Professional Documents
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Discussion:
This case highlights a hazard of airway management: airway device aspiration. A number of different devices are used to maintain patent airways during surgical procedures but among the most common is an NPA. In the course of perioperative airway management, it is possible for the NPA to be aspirated or become lodged in the airway. Although the incidence of airway device aspiration is not known from any (continued on page 550)
This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Christopher R. Lee, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, San Antonio, TX. (Citation: Lee CR. Who Nose Where the Airway Is? AHRQ WebM&M [serial online]. October 2009. http://www.webmm.ahrq.gov/case.aspx?caseID 208. Accessed February 26, 2011.) Dr Girard has no declared afliation that could be perceived as posing a potential conict of interest in the publication of this article.
doi: 10.1016/j.aorn.2011.02.007
642
AORN Journal
May 2011
Vol 93
No 5
May 2011
Vol 93
No 5
(continued from page 642) systematic study, published case reports1-4 and anecdotal evidence suggest that this case is not unique. Specic risk factors for NPA aspiration are not known. Patients who have aspirated airway devices can have different clinical presentations, depending on the degree of airway occlusion. The aspiration of an NPA may not be obvious because the open lumen of the airway device may allow air to pass with little or no obvious obstruction.1-3 Providers should be aware that patients who have undergone procedures that involved NPAs are at risk for immediate and delayed airway complications. In one case, the discovery of the aspirated NPA was delayed for weeks after the event and was discovered only after a persistent cough and recurrent chest infection triggered further evaluation.1 One death was reported in a case of an aspirated airway, although the death occurred in the context of signicant underlying respiratory failure.4 Strategies to prevent these types of events include both device modications and changes in practice to allow for early recognition of an airway aspiration or retained object. Two basic NPA designs exist: one with a xed ange at the distal end of the device and the other with a movable ange to allow for more individualized tting. It has been suggested that the adjustable ange may increase the risk of aspiration,2 but aspiration events have been reported with both designs. Device modication suggestions include attachments to the external portion of the NPA that would rest outside of the patients nose, the use of a safety pin,5 or the use of an endotracheal tube connector.6 During airway management, the person managing the airway is responsible for the equipment being used on the patient. Two aspects in this case complicated the situation. First, there was an unplanned change in airway management. Changes in airway management should trigger a reassessment of the patient and formulation of a new airway plan. It is difcult to ascertain when the NPA was lost into the nasopharynx of this patient, but a careful assessment of the patient by the anesthesiologist before he assumed care would have alerted both providers that the NPA was still present. The location of the NPA could have been ascertained, and the NPA could have been removed before or immediately after intubation.
550 AORN Journal
Perioperative Points:
Transitions in care should always be accompanied by a patient assessment. Transitions should include a clear transfer of responsibility and up-to-date information on the care provided thus far.8 Documentation of devices used must be entered on the patients chart and a thorough accounting of invasive devices made when circumstances promote an unplanned change in care. The use of standardized tools or checklists to facilitate hand offs can reinforce a culture of consistent communication.
References
Dhar V, Al-Reefy H, Dilkes M. Case report: an iatrogenic foreign body in the airway. Int J Surg. 2008;6(6): e46-e47. 2. Hayes JD, Lockrem JD. Aspiration of a nasal airway: a case report and principles of management. Anesthesiology. 1985;62(4):534-535. 3. Dua K, Saxena KN, Dua CK. Airway within airway: a case report. Indian J Anaesth. 2004;48(6):486-487. 4. Milam MG, Miller KS. Aspiration of an articial nasopharyngeal airway. Chest. 1988;93(1):223-224. 5. Mobbs AP. Retained nasopharyngeal airway. Reply. Anaesthesia. 1989;44(5):447. 6. Mahajan R, Kumar S, Gupta R. Prevention of aspiration of nasopharyngeal airway. Anesth Analg. 2007;104(5): 1313. 7. Perioperative Patient Hand-Off Tool Kit. AORN, Inc. http://www.aorn.org/PracticeResources/ToolKits/ PatientHandOffToolKit/. Accessed February 26, 2011. 8. Hand-off Communications. AORN, Inc. http://www .aorn.org/docs_assets/55B250E0-9779-5C0D-1DDC 8177C9B4C8EB/44F543CC-17A4-49A8-865FDDF 56132C37B/HandOff_Recommendations.pdf. Accessed February 26, 2011. 1.
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