was
undertaken by Dr. Lauren Berkow and Dr. Lynette Mark. The DART program, at Johns Hopkins is a
multidisciplinary team of anesthesiology, otolaryngology, surgery, and emergency medicine attendings and
residents, begun in 2008. It serves to provide safe intervention for airway emergencies, dissemination of
information to other health providers, and education, including all-day simulation courses four times a year.
High-risk patients are identified with DA bracelets and DA letters. Relevant information is communicated
during handoffs and documented in medical records. Uniform DART carts are present in multiple locations.

Since the inception of DART, the program has responded to 7-10% of code calls, had over 150 residents
complete the airway course, noted a significant decrease in airway-related non-OR events, and observed
improved resources inside the OR for unanticipated difficult intubations.

Standardization and a team approach have impacted outcomes. Change takes time and money. The OR still
plays an important role in completion of non-OR airway management, including less frequent, but more
complex pediatric DA management.

TAKE HOME MESSAGE: A multi-disciplinary team aimed at patients with complex airway issues, has
proven successful to reduce the incidence of sentinel airway-related events at Johns Hopkins. They suggest that
everyone consider organizing a similar team at other institutions.











Dr. Scott Weingart introduced the concept of being a resuscitationist during his presentation of Airway
Management in the Emergency Department - Whose Turf is it? In the emergency department (ED), 1/25
patients requiring emergency intubation are likely to have cardiac arrest. Regardless of specialty, the
resuscitationist must consider the patients pathophysiology; have a plan for airway management, a reviewed
checklist, and a plan (if required) for a surgical airway. To avoid arrest, the resuscitationist must work to
optimize conditions prior to intubation and remember HOP: H - Hemodynamics (optimize them), O-
Oxygenation (maximize it), P ph (reduce acidosis).

If intubation is indicated, there must be adequate patient preparation and proper equipment, including DA
adjuncts. If a surgical airway is required, decision-making to do so is the hardest part. This concept was
reiterated several times at this meeting. A quick and easy way to do a surgical airway is the bougie-aided
cricothyrotomy requiring a scalpel, finger, and bougie.

TAKE HOME MESSAGE: The ED is often different from the operating room, requiring hemodynamic
resuscitation of patients as the initial maneuver and then airway management. Decisions for surgical airway
should be made early, before it is too late.




Difficult Airway Response Team
Ongoing Results/Challenges
Lauren Berkow, M.D., Lynette Mark, M.D.

Airway Management in the Emergency Department - Whose Turf is it?
Scott Weingart, M.D.
8.

















During the lecture titled: Collaboration with ENT: What can we learn, what can we teach? Dr. David Healy
emphasized this sentence: Standardize what you can and communicate what you cant. Talking improves
patient care. It is clear that communication with each team member involved with the case (anesthesia, staff,
surgeon) is fundamental for patient safety.

He also commented about Lean Project. Lean is a management system designed to enhance productivity by
eliminating causes of time wastage, resources, and ineffective activity. The application of this technique to a
single operating room and surgical service improves efficiency and morale, sustains resident education, and can
provide considerable financial gains. Identification of MUDA (major areas of waste) and thinking about
solutions will help everyone to improve quality and security.

Dr. Healy also stressed that it is important to reach a consensus where you can: preoperative, intraoperative or
postoperative. Keyword: COMMUNICATION.












Dr. Keith Haller, during the lecture Evolution of new pediatric airway techniques and algorithms, reported on
the largest case series (350), using video-laryngoscopy in pediatric patients with airway anomalies. Infants,
children and young adults with congenital vascular and lymphatic malformations of the head and neck present a
unique set of challenges to the anesthesiologist.

Methodology included inhalational induction of general anesthesia, maintaining spontaneous respiration,
obtaining intravenous access, and administering appropriate doses of Fentanyl and Propofol before
instrumentation of the airway. Then, laryngoscopy was performed with an age-appropriate size of GlideScope
video-laryngoscope (Verathon, Inc.). Patients who could not be intubated with this technique were submitted to
another technique including combined GlideScope VL / fiberoptic bronchoscope (FB), FB alone, or a
Lindholm bivalve laryngoscope with zero degree rigid scope.

Moderator:
Valerie Armstead, M.D.





Collaboration with ENT: What can we learn, what can we teach
David Healy, M.D.

synopses authored by
Daniel Perin, M.D.,
Brazil



Session II Airway Collaboration II





Evolution of new pediatric airway techniques and algorithms
Keith Haller, M.D.
9.
The benefits to anesthesiologists were: a database for visual airway history and physical inspection. Twelve
teaching modules in a 2-DVD set were divided into three categories: 1) teaching for successful laryngoscopy, 2)
adapting to various anatomical challenges, and 3) diagnostic use of video-laryngoscopy.

The benefits to surgeons were acquiring therapeutic strategy-planning and decision-making capabilities.

Finally, the benefits to patients were visual tools for teaching parents and patients, and the development of the
Airway Passport. This Passport concept was very interesting. A DVD/USB copy of the laryngoscopy can be
given to the patient in a manner similar to medical alert bracelets and in case of an emergency surgery in which
anesthesia is required. An anesthesiologist unfamiliar with the patient can view the videos and know what to
expect on intubation. Keyword: AIRWAY PASSPORT.











Dr. Katherine Gil talked brilliantly about Medical missions Who should go? What should they bring? It was
a great lecture and also an excellent guide to everyone who wants to go to a mission abroad. You need to think
about what equipment you will have to carry and how to adapt this equipment and any existing equipment
according to the reality of the mission site.

Decide what kind of mission you are more inclined to (routine or disasters) and try to figure out what are the
mission supports because they can be very variable.

