5-7,march 20151dubai anaesthesia-2015. 5-7 march,2015dubai anaesthesia 2015_pfkotur2

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SDU

I N D I A

C H I N A

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5-7 March,2015 Dubai Anaesthesia 2015_PFKotur

Kolar

4

Evidence Based Airway

Management ……….is it

possible to practice ?5-7, March 2015

Dr P F Kotur MD, PhDVice Chancellor & Sr Prof. Sri Devaraj Urs University

Karnataka, IndiaEx Member ExCo WFSA

Past President, ISA & Ex Editor IJAEditor,SAARC Journal of Anaesthesia


What I am going to talk ?

What, When, Why, How…..EBM?

Benefits, Challenges & Limitations of

EBM ?EBM ?

Special issues/considerations for EBAM.Special issues/considerations for EBAM.

Current evidence s on Airway Current evidence s on Airway

ManagementManagement


What is Evidence Based What is Evidence Based Medicine?Medicine?……. defined as optimal integration

of : -

- best research evidence with

clinical expertise and patient

unique values and

circumstances. Gordon H Gordon H

GuyattGuyatt

Triangulation of these three, needed for optimizing patient

care


What is Evidence Based Medicine?

EBM is also defined as the - explicit use of valid external evidence combined with the prevailing internal evidence


Recent Concept of EBM

Evidence to practice and practice to evidence redefines EBM as a circular integration of its 3 components.


Best Research Evidence Clinical Expertise

Patient Values

When did EBM begin ?

Professor Archibald Leman Cochrane,, (1909 – 1988) Subsequent advocacy 1972, caused increasing acceptance of the concepts behind evidence-based practice.

The explicit methodologies of EBM established by the McMaster University research group led by David Sackett and Gordon Guyatt- 196310, Feb.2015 10EBM_SDU_2015

Kaozeng- B.C China, Ancient GreecePost-French Revolution - Paris -Pierre Louis

http://en.wikipedia.org/wiki/McMaster_University

http://en.wikipedia.org/wiki/David_Sackett

http://en.wikipedia.org/wiki/Gordon_Guyatt

Why Why Evidence Based Evidence Based

Medicine?Medicine?


“The knowledge and skills of medicine, obtained

during the course of study are insufficient to carry on

life long successful & competent clinical practice”


Why EBM?

Need of the Day is to cater to the

present day needs of the society

CPD is a MUST & EBM teaches SDL

EBM is a process of life long PBL .


Forces driving the EBM Movement

Daily need for valid information

Inadequacy of traditional sources

Disparity between Clinical Skills & Clinical Judgment, and Up to date knowledge and Clinical performance

Lack of time to gather evidence by traditional methods


Is it necessary to practise Evidence Based Medicine ?


Basis of current Clinical Basis of current Clinical PracticePractice

Evidence from Clinical Research – 4%Evidence from Clinical Research – 4%

No evidence but strong consensus – 45%No evidence but strong consensus – 45%

Little evidence or consensus – 51%Little evidence or consensus – 51%

The Need for Evidence-Based Medicine;In Clinical Obstetrics and Gynecology The Need for Evidence-Based Medicine;In Clinical Obstetrics and Gynecology 41(2): 233-23441(2): 233-234


Conventional Wisdom & Bare Truth!

“only about 15% of medical interventions are supported by solid scientific evidence”

“..... this would put 80 to 90 per cent of accepted medical procedures in this country under the heading of Quackery!”

( Editorial BMJ 1991;303:798-9.)


Remedy

To keep up to date in Internal Medicine, I need to read 17 articles a day, 365 days a year

At the end of this one year Commitment & Dedication, I will be two years behind

Choices are : Read more OR Don’t read OR Practice EBM


How does one How does one practice EBM?practice EBM?


The 5 Steps The 5 Steps approachapproach

1.1. Formulating the question-PICO Formulating the question-PICO

modelmodel

2.2. Tracking the evidenceTracking the evidence

3.3. Critically appraising the evidenceCritically appraising the evidence

4.4. Applying the evidence in practiceApplying the evidence in practice

5.5. Evaluating the process &Evaluating the process &

developing guidelinesSdeveloping guidelinesS


Systems

Summaries

Synopses

Syntheses

Studies

Examples

Computerized decision support

Evidence-based textbooks

Evidence-based journal abstracts

Systematic reviews

Original journal articles

The evolution of information resources for evidence-based

decisions


What are the What are the hierarchies of hierarchies of evidence in evidence in

EBM?EBM?


