Airway Issues

[Plinko]

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Just curious what the airway success rate is in the first and second year of residency among the EM residents out there. I'm in a 4 year program (1+3) and about to start my third pgy year. I have a greater than 90% success rate with garden variety intubations in the ER, but I work at a trauma center and my success rate for trauma cases is dismal. I've had to have the attending or anesthesia bail me out on way too many occasions. Is there a point when things click and your success rate skyrockets? If things don't improve soon I'm going to start asking about openings in Derm. Kidding of course, but I'm about to a be senior resident and it's getting kind of embarrassing. What's worse, the trauma attendings at my hospital always seem give me a hard time when I ask for the collar to be removed and to use in line c spine stabilzation so I've stopped asking for it. Had a GSW to the face recently during which I couldn't even get the mac blade into the mouth. I'm about at wits end. Any personal anectdotes that suggest some dramatic turnaround is in my near future would be appreciated.

 

[southerndoc]

It's all about positioning. Make sure the bed is at the proper height, make sure you are performing laryngoscopy correctly (i.e., not rocking the blade/using it as a fulcrum), etc.

 

[Aloha Kid]

Plinko,

Overall, trauma airways are the hardest due to the fact of positioning. Take into account facial/head trauma, unstable patients, and the scrutiny of the entire trauma team/attendings/backup anesthesia watching and it makes it tough. I'd be willing to bet for trauma patients the success rate for an inexperienced operator is 80%. I have no figures to support this.

The more we do, the more we try to learn, the better we get. And don't forget, the Airway humbles anyone who thinks they have finally mastered it. Even the Anesthesiologists.

Couple of good books out there. I really like the Airway book by Levitan. Lots of pictures, easy reading, and very insightful. I have found my failures and difficult intubations to be the best learning experience there is. I have gained motivation from missing airways and then watching anesthesia slip it in like butter with a smirkiness on their face of course.

 

[kungfufishing]

First, I'd say if you are the one in charge of the airway and you want the collar off and someone to hold Cspine, collar comes off and someone holds Cspine. Try to ignore the social stuff if you can and focus on that one job, the plastic in the trachea, happening.

Easy for me to say on the internet, but I have found that when I get my own procedural "feng shui" right - especially positioning - regardless of procedure, I do better.


I'm no grizzled vet, just finished residency, but I like the miller for immobilized airways better.

Reading your post, it sounds like all of this has undermined your confidence (even though you are probably better at this than you think). Perhaps you could figure out what it would take for you to be satisfied with your own performance and make a plan to make that happen before you finish. Talk to your faculty/PD etc. - ultimately, they should be looking to produce graduates who are competent and confident in their skills. This might mean some pride swallowing but in 2 years will you care?

 

[corpsmanUP]

I'm just starting 3rd year, and have only been doing trauma airways the last year. But I can tell you I always take down the front of the collar, have someone else hold c-spine out of my way, and I then can easily enter the mouth, and give forward traction without difficulty. I have tried intubations in the past when I was a medic with the collar on, and they suck! You need to have a discussion with your trauma folks with supporting documentation showing the technique I mention (which I thought was rather standard in our field). I also like the Miller in immobilized patients or just large no-neckers. It's a harder blade to use but can really save your buttttt. Don't get down on yourself though, as I am sure you are much better than you think.

 

[Plinko]

Aloha Kid, thanks for the book recs. You are right, I should be reading more on airway. I've fallen into the trap of allocating most of my reading efforts towards medicine and not putting any time in on reading up on procedural info. I've always felt that procedural knowledge should come from the osmotic properties of experience gained. But obviously that is not always the case.

Kungfu and corpsman, I agree the collar should come off per the operator's preference. My program has a sketchy alliance with the trauma service, and the ER director/attendings have been allowed to be coerced into giving the resident "a try at the intubation" for teaching purposes only, thus the culture in the trauma bay isn't really conducive to reproducing the reality of the practice of EM out in the world. We've only been a trauma center for a couple of years and are thus still defining ourself in that regard. Ive heard the new chiefs are working on changing the concept of the resident as chief airway operator though. We'll see.

Miller blades are intimidating to me being that I've only used them for a handful of cases--mostly the severely obese guy in decompensated chf or one who decided to take a trash can full benzos. Maybe I'll give it a try next time around. At this point I don't feel like I have much to lose.

Again, thanks for the insights and words of encouragement. Much appreciated.