Anticipate medical mission effects and assess mission fitness. Participating in a mission means that you will
need to have good qualifications, good professional skills, and great adaptive skills including language skills.

You will need to ask some questions: What is missing? Do we have professional resources?

Look for free medical supplies for physicians on various Internet sites, try to use your networking, and consider
enlisting a biomedical engineer and/or an anesthesiology technician. Whatever missions you decide to go on,
check it out for safety/efficacy and try to resolve problems in a smart way.

Dont forget about possible negative mission effects like multiple vaccinations, anti-malarial drugs, health risks,
loss of vacation time, debriefings, media interviews, and be prepared for some missions where people will die!

Be sure that you will benefit from the positive mission effects: privilege of assisting patients, learning what
floor nurses do, working with caring people, incredible memories, and finally many wonderful people.
Keyword: PREPARE YOURSELF.









Find all the information you need on the SAM website at
http://www.samhq.com
Airway Gazette publishing guidelines are also on the website



Medical missions Who should go? What should they bring?
Katherine Gil, M.D.

















During his lecture entitled, Research in Airway Devices: What Questions Should We Be Asking? Dr. Michael
Aziz explained different study designs (cohort, observational, randomized controlled trials, and systematic
reviews).

He emphasized the FINER criteria:

1) Feasible: ask yourself a question and fine tune a hypothesis, conduct a power analysis, and use collaboration
with others such as statisticians, epidemiologists, and experts
2) Interesting: you must be interested and the reader must be, too; ask your colleagues to give their opinions
3) Novel: try approaches that havent been studied
4) Ethical: use the local research integrity offices
5) Relevant: ask yourself if the subject will change your practice, if it will definitely answer the question, or will
it guide future research

In conclusion, research ideas should be first exposed to the FINER criteria and ensure that the study is
feasible and relevant. Also, the effect size and the sample size estimates are critical. And, if possible, it is
always good to try something new.












Simulation Research: Are Trainees the New Guinea Pigs? was presented by Dr. Meltem Yilmaz and Dr.
Ljuba Stojiljkovic who stated that the technical skill learning curve in airway management consists of three
phases: cognitive, integrative, and automatic. The cognitive phase consists of observing a procedure and trying
to replicate observations. During training, this phase is prone to cognitive errors.

It was affirmed that we have two types of thinking: System 1: Intuitive and System 2: Rational. System 1 is
automatic, neglects ambiguity, and suppresses doubt. It executes skilled responses and generates skilled
intuitions after adequate training but is prone to bias because it relies on the most readily available answers and
Moderator:
Arnd Timmermann, M.D.





Research in Airway Devices:
What Questions Should We Be Asking?
Michael Aziz, M.D.

synopses authored by
Mauricio Amaral, M.D.,
Brazil




Session III Collaboration in Research





Simulation Research: Are Trainees the New Guinea Pigs?
Meltem Yilmaz, M.D., Ljuba Stojiljkovic, M.D.
11.
is not capable of statistical thinking. System 2 is slow and easily distracted or overwhelmed. It is responsible for
editing, questioning, and correcting. It is directly impacted by time pressure and can easily defer to system 1s
conclusions. It requires continuous exertion: vigilance. Its clinical effect on trainees, include dilated pupils and
increased heart rate.

The imbalance between these two systems leads to judgment errors and bias. The concept of cognitive ease is
what makes one susceptible to illusions, while cognitive strain shifts one from intuitive to analytic thinking.
Unless System 2 is activated, judgment and decisions will be shaped almost exclusively by bias and
illusion/intuition.

It was concluded that in the case of emergency airway training, selection and order of presentation of examples
and stimuli affected decision-making and vulnerability to cognitive bias and the curricular design should
consider potential effects of cognitive bias and errors.











Dr. Yandong Jiang discussed Ventilation via the Nasal Route: Implications for Resuscitation. He showed that
in 2010, the American Heart Association guideline for cardiopulmonary resuscitation stated that for most adults
with out-of-hospital cardiac arrest, bystander CPR with chest-compression-only resuscitation appeared to
achieve outcomes similar to those of conventional CPR.

However, for children, conventional CPR was superior. He explained that one recent finding published in 2011
in the BMJ stated that conventional CPR was associated with better outcomes than chest compression-only CPR
for one-month survival and neurologically favorable one-month survival.

Dr. Jiang also showed studies indicating that the nasal route is better than the oral route for ventilation in three
scenarios: under general anesthesia, during sleep, and during pediatric CPR.

He compared nasal-mask ventilation versus face-mask ventilation, and mouth-to-mouth breathing with the head
in neutral or extended positions versus mouth-to-nasal breathing with the head in neutral or extended positions.
The study concluded that nasal-mask ventilation produced more effective ventilation than that by face-mask.
Also, mouth-to-nose breathing was more effective than mouth-to-mouth breathing with the head in a neutral
position.

Finally, he concluded his lecture by saying that the nasal route ventilation is more effective than oral route in
emergency situations but the efficiency and effect on outcome of the victim requiring CPR remains to be
established. We need more research to decide if ventilation should be abandoned during field CPR.