US Prevention Service Task Force Ranking

Level I: E. from at least one properly designed RCT Level II-1: E. from well-designed controlled trials

without randomization. Level II-2: E from well-designed cohort or case

control studies, preferably from more than one center Level II-3: Evidence obtained from multiple time

series with or without the intervention. Dramatic results in uncontrolled trials might also be included

Level III: Opinions based on clinical experience, descriptive studies, or reports of expert committees.


UK-NHS : LOE

Level A: Consistent RCT, Cohort Study, Level B: Consistent Retrospective

Cohort, Exploratory Cohort, Case Control Study; or extrapolations from level A studies.

Level C: Case Series or extrapolations from level B studies.

Level D: Expert opinion without critical appraisal, or based on physiology,


What are the What are the challenges in challenges in

adopting EBM?adopting EBM?


Challenges in EBMChallenges in EBM Resources Resources

IT InfrastructureIT InfrastructureInternet ConnectivityInternet ConnectivityOnline informationOnline information

SkillsSkillsSearching the evidenceSearching the evidenceCritically appraising the evidenceCritically appraising the evidence

Attitude !!!Attitude !!!5-7,March 2015 26Dubai Anaesthesia-2015

What are theWhat are the relevant outcomes of

adopting EBM?adopting EBM?



Relevant outcomes?

Attitudes changed

Knowledge enhanced

Skills improved

Behaviours altered

Clinical outcomes optimised

Limitations of EBM

Availability of Research-based evidence to clinicians;

Evidence may be viewed as static rather than dynamic.

Infrequent application of available resource


Evidence Based

Airway

Management

(EBAM)

Current Literature5-7,March 2015 Dubai Anaesthesia-2015 30

Airway Management

Very few techniques are supported by RCTs

Many supported by, Anatomical- Patho Physiological understanding, Studies involving Volunteers and Animals and series of Patient experiences .

Some times intuition?5-7,March 2015 Dubai Anaesthesia-2015 31

Current Scenario Cuffed ETI is the Gold Standard (GS) for

airway management & other devices /technics are compared and contrasted with GS.

Many of the reported studies are based on controlled use of ETTs in OR for short periods and use of such evidence to generalize to other areas, such as the pre-hospital phase of resuscitation or the post-injury phase of ICU is of Questionable Validity.


Mandatory mask ventilation before relaxation. Where is the

evidence?If a functional airway obstruction is responsible for difficult mask ventilation … Muscle relaxants improve facemask ventilation and facilitate ETI. This is probably one of the reasons why most of us administer muscle relaxants even though mask ventilation is difficult or impossible. To prevent a CVCI situation, a careful preoperative evaluation of patient airway essential. Anaesthesist. 2012 ;61(5):401-65-7,March 2015 Dubai Anaesthesia-2015 33

Equipment and strategies for emergency tracheal access in the

adult patient. No consensus on the best technique

or device for CVCI It is recommended that all

anaesthetists are skilled in more than one technique of emergency percutaneous airway. Avoiding delay in initiating rescue techniques is at least as important as choice of device in determining outcome. Anaesthesia. 2011;(66) :65-80.


Barriers to adoption of EB prehospital airway management practices

In areas of EMS where robust evidence exists, physicians (100%) will discontinue or not adopt skills that potentially harm patients, such as RSI, but are unlikely (12%) to discontinue procedures that show no benefit to patients

Difficulty in generalizing results of studies across diverse EMS systems and perceived lack of evidence that the procedure should be abandoned

Prehosp Emerg Care. 2010 ;14(4):505-9


Equipment to manage a difficult airway during

anaesthesia The Australian and New Zealand College of Anaesthetists, based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway

Will be reviewed at the end of 1 year and thereafter every 5 years or more frequently if necessary

(www.anzca.edu.au/resources/professionaldocuments)

Anaesth Intensive Care. 2011 Jan;39(1):16-34.5-7,March 2015 Dubai Anaesthesia-2015 36

Evidence for benefit vs novelty in new intubation

equipment. A myriad of new intubation equipment has

been introduced commercially since the appearance of Macintosh/Miller blades in the 1940s. …….... Ideally, such devices should be available in all settings where tracheal intubation is performed.

