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O.A.S.I.S. : Optimal Airway Strategy In Situation

So you might have noticed a bit of banter in the community about airway management in the last few weeks!  What’s new?

[ I usually try to stay out of the airway stuff – as there are many brighter and more expert “airway bloggers” out there. ]

A lot of debate about cricoid pressure and the way we do this in a medico-legal system where expert opinion is not consistent or often appropriate to the setting in which we practice.

My good mate Dr Tim Leeuwenburg has been pondering this topic deeply in the last week or so and has tried to reach a consensus – a deep dive into the literature around emergency airway management with all of its dogmatic idiosyncrasies and variations.  The idea is that we need a template which we can all agree upon.  We need a set of workable guidelines as to what constitutes “best practice” in 2014.  However….

…the problem is that there are many ways to skin a cat.  There are many different situations in which one might flay a feline, many different morphs of moggy and there are a lot of varieties of domestic taxidermists out there with a range of skills, tools, preferences and training.

One might argue that writing a consensus statement around this is like trying to… herd cats.  Too many variables – prehospital, ED, in helicopter, ICU, in CT scanner or a well-lit OT.  And that is just in location, before we even consider the other variables.  Is it really appropriate to try and define a standard that covers…?

  • an occasional intubator by the roadside at night using a spoon and the reflected light off of his high-beams,
  • an ED with lots of junior trainees, supervision and plenty of resources
  • a post-op ICU with a consistently sick, difficult airway [surgically inevitable] patient population
  • a small country hospital with a heterogenous mix of practitioners working with a team that changes daily with high staff turnover.
  • an elective theatre suite with  high-volumes of fasted, well prepared and healthy patients?

In case you were wondering about my answer to this question…  “No!” in a word.  There is no single standard that we can apply.  In my opinion even recommending a basic minimum standard is unrealistic / unachievable in some settings.  Tim gave a fantastic talk at SMACC GOLD about his rural Resus room feng-shui.  But trust me, he is an exceptional Doc and an exception to the rules when it comes to remote and rural emergency airway practice.

Sure, you can argue the merits of evidence for or against a particular manoeuvre [cricoid pressure, Apnoeic oxygenation, ramping….]  and that is all OK. What we need in this debate is to have better data to replace the dogma that has little evidentiary basis.  I sense a communal breath-holding {excuse the pun} for more evidence to guide us.  However – what should we do in the meantime?

So I have been thinking about a hypothetical scenario.  Imagine that you were asked by some MDO lawyers to act as an ‘expert’ witness in the case of an airway disaster involving one of my fellow rural GPs. [ I am not likely to do this any time soon 😉 ]

The thought experiment is as follows: what would you state when asked by the judge to define the ‘standard of care’ for emergency airway management?  Could you do this in simple terms without boring the assembled legal minds to death with jargon and dogma that really is as clear as mud?  Could you make a case for the accepted variations in practice around the country / world?

Well here is how I might answer the question:

  1. At the present time there are multiple safe and reliable approaches to airway management in emergency care.
  2. There are a number of specific techniques and manoeuvres which might be utilised in differing settings
  3. One must consider the following factors in choosing the specific strategy:
    • The team’s experience / skill set
    • The patient:  premorbid state and acute problem
    • The resources and equipment available
    • The environment – geographic, lighting, access to the patient etc.
    • Alternative options – such as delaying intervention, temporising therapies or getting more support
  4. The chosen strategy should include a pre-defined set of alternate options should ‘plan A’ fail

In summary – the practitioner should be able to provide the Optimal Airway Strategy In the Situation  (O.A.S.I.S).  In many situations the OASIS will in fact be a ‘formal’ RSI with all the traditionally described drugs, gear and team set-up.  However, we must be aware that there is a range of acceptable practice patterns and that in many situations these will be preferable to what has been described traditionally. (For, example: cricoid pressure would appear to be a poor utilisation of resources in a team of 2.)

So – that is my answer.  I am introducing a new meme – the acronym OASIS.  We can use this term to describe the best airway strategy for that team, at the time in the situation they find themselves.

Now just to be clear – I do not think that this is a justification for rampant pragmatism or “fly by the seat of one’s pants” medicine.  One must understand all the evidence and have multiple tools in the cognitive and practical toolbox in order to achieve an OASIS on any given day.

So if you find yourself on the pointy end of criticism about your airway management – I would be more than happy to defend you if it were clear that you were going for the OASIS in the desert you found yourself.

And it is worth saying that at the institutional level we ought to be making our hospital, clinic, theatre (or car in Tim’s case) into a fertile OASIS.  We should have the kit & training to provide a range of OASISes for our patients.

