Algorithmen zum Atemwegsmanagement

Algorithmen zeigen die Lösung für ein Problem auf. In konkreten Einzelschritten wird die Vorgehensweise vorgezeichnet, basierend auf Wenn-Dann-Entscheidungen. Ein guter Algorithmus muss darüber hinaus übersichtlich und einfach verständlich sein, um sich auch im Notfall zu eignen. Der Beitrag untersucht die bestehenden Empfehlungen und Leitlinien zum Atemwegsmanagement auf ihre Praxistauglichkeit und Evidenz.

Abstract

Centuries ago an “algorithm” was originally inaugurated to depicture a pathway to solve mathematical problems using a decision tree. Nowadays this tool is also well established in clinical medicine. Ever since management errors in difficult airway handling and subsequent litigations remain high referring to ASA closed claims database. However, even since 2010, the ESA postulates every institution dealing with airway management should have a DAM algorithm (ESA Declaration of Helsinki on Patient Safety in Anaesthesiology). In 2018 a systematic review of 38 international DAM algorithms was published; most of them show a four-step flow chart: failed tracheal intubation, insufficient bag-mask ventilation and supraglottic airway, leads to establish an emergency sugical airway. In conclusion authors state that a universal, globally valid, DAM algorithm is lacking. German language guideline development is governed by the AWMF, which labels guidelines with the highest evidence levels and methodological strength “S3”. The ASA published a revised DAM practice guideline in 2022, which was developed by 13 international members and was endorsed by international anesthesiological societies. – Though it is based on a systematic literature search and evaluation, final recommendations (without grading) were generated by a survey among experts in the field: Pre-procedural evaluation of the airway is essential; meanwhile more data are available especially regarding ultrasound examination of the upper airway and in 2022 a promising nomogram was developed for the prediction of difficult laryngoscopy. Pre-procedural planning of expected DAM: it should be decided beforehand, if awake intubation is feasible for the patient. Preoxygenation of every elective patient (3 mins with PEEP 5 cmH₂O, aim: 95% pulse oxymetry) and continuous nasal high-flow oxygen delivery during airway management. In case of unexpectedly difficult/emergency airway, ASA recommends: call for help, use cognitive aid (algorithm), consider restoration of spontaneous breathing, adjust bag-mask ventilation, monitor time passing; if „cannot intubate, cannot oxygenate“ situation occurs (etCO₂ < 10 mmHg, < 80% pulse oxymetry) establish surgical airway; if failed consider ECMO therapy, if feasible and available. ASA restricts intubation attempts to 3+ based on experience and decision of the clinician, however evidence shows, that attempts should not exceed 2 attempts to avoid serious complications, e.g. hyoxemia and even cardiopulmonary resuscitation (CPR). Additionally, we recommend a cockpit strategy for airway management using crisis resource elements as used in aviation (situation awareness, sterile communication, read-back/hear-back and canned decisions) and a supervisor/team leader as already established in CPR. Last, but not least, continuous airway management training increases algorithm adherence.

Kernaussagen

• Das Erkennen des schwierigen Atemwegs ist konventionell nicht immer möglich (Nomogramme, die Ultraschalluntersuchungen der oberen Atemwege und Tests kombinieren, scheinen die Vorhersage signifikant zu verbessern; dies muss aber weiter evaluiert werden).

• Einfache Algorithmen zum Atemwegsmanagement mit sog. Canned Decisions sind als kognitive Hilfen essenziell (z. B. Trichteralgorithmus in [Abb. 4], vorab definierte Entscheidungswerte).

• Das Notfall-Equipment muss vertraut sein:

  • Videolaryngoskopie (VL),

  • Larynxmaske (LMA),

  • fiberoptische Wachintubation (FOI),

  • Koniotomie.

• Präoxygenierung ist essenziell plus kontinuierliche Sauerstoffgabe mit hohem Fluss während der Atemwegssicherung.

• Briefing: Bei erwartet schwierigem Atemweg vorab Festlegung, ob fiberoptische Wachintubation (Goldstandard) möglich ist oder ein unkooperativer Patient in Narkose versorgt wird (ggf. Tracheotomie in Lokalanästhesie/leichter Sedierung; HNO-Stand-by).

• Unerwartet schwieriger Atemweg mit guter Maskenbeatmung: Es sind 2 Intubationsversuche möglich. 1. Wahl Videolaryngoskopie, Larynxmaske; (ggf. darüber Intubation); Patient aufwachen lassen möglich?

• CICV-Situation („cannot intubate, cannot ventilate“; zeitkritischer Notfall): chirurgischer Zugang zur Trachea, wie im Algorithmus verankert (z. B. etCO₂ < 10 mmHg und SpO₂ < 80% nach gescheiterter endotrachealer Intubation und insuffizienter Gesichts-/Larynxmaskenbeatmung).

• Falls dies misslingt, extrakorporale Membranoxygenierung (ECMO) (soweit sinnvoll und vorhanden) etablieren.

Schlüsselwörter

Flowchart - Handlungsanweisung - Atemwegsmanagement - schwieriger Atemweg - Intubation

Keywords

flowchart - airway management - difficult airway - intubation

Publication History

Article published online:
15 February 2023

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