CEDIVA Dénia, Training Center in Difficult Airway Management

Anesthesia and ICU Department

Hospital de Dénia
Francisca Llobell, Daniel Paz,Inés Carpi, Remedios Pérez, Isabel Estruch,Maria Serna, Jose Luis Dieguez, Juan Cardona.

Annual Meeting
14th Annual Society for Airway
Management Scientific Meeting
OBJETIVE

Prospectively evaluate the effectiveness of a simple

manikin practice in teaching the technique flexible
fiberscope to anesthesia trainees during anesthesia
residency .
 In the workshop Cediva have a training program fibreoptic
intubation during anesthesia residency that includes a
number of methods of initiation into the use of the device
on mannequins before fibreoptic oro/nasotracheal
intubations in the operating room. The first method must
practice the trainee is PRACTICE CLOCK (SEE FIG 1).

CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA

Address to the central
point . Try vertical
movement following
the numerical
sequences. Repeat
every one 10 times.
(figure 2)

* 12 * 6

* 6
CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA
* 12
Vertical movement of the
tip of the fiberscope
following the numerical
sequence (fig 3)
Repeat this sequence four
times.

* 12 * 12 * 12 * 12 *
* 6
* 12 DENIA
CEDIVA * | FORMACIÓN
6 * CONTINUADA
12 * EN VÍA6AÉREA*
 Horizontal motion of the
tip of the fiberscope
following the numerical
sequence (Fig. 4)
Repeat this sequence
four times.

* 9
* 3
* 9 *
CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA 3 * 9 * 3 *
 Rotational movement
* 12 9 6 9 12 *
of the tip of the
fiberscope in the
sequence number
(fig 5) Repeat the
sequence four times.

* 12 3 6 3 12 *

CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA

Combined drawing a Z Movement; further sequence of letters ABCD
maneuver repeated four times.(Figure 6)

* A B C D C B A *
* B A D C D A B *

Figure 6
 CLOCK PRACTICE

With this method, assisted, the resident acquires the

ability to direct manual fiberscope tip oriented in
three dimensions and must be the practice of
initiation in the advanced management of difficult
airway requires the use of flexible fiberoptic device
that demonstrated that solves 100% of cases of
patients with difficult airway.
CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA
 Annual events and References

CEDIVA DENIA | Training Center in Difficult Airway

Anesthesia and ICU Department. Dénia Hospital 2010
 Annual Meetings in Dénia Hospital

CEDIVA DENIA | Training Center in Difficult Airway Management

CEDIVA DENIA | Training Center in Difficult Airway Management.
 American Society of
Anesthesiologist (ASA)
Annual Meeting

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 American Society of Anesthesiologist. Annual Meeting , Chicago-Illinois 2006

Llobell F,Madrid V et al.

The Difficult Airway Extubation Table: A buffet of Airway Devices and
Management Strategies. ASA 2006; A17:pp437.

CEDIVA DENIA | Training Center of Dificult Airway Management

CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA
 ASA 2007
CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA
 Extubating the difficult airway: A protocol for timing and not burning bridges
Francisca Llobell, M.D.1, Patricia Marzal, M.D.1, Luis Gonzalez, M.D.1, Lauren K. Hoke, B.S.2, Yvon F. Bryan, M.D.2
1. Hospital G. U. Marina Alta, Denia (Alicante), Spain 2. Wake Forest University Baptist Medical Center, Winston-Salem, NC

Introduction Results Discussion

•Protocol provided strategy for timing

•Timing extubation in patients with difficult
extubation with the availability of devices
airways (DA’s) is critical
needed to bridge
•Device choice for delaying or bridging extubation
•Protocol allowed for versatility in
depends on urgency and potential problems
managing various patient conditions
encountered after extubation
•Further research required in establishing
•We present our initial experience with a protocol
extubation protocols for DA’s
used for extubating patients with DA’s

Methods Abstract
•Protocol combines timing of extubation with
availability of necessary devices Title: Extubating the difficult airway: A protocol for timing and not burning bridges

Francisca Llobell, M.D., Patricia Marzal, M.D., Luis Gonzalez, M.D., Lauren K Hoke, B.S. and Yvon F Bryan, M.D..
Department of Anesthesiology, Hospital G.U. Marina Alta, Denia, Alicante, Spain.