For All SAM MEMBERS
We all appreciate getting tips on airway management
Please help your colleagues: Send in your TIPS and TRICKS, case reports,
ideas for topic reviews, work projects, and/or research.
E-mail k-gil@northwestern.edu




Ventilation via the Nasal Route: Implications for Resuscitation
Yandong Jiang, M.D.

synopses authored by
Katherine Gil, M.D.,
Chicago




















The DAS Speaker, Dr. Peter Groom, began his explanation of Management of the Anticipated Difficult
Airway with a description of the fascial deep neck spaces. Their
importance is due to intercommunication where cases of infection can
spread extensively, leading to upper airway obstruction with high mortality
rates (mediastinitis 40-50%, carotid artery rupture 20-40%, Lemierres
syndrome 60%) and possible osteomyelitis causing spinal cord injury. The
five deep spaces are shown in figure 1. Infections can spread wickedly fast
in diabetics or immunosuppressed patients and usually are due to
odontogenic causes in adults or tonsillitis in children.
To complete a thorough preoperative assessment, he emphasized analyzing
answers to six questions: Fig. 1 Middle: five spaces
1) How much time is there?
Nonerequires immediate action
Some timeactions may improve or worsen the time frame
Enough timethese latter two can be differentiated by symptomatology (degree of sepsis, trismus,
temporomandibular joint involved, stridor, dysphagia, drooling, and/or immobile tongue). Nasal
endoscopy and radiologic studies may help.
2) Which spaces are affected?
Floor of the mouth is most worrisome for airway compromise
Submasseteric is a lesser concern
Ludwigs angina is associated with very rapid infectious spread
3) How compromised is the airway?
Any of the symptomatology mentioned may reflect compromise. Plus, how septic the patient
appears, whether there is rigidity of the mouth floor, mediastinitis, extensiveness of cellulitis,
and the likelihood of performing a successful tracheostomy are factors for consideration.
4) What airway access is feasible? nose, mouth, neck
5) Which airway management plan is best?
6) What could make the situation worse? such as
Direct laryngoscopy (DL): rupturing an abscess, airway soiling, failed intubation, trauma, edema
Awake nasal intubation: Similar to DL, plus excess sedation, epistaxis
Awake tracheostomy: trachea not found, airway loss, bleeding, and infection

He advised that a clear understanding of the situation, equipment preparedness, and colleague consultation
might be of prime importance.
Dr. Groom finished the session by reminding everyone of the post-operative concerns, such as whether or not
the patient needs to remain intubated. Knowledge of the possibility of worsening edema, airway monitoring,
Moderator:
Richard Cooper, M.D.





DAS Speaker:
Management of the Anticipated Difficult Airway
Peter Groom, M.D.
Session VI Plenary Session




DAS
Representative
13.
and communication of patient problems prominently displayed, are all valid points to keep in mind. When
planned difficult extubation is considered, appropriate plans and settings should be investigated.











LTC Robert Mabry, MD gave an overview of Lessons from the Battlefield: Airway Casualties and
Preparedness that kept hushed participants on the edges of their seats with an engrossing video of trauma
occurring to an actual soldier during battle, up to the point of assistance from his companions.

Dr. Mabry emphasized the differences associated with military casualties including the fact that the battlefields
are often in close proximity to hospitals. Fellow military personnel frequently manage injured patients in
dark, noisy surroundings. These assistants are often comrades in peril, attempting to give medical treatment and
often, what often amounts to life-saving care from only a backpack full of equipment. Casualties are more
likely to be multiple and have distinct injuries.

Commonly, combat medics and corpsmen have EMT-B level
training, mostly on mannequins, including SGA and surgical
cricothyrotomy (CT) and often are in combat for the first time.
Most medical officers are primary care specialists with training
including rapid sequence induction and intubation. Often there is
no oxygen, suction, or refrigeration.

Outcomes for prehospital combat patients included correctly
placed endotracheal tubes in 94% of patients. In contrast, for
most vertical incision CT, success was noted to be ~75%. Dr.
Mabry presented an algorithm for improved CT success shown in
figure 2. He described a study on cadavers comparing standard
CT to a bougie style device allowing for visual and tactile
confirmation of CT placement. This latter device was associated with faster CT placement and much more
successful intratracheal placement.

Future problems needing resolution within the military arena included optimal traumatic brain injury
management in the field, a consensus as to which is the best SGA, sedation options, technology advances such
as a small end-tidal carbon dioxide monitor, and training of medical personnel.









Dr. Eric Hodgson presented a discussion of the Management of Difficult Airways with Limited Resources,
starting with the three As of airway management: 1) Assessment of laryngoscopy and mask ventilation with
rescue backups as either supra or infraglottic, 2) Apparatus location, and 3) Attempt at optimal laryngoscopy.
Difficult laryngoscopy in turn was more likely in the presence of the four Ds: 1) Distortion of airway, 2)
Dentition problems, 3) Disproportion of anatomic structures, and 4) Dysmobility of neck and so forth.

Ovassapian Lecture: Lessons from the Battlefield:
Airway Casualties and Preparedness
LTC Robert Mabry, M.D.
Ovassapian
Memorial Lecture

International Speaker: Management of Difficult Airways
with Limited Resources
Eric Hodgson, M.D.
International
Lecturer
14.

Supraglottic difficulty was anticipated with the mnemonic, RODS: Restricted mouth opening, Obstruction of
upper airway, Distortion/disruption of trachea, and Stiff lungs.
Infraglottic difficulty could be suspected with the mnemonic, SHORT: Surgery in the area, Hematoma or other
problem causing impalpability of the CT space, Obese or impossible access, Radiation or Trauma in the neck.

Dr. Hodgson remarked on how anesthesia providers had to choose equipment that everyone would come to
know, do this wisely in terms of cost, and had to be resourceful when equipment was unavailable.

He described cheaper single-use fiberscopes that possibly could be re-used in limited resource situations. He
showed pictures of a cut oropharyngeal airway adapted as an intubating oral airway. Retrograde intubation is a
commonly used, cheaper technique for difficult intubation patients when significant desaturation is not present.

Dr. Hodgson favoured training teams in practice simulation scenarios. He advocated optimization of airway
maneuvers, including experienced providers, optimal position, sufficient assistance, appropriate devices, and
adjuncts.

