Educational Session: Evaluation and Management of the Difficult Airway

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1 Educational Session: Evaluation and Management of the Difficult Airway Diane M. Birnbaumer, MD, FACEP 3/24/2010 7:30 AM - 8:30 AM

2 The Difficult Airway What s Up YOUR Sleeve? Diane M. Birnbaumer, M.D., FACEP Professor of Medicine University of California, Los Angeles Associate Residency Director Department of Emergency Medicine Harbor-UCLA Medical Center Advanced Airway Management Options Definitive airway management ETT Rescue Airway Devices Bougie Rigid intubation devices Extraglottic devices Videoscopic intubating devices Flexible fiberoptic intubating scopes Cormack-Lehane Laryngeal View Grade System Cormack-Lehane Laryngeal View Grade System The Bougie Commonly used airway adjunct for difficult airway Long track record in Europe and U.S. since 1949 Complications Difficult to find in the literature The Gum Elastic Bougie aka Eschmann tracheal tube introducer aka intubating stylet Some have graduations at 10 cm intervals Can be used with ETTs 6.0 or larger Disposable and reusable versions available

neoplasms Foreign material in the upper airway Inability to position the patient Allows verification of correct placement before placing the endotracheal tube Technique Overview Performed after rapid

3 Indications From Moscati R, et al. Endotracheal tube introducer for failed intubations: A variant of the gum elastic bougie. Ann Emerg Med. 2000;36:52-56 To facilitate orotracheal intubation when the cords are not visualized or neck movement is contraindicated Short, thick neck Pregnancy Laryngeal edema Anatomical variation Supra-glottic neoplasms Foreign material in the upper airway Inability to position the patient Allows verification of correct placement before placing the endotracheal tube Technique Overview Performed after rapid sequence induction Three-step process 1. Intubation of the tracheal with the bougie 2. Passage of the endotracheal tube over the bougie into the trachea 3. Removal of the bougie and securing the ETT Technique Position the patient in the sniffing position if possible Pre-oxygenate Premedicate Curve the bougie and ensure the distal tip is formed into a J-shape Using the laryngoscope, elevate the pharyngeal soft tissue to obtain the best view possible of the glottis Technique (cont.) While visualizing the glottis, advance the bougie; keep angled tip pointing anteriorly toward the epiglottis (concavity facing forward) Visualize the tip of the bougie passing posteriorly to the epiglottis Once the tip is past the epiglottis, continue to advance it in the midline in an anterior direction When the tip enters the trachea, feel for clicks/bumps as you run it along inside the trachea (the tracheal rings) Using the Bougie Laryngoscope is placed and used normally. Bougie tip is advanced.

Using the Bougie Using the Bougie Bougie tip is advanced just beyond the epiglottis.

airway narrows (Cheney s sign), (3) bougie rotates as it enters mainstem bronchus.

Endotracheal tube is advanced over the bougie while ensuring that the bougie does not advance.

Withdraw the bougie and re-attempt correct placement Correct placement?

4 Using the Bougie Using the Bougie Bougie tip is advanced just beyond the epiglottis. Bougie is advanced anteriorly feeling for (1) clicking of tracheal rings, (2) abrupt stop to advancement as the airway narrows (Cheney s sign), (3) bougie rotates as it enters mainstem bronchus. Using the Bougie Using the Bougie After confirmation of tracheal placement, bougie is withdrawn to 15 cm. Endotracheal tube is advanced over the bougie while ensuring that the bougie does not advance. Troubleshooting No clicks or can t advance? Indicates esophageal placement. Withdraw the bougie and re-attempt correct placement Correct placement? Hold the bougie in place maintaining laryngoscopy DO NOT PUT DOWN THE LARYNGOSCOPE!!! Have assistant pass the ETT over the proximal end of the bougie (Seldinger-like technique) From Nocera, A. A flexible solution for emergency intubations difficulties Ann Emerg Med, 1996;27(5):

opening while visualizing Once the ETT is in place, withdraw the bougie and verify correct tube placement Airway Rescue Devices Extraglottic Devices

Glidescope CMAC McGrath Flexible Fiberoptic Intubation Devices Surgical or percutaneous cricothyrotomy Airway Rescue Devices The Combitube Extraglottic

