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Post by katevaughn on Feb 26, 2017 11:19:27 GMT -5
This month's journal club is presented by Katya. She chose a great article concerning the planning process for extubation of a difficult airway. The article discusses that anesthesia providers often plan extensively for the intubation of the difficult airway but tend to relax when it comes to extubation. This will provide you with some tips you can use in your practice as well as help you identify criteria to determine patients that will be at risk for post-extubation complications. Enjoy! This is the link to the article. Here are the questions for you to encompass within your discussion: 1. Any thoughts on the Bailey maneuver? Has anyone used it in practice? 2. What are your thoughts on how to prepare yourself for the difficult airway case for new CRNAs? (equipment collection, how to connect different parts of the equipment, and use of different equipment)
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nanci
Junior Member
Posts: 57
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Post by nanci on Feb 27, 2017 18:02:50 GMT -5
1) Thoughts on the Bailey maneuver....funny I didn't know it had a name. I always thought it was called how to emerge from Dr. Eckhauser's hernia repairs so the patient doesn't "buck". Or, another name for the technique was...how Dr. Mittman likes to extubate when he's the attending on Dr. Eckhauser's hernia repair patients. Either way, interesting read and thank you Katya for the submission. Used this technique often, but actually, not so much now that Dr. Eckhauser is not in practice here anymore. Seems to work when it is put into place with the patient "deep" and not in stage 2 of emergence. Have used Lidocaine to attenuate the airway reflexes in the past as well, only once with the "Bailey maneuver" to my recollection. Made the patient very sedated and took awhile to emerge (longer than surgeon liked).
2) Thoughts on how to prepare myself for a difficult airway case are to have multiple backup plans, discuss the plan(s) with whomever working with, equipment in place, checked, and keep lines of communication open. I would hope that new CRNA's would have adequate experience with the difficult airway and had searched out such experiences when they were SRNA's. If a new CRNA (to the institution) has questions, during orientation it should be discussed at some point the options we have readily available at this Level 1 trauma center and go over some options of what they are used to having, their preference of options A,B,C, etc... and if we have different equipment go over it and hope to have them use it during their orientation process so that they feel comfortable with what they have available to them. Always good for not-so-new CRNA's to keep practicing alternative airway techniques on non-difficult airway patients as well so that when they encounter a "difficult airway" they are more comfortable with the process. Again, keeping lines of communication open really helps so that all are on the same page. This is stressed often when carrying the code pager and partaking in anesthesia only intubations and DART's throughout the hospital- I have found.
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Post by AugustineEmmanuel on Mar 2, 2017 9:34:16 GMT -5
1. I've used the Bailey maneuver in practice and it can be efficacious for the right patient. A few concerns that I do have with the Bailey maneuver is the ability to adequately ventilate a patient after insertion of the LMA (obese patients, anatomic challenges). The key to successfully using this maneuver is of course keeping the patient deeply anesthetized and/or paralyzed appropriately. 2. If I do suspect a true difficult airway, I default to an awake fiber optic intubation. I personally prefer using the C-Mac set up with the fiber optic scope vs. the tower due to the ease of set up. In regards to becoming familiar with the set up and connection of the equipment I'd suggest practicing with these equipment during regular cases to become comfortable with use. I think the one thing that would be important for everyone to familiarize themselves with is how to use a cricothyrotomy kit.
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Post by vania on Mar 3, 2017 11:26:43 GMT -5
1. I have never used the Bailey maneuver, but it certainly sounds like a viable option when there is great concern for "bucking" due to surgical concerns, although I'd just prefer a deep extubation if that's a possibility. I do always worry about a patient becoming light and/or coughing with an LMA in place due to the risk of laryngospasm. I suppose with enough lidocaine or alternative medication therapies, this could be avoided, though they may actually prolong wakeup.
2. For new CRNA's or those that haven't had much experience with difficult airways since training, I would highly recommend seeking out one of the knowledgeable, experienced CRNA's and/or attendings to learn about all of the options available to us. I do love having a C-mac readily available in the room if there is ANY question about airway difficulty, and of course full ability to perform fiber optic intubation in a previously determined difficult airway.
