The 2025 Difficult Airway Society (DAS) guidelines introduce a paradigm shift in airway management by emphasizing proactive planning and priming, where clinicians must prepare all equipment and strategies before attempting intubation rather than reacting to failures. The guidelines now recognize physiologically difficult airways (involving hypotension, oxygen saturation issues, and acidosis) alongside anatomical difficulties, requiring assessment of multiple complexity components including patient physiology, operator training, location, and available equipment. Key changes include making video laryngoscopy a requirement in Plan A, mandating adequate neuromuscular blockade with depth monitoring, and implementing a 'stop, think, and communicate' protocol during crisis situations. The guidelines also recommend vertical incisions for surgical cricothyrotomy and emphasize that skills like cricothyrotomy require recurrent training every six months to maintain proficiency.
3 atualizações em VIA AÉREA DIFÍCIL que mudam tudo em 2026Added:
Anesthetic greetings, everyone.
Welcome everyone. Today we're going to have a chat with my great friend, Dr. Ricardo Zan Lourenzi. Well, and for those who don't know Dr. Ricardo, he's the president of SESC, Ricardo, coordinator of the SBA training center in Joinville, head of the anesthesiology service in Joinville, and also the founder of Pomodoro Medical Learning.
I spoke correctly, didn't I, Ricardo? Perfect.
I spoke. Beauty. Ricardo, personally, I've known Ricardo since the beginning of my first year of residency. He's always been a great reference for me in terms of airway management, and he's a great science communicator in that area and in medical education in general. We'll also leave his social media links here during our conversation, for those of you who don't know him yet. And I wanted to welcome you, Ricardo, and thank you for your availability to be here and have this chat with us. I'm sure it will be very enriching. I wanted to open this space upfront, in case you have any initial messages for people before we get into the actual topic.
Thank you, J. So, hello everyone.
Thank you very much for the invitation. It's an honor to be here with you all, discussing this topic. I say that my biggest conflict of interest, my main focus, is my interest in airway management, right?
I always say in class that sometimes when we're really interested in or enjoy a topic, we end up overvaluing it. So, this is really the topic we're going to talk about here, which is fish management, and it's definitely the topic I most enjoy discussing. So, it's always a pleasure to talk about this, and I think it 's very necessary for us to discuss it. Perfect, Ricardo. I think one of the main reasons for our conversation here today, when we were defining the topics, was to discuss in more depth the guidelines of the Difficult Path Society, which were published at the very end of last year, the very end of 2015, and which replaced the 2015 guidelines. And to begin this discussion specifically about these guidelines, we have some questions that some professors and students have sent us about them, but I'd like you to initially give a general overview to provide background for those who haven't read the guidelines yet, for those who are unfamiliar with them. And I'll also leave you with an initial question to bring up during your opening remarks. If the patient considered to have a difficult airway has changed in the last 10 years, who will be considered a difficult airway patient in 2026? And do you think that the experience we've had in the last 10 years with the pandemic, with COVID, has influenced in some way the development of this new guideline? I hope you can bring us this initial overview with these questions in mind.
Perfect. Okay, so let's start with the hardest question there is. That's a tough road, isn't it? That's very complex, isn't it? If I normally ask in class, and sometimes even at conferences, I put that question in the cup, what is a difficult path for you, right? And the staff were there during the workshop, and people were struggling; it was more than three attempts, there was difficulty with intubation, there was difficulty with all approaches. So, this definition is very complex, and in fact, what we have—I think the most didactic way for us to approach what a difficult road is—is a definition that a road isn't just one thing; it has several stages, right? It has several components of complexity that can make it difficult. So, for example, there's the anatomical aspect, which is classically what we pay the most attention to and evaluate, so to speak. This is a component, right, of the Vieira difficulty, which is the most classic one. So, taking advantage of this, and even using COVID as a starting point, in 2015 an article was published by emergency physicians about the concept of physiologically difficult venous fistula, which is one that involves the component of hypotension, right, the component of oxygen saturation, the acidotic patient or not, such as right ventricular dysfunction. Typically, these four components are what involve the complexity related to patient management. So, managing a visceral infection isn't just about inserting a tube or a laryngeal mask; the patient has to be alive, have adequate blood pressure, and adequate oxygen saturation.
So this is another component that COVID brought us quite a bit, because most COVID patients were physiologically difficult; those who participated in this pandemic were the patients who, when intubated, either didn't improve their oxygen saturation or desaturated very quickly. So, they were all physiologically difficult airways, for example, I'm an easy guy to intubate, except for the beard which can be difficult to ventilate, but intubation is easy. If I have COVID and I'm on a high-flow nasal cannula or non-invasive ventilation, saturating at 80%, the moment they put me in apnea, in 10 seconds I'll go to 30 and stop. And that's what happened with COVID, right? So we have these two components, the physiological and the anatomical. And then we have other components that are increasingly being brought into play, which are the situation and location where this route is managed, and also who is managing it, right? So, if the colleague who is handling the procedure doesn't have adequate training with video laryngoscopy, with laryngeal mask insertion, etc., that vein will sometimes be more difficult for them.
And for Dr. Charles, who has been around longer, you know, for a few more hours on the road, it will be easy for him.
Charles has the same airway; it might be difficult if he manages it in the MRI machine because he can't position it correctly, or in the endoscopy room because they don't have bed mobility. No, he's not used to it, and there's no one to help. I'm even talking about nursing technicians, right? Uh, you say laryngeal mask, they don't really know, the staff aren't trained. So, look, viafil, folks, it's very complex. And that brings up the question you raised, this has been changing, especially since 2015, which, interestingly, was when the last Difficulty Society guideline was published.
Then, 10 years later, they revised it and it was published now in 2025.
This article also came out that it was physiologically difficult, which wasn't even contemplated in that 2015 guideline. And our 2025 guideline already includes the concept of a physiologically difficult airway, in addition to the anatomical one, which we also have to evaluate from a physiological point of view, right? He brings up some scores there, within the guideline, for us to use, which is the MACOCH score, which is used to assess whether the person managing the airway is an anesthesiologist. One of the points there is all in the guideline, which is openly accessible on the DAS website. So it's interesting that they bring that up in a very pronounced way, you know, in Gaisle. So I think to introduce, I think this beginning about the various components of a viéria edificicil. So, the operator, the location, right, the equipment that's available. So, for example, if you go to an emergency room that only has a laryngoscope, an Ambu bag, and a Guedel airway, and you don't even know if they have a cannula, a cricothyrotomy kit, you don't know if they have a supragothic ventilator, even though they probably do, but you don't know, uh, you don't know if they have a bug, maybe just what you have in your backpack. It's clear that a large portion of the airways will be difficult to navigate. The larynx is a larynx with poor lighting, with two blade sizes. So you see, Viera is dynamic, depending on who is going to operate it, the way it's being handled, the way it's being handled, the training of the person who is doing it.
So, you see, we have to evaluate all these components when we're, of course, the R1, most of the R1s who are starting out, will find it more difficult than for another colleague who has more experience, right? So this needs to be taken into consideration when we're evaluating and managing a road, right?
Okay, so for those of you talking more about the guideline, right, about this universe of airway guidelines, we have, in anesthesia, in a very summarized way, the main societies that publish these guidelines, and the guideline, you see, it guides you, it does n't determine anything, it's a basis for you to make a decision based on your clinical judgment. It 's important to make that clear, right?
We can't treat that like a bridle, can we? So, clinical judgment is always a reflection on what has been published. It's important. That's why our critical thinking is always so important, right? We need to reflect on what has been published.
We have the 2022 publication, the latest one, from the American Society of Anesthesiologists (ASA), which brought some changes, but they are always quite conservative.
