56.3.1 What Are the Equipment Considerations for Difficult Airway Management in the Developing World?
Aggressive attention to the needs of the developing world has been undertaken by the international anesthesia community since 1989,2 and a series of standards have evolved, most recently the WHO Guidelines for Safe Surgery.9 These guidelines are sensitive to an immense global variation in resources and capacities, and standards are stratified to reflect what is possible for most regions.
126.96.36.199 Equipment Recommended for Level 1 Facilities: Small Hospitals or Health Centers
Such facilities provide minor surgery, normal obstetric delivery, and stabilization of emergencies. Level 1 facilities are staffed by paramedical staff, anesthetic officers, nurses, and midwives. In many environments, the supply of compressed gases is unreliable and expensive, meaning that oxygen concentrators, and draw-over anesthesia offer significant advantages.10 If only a single laryngoscope blade can be made available, it perhaps should be a Macintosh #4, as the tip of the blade can be used for neonates and children. WHO guidelines for medication and equipment availability in Level 1 facilities appear in Table 56-2 and 56-3.
Table 56-2 Medications Available in Level 1 Facilities
Table 56-3 Equipment Available in Level 1 Facilities ||Download (.pdf)
Table 56-3 Equipment Available in Level 1 Facilities
- Adult and pediatric self-inflating bags with mask
- Foot-powered suction
- Stethoscope, sphygmomanometer, thermometer
- Pulse oximeter
- Oxygen concentrator, or tank oxygen
- Draw-over vaporizer with hoses (at times)
- Tracheal tube introducers (bougies)
- Tracheal tubes
188.8.131.52 Equipment Recommended for Level 2 Facilities: District or Provincial Hospitals
Level 2 facilities undertake procedures such as caesarean section, laparotomy, and internal fixation of fractures that do not require a high level of specialization and technology. Such facilities have at least one trained anesthesiologist, with district medical officers, senior clinical officers, nurses, and midwives. There are one or more resident surgeons and obstetricians, and there are visiting specialists. Additional drugs and equipment are available to supplement those found in Level 1 facilities (Tables 56-4 and 56-5).
Table 56-4 Additional Medication Available at Level 2 Facilities ||Download (.pdf)
Table 56-4 Additional Medication Available at Level 2 Facilities
Table 56-5 Additional Equipment Available at Level 2 Facilities ||Download (.pdf)
Table 56-5 Additional Equipment Available at Level 2 Facilities
- Pediatric anesthesia systems
- Pulse oximetry—adult and pediatric probes
- Face masks size 00-5
- Oxygen analyzers, oxygen supply failure alarms
- Laryngoscopes, Macintosh blades 1-3 (4)
- Magills forceps, adult and child
- Oral airways, size 000-4
- Tracheal tubes size with ID 3-8 mm
184.108.40.206 Equipment Recommended for Level 3 Facilities: Referral Hospital
Such facilities usually have the capacity to undertake facial surgery, intracranial surgery, bowel resection surgery, pediatric and neonatal surgery, thoracic surgery, major eye surgery, major gynecological surgery, and the management of critically ill patients. Personnel include surgical, anesthesia, and critical care subspecialists. Available recommended medications and equipment (in addition to those available at Level 1 and 2 facilities) appear in Tables 56-6 and 56-7.
Table 56-6 Additional Medication Available at Level 3 Facilities ||Download (.pdf)
Table 56-6 Additional Medication Available at Level 3 Facilities
- Various modern neuromuscular blocking agents
- Various modern inhalational agents
Table 56-7 Additional Equipment Available at Level 3 Facilities ||Download (.pdf)
Table 56-7 Additional Equipment Available at Level 3 Facilities
- Laryngeal mask airways, size 2, 3, 4
- Tracheal tube introducers, adult and child
These guidelines provide a useful measure of the resources which will likely be encountered in developing countries. At times, resources available may exceed those recommended in the WHO guidelines. Not infrequently, however, material support suggested in guidelines may not be available.11 In addition, teaching clinicians can expect to encounter local practitioners with less airway management experience due to the extensive use of local and regional anesthesia for surgical procedures.
56.3.2 What Are Portable Equipment Considerations for Volunteers on Missions?
There is a dichotomy in the needs for difficult airway equipment in austere environment practice, depending on the nature of the mission. Longer-term teaching missions generally involve teaching local practitioners to use equipment already present (or easily obtained) and maintained in the environment. In general, equipment inventory will reflect WHO standards. In contrast, with short-term service missions, a traveling team arrives to directly provide medical care, and airway equipment is generally transported in and out with the team.12
220.127.116.11 Airway Equipment Considerations for Longer-Term/Teaching Missions
In general, a fundamental premise of longer-term teaching missions is to teach and use airway equipment that is locally sustainable. A "locally sustainable" device is defined as one that is already present in the environment, or can readily be obtained from that location (Tables 56-3, 56-5, and 56-7). In addition, it must be easily disinfected and should be simple to maintain or repair if broken. If electronically powered, the device should have a reliable power source, batteries or otherwise, and in this context, it must be stressed that electrical power (and compressed gases), are often unreliable in disadvantaged countries. Generally, equipment must be reusable, and it must be assumed that any single-use items will be reused.
