Airway Educational Project

Medinfo Sites weblog

D.A. Algorithm @ UF. Survey 10-09

By •• Posted in Education

Survey attitude towards the ASA D.A algorithm @UF  (Actually realistically the response was not that great, so in truth I could have taken the “UF” out)

4 Responses to “D.A. Algorithm @ UF. Survey 10-09”

  1. Tyson Ulmer says:

    The airway topic gurus are conservative because a comparison of airway techniques lacks class 1A evidence, such as the kind we refer to for aspirin use in CAD.

    The ASA Difficult airway algorithms are therefore guidelines, not rules. They assume the caregiver has skills and good judgment to use the tools available they best way they can.

    Video laryngoscopes fit in wherever direct laryngoscopes fit, assuming one can show that the two techniques have equal outcomes. Does such a study exist? If not, then the VL should be left out of the D.A. Algorithm.

    I agree more could be added to the D.A. Algorithm regarding preoxygenation and extubation.

    I have yet to encounter a true CNV/CNI situation.

    The differece in reported CNV/CNI incidence varies from selection bias. Those in Minnesota have more CNV/CNI than California perhaps due to the difference in patients’ body-mass-index, for instance.
    Whatever the reason, it seems the overall incidence is low (per the data) and we can assume that not all difficult airway patients are the same. Among the common variables that make up a D.A., such as a large BMI, an unfavorable airway exam, etc, some studies have now made index scores using all the myriad signs of a possible D.A. Perhaps someday the D.A. will be so exhaustively researched that textbooks will say, ‘a patient with a D.A. index score of X must be intubated with either the Miller blade, or the Urdaneta blade, to do otherwise would be folly.’

    Until then, we still have art in medicine.

  2. Felipe Urdaneta says:

    Conservatism is not a bad thing, being not open to new suggestions and new evidence is. However I agree with you that the ASA Algorithm is part of a guideline, medico-legally speaking if you have a bad outcome and you deviated from what it says I do not need to spell out what happens.Perhaps in the future your statement about VL will be true but not at present times. One argument against your statement of the study for VL is that other than time, have you really ever read a big study comparing DL to blind nasal, or digital palpation and comparing both blades themselves? With regards of your last statement I somewhat disagree that it is just selection bias. It has to do more with lack of formal studies, from lack of proper definitions, from the fact that Benumof compiled retrospective data for which no control exists. Also if you take different eras, you are asking for trouble when making conclusions. I am being harsh with his numbers, but in reality they are the only ones we have. Small studies even from last month point out that large BMI is not a risk factor for D.A! that is certainly not my experience. And last, I am afraid the D.A will never have the study or the database you comment on, because in order to come up with adequate numbers would require a monumental study in a short period of time, so that new devices do not cloud the picture; in other words, in my next life or two we will have more evidence!

  3. Dietrich Gravenstein says:

    I was intrigued by the disparity in the resident vs faculty experience with d.a. Why would that be? I can only imagine that if this were a representative sample for both groups, that experience counts! Where a resident may fail, by any technique, to either ventilate or intubate, the attending steps in to rescue the airway. But I also suspect definitions play a part in this difference. If one struggles to ventilate, with two practioners, for 5 min, before intubating – is that a can’t ventilate? How many attempts to intubate before one calls it a can’t intubate – even if the guy intubating was a third person? How many of these resulted in an ‘assist/code’ call for help might be the better question – and we know there are quite a few of those.

  4. Felipe Urdaneta says:

    Thanks for your response: I agree with you that experience plays an important part of this flawed survey and all others (I say flawed because the response was poor). As far as your description of a struggling two person ventilation, in my opinion this is better than a true CNV that makes intubation or surgical airway mandatory, rather than elective. Although the algorithm talks about awakening the patient, if you do not supply oxygen until he/she does, there is no chance that the patient will wake up. On another note if the situation that lead to the intubation is an emergency CODE or a patient in coma, well “awakening” is not really an option.


Leave a Reply - Comments are open to all Gatorlink users

Log in with your Gatorlink account to reply.

You can follow any responses to this entry through the RSS 2.0 feed.