We have a publication from our colleagues here in Brazil by the travel committee, which was published about two years ago, I think it was in 2024, the one for pediatrics and the one for adults. Hey, but what happened? There's no flowchart, is there? It's more of a, let's say, a literature review, right? Well, based on the experts here, it turned out really good, right? It's very much based on the American model, which is great for us to use in hospitals, right? Because it's a document from Brazilian society, but it doesn't have a flowchart like the one we'll see here for us to follow, which is a more visual thing that makes our approach a little easier. And then there's the one from DAS, which is Difficulty Society, which is, let's say, the air transport society of the United Kingdom, right? So, uh, and DAS and SAM, which is the Society for Airway Management, the American one, uh, are the main societies for stingless bee management along with the European one, but the European one is a little, let's say, less active. And DAS, they are very, how can I put it, involved from the point of view that, even though they are based in the United Kingdom, they have a global reach and influence, right? So, they publish every 10 years. The first one was published in 2004, then a revision was published in 2015, and now in 2025. What has changed, right? In a very summarized way, the overall Gain strategy, we'll talk about each strategy. The main change is that we stopped, let's say, trying to make up for lost time.
So, if it went wrong, what do I do? to look and reflect and try to evaluate beforehand and try to have a strategy and a plan already in place. It's not that we didn't recommend this in the other one, but what we're going to see that becomes very clear is that for each strategy, for each plan, for each approach, we're already ready for the next one. Okay, so I'll try to perform the intubation. and fail the intubation attempt. I already have my crico kit in the living room. It's not open yet, but it's already there. I'm already there. So what's my next plan?
Ah, it's a laryngoscopy mask. I already have two sizes of masks. The one I think will work best is perhaps already open and ready to implement, and the entire team is aware of it. So it's much more that he, in fact, he took a lot from what the NEP was published in 2011, right, even before the 2015 guideline, which has a lot of the NEP in it, but he took, uh, let's say, he refined a lot of what the 2015 one brought us, especially in relation to this issue of planning, right, of already being prepared for the next step, which is something that we tend to say: "Ah, I know what I'm going to do, but I'm not 100% ready for it, right?" So, we have a plan, we have what we're going to do, but like, "ah, I know I have to use an Indian face mask if I can't ventilate with a face mask," okay? But which mask? Where is she? Which device? Which brand do you know how to apply? It has all of that. It's a lot, generally speaking, right? We'll talk about each point, but in general, this guideline changes this—I do n't really like the word now, it's very fashionable—mindset, but it changes this approach, you know, of really chasing after things like, "Oh, it went wrong, what am I going to do?" I'll go there and do it so you can anticipate the mistake, right?
Yes, I think that's very important for the moment when it happens, right, Ricardo? Because, well, I have the impression that after we read the guideline, it becomes kind of obvious to us, right? You read it, and you say, "Dude, it's obvious that's how it has to be.
" But it wasn't phrased that way, was it? I think the way the guideline phrased it made this a bit clearer, because what we see in practice, at least what I witness most of the time, is this: it went wrong, now I'll think about what to do. based on the plan that's written. And then it turns around, and you're already in a critical scenario, a high-pressure situation, a patient's airway that you're losing, and if everything isn't very well planned, perfectly organized, and ready to go, you end up having more difficulty controlling that airway because everything wasn't prepared, right? I think this is indeed a very important change.
We have a question, we have a question about anesthesia, just like you said, that a good part of our airways, in general, are physiologically and anatomically calm. Uh-huh.
So, this is good, but it's also bad, because it puts us in a very comfortable zone, right? So, if you take the colleagues, you know, the most prepared ones, who work with the most critical patients, in the ICU or emergency room, generally those who have a little more training, they understand, and this is now very clear in the literature, that if you don't perform the first laryngoscopy correctly on that patient, the morbidity and mortality increase exponentially. So, generally speaking, these people either prepare everything and have everything meticulously planned and trained, or patients start dying.
Not in our case, you understand? In our case, it goes wrong. The patient has a good reserve, you understand? You can call for help.
He was a healthy patient, he came from home, and he has good functional capacity.
So, the world, the universe, is more tolerant of errors in anesthesia in general. Of course, there are critically ill patients under anesthesia too, right? But that's what I see here, that's why several colleagues, sometimes over time, if the guy only works with endocrine surgery, and has few critical patients, the guy relaxes, he doesn't position them properly, and then he doesn't pre-oxygenate, you know?
You're starting to take things a little too lightly, aren't you, Ricardo? Like, everything's so easy, right, man? A very easy way. We say that while studying in workshops, there are two guys who look for workshops, airway management courses. The one who loves air travel, the one who adores it, that guy who goes every year, and so on, and the one who had a problem. Uh-huh. Did you understand? And then he realized that air travel isn't so easy after all.
Yes.
Whether the outcome is favorable or unfavorable. Dude, that's pretty clear, you understand? Very clear. So the guy doesn't just go in like this: "Oh, I think I need to do some research on airways." No, because in terms of air transport, even though we handle it every day, we can manage it well with our current training.
But when the world sends a message like that, the guy grabs a ventilator, you know? So, the guy there really ca n't apply a mask, can't rescue them, there's a serious interaction with a patient, whether critical or elective, and the guy says: "Man, uh, I need to do something so this does n't happen again, right?" But normally some adverse event needs to happen, unless the institution, or the anesthesia team there, brings this need for continuous retraining, which I believe is ideal, right?
Well, normally, individually, we have this perception, and the guideline tries to bring us, you know, this context of anesthesia itself, that we are generally negligent. This isn't just happening in Brazil, folks. It's the same in the UK, you understand? The whole country is like that, anesthetics are all the same all over the world, okay? So, yeah, not much changes, just the address changes. So, it's really cool that they brought up the issue of planning, right? Well, they put it as priming, right, within the gas, right, which you 'll see in the strategies. And I think that this will certainly add value; following this will add a lot of safety to the management of patients' airways. Just a quick interruption to remind you that here at Nest Review we have open spots for our extensive course, whether you're preparing for the TEIA or TSA exams, your residency quarterly exams, or simply want to stay up-to-date in anesthesiology. Rest assured, we have the right product to accompany you throughout your academic journey. The Q Recode is right here on the screen, so don't miss out. Let's continue our discussion.
The algorithm, right, the general algorithm, plans A, B, C, and D, which has been maintained with some differences that you brought up, right, in relation to this priming, right, to perhaps, I even mentioned the word with you, perhaps, to set up the next step.
No, that word, that translation you mentioned, I think it's a good comparison. We sometimes have a little difficulty with literal translations from English, because the word has a meaning, you can understand it, but you want to translate it into Portuguese so we can sometimes use it in a translation, right?
We are actually in the process of translating the DAS guideline for publication and making it available via SBA. And we have this difficulty now, really with words, even leading to discussions among colleagues, right? Like, ah, I think this one sounds better, I think this one sounds better, because it's really difficult to translate literally, because we have to convey the meaning, right?
But I think we need to focus here, so we don't get carried away, and we're going to go over each image, highlighting some things we need to emphasize. So, notice that in the column on the left there is oxygenate during all the planes and during the transition between one plane and another. So, this is called "they brought it," we translated it as peroxygenation or perioxygenation. I think perioxygenation is bad; it's been changed to peroxygenation, which means oxygenating before, during, and after handling snakes, all the time. Remember that patients don't die from plastic surgery or endotracheal tube defects; they die from hypoxia. So, don't forget to always oxygenate. And here I'm not talking about apneic oxenation, Ricardo is a fan of apneic oxenation, no. Well, during intubation attempts, you just ventilate with a face mask on, right? However you prefer to oxygenate, okay? Just because you're attempting intubation and you don't want to move on to the next life stage doesn't mean you can't perform rescue operations during intubations with a face mask. So, I think that's interesting because sometimes we look at the gas, and we say, "No, plan A, I'm just going to intubate." Then, if I can't intubate her, that's when I'll go. No, that's not how it works. We need to be able to ventilate and oxygenate the patient through ventilation with a face mask. This is brought up in Gaidã during our attempts, right? We'll even see, you'll see that plan C there is the last attempt at ventilation with a face mask. So that means you've probably already tried or ventilated a few times with a face mask during some... during some attempts, right? Some things here in plan A that we'll outline later, but the issue is to determine a maximum number of attempts beforehand. So, of those three attempts, plus one more—and that one is a specialist, someone who has a better chance of successfully performing intubation than the other three, right? Notice that in all the strategies outlined in plan B, this is interesting even for exam purposes, okay? In the DAS guardline, plan B is always an attempt with a supertype. And in the ASA's (Acute Safety) guardline, plan B is ventilation with a face mask, okay? So, this is a very cultural thing, because in the United Kingdom, supra-Gothic art is used very widely, so they have, let's say, a learning curve; they have a great ease and familiarity with supra-Gothic art, right? So here's where plan B comes in, the supra-gothic style with a maximum of three attempts. So, look at this priming thing here, right? We talked about setting it up properly. They were unable to intubate him. They're going to declare intubation failure and leave the kit behind. And another thing that's done here is the standardized nomenclature for cricothyrotomy via surgical approach, which is ifodona emergency front of neck access.
