**6. Monitoring**

Maintaining standards of monitoring is the most important modality used to ensure the safety of the patient and to avoid airway complications. Adherence to the current best practice guidelines [4] is essential when planning and equipping areas outside the OR. This should include the pulse oximeter and capnograph. Failure of capnography contributed to 74% of cases of death or persistent neurological injury [5]. **Figure 5** shows a snapshot of a monitor used in a patient who is deeply sedated with a Target Controlled Infusion (TCI) of Propofol, spontaneously breathing with supplemental oxygen delivered via a nasal cannula. No other airway adjuncts were necessary. The nasal cannula is incorporated with a sampling port for expired gases (**Figure 6**) and a clear EtCO2 (end tidal carbon dioxide) trace and value is displayed on the monitor. In a fully open circuit as is with nasal prongs, the value displayed is dependent on the flow of oxygen delivered and the depth of breathing. Although the exact value displayed is not of true significance always, the characteristics of the trace and the trend of the number displayed warns clinicians of impending airway compromise and the need to intervene.

Capnography use has the highest potential to prevent deaths from airway complications outside of the operating theater complex [6, 7].

Monitoring depth of sedation has been looked at using a bispectral index (BIS) monitor. The depth of sedation is calculated by measuring cerebral electric activity via an electroencephalogram (EEG). The BIS algorithm processes the frontal EEG and converts the signal to a waveform on the BIS monitor, and displays a number between

#### **Figure 6.**

*A capnography module for the monitor and a nasal cannula with an oxygen tubing and an integrated CO2 sampling line that fits into the module.*

100 (fully awake) and 0 (no brain activity). This has proved very useful during general anesthesia in avoiding awareness due to inadequate hypnosis, by keeping values between 40 and 60, but its use to achieve a particular level of sedation on the continuum of sedation has proved difficult to interpret. Levels of 60–70 have been postulated and the aim should be to avoid letting the patient slip into general anesthesia from deep sedation, risking apnea and hypoxia. This has not always correlated to an adequate level of sedation and most operators adjust the level of sedation based on response to any stimulus the patient experiences during the procedure.

#### **7. Improving airway management outside the OR**

At least 25% of major airway events are from outside of the OR environment [8]. Complications are associated with hypoxia, aspiration, unrecognized esophageal intubation, airway trauma and obesity.

As we have seen above, areas outside the OR need to be prepared with equipment to manage the airway in a patient who may need it. We should plan and equip every area where this is anticipated, usually due to the fact that we as clinicians give patients drugs to aid procedures to happen, putting them in harm's way. Apart from eternal vigilance and monitoring, we should be prepared to step up the management of the airway that can become compromised.

Capnography is a tool that has become part of the basic standards of monitoring the world over, in patients having sedation or general anesthesia. It is a very important tool to detect a deterioration in ventilation in a spontaneously breathing patient due to increasing levels of sedation. All staff involved with sedating patients need to be trained in its use.

Checklists have improved patient care [9]. In areas where intubations are not routinely carried out, an intubation checklist has proved invaluable. Checklists have also helped in pre-assessment of patients and has helped recognize potential difficulties. For example, obesity is recognized as an increased risk factor for airway complications. These allow for thorough back-up strategy planning, both for intubation and extubation, as it may not be routine in areas outside the OR.

**47**

**Figure 7.**

*An airway trolley in a patient recovery area.*

*Airway Management Outside the Operating Room DOI: http://dx.doi.org/10.5772/intechopen.93362*

The availability of the difficult airway trolley (**Figure 7** and **Table 3**) is paramount in areas where airway maneuvers are planned. These require regular checking and maintenance with replacement and stocking done every day. Since many areas exist outside the OR for airway procedures and since not every area is used on a daily basis unlike the OR, a designated person should be responsible to oversee this task. Every area should also have a plan to access video-laryngoscopes and fiberoptic bronchoscopes without much delay. Front of neck access equipment should always be available on the difficult airway trolley, and regular training

should happen among the staff who look after the airway of patients.

patients for ERCPs and upper endoscopy procedures.

prolonged use of HFNC in patients who may go apneic.