OK enough said.  Try it out – next time that you decide to smoke the blue cigar ask yourself first – what is our OASIS?

Casey

PS: there has been a Twitter meltdown over this involving the usual airway Foamies – so we have created a Google discussion thread on the Broome Docs community page to make it more workable and leave all the nice twitter followers in peace!

Here is the link : https://plus.google.com/u/0/communities/112402831578834720667

Comments

  1. Nice one Casey. Agree 100%, it is very difficult to define a ‘one size fits all’ standard for RSI of the critical patient

    In fact, I do not think we should. Certain key elements of RSI remain – but the current day RSI is a LONG way down from the original description by Stept and Safar (precurarisation, head up, thio, sux). Should we add in Sellicks procedure? Purists say ‘yes’ (and may hang you out to dry in Court if omitted) – yet Sellick described this in head down position to both tether oesophagus against vertebrae and to minimise aspiration. How does that square?

    How about dose of induction agent? Stept & Safar described a bolus technique…yet many practice a titrate to LOC approach. Indeed, a UK anaesthetist has recently been harshly criticised in a ‘fitness to practice’ tribunal for bolusing thio not titrating in her RSI (admittedly there were many other problems highlighted in that particular doctors practice).

    So it is salutory to see how experts will criticise RSi practice, even though there are marked differences in how we practice between individuals, institutions and nations. Is that logical?

    So….there does not appear to be a uniform description of modern RSI…rather a plethora of recent literature acknowledging the differences and ALSO suggesting improvements…many of which are espoused by members of the FOAMed community. Not just the cricoid debate, but also

    – positioning (head up? Head down? Supine?)
    – choice of induction agent (thio? Propofol? Ketamine?)
    – bolus vs titrate dose
    – sux or roc?
    – CP or not?
    – gentle (<15cm H2O) BMV before paralysis?

    Add in the things we KNOW to work – apnoeic diffusion oxygenation, adequate preox using approp BMV w PEeP or a Mapelson B or C circuit, us of crisis checklists. Difficult airway plans and pre-RSI brief, even the Vortex approach…

    Shouldnt we promote these as a move towards best practice rather than the current 'lets do RSI the way we were taught…even though we can do better'?

    So – yes – I believe it is time to put out a position statement on RSI in the critically unwell.

    Not a dogmatic statement, but a paper that acknowledges controversy, recommends certain approaches (ramp, NODESAT, PEEP, rocketamine, CP on/off, bougie etc to maximise 1st pass success in the critcal patient)

    Once there is an acknowledgment that there are agreed vagaries in RSI and some significant advantages in certain manouevres for the critical patient, then we can put behind us the spectre of 'expert' medicolegal testimony that is based on tradition and dogma.

    Am putting finishing touches to a draft, welcome input from FOAMites who are interested in this sort of thing.

    Believe me, there a LOT more to the RSI debate than CP…and it behoves us to put a coherent summary of best practice out there.

  2. I like the idea of OASIS for sure

    But I am afriad that the reality is that if there is an airway catastrophe I very much doubt that the expert witness will be yourself (much as. I would like that to be the case)…rather, will be some crusty old anaesthetist from the thio-sux-tube school.

    Can you hear them in court? “Whats that? Nasal cannulae and NODESAT? Never heard of it. ketamine for induction? Madness? Rocuronium? For a critical patient? Should ALWAYS use sux (unless theres a contraindication) so we can wake ’em up”

    Even suppose we manage to knock this medicolegal expert off the stand and substitute yourself, will reference to a blog post and OASIS cut the mustard? I doubt it. But a position paper incorporating all the FOAMed goodness and acknowledging the many ways to skin a cat (sure, tag as OASIS) would be a useful reference for expert testimony

    I honestly cannot find a decent position paper of that ilk out there.

    Wanna co-author?

    ok…late now…off to bed.

  3. Greg Miller says:

    I like your OASIS concept. I applaud the emphasis on knowledge of options and always having a Plan B, C, … and preparing for such as circumstances allow.

    Balancing the pro/con along a wide spectrum of constraints is a common theme in acute-care patient management.

  4. ..and OASIS collaborative project is consistent with FOAMed principles, as espoused by Radecki in 2014

    Radecki R. (2014) How are we acclerating knowledge tranlsation? EMJ blog online accessed 28 April 2014, Available via URL http://blogs.bmj.com/emj/2014/04/21/how-are-we-accelerating-knowledge-translation/

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  1. […] statement on RSI of the critically unwell – or what Casey Parker coined the OASIS consensus (Optimal Airway Strategy in Situation). I hope that it may serve to guide the development of institutional guidelines and SOPs on […]

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