Even if a device can be obtained and maintained, other factors must be considered. Introducing devices with unfavorable learning curves, or complex storage or disinfection needs, should be discouraged. Donation of equipment that is fragile or requires frequent servicing (eg, a flexible bronchoscope with a video tower), while well-meaning, can be futile and counterproductive in an austere environment. If such a device is presented, it helps to designate one local practitioner as champion for the product, charged with responsibility for ensuring it is used, cleaned, and stored appropriately.
18.104.22.168 Equipment Considerations for Short-Term/Service Missions
Airway equipment considerations differ for a short-term service mission (Table 56-8). Under these conditions, routine and difficult airway equipment is transported by the team, such equipment being limited only by its portability and robustness. The equipment should ideally be available in adult and pediatric versions, given the high occurrence of pediatric cases. If battery powered, sufficient batteries should also accompany the equipment, and disinfection requirements should be straightforward. It should be noted in this context that many practitioners consider the use of outdated medications or equipment unacceptable.
Table 56-8 Sample Airway Equipment for a Short-Term Service Mission ||Download (.pdf)
Table 56-8 Sample Airway Equipment for a Short-Term Service Mission
|• Portable pulse oximeter/capnograph|
|• Draw-over circuit and vaporizer|
|• Laryngoscopes with spare blades, bulbs, and batteries|
|• Face masks|
|• Complete set of tracheal tubes and stylets|
|• Oxygen tubing|
|• Tracheal tube introducers (Eschmann Tracheal Introducers) adult and child|
|• Precordial stethoscope|
|Difficult airway equipment|
|• Alternative intubation devices, eg, one or more of:|
|• Rigid fiberoptic, eg, Bullard, optical stylets|
|• Optical devices, eg, Airtraq|
|• Flexible bronchoscope, battery powered|
|• Extraglottic devices|
|• Seldinger cricothyrotomy device|
|• Colorimetric CO2 detection devices19|
56.3.3 What Can Be Done to Disinfect Equipment in an Austere Environment?
Disinfection methodologies of the developed world are seldom possible in austere environments and a great deal of ingenuity can be found in the methods of steam/sterilization, hypochlorite (bleach), boiling, formaldehyde, and chlorhexidine/cetrimide. Balance is often required between levels of sterility assurance and the possibility of doing a greater good with surgery. High-level disinfection may have to be accepted rather than sterilization. A sampling of common practice guidelines can be found in Tables 56-9, 56-10, and 56-11.
Table 56-9 Recommended Equipment Management in Austere Environments ||Download (.pdf)
Table 56-9 Recommended Equipment Management in Austere Environments
Single-use bacterial filters are now standard issue for many missions.
Rubber reusable and plastic single-use tubing should be decontaminated and cleaned. After drying, rubber tubing can be autoclaved. Plastic tubing cannot be autoclaved and should be disinfected.
Ambu or Heidbrink valves must be decontaminated, cleaned, and disinfected after each patient when a filter is not used. Ambu valves can be autoclaved.
Face masks, Guedel airways, laryngoscope blades, Yankauer suctions are decontaminated, cleaned, and sterilized (metal) or disinfected (plastic).
Table 56-10 Management of Consumable Anesthetic Equipment in Austere Environments ||Download (.pdf)
Table 56-10 Management of Consumable Anesthetic Equipment in Austere Environments
Single-use tubes are to be used as single use if supplies are sufficient. If in short supply they can be decontaminated, cleaned, and disinfected. Great care is required to ensure that disinfectant solution is removed.
Reusable rubber tubes are to be decontaminated, cleaned, and autoclaved.
Reusable laryngeal mask airways (LMA-Classic™) are to be decontaminated, cleaned, and autoclaved between each patient.
Table 56-11 Disinfection Options in Austere Environments ||Download (.pdf)
Table 56-11 Disinfection Options in Austere Environments
|1. Items should be decontaminated and thoroughly cleaned.|
|2. Items should be left for 20 minutes in solution. Chlorhexidine/cetrimide solution is satisfactory for this purpose, but another solution (eg, gluteraldehyde, bleach) may be used if more appropriate for the program.|
|3. A rolling boil (100°C for 10-20 minutes) may be preferable for materials that will be reused in the airway. Must boil for longer time at altitude (water boils at 85°C at 5000 ft).|
|4. Rinse well with water.|
|5. Dry before next use. |
|6. Chlorhexidine/cetrimide solution: |
|• 20 mL of 1.5% chlorhexidine/20% cetrimide solution is diluted into 1000 mL of water.|
|7. Hypochlorite (bleach) solution:|
|• 1 part bleach to 49 parts water for disinfection.|
|• Soak in mixture for 20 minutes.|
|• Corrodes metal and may destroy adhesives with prolonged soaking.|
|• Wash thoroughly.|