 

[DrQuinn]

Interesting.

Where we're at, the trauma airway has been an issue for the past year. We as the ED attendings (we are still a new program that just got PGY3s today), have to do the trauma airways. it was always anesthesia until about 7 months ago, now its just me. I have probably tubed ~ 40 people in 7 months, and have had one miss (that anesthesia missed as well).

I ALWAYS have someone hold C spine for me. The collar is crap, and A is always before D. I have found that trying to tube with a C Collar on is just a recipe for disaster. Have the intern or medical studnet or nurse or osmeone take off teh collar and hold it. I'm less worired about cricoid pressure anyways (after recent articles).

Part of your problem as some have alluded to is the psychological factor. You are probably stressing out when yo don't need to, and your skills are higher than you think.

In my *now* three years as being an attending, I have had two misses (GSW to face, airway completed occluded by pouring blood, anesthsia couldn't tube either, so had to cric.... then an old lady with perfed ulcer who was the most difficult intubation I've ever had even though I coudl see arytenoids, tried mac, miller, glideoscope, had to cric eventually). Sometimes bro you are just gonna not get them. But now is your time to flex your muscles and try as many intubations, especially hard trauma ones, and to get some hard tubes under you rbelt. Push yourself to DO them and to do them the way YOU want them, because that's how it is in the real world. Who cares waht surgery says, let them hang out at the belly and do their FASTs.

Q

 

[roja]

Just to reiterate what has been said here:
1. Position is key.
2. Read. I like Ron Walls book. Simple, direct, lots of good pearls.
3. SWEEP. (its one thing if you cant get a blade in the mouth, but I can't tell you how many times I see residents stick the mac in at the middle of the mouth, which just pushes the tongue back and suprise! all you see is vallecula. ) Learn to SWEEP on every intubation. Its a habit and although you can probably intubate most without it, its the crunch airways that screw you.
4. Do your own cric pressure! Put your hand on the neck and move that sucker around. When you get it, tell someone 'here' and if it moves, put your hand on thier hand and move it around. This is not the time for 'southern social manners'.
5. Always have a scalpel in your pocket. The biggest mistake in a surgical airway is not doing one in time.

 

[Dienekes]

I'd be willing to bet for trauma patients the success rate for an inexperienced operator is 80%.

I have no data for EM residents, but I know that the first attempt success rate for the EMS operation I worked at averaged 68% when counting only trauma cases. This is the crude average over five to six years (non-consecutive due to my military service) based on the monthly CQI reports I had to file- and still have copies of- but it never deviated much, save one month (November 2004) during which we had six gunshot wounds to the face (one murder-suicide, the rest hunting accidents) out of 14 trauma intubations. By comparison, the first attempt success rate for non-trauma cases averages out to be 77%.

I know it's not the same thing, but felt compelled to share anyhow.

 

[southerndoc]

I have no data for EM residents, but I know that the first attempt success rate for the EMS operation I worked at averaged 68% when counting only trauma cases. This is the crude average over five to six years (non-consecutive due to my military service) based on the monthly CQI reports I had to file- and still have copies of- but it never deviated much, save one month (November 2004) during which we had six gunshot wounds to the face (one murder-suicide, the rest hunting accidents) out of 14 trauma intubations. By comparison, the first attempt success rate for non-trauma cases averages out to be 77%.

I know it's not the same thing, but felt compelled to share anyhow.

We had data from residency that was pretty good. A chief resident and our faculty member responsible for airway procedures looked at the data after EM residents started intubating trauma patients and compared it to anesthesia. The numbers were obviously higher (more successful) for anesthesia, but not by much. Not sure if it's been published (not even sure the former chief even submitted it).

 

[Jeff698]

In addition to opening up the collar w/ in-line stabilization (I agree), using a Miller (I also agree), I'd recommend always having a Bougie around for all trauma intubations.

As for the psychological factor, I don't think it is possible to underestimate this. Remember the movie Caddyshack? "Be the ball, Danny, be the ball"?

Turns out Chevy Chase was onto something.

Take care,
Jeff

 

[kungfufishing]

bougie, agree.

 

[Hawkeye Kid]

I'll third the bougie. At one of our EDs, our airway packs are on mayo stands in all of the critical care rooms and there's a bougie taped to the edge of every one of them. On what I anticipate to be difficult airways, I get it out of the package just because it seems like when I have it out I don't need it.

 

[Aloha Kid]

BOUGIE !!! OH YEAH!