5 Technique (cont.) As the ETT moves along the bougie and enters the level of the mouth, grasp it and carefully advance ETT along the bougie and through the glottic opening while visualizing Once the ETT is in place, withdraw the bougie and verify correct tube placement Airway Rescue Devices Extraglottic Devices Combitube King LT LMA (Unique, ProSeal) Rigid Intubation Devices Lighted Stylet AirTraq Intubating LMA SOS / Levitan / etc Video Intubation Devices Glidescope CMAC McGrath Flexible Fiberoptic Intubation Devices Surgical or percutaneous cricothyrotomy Airway Rescue Devices The Combitube Extraglottic Devices Combitube King LT LMA (Unique, ProSeal) Rigid Intubation Devices Lighted Stylet AirTraq Intubating LMA SOS / Levitan / etc Video Intubation Devices Glidescope CMAC McGrath Flexible Fiberoptic Intubation Devices Surgical or percutaneous cricothyrotomy Inserting the Combitube Inserting the Combitube

6 Inserting the Combitube 1 = pharyngeal balloon Ventilating Through The Combitube 1 = pharyngeal balloon Inserting the Combitube Ventilating Through The Combitube 2 = esophageal balloon 2 = esophageal balloon

Ventilating Through The Combitube Ventilating Through The Combitube Removing The

are inflated (1, then 2) Can try moving combitube to left of mouth and inserting

The King LT Obturator device blindly inserted into trachea One pilot balloon port

7 Ventilating Through The Combitube Ventilating Through The Combitube Removing The Combitube Suction through Tube 2 (stomach) Deflate balloons in same order they are inflated (1, then 2) Can try moving combitube to left of mouth and inserting laryngoscope If run into trouble, remove combitube (suction ready), then intubate The King LT Obturator device blindly inserted into trachea One pilot balloon port One ventilation port Only ventilates through side port holes Not a protected airway

The King LT King LT, LT-D, LTS-D No latex Reusable (King

.-D) LTS-D suction port into esophagus and stomach The

optimal Can be done in neutral position Sizes 3, 4 and 5

height The King LT Insert until airway connector at teeth

The King LT Variation on device allows distal suctioning

8 The King LT King LT, LT-D, LTS-D No latex Reusable (King LT) or disposable (..-D) LTS-D suction port into esophagus and stomach The King LT Inserted blindly into mouth Sniffing position optimal Can be done in neutral position Sizes 3, 4 and 5 if > 4 feet tall Specific sizes depend on patient s height The King LT Insert until airway connector at teeth Inflate balloons, withdraw until ventilation optimized The King LT Variation on device allows distal suctioning Possible to intubate over bougie placed through side port into airway The Laryngeal Mask Airway Inserting the LMA

Inserting the LMA The LMA in Place The LMA seated in front of the glottic opening Airway Rescue Devices Extraglottic Devices Combitube King LT LMA (Unique, ProSeal) Rigid Intubation Devices Lighted

9 Inserting the LMA The LMA in Place The LMA seated in front of the glottic opening Airway Rescue Devices Extraglottic Devices Combitube King LT LMA (Unique, ProSeal) Rigid Intubation Devices Lighted Stylet AirTraq Intubating LMA SOS / Levitan / etc Video Intubation Devices Glidescope CMAC McGrath Flexible Fiberoptic Intubation Devices Surgical or percutaneous cricothyrotomy Components Reusable handle Uses 3 AAA batteries Stylet Has retractable stylet Endotracheal tube Typical endotracheal tube If possible, cut to 25cm and reattach adaptor if time allows Assembling the unit Handle Stylet Endotracheal tube (cut to 25cm if time allows)

Assembling the unit Take stylet out of plastic Lock metal hook into slot in stylet Will

surfaces are opposed Pinch green mechanism to slide onto handle Assembling the unit Slide

bulb is palpable within tip of endotracheal tube Assembling the unit Bend stylet at the

straight except at the bend here point Viewed along its length, distal bend in tube

