Office-Based Emergency Airway Management (OBEAM) Diagnosing and Treating Difficult Airway A Simulation Course

This course is an AAOMS Approved Simulation Equivalency Course 

The Office-Based Emergency Airway Management (OBEAM) simulation course will prepare participants to manage airway emergencies during procedural sedation.  Attendees will review basics of airway management including use of adjunct assistive devices, as well as advanced techniques such as placement of laryngeal masks and laryngoscopy.  Simulation-based scenarios will also be reviewed and give participants the skills and confidence needed to ensure patient safety in an office-based setting.  

Objectives:

By the end of the curriculum, participants should be able to:

1. Identify and assess signs of a difficult airway.
2. Formulate a structured approach to managing a difficult airway.
3. Safely and effectively perform advanced airway management techniques.
4. Diagnose and treat laryngospasm during airway management.
5. Utilize adjunct airways to optimize ventilation and oxygenation.
6. Communicate effectively with a team during a critical airway scenario.
7. Recognize the role of alternative airway devices and techniques.

Components of the Curriculum:

Foundations and Assessment

1.    Introduction to Difficult Airways 

•     Definition and classification of difficult airways (e.g., anticipated vs. unanticipated difficult airway).
•     Airway anatomy and pathophysiology that contribute to difficult airway management.
•     Review of the American Society of Anesthesiologists (ASA) Difficult Airway Algorithm.

2.    Airway Assessment Techniques 

•     Mallampati score, thyromental distance, neck mobility, and other predictive factors.
•     Video demonstration of assessments.
•     Hands-on session using simulation mannequins to practice airway assessments.

3.    Team-Based Airway Management Simulation #1: Basic Difficult Airway Scenario 

•     Simulation of a straightforward but challenging airway scenario (e.g., Mallampati Class III, moderate obesity).
•     Emphasis on basic intubation techniques, patient positioning, and first-line devices (e.g., laryngoscope, bougie).
•     Use of adjunct airways (nasopharyngeal and oral airways) to optimize ventilation prior to intubation.
•     Participants must demonstrate proper use of adjunct airways within 30 seconds and establish adequate            ventilation within 1-    2 minutes.
•     Debriefing session with discussion on successes and areas for improvement.

4.    Emergency Cricothyrotomy/Alternative Techniques Workshop 

•     Demonstration of emergency cricothyrotomy using simulation models.
•     Hands-on practice of alternative airway management techniques (e.g., laryngeal mask airway [LMA], video      laryngoscopy, fiberoptic intubation).
•     Simulation scenarios focusing on failed intubation and the “can't intubate, can't ventilate” situation.

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Advanced Management and High-Fidelity Simulations

1.  Advanced Airway Devices and Techniques 

• In-depth session on advanced tools: video laryngoscopy, fiberoptic bronchoscopy, supraglottic airway devices, and transtracheal jet ventilation.
• Interactive stations for practicing with each tool.

2.  Diagnosis and Treatment of Laryngospasm 

              - Diagnosing Laryngospasm:

• Recognizing the clinical signs (e.g., high-pitched inspiratory stridor, inability to ventilate despite open airway, and cyanosis).
• Identifying patient risk factors (e.g., recent upper respiratory infection, use of certain anesthetic agents).

            - Management of Laryngospasm:

• Initial maneuvers: Continuous Positive Airway Pressure (CPAP) with 100% oxygen and jaw thrust.
• Administration of neuromuscular blocking agents (e.g., succinylcholine) if CPAP fails.
• Simulation of the progression from mild to severe laryngospasm and corresponding interventions.
• Time goals: Laryngospasm resolution within 2 minutes of onset (following proper treatment steps).

3.  Case Studies and Problem-Solving

• Review of real-life difficult airway cases and analysis of management strategies.
• Group discussion on decision-making, identifying errors, and alternative approaches.

4.  High-Fidelity Difficult Airway Simulation #2: Complex Scenario 

• Simulation of a complex airway scenario involving a trauma patient with a facial fracture, airway obstruction, or an obese patient with limited neck mobility.
• Team-based approach with roles assigned (airway leader, assistant, circulator, etc.).
• Participants must successfully establish airway and ventilation within 1-3 minutes depending on the scenario.
• Detailed debriefing and feedback on communication, decision-making, and technical execution.

5. Crisis Resource Management

• Emphasis on communication, leadership, and situational awareness during airway emergencies.
• Role-playing and discussion of human factors in difficult airway scenarios.

6.  Airway Management in Special Populations

• Managing airways in pediatric, obstetric, and bariatric populations.
• Specific simulation stations focused on these special populations.

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Key Resources:

1.  Mannequins/Simulation Models.

• Adult difficult airway mannequins with features like restricted mouth opening, limited neck mobility, and airway edema.
• Specialized cricothyrotomy trainers, laryngospasm simulators, and fiberoptic airway trainers.

2.  Airway Equipment:

• Laryngoscopes (direct and video), fiberoptic scopes, supraglottic devices, bougies, LMAs, jet ventilators, cricothyrotomy kits.
• Nasopharyngeal and oral airway devices for adjunct airway management.

3.  Instructor Team:

• Airway management experts (anesthesiologists, critical care specialists).
• Simulation specialists to facilitate scenarios and provide feedback.

4.  Debriefing Tools:

• Video recordings of simulations for review and debriefing.
• Structured debriefing models (e.g., the PEARLS debriefing framework).

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Conclusion:

This curriculum provides a comprehensive approach to recognizing and managing difficult airways and laryngospasm. Through simulation-based learning, participants will enhance their airway management skills, become proficient in using adjunct airway devices, and be prepared for real-life scenarios requiring quick, decisive action.

Faculty

George Tewfik, MD is a Board-certified anesthesiologist and an Associate Professor at Rutgers University New Jersey Medical School.  After graduation from Rutgers- NJMS, he completed his residency at NJMS, and obtained his MBA from Rutgers Business School.  He returned as a faculty member of the Department of Anesthesiology at Rutgers New Jersey Medical School in 2017 following 5 years in private practice and has served as the Director of Quality Assurance since 2018 and also serves as the Director of Simulation Training for the anesthesia residency program.  He is also a Fellow of the American Society of Anesthesiologists, a Certified Physician Executive, and has a Master of Science in Business Analytics.  

Rania Aziz, MD is a Board-certified Pediatric Anesthesiologist at Rutgers University New Jersey Medical School. She is originally from Egypt, where she graduated medical school from Cairo University Faculty of Medicine. Dr. Aziz completed her residency Rutgers New Jersey Medical School and her pediatric anesthesiology fellowship at Washington University School of Medicine. Dr Aziz completed her MBA degree at Kelly School of business and is a certified Professional in-patient safety.  Her interests include residents’ education and simulation. She has been a member of the Faculty in the Department of Anesthesiology at Rutgers New Jersey Medical School since 2013. 

Vincent B Ziccardi, DDS, MD, FACS attended Columbia University and earned his dental degree. Upon graduation from Columbia, he was accepted into the integrated MD/Oral and Maxillofacial Surgery residency training program at the University of Pittsburgh where he earned his MD degree and certificate in oral and maxillofacial surgery.  He serves as the Rutgers School of Dental Medicine Chair of the Department of Oral and Maxillofacial Surgery, residency program director, Chair and Chief of Service within University Hospital and Associate Dean of Hospital Affairs as well as the Director of the Craniofacial Center at University Hospital.