So, uh, why does this business talk like, oh, these guys like frills, right, folks? This issue of nomenclature is very complex, because when it comes to doing research, especially in scientific matters, there is a great deal of disagreement regarding nomenclature. This makes it very difficult for us to integrate the literatures, the works of all the productions that exist in the world. So, there's a project being led by the DAS, the Difficulty Society, including the worldwide standardization of nomenclature, uh, of all approaches, so that when you're doing a procedure, you can say: "Ah, uh, surgical approach is glycerosomia." Well, even in Portuguese, the word for cricostomy varies; if you look, there are different words, right? Well, emergency tracheostomy, anyway, there has to be a standard procedure. So, the standard now for access, uh, let's say, for emergency surgical venous access is IVF, right? But closing parenthesis, oh, leave the crico kit, right, already accessible. So that's the concept of leaving it triggered. It's not about you only picking up or ordering the cricothyrotomy kit when you're on a ventilator (not a tube) with the patient's oxygen saturation at 25%, right? So when you're in the "don't ventilate, don't intubate" phase and you're going to perform, let's say, the surgical airway, this kit is already open and the scalpel is already there, they're already handing you their hand, right? So that's the concept of Prime, okay? Another point, all our strategies always confirm ventilation, uh, or oxygen, but here the ventilation would be, right, with capnography. I know that in anesthesia this is very easy, because since 2008 we've had this published and supported by the CFM (Brazilian Federal Council of Medicine), but for people outside the operating room, in the emergency room, this isn't so widely available, right? So this is good for us to reinforce, let's say, this security that we already have in the surgical center. So, to wrap up this image here, folks, in a crisis situation, right? It's difficult for us to talk here sitting down with a heart rate of 55, what does a crisis situation look like? But I think everyone can imagine when you can't get in there a couple of times, the patient starts to saturate you, and then you finally manage to ventilate with a mask. Damn, at least it's ventilating. This is the time for this thing here, this little yellow square. Stop, think, and communicate. The time you left the emergency room is fine for you, okay, the patient's saturating well, is stable, what are we going to do now? That's right.
Oh, is it always a matter of waking the patient up? No, of course not. Sometimes it's just not possible to wake the patient. Sometimes waking the patient isn't the most appropriate course of action. It's not that it's impossible. It's possible, but maybe it's not necessary, right? What are you going to do? Ah, the patient is being oxygenated by a supragotic device. Damn, is it possible to play with supra-gothic? Oh, damn, it's a hysteroscopy that I was going to, I don't know, I was going to, I, I chose to go in because I thought the patient was obese, but she's ventilating well with the supraoptic shunt. Okay, high five. Oh no, man. It's a video-assisted colectomy. I rescued him. Is it possible? I don't know. Is it possible to go inside? Can my supra-gothic look fit inside? I don't know. Okay? Well, I wanted to bring up a case that Perim briefly recounted in the Copa workshop, which he had at the hospital where he works. He went there, he had to have a cricothyrotomy. So, why did he create Crico? How interesting! Well, he arrived to help, they called him to help in the room, they had already tried intubation, ventilating with a face mask, and he inserted a laryngeal tube, which is a shunt device, cleared the airway, and the patient was there saturating at around 90, he was stable. What did he do? Stop, think, and communicate. The guys needed to have the surgery, okay? It was a surgery that involved more than just waking the patient up.
What did he say? It wasn't saturating properly, they had already tried several times and he said: "I'm going to do a crico, why are you going to do a crico now?"
Then he said: "The patient is now oxygenated, I don't know how long I'll be able to oxygenate him, and he's not being adequately oxygenated and ventilated." So, the most appropriate course of action for us, since we've already run the algorithm, is undoubtedly to perform a surgical procedure. So, look how great, you're going to perform a surgical airway a little more calmly and not in a rush with the patient stopping, you understand, you made surgical access to the airway, great, the patient is fine, you saved the patient, everything's alright. So, this is placed in the guideline there, it's within the "stop thinking communicate" framework. As a last resort, you have the option of performing surgical access to the vein because the patient is being oxygenated, but it's understood that perhaps you won't be able to intubate through that supraglottic tube, you won't be able to maintain that oxygenation for very long. So, take advantage of the fact that you're in a stable situation and perform the procedure. I think this is something I wasn't so aware of, because we always think of Cricoa in a crisis situation, right? Damn, the patient is almost dying, and it shouldn't be like this, it doesn't have to be like this, right? But I think that's a real paradigm shift, right? And we're even backed up by the guidelines for that, right? The guideline brings this to us, and I think it's really good to discuss this, to really bring about this paradigm shift, that Crico can be a situation that can be addressed, not just a crisis situation. And of course, if there's someone more qualified than you to perform that surgical procedure, of course you should ask that person to do it, right?
So it doesn't have to be you who does it; ideally, it's better to have someone calmer from outside come in and be able to do it. Now it has to be someone qualified, someone who is trained, right? It can't be just anyone. Sometimes, depending on how often you train, if you take an ENT doctor who has only operated on tonsils for 25 years, uh, if you always train to do cryopreservation, maybe you are more capable than him, right? So, yeah, it's not that simple to determine who's going to do it or who's the most qualified, right? I think that's it. It's always, always up to us to reflect.
Perfect, Ricardo. So let's delve deeper into each of these plans, because there are a few questions I want to clear up with you about each one. So I think we can delve deeper into each of them. I'll start here with plan A, which would be the ideal scenario, tracheal intubation. What new things are you bringing to us in this Plan A? The most striking thing, isn't it, is that the use of the videolaparoscope is no longer a recommendation, it's a requirement.
We already have in the literature that it reduces the chance of esophagogastroduodenoscopy and increases the success rate on the first attempt. So, he's superior, but you have to train, right? It's no use trying it the first time; it's a new technique, it requires training, and it has a learning curve.
Point.
Perfect.
Ah, direct laparoscopic surgery is dead. No, they are always complementary. One doesn't exclude the other, okay? That's because with the McInosch blade you can even switch between direct laryngoscopy and video laryngoscopy.
Here he's talking about the use of video, not necessarily videolaparoscopy, right? You can perform laryngoscopy with a videoscope. So I think this is very important, even in terms of equipment in those locations.
Guys, I think this is just as relevant as the use of the vengoscope. Rest assured, let's put it this way, you're kidding, right? Well, make sure you have a proper neuromuscular blockade. Guys, I don't know how many times I've already helped out, and a colleague even told me about it, Pat Creden, who's a professor, and she said she helped a colleague the other day, and I did too. You arrive in the room, you're having a lot of trouble, you did Rocuronium. Ah, I made 20.
Who is 20 of ruminant for?
Why?
Sucamedex is widely available for use. It costs R$ 40 a polka dot, understand? There's TOFF in all the rooms, for example, in our case here. So, guys, don't make your lives harder, okay? Use an appropriate dose of nerve blocker, preferably monitoring the depth of the nerve block. And that, folks, is going to be the case in this strategy and in all strategies, okay? So, sometimes you administer an underdose or, let's say—this happens a lot in the emergency room—the patient uses succinylcholine, can't get a laryngoscope, tries to ventilate with a face mask, the effect of the succinylcholine has worn off, and they're having difficulty ventilating with a face mask and saying, "I can't intubate, I can't ventilate," you know? That's why the airway management system is increasingly becoming a key player, because it will help the patient stay relaxed within all airway management strategies, right? So that 's very important, of course, associated with time awareness, which, let's say, allows for greater situational and time awareness. So, of course, if you're, let's say, you induced the patient, you weren't going to administer intravenous anesthesia, and you've been there for 15 minutes managing the patient's airway, right?
