FIRST THINGS FIRST Anesthesia providers must focus on the safest and most effective airway strategies.

Your anesthesia providers should tailor their anesthesia and airway selections for nearly every procedure to ensure patients are breathing spontaneously soon after surgery ends. Here's a review of basic airway management strategies that you and your providers should use to speed patients toward uncomplicated discharges.

1 Choose natural when possible
Anesthesia providers must focus on the safest and most effective airway method well before cases begin. The proper method relies heavily on 3 closely inter-related factors: the type of surgery, the choice of anesthesia, and the medical history and physical condition of the patient. Providers must ultimately decide if they'll entrust a natural airway or artificial airway to do the job.

A natural airway is a patient's own nose and mouth. Patients may be fitted with a nasal cannula to provide oxygen, but they're otherwise breathing spontaneously without external assistance. Artificial airway techniques comprise anything that's placed in the nose, mouth or trachea to support oxygen delivery and ventilation. The most common choices for routine surgery are the nasal trump, oral airway, laryngeal mask airway and endotracheal tube. Each device has its own optimal situations for use, and advantages and disadvantages.

It's simple advice: Think of ways to avoid artificial airways whenever you can use natural airways. Patients who can maintain their own airways and are breathing spontaneously and comfortably immediately out of surgery are on the road to recovery as soon as they reach the PACU.

BREATHE EASY Think of ways to avoid artificial airways by maximizing the use of natural airways, says Dr. Ritchie.

2 Lighten up on anesthesia
A natural airway is more feasible if the choice of anesthesia doesn't impair patients' respiratory functions. Utilize local or regional anesthesia, including spinals, epidurals and peripheral nerve blocks, when a procedure permits.

Anesthetists in the ambulatory setting are constantly thinking about how to administer the least amount of IV anesthesia possible, and what anesthesia technique would allow them a natural airway option. In the best-case scenario, the local anesthetic or peripheral nerve block (delivered as a single shot or through a continuous catheter) can manage a patient's pain through discharge, which will necessitate less post-op narcotics and create less risk of PONV, respiratory depression and prolonged stays in recovery.

The selection of anesthesia for a case may be a matter of surgeon preference, so a good working relationship between your anesthesia providers and surgeons — and an awareness of what each is capable of — can pay off. While some physicians may express concerns over working on conscious patients, you might find out many are open to the idea of regional anesthesia to improve efficient throughput.

WALKING PAPERS Ambulatory anesthesia and efficient airway management contribute to speedy discharges and happy patients.

3 Can intubation be avoided?
For surgery taking place outside of the airway, efficiency-minded anesthesia providers are always calculating whether the case can be done without intubation. Sometimes it can't be avoided: In tonsillectomy cases there's going to be blood, and there's no way a nasal trump, oral airway or laryngeal mask airway (LMA) can be used when the surgeon's working in the airway. But in the interest of quick throughput, always consider whether an endotracheal tube (ET) can be avoided.

The ultimate goal of airway management is extubation and spontaneous breathing. For a time, anesthesia providers assumed that using LMAs was a faster technique, that they'd be able to remove them from patients' airways sooner. Residents who visit our ASC on their rotations think that if they do all their cases with LMAs, they'll be out faster. "Not true," I'll say, before directing them to the study by Girish P. Joshi, MBBS, MD, FFARCSI, et al., in the September 1997 issue of the journal Anesthesia and Analgesia (tinyurl.com/ml3cess).

In a comparison between tracheal intubation and LMA use, Dr. Joshi and his colleagues found that LMAs were useful for ambulatory anesthesia and airway management, largely because they didn't result in the high incidence of sore throats and patient complaints often associated with ET tubes. Granted, patient comfort is a big score. But they saw no significant difference between the number of placement attempts and failures for each method, the amount of drugs administered to patients or the length of time it took to insert or remove each device.

SETTING A STRATEGY
Choose the Safe and Effective Choice

SEEKING THE SHOT Regional anesthesia allows spontaneous breathing without the need for artificial airways.

What type of surgery is the patient scheduled to undergo? More specifically, where is the surgical site? This consideration goes hand in hand with which anesthetic technique will likely be used. And both of these factors will consequently determine the airway methods at an anesthesia provider's disposal.

Let's look at a few scenarios. Suppose surgery is planned on a patient's extremity: an anterior cruciate ligament repair, for example. The anatomy of this surgical site gives providers the latitude to employ local anesthesia, regional anesthesia via neuraxial blockade or a peripheral nerve block. This awake sedation infiltrates the area at issue or numbs the limb and nothing but the limb, leaving breathing operational.

Plus, because the surgeon won't be working around the head and neck or in the airway, the patient's head won't be turned away from the anesthesia workspace. In this situation, providers might be able to use a natural airway, a nasal cannula and medication for pain control. Even if they opt for an artificial airway — a laryngeal mask airway (LMA) can be placed in patients who are spontaneously breathing — they won't need to insert an endotracheal tube (ET).

In contrast, during tonsillectomy-adenoidectomy, the ET tube is the only option for maintaining respiration, because the surgeon will be occupying the airway for the procedure. In the case of a non-superficial abdominal surgery, such as a laparoscopic cholecystectomy, a muscle relaxant and paralytic will be necessary, which will impair natural spontaneous respiration. For any case involving general anesthesia, which triggers a complete loss of reflexes, an ET is required to manage the airway.

As with the type of surgery and choice of anesthesia, the patient's physical condition and medical history can also impact airway management options. Is the patient pediatric or morbidly obese? What are their airway anatomies like? Do they suffer from any potentially complicating comorbidities, such as obstructive sleep apnea? Have they presented intubation difficulties during previous surgeries? The imaging abilities of video laryngoscopes, which provide direct views of the glottic inlet, can help providers place artificial airways more easily in challenging anatomies, but they must be mindful of whether the airway will remain open throughout the procedure.

Patients who are extremely overweight, who suffer from obstructive sleep apnea and severe gastric reflux, might not be able to protect their own airway when anesthetized. They'd likely obstruct quickly without artificial means, so anesthetists would never consider placing just an oral airway. In such situations, an ET tube is the only true option.

— Rosalind Ritchie, MD

END IN MIND The goal of any anesthetic technique is to get patients breathing spontaneously as soon as possible after surgery.

4 Time the technique
When you administer anesthesia is just as important as which agent you use in determining how quickly patients wake and spontaneously breathe, and how soon you can remove an artificial airway. Your anesthetic technique at the beginning of a case should have the end in mind.

For example, if it's necessary to give long-acting opioids, such as morphine, give them at the beginning of the case. Toward the end of the case, short-acting narcotics like fentanyl can be administered. Among the inhalational agents, sevoflurane and desflurane have faster uptake and elimination, making them ideal for ambulatory anesthesia. Providers may use the slower agent isoflurane during longer cases for cost-effectiveness, then switch to one of the faster agents toward closing.

This is basic knowledge for anesthesia providers, but it's important to train your post-op nursing staff to it as well. How are your patients medicated once anesthesia providers hand them off in recovery? Are your PACU nurses fully aware of the effects of the post-op meds they're giving?

Saving and satisfying
As a medical director, I'm always looking to improve outcomes, efficiency and productivity. You probably do the same, and know that staffing costs as much as or more than supplies and medications. By bypassing phase 1 recovery, you can save on nursing costs. Doing so can also boost patient satisfaction: When the door-to-door perioperative process seems short to them, they'll think they're doing great. Efficient, ambulatory airway management can therefore help you meet financial and patient satisfaction goals.