Most importantly, experience and competence with any of the new devices are critical for their successful use in any clinical setting.

Anaesthesia. 2011;(66):57-64.


Surgical versus percutaneous tracheostomy: an evidence-based

approach

Risks and Benefits of: Prolonged ETI versus Surgical airway have been documented.

The choice between surgical (ST) and percutaneous tracheostomy (PT) is not often based on evidence and is debatable

Eur Arch Otorhinolaryngol. 2011 ;268(3):323-30.


.The critical airway in adults:

The facts. In urgent scenarios, there is no

clear or established consensus as to specifically who should receive a tracheostomy and more importantly, when.

In literature, specific indications for emergency tracheostomy are scattered and are biased….

J Emerg Trauma Shock. 2012 ;5(2):153-9


Therapy That Evidence Supports

Noninvasive Ventilation: key points

First option: Severe exacerbation of COPD or cardiogenic pulmonary edema.

Patients with COPD can be considered for a trial of early extubation to NIV.

Patients with ARD or hypoxemia, either in PO setting or in the presence of immunosuppression, can be considered for NIV.

Cochrane Database Syst Rev 2008(3):CD005351 CMAJ 2011;183(3):E195-E214.

Healthcare Research and Quality; 2012. Report No. 12-EHC089-EF.


Therapy That Evidence Supports

Lung-Protective Ventilation: Higher survivalLower VT benefits patients who do not have ARDS.

lower incidence of pulmonary infection, lower hospital stay, higher PaCO2 lower pH, and similar PaO2 /FIO2 NEJM 2000;342(18):1301-1308 ; BMJ

2012;344:e2124.

Ventilator Discontinuation ProtocolsAvailable evidence supports that the use of ventilator discontinuation protocols improves patient outcomes. BMJ 2011;342:c7237


Therapy That Evidence Does Not Support

Weaning Parameters: RSBI (rapid

shallow breathing index ) should not be used

routinely in weaning decision-making. A

properly monitored SBT (spontaneous

breathing trials) is very safe and effectively

identifies patients ready for liberation from

mechanical ventilation

Crit Care Med 2006;34(10):2530-

2535.5-7,March 2015 Dubai Anaesthesia-2015 42

Therapy That Evidence Does Not Support

Albuterol for ARDS :Routine administration of ß2 agonists to mechanically ventilated patients with ARDS cannot be recommended as it is unlikely to be beneficial, and could worsen outcomes.High Frequency Oscillatory Ventilation for Adults.

The accumulated evidence does not support the use of HFOV in adults with ARDS

Am J Respir Crit Care Med 2011;184(5):561-568. Lancet 2012;379(9812):229-235.5-7,March 2015 Dubai Anaesthesia-2015 43

Therapy With Equivocal Evidence

Airway Clearance in COPD patients Active : Passive : Supportive techniques

COPD 2011;8(3):196-205. Aerosol Device in Acute Lung Injury Am J Respir Crit Care Med 2011;184(5):561-568

PEEP for ARDS.

Respir Care 2011;56(10):1555-1572. Respir Care 2011;56(5):710-713. JAMA 2010;303(9):865-873.


Why Isn’t the Best Evidence Implemented Into Practice?

They do not recognize the evidence (laziness)They do not read the literature/ attend conferences,/ talk to colleague,

They do not believe the evidence (ignorance)They do not believe the right study was done (eg, wrong dose), the study is not consistent with lower levels of evidence (eg, animal studies)

They believe that incorporating the evidence into practice is someone else’s job (blaming)The system prevents incorporating the latest evidence: not enough time/ right resources not available/ no hospital policy supporting the practice change

They do not think the evidence applies to their practice (stubbornness)Their sick/old patients have done fine with their “expert” treatment5-7,March 2015 Dubai Anaesthesia-2015 45

Can we make airway management (even) safer? – lessons from

national audit Anaesthesia, 2011, 66 (Suppl. 2),

pages 27–33


NAP4 4th National Audit Project (NAP4) of R Co A and

the DAS has published 160 recommendations, reviewing both current practices of airway management and the associated complications in ORs, ICUs and EM departments.