Bougie is always my backup. Its quick and easy, takes no extra time at all and solves a lot of the problemed airways. Ex, cant visualize the cord, partial visualization of the cord, etc. Some people use it as a stylet all the time. For me, if the patient looks hard, I pull out the bougie to have on standby.

 

[radslooking]

If it makes you feel better plinko...difficult airway management is considered the number one issue affecting patient care by anesthesiologists. its not always an easy issue, especially in uncontrolled situations.

 

[Mighty Mouse]

tubed an awful airway the other day. first look (still in c-collar) couldn't see crap. took off collar, bagged back up, got a better look, but not great....passed the bougie...felt the knocking on the rings....said, "jackpot baby!" and put in the tube. it was dope.

moral of the story: another gold star for the bougie.

 

[Egon]

In the ED you should never have the c-spine collar on during intubation. you need to be able to open the mouth as you shouldn't/can't flex the neck.

I have never seen an ED airway done with the collar on...

The bougie is the cheapest airway device and is excellent for trauma, you only need to see epiglottis. You should practice with the bougie on your medical cases and use it as your airway of choice in trauma if you are still having probems. The bougie can also be cidexed and reused, and only run bewteen $12-35 dollars.

You should also practice c-spine immobilization in your regular pts if you need to build confidence/skills.

 

[southerndoc]

I agree that you should never tube with the collar on. There's enough help around to hold c-spine.

The bougie is a great device, but it's not fool proof. Sometimes you can't feel the tracheal rings very well.

Finally, I believe bougies should be kept in a very cool environment. Don't put it in a warm trauma bay (or worse, a burn bay where the temp is 80 degrees). They can become quite flexible and it can be very difficult to use them. Maybe we should put them in the refrigerator.

 

[jetproppilot]

Great thread with some very good advice.

Anesthesiologist in 12th year of private practice.

Heres the points I'd emphasize....they've already been mentioned by your colleagues btw but I'll repeat them for emphasis:

1)manipulating the larynx with your right hand....I think it was Roja who mentioned this......is probably one of the most useful actions that is not widely taught in academic institutions. Get your blade where you want it and if you dont see cords, move the larynx around. Frequently you will catch a glimpse of the cords.

2) Agree with removing anterior portion of C collar with manual axial traction.

3) If blood/vomit is anticipated (like a GSW to face or MVA with head trauma) go into the airway with blade in left hand and Yankeur in right hand....stick them in simultaneously to suck stuff out while you look.....this will save you valuable time thats not-well-spent looking for suction at the worst possible moment...

4)Blade selection is a controversial issue in my mind. I hate it when people spout that one blade is better than the other, or that one blade is better for a certain situation.....this is simply myth. It all has to do with what you are most deft with. My chairman when I was a resident was a brit...those guys are very deft with Mac 3s.....I never saw him miss, and I never saw him reach for any other blade. I on the other hand feel most comfortable with a Miller 2....if its a difficult intubation I drop the bed all the way down as I'm visualizing, I drop down onto one knee....this action provides me with optimum leverage and stabilization of the blade.

SOOOOO.....with a difficult intubation I'd start with your-most-deft blade. Its up to you to establish a dominant one and stick to it. I've seen deftness with both types.

5) The bougie is revolutionary, albeit not a new tool. Funny I wasnt exposed to it until my first few years in practice....guess my chairman wasnt privy to its efficacy. It has almost eliminated the need for me to do fiberoptic intubations. Its not uncommon in a difficult airway to catch enough glimpse to pass a bougie but not a tube. Dont hesitate to use it if you see the holy grail but dont think you can pass a tube. Hold your blade in the same position even after the bougie passes....a common mistake is to lighten up with your blade after the bougie is in. I've even seen individuals remove the blade altogether after bougie placement. Don't do either......hold whatcha got position-of-blade-wise after bougie placement until the tube is in.
Someone posted that "all you need to see is epiglottis." I humbly disagree with that statement. Seeing only epiglottis and blindly inserting the bougie yields a low percentage success. I use the bougie primarily for an "incomplete" visualization....where I can see an airway landmark but know I cant pass a tube. Yes, one can occasionally blindly pass a bougie but more often than not this will yield negative results. Better to reposition, come out and bag and try again, etc. TAKE HOME MESSAGE ON DA BOUGIE: Use it when you see something (bottom of arytenoids, etc).