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Post by Vania on Mar 3, 2017 12:25:32 GMT -5
1. I have never used the Bailey maneuver, but it certainly sounds like a viable option when there is great concern for "bucking" due to surgical concerns, although I'd just prefer a deep extubation if that's a possibility. I do always worry about a patient becoming light and/or coughing with an LMA in place due to the risk of laryngospasm. I suppose with enough lidocaine or alternative medication therapies, this could be avoided, though they may actually prolong wakeup.
2. For new CRNA's or those that haven't had much experience with difficult airways since training, I would highly recommend seeking out one of the knowledgeable, experienced CRNA's and/or attendings to learn about all of the options available to us. I do love having a C-mac readily available in the room if there is ANY question about airway difficulty, and of course full ability to perform fiber optic intubation in a previously determined or currently known difficult airway. I for one could use more exposure to different techniques as these evolve over time... Our colleagues are our best resource! The tech's are also generally very knowledgeable about the location and availability of equipment. Always have a plan and a back up plan and even a last resort plan. I agree that using these devices for regular cases would be very helpful for familiarity purposes.
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Post by mscotth2 on Mar 6, 2017 11:15:44 GMT -5
Great read, thank Katya for posting!
One of the hospital I did clinicals deep extubated everyone, even difficult airways. the CRNAs could handle it and the PACU nurses were educated on how to recover the deep extubations and were assigned 1 to 1 until the patient woke up. I haven't done the Bailey maneuver, not sure that it is any better than placing an oral airway if needed? Really isn't the LMA a big oral airway? Maybe I have been in pediatrics too long! Of course, I would never take a deep patient out to san adult PACU here.
My advice is to never underestimate a difficult airway and there is no such thing as over preparing. I make sure I have all of my adjuncts in the room and that they work. I also identify the most experienced hands in the vicinity and will include the ENT surgeons if I am especially concerned. If you do get into trouble, call for help early. It's easier to send them away if you don't need them than to intervene when you are in an arrest situation. If you have the opportunity to practice with airway adjuncts on routine cases you should do so, then you are more comfortable in an emergency using it.
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Post by Wai-Ling Lo on Mar 6, 2017 18:15:12 GMT -5
1. I read about the Bailey maneuver but I haven't used it in practice. Like Augustine said, it needs to be for the right pts. With the epidemic of obesity and DM, LMA may not be appropriate. In that case, airway exchange catheter may come handy which I've used more often. Another note on reducing stimulation during extubation, remifentanyl or dexmedetomidine may be useful. Hopefully dexmedetomidine will be approved to be used in Hopkins whenever needed in the near future. 2. As for the preparedness for difficult airway case, be prepare all the time and practice is everything and practice on normal pts first. Keeping Dr. Mittman's bronchoscope compatibility chart handy is helpful. U may also consider joining the OL cohort for more exposure to difficult airway cases.
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Post by emedina1 on Mar 10, 2017 18:45:26 GMT -5
I have not used the Bailey maneuver but reading the description, I t is not something I would try.I agree with the article. We should always be prepared with all the equipment we are familiar to use in dealing with a difficult airway. On extubation, i would like to be sure that the patient can handle his own airway before I take that tube out. Beth Medina
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Post by faraclarke on Mar 16, 2017 18:48:58 GMT -5
1. This is a great article because I have not heard of the Bailey maneuver prior. It sounds like a useful method in the "right" patient population. I don't anticipate that I would use this very often in clinical practice just based on my personal cohorts because most of the patient I take care of are very well pre-surgically optimized/managed or don't have considerations such as asthma, severe CAD, or risk of surgical site rupture upon extubation, even with the consideration of a difficult airway. In addition, with the frequency in which we take care of obese patients, I would prefer to have them fully awake rather than to risk a difficult or impossible ventilation scenario.
2. I think a good thing to keep in the back of the mind is that any patient can be a difficult airway, even if their airway exam leads on to conclude otherwise. Keeping a plan and back-up equipment in the back of your mind so that you can act quickly in any scenario. This can be as simple as having a bougie, a back-up blade, or video assistance. I think it would be great if we had a periodic difficult airway workshop so that we can become more and remain familiar with the equipment, as I have not encountered many true difficult airways and it would be great if those of us who don't encounter difficult airways frequently had more of a frame of reference, if and when the time comes.