If the ETT goes into the esophagus, he suggested keeping it there to allow removal of gastric contents and
prevention of a repeat occurrence of this happening. Reverse transillumination for intubation and radiologic
support are also worthwhile.

He also advocated improving the lost art of facemask ventilation skills by obligating the mask ventilation of all
patients for the first 20 minutes of anesthesia (where not contraindicated). Similarly, he recommended increased
use of blind nasal intubation (while utilizing cuff inflation to direct the tip anteriorly) and the use of VL. He also
advised that airway management providers should try to obtain Combitube and CT experiences.

Particularly, Dr. Hodgson observed that for ecological and economical purposes, many devices considered
disposable or having limited reusability, are being reused many times after appropriate cleaning (such as the 40-
use LMA, which in South Africa may be used over 140 times).




















The lecture titled: Intubation Via a Supraglottic Device, was thoroughly detailed by Dr. David Wong. He
initially discussed the 2013 ASA Difficult Airway Algorithm and paid particular attention to the steps that
occurred in sequence subsequent to unsuccessful beginning attempts at intubation. The next step was an attempt
at facemask ventilation. If this is proved to be unsuccessful, SGA or attempts at other methods of intubation
were the succeeding steps. He compared this to the 2004 DAS Difficult Airway algorithm, which after initial
intubation failure, quickly moves on to placement of ILMA or LMA devices as a plan B, followed by intubation
through either device. Plan C reverts to face mask ventilation if plan B is unsuccessful for oxygenation through
either of the two devices.
SAM 2013 SNCSLS art Deux
Moderator:
Lorraine Foley, M.D.





Intubation Via a Supraglottic Device
David Wong, M.D.
Session VII How I Do It Some Real World Solutions




15.
Dr. Wong described several SGA devices which permitted passage of a full adult-size ETT, including the ILMA
(Fastrach), air-Q, and i-gel and noted that others brands were also available. In contrast, LMA variants such as
Classic, Supreme, or Proseal have problems with passage of these sizes for various reasons (tube size, aperture
bars, and so forth) and require insertion of some sort of introducer (such as an Aintree catheter through these
SGA devices with a secondary step of railroading an ETT over the introducer catheter.

He described the advantages of intubating through a SGA, including: use for unanticipated difficult intubation,
patient being asleep and paralyzed, ability to use SGA devices in bloodied or collapsed airways (bloodied
material within the SGA should be suctioned before passing the ETT), and ability for SGA rescue ventilation.

Lastly, Dr. Wong indicated what should be done for cannot intubate, cannot ventilate situations in the
following steps:
1) Remove SGA and perform FOI
2) Remove SGA, and use a GlideScope
3) Remove SGA, place an intubating SGA, and intubate through it
4) Intubate via the SGA








Dr. Sonia Vaida spoke expertly on the topic of Exchanging a Combitube / Easy-tube / King LT for a
Definitive Airway. She described endoluminal exchanges (Endo E) with exchange catheters (fiberoptic or
blind wire-aided) and extraluminal exchange (Extra E) methods.

Extra E methods may require at least partial deflation of the devices cuff (note that the King has a single
inflation design for both cuffs, as opposed to the other two devices, which have separate cuff inflations. For the
Extra E method, a pediatric fiberscope is passed intranasal and the pharyngeal cuff is deflated to allow passage
toward the larynx. Even partial deflations of the pharyngeal cuffs however, often still allow relatively adequate
seals and oxygenation/ ventilation. Increased muscle tone and spontaneous movement of the epiglottis and
vocal cords during spontaneous ventilation improve identification of the epiglottis and larynx.

Endo E usually take ~40% less time than Extra E which average ~110 seconds, with advantages of coursing a
shorter distance and allowing continued oxygenation/ ventilation.

Problems with exchanges include: 1) loss of airway, 2) the need for assistance, 3) complexity of procedure, and
4) through the King LT, cuff deflation may not allow ventilation because both cuffs deflate simultaneously.











The introduction of Pediatric ICU Patient, Re-intubation! by Dr. Paul Baker was prefaced by statistics
showing that 35% of pediatric ICU patients requiring intubation have moderate or severe tracheal injury and
unplanned extubation averages 0.1 to 2.3 events per 100 intubation days. Of these, 1% suffers cardiac arrest.


Exchanging a Combitube / Easy-tube /King LT
for a Definitive Airway
Sonia Vaida, M.D.

Pediatric ICU Patient, Re-intubation!
Paul Baker, M.D.
16.
Risk factors for reintubation include prolonged mechanical ventilation, caregiver activity, sedation within two
hours, copious secretions, and full ventilation at the time of the incident.

The ICU setting can be problematic if information, familiarity, equipment, or assistance is missing. He
recommends that the patients cardiovascular status is optimized, the patients history and physical examination
(including airway) should be known, oxygenation is maximized, equipment is prepared, experts and expert
assistance is available, sedation/relaxants are available, monitoring is prepared, and a thorough management
plan is created. If necessary, patients should be transferred to more familiar surroundings such as the operating
room for those airway providers that are more comfortable there.

High flow nasal or oropharyngeal oxygen cannulae may be particularly beneficial when applied concomitantly
during airway control procedures.

More than 2 attempts at laryngoscopic intubation were more commonly associated with problems compared to
!2 attempts in a study by Mort TC (Anesth Analg 2004). Problems in the more than 2 attempts at intubation
group included seven times (7X) the occurrence rate for hypoxemia, 10X for regurgitation, 14X for aspiration,
14X for bradycardia, and 16X for cardiac arrest. Those patients also had 5X the incidence of awareness.