10 Assembling the unit Take stylet out of plastic Lock metal hook into slot in stylet Will be at a right angle Assembling the unit Slide stylet through hole in handle so contact surfaces are opposed Pinch green mechanism to slide onto handle Assembling the unit Slide endotracheal tube onto stylet Lock endotracheal tube onto handle Slide stylet so light bulb is palpable within tip of endotracheal tube Assembling the unit Bend stylet at the bend here point Bend should be very sharp and at about 95 o In profile, unit should be straight except at the bend here point Viewed along its length, distal bend in tube should align with hook of stylet at handle Using the TrachLight Hold in whatever hand is most comfortable

Using the TrachLight Use other hand to open patient s mouth, using thumb to lift tongue and jaw Put handle down to patient s chest; insert bend end of ETT directly down into patient s mouth

force; will bend the stylet Watch for bright light at patient s cricothyroid membrane Using the TrachLight When bright spot of light seen, secure unit with one hand at patient s mouth With

11 Using the TrachLight Use other hand to open patient s mouth, using thumb to lift tongue and jaw Put handle down to patient s chest; insert bend end of ETT directly down into patient s mouth Using the TrachLight When tip of tube is in back of patient s mouth, gently lift the unit, tucking tube behind patient s tongue Using the TrachLight Keep midline at all times Do not use force; will bend the stylet Watch for bright light at patient s cricothyroid membrane Using the TrachLight When bright spot of light seen, secure unit with one hand at patient s mouth With other hand, pull back metal stylet about 2-3 cm only Using the TrachLight Advance unit 1-2 cm Unlock tube Using the TrachLight Pull out stylet / handle unit Secure tube / ventilate / check ETCO2

Troubleshooting Assure stylet hook is locked into stylet

spot and rest of unit is straight Check that stylet hook and

Stay midline when inserting unit AirTraq AirTraq

under direct visualization Single use, selfcontained AirTraq

not to advance to far distally Will obscure view AirTraq

12 Troubleshooting Assure stylet hook is locked into stylet slot Double check that bend is o only at bend here spot and rest of unit is straight Check that stylet hook and end of tube are aligned Make sure you get behind the tongue Stay midline when inserting unit AirTraq AirTraq Non-fiberoptic intubating device Places ETT into trachea under direct visualization Single use, selfcontained AirTraq ETT placed into channel on AirTraq Needs lubrication Careful not to advance to far distally Will obscure view AirTraq Once tube is in the channel, click on light Insert directly midline in patient s mouth

13 AirTraq To visualize cords, rotate back out of airway, lift, rock back in Visualize cords Pop off proximal ETT rightward; advance tube The Fastrach Intubating LMA The Intubating LMA The Intubating LMA Lubricate back of I-LMA and insert into mouth, rolling down into airway

epiglottic elevator is raised and tube should pass into the trachea The Intubating LMA The Intubating LMA Inflate the ETT cuff

14 The Intubating LMA The Intubating LMA Inflate the laryngeal mask Bag the patient through the LMA The Intubating LMA The Intubating LMA Insert the endotracheal tube through the intubating LMA When the black line on the ETT reaches the LMA, the epiglottic elevator is raised and tube should pass into the trachea The Intubating LMA The Intubating LMA Inflate the ETT cuff Remove the ETT adaptor and keep in a safe place (you ll be needing it) Deflate the LMA Use the flexible rod stabilizer to hold the ETT in place

The Intubating LMA The Intubating LMA Slowly remove the LMA Reach into mouth and hold ETT

flexible rod to do this Fully remove the LMA, pulling ETT pilot balloon through entire LMA

Airway Rescue Devices Extraglottic Devices Combitube King LT LMA (Unique, ProSeal) Rigid

Intubation Devices Glidescope CMAC McGrath Flexible Fiberoptic Intubation Devices Surgical

