Inhaled epoprostenol during one-lung ventilation.

We used inhaled epoprostenol (with intravenous phenylephrine) during one-lung ventilation to improve oxygenation in a patient with severe interstitial lung disease undergoing video-assisted thoracoscopic surgery. The pharmacologic manipulation of pulmonary blood flow remains an underused strategy for the management of hypoxemia during one-lung ventilation.

Management of unexpected difficult airway at a teaching institution over a 7-year period.

STUDY OBJECTIVE: To review an anesthesiology department's experience with managing unexpected difficult airways over a 7-year time span. DESIGN: Retrospective review of unexpected difficult airway reporting forms. SETTING: A tertiary care teaching hospital. PATIENTS: 447 patients who had an unanticipated difficult airway and had a difficult airway form filled out by their anesthesiologist. MEASUREMENTS: Retrospective identification of pertinent physical features associated with difficult intubation was noted. The techniques chosen, their success, and the frequency with which the different advanced airway techniques were chosen was reviewed. MAIN RESULTS: An anterior larynx was the most common anatomical feature associated with difficult laryngoscopy. When a laryngeal mask airway was placed in our patients, ventilation was possible in all patients. Intubation was successfully "blindly" achieved (ie, without the use of a fiberoptic bronchoscope) through the laryngeal mask airway in 52% of these patients. Fiberoptic intubation was unsuccessful in intubating approximately 10% of patients. The Bullard laryngoscope was the most common advanced airway technique chosen at our institution. CONCLUSION: Mastery with a number of advanced airway techniques should be sought, as multiple modalities may be needed when faced with managing an unexpectedly difficult airway. Formal written communication to the patient of an unexpected difficult airway encounter may allow future anesthesiologists to formulate an appropriate plan for patient care.

Resident training in advanced airway management.

Management of the difficult airway is an essential skill that should be taught during an anesthesiology residency. However, only a minority of anesthesiology residency programs have formal rotations in advanced airway management. We developed a formal advanced airway rotation as an integral part of our residency program, consisting of two 1-month rotations during the residency, each with a separate focus. While on the advanced airway rotation, the resident anesthesiologist is given a set of objectives, a list of required reading, and a required number of procedures unique to advanced airway management that they must perform during the rotation. We believe that this rotation has been beneficial in improving the residents' exposure to advanced airway techniques, and has dramatically improved their capabilities in this important aspect of anesthetic of anesthetic training. Additionally, the structure of the rotation ensures uniformity in the residents' acquisition of advanced airway skills.