Finally, Dr. Baker also emphasized the importance of timing and thoroughly planned management of extubation
in these patients.



















Dr. John Sakles had the Pro side in the debate over: Video-Laryngoscopy vs. Direct Laryngoscopy in Pre-
Hospital Airway Management. Aside from better teaching, there were many patient benefits that favoured VL.

He noted multiple studies indicating the better views of the larynx, higher success at difficult intubation, and
greater rescue of patients with VL (such as after intubation failed by direct laryngoscopy). In addition to this,
the shorter learning curve made sense to use this technique in pre-hospital airway management.

Dr. Richard Levitan advocated for direct laryngoscopy, emphasizing reported complaints during VL intubation
attempts: the view of the larynx is wonderful, but the endotracheal tube cannot be inserted through the larynx.

He also cited problems with VL such as increased time needed for intubation compared to direct laryngoscopic
intubation, complications unique to VL, equipment failure, the possibility of blood or secretions obscuring the
view when using VL compared to direct laryngoscopy, and costs.
Moderator:
Felipe Urdaneta, M.D.





Video-Laryngoscopy vs. Direct Laryngoscopy
in Pre-Hospital Airway Management
Pro: John Sakles, M.D. vs Con: Richard Levitan, M.D.
Session VIII PRO-CON Debates




17.







Dr. Michael Seltz-Kristensen took the Pro side in favour of taking a look at a patients airway before inducing
general anesthesia, in situations where there was any doubt as to the presence of an easy airway.

He cited factors such as gaining information prior to difficult airway management rather than approaching the
situation blindly. He also noted Dr. William Rosenblatts study on nasal endoscopy and association with the
prediction of difficult airway management.

On the other side, Dr. Ralph Slepian presented arguments against the idea of: If You Can See It, Put the Patient
Off to Sleep! The Awake Look. He noted no documented large prospective studies on difficult airway patients
and the success of taking a look beforehand.

He also cited a number of occurrences when the airway was very difficult to handle once anesthesia was
induced and muscle tone was lost, even though the quick look indicated otherwise.











Dr. Paul Baker was very much in favor of the Pro side of the statement: Muscle Relaxants Are Preferred for
the Anticipated Difficult Airway in Pediatrics. He emphasized the fact that laryngospasm is the most common
cause of respiratory factors resulting in cardiac arrest in these situations.

He noted that muscle relaxants (succinylcholine) are more likely to allow mask ventilation and difficult
intubation and do less disservice than the deeper anesthetic that would be otherwise required. Trauma to vocal
cords and secondary respiratory consequences of difficult intubation are also less frequent with muscle relaxant.

Dr. Narsimhan Jagannathan itemized problems with muscle relaxants such as the need to provide positive
pressure ventilation (less hands free), the difficulty to reverse non-depolarizing muscle relaxants within a short
period of time, and the possible inability to oxygenate/ ventilate if there is airway compression.

He also noted that advantages of continued spontaneous ventilation, in addition to the opposite of the above
situations, included a better setting for inexperienced clinicians and the possibility that some patients might
have a bad reaction to muscle relaxants.








If You Can See It, Put the Patient Off to Sleep!
The Awake Look Is a Valid Technique vs. Not
Pro: Michael Seltz-Kristensen, M.D. vs
Con: Ralph Slepian, M.D.

Muscle Relaxants Are Preferred for the
Anticipated Difficult Airway in Pediatrics vs Not
Pro: Paul Baker, M.D. vs
Con: Narsimhan (Sim) Jagannathan, M.D.

The Society for Airway Management is a

501(c)(3) or not-for-profit organization














Dr. Patrick Olomu (Airway Teaching in Nigeria: Challenges and Rewards) related his experiences in Nigeria, of
conducting airway training for Nigerias first organized advanced airway workshop. He met health leaders,
including the Nigerian Secretary of Health and obtained firsthand knowledge on the state of anesthesia care.
There is less than one anesthesia provider per 170,000 residents. One out of every 100 maternal deaths is
directly related to anesthesia.

Challenges included: faculty training, transportation, funding ($25,000 in equipment and supplies were
donated), personal security, and resistance by US companies to do business with Nigeria.

Goals were airway education, training of super users to oversee other learners, and networking activities for
anesthesia providers and other healthcare personnel involved in airway management. The two-day curriculum
included a workshop so popular that the faculty had to repeat it. One hundred and fifty eager participants
received a DVD of reference materials and certificate of course completion.

Dr. Olomu presented two cases in which donated equipment and skills learned in the workshop proved to be
lifesaving.

Future goals include obtaining more supplies, ongoing training sessions, establishment of an online airway
forum, and support /encouragement of anesthesia resident training to grow in the anesthesia workforce.










Dr. Elizabeth Behringers topic, Airway Equipment Guidelines: Is Recycling an Option? gave a very timely
discussion of considerations in the evaluation process for choosing reusable over disposable equipment.

Cost per use, environmental sustainablilty, and mandates of cleaning/processing equipment were cited as factors
to determine the break-even point in the example of fiberoptic bronchoscope use. Analysis showed that fewer
numbers of FOB use per month favored disposable equipment. Another analytic tool, lifecycle assessment of a
device, favored reusable Laryngeal Mask Airways over disposables due to environmental impact from
manufacturing and packaging polymer production.

The risk of infection from equipment was highlighted by a report of five neonatal illnesses and two deaths
attributed to pseudomonas from laryngoscope blades. Health Care Infection Control Practices Committee
(HICPAC), JCAHO, and the CDC have since designated laryngoscope blades and handles as semi-critical
Moderator:
Ashutosh Wali, M.D.