Major findings and recommendations are related to: Capnography, Aspiration of gastric contents, Upper airway disease, Obesity etc.

Recommendations have implications for individuals, departments, organisations and potentially for national policy in terms of training, standards of practice and the need for guidelines.

They indicate directions for future research.. 5-7,March 2015 Dubai Anaesthesia-2015 47

NAP4 Despite ‘authoritative status’,

(influencing patient care- at all levels: viz individual/deptl/ national) NAP4 is based only on a large series of case reports and hence rated as low level of evidence in EBM (level D)

Sources of evidence like national audits and databases are as strong s as RCTs - Scottish Review Group

(BMJ 2001; 323: 334–6)


The DAS’ Airway Device Evaluation Project

Team Increasing no. of airway devices, introduced in market with no prior evidence of their clinical efficacy or safety

Although there are several National/International regulations for marketing the gadgets, no formal professional guidance as to how to purshase a product.

ADEPT has defined Minimum level of evidence needed to make a pragmatic decision about the purchase of an airway device and set /adopt a professional standard to create an infrastructure in which the required evidence can be obtained

a coherent national network of research-active units; and individual anaesthetists

Anaesthesia, 2011, (66), 726–737


Lack of Scientific Evidence in Literature

Described by the following terms.Silent: No identified studies address an intervention and its outcome.Insufficient: Too few published studies Inadequate: Available studies cannot be used to assess an intervention and its outcome, as they, either do not meet inclusion criteria or do not permit a clear causal interpretation of findings due to methodological concerns.


The Gap!......cause? The Benefits of EBAM are

undeniable. But the "empirical evidence." is itself Insufficient to provide for optimal clinical care.

A clear gap exists between empirical evidence and clinical practice. viz. issues those require consideration of Values, both Patient and Professional, prior to arriving at clinical decisions.


The Gap!.....cause?....solution

? Empirical evidence can not be directly applied to individual patient, as the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for that patient at hand.

Therefore, both forms of evidences should be viewed as complementary to each other and the latter should be incorporated into the empirical evidence to overcome the intrinsic gap .

Documentary versus Non-documentary Evidence


Therefore Clinicians need to incorporate knowledge from 5 distinct areas into each medical decision:

1) Empirical evidence. 2) Experiential evidence. 3) Physiologic principles. 4) Patient and Professional values, and 5) System features. Relative weight given to each of these areas is

not predetermined, but varies from case to case.

(Respir Care 2001 ;46{12): 1435-1440)


The Gap…..solution !

What is available for Optimal AM? UK:DAS:

Guidelines/Protocols/Algorithms-Intubation, Extubation, Paediatric, Rapid sequence, Failed Intubation etc , Airway Alert Form

USA:ASA-Practice Guidelines 2003 for Management of the Difficult Airway, Practice guidelines for obstetric anesthesia.

India:Consensus Guidelines on Resuscitation in India-2011- Airway & Ventilation


Indian Paradox! Airway management : How current

are we?

90% of Indian Anaesthesiologists are aware of

difficult airway algorithms of USA and UK.

Despite such a high degree of awareness , only

60% had local versions /a formal practiced

protocol available at their place of work.

When faced with CVCI, actions of 90% were in

absolute agreement with Current

International Guidelines. Indian Journal of

Anaesthesia;2011 (55):1: 5-95-7,March 2015 Dubai Anaesthesia-2015 55

Goal of anaesthetists to reduce airway-related deaths to zero

“ -Give us the tools that make it easy to get it right,

- Give us the processes that give safety a better chance, and - Give us the training so that we can use these and behave in a way to make a quantum leap in safe practice’’.

It must be the Goal and to accomplish this, we should follow this advice and look to make changes that will make it easier for us to get it right and to ensure safety conscious behaviour.


Final word! EBM has permeated all parts of

healthcare practice, including airway management. The principles of EBM provide us the tools to incorporate the best evidence into our everyday practice.

Although all tenets of EBM are not universally accepted, the principles of EBM nonetheless provide a valuable approach to improve airway management.


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saarc journal of anaesthesia

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little evidence

recent concept of ebm

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ebm movementdaily

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