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Post by Benjamin Waldbaum on Mar 20, 2017 9:26:55 GMT -5
Question 1: Personally I am a big fan of keeping it simple. It would appear the Bailey maneuver violates this principle and I've definitely see it fail or introduce new problems. I am not sure I agree with the premise of the article that more planning needs to be done regarding extubation as I believe most already do this. Does a pilot only plan the takeoff but not the landing? Does the pilot not have multiple contingences in place for failure of either? Regarding the Bailey maneuver I believe it is unnecessary. Optimiziation of case management, especially fluid, patient position, avoidance of end of case narcotics, and a multitude of other factors I believe to be much higher yield maneuvers. If despite all of this, my fall back option is to extubate over a cook airway exchange catheter with careful position of the depth to avoid injury from deep placement. It's very well tolerated and once I'm satisfied, I take it out. If they fail, I have an easy method to reintubate.
Question 2: If I am truly worried about an inability to reintubate, my default is to extubate over an airway exchange catheter as described above. Also, if the case had a complicated course with large volume shifts or if the patient is hemodynamically unstable, I'll think about if the patient would benefit from a stabilization period and controlled extubation in the ICU.
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Post by Kels on Mar 21, 2017 15:28:50 GMT -5
Nice article!
I did learn about the Bailey maneuver during my anesthesia training but I have not used this maneuver yet. Yes, like many maneuvers, this one has pros and cons but at least it is an option that is available to us.
Last year I was able to attend a difficult airway course. Like Ben, I think it is a great idea to extubate over an airway exchange catheter ( when appropriate ) . I don't think many of us have actually done this in practice but having a catheter that is guide direct to the airway is a wonderful thing.
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Post by katevaughn on Mar 22, 2017 14:34:37 GMT -5
The last person to respond (username: Kels), do you mind providing your name? You can email me personally if you would like. Just want to know who to give the credit to for responding Thanks!
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Post by Kels on Mar 28, 2017 8:19:55 GMT -5
Kels is me Kelsie Johnson . Thanks
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Post by LMeginnis on Mar 29, 2017 19:02:41 GMT -5
1. I had the opportunity to use the Bailey Maneuver during my training. I agree with Ben that I would prefer using an exchange catheter, I think there would be less chance of complications. 2. I think we should all be aware of all the options available to us when dealing with a difficult airway and then have the equipment readily available. Murphy's Law, the first time you forget to make sure you have a Bougie in your room (and you don't) will be the time you need it the most! I think this would be an excellent article for SRNA's.
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Post by BrittneyKeating on Mar 29, 2017 21:12:02 GMT -5
1.) I have heard of this technique, although this is the first time I have heard it given the name “Bailey maneuver.” The utility of this technique seems most relevant for the patient in whom bucking/coughing might cause injury to the surgical site such as Nanci mentioned in an earlier post with hernia repair, or for the asthmatic patient or other comorbid disease with known risk for bronchospasm. I would not utilize this technique for the patient with known difficult airway, or for a patient who was an easy intubation at the start of the procedure, but may have altered airway anatomy following the procedure due to the surgical procedure itself, positioning, massive fluid administration, length of procedure, etc. Use of a cook catheter/airway exchange catheter provides an extra margin of safety for the patient who might be at risk for extubation related complications. The brief education provided in this article on the airway exchange catheter is very helpful, as this is not a technique routinely needed/utilized, but it is vitally important to recall how to safely perform the technique when its use its necessary.
2.) I think one of the most important ways a new clinician can prepare himself/herself for the difficult airway is to become familiar with how to use various equipment, whether in clinical practice or simulation. The anesthesia program I attended frequently utilized simulation throughout the curriculum, however repetition with various equipment throughout the beginning years as a new provider is key to being prepared when faced with the difficult airway. Another key to preparation for the difficult airway is knowing the roles of other providers in the OR/ procedure room, and how to call for help when a situation escalates to a difficult airway. This is especially important at our institution where various methods of communication are preferred amongst providers in different clinical settings/suites.
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