This patient isn't anymore, even if you administered a high dose of opioid, they've probably already... "He's waking up, right? So this is very complex, and ideally we would have a stopwatch in the operating rooms, but generally, the monitors have a stopwatch, right? So, try to always start the stopwatch at the beginning of the airway management, of the patient's anesthesia. It's something that helps a lot and is already recommended, right?
Ah, this issue, Ricardo, of muscle relaxants never occurred to me since the beginning of my residency, because, for us anesthesiologists, for most of us, we already perform an adequate blockade from the very beginning of the attempt. At least that's how I've always been educated, right? I've always studied that way. And then, when I started using the internet more, I started seeing one place or another asking questions like: 'Oh, every situation uses neuromuscular blockers for every patient.' I said: 'What do you mean?'" "Is there any situation where you don't use this to intubate a patient?"
Because it does n't make sense where that came from, right? So I think that's well written in the guidelines. It's one more thing, but I have the impression that this is somewhat ingrained in the emergency room staff, like if I ca n't intubate, as if the patient will spontaneously start breathing again just because they're without the neuromuscular blocker. Nobody counts the hypnotic, opioid, all that, right?
Exactly. It doesn't make sense.
No. Exactly. And even more so, right? The emergency room staff in the ICU, when the patient is critical. So sometimes, they're not even ventilating properly, they're already in a state of consciousness, so they weren't even breathing properly. Do you think now they're going to start breathing again? No, you understand? Intubate them, that's what will be better for everyone, right?
Yes. Yes.
And Ricardo, and a question before you continue your reasoning in plan A, that I wanted to ask you in relation to the video Laryngoscope, uh, I'm not even going to lead you on, I just wanted to ask you this question more bluntly. In 2026, Ricardo, having a video laryngoscope available in the room, is there any practical situation where you prefer direct laryngoscopy alone?
Well, I alternate quite a bit between video and direct laryngoscopy, okay? So, I don't intubate all patients. I think, if I can say so, 75% I intubate with a conventional laryngoscope.
Uh, and there are still sectors that don't have a video laryngoscope, but most of the sectors I work in do. Uh, so whenever I have any reason to use the video laryngoscope, I always use it, preferably always with the hyper-angled blade. But normally the answer everyone would expect from me is something like: "Ah, a situation with a high risk of regurgitation, right?" "Ah, because then the blade will get wet, and so on." Uh, it's not, it's not, it 's not my choice, okay? So there's no situation where I look at it and say, "Oh, damn, these are... especially since there's even a study by John Secles, the emergency physician, which is an observational study that shows that there isn't, it's the only one that, for now, doesn't show superiority to direct laryngoscopy in this patient with regurgitation, right?" So, bleeding, have you seen anything like it, Ricardo? Hi.
Active bleeding in the airway, trauma, something like that.
It depends on the technique you use, right?
Like, uh, if you have active bleeding, if you use that salad technique where you first go with a thicker, more caliber vacuum cleaner in front of the blade, right? If you insert the blade with secretion, along with the blade with video, it won't work, right? So I think you have to use a separate, different technique if you're going to use the video catheter in an airway with a high potential for contamination, or one that's already contaminated, okay? Well, what makes sense to me?
I end up using the laryngoscope with the blade, the Mac video laryngoscope with the blade, if I need to, you know? Which is exactly what I did, man. I even posted on my Instagram about a patient who had already discontinued Zenque, it was last week, a robotic surgery, a hernia repair.
I put it in, man, it was Resident Evil who went in and then with the McIntosh blade.
So, man, the moment he put the air conditioner on, it started coming back up, and I wasn't even prepared, like, the vacuum cleaner was already assembled, right? The probe was loose and all, damn, I squeezed and stuff, tried to aspirate, the white guy aspirated a little bit and I said, I said: "Excuse me, let me take over." And dude, I did n't automatically assume it was videolaparoscopy. I took it from his hand, didn't even look at the screen, lifted it and passed the tube straight through.
Because it was a quiet path like that, he was learning, he and the residents come in there with us to learn and they like to use the video laryngoscope, especially on more sensitive patients and such. So, I've been reflecting on this, but I think it's because, I don't know, I'm still a little old-fashioned, well, I 'm not really old, I think it's really because I don't have the habit of always using the video player.
Yeah, I see, I have several colleagues in São Paulo who share their experiences and chat with me on Instagram, and they say they work in top hospitals. He even said something like : "Dude, here, all approaches are video-based, right?" So, like, uh, they already bring it into the room there, in their case they have the brand they use there, they already bring it into the room and that's it, it's not a thing, damn, oh, bring the video player. So, that's it, but what is it? It's the institution that's bringing this about, right? Well, it's not that I can't, generally speaking, you have the blade there, especially the reusable one, you can use it every time, but when the institution brings this up and says, look, our standard is video-based, generally speaking, the tendency to adopt it is a little, a little, a little higher, right? Because, man, we tend to stay in our comfort zone, just sitting there in the shopping cart, and that's it, okay, use it here, bye, done, right?
That's exactly it. So, what do I generally do? Well, when I think it's going to be a more challenging approach, or that I want to use the video laryngoscope, or even that there's a chance of regurgitation, I use the video laryngoscope with the McIntos blade, because then if I have any difficulty with direct laryngoscopy, I can just switch to violaroscopy, you know?
So for me, that's what makes the most sense. He's the most practical and flexible one, you know? That's different from a hyperangled blade. She's a pergulated, damn it, sometimes you're a little more difficult, you can't change it with direct lymphoscopy, you know. So, if you have a pre-existing anatomically difficult pathway, I already know, and normally I just paste it onto the hyperblade. This is more or less the selection I make, you know?
But if I don't go with the video, I'll just use the blade too. Dude, I really don't see why you wouldn't use a video laryngoscope, because, man, if you don't want to look at the screen, don't look, a laryngoscope is ready to go.
Yeah.
Right? Perfect.
And there's one thing I think is always worth considering: what kind of laryngoscope you have, because with the Chinese influx, we have a lot of blades that don't have proper names or sizes. They bought a blade for the hospital here, and, man, blade number four looks like blade number three, okay? And then she even went by machine. Then there's another video there that shows they bought the blade size: small, medium, and large. And it doesn't say whether it's hyperangular or not. I think so, okay? So, when you look at it like this, we have, let's say, I'll mention the brands here because they are the brands, I was even talking to a Brazilian colleague who works in Canada, Fabrício, who was at the Vi workshop, and he said: "Man, in Canada it's like this, it's Glidop, CMAC, and Magra. Period. Those are the videongoscopes, okay? Those are the three. Choose between those three. And then you have it in a very easy and straightforward way, because they have a standard blade size. The hyper-angled blade is hyper-angled. It's easy to understand here in Brazil, man, it's a mess, you know? Because there's everything and there are different things. So I think that 's very important, to know what equipment you have and to be trained on that one, you know? Because otherwise you end up cursing the device and in reality the problem is you. It's you, right? Especially talking about the videongoscope.
Perfect. Ricardo, you can continue. Let's continue with plan A then. We talked about plan A for us Okay, let's wrap this up. To close up here on plan A.