Apart from airway equipment that is routinely used in the OR, certain newer developments in airway management have potential roles in areas outside the OR [11]. These include Laryngeal Mask Airways (LMA) modified with a separate channel to allow endoscope access into the esophagus, and high flow nasal oxygen delivery devices. Examples of the separate channel devices include the LMA® Gastro™ Airway from Teleflex, and the Gastro-Laryngeal Tube from VBM Medizintechnik GmbH (**Figure 8**). These modified airway devices have made it easier to anesthetize

The use of heated and humidified high flow nasal cannula (HFNC) with flows of 60–70 L/min has also become increasingly popular in deeply sedated patients outside the OR [12]. This can be used in various areas and addresses the concerns of transient apneas and hypoventilation and hypercarbia. It is recommended to use transcutaneous carbon dioxide (TcCO2) monitoring during *Airway Management Outside the Operating Room DOI: http://dx.doi.org/10.5772/intechopen.93362*

*Special Considerations in Human Airway Management*

100 (fully awake) and 0 (no brain activity). This has proved very useful during general anesthesia in avoiding awareness due to inadequate hypnosis, by keeping values between 40 and 60, but its use to achieve a particular level of sedation on the continuum of sedation has proved difficult to interpret. Levels of 60–70 have been postulated and the aim should be to avoid letting the patient slip into general anesthesia from deep sedation, risking apnea and hypoxia. This has not always correlated to an adequate level of sedation and most operators adjust the level of sedation based on

*A capnography module for the monitor and a nasal cannula with an oxygen tubing and an integrated CO2*

At least 25% of major airway events are from outside of the OR environment [8]. Complications are associated with hypoxia, aspiration, unrecognized esophageal

As we have seen above, areas outside the OR need to be prepared with equipment to manage the airway in a patient who may need it. We should plan and equip every area where this is anticipated, usually due to the fact that we as clinicians give patients drugs to aid procedures to happen, putting them in harm's way. Apart from eternal vigilance and monitoring, we should be prepared to step up the manage-

Capnography is a tool that has become part of the basic standards of monitoring the world over, in patients having sedation or general anesthesia. It is a very important tool to detect a deterioration in ventilation in a spontaneously breathing patient due to increasing levels of sedation. All staff involved with sedating patients need to

Checklists have improved patient care [9]. In areas where intubations are not routinely carried out, an intubation checklist has proved invaluable. Checklists have also helped in pre-assessment of patients and has helped recognize potential difficulties. For example, obesity is recognized as an increased risk factor for airway complications. These allow for thorough back-up strategy planning, both for

intubation and extubation, as it may not be routine in areas outside the OR.

response to any stimulus the patient experiences during the procedure.

**7. Improving airway management outside the OR**

ment of the airway that can become compromised.

intubation, airway trauma and obesity.

**46**

be trained in its use.

**Figure 6.**

*sampling line that fits into the module.*

**Figure 7.** *An airway trolley in a patient recovery area.*

The availability of the difficult airway trolley (**Figure 7** and **Table 3**) is paramount in areas where airway maneuvers are planned. These require regular checking and maintenance with replacement and stocking done every day. Since many areas exist outside the OR for airway procedures and since not every area is used on a daily basis unlike the OR, a designated person should be responsible to oversee this task. Every area should also have a plan to access video-laryngoscopes and fiberoptic bronchoscopes without much delay. Front of neck access equipment should always be available on the difficult airway trolley, and regular training should happen among the staff who look after the airway of patients.

Apart from airway equipment that is routinely used in the OR, certain newer developments in airway management have potential roles in areas outside the OR [11]. These include Laryngeal Mask Airways (LMA) modified with a separate channel to allow endoscope access into the esophagus, and high flow nasal oxygen delivery devices. Examples of the separate channel devices include the LMA® Gastro™ Airway from Teleflex, and the Gastro-Laryngeal Tube from VBM Medizintechnik GmbH (**Figure 8**). These modified airway devices have made it easier to anesthetize patients for ERCPs and upper endoscopy procedures.

The use of heated and humidified high flow nasal cannula (HFNC) with flows of 60–70 L/min has also become increasingly popular in deeply sedated patients outside the OR [12]. This can be used in various areas and addresses the concerns of transient apneas and hypoventilation and hypercarbia. It is recommended to use transcutaneous carbon dioxide (TcCO2) monitoring during prolonged use of HFNC in patients who may go apneic.