Airway Teaching in Nigeria: Challenges and Rewards
Patrick Olomu, M.D.

synopses authored by
Marie Young, M.D.,
Philadelphia



Session IX Current and Future Trends





Airway Equipment Guidelines: Is Recycling an Option?
Elizabeth Behringer, M.D.
19.
devices, needing high-level disinfection and sterilized blade packaging. JCAHO has deferred to individual
state mandates regarding sterilization as applied to handles.

Dr. Behringer cited barriers to effective changes in behavior for personnel, including low infection risk,
financial/logistical factors, and staff apathy.

She concluded by reminding attendees of Dr. William Rosenblatts not-for-profit organization: Recovered
Medical Equipment for the Developing World (Remedy), to send appropriate unused medical supplies to
countries for global aid and encouraged SAM membership to support this effort.









The right amount of the right drug at the right time for managing the airway was the introduction to Dr.
Michael Seltz-Kristensens thoughtful discourse on Drugs for Airway Management.

He noted that for airway management specialists, the balance between airway protection and patency requires
considerable clinical judgment and represents much of what we do. Yet, this topic is not well addressed in the
many airway algorithms and guidelines.

His dramatic video of induced laryngospasm reminded the audience that patient risk for laryngospasm is
greatest during light anesthesia. He tackled the classic controversy over ventilate then paralyze versus
paralyze then ventilate, with data illustrating that paralysis does not guarantee ability to mask ventilate, but it
often improves and doesnt worsen the ability to ventilate. Since the use of short-acting neuromuscular
blockade drugs (NMB) does not guarantee return of spontaneous ventilation before the onset of hypoxia, and
ventilation is further suppressed by concomitant use of sedatives and opioids, he recommended choosing
succinylcholine or ultra short-acting, rapid-onset NMB if administered before ventilation is attempted.








Dr. Leonard Pott reported on the activities of the SAM Research Subcommittee. A blinded panel for the 2013
meeting accepted 57 abstracts. The high quality of the submissions was noted. Future meetings will require a
standardized format for the presentations.

Two $5000.00 research grants were awarded. Members were encouraged to apply for funding.

He solicited audience feedback in determining the direction the SAM Research Subcommittee should take. Two
bibliography formats were presented (posted on the SAM website). The first is more learning/education
focused. The second format includes SAM member publications from the past five years, with members names
highlighted. The audience was asked whether providing unique identifiers (e.g. PMID or DOI) would enhance
the value of the bibliographies and a significant majority felt that this was unnecessary. Nearly 90% of the
audience responded affirmatively that SAM should act as a brokering service for multicenter research.

Drugs for Airway Management
Michael Seltz-Kristensen, M.D.

SAM Research Projects
Leonard Pott, M.D.
20.

















Save Lhe uaLe for WAMM 2013 - Lhe llrsL World Alrway ManagemenL MeeLlng!
An exclLlng [olnL venLure of Lhe SocleLy for Alrway ManagemenL (SAM) and Lhe ulfflculL Alrway SocleLy (uAS) ls
on lLs way! 1he flrsL World Alrway ManagemenL MeeLlng (WAMM) wlll Lake place ln uublln, lreland from
november 12-14, 2013. 1hls flrsL of lLs klnd meeLlng wlll commemoraLe Lhe 20Lh Annlversary of each SocleLy.
1he 3-day meeLlng wlll showcase a one-day alrway workshop LaughL by lnLernaLlonal experLs, plenary
sesslons, round Lable sesslons, and keynoLe speakers.

Cne plenary sesslon wlll be devoLed Lo Lhe besL absLracLs of Lhe meeLlng. 1wo posLer sesslons wlll be
dedlcaLed Lo a varleLy of Loplcs ln baslc and advanced alrway managemenL. 1he conference ls dedlcaLed Lo
showcase Lhe besL sclenLlflc and educaLlonal lnformaLlon on advanced alrway managemenL whlle engaglng a
worldwlde audlence.

1ours of uublln, Lhe exclLlng CaplLal clLy of lreland, wlll be offered. A gala evenlng evenL wlll be held on lrlday,
november 13, 2013.
urs. LllzabeLh C. 8ehrlnger (asL resldenL of SAM) and Lllen C'Sulllvan (asL resldenL of uAS) serve of Co-
Chalrs of WAMM 2013. CLher sLellar members of Lhe WAMM organlzlng commlLLee lnclude urs. Carln
Pagberg (SAM LxecuLlve ulrecLor), 8lchard Cooper (currenL SAM resldenL), Anll aLel (London, uk), Mlchael
SelLz krlsLensen (Copenhagen, uenmark), aul 8aker (Auckland, nZ), !. 8ernard Llban (London, uk), Ankle
Pamaekers (MaasLrlchL, neLherlands), and Arnd 1lmmermann (8erlln Cermany). AddlLlonal lnformaLlon can be
found aL Lhe WAMM webslLe: www.WAMM2013.com
















21.









SAM Iorum L-L|ghts. Felipe Urdaneta, M.D.