Introduction
Different airway devices may be used to facilitate extubating patients with difficult airways (1, 2). The timing and
devices needed to bridge the extubation, however, depend on the patients condition and risk. The possibility of
aspiration, experiencing potential difficulty with oxygenation and ventilation and the need for re-intubation are
problems frequently encountered. A protocol for extubation must take into account these problems and combine
them with the timing of extubation and the availability of the necessary airway devices needed to bridge. We
present our experience using a protocol for extubating patients with difficult airways.

Methods
The protocol for extubating patients with difficult airways combined the timing (immediate versus delayed) of
extubation with the availability of the necessary airway devices required for bridging (see Figure 1). A table of
airway devices set up according to their function was used for the patients (3).

Results
No com plications occurred in any patients in which the protocol was used (see Table 1).

Discussion
The extubation protocol provided a strategy for timing the extubation with the necessary airway devices needed
to bridge the extubation. The protocol was designed to take into account the risks associated with the patients
underlying condition and/or surgical intervention with the airway device best suited for the patient. By allowing
for versatility, the protocol facilitated reassessing the patients need to remain intubated, to bridge or to delay the
extubation. Further studies are needed in the management of patients with difficult airways during extubation.

References
1) Anesth Analg 2007; 105:1357-1362.
2) Anesth. Analg. 2007; 105: 11821185.
3) Llobell F, et al. Euroanaesthesia 2008 Annual Meeting.

CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA ASA 2008

 Managing the difficult airway at extubation: Vices or devices
Francisca Llobell, M.D.1, Patricia Marzal, M.D.1, Maria Serna, M.D.1, Lauren K. Hoke, B.S.2, Yvon F. Bryan, M.D.2
1. Hospital G. U. Marina Alta, Denia (Alicante), Spain 2. Wake Forest University Baptist Medical Center, Winston-Salem, NC

Introduction Methods Discussion

Table 1: Extubation survey questions
•Devices used during intubation may not be •Our survey found a high incidence of
successful during extubation and/or re- problems occuring at extubation
intubation
•Anesthesiologist experience and familiarity
•Timing of extubation depends on patient with different airway devices may have
condition and practioner experience influenced choice of device
•We present the experience of •Further research is required in developing
anesthesiologists during extubation of protocols for use during extubation in
patients with DA’s in a region of Spain patients with DA’s

Abstract
Methods Results Title: Managing the difficult airway at extubation: Vices or devices

Francisca Llobell, M.D., Patricia Marzal, M.D., Maria Serna, M.D., Lauren K Hoke, B.S. and Yvon F
Bryan, M.D.. Department of Anesthesiology, Hospital G.U. Marina Alta, Denia, Alicante, Spain.

•Survey consisted of 10 questions regarding Introduction

management of DA during extubation Problems encountered during extubation of patients with difficult airways are prevalent though formal guidelines
seem to be lacking (1). This dichotomy of problems occurring at extubation and a lack of specific strategies may
be due to anesthesiologist experience and/or training with specialized airway devices required during the
management of the difficult airway (2). Certain airway devices may be best suited for rescue (oxygenation and
•Surveyed 38 anesthesiology departments in the ventilation) while others are better used to bridge (reintubation) and to delay the extubation. We surveyed
Spanish anesthesiologists about their clinical practice management for the extubation of patients with difficult

regions of Valenciana and Murciana in Spain airways.