#### **Table 3.**

*An example of an adult difficult airway trolley [10].*

**Figure 8.** *(a) LMA® gastro™ airway; (b) gastro-LT.*

### **8. Human factors and team working**

Human factors such as poor team working, poor communication and failure to call for help all contribute to airway critical events. Human factors extend to institutional organization and structure, equipment availability and use of standard operating protocols (SOP) [13].

**49**

**10. Conclusion**

*Airway Management Outside the Operating Room DOI: http://dx.doi.org/10.5772/intechopen.93362*

the entire outside OR working environment.

**9. Post-procedure care**

Junior staff should always have senior help readily available, and non-anesthesiologists should have a system in place to get anesthetic help in case of problems. All staff involved in airway management outside the OR should undergo airway training, both basic and advanced, and have annual refresher practice sessions of the less used skills, preferably in a dedicated simulation lab. They should also be familiar with the interpre-

Communication channels and links should be established between various departments and senior clinicians in the Emergency Department, Anesthesia, Intensive Care Unit and ENT (Ear Nose and Throat surgery department). Regular audits should take place of airway management problems or events, in all areas. High-fidelity simulator training provides anesthesiologists and other doctors involved in sedating patients outside the OR with the opportunity to develop their technical and non-technical skills for managing rare and dangerous scenarios related to airway management. It provides a safe multidisciplinary learning environment, and simulators can replicate a specific aspect of airway management, or

Post-procedure care should be the same as that required after an anesthetic in the operating room. This should be the rule, irrespective of the procedure done. If the patient has had sedative drugs or a general anesthetic, they are prone to having airway complications in the recovery phase. The risk is dependent on the drugs used, airway technique applied intra-procedure, and the duration of the procedure. Ideally a designated area of the corresponding suite should be available for patient recovery. This should be adequately equipped with facilities and trained personnel like a theater recovery room. This is an area that needs to cater to the monitored recovery of different kinds of patients, from those who may have had only moderate sedation, all the way to the patient who has had a full general anes-

For most, such a facility may not be available, and depending on the area, may not be possible. This would require patients to be transported to the main theater recovery room (the post-anesthetic care unit-PACU). For safe transfer one must ensure that adequate equipment and personnel are available in advance, and organized with the PACU team. It is vital to have the location of recovery and logistics of transfer if required, planned in advance, before embarking on anesthetizing in a remote location. Safe post procedure discharge from the intervention unit to the ward or home should be done following local discharge criteria. At the least patients should have vital parameters (Heart rate, blood pressure, oxygen saturation on room air and respiratory rate) within 20% of pre-procedure baseline levels, not be too sedated (either alert or responding to verbal stimulation), have a core temperature of more than 36°C, have no nausea or vomiting, and be pain free. The patient should be able

Airway management outside the OR can be a challenging task, not just due to the situationally difficult airway that can arise, but also due the different environments having different SOPs, differences in equipment availability and expertise of personnel present. It is crucial to standardize equipment availability in all areas where sedation will be given. This has to be drawn up and agreed upon with the anesthetic

thetic (with an indwelling endotracheal tube) for a few hours.

to sip fluids orally without features of aspiration or coughing.

tation and use of capnography along with other monitoring equipment.

*Airway Management Outside the Operating Room DOI: http://dx.doi.org/10.5772/intechopen.93362*

*Special Considerations in Human Airway Management*

Drawer 1 • Laryngoscope handles

Drawer 3 • Facemask sizes 3, 4

*An example of an adult difficult airway trolley [10].*

• Stylet • Lubrication gel

• Magill forceps • Adhesive tape or tie

• Lubrication gel • Inflation syringe 20 ml • Orogastric tube sizes 12, 14

• Syringe 10 ml

tube size 6.0

On top of trolley • Difficult airway algorithm flowchart

• Introducers/bougies • Airway exchange catheter • Suction catheters

• Endotracheal tubes: sizes 5–8

• Cuff inflation syringe 10 ml

Drawer 2 • Second-generation supraglottic airway devices (SADs) sizes 3, 4, 5

• Oropharyngeal airways sizes 7–11 • Nasopharyngeal airways sizes 6–8

Drawer 4 • Emergency front of neck access—scalpel blade 10, bougie, endotracheal

• Direct access phone numbers to anesthesia/ICU/ENT

• Portable monitor for videolaryngoscope

• Laryngoscope blades: Macintosh sizes 3 and 4 • Videolaryngoscope blades depending on make

**Level Contents**

On the side of trolley

**48**

**Table 3.**

**Figure 8.**

**8. Human factors and team working**

operating protocols (SOP) [13].