When d|scuss|ng the usefu|ness and a need to rev|se our D|ff|cu|t A|rway Carts (DAC's) someone
brought up the po|nt of wasted equ|pment. W|th ava||ab|||ty of newer dev|ces such as SGDs (or SGA), VLs,
and I8, do we rea||y need a DAC? now often have you used your DAC, and wh|ch type of equ|pment do you
use? What about stuff that rare|y gets used? Dr. kather|ne G||

A) Cur uAC's serve as a plaLform for Lhe flexlble l8's, and oLherwlse are Lasked for holdlng oLher supplles,
whlch are rarely needed or used. Also, Lhe uAC hold double lumen Lubes ln some cases for our 1horaclc cases.
Pavlng Lhe Clldescope vL on lLs own rolllng sLand does lncrease lLs moblllLy. ur. !ames uuCanLo

8) 1lmely dlscusslon. l Lhlnk we do need a uAC for Lhe less commonly used lLems, lncludlng Lhe bronchoscope,
lnLubaLlng LMA', Alrway exchange and oLher alrway caLheLers, and some oLher speclalLy devlces such as !eL
venLllaLlon. ln our experlence, as good as vL's are, Lhey are noL Lhe soluLlon Lo all problems and we need
addlLlonal lLems Lo be readlly avallable. ur. Charles WaLson

D.//.@%4$E now often do you or does anyone e|se ever use spec|a| a|rway dev|ces such as retrograde
|ntubat|on k|ts, comb|tubes, [et vent||ators, etc. once a month, once a year, once every ten years? Ior
those that have |arge C.k.'s or |ocat|ons |n d|fferent bu||d|ngs or f|oors do you have DAC's at each |ocat|on?
Dr. kather|ne G||

C) We use Lhe lCS (l8) ofLen. 8eLrograde rarely now LhaL Clldescope ls here. lor many, Lhe vL has become Lhe
newesL hammer and nall" LhaL ls forced lnLo every slLuaLlon as uL (dlrecL laryngoscopy) was ln pasL. l sLlll
Lhlnk we need several useful opLlons. ur. Charles WaLson

u) We have #3 uAC's for Lhe maln C8 (22 rooms), and #3 ln Lhe "PearL 1ower". lL ls lnfrequenL LhaL anyLhlng
aslde from Lhe Clldescope, or flexlble bronchoscope (usually Lhrough an Alr-C) geLs used nowadays. We sLock
Lhe lasLrach LMA, we do noL have Lhe ComblLube or Laryngeal 1ubes. We keep a [eL venLllaLor/ [eL venL
caLheLers/ Melker klL on Lhe carLs, buL, Lhey haven'L been used ln more Lhan 10 years. ur. !ames uuCanLo

L) 1he SouLh Afrlcan Alrway LqulpmenL guldellnes make provlslon for Lwo alrway resources: a) An emergency
alrway box conLalnlng Supreme LMAs and adulL and pedlaLrlc crlcoLhyroldoLomy klLs. b) An alrway resource
carL for elecLlve dlfflculL alrway managemenL conLalnlng a varleLy of devlces cusLomlzed Lo Lhe pracLlce of Lhe
parLlcular hosplLal. ur. Lrlc Podgson


SAM always encourages trainee participation
sending in reviews of published airway-related articles,
sending in abstracts or posters for the national meeting,
applying for travel awards, and becoming members!


22.
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7-$('("# /#7 >(#/#$(/% 5"''(<(%(0(-'G +,- .-/% 6&-'0("# (' /<"&0 $"#0-#0'G +,(' (' / /# (#0-.-'0(#C /#7 5."2"I(#C
6&-'0("# 0,/0 4/I-' &' %""I </$I /#7 '-- 0,- 0.-4-#7"&' 5."C.-'' /(.1/3 4/#/C-4-#0 ,/' 4/7- "2-. 0,-
5/'0 7-$/7- /#7 ,"1 4&$, 4(C,0 #"1 <- .-C/.7-7 /' "<'"%-0-G J#- 5.(#$(5%- .-4/(#') => 0,-.- (' /#30,(#C (#
0,- $/.0 0,/0 5-"5%- 4(C,0 #"0 <- >/4(%(/. 1(0, 5-.("7($ 0./(#(#C ',"&%7 <- 5."2(7-7G ur. lellpe urdaneLa
.............................................

M|dd|e aged ma|e presented for urgent surgery. 1he pat|ent had mu|t|p|e med|ca| comorb|d|t|es
|nc|ud|ng end-stage rena| d|sease (LkD) on transp|ant ||st, he a|so had mu|t|p|e |nd|cators of d|ff|cu|t d|rect
|aryngoscopy: 1. Cbes|ty]s|eep apnea]fat neck, Ma||ampat| 4, thyromenta| d|stance 6 cm, neck range of
mot|on ||m|ted to |ess than 90 degrees. My |an (A) was to pre oxygenate through 8|A, fo||ow|ng w|th
DL]VL w|th moderate to deep sedat|on (no succ|ny|cho||ne and non-depo|ar|z|ng musc|e re|axants, as mask
vent||at|on pred|cted to be d|ff|cu|t to |mposs|b|e). |an (8) was to use an SGA based techn|que, based on
the needs for sedat|on and top|ca| |oca| anesthet|c app||cat|on.
1h|s |s how the p|an unfo|ded:
a. D|ff|cu|t pre-oxygenat|on per|od, w|th ||ght sedat|on (fentany| 20 mcg, hydromorphone 0.2 mg,
m|dazo|am 1 mg) and poor mask f|t w|th t|ght f|tt|ng mask straps proved to be prob|emat|c unt|| I manua||y
|mproved the mask f|t and performed a ||ght [aw thrust to a||ow the Cxy|ator to reach |ts pressure re|ease
sett|ng of 20 cm n2C.
b. Upon reach|ng the target pre oxygenat|on |eve| per gas ana|yzer (Lnd-t|da| C2 88), deep sedat|on
|nduced w|th rap|d |n[ect|on propofo| S0 mg |n ||doca|ne 70mg.
c. D|rect |aryngoscopy showed Cormack-Lehane grade 2A v|ew, V|deo |aryngoscopy grade 1 w|th the
McGrath Mac 3. A br|ef pause of the trachea| tube at |aryngea| open|ng a||owed for the re|axat|on of voca|
cords to perm|t trachea| tube passage off of a G||dek|te sty|et.
D|scuss|on:
1. 8|A preoxygenat|on contr|buted to the safety of th|s procedure. ass|ve pre-oxygenat|on procedures
(wh|ch are standard operat|ng procedure |n the current day and age) requ|re substant|a| rev|s|on when
dea||ng w|th a|rways |n wh|ch d|ff|cu|ty w|th trachea| |ntubat|on are pred|cted.
2. 1he use of a comb|ned DL]VL dev|ce perm|tted me to "grade" the DL exper|ence for future a|rway needs,
|t a|so a||owed me the f|ex|b|||ty and safety of hav|ng an advanced a|rway too| |n the event that the
|ntubat|on was not poss|b|e by DL.
3. 1he McGrath Mac |s ||ghtwe|ght and a||ows gent|e endoscopy, wh|ch perm|ts |ts use dur|ng sedated
|aryngoscopy procedures. Io||ow the base of tongue w|th the dev|ce |nto the proper pos|t|on before force |s
app||ed to document the DL grade, a||owed the procedure under deep sedat|on. Dr. Iames DuCanto