Uh, notice that it includes the placement of some kind of introducer, okay? So, what is the tube for? The tracheostomy tube is used to deliver a mixture of gases to the lungs. Period. What is the introducer for? The introducer is used to introduce this device, which is the tube, into the trachea. The tube itself, although we use it to introduce it, uh, it's not ideal for this. That's what introducers, guide wires, are for. So, ideally, we should always use something, because these introducers, yes, they are used to introduce the tube into the trachea, and the tube is for ventilation through some device that we use. So, I think it's interesting to bring this up. Uh, another cool thing is that it mentions the external orange maneuver for us to use. Uh, if you're doing cricothyrotomy there, it doesn't really come into play, sorry, cricothyrotomy, uh, cricothyrotomy, right, which is the celic pressure. If you have Applying cricoid pressure, no, it doesn't specify whether it 's recommended or not, but if it's being done and you're having difficulty, remove it, optimize the positioning, and change the device or the blade, you know, the type or size of the blade. So, you see, for me, man, nothing was missing, you understand? What they put here is complete. So, if you do what 's instructed here or if you study based on what's presented here, there's nothing more you can do. If you did everything that's instructed here and it didn't work, man, you can go to another strategy, because intubation really won't work, right? And then, in a very interesting way, they state: "You just, let's say, say that it's OK, that you managed to intubate in an ideal way, with a double check of the capnography with yesterday's shape, with visual confirmation, right?" What happens? You've had some cases in the UK where people confused the caponography curve with the ventilation curve, right? And in the rush, in the crisis, and so on. And then they performed esophagogastroduodenoscopy, the patient stopped breathing, they couldn't identify it, right? So this double-checking thing is necessary, it doesn't necessarily have to be another doctor, right? It's only someone trained to identify the capography curve, right?
In fact, the recommendation today is that the caponenography curve should be that filled-in curve, right? Let's hope it's not an empty curve, right? To differentiate it from the curve, as if it were exactly like this, the capnography curve, it should be filled in instead of just being, let's say, a line, right?
To help you differentiate it from the other ventilation curves, right? So this is a recommendation.
Yeah, I think it might pass. Yes, from there I think we can move on to plan B since that brings us into the issue of supraglottic lobes.
Ah, the supraglottic ones, this has been the case since the Gideline 2015, uh, always giving preference to second generation. And here I am speaking, conversing with you as someone who lives in Brazil and is in the same boat. Do you think I have second-generation supra-Gothic patients in all my hospitals? Did you understand? I managed to put it in the difficult-to-access cart, right? Knowing that it can withstand higher sealing pressure, right? But I can eventually get around to using it in slightly more challenging cases. But just like routine, which has been the recommendation since 2015, it doesn't exist. So, this is a very big challenge that we still have here in Brazil, right? Well, it's always recommended to use second-generation supraglottic implants because they don't have robust scientific evidence. Ah, Ricardo, they reduce the chance of aspiration pneumonia, they reduce complications. Uh, no. What we know is that they have a seal pressure, allowing you to apply higher ventilation pressures to oxygenate the patient, right?
So, from an inferential point of view, by draining the stomach, theoretically you would have less chance of the patient eventually aspirating if they regurgitated. But, Ricardo, has there been substantial data on that?
No, it doesn't have one, okay?
Okay, and remember that even with supraglottic obstruction, if you're resuscitating the airway, apply the appropriate neuromuscular blockade, okay? Well, I can say that today, man, I think, I don't know, 80% of the masks I apply, I do a muscle-blocking treatment. I have ToF in all rooms, and if it hasn't reverted, I'll run Gammadex.
Dude, like I said, if Gamadex costs R$40, don't be a cheapskate in this situation, okay? Honestly, I don't think it's going to be [expensive], the time when it was expensive is over, right? It's over already, man. Yes, yes. Someone might criticize me, say that I'm breaking the healthcare system, I don't know.
But like this, and I'll tell you that more than 50% of the time you don't need to do it, because then you won't be taking such a large dose, you know, obviously.
So, man, if the surgery takes an hour, an hour and a bit, you have the TOFF, man, most of the time you'll have already administered 30mg of rocuronium supraglottically, because then you won't need, you're not giving a dose that will require intubation, you won't need it, you don't need that time there, you give a dose to facilitate your ventilation there, right? So I don't judge those who don't want to use it, but if you're using it for rescue, it's mandatory that you use it, right?
The patient needs to be very relaxed. If you can't get it to fit properly, you have three attempts, and in these exchanges and attempts, always focus on changing the size or type, the model, right? Hey everyone, in supraglottic laryngoscopy, the learning curve is actually steeper than that of laryngoscopy and incubation, because we have many models, you know? Well, we have the coupling depending on the patient's age, it's very complex, okay?
So, the insertion of supraglottic tubes and troubleshooting when the supraglottic tube doesn't attach properly is actually very complex, and it usually takes longer to learn how to insert the supraglottic tube correctly than it takes to learn how to intubate. And value the inclusion of supra-optical devices both for your daily lives and for, uh, rescue, right? And what do I generally do for rescue operations? That company hasn't published anything of a high standard or with substantial evidence, okay? I always suggest that people include Idol; I have absolutely no conflict of interest, okay?
From Interscurgica. Why? Because it's very easy to insert, okay? It has good sealing pressure, right, when it attaches and you can intubate from inside it, guided by fiberoptic bronchoscopy, right, by flexible endoscopy. So, what do I think? I think about the guy in the ER, uh, I think about the ICU, you know? Man, these guys don't know how to be paranoid. If even we, who are anesthesiologists, do n't know how to insert it properly, imagine them. So, what do I need? I need the guy who can handle the business, he just knows that he can't insert the mask upside down.
If he inserts it correctly like this, there you go, that's all that's needed, okay? So, and I see here in one of the institutions at Unimed that I'm more involved with, I see that this works, okay?
When people use it there, they even say things like, "Wow, I didn't even remember that existed, I just passed by this revolutionary thing, you know? It's not an expensive mask, it's a mask that costs, I don't know, 150 bucks. So, for rescue operations, I think it's really great. Sometimes you think, ' Ah, for everyday use, depending on the institution, it's kind of expensive, but it's a second-generation mask, right?'" "And it 's a legal device." Now, ah, and the others, right? The others, folks, require much more technique for insertion.
So, the cuff must be deflated, right?
Performing mandibular traction or a thrust there to insert it into the passage at the base of the tongue will help you move the epiglottis out of the way. So, but the message I wanted to bring to you here with the supraoptic cuff is when you rescue with the supraoptic cuff, right?
Uh, remember, uh, or you're having difficulty rescuing with the supraoptic cuff, remember the neuromuscular blockade, okay? And remember, uh, that the moment you rescue and oxygenate the patient, the "stop, think, and communicate" is the time to think, call for help to talk, to see what to do. Ah, it's possible to operate with the supraoptic cuff, let's wake the patient up. That's what rescue and airway management are for, so we can get out of the crisis and think, be aware to make the best decision for that case, because it's all very individual, you understand? It depends on the surgeon, the surgery, uh, Regarding the patient, there's no way to set a standard, right?
Another thing I forgot to mention here, which I'll close up, is that there's always an airway assistant here, okay? And that brings up an issue I have a lot of difficulty with in my reality, which is training the technicians together in the airway approaches. Ideally, you'd have a well-trained technician bringing the airway cart, getting everything ready, monitoring the time, or even saying, "Doctor, this is the third attempt, then we'll move on to another strategy." Ideally, we would really communicate this to the team so that next time, right? So that there would be someone there who would be like in the CLS, monitoring the time, saying, "Look, it's almost over, we're on the last attempt, and if it doesn't work, we'll move on to the next one, right?" But this requires a great deal of institutional maturity and even a bit more maturity from a hierarchical relationship standpoint, right?
But considering this here in The guideline, I think, is a starting point for us to understand that it's no use training only the medical team; we have to train the entire team, right? We have to involve the team.
This isn't about teaching people medical procedures, it's not that.
It's about teaching people the step-by-step process, what will be done so that everyone participates in what's happening.
Everyone speaks the same language there, right, Ricardo? That's what we need to advance from an institutional point of view, as I understand it. And I was even going to ask you this question.
Go ahead, Ricardo. Go ahead, continue.
No, no, no, you can continue.
I was even going to ask you this question a little later, but do you consider this recommendation the most difficult to implement in our daily lives, considering the DAS guideline as a whole?
Absolutely. Absolutely, absolutely.
Yes, I can't, in one of the institutions where I manage to do annual vieira training, right, for everyone who handles vieira, I can't include people. that are not medical. The institution doesn't see the point, saying it would be expensive, that it would be too complex, because it would require training a lot of people, and there's a high turnover rate of employees. So, it 's a step that I think is still difficult to take. I know there are institutions, for example, in São Paulo, like Santa Joana, right? They train, they... for me, that's ideal.