*(a) LMA® gastro™ airway; (b) gastro-LT.*

Human factors such as poor team working, poor communication and failure to call for help all contribute to airway critical events. Human factors extend to institutional organization and structure, equipment availability and use of standard

Junior staff should always have senior help readily available, and non-anesthesiologists should have a system in place to get anesthetic help in case of problems. All staff involved in airway management outside the OR should undergo airway training, both basic and advanced, and have annual refresher practice sessions of the less used skills, preferably in a dedicated simulation lab. They should also be familiar with the interpretation and use of capnography along with other monitoring equipment.

Communication channels and links should be established between various departments and senior clinicians in the Emergency Department, Anesthesia, Intensive Care Unit and ENT (Ear Nose and Throat surgery department). Regular audits should take place of airway management problems or events, in all areas.

High-fidelity simulator training provides anesthesiologists and other doctors involved in sedating patients outside the OR with the opportunity to develop their technical and non-technical skills for managing rare and dangerous scenarios related to airway management. It provides a safe multidisciplinary learning environment, and simulators can replicate a specific aspect of airway management, or the entire outside OR working environment.

#### **9. Post-procedure care**

Post-procedure care should be the same as that required after an anesthetic in the operating room. This should be the rule, irrespective of the procedure done. If the patient has had sedative drugs or a general anesthetic, they are prone to having airway complications in the recovery phase. The risk is dependent on the drugs used, airway technique applied intra-procedure, and the duration of the procedure.

Ideally a designated area of the corresponding suite should be available for patient recovery. This should be adequately equipped with facilities and trained personnel like a theater recovery room. This is an area that needs to cater to the monitored recovery of different kinds of patients, from those who may have had only moderate sedation, all the way to the patient who has had a full general anesthetic (with an indwelling endotracheal tube) for a few hours.

For most, such a facility may not be available, and depending on the area, may not be possible. This would require patients to be transported to the main theater recovery room (the post-anesthetic care unit-PACU). For safe transfer one must ensure that adequate equipment and personnel are available in advance, and organized with the PACU team. It is vital to have the location of recovery and logistics of transfer if required, planned in advance, before embarking on anesthetizing in a remote location.

Safe post procedure discharge from the intervention unit to the ward or home should be done following local discharge criteria. At the least patients should have vital parameters (Heart rate, blood pressure, oxygen saturation on room air and respiratory rate) within 20% of pre-procedure baseline levels, not be too sedated (either alert or responding to verbal stimulation), have a core temperature of more than 36°C, have no nausea or vomiting, and be pain free. The patient should be able to sip fluids orally without features of aspiration or coughing.

#### **10. Conclusion**

Airway management outside the OR can be a challenging task, not just due to the situationally difficult airway that can arise, but also due the different environments having different SOPs, differences in equipment availability and expertise of personnel present. It is crucial to standardize equipment availability in all areas where sedation will be given. This has to be drawn up and agreed upon with the anesthetic

department. The need for the availability of special equipment like the video-laryngoscope or the fiberoptic bronchoscope will be decided depending on local protocols. Having capnography in all these areas is of utmost importance for patient safety in this day and age. Staff involved in monitoring these patients need to be educated in its use. The importance of eternal vigilance cannot be emphasized enough. Airway management can be more of a challenge in these areas and in an attempt to prevent a deterioration in the airway of a patient, constant monitoring by a dedicated member of staff is paramount throughout the procedure and into the recovery phase. The ability to manage airway emergencies must be a skill mastered by all staff involved in sedating patients outside the OR and this can only be made possible through regular training. Airway management outside the operating room is challenging. Difficult airway management guidelines from the Difficult Airway Society (DAS), UK, or the American Society of Anesthesiologists (ASA) remain the standard reference guide [14].
