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