15 The Intubating LMA The Intubating LMA Slowly remove the LMA Reach into mouth and hold ETT when visualized ETT pilot balloon will need to pull through LMA Will need to remove flexible rod to do this Fully remove the LMA, pulling ETT pilot balloon through entire LMA The Intubating LMA Reattach ETT adaptor Check ETCO2 Bag patient or attach to ventilator Airway Rescue Devices Extraglottic Devices Combitube King LT LMA (Unique, ProSeal) Rigid Intubation Devices Lighted Stylet AirTraq Intubating LMA SOS / Levitan / etc Video Intubation Devices Glidescope CMAC McGrath Flexible Fiberoptic Intubation Devices Surgical or percutaneous cricothyrotomy Glidescope Fiberoptic Direct visualization of the airway Intubation device

laryngoscope, technique for use is a bit

mouth Need to curve ETT exactly like handle

Scope Inserted in center of mouth Visualize

ETT inserted directly along curve of scope

16 Glidescope Various versions available Glidescope Various versions available Glidescope Various versions available Glidescope Although looks like laryngoscope, technique for use is a bit different Inserted into the center of the mouth Need to curve ETT exactly like handle Use special stylet or curve routine stylet appropriately Need to partially remove stylet as inserting tube Learning curve - quick CMAC Video Intubating Scope Looks just like MAC blade Sizes 2, 3, 4 Not disposable (yet) Will come out with straight blades soon CMAC Video Intubating Scope Inserted in center of mouth Visualize on external screen ETT uses standard stylet ETT inserted directly along curve of scope blade

McGrath Videoscope McGrath Videoscope Airway Rescue Devices Extraglottic Devices Combitube King

Levitan / etc Video Intubation Devices Glidescope CMAC McGrath Flexible Fiberoptic Intubation

Extraglottic Devices Combitube King Devices Surgical or percutaneous cricothyrotomy Equipment

17 McGrath Videoscope McGrath Videoscope Airway Rescue Devices Extraglottic Devices Combitube King LT LMA (Unique, ProSeal) Rigid Intubation Devices Lighted Stylet AirTraq Intubating LMA SOS / Levitan / etc Video Intubation Devices Glidescope CMAC McGrath Flexible Fiberoptic Intubation Devices Surgical or percutaneous cricothyrotomy Airway Rescue Devices Surgical Cricothyrotomy Extraglottic Devices Combitube King LT LMA (Unique, ProSeal) Rigid Intubation Devices Lighted Stylet AirTraq Intubating LMA SOS / Levitan / etc Video Intubation Devices Glidescope CMAC McGrath Flexible Fiberoptic Intubation Devices Surgical or percutaneous cricothyrotomy Equipment needed Trousseau dilator Tracheal hooks Retractors 15 blade scalpel Betadine Size 4 or 6 cuffed tracheostomy tube

Surgical Cricothyrotomy Prep neck Make vertical incision over membrane

Insert tracheal hook; pull cephalad Dilate with trousseau dilator in

Remove tracheal hook Percutaneous Cricothyrotomy Melker Kit or Cook

the neck, insert the needle caudad aspirating for air Leave needle in

remove needle Cut a hole through skin along wire Put dilator through

tracheostomy tube, insert unit over wire percutaneously through skin into

18 Surgical Cricothyrotomy Prep neck Make vertical incision over membrane Palpate cricothyroid membrane Make horizontal incision into membrane Insert tracheal hook; pull cephalad Dilate with trousseau dilator in horizontal and vertical directions Insert tracheostomy tube; secure Remove tracheal hook Percutaneous Cricothyrotomy Melker Kit or Cook Universal Cricothyrotomy Kit Percutaneous Cricothyrotomy After prepping the neck, insert the needle caudad aspirating for air Leave needle in place, insert wire Percutaneous Cricothyrotomy After inserting the wire, remove needle Cut a hole through skin along wire Put dilator through trach tube Percutaneous Cricothyrotomy After putting dilator through tracheostomy tube, insert unit over wire percutaneously through skin into trachea Remove dilator and wire The Cook Universal Cricothyrotomy Kit Allows either percutaneous or open technique

19 Airway Devices: Bottom Line Have lots of money and staff to look after the equipment? Bougie Intubating LMA GlideScope or CMAC Flexible fiberoptic intubating scope Universal Cricothyrotomy Kit Airway Devices: Bottom Line Not so much money and no dedicated staff? Bougie Intubating LMA disposable KingLT AirTraq Universal Cricothyrotomy Kit +/- TrachLight +/- GlideScope Ranger Thank You For Your Attention! Any Questions?

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