They have a person assigned to the simulation lab, and then the whole team is trained in their specific protocols. I think the maximum evolution of Manéa, in my view, would be that, right? It would n't be necessary to have just one person, but to have annual training, at least, for the entire team involved in vieira management, from all sectors, so that everyone speaks the same language. And, I think that would even engage people more, because people would feel recognized, right? And to feel... once again, a word that's fashionable, but I don't... I like it, but to feel empowered in being able to contribute to virus management. I think that sometimes the person is intimidated, you know? They say things like: "Oh no, I see that this is the last attempt, but okay, if he wants to try another 10, he's the doctor, you know?" "Let him figure it out, right?"
And that's generally what we see in practice, right, Ricardo? Of course, of course.
Especially sometimes colleagues who are more, I could say, stubborn or older, have a very big ego, right? Because I think that's a big difficulty we have with many anesthesiologists. I'd even say this class here is for our residents, this discussion is for our residents too. And you, as a residency preceptor, I don't know if you have this perspective, you could even share it with us, but one thing I've noticed is that during residency we reach a point where we think we're invincible when it comes to airway management. I, at least, experienced this very clearly during my residency.
You arrive knowing nothing and then you start intubating and then you start intubating patients too easily, saying: "Wow, this is so easy."
And then they call you to the ER and you go with your preceptor, you intubate, nobody there could do it, and then you think, wow, I'm awesome, without managing the airway like... Nobody. And then you enter a very dangerous scenario that you will probably learn through pain if you do n't have the humility to recognize it. I have this view very much, and it happened to me. I reached a point in my residency where I was sure that no airway was un-intubatable; it was simply that people didn't know how to manage the airway. And you feel kind of invincible, like, "I know everything," and that's dangerous, right? The ego gets very big. And then one day, God... Exactly. And in anesthesiology, regarding intubation, I have the impression that this happens very quickly for most people. And then you will eventually encounter a truly difficult airway, and on that day you will rethink many things and realize that the guidelines are there, the recommendations are there because these scenarios happen, right? So I think that in life, beyond residency, right? There are times when, damn, in your life, everything is going well, a major surgery is going well, and suddenly you start not being able to function properly... The arteries suddenly can't get used to doing some HACCPs. My wife, who's also an anesthesiologist, said, "Man, I'm going through a bad phase, my HACCPs are failing, everything's bad, man." That's how it is. If you don't have the humility to ask for help and see what's happening, like, "I'm kind of nervous, it's not good," this is going to happen, the universe is going to give you some hard knocks, right? And I think that's definitely a very frequent thing. Why? Because we intubate a lot, we manage a lot of airways. So the learning curve, man, is really cool. You see a resident who entered in their first year, you see at the end of their first year, damn, they didn't even know how to set up an IV, you know? And man, they're intubating, doing HACCPs, you know?
Skipping arteries, man, it's cool, you know? And I'm only talking about procedures, besides the reasoning behind it, and the issue of mechanical ventilation, anyway. Uh, but it's very, and the learning curve is very steep. Beginning. So, depending on the person, it really inflates the ego. And some people learn faster, some people learn slower, it varies a lot. So, this is very, very common. And like you said, if you don't have the humility to realize it, man, it's going to happen eventually, you know? It's going to happen. And sometimes it's a somewhat unpleasant situation, but everyone learns, right? Life teaches. So, exactly.
I think this is a message for the residents who are listening to us, especially those who are starting now, to respect the airway, right? Because it takes its toll if you don't take care of it during your training. Okay, Ricardo, I think we can move on to plan C. Yes, yes, you can move on to C. You can move on to C. You can move on to C. So now here we are on B, let's go to plan C. Look, this here, folks, the title already says you have to pay attention. It's last attempt at ventilation with Facial mask. So, as I mentioned, probably even between attempts to ventilate the patient in some way, if you're trying to insert your supraglottic tube to try to oxygenate better, between attempts to insert this supraglottic tube, you can try to ventilate him, right? That's not wrong. So, you see, plan C is, if intubation and supraglottic tube insertion have failed, it's a last attempt to oxygenate your patient to get him out of an emergency situation.
And once again here, look, adequate neuromuscular blockade, patient positioning. Then, obviously, here are the C and E shapes, with both hands, and another shape, which is the V and A shape, where you take the hypothenar region of your hand like this, compress it against the patient's face and place your fingers here at the angle of the mandible like this, right? And of course... The patient is being induced, is asleep so you can try to better seal the airway and, of course, check the depth of anesthesia, right?
This, as I mentioned at the beginning, it's always interesting that we have this situational awareness, okay? If you want to put it, Charles, that CO2 graph now, because it's precisely here that I think this one... Okay?
So, folks, we have some scales to check, to evaluate whether ventilation with a face mask was successful or not. The most classic and subjective one is the RAN scale, which says, "I will be able to ventilate with the one-handed technique without Guedel, grade one of frog." Then grade two of frog you ventilate with four hands. Grade three of frog with the canopharynx, and grade four of frog you don't ventilate properly even with the canopharynx or nasopharynx with four hands, right? Uh, that was the scale that was classically used. Now there's this recommendation here that even with face mask ventilation, the Okay, so let's look at the effectiveness of this ventilation with capnography, right? So, look here, grade A is ventilation where you have a capnography curve similar to intubation. So, you can see that the patient is exhaling a lot of CO2, meaning they are being ventilated, right?
Grade B shows that there might be some obstruction somewhere, it's not being ventilated so well. Grade C is when half is going to the stomach and half to the lungs, right? And grade D has no capnography at all, meaning the patient is not being ventilated, okay?
And then you have another, let's say, another checklist here to fill out, which would be whether you used one hand, two hands, right? Or four hands there, in the case of two hands, right? Because someone is squeezing the bag and one is an oropharyngeal tube, right? So this is another classification suggested by the DAS for us to use when we are going to say what the degree of ventilation, difficulty of ventilation of our patient is. And She's much more objective, right? So I wanted to bring this to you to use capnography not only to confirm intubation or during anesthesia, but also when you're ventilating your patient before intubation, if it's a patient who doesn't have contraindications, so you can see how the ventilation is going, right?
That patient, sometimes, even if you've properly attached the mask, it makes that sound, and then you start to get a little worried, right? Or that patient who has a beard and isn't properly attached to the mask and for some reason isn't ventilating, if there's no capnography curve, the capnograph is attached, you can't forget to attach the capnograph. This also happens, right, to have the capnography curve, okay? But I wanted to bring this classification here, it's recommended by the DAS in this gas.
You can go back there, chats.
And so, but I think that's it, confirm with capnography. And once again, oxygenated the patient with the face mask, stop, think and communicate, okay?
And Okay, so you'll see what we're going to do: reverse the nerve block and wake the patient, or we'll go for emergency airway access, okay? And then, when we go for emergency airway access, you declare the emergency situation here, folks. It's a no-tube, no-emilion.
Emergency statement. If you haven't called for help, which you should have already done, now you have to call, right? So help has to be present here. They even say in the guideline that ideally someone else, not the one managing the situation, should come here and do it, because your heart rate will be 140, you'll be a bit nervous.
So, making an incision in the neck might not be so comfortable.
And here we bring another big change in the guideline, which is the sole recommendation of a vertical incision and the recommendation of the scalpel bug technique, right? So in the old guideline, if you palpated the cricothyroid membrane, the recommendation was for a transverse incision, right? Right there on the cricothyroid membrane. And here, no, here the recommendation now is a vertical incision, palpate or not palpate, are you sure? No, you're going to make an incision, about 10 cm there. The patient's positioning is not in the sniffing position, ideally hyper- extended so you can expose this issue, this region of the neck. He puts a number 10 scalpel here. The availability of number 10 scalpels in Brazil is very small, right? We have 11, we have 12, but we don't have 10, right?
Why? Because it has a blunter tip, it would be better. But if you have any other smaller scalpel, then you just have to be careful with the number 11 scalpel, which is, it's kind of pointed, sharp, right?
It's what I have available here, for example, which was the easiest, right?
