Difficult airways

[sluggs]

I work in a very high census, high acuity ICU. I do about 90 airways a year. I work on all-comers, regardless of size, anatomy, acuity and co-morbidities. About 5-7 per year, I do with a glidescope, which I have to get from another department when I want it The rest I DL, Of my DLs, 5 or 6 require a second look due to difficult anatomy or sudden aspiration/crashing patient. I am very good at bag-masking/rescuing. I have once had a sat in the high 70s, otherwise mid-80s or better on these rare second looks. My colleagues call anesthesia for all of their airways. They think I should too, because of these "complications". Any thoughts on whether my #s sound like I have a "problem"?

---

Members don't see this ad.

 

[Doctor Bob]

I work in a very high census, high acuity ICU. I do about 90 airways a year. I work on all-comers, regardless of size, anatomy, acuity and co-morbidities. About 5-7 per year, I do with a glidescope, which I have to get from another department when I want it The rest I DL, Of my DLs, 5 or 6 require a second look due to difficult anatomy or sudden aspiration/crashing patient. I am very good at bag-masking/rescuing. I have once had a sat in the high 70s, otherwise mid-80s or better on these rare second looks. My colleagues call anesthesia for all of their airways. They think I should too, because of these "complications". Any thoughts on whether my #s sound like I have a "problem"?

If you had to cric a few patients a month because of inability to get a tube, or had some deaths due to lack of airway, then yes.

But sounds like you're getting airways just fine. Once you start calling anesthesia for all of your airways, then the airway management portion of your career is done. It's a use-it-or-lose-it skill...

 

[VentdependenT]

You NEED to do your own airways.

 

[Bostonredsox]

I'M With You Guys. I'm Supposed To Call Gas For All Of My Airways.

I Call Them For None Of Them. Unless I Really THink I Will Need Their Help.

Keep Doing What Your Doing Man. If No One is Dying And Crics Aren't happening left And Right then All Is Well IMO

Don't Know Wtf My Phone IS All CAps'n These Words But Its Annoying....

 

[Corwin29]

All physicians "should" be able to intubate, intensivist IMHO should be well qualified to manage airways without difficulty, realizing that if you think you need help before attempting is the time to do it. From Anes/CCM perspective drop your ego and realize that if its a difficult airway call for help (I will still call if I need help/equipment), if it doesn't appear to be difficult anes will not complain if its handled without them. The only issues I've seen is a known difficult airway attempted by med/ccm then emergency call to anes= bad outcome.

 

[dotcb]

My perspective is from Emergency Department airway management. It sounds like you're doing well, but that you could perhaps be more prepared for difficult airways. Personally, I think all airway attempts should have ready (beyond what you have) LMA, VL, and scalpel nearby. It may not be the known difficult airway that'll bite you, but the unanticipated difficult airway. Always be prepared for the worse case scenario. It sounds like you're great at getting airways, but also don't be so confident or too proud to call for help when it's needed.

 

[ORL10]

Im not so sure that not calling gas for any airways is the way to go. No offense Im sure you can intubate just fine, considering most airways are straight forward in general. However, in anticipated difficult airways sometimes two heads is better than one, or sometimes someone who is more experienced with airways (if you did very few "difficult airways" as a resident) will save your butt, and maybe teach you something. Im not saying don't do the airway, anesthesia is usually more than happy to give you the first crack at it.

I find in general anesthesia has a much more hemodynamically smooth way of approaching intubation than most IM or EM docs do (I should know since I trained in EM).

 

[VentdependenT]

If you have an anticipated airway it should be intuitive to call for help. No gold stars for being an idiot.

crashing pts who need immediate VENTILATION usually dont afford much time to dick around waiting, for these folks I RARELY need much if any induction agent.

Not paralysing worsens view.

Learn how to use LMA

learn how to MASK A PT WITH AN ORAL/NASAL AIRWAY.

People die from lack of VENTILATION not ibtubation.

MOST HEALTH CARE PROVIDERS OUTSIDE OF ANESTHESIA FORGET THIS. Most people flip and go right for the blade,forget about removing dentures, forget about CORRECT positioning, forget about supportive supraglotic airway devices, bougie, having different size tube, blade, oral/nasal airway, dont paralyse, dont use cricoid or RSI, dont have glide or FO available...

 

[jdh71]

I always imagine you gas guys thumping your chests and grabbing your c0cks when you post like this.

I mean, you're surely correct, but it does seem a bit over the top.

 

[VentdependenT]

All it takes is one. Causing an Anoxic brain injury due to arrogant or poor preperation is a crappy way to learn a lesson....but whatever. Too many people in medicine thump their chests. all it gets em is character assasination and sore flabby pectorals.

 

[VentdependenT]

All it takes is one. Causing an Anoxic brain injury due to arrogance or poor preperation is a crappy way to learn a lesson....but whatever. Too many people in medicine thump their chests. all it gets em is character assasination and sore flabby pectorals.

 

[jdh71]

All it takes is one. Causing an Anoxic brain injury due to arrogant or poor preperation is a crappy way to learn a lesson....but whatever. Too many people in medicine thump their chests. all it gets em is character assasination and sore flabby pectorals.

I hope I wasn't misunderstood. Your points are well taken by everyone, it's just the delivery of the points which I find amusing.

Back when I was playing football, our defensive line coach, who was a master sergeant in the army, would have us do push-ups, or sit ups, or run in place, or whatever while he would pace back and forth in front of us delivering what was extremely wise advice but like the drill instructor from Full Metal Jacket.

He was as serious as you are, and I still would always get into trouble for giggling occasionally. It's just commentary my friend.