Methods
A survey was sent to the anesthesiology departments of 38 hospitals in the provinces of the Comunidad
Valenciana (Castellon, Valencia, Alicante) and cities in the Comunidad Murciana (Murcia, Orihuela) of Spain. The
survey consisted of 10 questions pertaining to the clinical management at extubation of patients with difficult
airways (see Table 1). The surveys were completed anonymously and returned via self-return envelope to
Hospital G.U. Marina Alta in Denia (Alicante), Spain.
Results
A total of 10 out of 38 anesthesiology departments completed and returned the survey (as of March 1, 2008)
totaling 120 anesthesiologists. Problems at extubation were reported by 95% of respondents with only 12%
having a formal extubation protocol. 34% reported experiencing difficulty with reintubation and 23% reported
patients requiring surgical access for airway support. 7% reported a patient death or a severe brain injury as a
consequence of problems occurring at extubation. Of the airway devices used to rescue, 76% were
supralaryngeal devices (LMA, ILMA, Proseal LMA). To bridge the extubation, supralaryngeal devices and airway
exchange catheters were used 53% and 16% of the time, respectively. See Table 2.

Discussion
Our survey found a very high incidence of problems occurring at extubation in patients with difficult airways. A
lack of established extubation protocols and training with specialized airway devices may be the reason for the
problems. The devices used to rescue and bridge the extubation by the majority of respondents were
supralaryngeal in nature. This may have reflected the individuals training with these devices, the unavailability of
certain devices or not being familiar with other types of devices (ie, airway exchange catheters). Further research
is required in the management of the difficult airway to discern which devices are best suited for rescuing and/or
bridging during extubation.

References
1) Anesthesiology 2005:103(1);33-9.
2) Anesthesiology 2007:100;A934

ASA 2008
CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA
 IARS - International
Anesthesia Research Society
IARS Annual Meeting
USA

CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA

 The new VAMA® intubating airway: a unique design for fiberoptic intubation
Patricia Marzal, M.D. 1, , Juan Cardona, M.D.1, Andres Madrid 1, Valentin Madrid, M.D. 1, Yvon F. Bryan, M.D. 2*
1. Hospital G. U. Marina Alta, Denia (Alicante), Spain 2. Cincinnati Children’s Hospital Medical Center, Cincinnati, OH

Introduction Methods Discussion

•Lasermark on VAMA allowed clinician to

•Valentin Andres Madrid Airway (VAMA) is a orient FFB
new intubating airway •Detachable piece of airway facilitated removal
•New design features of VAMA facilitate FFB of VAMA without accidental ETT removal
intubation A. •Further research required using VAMA in
B.
•We present our initial experience using VAMA patients with difficult airways
airway

Abstract
C. D.
Title: The new VAMA® intubating airway: a unique design for fiberoptic intubation

Authors: Marzal Patricia, Llobell Francisca, Cardona Juan, Madrid Andres, Madrid Valentin, Bryan

Methods Results
Yvon

Introduction
Several available intubating airways facilitate performing fiberoptic intubation and placing an
endotracheal tube (1,2). The new VAMA intubating airway incorporates design features which address
common problems encountered during fiberoptic intubation. A line with an arrow (lasermark)
embedded on the distal part of the ventral surface of the posterior portion of the airway facilitates
•19 patients underwent FFB using VAMA •Age (mean and range) = 57.5 years (31-86) orientation (see Figure 1). A detachable piece on the proximal portion of the airway facilitates removing
the VAMA airway while the endotracheal tube (ETT) remains connected to the circuit; thus avoiding
interruption in ventilation and inadvertent extubation. We describe our experience with the VAMA®
•Awake/sedation with topical anesthesia or general •Time to intubation (mean,range) = 42 seconds intubating airway for fiberoptic intubation.

anesthesia (25-70) Methods

After obtaining verbal consent, 19 patients undergoing surgery and requiring endotracheal (ETT)
•Lasermark of VAMA facilitates orientation •Visualization of glottic opening on initial FFB intubation were recruited. After general anesthesia or sedation and topical anesthesia, a 5.5 mm flexible
introduction = 13/19 (68%) patients fiberscope was loaded with an ETT and placed orally via the VAMA® airway. Using lasermark on the
•Detachable piece facilitates removal of VAMA VAMA® for guidance, the FFB was inserted until the glottic opening was visible. After advancing the
FFB through the vocal chords, the ETT was railroaded into the trachea and the position was confirmed.
airway while ETT remains connected •Chin lift required for exposure of glottic opening The detachable piece of the VAMA® was first removed and while holding the ETT, the remaining part

= 6/19 (32%) patients of the VAMA® airway was removed without disconnecting the ETT from circuit.