To make available. I think that won't make that much of a difference, right? A tube six, The idea is to make a vertical incision, palpate there, make a horizontal incision, pass the tube, pass the tube, inflate the cuff.
There you go, right? A six-pack, okay? To have gas, to have some mechanism there to aspirate, because there will be bleeding, right? The comb is alive there, okay? And to clarify, Ricardo, you said the incision is vertical in the skin, but not in the transverse membrane.
That's right. In the horizontal membrane. Perfect. Exactly. It's vertical in the skin, but not... Perfect. You have to... And then, if possible, try to maintain oxygen supply in the upper airway, either with apneic oxygenation or with ventilation, with a face mask, because remember, patients need oxygen to stay alive. And the role of the Airway Assistant here, obviously you won't do anything alone, it's someone who is helping you to do this management. So I think that, from a surgical perspective, what's really different here is the indication. In a very clear way, the surgical technique is not based on puncture, but on the use of a vertical incision in the skin for emergency airway access.
Perfect, Ricardo. And you have, I don't know if you have this number, but it's a question I wanted to ask you. How many surgeries, right? How many endosophageal surgeries, right?
That a typical anesthesiologist will perform in their career, if we have that number. And as I think you've already touched on this answer, but I wanted to hear it in a more standardized way, how do we maintain this skill, given that we practically never use it, right? And when we eventually need to use it, it's in a crisis scenario.
So it's already in a scenario where we have difficulty, right? We would need to already have a motor skill ready to do that. So, what is your recommendation in this sense so that anesthesiologists can train and maintain this skill?
Ideally, we would have this training, the recommendation. There are some studies in the literature already showing that... This skill, this mental step-by-step process of cricothyrotomy—the incision, and the manual execution of these movements— we start to lose this mental step-by-step process after six months, right? So, ideally, we should practice.
Richard Levitan made one called Cryalot. It's really good. You can share the link later if you want, but it's not available in Brazil, right? It 's a small box that comes with little pieces for you to practice at home, so each person can do their individual training. There are 3D cricothyrotomy models that you can print and then do the training, but ideally, every six months we should do some training: incision, you have to do the step-by-step process, palpation, transverse incision, inserting the bug, inserting the tube, inflating the cuff and ventilating, right?
Because this is a mental step-by-step process that you will do during a crisis.
Right? So, ideally, this training would be every six months. If the anesthesiologist doesn't work in emergency medicine, you know, how many surgeries does an anesthesiologist perform? There's no exact number, but I'll do what I hear from people who give me feedback on social media and in the airway management courses I participate in. If the person doesn't work in SAMU (Brazilian emergency medical service), because there are many anesthesiologists who work in SAMU, on emergency room shifts, etc., those people will certainly perform at least two or three surgeries in their lives, because they'll eventually get there. An anesthesiologist who only works in surgical emergencies generally does one or two in their life, right? And if they're doing a lot, they're making mistakes in my opinion, right? It 's not right, right? Prescribing too little in awake intubation, right? So I think that 's really the exception in an elective scenario, and it varies a lot depending on the profile of the hospital you work at, the institution that... You work. So you have a lot of critical patients, sometimes maybe the chance, you only work on elective patients, so the chance will be a little lower due to incidence, difficulty, right, anatomical aspects in airway management. But in general, with the colleagues I talk to, most have never done a critical procedure like that, if they do, it's one, right? So, precisely for that reason, right? These are skills that have low frequency and they require high accuracy, a high level of technical skill, right? And that's why recurrent training is necessary, because we never know when we'll eventually need to perform the damn Macrico maneuver, right? So, that's why ideally we should have this, I understand, annual training, and annual is not enough, damn, it's a year, it's a long time, annual training, right, for the team there, for everyone who manages the airway in the institution, man, it doesn't burden anyone, it's not that expensive. And man, the impact of this on care is very large, it's very large for Standardizing care, right, the airway management approach, right? I have a place here where I managed to standardize it, which was an institution that bought into my idea, Unimed Blumenau. Uh-huh.
Especially in the ICU, in the emergency room, we created difficult airway management kits and airway checklists, and now they address all airways in critically ill patients, either in the emergency room or in the ICU, in pairs.
So, one doctor stays only on hemodynamics and vasopressors, and the other stays only on airways. So, they are always in pairs. I only did the technical cosmetic training; it wasn't allowed for the technicians, but the technicians ended up picking up the routine quite well and getting into, let's say, the checklist. And, man, they say that airway management was a game-changer for them. They went from a critical situation, because they had a merger of hospitals, a different clinical staff came in, which caused some chaos, and now they have standardized the approach in a safe way.
Medication, dosages, you understand? Doses of rocuronium, what drug do you use for critically ill patients, use of self-flow nasal cannula for practically everyone for pre-opening, these guys have the resources, you understand? So they had the devices, they just didn't know how to organize their use. And man, I think that's really cool, you understand? Because it's something so simple, you understand? And it can have a very big impact, you understand? So, the airway is no longer a problem for the institution. Let's look at the others now, oh, infection, etc. And man, how much did they spend on that, man? It's... it's not even funny to talk about it. Yes, and in the end it even generates savings, right, Ricardo, for the hospital? Of course. Of course it does. Exactly. Of course it generates savings for the hospital, you understand? It makes people, colleagues feel more comfortable performing airway management, you understand? And they even feel, let's say, they understand that the institution is concerned about them, right, about their training, about the care that... They're giving it. So, it's a very simple thing, you know? But it still depends on us. We're the ones who have to go there and talk to the institution, tell them that this is important, right? So it's really a painstaking task, but I really believe in it, because there have been people who have told me, "Hey, you want to keep doing these things that you think are cool, but it's working, it's working, it's not working, is it?" He understands?
Exactly.
It's working until it's not working, you know? What happened here the other day?
Do it here. Then they came to ask me about the capnograph. Then I said, "Look, I've been telling you to buy PS capnograph modules for the ICU since COVID, but no, it took this awful intubation crisis for you all to come looking for them now, so we can finally take this step forward." So, yes, yes. It will depend on the institutional maturity of each place. It will happen eventually.
Statistics never lie, you understand? It's statistical, man. It's going to happen, it's going to happen, you understand?
It happens even when you do everything right.
Yes, yes, that's true.
So, statistically, it will happen. It's going to happen, man. It will happen. And then I say, speaking to the residents, you know, you're going to have complications, you're going to have cases, but it's going to happen. If you're working, it will happen. The big question is how you're going to drive and whether you're prepared and capable of driving. That's the main point.
Complications will happen even with the best anesthesiologist in the galaxy, you understand?
The big question is how he's going to conduct himself, whether he'll have the ability to identify what's happening, right? That's why continuing education is so important, because we're going to... I've been doing anesthesia for 9 years, man, it's been a long time, I'm starting to feel old. If you don't keep up to date, man, you lose things, you forget, you know? Yes, it's impressive.
Everyone's so fast these days, right, Ricardo?
That. And time flies by, you know? Time flies by, we don't even notice, before long it's gone and you're still doing the same thing, right? And then, an incident will happen, and you won't know how to handle it, and that's when you'll look for a driving course.
Yes. Exactly.
So, Ricardo, it's best to ask one question before I ask you the final question about our conversation. It's a question I have myself. Do you have any reservations about why the guideline doesn't address, but rather those ready-made cricothyrotomy kits that we find out there, for example, cricothyrotomy kits, there are several brands out there in Brazil, right?
Would you have any reservations about that? Because I believe the guideline doesn't address this, since the simplest solution there is actually the scalpel, the bug, and the fubo. That stuff is everywhere, everyone has it in their hands. It may not have blade number 10, but it has some kind of blade.
But what do you say about these ready-made kits?
I have. So, there's a current recommendation, not only from society, but also from emergency room personnel, that is, surgical access, not puncture, not percutaneous. It can be done, it can be done. There is the possibility of using a puncture kit, but you will only be able to oxygenate the patient with high-pressure jet ventilation, which, if you want to search for on the internet, is a completely different kit. It requires very high pressures, and if you try to attach an Ambu bag with a three-centimeter syringe, it won't work, okay? You won't be able to oxygenate the patient, okay? You can send some oxygen, but it won't oxygenate the patient properly. Then there are the percutaneous kits, right? These are the ones that are available and sold, which are the middle ground, right? So, you have a 4mm adult-sized diaphragm, but it would work directly from the moment you palpate the membrane and click. There is very little research on this, including comparing percutaneous kits with surgical ones.
