Is it Time to Sharpen Your Safe Sedation Airway Management Skills?

Observation of the Patient's Airway Position

Look and listen for:

• The rise and fall of the chest (depth and rate of respiration). The normal respiratory rate in adults is 12-16/min; in children, it is 18-22/min.
• The expansion and contraction of a reservoir bag if being used. As long as the mask or tube creates a good seal, the rise and fall of the reservoir bag is a good indication of respiration.
• Breathing sounds with or without a stethoscope: Normal breath sounds are a smooth, barely audible "whoosh." Abnormal sounds include snoring (partial obstruction of the upper airway), gurgling (water in the upper airway), wheezing (bronchospasm), or crowing (laryngospasm).
• The patient's skin and mucosa color: Hypoxia gives skin and mucosa a bluish tint, a very late sign of the oxygen desaturation process.

The sedation team must also be trained in using and interpreting monitoring equipment designed to measure blood oxygenation (oxygenation) and carbon dioxide expiration (end-tidal CO2, capnography, and capnometry).

The saturation of available hemoglobin sites with oxygen to a minimal level of 90%, as measured by the pulse oximeter, indicates at least adequate oxygen saturation. The Oxyhemoglobin Dissociation Curve explains the significance of the 90% level.

End-tidal CO2 reflects actual ventilation and is a more immediate indication of the delivery and use of oxygen for cellular metabolism.

Mallampati Classification

The upper airway anatomy can clue the practitioner to the possibility of airway compromise during sedation and make emergency airway management more challenging. Examination of the position and quantity of the soft palate and uvula when the patient opens wide and sticks out their tongue without phonating is the basis for the Mallampati score used by anesthesiologists to grade the difficulty of intubation.

This same classification can be utilized by those who do not intend to use intubation for anesthesia to evaluate the degree of potential soft tissue impingement of the airway.

Respiratory Diseases Impacting Airway Management

Patients with respiratory disease pose the highest risk for sedation issues, requiring further evaluation and monitoring once they’ve been determined to be acceptable sedation patients.

COPD, Asthma, and Obstructive Lung Diseases

The two most common forms of obstructive lung disease are asthma and COPD. In these conditions, bronchial tubes become narrowed or blocked by mucus, smooth muscle contradiction, or inflammation, making it hard to move air in and especially out of the lungs. The alveoli also deteriorate, making gas exchange inefficient.

These conditions raise a person's chances of bacterial pneumonia, pulmonary embolism, or airway obstruction. Potential triggers, reduced airflow, or inadequate pulmonary function can impact the planned sedation dentistry procedure. Asthmatic patients should be addressed on a case-by-case basis, as flare-ups and severity can significantly differ from one individual to the next. Any patient with severe respiratory disease is immediately categorized as an ASA IV patient and ineligible for sedation.

Sleep Apnea

Patients with obstructive Sleep Apnea (OSA) and Central Sleep Apnea (CSA) may require extended monitoring as they recover from a sedation procedure due to their irregular breathing patterns and oxygen intake. OSA patients require modifications to prevent hypoxemia and are at a statistically high risk for congestive heart failure. In contrast, CSA patients may experience high carbon dioxide levels in their blood due to inadequate neurological feedback. Given the connection with cardiovascular events, thorough medical screening is essential. Patients with CSA may be more sensitive to lower doses of sedation medications.

Asthma

It's reported that 25,000,000 people in the U.S. have asthma. Manifestations can range from mild to severe varieties where marked airflow obstruction is always present. In fact, 4,000 people die each year from complications from asthma.

In addition, asthmatic patients are predisposed to chronic inflammation of the lungs in which the bronchi are reversibly narrowed. Asthma 'attacks' occur when the smooth muscle in the bronchi constricts, along with excess mucus production.

Asthma Vs. COPD

It’s important to distinguish between asthma and COPD in patients with airway complications.

Questions to ask include when the disease developed and if there's been a medical diagnosis. Asthmatic patients tend to have it in childhood; an allergen can trigger worsening symptoms. With COPD, triggering agents can include long-term cigarette smoking.

COPD

Commonly caused by inhaling harmful chemicals (such as tobacco), it’s estimated that 24 million Americans have COPD, of which 50% are undiagnosed. COPD consists of:

• Chronic Bronchitis.
• Emphysema.
• Most people with COPD have a combination of both conditions.
• Forty percent of people with COPD also have asthma.

Guidelines for Sedating Respiratory Disease Patients

Patients with moderate to severe liver disease and moderate to severe respiratory disease carry the most significant risk associated with sedation in the outpatient setting. Proper patient evaluation, selection, and appropriate treatment modifications are paramount to a safe, successful outcome.

Patient evaluation is a mandatory component of safe sedation, and for those with respiratory disease, it helps determine whether they're a proper candidate for sedation.

Any patient with severe or complex respiratory disease is ASA IV and is not a candidate for sedation. These 'severe' patients will need to be sedated in a facility and by medical personnel who are prepared to treat potential respiratory emergencies, including intubation competently.

In Conclusion

Maintaining a clear airway is crucial during dental procedures, especially when sedation is involved. The sedation team undoubtedly plays a critical role in monitoring and protecting the airway to ensure patient safety.

Strategies for airway protection, vigilant monitoring of breathing and airway status, and thorough training in handling airway emergencies are essential. Additionally, understanding how respiratory diseases impact airway management and then adapting procedures accordingly is vital for patient safety.

The sedation team can provide a safe and effective dental care experience for all patients, even those with mild to moderate respiratory disease, by prioritizing airway management and implementing careful monitoring and proactive measures.

Visit the course page for the DOCS Home Study course "RESPIRATORY DISEASE AND SEDATION—ASTHMA & COPD" here, taught by Dr. Anthony Feck, DMD. (This DOCS Home Study course has a prerequisite to qualify for CE validation.)