•Removal of VAMA does not interrupt ventilation or •Intubations on first attempt (one patient required Results

risk inadvertent extubation 3 attempts) = 18/19 (95%) patients The mean and range of age and time to intubation were 57.5 years (31-86) and 42 seconds (25-70). In
13 patients, the glottic opening was visualized on first pass of the FFB placed in the VAMA® airway. In
6 patients, a chin lift exposed the glottic opening. All intubations occurred on first attempt, except one
•5 patients with known difficult airways which required three attempts. Five patients had known difficult airways (DA), 7 intubations were
awake and in 7 patients, paralytic agents were used. Discussion
•7 intubations performed awake/sedation, 7 The lasermark of the VAMA® airway helps identify the anatomical landmarks necessary for fiberoptic
intubation. Disconnecting the removable piece facilitates complete removal of the VAMA® airway.
intubations using paralytics Further research is required comparing to other intubating airways in patients with known DA’s who are
both awake and anesthetized.

References
1) J Clin Anesth 2004 16:66-73.
2) Anaesth 2004 59: 173–176.
3) VAMA Canula Package Insert www.ajlsa.com

*Wake Forest University Baptist Medical Center

IARS 2007, San Francisco USA

European Society of
Anesthesia
Euroanesthesia
TITULO SEMINARIO | SUBTÍTULO

Aquí se escribe el texto

F.Llobell, P.Marzal; M.Echeverri,

L.Hoke, Y.Bryan . Strategy for
extubation of the difficult airway: A
protocol and table of airway devices.
Eur J Anaesthesiol 2008; 25 (Suppl 44):
19AP6-8.
 SEDAR Sociedad Española
de Anestesia y Reanimación
Annual Meeting 2009

CEDIVA DENIA | FORMACIÓN CONTINUADA EN VÍA AÉREA

 M. B. Serna; F. Tarín; R. Pérez; F. Llobell. Hospital de Denia

El manejo de la vía aérea difícil conocida exige elaborar un plan para minimizar el riesgo
de hipoxia aguda ante una demora en la intubación siguiendo la estrategia establecida
según los algoritmos de referencia (Anesthesiology 2003).
CASO CLÍNICO
• Mujer, 43 años.
• Obesidad, DMNID. Varios episodios de crisis tónico-clónicas por Encefalitis de
Hashimoto.
• Nuevo episodio refractario a tratamiento médico (Fenitoína y Diazepam i.v.).
MANEJO
SEDOANALGESIA CONTROL DE LA VÍA AÉREA

INTUBACIÓN ENDOTRAQUEAL
* La ASA recomienda valorar:
• VENTILACIÓN DIFÍCIL - IMC 34,6 kg/m2
• INTUBACIÓN DIFÍCIL – Historia de VAD anticipada, cuello corto y grueso, retracción
mandibular, macroglosia
• COOPERACIÓN - NO, dada la situación clínica
• TRAQUEOSTOMÍA DIFÍCIL - SI