6) Yield THE FORCE. A psychological component has been mentioned and I concur. Enter the airway like Matt Hughes entered the octagon during his glory days:

[/IMG] Confidence in yourself and being able to block out whats going on around you are the traits of a warrior, no matter what octagon (UFC, ER, OR, etc) you choose to practice in.

Best of luck, Dude.

You can conquer this. 👍

 

[Apollyon]

That's why Jet is way cool in my book - a great post, but it ain't complete until it 1. mentions THE FORCE and 2. has a great pic of someone cleaning house!

And, to echo the blade selection point - what is the best blade to tube with? Miller? Mac? Grandview? Flagg? Wisconsin? (Ever even heard of the last two?)

The best blade is the one you get the tube in with. Period.

 

[c.bear]

My 2cents

"4. Do your own cric pressure! Put your hand on the neck and move that sucker around. When you get it, tell someone 'here' and if it moves, put your hand on thier hand and move it around. This is not the time for 'southern social manners'." Our airway attending calls it ELM (external laryngeal manipulation) - but I love it.

Some other thoughts: The people I have seen that leave c-collar on practically lift the pt from the bed - yikes...

 

[kungfufishing]

Does anyone else like the frova bougie?

 

[southerndoc]

Does anyone else like the frova bougie?

How is that different than a regular bougie?

 

[kungfufishing]

I think it is officially called the "frova intubating introducer" and instead of being gum elastic, it is hollow with a malleable stylet. if the stylet is removed, you can also use it to oxygenate the patient.

 

[southerndoc]

I think it is officially called the "frova intubating introducer" and instead of being gum elastic, it is hollow with a malleable stylet. if the stylet is removed, you can also use it to oxygenate the patient.

Interesting. I've never heard of it. I'm only accustomed to the gum elastic bougie.

 

[Arch Guillotti]

Agree w/what most have said.

Back when I was an anesthesia resident (two weeks ago) tubing a trauma pt. in the OR was always a three person endeavor. Always took the collar down first then one person held in line stabilization, one cricoid and one for the DL. Not being able to manipulate the neck probably worsens your view by +/- one grade. The best blade is the one that you are most comfortable with. Many will tell you the Miller is better for the trauma situation but I have my best success with the MAC so that's what I go with. The bougie is great, it has saved my butt on a few occasions. I always tell students who are learning to tube to look for the epiglottis, once you have it you are money, with the mac just lift up and flip it outta the way. I don't think the Bougie is foolproof for when you see epiglottis but don't have a view of the cords - agree w/JPP on this one. I tended to use it for when I would catch a glimpse of the arytenoids. In anesthesia the tubes are usually pretty well-controlled situations but we also carried an airway sack for stuff up on the floor and those situations were usually uncontrolled involving a non anesthesia resident inducing and then taking multiple DL's without any success except in bloodying up the airway. I ALWAYS had the bougie at my side ready to go and sometimes I would load it up as the stylette for the tube. Anyways it took me about 40-50 tubes the first month to get really comfortable with it but everyone has a different learning curve. Repetition is key. I think that mentally going through the steps prior to the tube can be helpful as well so that they become automatically ingrained in your brain. Intubation is not a hard skill (nurses can do it🙄) but there is a significant psychological component to it (AKA THE FORCE). Just focus on getting the tube in, try not to think about all those eyes looking at you in the trauma bay and don't let the misses get you down.

 

[Jeff698]

Just focus on getting the tube in, try not to think about all those eyes looking at you in the trauma bay and don't let the misses get you down.

Very good point.

One last thing. Don't let people tell you that they never miss tubes. EVERYONE misses tubes if they do enough of them. Obviously, you have to recognize and react to it, but it's gonna happen.

Those people who've never missed a tube are either 1) lying or 2) haven't done very many of them.

Take care,
Jeff

BTW, many bonus points for the picture w/ reference to the FORCE.

Strong.

 

[kungfufishing]

Isnt it great how medicine is populated with all these people who never make mistakes or struggle with anything?

 

[Jeff698]

Isnt it great how medicine is populated with all these people who never make mistakes or struggle with anything?

Don't you wonder what it is about the process we go through to become physicians that turns so many of us into pompous jerks?

Or perhaps its just a selection bias.

Take care,
Jeff

 

[roja]

3) If blood/vomit is anticipated (like a GSW to face or MVA with head trauma) go into the airway with blade in left hand and Yankeur in right hand....stick them in simultaneously to suck stuff out while you look.....this will save you valuable time thats not-well-spent looking for suction at the worst possible moment...