What do I suggest? See what your institution has to offer. If you have the percutaneous option, great, because nothing prevents you from sometimes making an incision or surgical access and inserting the percutaneous cannula, some of which have a CUF (cubitus ulcer), or not, but you have to know which one you have, you have to know how to use it, because it's all full of little parts, you remove one part, put another part on, so ideally you should practice.
Now, from a cost- benefit perspective, these kits are expensive, okay? They're quite expensive, okay? And the bugi, a bug, a scalpel, a gas packet and a six-pack, man, not even without money, okay? So, I don't see the point. In the institutions that I set up and that I am responsible for, I removed all those kits that were there, because then they expire and then you don't use them and then you have to buy the name again later.
You have to buy it on the screen, that one. Perfect, then. This is one of them. So, man, it's cool, really cool. So there's an introducer there for you to put in, you remove the introducer, right? And it's the same thing we talked about regarding training. If you want to train with the kit, the surgical cricothyrotomy kit, practice the surgical step-by-step process. If that's the one they have in your hospital, practice the step-by- step process using that one. So, if he comes, if it's through, if he makes an incision, if you operate on him directly, right? You have to practice step-by-step what you're going to do in your own reality, okay? But if I could recommend something, well, get the surgical kit, assemble your surgical kit, put it in a ziplock bag, and there are no restrictions from a regulatory standpoint. I pursued this, you know, so I could implement it in my institutions. So, it's not forbidden to not include a kit that is only sold pre-made. You can assemble your own kit, right?
As long as everything is properly identified inside, you can have this; this is a surgical airway kit, which is what is mainly recommended by the CFM (Brazilian Federal Council of Medicine), and it depends on the type of institution you work for, right? And here's a recommendation I always ask when I'm at the Surgical Scalpel Station during workshops.
Dude, over 70% of people don't know where the critical care kit is or what it is in their hospital. Look, that's basic, okay?
You have to see which one it is, you understand? At least you have to know where it is and what it is, you understand? Otherwise it gets difficult, right?
It's difficult to help, okay? But if you try to do it with Prime, it wo n't work there, right? He doesn't even know where he is. Exactly. But from a personal point of view, nowadays, we increasingly try to bring forth evidence from what's in the literature on this subject. Ah, the surgical one is superior. Look, at Nep for we have very clearly seen that in more than 50% of cases, puncture cricothyrotomy had to be converted to surgical cricothyrotomy due to failure. So, uh, this is the more robust evidence we have regarding this. Regarding the percutaneous approach, which would involve these kits, there is very little literature on that.
So, by inference, even considering the cost, as I said, go for surgery and don't complicate your own life, right?
Good. Great, Ricardo, I think that within the guidelines of the DAS, we did well, we're getting close to... And I think we can start moving closer to the end. I wanted to ask you one final question here in our conversation.
Sure, it's a question I've been asking all our podcast guests here, which is this : if you, Ricardo, could go back to your first day as an R1 and give yourself a message, what would you say to Ricardo, the R1 anesthesiologist, a few years ago?
Look, guys, I don't want to sound old here, okay? And I... that's something that I see, I 'm not with the residents as much as I was a while ago in terms of presence, but the main characteristic of a resident, in my opinion, now that I'm a little older and that I see, is commitment.
Commitment to the patient, commitment to the service, right? And I 'm not talking about, oh, doing the work, running the office alone, that's not it. It's about commitment to what you set out to do, which is medical residency, okay? So, do your best during that time. Well, it's very clear to me that the opportunities I had at the end of my residency were all a consequence of my behavior as a resident. And I see here at the job I'm at now that it's the same thing. So, at the end of residency, all the third-year residents want recommendations, they want referrals, and of course, everyone will manage to get a job, but the anesthetic world is very small, everyone knows each other, you know? Everyone talks to each other, and it's not about sucking up, but come on, be committed, okay? Be, uh, I think really committed.
Respect your superiors, and that 's not being subordinate, it's something different. But what I want to bring up is that I think what's really lacking a bit is this commitment, because the biggest comparison I make when I give some Alpos R1 lectures here is that residency is like a plane trip. Nobody travels by plane just for the sake of traveling, except for the pilot, right, who's getting paid, right? But you travel by plane to get there, okay? So the trip will end, the residency will end, but you can have a slightly less awful trip. It's an economy class trip, of course, right? It's not from the executive branch, but you can have a little trip, sometimes the resident sabotages their own trip, you know? So be committed, dedicate yourselves during that period, it's only 3 years, it goes by super fast. What I see quite often is that people, when someone enters residency, they know it's going to end, one way or another. And the guy just keeps going, you know? It will end up being a poorly built residence, as you yourself said, even in a good location, okay? It might be the best place there is. We'll see you here in Joinville, okay? Here in Joinville there's a pediatric hospital that doesn't have anesthesia and it's the reference hospital for the entire state. Man, they make more congenital R3s here in Joinville than, I don't know, most places in Brazil. Of course, there will be R3s that are not very committed, that will leave without knowing how to put the whole package together, that it depends on them, you understand? Not from the service, understand? Now, whoever takes advantage of the opportunity, man, the guy has a pediatric R4 embedded in his R3 (third year of residency) in his residency program.
So, uh, why? Because there's no R4 to steal procedures from, nothing. So, it's an opportunity that I see, but it 's difficult, you know? I can see that very clearly, but the guy who's in the middle of it all can't see that opportunity he's having in the job he's in. Yes.
And any residential service has good things and bad things. So I did it in a private medical residency program and there was a lot of hands-on work involved, you know? And there were many low-complexity procedures. What did I do, man? I went there and asked the pros to let me do an internship at a place that operated, something bigger that I couldn't see. And it worked, you understand?
But yeah, I went after the deal. So, man, your training as a resident depends on you, you understand?
Even if you're at the Hospital das Clínicas in Minas Gerais, or the Hospital das Clínicas in São Paulo, which are great facilities, right? They cover everything, they have good staff, and the facilities are already well-established, there are still bad residents who come from those places too, you know? So residency depends more on the resident themselves than on the place where they are working. So I think that's the message, actually it's kind of discouraging, but it's about accountability, you know? Because we are responsible, we are at a powder level, we residents are at the postgraduate level, no longer at the undergraduate level.
In college, the professor takes you by the hand and says, "Look, you have to study this and so on." Postgraduate studies, my friend, are up to you, the decision is yours, if you want to graduate half-heartedly, okay? So I think that sometimes there's a lack of understanding from the residence staff, that it's their duty to go there and pick him up by the nose.
Negative, my son. We are at a postgraduate level. It's in your best interest. It's up to you to get a good education. I'm here to help you. Did you understand? Now, if I take her by the hand there, I think that's... it's not me, it's not because I'm bad, it's because I'm a tormentor, it's not that. This is a matter of competence and determination in training. That's how it is here, that's how it is here in the United Kingdom, you understand?
Medical residency is a postgraduate level of study, right? So you have to have that kind of individual perception.
Excellent, Ricardo. Excellent. Very good message. I really enjoyed the discussion we had here. I'd like to thank you once again for participating in this conversation with us. It's always a pleasure talking to you, especially regarding the airway section, which I know you can feel the excitement in when you talk about it. So it's always good to learn, and I'd like to express my gratitude on behalf of everyone at Nest. Uh, we're going to make this episode available on our system and also on YouTube, okay? In our system, we'll have it open for questions, so we'll pass any questions that come up on to you. But I think everything is pretty clear now, let's make the guideline available to everyone as well. So we're going to wrap things up here, folks, and I'd like to thank you once again on behalf of our entire team, Ricardo!
Thanks. Thank you for the invitation.
I hope this has helped the people out there.
For sure. Thanks, Ricardo.
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