VÍA AÉREA DIFÍCIL

 ESTRATEGIA
* Considerar ventajas y desventajas de:
INTUBACIÓN DESPIERTO INTUBACIÓN TRAS INDUCCIÓN
MANTENIMIENTO DE LA VENTILACIÓN SUPRESIÓN DE LA VENTILACIÓN
ESPONTÁNEA ESPONTÁNEA
TÉCNICA NO INVASIVA TÉCNICA INVASIVA
Limitaciones en el paciente crítico vs. urgencia.
ESTRATEGIA PRIMARIA ALGORITMO 1 ASA
FIBROBRONCOSCOPIO FLEXIBLE VÍA NASAL
ESTRATEGIA SECUNDARIA
MASCARILLA LARÍNGEA CON CANAL DE DRENAJE GÁSTRICO:
• Supreme®, Proseal®
MATERIAL NECESARIO
Oximetazolina Spray
Cánula nasal Rüsch
TET reforzado nº7 nº26

MAD Mucosal Atomization Lidocaína

Device
MADgic Laryngo-Tracheal Mucosal Atomization
Device
CEDIVA DENIA |Formación Continuada en Vía Aérea
Servicio de Anestesiología y Cuidados Críticos del Hospital de Dénia
 DESCRIPCIÓN DE LA TÉCNICA
Instilación de Oximetazolina para evitar
hemorragias.
Atomización de Lidocaína 3% mediante
MAD® de fosa nasal.
Atomización de Lidocaína al 4% mediante
MADgic® de cuerdas vocales.
Introducir cánula de Rusch a través del
orificio nasal elegido.
Introducir el TET reforzado y lubricado a
través de la nariz.

Progresar a través del TET el

fibrobroncoscopio hasta visualizar las
cuerdas vocales. Una vez abiertas
llegaremos hasta carina. Deslizar el tubo
aplicando giro antihorario para facilitar su
inserción.
CONCLUSIÓN
LA TÉCNICA DE INTUBACIÓN CON FIBROSCOPIA CONSCIENTE ES APLICABLE EN
SITUACIÓN DE URGENCIA SI EL ESCENARIO LO PERMITE Y EL PACIENTE LO
REQUIERE.
Bibliografía:
•ASA 2002 Practice Guidelines for Management of the Difficult Airway.
•Engel TP, Applegate RL, Chung DM, Sanchez A. Management of the difficult airway. Gasnet, 2001.
1. Llobell F, Madrid V, Taghon TA, Bryan Y. The Difficult Airway Extubation Table: A buffet of Airway
Devices and Management Strategies. En: ASA Annual Meeting 2006; pp 437.

2. Romagosa H, Charco P, Llobell F, Madrid V, Garrido P. Prevención del edema laríngeo

postextubación. Estrategias para una extubación segura. Rev Esp Anestesiol Reanim 2005; 52:202-3.

3. Llobell F, Marzal P, Bryan y, Charco P, Martinez-Pons V, Madrid V. Complicaciones tras la Extubación:

Dimensionando el problema. 13 Congreso Hispano-Luso de Anestesiología. Valencia, Abril 2007.

4. Llobell F. Estrategia para el intercambio de un TET. Algoritmo de Extubación. XXVII Congreso de la

SEDAR.Resúmenes de Ponencias. 2005;pp 71-3.

5. Llobell F, Madrid V, Marzal P, Hoke Lauren K, Bryan Y. Airway Management Strategies of Difficult
Airways at Extubation: Despite Risk Much Left to Chance. En: ASA Annual Meeting 2007; A934.

6. F.Llobell, P.Marzal; M.Echeverri, L.Hoke, Y.Bryan . Strategy for extubation of the difficult airway: A
protocol and table of airway devices. Eur J Anaesthesiol 2008; 25 (Suppl 44): 19AP6-8.

7. F.Llobell, P. Marzal, M. Serna, L. Hoke, Y Bryan. Managing the Difficult Airway at Extubation: Vices or
Devices. A1725 ASA 2008.

8. F.Llobell, P. Marzal, L.Gonzalez, L. Hoke, Y Bryan. Extubating the Difficult Airway: A protocol for Timing
and not Burning Bridges. A1729 ASA 2008.

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CEDIVA DENIA |Training Center in Difficult Airway Management

Anesthesia and ICU Department
Dénia Hospital