Good tip. I always have it on hand, well, in my colleagues hand but I think I am going to do this. makes perfect sense. 👍

4)Blade selection is a controversial issue in my mind. I hate it when people spout that one blade is better than the other, or that one blade is better for a certain situation.....this is simply myth. It all has to do with what you are most deft with. My chairman when I was a resident was a brit...those guys are very deft with Mac 3s.....I never saw him miss, and I never saw him reach for any other blade. I on the other hand feel most comfortable with a Miller 2....if its a difficult intubation I drop the bed all the way down as I'm visualizing, I drop down onto one knee....this action provides me with optimum leverage and stabilization of the blade.

SOOOOO.....with a difficult intubation I'd start with your-most-deft blade. Its up to you to establish a dominant one and stick to it. I've seen deftness with both types.

Couldn't agree more. I *love* mac 3. But during residency, I got familiar with miller's also (you never know in a county hospital if your blade of preference is going to be working). But I always reach for the mac 3. I just hate seeing residents use Mac4's because they think the bigger size means a better look. *shudder* I have also dropped down to my knee to see an anterior set of chords. About 6 weeks ago, I walked into my overnight shift to take sign out and a pt was being tubed. Resident had tried twice already. Coultn' get the bougie in (only saw epiglottis), so I took over, couldn'tn see squat, and got all the way down on my knees and viola! chords.

5) The bougie is revolutionary, albeit not a new tool. Funny I wasnt exposed to it until my first few years in practice....guess my chairman wasnt privy to its efficacy. It has almost eliminated the need for me to do fiberoptic intubations. Its not uncommon in a difficult airway to catch enough glimpse to pass a bougie but not a tube. Dont hesitate to use it if you see the holy grail but dont think you can pass a tube. Hold your blade in the same position even after the bougie passes....a common mistake is to lighten up with your blade after the bougie is in. I've even seen individuals remove the blade altogether after bougie placement. Don't do either......hold whatcha got position-of-blade-wise after bougie placement until the tube is in.
Someone posted that "all you need to see is epiglottis." I humbly disagree with that statement. Seeing only epiglottis and blindly inserting the bougie yields a low percentage success. I use the bougie primarily for an "incomplete" visualization....where I can see an airway landmark but know I cant pass a tube. Yes, one can occasionally blindly pass a bougie but more often than not this will yield negative results. Better to reposition, come out and bag and try again, etc. TAKE HOME MESSAGE ON DA BOUGIE: Use it when you see something (bottom of arytenoids, etc).

I agree! Most people only see epiglottis due to poor technique. (ie not sweeping) Also, never take your 'eye off the ball' until the tube is in place. Even with the bougie. Its a great tool but you don't always feel clicks (s'kay, you will get hold up) and there are reports (and had it happen once) where the tube wouldn't pass over the bougie.. you can try rotating the tube a little.

6) Yield THE FORCE. A psychological component has been mentioned and I concur. Enter the airway like Matt Hughes entered the octagon during his glory days:

Best of luck, Dude.

You can conquer this. 👍

I have sold many a pieces of my soul under this technique.



Jetprop, you are awesome! great post!

 

[Arch Guillotti]

Couple of thoughts on rojas post. Mac 3 can get the job done almost every time, same for a Miller 2. Bigger blades are not always better. I think it is dumb to start out w/the big uns every time. If I had to pick one blade it would be a Mac 4 because I feel that anyone I can intubate with a Mac 3 I can also get with a 4 however if you aren't intimately familiar w/both then I think te 4 can hurt you sometimes. Some folks will have 2 suckers at the ready for all RSI's in case one should fail. If you do enough intubations you will have equipment failure at some point but I think it might be overkill unless you are expecting a bloody mess. I don't know that I have ever not been able to pass an ETT over a bougie but it has been a challenge on more than once, seemed to happen mostly on tube changes where sometimes it can be hard to pass the bend of the bougie.

 

[kungfufishing]

I also find the agility of the mac 3 to be just about right most of the time, but I guess each to his or her own.

Have any of you used any of the prefab cric kits?

 

[roja]

No. I have done 4 surgical airways. I have 'played' with them and just find them to not be quite as, well, elegant. I use a needle aspiration technique and it has worked very well. *fingers crossed* so far.

Something about just blindly shoving that huge thing into that tiny space... makes me nervous