A) 1hank you for sharlng your always valuable lnslghL ln Lhls challenglng case! l applaud your approach:
1. uolng uL Lhen vL, provldes lnvaluable lnformaLlon ln case fuLure alrway lnsLrumenLaLlon ls needed.
23.
2. 8egardlng Lhe lssue of dlfflculLy applylng 8lA vla LlghL face mask prelnLubaLlon. l wlsh Lo share a case
(hLLp://www.sprlngerllnk.com/conLenL/43734160p241h6h2/) we reporLed ln a large paLlenL wlLh CSA and
dlfflculL bag-mask-valve (8Mv)/l8 on 8lA.
Whenever we removed 8lA Lo Loplcallze for Lhe flberopLlc lnLubaLlon (lCl), he dropped saLuraLlons very
qulckly. We placed an Alr-C and applled 8lA, whlch was well LoleraLed and ln facL Lhe paLlenL was relleved.
1hen lnLubaLed uslng l8 vla alr-C whlle 8lA was malnLalned. Pe dld noL drop saLuraLlons once Lhe Alr-C was
ln. l belleve Lhls ls a useful ad[uncL ln dlfflculL paLlenLs. ur. uavld Wong

8) l wanLed Lo avold Lhe usual Monday mornlng quarLerbacklng (MMC) because of lack of some deLalls (e.g.
no dlmenslons of paLlenL and was Lhe 90 degree 8CM lncluslve of flexlon and exLenslon?). AlLhough you gave
plenLy of reasons why Lhls alrway would be dlfflculL, l was wonderlng whaL your crlLerla were Lo avold awake
flexlble flber-opLlc lnLubaLlon? Also, why hydromorphone? why noL keLamlne, remlfenLanll or
dexmedeLomldlne? ur. kaLherlne Cll

C) l cannoL avold a dose of MMC: uesplLe Lhe facL LhaL Lhere were slgns of boLh dlfflculL 8Mv and dlfflculL uL,
Lhe paLlenL was sedaLed and puL Lo sleep Lo perform boLh. 8Mv was lmproved by Lhe use of 8lA buL
Laryngoscopy was noL opLlmlzed (no muscle relaxanL was glven). lf Lhere ls so much concern abouL glvlng nM8
agenLs, should Lhe paLlenL be puL Lo sleep ln Lhe flrsL place? lL ls hard Lo [udge and Lhe resulL was a success llke
many cases are, buL lL could have noL have been. ur. lellpe urdaneLa

D.//.@%4$E My |og|c doesn't move |n stra|ght ||nes somet|mes, but to c|ar|fy, my centra| concern here |s to
m|n|m|ze apnea t|me, and max|m|ze vent||at|on. 1he techn|que worked, and everyth|ng went we||,
however, |f |t had not, I wou|d have gone to p|an 8, C, or D a|ways w|th the goa| of ma|nta|n|ng vent||at|on.
I knew th|s pat|ent wou|d present prob|ems w|th DL and prob|ems w|th mask vent||at|on. ne was |n rena|
fa||ure, so def|n|te|y no sux. It made sense at the t|me to s|mp||fy h|s management w|th a method that
wou|d be fast and max|ma||y effect|ve, offer DL grad|ng capab|||ty, and a||ow for rap|d recovery from
moderate to deep sedat|on |n the event that the approach was not successfu|.
1he narcot|c se|ect|on |s based on my preference to comb|ne fentany| 100 mcg w|th nydromorphone 1 mg |n
a 10 m| tota| d||ut|on for adm|n|strat|on dur|ng surgery. I gave 2 m| of |t, |.e. 20 mcg fentany|, .2 mg
nydromorphone. Dr. Iames DuCanto

C) Pow does one apply 8lA ln Lhe operaLlng room uslng Lhe clrcle sysLem apparaLus anesLhesla clrculL?
ur. uonald keusch

u) !lm uses Lhe CxylaLor, whlch ls an lnLeresLlng and dlfferenL Lechnology Lhan Lhe one used ln our anesLhesla
machlnes. 1here are anesLhesla machlnes LhaL have a pressure supporL mode. ?ou can achleve 8lA wlLh a
LlghL flLLlng mask by puLLlng Lhe paLlenL on pressure supporL and addlng LL. aLlenLs, parLlcularly Lhose on
home CA or 8lA for CSA, seem Lo LoleraLe lL well. ur. 8lchard Calgon

u) ln Lhe old days we dld lL wlLh an educaLed hand on Lhe bag. LaLely we have venLllaLors LhaL mlmlc 8lA
wlLh pressure supporL venLllaLlon and LL. S l sLlll use my hands someLlmes. ur. C. WaLson (SlC)


24.
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