 

[VentdependenT]

I know you know, but cmon man, there are tons of clueless providers.

Now the thing is NO DESAT (NC on 15L while intubating). I usually just dont have enough O2 sources to pull this off.

 

[jdh71]

I know you know, but cmon man, there are tons of clueless providers.

Now the thing is NO DESAT (NC on 15L while intubating). I usually just dont have enough O2 sources to pull this off.

Yeah. Sometimes I feel a bit bad for the gas residents who have to come up to the unit to intubate some of our university MICU bombs . . . bag, Bag, BAG . . . best sats like 86 or something. Heh. Please give this man plastic, just do it, so I can do my best to fix this problem with the vent. Don't feel bad you can't bag him up, he just has lungs that suck THAT much.

 

[europeman]

In my opinion, your responsibility of being prepared for airways in part relies on you doing a certain frequency of them to keep the skills up. Obviously known difficult airways should have anesthesia backup (if time permits). I personally prefer just to have another colleague... Whatever the specialty, who has airway facility because two heads are better than one.


In my personal experience, the ER peeps at my shop are by far the best at emergency airways / far better than the anesthesia folks who really don't have as much of a grasp of the whole picture.

In any regard, if you rely on anesthesia all the time u will for sure have some anoxics in your practice because your skills will eventually be so bad that you are completely dependent on them. And when they can't respond immediately?


Again it depends on your institution and availability of help of course.

I'm a surgeon who has a particular interest in airway.... And none of my patients will be anoxic because my patient WILL get an airway.


Of course if I had a cric a month that may be a problem! But that's not the case....

 

[VJWDO]

I am about to graduate from pulm/cc fellowship and have never done a cric. I will be going out into private practice in 4 months and have been really concerned about the possibility of needing to do this. (where I am training we have immediate help 24/7, not sure if I will have this at my new hospital). What is everyone's opinion on attempting intubation but not knowing how to get a surgical airway. Is that like sacreligious?

 

[Bostonredsox]

I am about to graduate from pulm/cc fellowship and have never done a cric. I will be going out into private practice in 4 months and have been really concerned about the possibility of needing to do this. (where I am training we have immediate help 24/7, not sure if I will have this at my new hospital). What is everyone's opinion on attempting intubation but not knowing how to get a surgical airway. Is that like sacreligious?

Take a difficult airway course you get some good cric practice. Also, ask the surgeons to let you do bedside trachs with them. I have never cricd either but I've done 7-8 bedside trachs and the procedure is extremely similar, you just make a cut in a different spot. But in reality that's the most training we can get in it as with modern VL toys and fiberoptics true surgical airways are just not very common, especially in the MICU. Traumas in Ed, I'm sure they see a bunch, but we don't see lots upstairs. Practicing with trachs is probably the best you can get to be prepared in the event there is a pt you need to cric.

 

[Dwindlin]

Take a difficult airway course you get some good cric practice. Also, ask the surgeons to let you do bedside trachs with them. I have never cricd either but I've done 7-8 bedside trachs and the procedure is extremely similar, you just make a cut in a different spot. But in reality that's the most training we can get in it as with modern VL toys and fiberoptics true surgical airways are just not very common, especially in the MICU. Traumas in Ed, I'm sure they see a bunch, but we don't see lots upstairs. Practicing with trachs is probably the best you can get to be prepared in the event there is a pt you need to cric.

Not really. Maybe a little more common, but I would hardly classify it as "a bunch." The same reason they are rare in the MICU is the same reason they are rare everywhere. VL was a game changer, not being able to get a view with a Glidescope/C-MAC is rare.

 

[Bostonredsox]

Not really. Maybe a little more common, but I would hardly classify it as "a bunch." The same reason they are rare in the MICU is the same reason they are rare everywhere. VL was a game changer, not being able to get a view with a Glidescope/C-MAC is rare.

I merely meant in perspective to upstairs I'm sure the number is higher.

 

[Dwindlin]

I merely meant in perspective to upstairs I'm sure the number is higher.

Oh I'm sure it's higher, but I doubt meaningfully higher.

 

[europeman]

Just a little opinion (I'm a surgeon who had done 4 crics).

A cric is *nothing* like an elective trach.

While I encourage you to do trachs to get familiar with the anatomy, see the trachea, etc etc..... In fact I have personally seen non-cric trained surgeons take longer and struggle more than cric-trained ER staff on this procedure.

Emcrit.org has a nice cric video I encourage you to watch.

Anyway I digress....

 

[deuist]

I'm an EM attending and have done all of one cric over my lifetime. They're not that hard to do: cut a vertical incision in the anterior neck and feel for the membrane, then keep cutting till you're through. Catch the top of the trachea with a hook, slide in a bougie for a guide, and then run an ET tube over it. The whole process takes less than 30 seconds. And I agree with europeman about watching the videos. They're informative about what to look for.

 

[europeman]

Cut horizontal into the trach!

Hard part is not losing the hole. It's a blind and bloody procedure so just stick your finger into the trachea after u make the horizontal incision into it and then maneuver a small et tube or preferably a boogie and then tube.

 

[IlDestriero]

If you're doing 90 airways a year and only needing a second look on a few, it sounds like you're doing fine.
We have a policy that the difficult airway page is called at the time of the 3rd attempt or for a known difficult airway.
We don't get a lot of calls, and when we do, we can usually get there before the challenging airway was made nearly impossible by 10 bloody attempts by 3 different people.
It also pages ENT.
Why not put together a difficult airway cart for your unit with advanced equipment, including bougies, cric kits, glide or VL, etc. Everything you may need can be wheeled in to the room in no time at all, while the nurse is getting drugs and you are positioning and maximizing oxygenation.